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Asthma 101

Teaching children to use metered dose inhalers

Chike-Harris, Katherine E., DNP, APRN, cPNP-PC, NE; Kinyon-Munch, Kathryn, DNP, APRN, PPCNP-BC, AHN-BC

doi: 10.1097/01.NURSE.0000552703.80996.43

Abstract: Providers across the spectrum of healthcare must be aware of their patients' inhaler use. This article addresses common errors and the proper use of pressurized metered-dose inhalers in pediatric patients.

Assess for these common usage errors and teach children to use pressurized metered-dose inhalers correctly.

Katherine E. Chike-Harris and Kathryn Kinyon-Munch are instructors at the Medical University of South Carolina College of Nursing in Charleston, S.C.

The authors have disclosed no financial relationships related to this article.



DESPITE IMPROVEMENTS in pharmacologic therapies and the increased use of controller medications, asthma remains a concerning diagnosis for patients of all ages, ethnicities, and socioeconomic statuses. According to the most current statistics from the CDC, approximately 54% of pediatric patients under age 18 diagnosed with asthma reported at least one asthma attack in 2016.1 Why are asthma attacks still so common, and what can nurses and other healthcare providers do to reduce this number?

Research has demonstrated that one of the barriers to asthma management is the correct use of inhalers and simple spacers.2,3 This article focuses on use of pressurized metered-dose inhalers (pMDIs) for pediatric populations, addressing some common errors made by both patients and providers. Only pMDIs with or without a simple spacer or valved holding chamber (VHC) are addressed in this article, but patients and providers must also know the proper techniques for other types of inhalers, such as dry-powder inhalers.

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Methods of delivery

Inhaled therapy has been a cornerstone for asthma treatment in children, and the 2018 Global Initiative for Asthma (GINA) guidelines state that pMDIs with a VHC or valved spacer are the preferred delivery system for all ages.4

Although prescribing practices have changed, many patients still rely on inhalers to control or manage acute asthma symptoms. A 2016 meta-analysis found no improvement in the percentage of patients correctly using inhalers or simple spacers in 40 years of research.5 Additionally, separate research suggested that approximately 90% of patients cannot use an inhaler correctly with or without a simple spacer.2,6,7 A 2012 study also demonstrated that an incorrectly used pMDI delivered between 50% and 80% of medication to the oropharynx rather than the lungs, leading to inappropriate medication administration and dosage.8



Given the variety of inhalers, simple spacers, and holding chambers available to patients, the administration of asthma medications can be confusing even for veteran healthcare professionals. Research suggests that 15% to 69% of healthcare professionals cannot demonstrate the correct use of an inhaler or VHC, potentially resulting in improper patient education.5,6,9,10

Although similar, simple spacers and VHCs are not the same thing. These terms are often used interchangeably, but there are significant differences:

  • A VHC is a specialized spacer that incorporates a one-way valve between the chamber and the mouthpiece.11 The one-way valve holds the actuated medication in suspension, allowing for slow and deep inhalation.8 Additionally, particles remain in the chamber for multiple breaths, which is important for infants and young children, as one inhalation may not be enough to clear all medication.8,12 Because the VHC allows for a slower inhalation, the medication can navigate the right-angle curve at the posterior oropharynx to the lungs with less risk of entering the gastrointestinal system. VHCs also reduce the risk of dysphonia and oral candida by reducing oropharyngeal deposition by 70% on average.8
  • A simple spacer is typically a tube of sufficient volume to allow the aerosol plume from the pMDI to expand and the propellant to evaporate. Like a VHC, this delivery device assists in the proper inhalation of the actuated medication, preventing delivery to the tongue or into the air rather than into the lungs. However, simple spacers do not include a one-way valve, so the timing must be planned to ensure that the patient receives a full dose of medication.2,8,12
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“Device delirium”

Many different inhalers are available on the market, including manually actuated pMDIs and breath-actuated pMDIs. Each type requires a different technique for effective use. Confronted with so many inhalers and the choice between simple spacers or VHCs, both patients and providers can easily become confused. In one 2012 study, this confusion was described as “device delirium,” which limits both efficacy and adherence.8

Many pMDIs are designed for use with an external VHC, but some feature a built-in simple spacer that cannot be used with a VHC. Manually actuated pMDIs are typically activated by applying pressure on the top of the canister. The inhaler should not be placed in the mouth if the patient is using the open-mouth technique (see Steps for use).13,14Breath-actuated pMDIs release the medication automatically as a patient inhales.13,14

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Common errors

The Inhaler Error Steering Committee developed a list of common errors associated with inhaler use in 2013 (see Common pMDI errors).5 Besides these, family and patient beliefs can contribute to incorrect asthma inhaler usage with a simple spacer or VHC, including overconfidence on the part of parents or children. For example, parents may believe their child is old enough to use an inhaler without supervision and children may be unsure about proper use. Ideally, patients should demonstrate the proper use of their devices to reinforce the required steps.

A 2016 study found that 75% of pediatric patients who were confident in their inhaler technique with or without a VHC missed more than one of the eight required steps for proper usage, with some missing as many as four.15 This study underscored the need for inhaler use reassessment and reeducation, despite a patient's confidence in his or her ability to use the device.

