Paeds · clinical-pharmacology-and-therapeutics
Inhaled therapies and device selection
Also known as Inhaler device selection in children · Spacer and valved holding chamber use · MDI, DPI and nebuliser in paediatrics · Aerosol drug delivery in children · Age-based inhaler choice
A fellowship approach to inhaled therapies and device selection in children covering the four device families — pressurised metered-dose inhaler, dry-powder inhaler, soft-mist inhaler and nebuliser — why a valved holding chamber (spacer) transforms pressurised-inhaler delivery, how aerosol particle size, inspiratory flow and coordination decide where a drug lands, and the age-based device ladder from the masked spacer in infants and toddlers to the dry-powder inhaler in the school-age child and self-managed adolescent.
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Target exams
Red flags
- A pressurised metered-dose inhaler prescribed for a child under four without a spacer and a tightly-fitting face mask
- A dry-powder inhaler prescribed for a preschool child who cannot generate the inspiratory flow it needs
- An unprimed or static-charged plastic spacer used to deliver an inhaled corticosteroid or reliever
- Acute severe asthma managed by nebuliser in a child who could use a spacer, while oxygen is withheld
- Technique never rechecked at a follow-up visit despite poor symptom control
- Inhaled corticosteroid continued without a rinse-and-spit or without a dose counter check
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Current 2026 PREP curriculum — Learning Objective: Safe prescribing and medication management in infants, children and young people
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: Clinical management – essential general paediatrics
- Renewed curriculum for first-year trainees from 2027 — Learning goal 9: Quality and safety, including medication safety
- Clinical Applications
- Medical Sciences — Pharmacology
- Long Cases
- Short Cases
- 4. Professional skills and knowledge: Patient management
- 7. Patient safety, including safe prescribing
- Respiratory: Selecting and teaching the correct inhaler device for the child's age and ability
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- General Pediatrics Content Outline — Domain 10: Principles of Pharmacology and Medication Management
- General Pediatrics Content Outline — Domain 8: Respiratory
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- Medical Knowledge 2: Diagnostic and Therapeutic Decision Making
- Patient Safety/Quality Improvement 1: Medication Safety
- Systems-Based Practice: chronic disease management and adherence
- Medical Expert
- Pediatrics: Core EPA #5 — Recommending and Initiating Pharmacologic Interventions
Overview & Definition
Picture a wheezy eighteen-month-old, a five-year-old with viral wheeze, and a twelve-year-old with established asthma. All three need an inhaled bronchodilator, but what they actually need to make that drug work is three different devices. The toddler cannot time a fast aerosol cloud to a single breath and cannot draw the powder through a disk, so she needs a pressurised inhaler seated in a small spacer with a mask sealed to her face. The five-year-old can use a spacer with a mouthpiece but probably cannot yet inhale a dry powder reliably. The twelve-year-old can choose a dry-powder inhaler or a spacer, guided by her own inspiratory flow and preference. [1] [2]
Two ideas govern everything that follows. First, the dose that reaches the lung is not the dose written on the label — it is the fraction that escapes the device, survives the upper airway, and is small enough and timed well enough to deposit in the bronchi. A pressurised inhaler used without a spacer deposits most of its dose in the oropharynx, not the lung; the same drug through a spacer multiplies lung delivery several-fold. [1] Second, that fraction depends on properties of the child that change with age — tidal volume, inspiratory flow, breath-hold ability, and the seal of a mask. A device that fits a teenager will deliver almost nothing to a toddler, and a device that fits a toddler will frustrate a teenager into non-adherence. Selecting the device is therefore a clinical act, not a pharmacy default. [2] [3]
From the prescription to the lung
- 1
1 · Choose the drug
Select reliever (salbutamol) or preventer (inhaled corticosteroid) by the child's diagnosis and severity, weight-based where relevant.
- 2
2 · Match the device
Pick the device by age, inspiratory flow and coordination — spacer plus mask under four, spacer plus mouthpiece four to six, DPI from school age.
- 3
3 · Prepare the device
Prime a new spacer, shake a pressurised inhaler, load a dry-powder device, and ensure the mask seals or the mouthpiece is sealed by the lips.
- 4
4 · Deliver the breath
One actuation into the spacer followed by slow tidal breathing (younger) or slow deep breaths with a breath-hold (older); one sharp inhalation for a DPI.
- 5
5 · Check and re-teach
Rinse after an inhaled corticosteroid, count the doses, and re-check technique at every visit — technique drifts.
References11ShowHide
- [1]Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest, 2005.PMID 15654001
- [2]Pedersen S, Dubus JC, Crompton GK The ADMIT series--issues in inhalation therapy. 5) Inhaler selection in children with asthma. Primary Care Respiratory Journal, 2010.PMID 20640390
- [3]van Aalderen WM, Garcia-Marcos L, Gappa M, et al. How to match the optimal currently available inhaler device to an individual child with asthma or recurrent wheeze. NPJ Primary Care Respiratory Medicine, 2015.PMID 25568979
- [4]Kuek SL, Wong NX, Dalziel S, et al. Dry-powder inhaler use in primary school-aged children with asthma: a systematic review. ERJ Open Research, 2024.PMID 39655170
- [5]Cates CJ, Welsh EJ, Rowe BH Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database of Systematic Reviews, 2013.PMID 24037768
- [6]Iramain R, Castro-Rodriguez JA, Jara A, et al. Salbutamol and ipratropium by inhaler is superior to nebulizer in children with severe acute asthma exacerbation: Randomized clinical trial. Pediatric Pulmonology, 2019.PMID 30672140
- [7]Sugiura K, Hagiwara Y, Nomura O, et al. Procaterol via nebulizer versus metered-dose inhaler with a spacer for acute asthma exacerbation in children. Pediatrics International, 2025.PMID 40365987
- [8]Amirav I, Newhouse MT Aerosol therapy in infants and toddlers: past, present and future. Expert Review of Respiratory Medicine, 2008.PMID 20477295
- [9]Amirav I, Newhouse MT, Luder A, et al. Feasibility of aerosol drug delivery to sleeping infants: a prospective observational study. BMJ Open, 2014.PMID 24670428
- [10]Williams DM, Rubin BK Clinical Pharmacology of Bronchodilator Medications. Respiratory Care, 2018.PMID 29794201
- [11]Stempel DA, Szefler SJ, Pedersen S, et al. Safety of Adding Salmeterol to Fluticasone Propionate in Children with Asthma. New England Journal of Medicine, 2016.PMID 27579634