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Inhaler devices for children under five

Cathy Warde
RGN BSc(Hons)

Maggie Bunker
RSCN/RGN
Respiratory Nurse Specialists
Royal Alexandra Hospital for Sick Children
Brighton

In the present climate of paediatric care, inhaler devices may be used for a number of conditions, the most common of which is asthma. Asthma symptoms affect the lower airways leading to wheeze, breathlessness and cough. Symptoms can be acute and episodic or chronic and can have a profound effect on the family and child. Asthma treatment that involves both acute symptom relief and prevention of ongoing symptoms is best delivered predominantly in an inhaled form directly to the site of action in the airways. In the UK, treatment is influenced by the 1997 British Thoracic Society (BTS) Guidelines,(1) which promote a stepwise approach to ­treatment depending on severity.
There is controversy in young children about the diagnosis of asthma, as some children have postbronchiolitic wheeze or viral-induced wheeze, which may not develop into true asthma after the preschool years but which may still require inhaled treatment. However, the number of children under five years diagnosed with asthma appears to show a genuine increase.(2) A study in Leicester found that the percentage of children under five diagnosed with asthma had increased from 11.6% in 1990 to 21.3% in 1998.(2) It is estimated that 9% of all boys and 6% of all girls under five are prescribed inhalers.(3) Children under five years present a particular challenge as delivering inhaled medication can be difficult, and cooperation with treatment is often a problem. However, by delivering appropriate care we can substantially improve their health potential.

Management of chronic asthma
An NHS initiative to provide guidance for both NHS health professionals and patients on aspects of clinical care has recently been established and is known as the National Institute for Clinical Excellence (NICE). In August 2000, NICE published its Guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma,(3) which addresses a problem that is often under-estimated. In a climate where adult medicine ­predominates, it highlights the need for appropriate treatment from an early age and acknowledges that data regarding treatment cannot be directly extrapolated from evidence regarding older children or adults. 
The NICE guidance suggests that both preventive and relief treatment should be delivered by pressurised metered-dose inhaler (pMDI) and spacer. A facemask should be used until the child can operate the ­mouthpiece (approximately 2.5 years). The choice of pMDI and spacer should depend on individual need and the likelihood of good cooperation with the device. It is also suggested that nebulised therapy or a dry-powder inhaler (DPI) may be an option in specific circumstances. The challenge is to ensure a maximum therapeutic effect with minimal side-effects.
The guidance is particularly pertinent to primary care where independent practice may mean that standardisation of care may not always be achieved. The NICE guidance alongside the BTS guidelines should lead to increased uniformity in this respect. Practice nurses trained in asthma care are the ideal health professionals to teach inhaler technique and to offer regular review, being responsive to changing health needs within the family. They should also be aware when referral to a specialist respiratory nurse or paediatric consultant is necessary for patients failing to respond to treatment or who are on high-dose preventive treatment.

Holistic approach
The selection of an inhaler is only one aspect of ­asthma management. The provision of care should be viewed comprehensively in a holistic manner, ­recognising the need for education, support and guidance for parents/ carers. It is recommended that clinicians implement patient management plans to audit their own ­compliance with the guidance. This may have a positive effect in ensuring that each individual child has an appropriate review of its medication and device, ­therefore improving overall management. Furthermore, it is recognised that there is a range of spacers and the choice should be made dependent on the specific needs of the child. GPs, practice nurses, specialist asthma nurses, health visitors and school nurses may all be involved in the process of delivering consistent information and reinforcing the ­appropriate use of the spacer and pMDI to promote adherence. This also helps in the provision of seamless care in both primary and secondary health sectors.

Medications used in the under-fives
Table 1 shows the most appropriate and commonly used medication available for the under-fives.

[[NIP01_table1_20]]

Salmeterol (Serevent [Allen & Hanburys Ltd]), a long-acting bronchodilator, may be indicated in children with less than optimum asthma control on inhaled steroids as an alternative to increasing the dose of steroids further. It is not licensed for children under four years.
Seretide [Allen & Hanburys Ltd], a combination of fluticasone and salmeterol, may be considered for children over four years.
Aerochambers have a universal port and can be used for any of the above medications if indicated for a child instead of a large-volume spacer.
Dry powders may be a possibility for relief treatment in 4-5-year-olds but are not indicated for cortico-steroids. A spacer may still be useful in the event of an acute asthma attack.