No clinical evidence supports using a mask versus a mouthpiece, so the best device depends on the patient's age, tolerance, and preference.8 To ensure the correct device is being used, reevaluate its efficacy and usefulness as a child matures. For example, infants can use a VHC infant mask up to age 12 months, but they must switch to a child-size mask as toddlers.8 In another example, school-age children may require a VHC with a mask at school, but they may use a VHC without a mask at home with parental coaching.8

To determine the optimal aerosol delivery system, consider the following factors:

  • age
  • physical and cognitive abilities
  • device tolerance with minimal distress
  • caregivers' capabilities and willingness to administer medications
  • likelihood of insurance coverage.
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Cleaning and storage

The final step in using a pMDI with a simple spacer or VHC is proper cleaning and storage according to the manufacturer's instructions. Typically, if the device is used daily, it should be washed weekly in a clear dish soap, rinsed well, and allowed to air dry.16,17 Tell patients and their parents not to leave the device in a hot car, as the heat can distort it and cause malfunctions.

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Patient and provider awareness

Healthcare providers in all clinical settings must be aware of how patients with asthma are using their inhalers and simple spacers. By perfecting the use of pMDIs with or without simple spacers or VHCs, patients can reduce asthma exacerbations and ED visits.

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Steps for use14

The three methods for using a pMDI are open-mouth technique, with a VHC without a mask, and with a VHC and a mask. Each varies slightly, and patients or responsible guardians must perform each step as listed to ensure proper dosage.

Using the open-mouth technique:



  1. Stand to use the inhaler.
  2. Shake the inhaler three to four times and remove the cap.
  3. Open your mouth wide while holding the inhaler 1 inch from your lips.
  4. Remember to breathe out normally before dosing.
  5. While inhaling, press down on the inhaler canister and continue to breathe in slowly for 3 to 4 seconds.
  6. Hold your breath while you count to 10.
  7. If this is a rescue inhaler, wait at least 1 minute before repeating steps three through six.
  8. Always remember to swish and spit with water or another fluid after using an inhaled corticosteroid medication to help prevent oral thrush.
  9. If you can see mist from the medication coming out of your mouth, either the timing was off or you did not breathe in deeply enough.

Using a VHC without a mask:



  1. Stand to use the inhaler.
  2. Shake the inhaler three to four times and remove the cap.
  3. Attach the inhaler mouthpiece to the open end of the VHC.
  4. Remember to exhale normally before dosing.
  5. Place your lips snugly around the VHC mouthpiece.
  6. Actuate the inhaler once to release the medication into the chamber.
  7. Breathe in slowly over 3 to 4 seconds. If you hear a whistle sound, you inhaled the medication too quickly.
  8. Hold your breath while you count to 10.
  9. If using a rescue inhaler, wait at least 1 minute between each breath before repeating steps four through eight.
  10. Always remember to swish and spit with water or another fluid after using an inhaled corticosteroid medication to help prevent oral thrush.


Using a pMDI with VHC and mask:



  1. Shake the inhaler three to four times and remove the cap.
  2. Attach the inhaler mouthpiece to the open end of the VHC.
  3. Apply the face mask so the child's nose and mouth are covered.
  4. Keep the mask firmly in place and actuate the inhaler canister once to release the medication into the chamber.
  5. Keep the mask in place and have the child breathe in and out five or six times to insure all medication has been inhaled.
  6. If using a rescue inhaler, wait at least 1 minute between breaths before repeating steps four through five.
  7. After using an inhaled corticosteroid medication, wipe off the child's face around the nose and mouth.
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1. Most Recent Asthma Data. Centers for Disease Control and Prevention. 2018.

2. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma – Full Report 2007. U.S. Department of Health and Human Services; National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program. 2007.

3. Levy ML, Dekhuijzen PN, Barnes PJ, et al Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT). NPJ Prim Care Respir Med. 2016;26:16017.

4. Global Initiative for Asthma. 2018 GINA report, global strategy for asthma management and prevention. 2018.

5. Price D, Bosnic-Anticevich S, Briggs A, et al Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013;107(1):37–46.

6. Goodwin R, Heraghty J. Do healthcare professionals understand asthma devices. Arch Dis Child Educ Pract Ed. 2015;100(6):302–305.

7. Peters SP, Busse WW. New and anticipated therapies for severe asthma. J Allergy Clin Immunol Pract. 2017;5(5S):S15–S24.

8. Fink JB. Delivery of inhaled drugs for infants and small children: a commentary on present and future needs. Clin Ther. 2012;34(11):S36–S45.

9. Alismail A, Song CA, Terry MH, Daher N, Almutairi WA, Lo T. Diverse inhaler devices: a big challenge for health-care professionals. Respir Care. 2016;61(5):593–599.

10. Bosnic-Anticevich S, Callan C, Chrystyn H, et al Inhaler technique mastery and maintenance in healthcare professionals trained on different devices. J Asthma. 2018;55(1):79–88.

11. Hess D, Dhand R. The use of inhaler devices in adults. UpToDate. 2018.

12. Schoessler S, Winders T. Enhancing asthma medication delivery: spacers and valved holding chambers. NASN Sch Nurse. 2016;31(4):200–201.

13. Spacers and valved holding chambers (VHCS) for use with metered dose inhalers (MDIS). American Academy of Allergy, Asthma, and Immunology. 2018.

14. Sanchis J, Gich I, Pedersen S. Systematic review of errors in inhaler use: has patient technique improved over time? Chest. 2016;150(2):394–406.

15. Alexander DS, Geryk L, Arrindell C, et al Are children with asthma overconfident that they are using their inhalers correctly. J Asthma. 2016;53(1):107–112.

16. Aerochamber Plus ZStat AVHC: cleaning. Monaghan. 2018.

17. Asthma: caring for the metered-dose inhaler (MDI) and spacer. AboutKidsHealth. 2009.

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Dry powder inhaler (DPI). National Jewish Health. 2018.

What Is Asthma? KidsHealth from Nemours. 2018


asthma; breath-actuated pMDI; inhaler; manually actuated pMDI; pressurized metered-dose inhaler (pMDI); simple spacer; valved holding chamber

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