Respiratory
Inhaler and spacer use in children with asthma
Short clinical summary
In asthma treatment, a medication's effect depends on the device being used correctly. A spacer is recommended for children using a metered-dose inhaler; without one, most of the medication remains in the mouth and throat. Correcting technique errors is often more effective than increasing the dose.
Why does device technique matter so much?
In inhaled therapy the real question is not "which medication is being used" but "is the medication reaching the lungs". When a device is used incorrectly, symptoms remain uncontrolled, dose escalation comes onto the agenda, and the impression arises that treatment is ineffective.
Dr. Ayça Sözen's academic interests include inhaler device use in children and family education. In clinical practice, device use is therefore not simply explained: the family's technique is observed and incorrect steps corrected.
Which device at which age?
- Metered-dose inhaler + spacer with mask: Usually preferred in younger children. Because it does not require coordination with the child's breath timing, delivery is reliable.
- Metered-dose inhaler + mouthpiece spacer: Used once the child can follow instructions and breathe steadily through a mouthpiece.
- Dry powder inhaler: Requires sufficient, rapid inspiratory effort, so may suit older children.
- Nebuliser: Used in specific situations; however, spacer delivery is at least as effective in many circumstances and more practical.
Device choice is made together with the physician according to the child's age, level of cooperation, attack frequency and ease of use for the family.
Step-by-step administration with a spacer
Using a spacer with a mask
- Attach the mask to the spacer and insert the inhaler into the back of the spacer.
- Shake the inhaler for 5 seconds (on first use, prime it according to the device instructions).
- Hold the child upright, ideally seated on your lap.
- Place the mask so that it covers the mouth and nose completely, with no gaps at the sides.
- Fire one dose only.
- Without removing the mask, let the child take 5–6 normal breaths (about 10–15 seconds).
- If a second dose is needed, wait about 30 seconds and repeat steps 2–6.
- If an inhaled corticosteroid was used, rinse the mouth afterwards; in infants, wipe the face and offer water or breast milk.
The most common technique errors
- Spraying directly into the mouth without using a spacer
- Not shaking the inhaler before firing
- Firing two doses at once without waiting in between
- A mask that does not seal to the face, letting air escape at the sides
- Administering while the child is crying (medication reaches the lungs poorly during crying)
- Removing the mask before enough breaths have been taken
- Skipping mouth care after corticosteroid use
- Never cleaning the spacer, or scrubbing it harshly
Check technique before increasing the dose
When treatment is not working, the first things to assess are whether the medication is being used regularly and whether device technique is correct. Any change of dose or medication is decided only by the physician, after examination and a technique check.
Spacer care
A spacer is generally washed with warm water and liquid dishwashing detergent, rinsed or not rinsed according to the manufacturer's instructions, and then left to air dry. Drying with a towel can create static electricity, causing medication to stick to the chamber wall. The device's instruction leaflet should guide cleaning frequency and method.
A written asthma action plan
It is important for families to have a written plan in asthma follow-up. This sets out the daily medications, what to do if symptoms increase, when and how often to use the reliever, and the criteria for attending emergency care.
Findings requiring urgent assessment
- Wheezing that does not respond to the reliever inhaler, or recurs quickly
- Inability to complete a sentence while speaking, or difficulty feeding
- Retractions below the ribs or in the neck, rapid breathing
- Bluish discolouration around the lips or tongue
- Marked lethargy or difficulty waking
Frequently asked questions
Is a spacer really necessary?
A spacer is recommended for children using a metered-dose inhaler. Without one, a significant proportion of the medication remains in the mouth and throat. A spacer increases the amount reaching the lungs and makes delivery independent of breath timing.
Mask or mouthpiece spacer?
Younger children use a spacer with a mask that seals against the face. Once a child can follow instructions and breathe steadily through a mouthpiece, a mouthpiece spacer is used. The choice is made with the physician according to age and cooperation.
Do inhaled steroids affect a child's growth?
Inhaled corticosteroids used at guideline-recommended doses are considered far safer than uncontrolled asthma itself. Dose and duration are kept at the lowest effective level through regular review.
Can I stop the medication while my child is well?
Stopping preventer (controller) treatment on your own is not recommended; good symptom control shows the medication is working. Reducing or stopping is planned by the physician at a review consultation.
Where can I learn the technique?
Device education is part of the clinic consultation. The technique is demonstrated by the physician, the parent's own administration is then observed and corrected, and technique is reassessed at follow-up visits.
References
- Childhood sections of international asthma diagnosis and management guidelines.
- Consensus reports on inhaler device selection and spacer use in children.
- Clinical studies examining the effect of inhaler technique errors on treatment outcomes.
- Official instructions for use from device manufacturers.
This content is provided for general information purposes and does not replace individual medical assessment, diagnosis or treatment. Device and dose selection are determined by your physician.
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Author and medical reviewer
Ayça Sözen, MD
Specialist in pediatrics. Academic interests include inhaler device use in children and family education. Currently seeing patients at Acıbadem Ataşehir Hospital.