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Correct use of a MDI Shake the MDI. Squeeze it once in the air if it has not been used for some days. A puff should be seen. Hold the MDI before the child's open mouth. (The technique for using it with a spacer is different). Ask the child to start breathing in. This should be done through the open mouth only. If necessary, pinch the nose shut. Squeeze the MDI, releasing a puff of medicine into the child's open mouth. The child should continue breathing in, thus taking the medicine into the lungs. If the child is old enough, holding the breath for a few seconds increases the effectiveness. This may be difficult if the child is breathless due to an acute asthma attack. 5-10% of the metered dose released by the MDI reaches the lungs. The rest is deposited in the mouth, and swallowed. Rinsing the mouth after every puff from a MDI removes the drug in the mouth and reduces side effects. Most children find it difficult to coordinate breathing and activation of the MDI. This can lead to reduced or absent effect.

Metered Dose Inhalers

These small devices have made a tremendous difference in the management of asthma. They consist of a small canister of medicine under pressure, and a mechanism to release a measured amount of the medicine every time the device is squeezed. They contain freon gases as an inert propellant, though newer ones use environment friendly gases such as HFA. Correctly used, about 20% of the drug released reaches the lungs, but correct use is difficult and rare, even among adults.

Metered dose inhalers are used commonly to treat asthma, and a large variety of drugs is available in this form. While children find it difficult to use them, the use of a   spacer   makes the task easy and effective. The combination of a spacer and metered dose inhaler make the advantages of   inhaled therapy   available to children.

Unlike with   dry powder inhalers, a strong breath is not needed to benefit from a metered dose inhaler. Even small babies can be given   inhaled therapy, with a metered dose inhaler. The device also works in breathless children with an acute attack of asthma. However, correct technique is very important for the proper effect (see box).

What drugs are available?

All the drugs available for inhaled therapy are available as metered dose inhalers.
Reliever drugs:- salbutamol, terbutaline, ipratropium.
Controller drugs:- cromoglycate, formoterol, salmeterol, beclomethasone, budesonide, fluticasone.

Children and MDIs

The problem for children is that metered dose inhalers (MDIs) require that the squeezing of the device be done just when inhalation is being started. This coordination is difficult even for adults. Younger children are simply unable to do it. Even older children who use a MDI regularly may be unable to do it when suffering an acute asthma attack with difficulty in breathing.

Fortunately, solutions are available. A breath actuated MDI is available, which can be prepared and placed in the child's mouth. When the child breathes in, the MDI is activated, releasing the drug. However, some children are unable to breathe hard enough to trigger it off. When the device is triggered off inside the mouth, the stimulus can cause the child's throat to close, preventing drug reaching the lungs (this is known as the cold freon effect).

The best solution is the use of a spacer device. The drug is held suspended in the air inside the spacer for a short while, from which the child breathes it in over 4-5 breaths. These devices, with a face mask, allow even small babies to use a metered dose inhaler effectively. Spacer devices are easily available in India in different sizes.

Cost considerations

MDIs are available in 200 dose canisters, and the cost varies from Rs 70 for salbutamol to several hundred rupees for newer drugs like fluticasone. The initial cost can be pushed up by the need for a spacer, which costs Rs 195-375/-.

Last revision: July 15, 2007

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