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Asthma Inhalers

Understanding Childhood Asthma

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Updated November 04, 2013

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Asthma Inhalers

Asthma inhalers are a convenient way to get asthma medications to a child's lungs. While a nebulizer might be easier to use, many parents and kids don't like how long they take to deliver an asthma treatment.

Unfortunately, while convenient, asthma inhalers must be used properly, requiring multiple steps, if they are going to be effective. That can be simplified by combining a metered-dose inhaler with a spacer or a spacer with a mask, but the inhaler with spacer must still be used correctly.

You might not be able to get away from using an asthma inhaler though, as some asthma medications are only available as an inhaler. For example, while there are nebulized forms of albuterol, levalbuteral (Xopenex), and Pulmicort (budesonide), most other medications to treat asthma are only available as inhalers.

Types of Asthma Inhalers

There are two main types of asthma inhalers, including the older metered-dose inhalers (MDI) that many people are familiar with, and the newer dry powdered inhalers (DPI). In general, most people think that dry powdered inhalers are easier to use because they are breath actuated (medicine doesn't come out until you take a breath), while metered-dose inhalers require the user to coordinate taking a deep breath with activating the inhaler.

  • metered-dose inhalers (CFC) - inhalers with chlorofluorocarbons have been phased out because of environmental concerns
  • metered-dose inhalers (HFA) - the newer CFC-free hydroflouroalkene propellant inhalers
  • breath actuated metered-dose inhalers (HFA) - more expensive than other MDIs
  • dry powered inhalers - typically can't be used until kids are at least 5 to 6 years old and can take a deep, forceful inhalation. Younger kids often try to blow into the inhaler, instead of breathing in.

When using a dry powdered inhaler, many younger children make the mistake of:

  • positioning the inhaler incorrectly
  • forgetting to exhale fully before using the inhaler
  • not taking a deep, forceful inhalation
  • not holding their breath for about 10 seconds
  • forgetting to breath out slowly afterward

Of course, it is common to make mistakes with metered-dose inhalers, too. A common mistake is for kids to forget to take a slow, deep inhalation, breathing in too fast instead.

Inhalers with Spacers

Although your child may be able to use a metered-dose inhaler once he is about 6 years old, it can still be a good idea to use a spacer to make sure he gets the full dose to his lungs.

A spacer is a small device that can be attached to an inhaler and can even include a mask for infants, toddlers, and preschoolers who are 4 years old or younger. They include a holding chamber that keeps the medicine in the spacer until your child takes a breath, so that he doesn't need to coordinate taking a breath with activating the inhaler.

Rescue Asthma Inhalers

Rescue asthma inhalers include short acting beta-agonists that can provide quick relief when your child is having asthma symptoms:

  • ProAir HFA (albuterol inhaler)
  • Proventil HFA (albuterol inhaler)
  • Ventolin HFA (albuterol inhaler)
  • Ventolin HFA 60 (albuterol inhaler)
  • Xopenex HFA (levalbuterol inhaler)
  • Maxair AutoHaler (pirbuterol inhaler) - a breath actuated MDI

These rescue inhalers are typically only used on an as needed basis and not every day. Talk to your pediatrician if your child seems to need to use his quick relief asthma medication more than about two times a week.

Preventative Asthma Inhalers

Inhaled corticosteroid inhalers are a mainstay of asthma preventative therapy. Unlike rescue inhalers, which can give quick relief for asthma symptoms, steroid inhalers are typically used on a daily basis to help prevent your child from developing asthma symptoms.

Although it may seem like steroid inhalers are all the same, the particle size of the drug can affect how they are absorbed. In general, those with a small particle size, like Aerobid, Alvesco, and Qvar, are supposed to get deposited better in the lungs.

Perhaps more important than particle size is simply obtaining a steroid inhaler and using it properly every day:

  • Aerobid (flunisolide) - an MDI approved for children who are at least 6
  • Alvesco (ciclesonide) - an MDI approved for children who are at least 12
  • Asmanex Twisthaler (mometasone) - a DPI approved for children who are at least 12
  • Flovent Diskus (fluticasone) - a DPI approved for children who are at least 4
  • Flovent HFA (fluticasone) - an MDI approved for children who are at least 4
  • Pulmicort Flexhaler (budesonide) - a DPI approved for children who are at least 6
  • Qvar (beclomethasone) - an MDI approved for children who are at least 5

Each inhaler is available in multiple strengths to help get your child's asthma under good control. If a low dose inhaler isn't working, then moving up to the higher dose might, for example, moving up from Qvar 40 to Qvar 80.

For children with moderate to severe asthma who aren't controlled with an inhaled steroid, an inhaler that combines a steroid with a long acting beta-agonist can be helpful. These inhalers include:

  • Advair HFA - (Flovent + Serevent) - an MDI approved for children who are at least 4
  • Advair Diskus - a DPI form of Advair - approved for children who are at least 4
  • Dulera - (Asmanex + Foradil) - an MDI approved for children who are at least 12
  • Symbicort - (Pulmicort + Foradil) - an MDI approved for children who are at least 12

Once your child's asthma is well controlled while using a combination inhaler, talk to your pediatrician to see when it might be time to step down your child's therapy so that he is only using a steroid inhaler.

What You Need to Know about Asthma Inhalers

Perhaps the most important thing to know about your child's asthma inhalers is that you should keep using them until you are told by your pediatrician to stop them. An asthma action plan can help to make sure you know when to use your child's asthma inhalers and regular follow-up appointments.

  • Bring all of your child's asthma inhalers with you when you see your pediatrician so that they know what medicines your child is taking and so that your child can demonstrate how good (or poor) his technique is with his inhalers.
  • Asthma inhalers can be expensive and both the cost and reimbursement by your insurance company can be factors that influence which inhaler your child uses. If your insurance company has a drug formulary, consider bringing a list of preferred asthma inhalers to your visits with your pediatrician.
  • In addition to being compact and portable, using an asthma inhaler is much faster than a treatment from a nebulizer.
  • Many asthma inhalers are used off-label (against recommended guidelines) in kids who are much younger than the ages for which they are approved.

Talk to your pediatrician if you can't afford your child's asthma inhalers. Pediatricians often have samples and coupons for asthma inhalers or may be able to help you with the prescription assistance programs that many drug companies now offer.



Sources:

Adkinson: Middleton's Allergy: Principles and Practice, 7th ed.;

Dolovich M.B., Ahrens R.C., Hess D.R., et al: Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest 2005; 127:335-371.

Haughney, John. Choosing inhaler devices for people with asthma: Current knowledge and outstanding research needs. Respiratory Medicine CME, Volume 3, Issue 3, 2010, Pages 125-131.

Lavorini, Federico. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respiratory Medicine, Volume 102, Issue 4, April 2008, Pages 593-604.

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