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Spacers – a staple in paediatric asthma management

It’s a chilly Autumn day, when a mother and her young daughter walk into the Medical Centre to be seen by you, a Nurse. The child is on your file as having mild asthma and intermittent hay fever. Childhood asthma is a common presentation, but are we all aware of best practice and management?

She’s wheezy, the cough has gone to her chest, and the inhaler isn’t working, so we’re here for a nebulizer.”

Further questioning reveals Mum has tried giving has tried some over the counter cough mixture and a salbutamol inhaler that belongs to one of her other child. There’s no previous peak flow readings on file, so you get her to do one, but you wonder if the technique is quite right. When asked about a spacer, Mum says they don’t have one in the house. Spacers are for everyone, regardless of patient age or type of inhaler. In addition to being used for asthma, spacers are also recommended for those who have chronic obstructive pulmonary disease (COPD). However, for this we’ll focus on childhood asthma management.

Tessa Demetriou, the Head of Education & Research at the Asthma + Respiratory Foundation NZ says that use of a spacer not only helps medication move into the lungs, it also helps patients focus on their breathing. 

“A spacer should be used with all metered dose inhalers (MDI) as this will reduce the amount of medicine from the inhaler hitting the back of your mouth and throat. It also means that less medicine is swallowed.” 

Spacers can also reduce the side effects from inhaled corticosteroids, which can include sore throat, hoarse voice and oral thrush. Another strategy to decrease the risk is do a mouth rinse or clean your teeth after using a steroid containing inhaler. 

Another misconception is that an asthma exacerbation will always need nebulized medications, and some patients will even come into clinics asking for them. Despite their benefits, a degree of medication is exhaled with every breath, but new technologies are looking to combat this (Lavorini, Fontana &Usmani, 2014). 

There is also currently a step-wise approach to asthma management, unless a patient prevents in a severe exacerbation. Solutions can  involve increasing the amount and frequency of inhaler, adding in a preventer, or long acting beta agonist (LABA) if the person does not currently use one. Treatment with oral steroids or other adjuvants may also be considered, however inhaled corticosteroids via a spacer are preferred first over oral steroids due to decreased systemic effects (Pandya, Puttanna & Balagopal, 2014). The Australian Asthma handbook is available online here. Many other countries also have similar clinical guidelines available on their major asthma charity sites. 

“A spacer is as effective as a nebuliser for getting the medication into the lungs in an acute attack, it is faster to use, less expensive and is not dependent on a power supply. They are also less frightening, especially for children. Spacers are the recommended treatment for acute asthma, except for very severe/life-threatening asthma when oxygen driven nebulisation is recommended, Tessa says. 

Despite advances in asthma knowledge, many children in Australia and New Zealand are not being well managed. The reasons are diverse and include both home environment and availability of healthcare services, prescriptions and education from healthcare professionals (Asher et al, 2017). But it’s not only children that need help controlling their respiratory issues – a European study showed that up to half of allpatients were not using their inhaler correctly (Crompton et al, 2006). So if we can educate whole families, that’s even better, we can really make a difference. Sadly, we don’t always get our teaching right, and one study showed that even many Doctors do not adequately teach asthma management (Press et al, 2010) and that incorrect use of inhalers is associated with increased utilization of health services and increased oral steroid use (Melani et al, 2011). 

 One thing that we can do as nurses is teach good symptom management and spacer use. This can be done both in clinic and reiterated using an asthma management plan. An up to date action plan can be helpful not only for the patient but also for families and ambulance staff.  

If you want to learn more about asthma management you can check out our asthma update webinar with Marg Gordon from National Asthma Council Australia

Asher, I., McNamara, D., Davies, C., Demetriou, T., Fleming, T., Harwood, M., … & Rickard, D. (2017). Asthma and Respiratory Foundation NZ child and adolescent asthma guidelines: a quick reference guide. The New Zealand Medical Journal130(1466), 10-33. Retrieved from https://www.nzma.org.nz/journal/read-the-journal/all-issues/2010-2019/2017/vol-130-no-1466-1-december-2017/7425

Crompton, G. K., Barnes, P. J., Broeders, M. E. A. C., Corrigan, C., Corbetta, L., Dekhuijzen, R., … & Viejo, J. L. (2006). The need to improve inhalation technique in Europe: a report from the Aerosol Drug Management Improvement Team. Respiratory medicine, 100(9), 1479-1494. Retrieved from Science Direct. 

Lavorini, F.A., Fontana, G.A.,& Usmani O.S.B. (2014).New Inhaler Devices – The Good, the Bad and the Ugly. Respiration. 88, 3-15. doi.org/10.1159/000363390

Melani, A. S., Bonavia, M., Cilenti, V., Cinti, C., Lodi, M., Martucci, P., … & Neri, M. (2011). Inhaler mishandling remains common in real life and is associated with reduced disease control. Respiratory medicine, 105(6), 930-938. Retrieved from Science Direct. 

Pandya, D., Puttanna, A., & Balagopal, V. (2014). Systemic effects of inhaled corticosteroids: an overview. The open respiratory medicine journal8, 59-65. doi:10.2174/1874306401408010059

Press, V. G., Pincavage, A. T., Pappalardo, A. A., Baker, D. C., Conwell, W. D., Cohen, J. C., … & Arora, V. M. (2010). The Chicago Breathe Project: a regional approach to improving education on asthma inhalers for resident physicians and minority patients. Journal of the National Medical Association,102(7), 548-555. Retrieved from http://66.101.212.31/~nma2010/publications/July2010/OC548.pdf

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