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CHEO Childhood Asthma Devices

Asthma Monitoring Device (the Peak Flow Meter)

Peak Flow Meter

This device measures the maximum flow with which air can be forced out of the lungs. Early in an asthma attack the maximum flow may be decreased, and a peak flow meter may help detect an attack in its early stages. Most children over 6 years of age can use a peak flow meter reliably.

   Instructions

  1. Set the marker to the lower end of the scale (at zero). Make sure your fingers do not cover the number scale.
  2. Ask your child to take in as deep a breath as he/she can.decorative image
  3. Place the mouthpiece of the peak flow meter into your child's mouth with his/her lips tightly around it.
  4. Ask your child to blow out rapidly into the peak flow meter as hard and as fast as he/she can.
  5. Ask your child to breathe out, emptying his/her lungs.
  6. Read the peak expiratory flow value on the scale, then repeat steps 1 to 4, two more times.
  7. Record your child's highest expiratory flow rate on his/her diary card.

   Hints

  1. The best way to check your child's "normal" value is to check the peak flow rate several times when he/she has no asthma symptoms. The highest value achieved is considered your child's personal best.
  2. Peak flow rates should be recorded on a diary card each morning and night or according to your physician's instructions. There are also a variety of app’s available for your Smart phone, that will let you keep track of you or your child’s peak flow on a Smart phone. Finally, you can keep track of the peak flows on a spreadsheet on your computer. Your doctor should provide you with a written action plan to help you decide what action to take based on your child's peak flow readings.
  3. If the value drops below a predetermined range established by your physician, this should be considered a warning sign. Your physician should be contacted or you should start your medication action plan for asthma flare-ups.
  4. In general a peak flow between 80 to 100% of personal best is where your child should be every day. A peak flow between 50 to 80% of personal best indicates asthma is not under control, and a peak flow under 50% of personal best indicates your child is having a severe asthma attack.
  5. In people who aren’t certain what’s causing their asthma symptoms or whether breathing problems are due to asthma, peak flow meters can be a useful tool. For example, you can check whether your child’s peak flows change in hockey arenas, with animal exposure, or other potential exposures. You can also see if your child’s peak flow changes just after exercise; this can be a useful sign of exercise-induced asthma.

IF DESPITE YOUR BEST EFFORTS YOUR CHILD'S ASTHMA IS NOT WELL CONTROLLED OR WORSENS, PLEASE SEEK MEDICAL ATTENTION IMMEDIATELY.

Asthma Inhaler Devices:

The Turbuhaler®decorative image

Finely powdered medication is contained inside this device in pre-measured doses. This device can be used by most children over 5 years of age.

  • Pulmicort® (Budesonide) — brown base on turbuhaler® (steroid)
  • Bricanyl (Terbutaline) — blue base on turbuhaler® (short-acting bronchodilator)
  • Oxeze® (formterol) — green base on turbuhaler® (long-acting bronchodilator)
  • Symbicort® (budesonide and oxeze) — red base on turbuhaler® (long-acting bronchodilator plus steroid)

   Instructions

  1. Unscrew the cover and lift it off.
  2. Holding the inhaler upright, turn the coloured base to the right as far as it will go, then back to the left until you hear a click. This releases a measured dose of medication.
  3. Ask your child to breathe out, emptying his/her lungs.
  4. Have your child close his/her lips tightly around the mouthpiece then ask him/her to breathe in slowly and deeply through the mouth. For young children a deep breath is necessary. In older children a "medium sized" breath is best. Once your child has breathed in, remove the mouthpiece from the child's mouth, and have him/her hold the breath in for 5 to 10 seconds or as long as possible. Do not allow your child to breathe out into the turbuhaler®.
  5. If your child is to take a second dose of medication, wait 30 seconds then repeat steps 2 to 4.
  6. Replace the cover and screw it shut to protect contents from moisture.

