This is the standard mechanism for delivering drugs to small airways. It is essential that the patient/parent/carer is educated in the use of the device and that competence is checked. Adequate coordination is required.

• To use: shake inhaler to ensure inhaler is primed.
  
• Ask the child to exhale, place the mouthpiece in the child’s mouth. The child should commence breathing in as soon as the inhaler is pressed downwards to release the medication. They should continue to breathe in slowly and hold their breath for 10 seconds. If a second dose is required, the child should wait 
30 seconds before this is administered.

These devices allow the patient to prime the inhaler first and then when the patient takes a breath, the inhaler is activated. It avoids the need to coordinate breathing with release of the inhaler. It is useful for older children if they are able to use the device effectively.

Spacer devices slow down the particles and make coordination of activation and inhalation much less critical. They are useful for infants and children with poor inhaler technique. The main advantage is that they increase the proportion of dose delivered to the airways while reducing the proportion absorbed in the body. Inhalation from the spacer device should follow activation as soon as possible as the drug aerosol is very short-lived. The dose should be administered as a single actuation with tidal breathing for 10–20 seconds or five breaths.

Corticosteroid and bronchodilator therapy should be delivered by a pressurized MDI and spacer device (with a facemask if necessary) to children under 5 years. For children aged 5–15 years, corticosteroid therapy should be delivered by a MDI and spacer device. Spacers should be replaced annually or as the child grows and the spacer no longer is fit for their size. Cleaning should be carried out in accordance with manufacturer’s instructions.

These are small and portable, like MDIs, but require less coordination. The drug delivery to the lungs is dependent upon the patient’s peak inhaled flow rate. These may be useful for children over 5 years who are unwilling or unable to use a MDI with a spacer device.

The technique is the same as for MDIs but the number of doses available should be checked on the counter, then hold it horizontally, open the casing and push the level until it clicks. The dose is then ready for administration.