20 Dec 2023

Allergy Conditions

Asthma – Inhaler Devices in Asthma

Written by Dr Robert Gie

© Allergy Society of South Africa & SACAWG

 

Introduction
  • Asthma is caused by the inflammation of the airways (breathingtubes). The
  • swelling of the airways which is the result of the inflammationcauses the airways to be narrowed. During an acute asthma attack

    the airways are further narrowed by the contraction of the airways

    muscles (bronchospasm) (see “What

    is asthma?”)

  • Both the airway inflammation and muscle contraction are besttreated by delivering the medicine into the airways. This is best

    achieved by breathing the medicine into the airways

  • In this information sheet the best ways of delivering the medicinesto the airways are discussed.

Why inhale medicine into the airways?
  • It makes good sense to breath the drugs (medicine) into theairways (breathing tubes) of the lungs because this is where the

    problem is

  • Breathing the medicines into the airways is safe and fasterbecause:
    • The medicine is delivered to where the problems is and startsto work more rapidly.
    • Only a tiny amount of the medicine is needed.

Which drugs can be inhaled into the lungs?
  • All the drugs needed in the treatment of asthma can be inhaledinto the airways of the lungs. This applies to both the

    relievers and preventers (see “Asthma

    Medicines and how they work”)

  • The relievers (or bronchodilators)relax the muscles in the airways which are contracted during an

    acute attack whilst the preventers are anti-inflammatory

    drugs preventing inflammation developing in the airways

 

When should drugs be inhaled into the airways of the lungs?
  • Relievers should only be inhaled when the asthmatichas symptoms such as a tight chest, coughing after exercise, coughing

    at night or shortness of breath (see “Keeping asthma under

    Control”).

  • Relievers should not be used on a regular basis butonly with symptoms
  • The person with asthma needs to see the doctor if he or sheneeds to use the reliever regularly or if they do not give

    relief from the symptoms. The reason for this is that the asthma

    is poorly controlled and the treatment needs adjustment

  • Preventers MUST be used daily as prescribed. They donot prevent the inflammation in the airways if they are not used

    regularly. Some of the preventers have no effect at all if used

    irregularly.

 

Which children can inhale medicines?
  • Children of all ages can inhale medicine into the airways
  • It has been shown that even in babies and small children thebest way of delivering the treatment is by direct inhalation into

    the airways of the lungs

  • The babies and young children are unable to use the devicesavailable without an adaptation of the technique or the use of a

    different device. When these adaptations are used all children and

    adults can successfully be treated by the inhalation techniques.

    In the table below are the techniques suitable for babies and children:

 

Age-group Inhaler
Babies Pressurised aerosol inhaler with spacer
Nebuliser
Children under 4 years old Pressurised aerosol inhaler with spacer
Nebuliser
Children 4-8 years old Pressurised aerosol inhaler with spacer
Dry powder inhaler

Breath-actuated inhaler
Children older than 8 years old Pressurised aerosol inhaler
Pressurised aerosol inhaler

with spacer
Dry powder inhaler
Breath-actuated inhaler
  • Make sure that you or your child has received the correct inhalationdevice to ensure that the drugs reach the airways. Incorrect apparatus

    and incorrect use of the apparatus are important causes of poor

    control of asthma.

What are the different types of inhalers available?

1. Pressurised aerosol inhaler (asthma pump)

  • The medicine in a liquid form is forced into a holder (canister)under pressure
  • The canister is supplied with a holder. When the inhaleris pressed down in the holder the medicine is released through

    the mouth piece of the holder as a gas or cloud. It is this

    cloud of medicine which has to be inhaled

  • These inhalers (pumps) are cheap and effective if used correctly
  • To be used correctly co-ordination is needed between activatingthe inhaler and breathing the medicine in. This requires instruction

    from your doctor, nursing sister of pharmacist. They should

    also check to see if you are using it correctly every time you

    re-visit them

2. Pressurise aerosol inhaler and spacer

  • For babies, smaller children and children unable to correctlyuse an asthma pump an additional device is needed. This is called

    a spacer. They are plastic containers which make the asthma

    pump easier to use for all babies, children as well as adults

  • A spacer is a plastic holder into which the medicineis squirted. The spacer then holds the medicine until the child

    is ready to breath out of it

  • Spacer come in various shapes and sizes:
    • On babies and small children the spacer is fined witha mask which fits tightly over the babies/child’s mouth