   Hints

  1. Your child may not feel or taste anything after they inhale the medication.
  2. The sound you hear when you shake the turbuhaler® is a drying agent, not the medication. You don't need to shake the turbuhaler® before using it.
  3. With most turbuhalers®, there are about 20 doses left when the red mark appears at the top of the window underneath the mouthpiece. When the red mark reaches the bottom of the window, the turbuhaler® is empty, and must be replaced. However, the Symbicort® turbuhaler® contains a dose counter. When the "0" has reached the middle of the window, the Symbicort® turbuhaler® is empty, and must be replaced.
  4. The mouthpiece should never be washed, but may be wiped using a dry cloth.
  5. If your child is using Pulmicort® have your child rinse his/her mouth with water after each use. This will reduce the risk of developing a yeast infection in the mouth or throat.

IF DESPITE YOUR BEST EFFORTS YOUR CHILD'S ASTHMA IS NOT WELL CONTROLLED OR WORSENS, PLEASE SEEK MEDICAL ATTENTION IMMEDIATELY

The Metered-Dose Inhaler (MDI)

This is a metal canister placed in a plastic holder. Most children under the age of 9 cannot use an MDI properly. For these children, a spacer should be used with the MDI. Regardless of the child's age, spacers are recommended when a steroid inhaler is used, to reduce the risk of developing a yeast infection in the mouth or throat.decorative image

   Instructions

  1. Make sure that the metal canister is placed firmly in the plastic holder.
  2. Remove the cap and shake the MDI well. If you are using Airomir™ or QVAR™, it is not necessary to shake the MDI before using it. However, if the MDI hasn't been used for 2 weeks or more, release several (4) "puffs" of medication into the air away from anyone, by depressing the metal canister, before taking the medication yourself, or giving it to your child.
  3. Ask your child to breathe out, emptying his/her lungs.
  4. Have your child tilt his/her head back slightly and place the mouthpiece about the width of 2 fingers in front of his/her open mouth.
  5. Have your child start breathing in slowly and deeply through the mouth. About 1/3 of the way into the breath, have him/her depress the metal canister to release one puff of the medication, while continuing to breathe in all the way. Once your child has breathed in fully, have your child hold his/her breath in for 5 to 10 seconds or as long as possible before breathing out.
  6. If your child requires more than one puff of the medication, wait 30 seconds, shake the MDI again, then repeat steps 3 to 5.

   Hints

  1. If you see a mist escaping from the mouth during the inhalation, the child's technique must be improved.
  2. Rinse plastic holder of MDI regularly with warm tap water. Remove canister from plastic holder before rinsing. Let dry thoroughly before replacing the canister.
  3. To check the level of medication remaining in your MDI, remove the metal canister from the plastic holder. Placing a finger on the top of the canister, gently shake, feeling for liquid moving within the canister. When little liquid movement can be felt, the MDI is almost empty.
  4. If you are having trouble telling whether your child is using his or her MDI too much or too little, you may want to consider purchasing the MDI Chronolog®, an electronic device which fits on top of the MDI and will tell how many doses of medication have been used.
IF DESPITE YOUR BEST EFFORTS YOUR CHILD'S ASTHMA IS NOT WELL CONTROLLED OR WORSENS, PLEASE SEEK MEDICAL ATTENTION IMMEDIATELY.

The Spacer with Mask

decorative imageThe AeroChamber® is a holding device which helps to deliver medication in young children (usually under 5 years of age) who cannot coordinate their breathing well enough to use a metered-dose inhaler (MDI) alone. The AeroChamber® is used together with an MDI. There are two sizes of AeroChamber® with mask. The orange AeroChamber® is used for infants less than 1 year of age. The yellow AeroChamber® is used in children approximately 1 to 5 years of age.

   Instructions

  1. Prepare the MDI by removing the cap, shaking the canister well, and placing it upright in the rubber opening of the AeroChamber®.
  2. Place the mask of the AeroChamber® over your child's face firmly, making a good seal over the nose and mouth.
  3. Press down on the canister, releasing one puff of medication into the AeroChamber®.
  4. Hold the mask in place until your child has taken at least 6 breaths. In a clear AeroChamber®, you can watch the gray valve move inside the AeroChamber® to help you count the breaths.
  5. If your child requires more than one puff of medication, wait at least 30 seconds, then repeat steps 1 to 4. Remember to shake the canister well before giving another puff. Do not spray more than one puff at a time into the AeroChamber®.

