1. How to Administer Asthma Medications
to Children of Varying Ages
Web-Training
Developed by:
Mona G. Tsoukleris, PharmD
Associate Professor
Charles Ng, PharmD Student
Class of 2017
2. Learning Objectives
At the conclusion of this live webinar, child care providers will be
able to:
• Explain the difference between everyday controller and quick-relief
inhaled medications
• Describe proper use of currently available inhaled asthma medications
(metered dose inhalers, dry powder inhalers, nebulizers)
• Explain what masks are and when they are most commonly used
• Explain what spacers are and how they improve medication use
• Describe how to administer medications to children of different ages
• Describe common errors in medication administration and ways to correct
them
3. Overview of the Program
• Overview of asthma
• Different types of asthma medications
• Basics of medication delivery
• Specifics of using each type of inhaler
• How to administer inhalers to children
• Common errors and how to correct them
7. Different Types of Asthma Medications
1. Quick-relief Medicines
– Used to treat asthma symptoms
– Work fast
– Relax muscles around breathing tubes
– Only a “quick-fix”
– Unable to treat lung swelling (inflammation)
8. Different Types of Asthma Medications
2. Everyday Controller Medicines
– Treats asthma’s main problem (inflammation)
– Used every day
– Keeps asthma controlled
– Controllers PREVENT symptoms from happening
9. When Is Asthma Controlled?
• Does asthma keep child from doing some things?
• Is quick-relief inhaler needed for relief more than twice a
week?
• Does asthma wake the child up with cough or trouble
breathing more twice a month?
• Are more than 2 canisters of Quick-Relief medicine used in
a year?
Did you answer YES to any question?
If so, asthma is NOT controlled. The patient should talk to the
doctor. The child might need to be on an everyday controller
medicine.
10. Quick-Relief Medicines
• “Quick Fix” - Do not reduce swelling (inflammation)
albuterol
(Proventil®, Ventolin®, ProAir®)
levalbuterol
(Xopenex® HFA)
11. How do they work?
• FAST! They work in minutes.
• They relax muscles around the breathing tubes. That
makes it easier to breathe.
• Can also be used to prevent exercise symptoms
albuterol
(Proventil®, Ventolin®, ProAir®)
levalbuterol
(Xopenex® HFA)
12. Other Types of Quick-Relief
Medicines – By Mouth Steroids
• When taken by mouth, these medicines are
very strong.
• The doctor may give this for a bad asthma
attack.
• Also used to get quick control of asthma in
some people.
• This medicine does not replace your controller
medicine.
14. Everyday Controller Medicines
• Most common and important treatment for
asthma
• Work slowly
• Treat inflammation (swelling), which is the
cause of asthma
• If we can treat inflammation, we can prevent
permanent damage to the lungs.
15. Types of Everyday Controller
Medicines
1. Anti-inflammatory medicines
– control the inflammation and swelling in your lung
2. Medicines that relax lung muscles
– also used with the anti-inflammatory medicines
beclomethasone
(QVar®)
Fluticasone
(Advair®, Flovent®)
formoterol
(Foradil®, Symbicort®)
16. Basics of Medication Delivery
• Different types of inhalers
– Metered dose inhalers
– Dry powder inhalers
– Nebulizers
• Spacers
• Masks
• Slow versus fast inhalation
17. What are Metered Dose Inhalers?
• MDIs deliver either quick-relief medication or
everyday controller medications to treat asthma.
• They deliver a measured amount of drug through
the generation of an aerosol spray
• Once the canister is activated by depressing the
canister into the plastic mouthpiece, drug aerosol
is propelled from the canister. Then, the drug is
inhaled by the patient and deposited in the
patient’s lungs.
20. Properties of MDI propellants
• Freon
– Chlorofluorocarbons (CFCs) serve as propellants
for these inhalers. The spray is forceful and cold,
coming form the mouth piece at almost 60 mph.
