Inhalation or inhaler – a guide for beginners

Inhalation or inhaler – a guide for beginners

It’s important to understand that giving inhalation or using an inhaler with your child is kind of an international sport. There are soccer, volleyball, Ping-Pong and preforming inhalations.
In many countries, when you go to a doctor, the first time he will say it is viral. At the second round he will administer saline drops or something similar (sometimes even saline inhalations). At the third round he will administer inhalers or inhalations ± unnecessary antibiotics.
I request all the readers of this post to read the very important post about childhood illness in the winter time, where you can get basic definitions on what is upper respiratory tract infection and what are bronchiolitis and other very important definitions you should know (and are related to the use of inhalations or inhalers). That chapter is right here.
The main goal of this post is to understand the differences between inhalation and inhaler and how to give them correctly to kids.

What are inhalations or inhalers used for?

Inhalations or inhalers are both methods for administering medications directly to the lungs. Instead of taking medication in the form of pills or syrup, inhalation or inhaler is delivering the medication to the area where it needs to be active – the airways and the lung.
The indication for treatment is mainly asthma or “baby’s asthma” (a matter of definition by age). In other words – these medications are for children at any age, with obstruction of the lower airways (recognized by the physician). Not for children with a  just a cough and not for children with just any fever.

What is the main difference between inhalations and inhalers?

The active ingredients are the same (bronchodilators and steroids) but the methods of administration are different.
Inhalation – a machine that turns liquid into fumes. The medication is turned from liquid to fumes, and then inhaled by the child or adult.
Inhaler – a little device that can dispense the medication directly into the lungs of the child or adult. It is easy to picture an adult breathing out and then taking a deep breath while pressing the inhaler at the same time. Children are having a hard time synchronizing it, so using a spacer as well as an inhaler is a must.

What is a spacer and why do we need it?

A spacer is a container used for dispensing the particles of the medication to the lungs of a child, who cannot use the inhaler directly with a synchronized breath.
In one end of the spacer there is a space for inserting the different inhalers, and on the other end a mask that covers the mouth and nose of the child. Using a spacer eliminate the need for synchronized breath (which is needed when using an inhaler).
There are many different brand names for spacers. The brand itself is not important; the main thing is to have room for inserting the inhaler and a mask at the other end.
Remember that the mask has to be adjusted to the age and size of the child, so there are different sizes.

When will the physician recommend inhalation and when will he recommend inhaler?

The use of inhalers is almost always preferred over inhalation, just because the dispensing of the medication particles in the lungs is better using this method. Another practical and important advantage is the time factor. Inhalers take about one minute to administer, while inhalation takes about 10 minutes.
So one of the main messages of this post is that there is a true advantage in every medical indication to use inhalers over inhalation.
In some cases, when a family has an inhalation device left from the older brother and there is no desire to go outside late at night to purchase inhalers and a spacer, you might as well use inhalations.
But those of you purchasing a new inhalation device today, ask yourself (and your physician), why is it necessary? Those of you who have inhalation device at home and use it frequently, I suggest turning it into a planter and move on to inhalers.

What are the common medications used in inhalation or inhaler?

Most of the medications are bronchodilators or steroids.
Saline: this is not a medication, and mostly does not used for treatment at all. Using saline inhalation alone is mostly not necessary and is used as a sport for the parents (and for the physician as well), so they can feel they are doing something to help the child. The use of saline is mainly to give volume to the inhalation solution that is used.
Bronchodilators: these are used to relax the smooth muscle in the lungs and expand the airways. Bronchodilators are usually given with inhaled steroids.
Steroids: anti-inflammatory medications, used to treat acute asthmatic episodes.

What are the doses for inhalation?