   Hints

  1. If your child struggles when using this device, try to persist as most children will eventually get used to it. Your child will get medication into the lungs even if he/she cries.
  2. At about 4 to 5 years of age, your child should be switched to a spacer with mouthpiece as this will prevent loss of medication in the nose.
  3. If your child is using inhaled steroids, have your child drink or rinse his/her mouth with water if able after each use. This will reduce the risk of developing a yeast infection in the mouth or throat.
  4. The AeroChamber® should be replaced when the small gray rubber flap valve is cracked, hard, or gets permanently curled, if the rubber opening of the AeroChamber® becomes cracked or torn, or if the mask is damaged or has a hole in it.
  5. To avoid dust accumulation, keep your AeroChamber® in its plastic container when not in use.
  6. Rinse the AeroChamber® in warm tap water every few days, and clean weekly with a mild detergent. Let dry thoroughly before using.
  7. Rinse plastic holder of MDI regularly with warm tap water. Remove canister from holder before rinsing. Let dry thoroughly before replacing the canister.
  8. To check the level of medication remaining in your MDI, remove the metal canister from the plastic holder. Placing a finger on the top of the canister, gently shake, feeling for liquid moving within the canister. When little liquid movement can be felt, the MDI is almost empty.
  9. If you are having trouble telling whether your child is using his or her MDI too much or too little, you may want to consider purchasing the MDI Chronolog®, an electronic device which fits on top of the MDI and will tell how many doses of medication have been used.
  10. Some HFA-containing metered-dose inhalers, such as QVAR™ and Airomir™, do not fill well in the AeroChamber. If your child has been prescribed one of these medications and has an AeroChamber®, you may wish to ask your physician or pharmacist for a different, but similar medication, or for a different spacer device which accommodates these inhalers better.

IF DESPITE YOUR BEST EFFORTS YOUR CHILD'S ASTHMA IS NOT WELL CONTROLLED OR WORSENS, PLEASE SEEK MEDICAL ATTENTION IMMEDIATELY.

The Spacer with Mouthpiece

The spacer is a holding device which helps to deliver medication in young children (usually 5 years of age or older) who cannot coordinate theirdecorative image breathing well enough to use a metered-dose inhaler (MDI) alone. The spacer is used together with an MDI. Because children who use the spacer with mask will lose some of the medication in the nose, they should be switched to an adult spacer with mouthpiece when they are able to keep their lips tightly around the adult spacer mouthpiece. This is usually between 4 and 6 years of age. Regardless of the child's age, spacers are recommended when a steroid inhaler is used, in order to reduce the risk of developing a yeast infection in the mouth or throat.

   Instructions

  1. Prepare the MDI by removing the cap, shaking the canister well, and placing it upright in the rubber opening of the spacer.
  2. Ask your child to breathe out, emptying his/her lungs.
  3. Place the mouthpiece of the spacer into your child's mouth and have your child close his/her lips tightly around the mouthpiece.
  4. Press down on the canister, releasing one puff of medication into the spacer.
  5. Ask your child to take one breath in through the mouth as deeply as possible, and hold the breath in for 5 to 10 seconds. If he/she is unable to do so, ask your child to breathe in and out deeply and slowly for 3 to
    4 breaths instead.
  6. If your child requires more than one puff of medication, wait at least 30 seconds, then repeat steps 1 to 5. Remember to shake the canister well before giving another puff. Do not spray more than one puff at a time into the spacer.