• HFA
– Hydrofluoroalkane (HFA) is a replacement for CFC
propellant. HFA propellant is less forceful (30
mph) and doesn’t feel as cold when compared to
the CFC propellant.
21. How to use MDIs without a spacer?
1. Assemble the inhaler by placing canister firmly, but gently into plastic
mouthpiece.
2. Remove the cap. Check that nothing is inside the plastic case.
3. Shake the inhaler vigorously.
4. Exhale normally.
5. Close lips tightly around mouthpiece or Position mouthpiece of inhaler
2-3 finger widths from wide open mouth.
6. Press canister once and at the same time, inhale slowly (over 3-5
seconds) to a full, deep breath, keeping lips around mouthpiece (or
mouth open) for entire inhalation.
7. Remove inhaler from mouth.
8. Hold breath at least 5 seconds, preferably 10 seconds.
9. Exhale slowly
10. If taking additional puffs, wait 1 - 3 minutes before repeating steps
above.
11. Rinse mouth with water, gargle, and expectorate after taking dose.
22. MDIs Without a Spacer Video
• Infants
• Toddlers
• Young children
• Older children
• Teenagers
23. What to expect when using a Freon-
based MDI?
• A cold, forceful puff (60 mph)
• If it is a quick-relief medication, it should start opening the
patient’s airways within 5 minutes, but maximal effect may
not occur up to 30 minutes.
• If it is an everyday controller medication, the medication may
not produce any identifiable change for at least a few days, if
not a few weeks.
24. What to expect when using a HFA-
based MDI?
• A warmer, less forceful puff than a Freon-based MDI (30 mph)
• If it is a quick-relief medication, it should start opening the
patient’s airways within 5 minutes, but maximal effect may
not occur up to 30 minutes.
• If it is an everyday controller medication, the medication may
not produce any identifiable change for at least a few days, if
not a few weeks.
25. When should an Inhaler be replaced?
• To tell if the inhaler is empty, the only good
way is to count the number of puffs used or
to calculate them based on the prescribed
dose.
• An old technique called for “floating” the
inhaler in a bowl of water is no longer
recommended since it can make an inhaler
unusable.
26. Breath-Actuated Metered Dose
Inhalers
• The only currently-available breath-actuated metered dose
inhaler at this time is the AutoHaler
• This device delivers the aerosol when the device is triggered
by the force of the patient’s inhalation
• This is useful for patients who have difficulty triggering the
canister at the beginning of inhalation
27. How to use a Breath-Actuated Metered Dose Inhaler?
1. Remove the Autohaler mouthpiece cover.
2. Hold the Autohaler upright while raising the lever until it snaps.
3. Shake the Autohaler gently several times.
4. Exhale normally.
5. Close lips tightly around mouthpiece.
6. Inhale deeply with steady, moderate force to a full, deep breath
for at least 3 seconds.
7. Remove Autohaler from mouth.
8. Hold breath for at least 5 seconds, preferably 10 seconds.
9. Exhale slowly.
10. Lower lever.
11. If taking additional puffs, wait at least 1 minute before repeating
steps 2-10, above.
12. Rinse, gargle and expectorate after use.
29. What to expect when using a Breath-
Actuated MDI?
• A loud click noise will sound as the cool burst of medication
aerosol is released.
• Cold, less forceful puff than a Freon-based MDI
• If it is a quick-relief medication, it should start opening the
patient’s airways within 5 minutes, but maximal effect may
not occur up to 30 minutes.
30. Spacers
• They are used with typical CFC or HFA inhalers, but
can not be used with Breath Actuated MDIs or with
Dry Powder Inhalers.
• A spacer is a tube that lengthens the space between
the inhaler mouthpiece and the user’s mouth
• Spacers are used to improve drug delivery and
reduce side effects.
• Spacers minimize drug particle deposition on the
upper airway (oropharynx). This also decrease the
amount of medication that is swallowed.