Practical implications
The dose that spacer devices deliver depends on ­factors such as static charge, facemask design, spacer volume, the drug used and the breathing pattern of the child.(4) It is important that there is minimal delay between actuation of the inhaler and inhalation from the spacer.
Large-volume spacers such as Volumatic (700ml: Allen & Hanburys Ltd) or Nebuhaler (750ml: AstraZeneca) deliver more ­salbutamol than small-volume spacers.(5,6) However, the difference between spacers is less for budesonide, and spacers should be evaluated for each drug prescribed. Currently, large-volume spacers with or without a ­facemask are used most regularly in practice as they provide a cost-effective way of achieving good drug ­deposition. However, this depends on good and ­consistent education on the technique and parental understanding of the importance of spacer use. It also depends on the cooperation of the child, which in some cases the parents find too difficult to attain despite ­guidance. In these circumstances a small-volume spacer may be better as it is easier to handle and the lesser volume deposited would be outweighed by the parent's ability and thus confidence in using the device, adherence being key to effective management. Parents and carers need to be shown and supervised giving their child medication. They may need particular help in ­positioning their child so that the medication can be delivered. Encouragement is needed when the child starts to be more active than passive when taking their inhalers, particularly as they learn to operate the valve.
For children taking inhaled corticosteroids the teeth should be cleaned after the dose or the face wiped with a wet cloth if using a facemask.

Cleaning spacers
Electrostatic charge within the spacer may reduce the amount of medication that the patient receives. To minimise the effect of electrostatic charge, spacers should be washed in detergent and air-dried without rinsing before first use, and then once a month ­thereafter. The spacer should not be stored in a ­plastic bag that may induce electrostatic charge.
Some patients find it convenient to store the pMDI in the spacer device. This may scratch the surface and reduce the antistatic effect of the detergent. It may be sensible to increase the frequency of washing as a result.

Acute episodes
An acute attack can be life-threatening and is the carer's biggest concern. If there is an increase in asthma symptoms, relief treatment should be administered four-hourly. If the child requires relief more frequently or does not respond at all, the dose may be repeated but medical assistance should be sought.

Particular problems in the under-fives
Children under one present a particular problem as treatment response can be poor owing to the immaturity of the lungs and the lack of smooth muscle in the airways. A trial of medication may be the best way to see whether a response is elicited. Atrovent may be a more ­useful relief treatment as occasionally paradoxical ­bronchoconstriction occurs with a beta(2)-agonist. Some babies wheeze but do not seem distressed at all by their symptoms and treatment is unlikely to be indicated.
Corticosteroids are not normally indicated below the age of one as the response can be poor and there may be potential side-effects.
Occasionally, oral treatment such as theophylline may be added to an inhaled treatment regimen.

Conclusion
In practice, pMDI and spacers with or without facemask are the first choice for any inhaled medication in ­children under five. There is limited research for ­practice to be evidence-based, so further research in the efficient use of spacers and factors determining compliance is suggested in the NICE guidance. It is important that an inhaler device delivers a consistent and appropriate quantity of medication to the airways. The aim of treatment is for the child to lead an active life with ­minimal symptoms and normal growth and development. Treating asthma effectively in the under-fives will ensure optimal lung function as the child grows older.

[[NIP01_pp_21]]

References

  1. British Thoracic Society. Guidelines on asthma management. Thorax 1997;52(Suppl. 1):1-21.
  2. Kuehi CE, Brooke AM, Silverman M. Changes in prevalence of preschool wheeze in Leicestershire: two surveys 8 years apart. Thorax 1998;53(Suppl. 14):A53.
  3. National Institute for Clinical Excellence. Technology Appraisal Guidance - No. 10. Guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma. London: NICE; 2000.
  4. O'Callaghan C. Delivery systems: the science. Paediatr Pulmonol Suppl 1997;15:51-4.
  5. Barry P, O'Callaghan C. Inhalational drug delivery from seven different spacer devices. Thorax 1996;51:835-40.
  6. Zar H, Weinberg E, Binns H, Gallie F, Mann M. Lung deposition of aerosol - a comparison of different spacers. Arch Dis Child 2000;82:495-8.

Resources
National Asthma Campaign
Providence House
Providence Place
London N1 0NT
T:020 7226 2260
W:www.asthma.org.uk
National Asthma and Respiratory Training Centre
The Athenaeum
10 Church Street
Warwick CV34 4AB
T:01926 493313
W:www.nartc.org.uk
RCN Paediatric Respiratory
Nurses Group
RCN
20 Cavendish Square
London W1M 0DB
T:0845 7726100
W:www.rcn.org.uk

Further reading
Levy M, Hilton S, Barnes G. Asthma at your fingertips.
2nd edn. London: Class Publishing; 1997.
Milner A. Childhood asthma - ­diagnosis, ­treatment and management. 2nd edn. London: Martin Dunitz; 1993.
Silverman M, editor. Childhood asthma and other wheezing ­disorders. London: Chapman and Hall; 1995.