BNF for Children 2011-2012

BNFC 2011–2012 3.1.5 Peak flow meters, inhaler devices, and nebulisers 145NICE guidanceInhaler devices for children with chronicasthma (children under 5 years, August2000; children 5–15 years, March 2002)A child’s needs, ability to develop and maintaineffective technique, and likelihood of good complianceshould govern the choice of inhaler and spacerdevice; only then should cost be considered.For children aged under 5 years:. corticosteroid and bronchodilator therapyshould be delivered by pressurised metereddoseinhaler and spacer device, with a facemaskif necessary;. if this is not effective, and depending on thechild’s condition, nebulised therapy may be consideredand, in children over 3 years, a drypowder inhaler may also be considered [butsee notes above].For children aged 5–15 years:. corticosteroid therapy should be routinely deliveredby a pressurised metered-dose inhaler andspacer device;. children and their carers should be trained in theuse of the chosen device; suitability of the deviceshould be reviewed at least annually. Inhalertechnique and compliance should be monitored.Spacer devices Spacer devices are particularly usefulfor infants, for children with poor inhalation technique,or for nocturnal asthma, because the device reduces theneed for coordination between actuation of a pressurisedmetered-dose inhaler and inhalation. The spacerdevice reduces the velocity of the aerosol and subsequentimpaction on the oropharynx and allows moretime for evaporation of the propellant so that a largerproportion of the particles can be inhaled and depositedin the lungs. Smaller-volume spacers may be moremanageable for pre-school children and infants. Thespacer device used must be compatible with the prescribedmetered-dose inhaler.Use and care of spacer devices The suitability ofthe spacer device should be carefully assessed; openingthe one-way valve is dependent on the child’s inspiratoryflow. Some devices can be tipped to 458 to open thevalve during inhaler actuation and inspiration to assistthe child.Inhalation from the spacer device should follow theactuation as soon as possible because the drug aerosolis very short-lived. The total dose (which may be morethan a single puff) should be administered as singleactuations (with tidal breathing for 10–20 seconds or5–6 breaths for each actuation) for children with goodinspiratory flow. Larger doses may be necessary for achild with acute bronchospasm; for guidance on theManagement of Acute Asthma, see section 3.1.The device should be cleansed once a month by washingin mild detergent and then allowed to dry in airwithout rinsing; the mouthpiece should be wiped cleanof detergent before use. Some manufacturers recommendmore frequent cleaning, but this should beavoided since any electrostatic charge may affect drugdelivery. Spacer devices should be replaced every 6–12months.Able Spacer c (Clement Clarke)Spacer device, small-volume device. For use with all pressurised(aerosol) inhalers, net price standard device = £4.20;with infant, child or adult mask = £6.86AeroChamber c Plus (GSK)Spacer device, medium-volume device. For use with allpressurised (aerosol) inhalers, net price standard device(blue) = £4.53, with mask (blue) = £7.56; infant device(orange) with mask = £7.56; child device (yellow) with mask= £7.56Babyhaler c (A&H) DSpacer device, paediatric use with Flixotide c , andVentolin c inhalers, net price = £11.34Haleraid c (A&H)Inhalation aid, device to place over pressurised (aerosol)inhalers to aid when strength in hands is impaired (e.g.arthritis). For use with Flixotide c , Seretide c , Serevent c , andVentolin c inhalers. Available as Haleraid c -120 for 120-doseinhalers and Haleraid c -200 for 200-dose inhalers, net price= 80pOptichamber c (Respironics)Spacer device, for use with all pressurised (aerosol) inhalers,net price = £4.28; with small, medium or large mask = £7.00PARI Vortex Spacer c (Pari) DSpacer device, medium-volume device. For use with allpressurised (aerosol) inhalers, net price with mouthpiece =£6.07D; with mask for infant or child = £7.91; with adultmask = £9.97DPocket Chamber c (nSPIRE Health)Spacer device, small-volume device. For use with all pressurised(aerosol) inhalers, net price = £4.18; with infant,small, medium, or large mask = £9.75Volumatic c (A&H)Spacer inhaler, large-volume device. For use with ClenilModulite c , Flixotide c , Seretide c , Serevent c , and Ventolin cinhalers, net price = £2.81; with paediatric mask = £2.81NebulisersIn England and Wales nebulisers and compressorsare not available on the NHS (but they are free ofVAT); some nebulisers (but not compressors) areavailable on form GP10A in Scotland (for detailsconsult Scottish Drug Tariff).A nebuliser converts a solution of a drug into an aerosolfor inhalation. It is used to deliver higher doses of drugto the airways than is usual with standard inhalers. Themain indications for use of a nebuliser are:. to deliver a beta 2 agonist or ipratropium to a childwith an acute exacerbation of asthma or of airwaysobstruction;. to deliver prophylactic medication to a child unableto use other conventional devices;. to deliver an antibacterial (such as colistimethatesodium or tobramycin) to a child with chronicpurulent infection (as in cystic fibrosis or bronchiectasis);. to deliver budesonide to a child with severe croup;The proportion of a nebuliser solution that reaches thelungs depends on the type of nebuliser and although itcan be as high as 30% it is more frequently close to 10%and sometimes below 10%. The remaining solution isleft in the nebuliser as residual volume or it is deposited3 Respiratory system