32. How do spacers work?
• Spacers minimize drug particle impaction on the
upper airway and improve drug delivery to the site of
action
• Spacers accomplish these goals by slowing down the
particle velocity before reaching the patient’s mouth.
They minimize particle size as propellant evaporates
and particles too large for lung delivery deposit in
the spacer rather than in the patient’s upper airway
(oropharynx).
33. Who should use a spacer?
• Useful for patients who have difficulty mastering the numerous steps
required for effective MDI administration
• Children, patients who are cognitively impaired or unconscious, and any
individual who has difficulty holding the breath or mastering the eye
hand-lung coordination required for effective MDI delivery
• Patients who are using inhaled corticosteroids or anticholinergics because
they are effective at minimizing ocular exposure to aerosolized drug.
• Because they minimize oropharyngeal deposition (and therefore the
amount of swallows drug), they are particularly useful for administering
corticosteroid MDIs to any patient
• They may be used in almost all patients regardless of age to improve drug
delivery and reduce occurrence of side effects
34. What to expect when using a MDI
with a Spacer?
• Less medication taste
• Less sensation of cold or forceful spray
• Symptom improvement within 5 minutes of using a quick-relief
medication
• No change in symptoms when using daily controller medications
• Cloudiness of the space chamber after periods of use. This is due to
the static discharge holding the drug particles against the spacer
chamber and doesn’t mean that it is dirty on the inside.
35. Key Points in Using a MDI with Spacer
• Keep the mouth wrapped tightly against the
mouthpiece for the full inhalation
• Time the activating of the inhaler at onset of
inhalation
• Use 1 puff followed by 6 inhalations if unable to
hold breath for at least 5 seconds
36. How to use an MDI with Spacer?
1. Remove the cap. Check that nothing is inside the mouth
piece.
2. Attach the inhaler to the spacer.
3. Shake the inhaler (with spacer attached) vigorously.
4. Exhale normally.
5. Press inhaler once AND at the same time, inhale slowly
(over 3-5 seconds) to get full breath. Keep lips around
mouthpiece for entire inhalation.
6. Hold breath at least 5 seconds, preferably 10 seconds
7. Exhale slowly
8. Wait 1 - 3 minutes before taking another dose.
9. Rinse mouth with water, gargle, and spit when finished.
37. Use an MDI with Spacer Video
• Infants
• Toddlers
• Young children
• Older children
• Teenagers
38. Other Types of Spacers:
InspirEase, EZ-Spacer
• These are different from typical
spacers in that they have collapsible
reservoir bags. When the patient
inhales, the bag close and open when
patient exhales.
• These are useful for patients who
need visual feedback to facilitate
inhalation through the mouth rather
than the nose.
InspirEase
EZ-Spacer
39. Other Types of Spacers: OptiHaler
• These are different form typical spacers in
that it facilitates simultaneous canister
activation with the onset of inhalation.
• It does this through use of an end cap,
which must be pressed closed before use.
When the end cap is in the closed
position, the patient will have difficulty
inhaling. Once the canister is depressed to
release the medication, the end cap pops
open and air can flow freely.
• Instruct the patient to exhale first, place
the mouthpiece in the mouth, begin
inhaling the canister is activated.
OptiHaler
40. Using the MDI and Spacer with a
Mask
• They are useful when a
patient isn't reliably inhaling
through the mouth. This will
help to maximize inhalation
of drug and ensure optimal
delivery of drug to the
lungs.
• Mask come in a variety of
sizes and can be used with
patients of all ages,
including children and
adults with cognitive
impairment.
41. Key Points in Using a MDI with Spacer &
Mask
• Fit the mask so it covers both the mouth and nose and fits
snug against the face
• Time the activating of the inhaler at onset of inhalation
• Use 1 puff followed by 6 inhalations if unable to hold breath
for at let 5 seconds
42. What to expect using a MDI with Spacer &
Mask?
