Overview
Definition:
Asthma is a chronic inflammatory disease of the airways characterized by reversible airflow obstruction, bronchial hyperresponsiveness, and recurrent symptoms
In pediatric asthma, effective management at discharge hinges on ensuring guardians and children understand and can correctly use prescribed inhaler devices and spacers to achieve therapeutic goals and prevent readmissions.
Epidemiology:
Asthma is the most common chronic respiratory disease in children worldwide, affecting up to 10-15% of children in developed countries
Pediatric asthma contributes significantly to emergency department visits, hospitalizations, and school absenteeism
Proper discharge planning, including education on device use, is crucial for reducing exacerbations and improving quality of life.
Clinical Significance:
Inadequate inhaler technique and lack of spacer use in children are major contributors to poor asthma control, leading to frequent exacerbations, increased healthcare utilization, and potential long-term lung damage
Equipping caregivers and children with proper knowledge and skills at discharge is a critical step in optimizing treatment adherence and outcomes.
Inhaler Types And Indications
Metered Dose Inhalers Mdis:
MDIs deliver a specific dose of medication in a short burst of aerosol
They are commonly used for bronchodilators (e.g., salbutamol) and inhaled corticosteroids (ICS)
Requires coordination between actuation and inhalation
Suitable for older children or those with assistance.
Dry Powder Inhalers Dpis:
DPIs deliver medication as a fine powder when the patient inhales
They do not require a propellant and often have dose counters
Examples include Diskus, Turbuhaler, and Accuhaler
Requires a sufficient inspiratory flow rate, which can be a challenge for younger children.
Nebulizers:
Nebulizers convert liquid medication into a fine mist for inhalation over several minutes
Used primarily for severe exacerbations or for infants and young children who cannot effectively use inhalers
Usually administered in a hospital setting but can be used at home for specific cases.
Spacer Devices And Rationale
What Is A Spacer:
A spacer, also known as a valved holding chamber (VHC), is a device that attaches to an MDI
It holds the aerosolized medication, allowing it to slow down and form smaller droplets, making it easier for the patient to inhale effectively.
Rationale For Use In Children:
Spacers are essential for pediatric patients using MDIs, especially those under 5-6 years old
They improve medication delivery to the lungs by reducing the need for hand-breath coordination, decreasing oral deposition of medication (thus reducing side effects like thrush), and increasing lung deposition.
Types Of Spacers:
Spacers come with and without valved masks for different age groups
Valved masks ensure that the medication is inhaled during breathing efforts and exhaled into the surrounding air
Larger mask sizes are for infants, smaller sizes for toddlers and young children
Maskless spacers are for older children who can seal their lips around the mouthpiece.
Inhaler And Spacer Technique Education At Discharge
Mdis With Spacer Technique:
1
Shake the MDI well
2
Attach the spacer to the MDI
3
Place the mask snugly over the child's nose and mouth, or have the child seal their lips around the mouthpiece if older
4
Press down once on the MDI to release one puff of medication into the spacer
5
Have the child take 5-10 slow, deep breaths through the spacer
6
Remove the spacer from the child's face/mouth
7
Wait 30-60 seconds before repeating for a second puff if prescribed
8
Clean the spacer regularly.
Dpi Technique:
1
Load the dose according to device instructions
2
Hold the DPI flat and level
3
Exhale away from the device
4
Place the mouthpiece in the mouth and seal lips tightly
5
Inhale quickly and deeply until the lungs are full
6
Hold breath for 5-10 seconds
7
Remove device and exhale
8
Rinsing the mouth after ICS use is crucial to prevent oral thrush.
Nebulizer Technique:
1
Connect the nebulizer cup to the air compressor or nebulizer machine
2
Add the prescribed dose of medication to the cup
3
Attach the mask or mouthpiece
4
Turn on the machine
5
Have the child sit upright and breathe normally through the mask/mouthpiece until the medication is finished (typically 5-10 minutes)
6
Clean the nebulizer equipment after each use.
Reinforcement And Demonstration:
Crucially, education must include hands-on demonstration by the healthcare provider, followed by return demonstration by the caregiver and child (if age-appropriate)
Use visual aids and simplified language
Assess understanding repeatedly
Provide written instructions and contact information for follow-up questions.
Patient Education And Adherence Strategies
Simplified Instructions:
Use clear, concise language, avoiding medical jargon
Provide instructions in the local language
Utilize pictograms and diagrams to illustrate steps.
Caregiver Involvement:
Emphasize the critical role of the caregiver in administering medication, especially for younger children
Ensure caregivers are comfortable and confident with the technique.
Age Appropriate Education:
Adapt education for different age groups
For younger children, focus on making it a game or routine
For older children, involve them in understanding their condition and treatment.
Follow Up And Monitoring:
Schedule follow-up appointments to reassess technique, adherence, and asthma control
Address any barriers to adherence proactively, such as cost, side effects, or perceived ineffectiveness
Reinforce the importance of regular controller medication use even when asymptomatic.
Potential Challenges And Troubleshooting
Poor Coordination:
If coordination is an issue with MDIs, emphasize spacer use
For DPIs, ensure sufficient inspiratory effort
consider alternative devices if needed.
Mask Discomfort:
For young children, practice mask fit without medication initially
Use smaller masks for better seal
Distract the child during administration.
Medication Refusal:
Explore reasons for refusal (fear, taste, side effects)
Make medication time a positive experience
Involve older children in choosing the time of administration
Consider alternative delivery methods if appropriate.
Incorrect Cleaning:
Regular cleaning is vital to prevent bacterial growth and ensure device function
Provide clear instructions and demonstrate cleaning procedures
Ensure caregivers understand the frequency and method of cleaning.
Key Points
Exam Focus:
Understanding the mechanism of action of different inhalers and the rationale for spacer use in pediatrics is high-yield
Know the step-by-step technique for MDI+spacer, DPI, and nebulizers
Recognize common errors in technique.
Clinical Pearls:
Always perform a return demonstration with the caregiver and child
Assess inhaler technique at every visit, not just at discharge
Asthma education is an ongoing process
Emphasize adherence to controller medications.
Common Mistakes:
Assuming correct inhaler technique without assessment
Not using a spacer with MDIs in young children
Insufficient inspiratory effort with DPIs
Forgetting to shake MDIs
Inadequate cleaning of devices
Not rinsing the mouth after ICS use.