The Aerosol Drug Management Improvement Team ADMIT Slide Deck 2018

Part 4 Inhalers for children – Choosing and Using Sören Pedersen

Inhaler choice in children: considerations Ease of use Simple inhalation technique Convenience Drugs available in the inhaler Price In-vitro characteristics No single inhaler satisfies the needs of all age groups

It may be better for a clinician to focus Inhaler choice in children >100 different inhaler/drug combinations are available. This increases the likelihood of finding an appropriate inhaler. It also increases complexity and health-providers’ experience with each individual inhaler. It may be better for a clinician to focus on a limited number of inhalers to get better experience with the devices used Most frequently used devices: Pressurized metered dose inhalers (pMDI) Spacer devices Nebulizers Dry powder inhalers (DPI)

Inhalation therapy: retail sales of inhalation devices in Europe DPIs are the most commonly used in Europe, but marked differences are seen between countries Worldwide pMDIs are the most commonly used Lavorini et al Respir Med 2011;105(7)1099-1103)

Inhaler choice in children Pedersen S, Allergy 1986;41:118-124

children on regular treatment with a pMDI use it correctly Inhaler choice in children: common problems with pMDIs No shaking No exhalation prior to inspiration Less than 50% of school children on regular treatment with a pMDI use it correctly Co-ordination problems Optimal inspiratory flow Bronchoconstriction – cough (lubricants and CFCs) Cold freon effect Inhalation through the nose

No exhalation prior to inspiration Inhaler choice in children: breath-actuated HFA-pMDIs effect on children’s problems with correct inhaler technique No shaking No exhalation prior to inspiration Co-ordination problems Optimal inspiratory flow Bronchoconstriction (lubricants and CFCs) Cold freon effect Inhalation through the nose

No exhalation prior to inspiration Inhaler choice in children: effect of spacers on the most common problems with pMDIs No shaking No exhalation prior to inspiration ? Co-ordination problems Optimal inspiratory flow Bronchoconstriction (lubricants and CFCs) Cold freon effect Inhalation through the nose

Air leakage around mouth-piece Inhaler choice in children: main problems with spacers school-age children Inconvenient Air leakage around mouth-piece Multiple actuations in spacer Delay between actuation and inhalation Shallow, fast inhalations Static electricity (device dependent) Cleaning

Inhaler choice in children: main problems with spacers in pre-school children Air leakage around mouth-piece/face mask Multiple actuations Delay between actuation and inhalation Shallow, fast inhalations Static electricity (device dependent) Spacer volume may be too big for very young children Many young children need a face mask attached to the space. Some masks have a high dead space (rebreathing) if inhalation is shallow Valve may stick and not open correctly

Inhaler choice in children: PIF through Turbohaler in 265 children After 2 corrections After demonstration 120 110 100 90 80 70 60 50 40 30 20 10 3 5 7 9 11 13 15 17 19 PIFR (l/min) Age (years) Pedersen et al, 1996

Inhaler choice in children: inspiratory flow profiles through a DPI Inhaled volume (L) L/min 80 2 2.5 0.5

Inhaler choice in children Time [sec] 0,2 0,6 1,0 Flow [l/min] 60 30 0,4 0,8

Inhaler choice in children Exhalation through the inhaler (device dependent) Insufficient inspiratory flow rate (device dependent) Loading difficulties (device dependent) “Slow-start” inhalation profile (device dependent) Shallow inhalation

Correct inhaler use > 90% of time Inhaler choice in children Age (years) 1 2 3 4 5 6 7 8 9 20 40 60 80 100 % of patients DPI pMDI Spacer Nebulizer QVAR Correct inhaler use > 90% of time Pedersen S et al. Prim Care Respir J. 2010; 19(3):209-16

Inhaler choice in children: likelihood of correct inhaler use after tuition High pMDI-spacer Nebuliser DPI BA-pMDI Medium pMDI Low < 6 years 6 – 12 years

Inhalation therapy: welcome technical developments MDIs Dose counters and adherence monitoring More breath-actuated devices Teaching aids and feed-back systems DPIs Dose counters and adherence monitoring Inhalers in which exhalation through the device prior to inhalation does not affect dosing or particle size Devices which do not release the dose until a sufficient inspiratory flow rate has been reached Teaching and handling aids (latter mainly for elderly and arthritis)

Inhaler choice in children: GINA 2014 children 5 years and younger Inhaler Strategy Age Preferred Device Alternative Device 0–3 years Pressurised metered-dose inhaler plus dedicated spacer with face mask Nebuliser with face mask 4-5 years Pressurised metered-dose inhaler plus dedicated spacer with mouthpiece Pressurised metered-dose inhaler plus dedicated spacer with face mask or nebuliser with mouthpiece or face mask

Outcome – New challenges Assessment of asthma control: problems with symptom based assessment in children Challenges Solutions Outcome – New challenges