• Less medication taste
• Less sensation of cold or forceful spray
• Symptom improvement within 5 minutes of using a quick-relief
medication
• No change in symptoms when using daily controller medications
• Cloudiness of the space chamber after periods of use. This is due to
the static discharge holding the drug particles against the spacer
chamber and doesn’t mean that it is dirty on the inside.
44. What are Dry Powder Inhalers?
• Dry powder inhalers (DPIs) are devices that generate aerosols
through the force of a patient’s inhalation rather than through
the use of a propellant.
• DPIs are designed in order to achieve the end result of
delivering the dose to the lung
• Dry powder inhalers use blister packaging systems, gelatin
capsules, or multidose reservoirs to make the powder
available for inhalation
45. How do DPIs work?
• Dry powder inhalers work by delivering the drug in powder form after the
dose is loaded and the patient steadily and forcefully for a full, deep
inhalation.
• Lactose may be included with the drug as a carrier agent to help with
powder dispersion.
• These are several steps in common between ALL dry powder inhalers:
1. Expose mouthpiece
2. Load dose
3. Exhale to residual volume
4. Inhale steadily and forcefully for a full deep breath
5. Hold breath at least 5 seconds, 10 is preferred
6. Exhale normally
46. How to use a DPI: Diskus?
1. Hold the Diskus in one hand and put thumb of other hand on thumb
grip, pushing thumb away as far as it will go until mouthpiece appears
and snaps into position
2. Hold Diskus in a level, horizontal position with mouthpiece toward you
and slide the lever away from you as far as it goes until it clicks
3. Exhale fully while turning head away form mouthpiece
4. Close lips tightly around mouthpiece
5. Breathe in steadily and deeply through the mouth, the faster the better.
6. Remove Diskus form mouth
7. Hold breath at least 5 seconds (10 second is preferable)
8. Exhale slowly
9. Close the Diskus.
10. Rinse, gargle and expectorate after use
47. DPI: Diskus Video
• Infants
• Toddlers
• Young children
• Older children
• Teenagers
48. What to expect when using a Diskus?
1. A sweet taste or nothing, depending on patient.
2. The medication salmeterol will have a delayed
bronchodilation.
3. There is a dose counter on the Diskus that tells the
remaining number of puffs left in the device.
49. How to use a DPI: FlexHaler?
1. Unscrew the cover and lift off
2. Hold the inhaler upright and turn the colored base to the right as
far as it will go then back to the left until there is a click.
3. Breathe out (with the head turned away form the mouthpiece).
4. Close lips tightly around mouthpiece
5. Breathe in steadily and deeply through the mouth, the faster the
better.
6. Remove the TurbuHaler from mouth
7. Hold breath at least 5 seconds (10 second is preferable)
8. Breath out slowly
9. Rinse, gargle, and expectorate after use
52. What to expect when using a TurbuHaler?
1. There will be no taste, but you may notice a slight sweet
sensation.
2. When shaken, the dessicant (drying agent) will make a
sound.
3. This everyday controller medication will not produce any
identifiable change for at least a few days, if not a few
weeks.
4. TurbuHaler is empty when there is a red line that appears
at the bottom of the window.
53. How to use a DPI: TurbuTester?
1. Hold the inhaler upright and turn the colored base to the
right as far as it will go then back to the left until there is a
click.
2. Breathe out (with the head turned away form the
mouthpiece)
3. Close lips tightly around mouthpiece.
4. Breathe in steadily and deeply through the mouth, the
faster the better. The unit should make a horn noise
during the full inhalation.
5. Remove the TurbuHaler from mouth.
6. Hold breath at least 5 seconds (10 second is preferable).
7. Breath out slowly.
55. How to use a DPI: TwistHaler?
1. Hold the pink base and unscrew the cover. Lift off the cap
keeping the mouthpiece facing up. This loads the dose.
2. Breath out fully (with the head turned away from the
mouthpiece).
