Appendix II Devices for Respiratory Conditions Inhaler Devices

Spacer Devices

Metered Dose Inhalers (MDIs)

Dry Powder Inhalers (DPIs)

Nebulisers

References

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SPACER DEVICES

• Spacers are vital for an adequate therapeutic effect of inhaled therapy.
• Spacer devices should be used for all inhaled medications in all age groups to improve efficacy of medicine delivery and limit adverse effects.
• Use a spacer that is appropriate for the patient’s age.

	Infants <3 years	Children 3 to 6 years	Children >7 and adults
Spacer volume	150–250 mL	500 mL	500 mL
Valve	Required	Required	Optional
Delivery	Face mask	Mouthpiece	Mouthpiece
Technique	Deep tidal breathing	Deep tidal breathing	Single inhalation and breath-hold

• Inhalation spacer devices enable optimal aerosol delivery.
• Children < 3 years of age should have a spacer with a face mask, while older children and adults should use the spacer with a mouth piece directly.
• Demonstrate the relevant inhaler technique more than once to ensure the correct procedure (see below).

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Patient and caregiver education on inhaler and spacer techniques:

• If patients are switched between different types of devices (e.g. from MDI to DPI), patients need to be re-educated on inhaler technique.
• If changing from a DPI to MDI, consider if a spacer is required, and the optimal technique for inhalation.
• Doses may not be equivalent between different inhaler devices – ensure that patients are prescribed the correct dose when switching between devices.

METERED DOSE INHALERS (MDIs)

• A mask attachment must be used with the spacer for children < 3 years of age and be removed as soon as the child is able to use the mouthpiece.

A. Inhalation therapy without a spacer in adults: Single breath inhalation technique

1. Remove the cap from the mouthpiece.
2. Shake the inhaler well.
3. While standing or sitting upright, breathe out as much air as possible.
4. Immediately place the mouth piece of the inhaler between the lips and gently close the lips around it.
5. Start breathing in slowly.
6. Immediately press down the canister of the metered dose inhaler once to release one puff while simultaneously breathing in as deeply as possible.
7. Hold breath for 5 to 10 seconds, if possible.
8. Breathe out slowly through the nose and rest for a few breaths (30–60 seconds).
9. Repeat steps 2–8 for each puff prescribed.
10. Rinse mouth after inhalation of corticosteroids.

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B. Inhalation therapy with a spacer in adults and older children: Single breath inhalation technique

1. Remove the caps from the inhaler and the spacer.
2. Shake the inhaler well.
3. Insert the mouthpiece of the metered dose inhaler into the back of the spacer.
4. Insert the mouthpiece of the spacer into the mouth and close the lips around the mouthpiece.
5. Exhale fully into the spacer.
6. Start inhalation and immediately press down the canister of the metered dose inhaler once to release one puff into the spacer.
7. Breathe in slowly to full inhalation and hold the breath for 5 to 10 seconds.
8. Breathe out through the nose.
9. Repeat steps 2–8 for each puff prescribed, waiting at least 30 seconds between puffs.
10. Rinse mouth after inhalation of corticosteroids

C. Inhalation therapy with the spacer alone in younger children or in adolescent and adults unable to do single inhalation: Deep tidal breathing technique

1. Remove the caps from the inhaler and the spacer.
2. Shake the inhaler well.
3. Insert the mouthpiece of the spacer into the mouth and close the lips around the mouthpiece.
4. Press down the canister of the metered dose inhaler once to release one puff into the spacer.
5. Breathe slowly and deeply in and out of the spacer continuously for at least 6 breaths
6. If breathing through the nose as well as the mouth, pinch the nose gently while breathing from the spacer.

D. Inhalation therapy with a spacer and mask for infants and children < 3 years:

1. Remove the caps from the inhaler and the spacer.
2. Infants may be preferably placed on the caregiver’s lap or alternatively laid on a bed while administering the medication.
3. Shake the inhaler well.
4. Apply the mask to the face, ensuring that the mouth and nose are well covered.
5. With the mask held firmly onto the face, press down the canister of the metered dose inhaler once to release one puff into the spacer.
6. Keep the mask in place for at least six breaths, then remove.
7. Repeat steps 3–6 for each puff prescribed, waiting at least 30 seconds between puffs.

