Jane Scullion provides some simple and practical advice on optimal inhaler device selection for adults and children, in the third of a mini-series of feature articles.

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Read this article to learn more about: 

  • practical considerations for inhaler device selection in adults and children
  • useful guidance to help select the right inhaler device for each individual patient.

An inability or an unwillingness to use an inhaler device can lead to disease instability in people with asthma and chronic obstructive pulmonary disease (COPD); but choosing the right inhaler device for an individual is not always easy. Getting the device right depends on many factors including age, manual dexterity, personal preference, ease of use, inspiratory flow rate, licensing options, and the medication required.

NICE technology appraisal (TA) 10 on Guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma states that: 'It is important to ensure that an inhaler device delivers the drugs to the airways consistently and in the appropriate quantity.'1 This is of great importance in all age groups—not just children under the age of 5 years.

Children under the age of 5 years

Very little evidence is available on which to base recommendations for selecting inhaler devices for children under 5 years of age. Corticosteroids and bronchodilator therapy should routinely be delivered by a pressurised metered dose inhaler (pMDI) and spacer system, with a facemask where necessary, to children in this age group who have chronic asthma.1 It is important that the person responsible for administering the medication to the child is trained in the correct use of the pMDI and spacer.

Children aged 5 years or over

It should be possible for children 5 years of age or over to use a range of devices depending on their inspiratory flow and coordination. Both dry powder inhalers (DPIs) and breath-actuated pMDIs are dependent on the user's inspiratory flow rate to ensure effective delivery of medication to the lungs. For pMDIs that are not breath actuated it is necessary for an individual to coordinate inspiration and activation of the device simultaneously. Some of the difficulties with coordination can be overcome using a spacer device.

We know that young infants and disabled children are not aware how to inhale properly. Young children also have a low inspiratory flow rate and are not always able to hold their breath. Factors to consider when choosing an inhaler for a child with chronic asthma should include therapeutic need (drug and dose), ability to develop and maintain effective technique, suitability of the device for the child and carer's lifestyle (e.g. portability), and preference for and willingness to use a device.2 Licensing for the inhaler device and medication will also need to be considered as this can vary considerably. Once these factors have been considered, if there is more than one inhaler device to choose from, preference should be given to the one with the lowest overall cost to the NHS—taking into account daily required dose and product price per dose.2

Box 1: Inhaler choice in children3

  • Conscious inhalation possible:
    • sufficient inspiratory flow ≥20 l/min:
      • pMDI+spacer
      • breath-actuated MDI
      • DPI
    • insufficient inspiratory flow:
      • pMDI+spacer
      • breath-actuated MDI
  • Conscious inhalation not possible:
      • pMDI+spacer.

pMDI=pressurised metered dose inhaler; MDI=metered dose inhaler; DPI=dry powder inhaler.

Inhaler choice in adults

For adults requiring inhaler devices many types are now available. In a systematic review of literature there was no evidence of differences in the ability of patients to use pMDIs or DPIs.4 Furthermore, there was no evidence to support differences in clinical efficacy between inhaler devices. We need to be aware that impaired cognitive functioning, manual dexterity, and failing eyesight may contribute to an inability to use inhaler devices correctly.

Despite repeated instructions, inhalers are not always used correctly, and patients make mistakes when using both pMDIs and DPIs. If the prescriber takes into consideration the following factors, a better match may be made between the patient and device:5

  • patient characteristics (e.g. disease, severity, fluctuation in airflow obstruction)
  • class of medication that is indicated
  • where in the lung the medication should be delivered to.

An evidence-based approach can be taken, enabling a prescriber to make a rational choice of device for an individual patient in only a few minutes, by considering four simple questions—the 3W-H approach:5

  • who?
  • what?
  • where?
  • how?

Taking into account that placebo devices are not always available when deciding which device is right for a patient, a simple and practical algorithm to aid inhaler device choice has recently been developed by an expert group and uses inspiratory flow rate as a deciding factor (see www.GuidelinesforNurses.co.uk/WPG/inhaler-choice).6

Getting the device right for the patient is an important clinical need—as part of this process we need to be aware of patient factors. If people are not engaged with us, then they are less likely to use their inhaler.6

Considerations for adults and children

There are additions to devices, such as dose counters, and more intuitive devices with fewer operational factors—we need to ensure that these contribute to making the person comfortable with using their inhaler, rather than being dazzled by yet another new device.

The optimal device for both children and adults is dependent on many factors. Given that there is little difference in terms of clinical effectiveness, in the end it generally comes down to what medication is required within its product license and whether the patient can and will use it properly.

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  1. NICE. Guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma. NICE Technology Appraisal 10. NICE, 2000. Available at: www.nice.org.uk/ta10
  2. NICE. Inhaler devices for routine treatment of chronic asthma in older children (aged 5–15 years). NICE Technology Appraisal 38. NICE, 2002. Available at: www.nice.org.uk/ta38
  3. van Aalderen W, Garcia-Marcos L, Gappa M et al. How to match the optimal currently available inhaler device to an individual child with asthma or recurrent wheeze. NPJ Prim Care Respir Med 2015; 25. DOI:10.1038/npjpcrm.2014.88
  4. Brocklebank D, Ram F, Wright J et al. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess 2001; (26):1–149.
  5. Dekhuijzen P, Vincken W, Virchow J et al. Prescription of inhalers in asthma and COPD: towards a rational, rapid and effective approach. Respir Med 2013; 107 (12): 1817–1821.
  6. Usmani O, Capstick T, Chowan H et al.Choosing an appropriate inhaler device for the treatment of adults with asthma or COPD. Originally developed for Guidelines  2016; also published on Guidelines for Nurses 2016. Available at: www.GuidelinesforNurses.co.uk/WPG/inhaler-choice