Inhalers and Spacer Devices – Everything you need to know

Inhalers are devices used to deliver medication directly into the lungs for the treatment of respiratory diseases. They are commonly used to treat conditions such as asthma, chronic obstructive pulmonary disease (COPD), and other lung diseases. Inhalers work by delivering medication in aerosol form, which is inhaled into the lungs through the mouth or nose. Furthermore, spacer devices are also used with inhalers to make it easier for patients to inhale the medication correctly. In this article, we will explore the different types of spacer devices used for inhalers, the different types of inhalers, and the drugs used in inhalers, their uses, and appropriate ages for each of those.

Spacer Devices for Inhalers

Spacer devices are used with inhalers to make it easier for patients to inhale the medication correctly. These are designed to hold the medication and help patients inhale it more effectively. The different types of spacer devices are as follows:

Types of Inhalers

There are two types of inhalers: metered-dose inhalers (MDIs) and dry powder inhalers (DPIs). The different types of inhalers are as follows:

Inhaler Type	Description
Metered-Dose Inhalers (MDIs)	MDIs should not be used alone in children due to the need for coordination. Using an MDI through a spacer device significantly increases the proportion of the drug reaching the airways, reduces throat impaction, and requires less coordination. A soft face mask can be attached to the spacer for young children. Ideally, inhaled steroids should always be given by MDI and spacer, and spacers should be used in young children and during acute asthma attacks for delivering beta agonists. Spacers are highly effective at delivering bronchodilators and inhaled steroids to preschool children.
Dry Powder Inhalers (DPIs)	These inhalers deliver medication in powder form. They do not contain a propellant, and the medication is delivered when the patient inhales. Require less coordination than MDIs and can be used for delivering beta agonists in school-age children
Nebulizer	Nebulized treatment is now only given for severe life-threatening asthma, or rarely for children who need inhaled therapy but are unable to use any of these devices or require high doses

Drugs used in Inhalers

The drugs used in inhalers are used to treat respiratory diseases such as asthma and COPD. The different types of drugs used in inhalers are as follows:

1. Bronchodilators – These drugs relax the muscles in the airways, making it easier to breathe. They are used to treating conditions such as asthma and COPD.
2. Corticosteroids – These drugs reduce inflammation in the airways. They are used to treat conditions such as asthma.
3. Combination Inhalers – These inhalers contain both bronchodilators and corticosteroids. They are used to treat severe asthma.

Bronchodilators:

Bronchodilators are medications that are used to relax the muscles in the airways, making it easier for the patient to breathe. There are two types of bronchodilators: beta-agonists and anticholinergics.

Beta-agonists work by relaxing the muscles in the airways, which allows more air to flow in and out of the lungs. The two types of beta-agonists are short-acting and long-acting.

Short-acting beta-agonists (SABAs) are used to relieve symptoms of asthma and COPD. Furthermore, they are also used before exercise to prevent symptoms. Examples of SABAs include:

Generic Name	Brand Name
Albuterol	Ventolin
Albuterol	ProAir
Levalbuterol	Xopenex

Long-acting beta-agonists (LABAs) are used to prevent symptoms of asthma and COPD. They are not used for quick relief of symptoms. They are always used in combination with an inhaled corticosteroid. Examples of LABAs include:

Generic Name	Brand Name
Salmeterol	Advair
Budesonide/formoterol	Symbicort
Mometasone/formoterol	Dulera

Anticholinergics work by blocking the action of acetylcholine, a neurotransmitter that causes constriction of the airways. The two types of anticholinergics are short-acting and long-acting.

Short-acting anticholinergics (SAACs) are used to relieve symptoms of COPD. Examples of SAACs include:

Long-acting anticholinergics (LAACs) are used to prevent symptoms of COPD. They are not used for quick relief of symptoms.

Anticholinergics	Generic Name	Brand Name
Short-acting	Ipratropium	Atrovent
Long-acting	Tiotropium	Spiriva

Preventers:

Preventers are medications that are used to prevent symptoms of asthma and COPD. They are also known as controller medications. The most commonly used preventer medication is an inhaled corticosteroid.

