What is the appropriate dosage and treatment regimen for a pediatric patient in foster care using a Metered-Dose Inhaler (MDI) for asthma or COPD?

MDI Use in Pediatric Foster Care Patients with Asthma

For pediatric patients in foster care requiring MDI therapy for asthma, the delivery method and dosing must be strictly age-based: children under 4 years require MDI with valved holding chamber (VHC) and face mask, while children 4 years and older can use MDI with VHC alone, with specific attention to proper technique training for caregivers. 1

Age-Specific Delivery Systems

Children Under 4 Years Old

• Must use VHC with tight-fitting face mask allowing 3-5 inhalations per actuation 1
• Face mask reduces lung delivery by 50%, but this is the only feasible delivery method for this age group 1
• Actuate only once into spacer/VHC per inhalation 1
• Nebulizer therapy is an alternative for patients who cannot tolerate face masks and spacers 1

Children 4 Years and Older

• Use MDI with spacer/VHC without face mask 1
• Slow (30 L/min or 3-5 seconds) deep inhalation, followed by 10-second breath-hold immediately after actuation 1
• Most 4-year-olds can generate sufficient peak inspiratory flows for adequate dosing 1

Acute Exacerbation Dosing

Albuterol MDI for Rescue Therapy

• Children: 4-8 puffs (360-720 mcg) every 20 minutes for 3 doses, then every 1-4 hours as needed 2
• Each puff delivers 90 mcg of albuterol 2, 3
• MDI with VHC is as effective as nebulized therapy for mild-to-moderate exacerbations when proper technique is used 2
• For severe exacerbations, nebulized therapy is preferred 2

Alternative: Nebulizer Dosing

• 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses 2
• Dilute to minimum of 3 mL at gas flow of 6-8 L/min 2
• Consider adding ipratropium bromide 0.25 mg for moderate to severe exacerbations 2

Controller Medication Dosing by Age

Children Ages 0-4 Years

• Budesonide nebulizer suspension is FDA-approved for ages 1-8 years 1
• Low dose: 0.25-0.5 mg daily
• Medium dose: >0.5-1 mg daily
• Administer twice daily 4

Children Ages 5-11 Years

• Fluticasone propionate HFA/MDI 1
  • Low dose: 88-176 mcg/day (1-2 puffs of 44 mcg twice daily)
  • Medium dose: >176-352 mcg/day (2-4 puffs of 110 mcg twice daily or 1-2 puffs of 220 mcg twice daily) 4
• Beclomethasone dipropionate HFA/MDI is FDA-approved for ages 5-11 years 1

Adolescents 12 Years and Older

• Fluticasone DPI (Flovent Diskus) 4
  • Mild persistent: 100 mcg twice daily
  • Moderate persistent: 250 mcg twice daily
  • Severe persistent: 500 mcg twice daily

Critical Technique and Safety Considerations

Proper Administration Technique

• Always use spacer/VHC with MDI—never allow direct MDI use without spacer in children under 5 years 4
• Rinse plastic VHCs monthly with dilute household detergent (1:5000 or drops per cup of water) and let drip dry 1
• Instruct patient to rinse mouth and spit after each ICS use to prevent oral thrush 1, 4
• No eating or drinking for at least 30 minutes after ICS administration 1

Foster Care-Specific Considerations

• Provide written instructions and hands-on training to all caregivers, as foster placements may change 5
• Consider electronic monitoring devices (MDILog) to objectively assess adherence, particularly valuable when multiple caregivers are involved 5
• Verify proper technique at every visit—most patients use inhalers incorrectly, which mimics inadequate dosing 4

Monitoring and Follow-Up

Initial Assessment Period

• Reassess every 2-6 weeks initially 4
• If no clear benefit within 4-6 weeks, discontinue and consider alternative diagnoses 4
• Monitor for local effects: cough, dysphonia, oral thrush 4

Long-Term Management

• Step down therapy after 2-4 months of sustained control to find minimum effective dose 4
• At medium-to-high doses, monitor growth velocity in children (potential 1 cm transient suppression) 4
• Use lowest dose that maintains control—benefits of ICS occur primarily at low-to-medium dose ranges 1

Common Pitfalls to Avoid

• Never use LABA without ICS—increased risk of severe exacerbations and asthma-related deaths 4
• Do not extrapolate spacer/VHC data from one MDI-device combination to others—effects vary significantly 1
• Avoid continuing therapy indefinitely without reassessment—goal is minimal effective dose 4
• Do not assume technique is adequate without direct observation—verify at every visit 4
• Ensure proper cleaning of nebulizers to prevent bacterial infections 1

Treatment Goals

• Minimal daytime symptoms and no nighttime awakening 4
• No missed school days and full participation in activities 4
• Infrequent need for rescue bronchodilators (≤2 days/week) 4