Overview of the Treatment of Pediatric Asthma

Devices Used to Administer Asthma Medications

Metered Dose Inhaler (MDI)

Many medications that are used in the treatment of asthma are packaged in a small metal canister. The canister is then placed in a plastic holder unit called a Metered Dose Inhaler (MDI). The MDI consists of a holding unit for the small canister of medication and a mouthpiece over which the patient places his/her mouth. The MDI delivers one "puff" dose of medication whenever the canister of medication is pressed inside of the MDI. Children should use a "valve holding chamber" device along with their MDI.

Instructions for Using the Metered Dose Inhaler with Mouthpiece

1. Make sure that the metal canister of medication is placed securely in the plastic holder. As a unit, these two things together comprise the metered dose inhaler (MDI).
2. Remove the cap over the mouthpiece and shake the MDI well.
3. Ask your child to breathe out, emptying his/her lungs.
4. Have your child place the mouthpiece of the MDI into his/her mouth.
5. Have your child start breathing in, slowly and deeply through the mouth.
6. Shortly after the breath in has started, depress the metal canister to release one "puff" of medication, while continuing to breathe in a full breath.
7. The child should then remove the MDI from his/her mouth, and quickly close his/her lips to keep all the medication inside.
8. Have your child hold his/her breathe in for 10 seconds, and then exhale out through the nose.
9. If your child requires more than one puff of medication (usually a minimum of 2 puffs are prescribed), wait 30 seconds, shake the MDI again and repeat.

Hints about Using an MDI with Mouthpiece

• If you see a mist of medication escaping from the mouth while the child is inhaling, ask the child to keep his/her lips on the mouthpiece longer and take a longer breath in
• Rinse the plastic holder unit about once daily with warm tap water. Remove the metal medication canister before rinsing, and let the plastic holder dry thoroughly before replacing the canister.

Valve holding chambers: Because young children may lack the coordination to inhale medication directly from a MDI mouthpiece, a holding chamber (spacer device) may be used. The spacer looks like a wide hollow tube, or chamber, with a mouthpiece on one end and a rubber receptacle on the other end. The MDI is placed into the rubber receptacle end, and the mouthpiece of the spacer is placed in the child's mouth. For very young children who are too young to inhale medication through the mouth piece, spacers are available with a mask instead of a mouthpiece. The mask is then placed over the child's mouth and nose. The child is able to inhale the medication through the spacer device just by breathing normally.

Instructions for using the MDI with a Spacer with a Mouthpiece

1. The canister of medication should be placed inside of the MDI unit. Next, remove the cap over the mouthpiece of the MDI and place the mouthpiece into the rubber receptacle of the spacer. Next, shake the canister/MDI/spacer unit well (3-4 times).
2. Ask the child to breathe out, emptying his/her lungs.
3. Place the mouthpiece of the spacer into the child's mouth and have the child close his/her lips tightly around the mouthpiece.
4. Press down on the canister, releasing one "puff" of medication into the spacer.
5. Ask the child to take one deep breath in through his/her mouth, then to hold his/her breath while you count to ten. For the child who is too young to take in a large breath, ask him/her to breathe in and out deeply and slowly for 5 breaths. (Hint: Watch or feel the child's chest rise and fall to count out 5 breaths. Also, watch the small leaflet valves inside of the spacer chamber open up with each breath taken in.) If the child moves his/her face away before 5 breaths are taken in, just reposition the mask or mouthpiece and finish the count to 5. This process just described equals one "puff" of medication. Often, 2 to 4 puffs of medication are prescribed. Remember to shake the canister/MDI/spacer unit well before giving another puff. Also, do not spray more than one puff at a time into the spacer.

Instructions for using the MDI with a Holding chamber with a Mask

1. The canister of medication should be placed inside of the MDI unit. Next, remove the cap over the mouthpiece of the MDI and place the mouthpiece into the rubber receptacle of the spacer. Next, shake the canister/MDI/spacer unit well (3-4 times).
2. Place the mask of the spacer over the child's mouth and nose. The mask should form a good "seal" over the child's mouth and cheeks so that none of the medication escapes out through the sides of the mask.
3. Press down on the canister, releasing one "puff" of medication into the spacer. Because the holding chamber has a valve, you can release the puff of medication before putting the mask over the face.
4. Keep the mask over the child's mouth and nose for 5 breaths. Watch the child's chest rise and fall to count out 5 breaths. Also, watch the small leaflet valves inside of the spacer chamber open up with each breath taken in. If the child moves his/her face away before 5 breaths are taken in, just reposition the mask or mouthpiece and finish the count to 5. This process just described equals one "puff" of medication. Often, 2 to 4 puffs of medication are prescribed. Remember to shake the canister/MDI/spacer unit well before giving another puff. Also, do not spray more than one puff at a time into the spacer.