Inhaled corticosteroids work by reducing inflammation in the airways. They are the most effective medication for preventing symptoms of asthma and COPD. Examples of inhaled corticosteroids include:

Generic Name	Brand Name
Fluticasone	Flovent
Fluticasone	Qvar
Budesonide	Pulmicort

Corticosteroids:

Corticosteroids are medications that are used to reduce inflammation in the body. They are used to treat a variety of conditions, including asthma and COPD. Inhaled corticosteroids are the most commonly used type of corticosteroid for respiratory diseases.

Other types of corticosteroids include oral corticosteroids, which are used for severe asthma exacerbations, and intravenous corticosteroids, which are used in the hospital setting.

Corticosteroid Type	Generic Name	Brand Name
Oral	Prednisone	Deltasone
Intravenous	Methylprednisolone	Solu-Medrol

It is important to note that these medications have potential side effects, and patients should always consult with their healthcare provider before starting any new medication.

How to Instruct Patient

Specific instructions should be given to patients or the patient’s parent or guardian about the use of each of these devices, and even about how to clean them. First, you must assess the patient’s educational background and their ability to follow through with the instructions.

Pressurized aerosol metered dose inhaler (MDI)

1. Remove the mouthpiece and shake the inhaler well.
2. Hold the inhaler upright with the thumb on the base below the mouthpiece and the first finger on the metal canister.
3. Breathe out as far as is comfortable, then place the mouthpiece between the teeth and close lips around it. Do not bite it.
4. As you start to breathe in through the mouth, press on the top of the inhaler to release the medication whilst still breathing in steadily and deeply.
5. Hold your breath, take the inhaler from your mouth and continue holding your breath for up to 10 seconds if possible.
6. Wait 30 seconds prior to taking second puff.
7. Use with spacer device to improve drug delivery.CFC-free inhalers need device washing every 2-3 weeks, as they can block.

Spacer

(Nebuhaler, Volumatic Aero Chamber, Able Spacer)

1. Ensure spacer compatibility with patient’s inhaler
2. Remove inhaler cap and shake it
3. Insert inhaler into end of spacer device
4. Place other end of spacer in mouth
5. Press inhaler canister once to release one dose of drug
6. Take one deep breath in and hold, or take 3-4 steady breaths in and out
7. Repeat as indicated, ensuring valve rattles
8. Clean spacer once a month with mild detergent, rinse, and air-dry
9. Replace spacer after 6-12 months.

Breath-actuated devices

(Autohaler, Easibreathe)

1. Prime the device.
2. For an autohaler, remove the cap and lift the red lever. For an easi-breathe, open the cap.
3. Insert the device into the mouth.
4. Inhale slowly and deeply.
5. Continue inhaling when the device “clicks.”
6. Hold breath for up to 10 seconds if possible.
7. Slowly breathe out.
8. To take a second inhaled dose, lower the red lever and lift again.
9. For an autohaler, close the cap and reopen. For an easi-breathe, repeat the above sequence.

Dry powder devices

(Accuhaler, DiskhalerÂ, Turbohaler, Clickhaler,Twisthaler, Cyclohaler, Aerocaps, Spincaps)

1. Turbohaler: remove cap, twist base until click is heard, twist back.
   Clickhaler: shake, remove cap, click top down and release
2. Twisthaler: remove cap by twisting, dose is ready
3. Accuhaler: open cover, mouthpiece facing you, push lever down to pierce blister
4. Diskhaler: insert disc, lift back of lid to 90° to pierce blister, lower lid
5. To use all devices: hold level, exhale fully, place mouthpiece between teeth, inhale steadily, hold breath, remove inhaler. Repeat for second dose.

References:

American Lung Association. (2021). Inhalers: Types, Usage, and Tips. Retrieved from https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/treatment-management/inhalers

National

Heart, Lung, and Blood Institute. (2021). How to Use Your Metered-Dose Inhaler. Retrieved from https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_checklist_mdi.pdf

National Heart, Lung, and Blood Institute. (2021). How to Use Your Dry Powder Inhaler. Retrieved from https://www.nhlbi.nih.gov/files/docs/public/lung/asthma_checklist_dpi.pdf

NHS. (2021). Inhalers for Asthma. Retrieved from https://www.nhs.uk/conditions/asthma/inhalers/