At what age should a spacer be used with a metered-dose inhaler (MDI)?

Spacer Use in Metered-Dose Inhalers Based on Age

A spacer or valved holding chamber (VHC) should be used with metered-dose inhalers (MDIs) in all children under 4 years of age, and is recommended for all patients regardless of age who have difficulty with proper MDI technique. 1

Age-Based Recommendations for Spacer Use

Children Under 4 Years

• Must use a VHC with face mask 1
• Face mask allows MDIs to be used with small children
• Note that face masks reduce medication delivery to lungs by approximately 50%
• Should have tight fit and allow 3-5 inhalations per actuation

Children 4-24 Years

• Should use a spacer or VHC 1
• Helps overcome coordination difficulties common in children
• Improves lung delivery and clinical response
• Particularly important for inhaled corticosteroids to reduce oropharyngeal deposition and side effects (e.g., thrush)

Adults 25 Years and Older

• Standard MDI technique may be sufficient if proper technique can be demonstrated
• However, spacers are still beneficial for:
  • Patients who have difficulty coordinating actuation and inhalation
  • Elderly patients
  • When using inhaled corticosteroids to reduce oropharyngeal deposition

Benefits of Spacer Use

1. Improves drug delivery to lungs by:

   • Overcoming hand-breath coordination problems
   • Allowing more time for propellant evaporation
   • Reducing oropharyngeal deposition

2. Reduces side effects by:

   • Decreasing oropharyngeal deposition of medication
   • Reducing risk of topical side effects like thrush with inhaled corticosteroids 1

3. Improves clinical outcomes by:

   • Being as effective as nebulizers for delivering bronchodilators in mild to moderate exacerbations 1
   • Providing a cheaper and more convenient delivery system than nebulizers 1

Proper Spacer Technique

For optimal results with a spacer or VHC:

• Actuate only once into spacer/VHC per inhalation
• Use slow (30 L/min or 3-5 seconds) deep inhalation
• Follow with 10-second breath hold immediately after actuation
• For children using face mask, ensure tight fit and allow 3-5 inhalations per actuation

Common Pitfalls and Solutions

1. Poor technique: Video instruction can significantly improve inhaler technique in young children 2

2. Electrostatic charge on plastic spacers: Rinse plastic VHCs once a month with low concentration of liquid household dishwashing detergent (1:5000 or a few drops per cup of water) and let air dry 1

3. Multiple actuations: Actuate only once into spacer/VHC per inhalation for optimal delivery

4. Cost barriers: Home-made spacers can be effective alternatives when commercial spacers are not affordable 3, though commercial VHCs are preferred when available

5. Inadequate maintenance: Regular cleaning and maintenance of spacers is essential for optimal medication delivery

Alternative Options

For children who cannot tolerate face masks and spacers, nebulizers may be needed 1. However, MDIs with spacers are generally preferred due to:

• Lower cost
• Greater convenience
• Comparable efficacy to nebulizers in mild to moderate exacerbations

For children over 4 years who can generate sufficient inspiratory flow, dry powder inhalers may be an alternative option, with studies showing comparable efficacy to MDI with spacer in children 5-15 years old 4.