Overview
Definition:
A spacer is a device used with a metered-dose inhaler (MDI) to improve medication delivery to the lungs in patients with asthma
It holds the medication cloud after actuation, allowing the patient to inhale it slowly and deeply over several breaths, reducing the need for precise MDI-patient coordination.
Epidemiology:
Asthma is a common chronic respiratory disease in children, affecting approximately 1 in 10 children globally
In India, the prevalence varies by region but remains a significant public health concern
Effective MDI use, often facilitated by spacers, is crucial for managing childhood asthma.
Clinical Significance:
Correct spacer technique is paramount for optimal bronchodilator and inhaled corticosteroid delivery in pediatric asthma management
Poor technique leads to reduced medication reaching the airways, resulting in suboptimal symptom control, increased exacerbations, and a higher risk of hospitalizations, directly impacting patient outcomes and the effectiveness of therapy.
Patient Education And Technique
Understanding The Need:
Explain why the spacer is necessary for better medication delivery, especially in young children or those with coordination difficulties
Emphasize that it helps the medicine go directly to the lungs to control breathing
Highlight that it is not a cure but a tool for managing symptoms effectively.
Spacer Types And Selection:
Discuss common types of spacers, such as valved holding chambers (VHCs) with masks for infants and toddlers, and mouthpieces for older children
Select a spacer appropriate for the child's age and ability
Ensure the MDI fits snugly into the spacer
Masks should create a good seal around the nose and mouth.
Step By Step Technique Mask:
Shake the MDI well
Attach the MDI to the spacer
Place the mask snugly over the child's mouth and nose, ensuring a seal
Press the MDI to release one puff into the spacer
Have the child take 5-10 slow, deep breaths through the mask over 30-60 seconds
Remove the spacer
Wait 30-60 seconds before administering another puff if prescribed
Repeat the entire process for each prescribed puff.
Step By Step Technique Mouthpiece:
Shake the MDI well
Attach the MDI to the spacer
Have the child exhale fully
Place the mouthpiece in the child's mouth, closing lips around it
Press the MDI to release one puff into the spacer
Have the child take 5-10 slow, deep breaths through the mouthpiece over 30-60 seconds
Remove the spacer
Wait 30-60 seconds before administering another puff if prescribed
Repeat the entire process for each prescribed puff.
Cleaning And Maintenance:
Regular cleaning is vital to prevent medication buildup and ensure proper function
Wash the spacer and mask (if applicable) weekly with warm water and mild soap
Rinse thoroughly and allow to air dry completely
Do not use hot water or place in a dishwasher
Store in a clean, dry place.
Age Considerations
Infants And Toddlers:
Use a valved holding chamber (VHC) with a well-fitting mask
The child may not be able to coordinate breathing, so slow, tidal breaths are sufficient
Ensure a good seal with the mask
Explain that it is important for their breathing.
Preschool Children:
Transition to a VHC with a mask or a mouthpiece
If using a mouthpiece, teach them to seal their lips around it
Encourage deep breaths
Some may understand simple instructions to breathe in slowly and hold their breath.
School Aged Children:
Can typically use a mouthpiece
Teach them to exhale fully, seal lips around the mouthpiece, inhale slowly and deeply, and hold their breath for about 10 seconds
Regular reinforcement and demonstration are key.
Adolescents:
Most adolescents can master the mouthpiece technique
Reinforce the importance of technique for symptom control and adherence
Address any concerns or misconceptions they may have about using the inhaler and spacer.
Troubleshooting And Common Errors
Poor Seal Mask:
Medication can escape, leading to reduced efficacy
Ensure the mask fits snugly and covers both nose and mouth
Check for tears or damage in the mask.
Fast Breathing:
High-speed inhalation can cause medication to deposit in the back of the throat instead of reaching the lungs
Encourage slow, steady breaths
If using a mask, slow tidal breathing is acceptable.
Not Holding Breath:
Holding breath for at least 5-10 seconds allows medication to settle in the airways
Remind the child to try and hold their breath after inhaling.
Improper Mdi To Spacer Attachment:
A loose connection can lead to medication loss
Ensure the MDI is firmly seated in the spacer
Check for compatibility between MDI and spacer.
Infrequent Cleaning:
Can lead to blockage and reduced medication delivery
Emphasize the importance of the weekly cleaning routine
Advise discarding old or damaged spacers.
Assessment Of Technique
Observation:
Directly observe the child or parent performing the technique
Note adherence to each step: shaking MDI, proper MDI-to-spacer attachment, mask/mouthpiece seal, slow inhalation, breath-holding.
Verbal Reinforcement:
Ask the child or parent to explain the steps back to you
This helps identify misunderstandings and reinforce learning
Use simple language appropriate for the caregiver.
Demonstration:
Perform a return demonstration yourself and ask the child/parent to repeat it
This active learning approach is highly effective
Use visual aids if available.
Follow Up Assessment:
Schedule follow-up appointments to reassess technique and address any new challenges
Encourage patients to bring their inhaler and spacer to all appointments.
Key Points
Exam Focus:
Understand the rationale behind spacer use in pediatrics
Be prepared to explain the step-by-step technique for different age groups using both masks and mouthpieces
Know common errors and how to correct them.
Clinical Pearls:
Always demonstrate the technique and have the patient/caregiver perform a return demonstration
Use age-appropriate language and visual aids
Emphasize regular cleaning
A well-fitting mask is crucial for infants and toddlers.
Common Mistakes:
Incorrect mask seal, rapid forceful inhalation, failure to hold breath, inadequate MDI shaking, and poor cleaning are frequent issues
Correcting these improves therapy significantly.