Hints for Using MDIs and Spacers:

• If the child struggles when the mask is placed on his/her face, try to persist as most children will eventually get used to it.
• One possible side effect of using inhaled steroid medication is the development of thrush which is a yeast infection in the mouth. If the physician has prescribed inhaled steroid medication (such as Vanceril, Aerobid, Flovent, Pulmicort), have your child rinse his/her mouth with water, and then spit out the water, after each treatment. Taking the inhaled steroid before brushing one’s teeth is effective, and makes the dentist happy. If the child uses a face mask, wipe the child's face with a wet cloth after the treatment. Rinsing the mouth and wiping the face will help to prevent the development of thrush.
• Once a month (or sooner if the child was sick or the spacer became very dirty) the spacer must be cleaned. To clean, first remove the MDI and medication form the spacer. Next, peel off the rubber end-piece that is opposite from the mouthpiece or mask. Then, gently wipe off any residue that has accumulated inside of the spacer. Lastly, rinse the spacer device with plain warm water, and allow it to dry overnight. Using dish soap and water and putting the holding chamber in a dish drain can be effective.
• Each canister of medication holds 100 to 120 puffs of medication. For the child who is receiving a maintenance dose of 2 puffs twice a day, one canister should last close to one month. Some of the inhalers have counters. Unfortunately, there is no other way of knowing how much medication remains in the inhaler. Vigilance over start and end dates for the inhalers is important.

Turbuhaler

One of the medications that may be used in the treatment of asthma is budesonide (Pulmicort). Pulmicort is an inhaled steroid, and is packaged in a special canister called a Turbuhaler.

Instructions for using the Turbuhaler:

1. Unscrew the cover and lift it off.
2. Holding the Turbuhaler upright, turn the colored base to the right as far as it will go, then back to the left until you hear a click. This click signals that a measured dose of Pulmicort medication has been released into the Turbuhaler.
3. Ask your child to breathe out, emptying his/her lungs.
4. Have your child close his/her lips tightly around the mouthpiece and then ask him/her to breathe in slowly and deeply through the mouth. Once the child has breathed in, remove the mouthpiece from the child's mouth, and have him/her hold the breath in for 10 seconds.
5. The child should next exhale through the nose (do not allow the child to exhale out through the Turbuhaler).
6. Repeat step 2-5 for each subsequent dose. The usual prescribed dose is 2-4 puffs.
7. Replace the cover and screw it closed to protect the medication from moisture.
8. As with other inhaled steroids, have your child rinse out his/her mouth or brush his/her teeth after taking Pulmicort to prevent the development of oral thrush.

Special points about the Turbuhaler and Pulmicort:

Your child will not feel a spray or taste anything after inhaling the medication.
You do not need to shake the Turbuhaler before using it. The sound that is produced when the Turbuhaler is shaken is a drying agent, not the medication.
The mouthpiece should never be washed, but may be wiped using a dry cloth.

Aerosol Treatments by Nebulizer

Some asthma medications are administered in by a machine called a nebulizer. The nebulizer turns liquid medication into a mist, which can be breathed in. This method of delivering medication is especially useful for children who are unable to take in deep breaths, such as the very young or very sick.

Parts of the nebulizer:

Compressor: an electric machine which compresses air.

Air intake filter to filter impurities.

Hand-held nebulizer unit consists of:

A medication reservoir (cup) to hold the medication. The medication reservoir also has special ducts to vaporize the medication.

A cap which attaches to the top of the cup

Tubing which connects the medication reservoir to the air compressor.

A mask or mouthpiece which attaches to the top of the cap. The mask is held against the child's face allowing the child to breathe in the aerosolized medication. If the child is old enough to use a mouthpiece, the mouthpiece is placed in between the child's closed lips so that the medication may be inhaled with normal breathing. Many young children do not like the nebulizer mask over the face. If this happens, use the "T" connector component included in the nebulizer kit. Occlude one end of the "T" connector with your thumb or with a piece of tape. The mist form the nebulizer will then be directed out through the other end of the "T" connector. Hold the open end of the "T" connector about 2 to 3 inches from the child's face, allowing the mist to blow into the child's mouth and nose.

Medications: Medications for the nebulizer are available in two forms:

1. Medication which must be measured with a dropper or syringe, or
2. Medication which is pre-mixed and stored in tiny one-dose vials or ampules (called "unit dose vials" or "unit dose ampules").  Sometimes, two Medications are prescribed to be administered together through the nebulizer (for example, Pulmicort mixed with Xopenex). 

How to Use the Nebulizer

1. Wash your hands.
2. Assemble all the parts of the nebulizer. Plug in the compressor.
3. Measure the prescribed amount of medication(s), and put into the nebulizer cup.
4. Attach the cap to the nebulizer cup. Attach the mask or mouthpiece to the cap.
5. Attach one end of the tubing to the bottom of the nebulizer cup. Connect the other end of the tubing to the air outlet connector on the compressor machine.
6. Turn the compressor on. The medication should be coming out as a mist.
7. Hold the hand-held nebulizer unit upright, and place the mask onto the child's face. If using a mouthpiece, instruct the child to seal his/her lips around the mouthpiece and breath normally.
8. When the liquid is gone from the cup, and there is no more mist produced (usually about 10 minutes later), turn the compressor machine off.
9. After each treatment, take the hand-held nebulizer unit apart. Rinse all the pieces, except for the long tubing, with plain water. The tubing does not need to be   cleaned. Allow the pieces to air dry.