      (Aerochamber, Babyhaler)

    • Older children and adults use larger spaces (750 mL)(Volumatic, Fisionair). These larger spaces have mouth pieces

      with a valve through which the asthmatic breaths inhaling

      the medicine already deposited in the spacer

  • Cheap spacers can also be made from coffee cups and 500mllitre plastic cooldrink bottles
    • For babies and small children a useful spacer can bemade from a used polystyrene coffee cup by making a hole

      in the bottom. The coffee cup is then applied as a mask

      to the face of the baby or child

    • In larger children spacer can be made from a 500ml plasticbottle. A hole for the inhaler is cut in the bottom of the

      bottle and the child breaths through the nozzle of the bottle

      after the inhaler is pressed. Bottles larger than 500ml

      have a too large volume for the child

  • Spacers are more effecient than an inhaler alone. They areused to:
    • Give inhaled medicines to babies, small children, childrenunable to use an inhaler alone. They are also useful in

      patients unable to co-ordinate the breathing in effort with

      the puff of medicine and in old people with arthritis.

    • Reduce the unwanted effects of inhaled medicine. Lesslocal side effects occur in the mouth and throat when spacers

      are used

    • Enable asthmatics with an acute attack to use theirinhalers to maximal effect. Spacers can be used

      in an emergency when co-ordinating with the inhaler is difficult.

      It as effective as a nebulised medicine

    • Use the cheapest form of treatment (asthma pumps)
    • Increase the amount of medicine to the airways.Spacers

      have been shown to double the amount of medicinedelivered to the airways making it more cost effective

3. Drypowder inhaler

  • Dry powder inhalers make use of the medicine beingin a powder form which is then breathed into the airways of

    the lung

  • The dry powder medicine is enclosed in a capsule (Spinhaler),in a circular disk (Diskhaler) or a special apparatus (Turbuhaler)
  • When the child breaths in, the very small particles areinhaled into the lung
  • To be able to use a dry powder inhaler the child must beable to breath in fast enough to get the powder into a small

    enough particles that they reach the lung and not be deposited

    into the mouth

  • The great advantage that dry powder inhalers have over asthmapumps is that they do not need the co-ordination the aerosol

    inhalers need. They have very little advantage over aerosol

    inhalers if the inhalers are used with a spacer.

4. Breath activated inhalers

  • These are the same as pressured aerosol inhalersexcept that they have a special mechanisms which activates the

    inhaler when the asthmatic breaths in

  • They have the same advantage as dry powder inhalers
    in thatco-ordination between activating the aerosol inhaler and breathing

    in is not needed

5. Nebuliser (see “Home nebulisers for asthma”)

  • A nebuliser is a machine that works by blowing air or oxygenthrough a fluid (medicine) and turns it into a mist which is

    then breathed into the airways

  • To nebulise fluid to the airways of babies and childrenis an expensive form of treatment which in nearly all cases

    is not more effective than other correctly used forms of therapy

  • It should only be used after your doctor has supplied clearguidelines when to use it and what medicines should be used

 

 

How do you correctly use the different inhalers?

1. Pressured aerosol inhaler (asthma pump)

Use the inhaler as follows:

  1. Shake inhaler vigorously. after taking the cap off holdthe inhaler in the upright position and shake the inhaler vigorously.

    It is now ready for use

  2. Sit or stand and tilt your head back slightly
  3. Breath out all the air in your lungs slowly. The more airthat is breathed out the better the inhalation of the medicine

    will be

  4. Place the inhaler in the upright position in your mouth
  5. Breath in slowly. Just after the start of the breath pressthe inhaler once. Breath the medicine right down into the lungs.

    Breath in all the air you can

  6. Hold your breath for between 5 to 10 seconds. This allowsthe medicine to settle in your airways
  7. Breath out slowly.

