20 Dec 2023

Introduction

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  • Asthma is caused by the inflammation of the airways (breathing tubes). The
  • swelling of the airways which is the result of the inflammation causes 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 best treated 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 medicines to the airways are discussed.


Why inhale medicine into the airways?

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  • It makes good sense to breath the drugs (medicine) into the airways (breathing tubes) of the lungs because this is where the problem is
  • Breathing the medicines into the airways is safe and faster because:
    • The medicine is delivered to where the problems is and starts to work more rapidly.
    • Only a tiny amount of the medicine is needed.


Which drugs can be inhaled into the lungs?

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  • All the drugs needed in the treatment of asthma can be inhaled into 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?

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  • Relievers should only be inhaled when the asthmatic has 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 but only with symptoms
  • The person with asthma needs to see the doctor if he or she needs 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 do not 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?

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  • Children of all ages can inhale medicine into the airways
  • It has been shown that even in babies and small children the best 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 devices available 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 inhalation device 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?


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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 inhaler is 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 activating the 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 correctly use 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 medicine is 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 with a 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 500ml litre plastic cooldrink bottles
    • For babies and small children a useful spacer can be made 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 plastic bottle. 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 are used to:
    • Give inhaled medicines to babies, small children, children unable 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. Less local side effects occur in the mouth and throat when spacers are used
    • Enable asthmatics with an acute attack to use their inhalers 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 medicine delivered to the airways making it more cost effective


3. Drypowder inhaler

  • Dry powder inhalers make use of the medicine being in 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 are inhaled into the lung
  • To be able to use a dry powder inhaler the child must be able 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 asthma pumps 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 inhalers except 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 that co-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 oxygen through 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 children is 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 clear guidelines when to use it and what medicines should be used


How do you correctly use the different inhalers?

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1. Pressured aerosol inhaler (asthma pump)

Use the inhaler as follows:

  1. Shake inhaler vigorously. after taking the cap off hold the 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 air that 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 press the 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 allows the 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 medicine in 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 easily seen 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 opening of 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 the spacer. 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 up of 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 be punctured 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 device weekly in warm soapy water and dry carefully
  5. The device has many parts which are easily lost – take care.

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 that holds the disk. Replace the disk, and close the devise again
  2. To start puncture a hole in the dose by lifting the lid 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 of the 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 and then back again.
  3. Breath out until all the air is out of the lungs
  4. Place the turbuhaler in the mouth and breath in strongly.
  5. You do not need to hold your breath
  6. Keep checking the side of the turbulhaler to ensure that 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 powder that 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 wiping the inside with a dry cloth. Do not wash



5 key points to remember

  1. The correct use of the inhalation device is as important as the medicines that are prescribed
  2. You or your child’s asthma may be poorly controlled because the you are not using the inhalation device correctly
  3. Inhaled medicine is the best method of treatment as the 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 to use yours correctly

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Copyright: Allergy Society of South Africa.
Written by Dr
Endorsed by ALLSA.

ALLSA
P.O. Box 88
Observatory, 7935
Cape Town, R.S.A.

African Cuver
Background: Hyena