Miles Weinberger, MD
Professor of Pediatrics
Allergy, Immunology, and Pulmonary 

Use of an inhaled medication by a metered-dose inhaler

Inhaled medications are available in various types of metered-dose inhalers containing various types of medications.

The types of inhalers include pressurized meter dose inhalers and dry powder inhalers. While most metered dose inhalers require that actuation of the inhaler be carefully coordination with inspiration, at least one type of pressurized metered dose inhaler, the Maxair Autohaler, is self actuated by the inspiratory effort. The dry powder inhalers are becoming increasingly available as an alternative. These have the advantage of delivering the medication with the inspiratory effort. However, all inhalers require careful attention to proper technique to ensure drug delivery. You should receive instruction when these are prescribed, and technique should be demonstrated at each regular physician visit.

The types of medication in inhalers includes bronchodilators for intervention (albuterol, pirbuterol) to treat acute symptoms, anti-inflammatory corticosteroid medications for maintenance treatment of asthma, and long acting bronchodilators (salmeterol, formoterol) as adjunctive maintenance medication to be added to inhaled corticosteroids when low doses of the inhaled corticosteroid are inadequate for control of asthma.

Use of an inhaled medication by a metered-dose inhaler with an aerosol holding chamber as an assist device

Two types of assist devices can be used with pressurized metered dose inhalers in an attempt to improve delivery of medication. While simple spacers are simply extender tubes that result in reducing the amount of drug that settles out in the mouth and throat by having the larger particles settle in the extender tube, holding chambers are tubes or chambers with one way valves (the AeroChamber Plus and the Pari Vortex are two that are best studied) that enable the drug to be delivered into the tube and then inhaled from the tube without having to precisely coordinate inspiration with actuation of the inhaler. They are available with 3 different sizes of a soft flexible face mask that when pressed firmly against the face of an infant or young child permit drug to be delivered when they inhale without active cooperation on the part of the patient. When prescribed one of these devices, specific instructions and demonstration should be provided and reviewed at regular intervals.

Use of an inhaled medication by a nebulizer system

Since inhaled medication can be delivered just as effectively for most children using a metered dose inhaler with an assist device when needed, the traditional use of nebulizers to deliver aerosol medication should rarely be needed. Even for infants, a device such as the AeroChamber Max or PariVortex with soft flexible face mask delivers medication as or more effectively and much more rapidly than a nebulizer. Since the usual dose of albuterol by nebulizer is 2.5 mg and each actuation of a metered dose inhaler delivers 0.1 mg, studies demonstrating similar effect of albuterol metered dose inhaler have used 6 activations of the metered dose inhaler (one at a time with several breaths after each actuation into the chamber to evacuate the medication).

When a nebulizer is used, a face mask is preferred for infants and toddlers, while a mouthpiece is preferred if the child will use it. Effective delivery to the lungs is best served by mouth-breathing. Nose breathing filters out hte medication thereby decreasing delivery to the lungs. A screaming child gets less medication than during quiet breathing. Holding the mask or the end of the tube away from the face greatly decreases the amount of delivered medication.

Administration of oral medication to young children

Children vary in how well they are willing to take medication. The problem can be compounded when the medication is foul tasting. One solution is to teach children to swallow tablets or capsules whole as early as possible. This can be done at a much earlier age than is generally presumed (after all, toddlers often swallow chewing gum whole in addition to many other things they shouldn't swallow). Using M & M candies or jelly beans, the child can be offered the reward of being permitted to chew the next two for each one swallowed whole. They tend to learn fast when thus motivated. Once that is done, prednisone tablets (which are bitter if tasted) can be placed in empty gelatin capsules (available from a pharmacist) to avoid even the transient taste if the prednisone tablets are not swallowed quickly enough.

Delivery of inhaled bronchodilator

Determine simplest age appropriate method

The beta-2 agonists are best delivered by aerosol – these are much more effective and more free of annoying side effects that the oral agents in this class. While popularly used in the past as solutions in compressed air driven nebulae's, the use of valved holding chambers has been shown to be as effective when up to 6 inhalations of albuterol are used (which is still a lower dose than conventional nebulizer doses). The valved holding chamber (don’t call them spacers) eliminate the need for precise coordination of inspiration with actuation. Used with a soft flexible face mask, they can even be used for the youngest patients.