   Hints

  1. If your child is breathing through the (blue) Adult AeroChamber® too quickly, you will hear a musical sound. If this happens, ask your child to breathe in and out more slowly when using the AeroChamber®.
  2. If your child is using inhaled steroids, have your child rinse his/her mouth with water after each use. This will reduce the risk of developing a yeast infection in the mouth or throat.
  3. The AeroChamber® should be replaced when the small gray rubber flap valve is cracked, hard, or gets permanently curled, or if the rubber opening of the AeroChamber® becomes cracked or torn.
  4. Rinse the AeroChamber® in warm tap water every few days, and clean weekly with a mild detergent. Let dry thoroughly before using.
  5. To avoid dust accumulation, keep cap on mouthpiece when not in use.
  6. Rinse plastic holder of the MDI regularly with warm tap water. Remove canister from holder before rinsing. Let dry thoroughly before replacing the canister.
  7. To check the level of medication remaining in your MDI, remove the metal canister from the plastic holder. Placing a finger on the top of the canister, gently shake, feeling for liquid moving within the canister. When little liquid movement can be felt, the MDI is almost empty.
  8. If you are having trouble telling whether your child is using his or her MDI too much or too little, you may want to consider purchasing the MDI Chronolog®, an electronic device which fits on top of the MDI and will tell how many doses of medication have been used.
  9. Some HFA-containing metered-dose inhalers, such as QVAR™ and Airomir™, do not fill well in the AeroChamber. If your child has been prescribed one of these medications and has an AeroChamber®, you may wish to ask your physician or pharmacist for a different, but similar medication, or for a different spacer device which accommodates these inhalers better.

IF DESPITE YOUR BEST EFFORTS YOUR CHILD'S ASTHMA IS NOT WELL CONTROLLED OR WORSENS, PLEASE SEEK MEDICAL ATTENTION IMMEDIATELY.

The Diskus® decorative image

Consists of:

  1. a coloured body (green for Serevent®, a long-acting bronchodilator, blue for Ventolin®, a short-acting bronchodilator, purple for Advair™, a combination long-acting bronchodilator and inhaled steroid, and orange for FloVent®, an inhaled steroid), which has a built-in mouthpiece, mouthpiece cover, lever to open the mouthpiece cover, and dose counter.

The diskus can be used by most children over 5 years of age.

   Instructions

  1. Hold the outer case in 1 hand, and put the thumb of the other hand on the thumb grip (near the dose counter). Push the thumb as far as it will go, until you hear a click.
  2. You will now see a lever. Slide the lever as far as it will go, until you hear a click.
  3. Ask your child to breathe out (keeping the diskus away from your child's mouth). Bring the diskus to your child's mouth. Keeping the diskus level, have your child close his/her lips tightly around the mouthpiece.
  4. Ask your child to breathe in through his/her mouth as quickly and as deeply as he/she can. Once your child has breathed in fully, remove the mouthpiece from the child's mouth, and have him/her hold the breath in for 5 to 10 seconds or as long as possible. Have your child breathe out slowly.
  5. Slide the thumb grip back all the way, until you hear a click (You do not have to close the lever yourself; it will close automatically as you slide the thumb grip back).
  6. The diskus is not reusable. Each diskus contains 60 doses of medication. You should replace the diskus when there are no ("0") doses left.

    Hints

  1. If your child is using a FloVent® or Advair™, have your child rinse his/her mouth with water after each use. This will reduce the risk of developing a yeast infection in the mouth or throat.
  2. You can use the dose counter to tell if your child is taking his/her medication, or if your child is taking too much.

IF DESPITE YOUR BEST EFFORTS YOUR CHILD'S ASTHMA IS NOT WELL CONTROLLED OR WORSENS, PLEASE SEEK MEDICAL ATTENTION IMMEDIATELY. IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING THE USE OF THIS DEVICE, SPEAK TO YOUR DOCTOR AS SOON AS POSSIBLE.

 

The Twisthaler®

Consists of:
A rotating base, a mouthpiece, a dose counter, and a cap. The medication is shipped in a foil pouch. Write the date you open the medication on the cap, and throw the inhaler away 45 days after you’ve opened the foil pouch, when the dose counter reads “00,” or when the medication has expired (whichever comes first). Asmanex® is available as a Twisthaler®.

The medication is licensed for individuals 12 years of age and older.


