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Mini-Wright
c
, range 30–400 litres/minute, net price = £6.90,
replacement mouthpiece = 38p (Clement Clarke)
Pocketpeak
c
, range 50–400 litres/minute, net price = £6.53,
replacement mouthpiece = 38p (nSPIRE Health)
Note
Readings from new peak flow meters are often lower than
those obtained from old Wright-scale peak flow meters and the
correct recording chart should be used
Drug delivery devices
Inhaler devices
These include
pressurised metered-
dose inhalers
,
breath-actuated inhalers
,
and
dry pow-
der
inhalers
.
Many patients can be taught
to use a
pressurised metered-dose inhaler effectively but some
patients, particularly the elderly and children, find them
difficult to use.
Spacer devices
(see below) can help such
patients because they remove the need to coordinate
actuation with inhalation.
Dry powder inhalers may be
useful
in adults and children over
5 years
who are
unwilling or unable to use a pressurised metered-dose
inhaler.
Alternatively,
breath-actuated inhalers are sui-
table for adults and older children provided they can use
the device effectively.
On changing from a pressurised metered-dose inhaler to
a dry powder
inhaler,
patients may notice a lack of
sensation in the mouth and throat previously associated
with each actuation.
Coughing may also occur.
The patient should be instructed carefully on the use of
the inhaler and it is important to check that the inhaler
continues
to be used correctly because inadequate
inhalation technique may be mistaken for
a lack of
response to the drug.
NICE guidance
Inhaler devices for children with chronic
asthma (children under 5 years, August
2000; children 5–15 years, March 2002)
A child’s
needs,
ability to develop and maintain
effective technique,
and likelihood of
good compli-
ance should govern the choice of inhaler and spacer
device;
only then should cost be considered.
For children aged under 5 years:
.
corticosteroid
and
bronchodilator
therapy
should be delivered by pressurised metered-
dose inhaler and spacer device, with a facemask
if necessary;
.
if
this is not
effective,
and depending on the
child’s condition, nebulised therapy may be con-
sidered and,
in children over
3 years,
a dry
powder
inhaler
may also be considered [but
see notes above].
For children aged 5–15 years:
.
corticosteroid therapy should be routinely deliv-
ered by a pressurised metered-dose inhaler and
spacer device;
.
children and their carers should be trained in the
use of the chosen device; suitability of the device
should be reviewed at
least
annually.
Inhaler
technique and compliance should be monitored.
Spacer devices
Spacer devices remove the need for
coordination
between
actuation
of
a
pressurised
metered-dose inhaler and inhalation. The spacer device
reduces
the velocity of
the aerosol
and subsequent
impaction on the oropharynx and allows more time
for evaporation of the propellant so that a larger propor-
tion of the particles can be inhaled and deposited in the
lungs. Spacer devices are particularly useful for patients
with poor inhalation technique, for children, for patients
requiring high doses
of
inhaled corticosteroids
(see
Management
of
Chronic
Asthma
table,
p.
172),
for
nocturnal asthma, and for patients prone to candidiasis
with inhaled corticosteroids.
The size of
the spacer is
important,
the larger
spacers
with a one-way valve
(
Volumatic
c
)
being most
effective.
It
is important
to
prescribe a spacer device that
is compatible with the
metered-dose inhaler, see devices below. Spacer devices
should not
be regarded as
interchangeable;
patients
should be advised not to switch between spacer devices.
Use and care of
spacer devices
Patients should
inhale from the spacer device as soon as possible after
actuation because the drug aerosol
is very short-lived;
single-dose actuation is recommended.
Tidal breathing
is as effective as single breaths.
The device should be
cleaned once a month by washing in mild detergent and
then allowed to dry in air without rinsing;
the mouth-
piece should be wiped clean of
detergent
before use.
Some manufacturers recommend more frequent clean-
ing,
but this should be avoided since any electrostatic
charge may affect drug delivery. Spacer devices should
be replaced every 6–12 months.
Able Spacer
c
(Clement Clarke)
Spacer device
,
small-volume device.
For use with all pres-
surised (aerosol) inhalers, net price standard device = £4.20;
with infant,
child or adult mask = £6.86
AeroChamber
c
Plus
(GSK)
Spacer device
,
medium-volume device.
For use with all
pressurised (aerosol) inhalers, net price standard device
(blue) = £4.53,
with mask (blue) = £7.56;
infant device
(orange) with mask = £7.56; child device (yellow) with mask
= £7.56
Babyhaler
c
(A&H) D
Spacer device
,
for paediatric use with
Flixotide
c
, and
Ventolin
c
inhalers, net price = £11.34
Haleraid
c
(A&H) D
Inhalation aid
,
device to place over pressurised (aerosol)
inhalers to aid when strength in hands is impaired (e.g.
in
arthritis). For use with
Flixotide
c
,
Seretide
c
,
Serevent
c
, and
Ventolin
c
inhalers. Available as
Haleraid
c
-120
for 120-dose
inhalers and
Haleraid
c
-200
for 200-dose inhalers, net price
= 80p
Nebuchamber
c
(AstraZeneca)
Spacer device
, for use with
Pulmicort
c
aerosol inhalers, net
price = £8.56
Optichamber
c
(Respironics)
Spacer device
, for use with all pressurised (aerosol) inhalers,
net price = £4.28; with small, medium or large mask = £7.00
PARI Vortex Spacer
c
(Pari)
Spacer device
,
medium-volume device.
For use with all
pressurised (aerosol) inhalers, net price with mouthpiece =
£6.07D; with mask for infant or child = £7.91; with adult
mask = £9.97D
Pocket Chamber
c
(nSPIRE Health)
Spacer device
,
small-volume device.
For use with all pres-
surised (aerosol) inhalers, net price = £4.18; with infant,
small, medium,
or large mask = £9.75
Volumatic
c
(A&H)
Spacer inhaler
, large-volume device. For use with
Clenil
Modulite
c
,
Flixotide
c
,
Seretide
c
,
Serevent
c
, and
Ventolin
c
inhalers, net price = £2.81;
with paediatric mask = £2.81
BNF 61
3.1.5 Peak flow meters, inhaler devices and nebulisers
183
3
Respiratory system