1. The Aerosol Drug Management Improvement Team
ADMIT
Slide Deck 2018

2. Part 4
Inhalers for children – Choosing and Using
Sören Pedersen

3. 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

4. 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)

5. 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) )

6. Inhaler choice in children
Pedersen S, Allergy 1986;41:

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

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

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

15. 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

16. 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

17. 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

18. 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)

19. 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

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