DRY POWDER INHALERS (DPIs)

E. Inhalation therapy with a dry powder inhaler (DPI) for adults and children over 6 years of age:

1. There is no need to shake a DPI.
2. Open, twist or click the device to load the medication dose.
3. Stand or sit up straight and breathe out completely (away from the device, not into the mouthpiece).
4. Immediately place the mouthpiece into the mouth, close lips tightly around it and breathe in quickly and forcefully to full inhalation.
5. Remove the DPI from the mouth, hold breath for 5-10 seconds, then exhale slowly.
6. Optimise positioning and repeat steps 2–5 for each puff prescribed, waiting at least 30 seconds between puffs.
7. Rinse mouth with water after inhalation of corticosteroids

NEBULISERS

The guidance below is tailored to the use of jet nebulisers which are primarily used in the public sector.

1. Ensure the nebuliser cup is filled sufficiently to allow effective nebulisation (approx. 4L minimum volume). Volume must be more than the equipment dead space to be sufficient. The dead space in a nebuliser refers to the volume of the nebulizer chamber and tubing that remains filled with medication after treatment. This volume is not delivered to the patient and can vary depending on the nebulizer design. Typical dead space volumes in jet nebulizers is 2-3 mL.
2. Hold the nebuliser upright.
3. Select a flow rate of oxygen of 6 to 8 L/min for jet nebulisers.
4. Use a mouthpiece rather than a facemask in adults and in any child able to hold a mouthpiece between their lips and breathe via their mouths. Better medication delivery: The T-piece allows for more direct delivery of medication to the lungs, reduced medication loss, improved patient comfort, enhanced cooperation, reduced risk of skin irritation and easier observation of the patient's mouth and nose.
5. Place the mouthpiece in the patient’s mouth. Advise the patient to keep their lips firmly around the mouthpiece. If using a facemask, place it over the mouth and nose.
6. Ensure patient is calm and relaxed.
7. Advise patient to breathe slowly and deeply through the mouth as far in and as far out as possible until all the medication is used.

The following should be avoided when using nebulisers:

• Rapid or forceful inhalation (including crying)
• Nebulising whilst sleeping
• Using a facemask when a mouthpiece is possible
• A loose-fitting facemask or placing the nebuliser near a child’s nose and mouth rather than securing a facemask

LoE:IVb³

Click here for the pdf.

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Standard Treatment Guidelines And Essential Medicines List For South Africa, Primary Healthcare, 2020-4_Version 1_September 2024

Appendix II Devices for Respiratory Conditions Inhaler Devices

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References

¹ Spacers: Vincken W, Levy ML, Scullion J, Usmani OS, Dekhuijzen PNR, Corrigan CJ. Spacer devices for inhaled therapy: why use them, and how? ERJ Open Res. 2018 Jun 18;4(2):00065-2018. doi: 10.1183/23120541.00065- 2018. PMID: 29928649; PMCID: PMC6004521. Berlinski A. Pediatric Aerosol Therapy. Respir Care. 2017 Jun;62(6):662-677. doi: 10.4187/respcare.05298. PMID: 28546371. Patient education: Inhaler techniques in adults (Beyond the Basics) . https://www.uptodate.com/contents/inhalertechniques-in-adults-beyond-the-basics/print

² Optimal aerosol delivery: Levin ME. Optimal aerosol delivery. Current Allergy & Clinical Immunology. 2011; 24(1):27-30 Rubin BK Fink JB. Optimizing aerosol delivery by pressurized metered-dose inhalers. Respir Care 2005; 50 (9): 1191-1200. Devadason SG. Recent advances in aerosol therapy for children with asthma. J Aerosol Med. 2006 Spring;19(1):61- 6. doi: 10.1089/jam.2006.19.61. PMID: 16551216. Everard ML, Clark AR, Milner AD. Drug delivery from holding chambers with attached facemask. Archives of Disease in Childhood. 1992 May;67(5):580-585. DOI: 10.1136/adc.67.5.580. PMID: 1599292; PMCID: PMC1793709. Vincken W, Levy ML, Scullion J, Usmani OS, Dekhuijzen PNR, Corrigan CJ. Spacer devices for inhaled therapy: why use them, and how? ERJ Open Res. 2018 Jun 18;4(2):00065-2018. doi: 10.1183/23120541.00065-2018. PMID: 29928649; PMCID: PMC6004521. Esposito-Festen JE, Ates B, van Vliet FJ, Verbraak AF, de Jongste JC, Tiddens HA. Effect of a facemask leak on aerosol delivery from a pMDI-spacer system. J Aerosol Med. 2004 Spring;17(1):1-6. doi: 10.1089/089426804322994406. PMID: 15120007.

³ Optimal aerosol delivery: Levin ME. Optimal aerosol delivery. Current Allergy & Clinical Immunology. 2011; 24(1):27-30