What is the correct usage of a spacer with a mask for administering inhaled medications, such as bronchodilators (e.g. albuterol) or corticosteroids, to a child?

Correct Usage of Spacer with Mask in a Child

For children under 4 years of age, use a spacer (valved holding chamber) with a face mask that fits snugly over the nose and mouth, actuate the inhaler once into the spacer, and allow the child to take 3-5 tidal breaths (inhalations) through the mask before removing it from the face. 1

Step-by-Step Technique

Device Assembly and Preparation

• Shake the metered-dose inhaler (MDI) vigorously before each use 1
• Attach the MDI to the spacer device 1
• Ensure the face mask fits snugly over both the nose and mouth with no gaps 1, 2

Administration Technique

• Actuate only once into the spacer per treatment cycle - this is critical, as multiple actuations before inhalation reduce drug delivery 1
• Immediately after actuation, place the mask firmly over the child's nose and mouth 1
• Allow the child to take 3-5 slow tidal breaths through the spacer before removing the mask 1
• Wait at least 30-60 seconds between doses if multiple puffs are prescribed 1
• Repeat the process for each additional puff prescribed 1

Post-Administration Care

• Wash the child's face immediately after each treatment to prevent local side effects such as oral candidiasis, particularly when using inhaled corticosteroids 2
• This step is especially important for corticosteroid medications 2

Spacer Maintenance

Cleaning Protocol

• Rinse plastic spacers once monthly with a low concentration of liquid household dishwashing detergent (1:5000 dilution, or a few drops per cup of water) 1
• Allow the spacer to air dry completely (drip dry) rather than wiping with a towel 1
• This cleaning method reduces electrostatic charge on plastic spacers, which significantly improves drug delivery to the lungs 1

Replacement Schedule

• Replace disposable spacers every 3 months 1
• Replace durable spacers annually 1
• Replace immediately if you notice scratches, damage, or discoloration 1

Age-Specific Considerations

Children Under 4 Years

• Face masks are mandatory for this age group, as young children cannot coordinate breathing through a mouthpiece effectively 1, 2
• Children under 4 years cannot generate sufficient inspiratory flow to use dry powder inhalers or breath-actuated devices 1, 2
• The spacer with mask is the only effective delivery method for MDIs in this population 1

Children 4 Years and Older

• Transition to a mouthpiece (without mask) when the child can coordinate breathing and create a tight seal around the mouthpiece 1
• Mouthpieces are preferred over masks for inhaled corticosteroids to prevent facial deposition 1
• Continue using the spacer device even after transitioning to a mouthpiece, as coordination with MDI actuation remains challenging 1

Common Pitfalls and How to Avoid Them

Critical Errors to Avoid

• Never actuate multiple puffs into the spacer before inhalation - each actuation must be followed immediately by inhalation, as drug particles settle rapidly within the spacer 1
• Never allow gaps between the mask and face - even small leaks dramatically reduce drug delivery to the lungs 1
• Never skip shaking the inhaler - this is one of the most common errors, occurring in 82% of healthcare providers in training studies, yet it is essential for proper drug suspension 3
• Never wipe the spacer dry after washing - this creates static charge that attracts drug particles to the spacer walls rather than delivering them to the child 1

Timing Errors

• Do not rush between actuations - waiting 30-60 seconds allows the propellant to re-pressurize and ensures consistent dosing 1
• Do not remove the mask too quickly - ensure the child completes 3-5 breaths before removal 1

Clinical Context and Evidence

Why Spacers Are Superior to Nebulizers for Most Children

The European Respiratory Society guidelines establish that hand-held inhalers with spacers are as effective as nebulizers for most pediatric asthma management and should be the preferred delivery method 1, 4. The American Thoracic Society confirms that in symptomatic premature infants, MDI with spacer delivery avoided the paradoxical deterioration in airway resistance seen 5 minutes after nebulization 1.

Advantages of MDI with Spacer Over Nebulization

• Shorter administration time (5-15 minutes vs. longer nebulization) 1
• No cooling of gases 1
• Avoids paradoxical bronchoconstriction that can occur with nebulizers 1
• More portable and convenient 1

When Nebulizers May Be Preferred

Nebulizers remain appropriate for children who cannot tolerate a face mask, during severe acute exacerbations when the child is in significant respiratory distress, or when spacer technique has failed despite proper education 1, 4. However, even in acute severe asthma, MDI with spacer can be as effective as nebulizers when properly used 1, 4.

Device Selection Considerations

Spacer Volume and Design

• Large volume spacers (>750 mL) are recommended for young children to maximize drug delivery 1
• Valved holding chambers are preferred over simple tube spacers, as they allow the child to inhale at their own pace 1
• Antistatic spacers or properly cleaned plastic spacers significantly improve drug delivery compared to uncleaned devices 1