Common mistakes

with the use of the inhalers:

  • Not shaking the inhaler well enough
  • Breathing out to fast or not completely
  • Pressing the inhaler too early or too late
  • Breathing in too fast
  • Using an empty inhaler
  • An inhaler must be checked to see if there is still medicinein it. This can be done by shaking the inhaler. If there is

    still medicine in it you will hear it. Always start a new inhaler

    before the old one is completely empty (Have a spare one available)

  • The inhaler gets blocked.
  • The opening in the holding case gets blocked. This is easilyseen if the inhaler is pressed and a good cloud of spray is

    not seen. The case should then be washed in warm soapy water

    and left to dry completely

2. Spacer devices

The spacer are simple to use:

 

  1. Shake the inhaler vigorously
  2. Place the inhaler in the opening at the end of the spacer
  3. Place the mask over the face of the child or the openingof the mouth of the child 4. Press inhaler only once. Works

    best if only one puff is taken at a time

  4. Breath in slowly and deeply as possible in through thespacer. Five to six breaths should be taken after each time

    the inhaler is pressed

  5. When the spacer becomes dirty and there is a build upof powder the spacer can be washed in soapy warm water and

    left to dry. In those spacers with soft removable valves

    care must be taken in washing those valves

  6. It is not necessary to wash your spacer too regularly

 

3. Drypowder inhalers

There are many types of dry powder inhalers available. Each of them

has a different operating method. Some have to be loaded each time

they are used (Inhalator, Spinhaler, Rotahaler), others have disks

which have a number of doses (4 or 8), while other dry powder inhalers

have as many as 200 doses stored in the device (Turbuhaler)

3.1 The Spinhaler

  1. This is used to deliver one of the preventers 

    (Lomudol)

  2. The powder is enclosed in a capsule which needs to bepunctured 3. After the capsule punctured the powder is breathed

    into the lungs

  3. Do not breath back into the spinhaler
  4. Brush off loose powder everyday and wash the deviceweekly in warm soapy water and dry carefully
  5. The device has many parts which are easily lost – takecare.

 

3.2 The Diskhaler

This is used to deliver preventers (Flixotide and Becotide)

and relievers (Ventolin and Serevent). The dry powder

is contained in a circular foil disk each of which contain either

4 (Flixotide and Serevent) or 8 (Ventolin and Becotide) doses

in each disk. To use the diskhaler do the following:

  1. Load the disk into the devise by removing the part thatholds the disk. Replace the disk, and close the devise again
  2. To start puncture a hole in the dose by lifting thelid up as far as it will go vertically. This ensures that

    the dose is correctly punctured

  3. Breath out slowly until all the air is out of the lungs.Do not place the diskhaler in the mouth when breathing out
  4. Place the diskhaler in your mouth and breath in rapidly
  5. Do not breath back through the diskhaler as part ofthe dose will be blown out 6. Look after the diskhaler by

    brushing away the loose powder every time the foil disk

    is replaced. The disk holder can be washed in warm soapy

    water and left to dry

3.3 Turbuhaler

This is used to deliver a preventer (Pulmicort) and

a reliever (Bricanyl) and holds 200 pre-packed doses

of medicine. To use the turbuhaler the following:

  1. Hold the turbuhaler in the upright position
  2. Grip the base and turn the device in one direction andthen back again.
  3. Breath out until all the air is out of the lungs
  4. Place the turbuhaler in the mouth and breathin strongly.
  5. You do not need to hold your breath
  6. Keep checking the side of the turbulhaler to ensurethat there is not a red warning in the little window. If

    there is the red sign there are only 20 doses left and the

    turbuhaler needs replacing

  7. If you shake the turbuhaler and heal powderthat does not mean that the Turbuhaler still has medicine

    as this can be the drying powder

  8. Watch the window on the side
  9. Clean by removing the mouth piece weekly and wipingthe inside with a dry cloth. Do not wash

 

 

 

5 key points to remember

 

  1. The correct use of the inhalation device is as importantas the medicines that are prescribed
  2. You or your child’s asthma may be poorly controlledbecause the you are not using the inhalation device correctly
  3. Inhaled medicine is the best method of treatment asthe medicine is delivered directly to the lungs were it

    lungs quickly and only requires very small amounts to achieve

    it. This ensures that the anti-asthmatic effect is achieved

    at the safest dose

  4. There are devices that suite all asthmatics
  5. Ensure your doctor, nurse or pharmacist teach you touse yours correctly