Asthma in Children: Inhaler and Spacer Technique, Action Plans and Preventing Attacks

Asthma is one of the most common long-term conditions in children worldwide. Most children with asthma can live normal, active lives if their condition is well controlled. But studies consistently show that many children (and adults) use their inhalers incorrectly, so medicine doesn’t reach the lungs. Nurses who teach good technique and support families with an action plan can prevent attacks, hospital admissions and deaths.

Preventer vs reliever

• Reliever (often blue, e.g. salbutamol): opens the airways quickly during symptoms. Frequent use is a sign asthma isn’t controlled.
• Preventer (often brown, orange or purple, inhaled corticosteroids): reduces airway inflammation. Must be taken every day, even when well.
• Some older children and adolescents may use combination inhalers per newer guidelines (e.g. GINA recommendations for those 12+).

A common misunderstanding is stopping the preventer when the child feels better. Explain that it works in the background.

Why use a spacer?

Pressurised metered-dose inhalers (pMDIs) require coordinating pressing and breathing. A spacer (valved holding chamber) solves this, delivers more medicine to the lungs, and reduces side effects like oral thrush. Children using a pMDI should use a spacer. Even during an attack, a pMDI with a spacer is as effective as a nebuliser for most children.

In low-resource settings, a homemade spacer from a clean 500 ml plastic bottle can be used if commercial spacers aren’t available; WHO and others have described this method.

Technique by age

Under about 3–4 years: spacer with face mask

1. Remove the cap and shake the inhaler.
2. Insert into the spacer.
3. Place the mask firmly over the nose and mouth to make a seal.
4. Press the inhaler once.
5. Hold in place while the child takes about 5–10 normal breaths (or ~10 seconds).
6. Repeat for each puff, shaking in between.

Older children: spacer with mouthpiece

1. Shake the inhaler and attach to the spacer.
2. Breathe out gently, then seal lips around the mouthpiece.
3. Press the inhaler once.
4. Either take one slow deep breath and hold for 10 seconds, or take about 5 normal breaths.
5. One puff at a time.

Rinse the mouth after steroid inhalers. Wash spacers monthly in warm soapy water and air-dry without rinsing or towel drying (reduces static).

Check technique every visit

Ask the child or parent to show you, rather than asking if they know how. Correct errors gently. Check the inhaler isn’t empty and isn’t expired.

Personalised asthma action plan

Every child with asthma should have a written plan, shared with school, covering:

• Green: well. Daily medicines.
• Amber: getting worse (coughing, wheezing, waking at night, using reliever more). What to increase and when to see a nurse or doctor.
• Red: emergency. What to do and when to call for help.

During an asthma attack

• Sit the child up, stay calm.
• Give reliever via spacer as per action plan (a common approach is 1 puff every 30–60 seconds up to 10 puffs).
• Call emergency help if not improving, if too breathless to talk or feed, lips turning blue, exhausted, or if you’re worried.
• Repeat reliever while waiting.

See our acute asthma management guide.

Triggers to reduce

• Tobacco smoke (including second-hand), smoke from cooking fires and kerosene stoves.
• Dust mites, mould, pets, pollen, harmattan dust.
• Viral infections; encourage flu vaccination where recommended.
• Cold air and exercise (pre-treat with reliever if advised; don’t avoid activity).

Based on the Global Initiative for Asthma (GINA) strategy, BTS/NICE/SIGN asthma guidance and WHO resources. Educational content: follow national guidelines.