What is the proper technique for using an inhaler spacer with a metered-dose inhaler (MDI)?

Proper Inhaler Spacer Technique

The proper technique for using an inhaler spacer with a metered-dose inhaler (MDI) requires a slow, deep inhalation followed by a 10-second breath hold after actuation to maximize medication delivery to the lungs. 1

Correct Spacer Technique

Preparation Steps

• Shake the MDI vigorously before use 1
• Remove the cap from the MDI and spacer
• Insert the MDI mouthpiece into the spacer device
• Ensure proper assembly of the spacer 2

Inhalation Technique

1. For adults and children ≥4 years old:

   • Place the spacer mouthpiece between teeth and seal lips around it
   • Actuate the MDI only once into the spacer 1
   • Take a slow, deep breath (30 L/min or 3-5 seconds) immediately after actuation 1
   • Hold breath for 10 seconds 1
   • If another dose is needed, wait 30-60 seconds before repeating

2. For children <4 years old:

   • Use a spacer with a face mask attachment
   • Ensure the face mask has a tight fit 1
   • Allow 3-5 inhalations per actuation 1
   • Note: Face masks reduce delivery to lungs by approximately 50% 1

Maintenance of Spacer Devices

• Rinse plastic spacers/valved holding chambers (VHCs) once a month with a low concentration of liquid household dishwashing detergent (1:5000 or a few drops per cup of water) 1
• Allow to air dry completely 1
• Do not wipe dry as this may increase static charge 3
• Replace spacers according to manufacturer recommendations

Benefits of Using Spacers

Spacers provide several important advantages over using an MDI alone:

• Minimize coordination difficulties between actuation and inhalation 3
• Reduce oropharyngeal deposition of medication 1, 3
• Increase lung deposition of medication 3
• Decrease risk of topical side effects (e.g., thrush) with inhaled corticosteroids 1
• Provide clinical effectiveness equal to nebulizer machines 1

Common Errors to Avoid

• Not shaking the MDI before use 2
• Insufficient breath holding after inhalation 2
• Actuating multiple times into the spacer before inhaling 1
• Exhaling into the device before inhalation 4
• Using a spacer with accumulated static charge 3
• Improper assembly of the spacer device 2

Special Considerations

• If a commercial spacer is unavailable, improvised spacers made from a 500-mL plastic bottle or 150-mL disposable paper cup can provide similar drug delivery 1
• Antistatic VHCs or properly rinsed plastic non-antistatic VHCs enhance delivery to lungs 1
• Spacers are particularly beneficial for patients who have difficulty with proper MDI technique, including elderly patients and young children 1

By following these steps, patients can maximize the effectiveness of their inhaled medications while minimizing side effects and medication waste.