Instructions:

  1. Hold the device straight up, and twist the cap off (counterclockwise). Twisting the cap off loads the medication. The white arrow at the bottom of the Twisthaler® should be pointing at the dose counter.
  2. Ask your child to breathe out fully. Hold the Twisthaler® level, place the mouthpiece in your child’s mouth, and have your child put his or her mouth tightly around the mouthpiece.
  3. Ask your child to breathe IN through his/her mouth as quickly and as deeply as he/she can. Once your child has breathed in fully, remove the mouthpiece from the child's mouth, and have him/her hold the breath in for 5 to 10 seconds or as long as possible. Have your child breathe out slowly. DO NOT breathe out (exhale) INTO the inhaler.
  4. Wipe the mouthpiece dry (if needed), and REPLACE the cap, turning it clockwise while you gently press down, until you hear a “click,” You need to hear the “click” to ensure the cap is fully closed.
  5. The Twisthaler® is not reusable. Once the device counter reaches “00,” the device will lock and needs to be thrown away. At that point, start a new inhaler.
    Hints
  6. Have your child rinse his/her mouth with water after each use of Asmanex®. This will reduce the risk of developing a yeast infection in the mouth or throat.
    The powdered medication is very fine, and your child will probably not taste or feel the medication.
  7. You can use the dose counter to tell if your child is taking his/her medication regularly, at the prescribed frequency, OR, if your child is taking too much.
  8. IF DESPITE YOUR BEST EFFORTS YOUR CHILD'S ASTHMA IS NOT WELL CONTROLLED OR WORSENS, PLEASE SEEK MEDICAL ATTENTION IMMEDIATELY. IF YOU HAVE ANY QUESTIONS OR CONCERNS REGARDING THE USE OF THIS DEVICE, SPEAK TO YOUR DOCTOR AS SOON AS POSSIBLE.

 

Nebulizers and Compressors

Aerosol Treatments by Nebulizer

decorative imageInhaled medications are given by nebulizer most often in children who don't respond when asthma medications are given by cheaper and more portable alternatives, such as metered-dose inhalers with a spacer device. If you have a nebulizer at home and another asthma inhaler, and your child responds better to his Reliever medication when it is given by nebulizer, you should use the nebulizer during asthma attacks. Note: There are many different nebulizers on the market. You should check your instruction manual or ask the company that supplied your nebulizer for exact instructions on how to use your nebulizer and compressor.

Different Parts of a Nebulizer?

compressor — an electric air compressor

nebulizer kit — consists of:
  1. a medication reservoir (cup): this holds the medication, and has special ducts to vapourize the medication. A cap attaches to the top of the cup, and a tube attaches to the bottom of the cup.
  2. cap this attaches to the top of the cup.
  3. tubingthis connects the nebulizer (cup) to the air compressor.
  4. maska soft face mask which attaches to the top of the cap. Masks are available in children's, and adult sizes. The mask is held against the child's face so that the medication mist can be breathed in by the child OR
  5. mouthpiecethis attaches to the top of the cap. The child places his lips around the mouthpiece, and breathes through it. The mouthpiece is preferable in children old enough to understand how to use it.
  6. medication — a syringe may be required for measuring the medication (make sure a healthcare professional teaches you how to read the medication dose on the syringe). Once the medication is opened, it should be stored in the refrigerator, and any unused medication discarded after one month. Some medications may be given in combination — check with your physician or pharmacist. Some medications come in pre-mixed little containers, called ampules or nebules, or unit-dose vials.

How to Use a Nebulizer

  1. Wash your hands.
  2. Measure the desired amount of medication, being careful to remove any air bubbles, and put it into the nebulizer cup. Measure and add the normal saline, if required. OR
  3. If you're using a pre-mixed nebule, open the top of the nebule and dump all of the liquid (or give the amount recommended by your doctor) into the cup.
  4. Attach the cap to the nebulizer cup. Attach the mask or mouthpiece to the cap.
  5. Attach one end of the tubing to the bottom of the nebulizer cup.
  6. Connect the other end of the tubing to the air outlet connector on the compressor.
  7. Plug in and turn on the compressor.
  8. Holding the nebulizer upright, put the mask onto the child's face. If using a mouthpiece, instruct the child to seal his/her lips around the mouthpiece and breathe normally by his/her mouth.
  9. When the liquid is gone from the cup, and there is no more aerosol produced (usually about 15 minutes, depending on the amount of medication), remove the nebulizer, and turn off the compressor.