It depends on the specific recommendation from the physician. And yet, in most cases the dosages are:
Bricalin/Ventolin/Terbulin: in children over 6 months – 0.5 ml, in children younger than 6 months – 0.3 ml.
Budesonide (Budicort or Budecort): In most settings, Budesonide comes in two forms (called respules), in two different concentrations. A lower dose of 2 ml = 0.5 mg, and a high dose of 2 ml = 1 mg. I recommend using the high concentration. In the inhalation device you usually put 1 ml of Budesonide (in the concertation recommended by your physician). I hereby call out for “Astrazeneca”, the manufacturer of this popular medication (Budicort) to manufacture it in little vials of 1 ml (in different concentrations), and lower its price accordingly. On the other hand, on the consumer pamphlet, is it specified that the respules can be kept open for 12 hours, so can be used again for the next inhalation. Read more about it in this link.
Saline: 0.5 ml.
Overall there should be 2 ml in the inhalation device before starting the treatment.
In children younger than 6 months, you should lower the dose of Bricalin/Ventolin/Terbulin to 0.3 ml. In that case you can up the saline to 0.7 ml to complete the solution to a total of 2 ml.
At the end of each treatment you should let the child drink a little water (or formula) to wash the rest of the steroids from the mouth, and prevent the development of oral Candida.

What are the dosages, order of administration, and how to treat a child with an inhaler?

In this scenario, you should also ask your physician for his recommendation for each specific case. Yet, in most cases the order of administration and the dosages will be like so:
Always start with Salbutamol (Ventolin/Salamol/Albuterol sulfate), in a constant dose of 100 mcg. Start by sealing the mouth and nose of the child with the mask, until he is calm (though it is not the end of the world if he is not calm when starting). Then, press the inhaler attached to the other side of the spacer and wait with the mask on the child’s face for about 10 seconds. Then press the inhaler for the second time and wait 10 more seconds.
After that you can go on and use the Flixotide inhaler (comes in a variety of beige color, depending on the dosage). Dosage can be 50/125/250 mcg, as per the decision of your physician. I do not have a solid opinion on the dosage, since the consumer pamphlet and the manufacturer are very vague about it. So what do I do? In young infants (younger than one year old) I recommend using 50 mcg. In older children (1-4 years) 125 mcg, and in children older than 4 years, where there are alternatives to this inhaler, I recommend using the 250 mcg inhaler.
The process is the same as it was with Ventolin (pressing the inhaler, waiting 10 seconds and repeating the process).
At the end of each treatment you should let the child drink a little water (or formula) to wash the rest of the steroids from the mouth, and prevent the development of oral Candida.
The treatment with inhaler is usually given twice a day. If needed – the physician can recommend additional treatments throughout the day, though it will usually be just Ventolin, without steroids.

How long is a treatment course?

Again, it will be per the physician decision according to the diagnosis and the severity of the attack. Usually when starting treatment you will continue for additional 24 hours after the child feels better. It you treat your child more than 5 days with no real improvement, go see your physician for additional evaluation.
There is an approach that allows decreasing dosage after an initial improvement. For example, giving one inhalation a day instead of two, or treating with an inhaler with just one press from each substance (Ventolin and steroids). These are decisions the pediatrician needs to make along with you.
I remind you that there are children receiving preventive treatment, usually just steroids, for a more persistent asthma. This will not be discussed here.

What are the side effects when treating with inhalations or inhalers?

Bronchodilators – mainly elevated heart rate, tremor and feeling uncomfortable. This is way babies younger than 1 year old are getting a decreased dose of 0.3 ml. in cases these symptoms occur in older children, you can decrease the dose next time.
Steroids – inhaled steroids given for such short periods of time do not have any significant side effects. You can say that if the indication for treatment was correct (and not just because the parents arrived 3 times in one week to the clinic), the child will enjoy the relief in symptoms more than he will suffer from the minor side effects of steroids. Just remember to wash the mouth after treatment so the child will not develop oral candida. Hoarseness is also described after steroids inhalers, be it will pass after a while.
Growth stunt or other long term steroid side effects? Absolutely not.
Clearly, as with any other medication you need to choose the right dosage for the child. What I mean is – do not give 4 doses of 250 mcg Flixotide to a small baby, but use the correct and age adjusted dosage.

For conclusion – this post waited a long time to be written. My hope is that these small rules will help your child get the best treatment. In one hand – do not get unnecessary treatment when no intervention is needed, on the other – get the correct treatment when it is needed. This is pediatrics 101.

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