3. Close lips tightly around mouthpiece.
4. Breathe in steadily and deeply through the mouth, the
faster the better.
5. Remove the TwistHaler from mouth.
6. Hold breath at least 5 seconds (10 second is preferable).
7. Breath out slowly.
8. Rinse, gargle, and expectorate after use.
57. What to expect when using a TwistHaler?
• There may be a slight sweet taste and sensation.
• This everyday controlled medication will no produce
any identifiable change for at least a few days, if not
a few weeks.
• After using the last remaining TwistHaler dose, the
cap will screw on and not reopen
58. Nebulizer
• A nebulizer is used to
administer the medication
in the form of a mist
inhaled into the lungs.
• A patient must be willing
to keep in place 5-15
minute treatment.
59. How to use a Nebulizer?
1. Measure correct amount of saline solution using a clean dropper. Put the saline
into the nebulizer cup.
2. Measure correct amount of medicine using a clean dropper and add it to
nebulizer cup containing the saline.
3. If you are using a premixed medicine, add the correct amount.
4. Attach mouthpiece to T-shaped part. Fasten this unit or mask to the cup.
5. Turn on air compressor.
6. Put mouthpiece in mouth, between teeth and seal lips tightly around it.
7. Take slow, deep breaths in through the mouth
8. If you are unable to take slow, deep breaths, breathe normally into mask.
9. Hold each breath for 1 to 2 seconds before breathing out or hold each breath
for 1-5 seconds every 3-5 inhalations.
10. Continue breathing this way until medicine is gone from the cup (about 5-15
minutes).
61. What to expect when using a Nebulizer?
• You will see symptom improvement within 5
minutes.
• The masks should be closing fitting.
62. MDI Common Errors
• Forgetting to shake or insufficient shaking of canister
• Forgetting to prime (new or not-used-for-awhile inhaler unit)
• Forgetting to clean inside plastic sleeve
• Head position either too flexed or too extended (not in neutral position)
• Mouth not tightly around mouthpiece (for closed-mouth technique only)
• Tongue/teeth in way of mouthpiece opening
• Inhaler directed upward toward palate or down toward tongue
• Double actuations at one time
• Poor coordination/timing with actuation/inspiration (too late or too early
with actuation relative to inspiration)
• Stopping inspiration (“freezing”) as aerosol strikes throat
• Inspiratory flow rate too rapid; sometimes, too slow
• Inhalation through nose rather than through mouth
• Exhaling during actuation
63. Spacer Common Errors
• Using an empty inhaler
• Forgetting to shake or insufficient shaking of canister
• Head position either too flexed or too extended
• Mouth not tightly around mouthpiece
• Tongue/teeth in the way of spacer mouthpiece opening
• Spacer directed upward toward palate or down toward tongue
• Spray all puffs at once into spacer
• Waiting too long after actuation before inhalation
• Start inhalation too early (before actuation)
• Inspiratory flow rate too rapid; sometimes, too slow
• Inhalation through nose rather than through mouth
• Exhaling during actuation
• Incomplete inspiration
64. DPI Common Errors
• Head position either too flexed or too extended
• Not keeping device in horizontal position when moving lever/inhaling
• Not closing lips tightly around mouthpiece
• Tongue/teeth in way of mouthpiece opening
• Breathing into the device before inhalation
• Forgetting to move lever before taking dose
• Moving lever forward then back, rather than just forward
• Inverting device after loading and losing dose
• Thinking that inhalation should take place coordinated with moving lever forward
• Inhalation through nose rather than through mouth
• Inspiration effort not rapid enough
• Incomplete inspiration
• Ignoring counter device, and using empty inhaler as result
• Opening and closing device without dosing, throwing counter off
• Forgetting to close device after use
65. Nebulizer Common Errors
• Incorrect size for child
• Not fitting tightly on face/mouth/nose
• Not holding nebulizer upright
• Stopping too early, before dose done