Cleaning

After each treatment, take apart the nebulizer kit. Rinse the nebulizer cup, cap and mouthpiece/mask, and syringe. Allow to air dry completely before reassembling. The tubing does not need to be cleaned.

Once per day wash the nebulizer cup, cap, mouthpiece/mask and syringe in lukewarm soapy water (mild dish detergent). Rinse well, and allow to air dry completely.

Some nebulizer kits are dishwasher safe — but check first with the manufacturer's instructions or your home care provider.

Remember that most children's asthma is aggravated by upper respiratory infections, or "colds", so it is essential to keep the supplies clean.

The Care and Feeding of your Home Compressor

It is a good idea to unplug the compressor when not in use. Keep the compressor in a dust-free area. Most compressors have an air intake filter, which discolours as it gets clogged. The filter is easy to change (Check the Operator's Manual for your compressor). If the compressor becomes hot during use, and/or if the treatment takes longer to nebulize, then the compressor may require service. Most compressors are waranteed by the manufacturer 3 to 5 years. Check with your Home Care company for service.

Troubleshooting

No aerosol output
  • Check that the tubing is firmly attached to the nebulizer and compressor.
  • Try another nebulizer (they are sometimes defective); It is seldom that it is a problem with the compressor.
The tubing keeps popping off
  • Check that the tubing is not kinked.
  • Check that the air duct into the nebulizer cup is clear.
  • Change the tubing (sometimes it becomes worn at the connections).

Hints

Decide on your equipment needs carefully. You may want to lease equipment.

Check with your Extended Health Insurance or Drug plan about your coverage.

If the medication is refrigerated, it should be warmed to room temperature before it is given, because cold air can aggravate asthma symptoms. An exception to this is if the child has "croup" (barking cough) — the cool mist can help reduce airway swelling.

Some medications can be combined in the nebulizer cup, eliminating the need for normal saline and multiple treatments. Check with your doctor or pharmacist.

If your child is receiving an inhaled steroid, have him/her mouth rinse or offer a drink following the treatment. This reduces the risk of yeast infection, a possible side effect of inhaled steroids. If the child uses a facemask, wipe the child's face. This reduces the risk of a rash on the face.

If you use a syringe to measure your medication, you may wish to use an indelible marker, nailpolish or waterproof tape to carefully mark the desired fill line on the syringe. This needs to be changed if the dose of your child's medication changes.

Travel Tips

If you are traveling abroad, be sure to have a transformer, and an adequate supply of medications (in the original packaging).

If you are traveling by car, and/or enjoy camping, there are compressors which will plug into a car lighter. In general, these compressors are not as powerful as electric main units. Check with your vendor — you may be able to lease one for your vacation needs.

Many of the medications for use in home nebulizers are available in unit-dose ampules, eliminating the need for normal saline and syringes. Although they are more expensive, they are easy to use, and do not require refrigeration. This makes them handy for caregivers, schools, camps, and/or travel. They may, in fact be more economical for infrequent use, since less medication is discarded.

Commonly Asked Questions

Q: My baby always cries during the treatments. Does this hurt?

A: No, and a crying child is breathing deeply. Try to persist, and the child will become used to the treatments. It may be helpful to allow the child to play with the mask in between treatments, to familiarize him/herself with it.

Q: My infant always falls asleep following the aerosol treatment. Is there any sedation in the medication?

A: No. Infants often tire from the increased work of breathing, and cry throughout the treatment. The rhythmic sound of the nebulizer, combined with the eased breathing, provide conditions for a contented sleep.

 

 

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