Jane Scullion provides some simple and practical advice on optimal inhaler device selection for adults and children, in the first of two feature articles.

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Read this article to learn more about practical considerations for inhaler device selection in adults and children.

After reading this article and the next article in this series, ‘Test and reflect’ on your updated knowledge with our multiple-choice questions. Earn a total of 2 CPD credits for reading the articles and completing the MCQs.

We know that an inability or an unwillingness to use an inhaler device leads to disease instability in people with asthma and COPD, but getting the right inhaler device for people whether children or adults is not always easy and will be dependent on many factors including age, manual dexterity, personal preference, ease of use, inspiratory flow rate, licensing options, the medication required and so on. NICE Technology Appraisal 10 states that ‘It is important to ensure that an inhaler device delivers the drugs to the airways consistently and in the appropriate quantity’.1 This is important for all age groups. This article considers inhaler device selection in adults and children.

Children under the age of 5 years

There is very little evidence available on which to base recommendations for selecting devices for children under 5 years of age. Since 2000 NICE recommends that for children under the age of 5 years who have chronic stable asthma, both corticosteroids and bronchodilator therapy should routinely be delivered by pressurised metered dose inhaler (pMDI) and spacer system, with a facemask where necessary.1 It is important that the person who is going to administer the medication to the child should be trained in the correct use of the pMDI and spacer. 

Children aged 5 years and over

This age group should be able to use a range of devices depending on their inspiratory flow rate and coordination. Both dry powder inhalers (DPIs) and the breath actuated pMDIs are dependent on the user’s inspiratory flow rate to ensure effective delivery of the drug to the lungs. pMDIs that are not breath actuated require the person to coordinate inspiration and activation of the device simultaneously. Some of the difficulties with coordination can be overcome using a spacer device.2

The choice of inhaler should be determined by individual needs, including the medicine the child needs, and the child’s ability and willingness to use a particular inhaler.3 We know that young infants and disabled children are not aware how to inhale properly. Young children have a low inspiratory flow and are not always able to hold their breath. If after these factors have been taken into account, there is more than one inhaler to choose from, the inhaler with the lowest overall cost to the NHS should be chosen.3 The licensing for the inhaler will also need to be considered as this can vary considerably.

Questions to consider

  • What is the age of the child?
  • Can he/she consciously inhale?

Box 1: Inhaler choice in children4

  • Conscious inhalation possible:
    • sufficient inspiratory flow ≥20 l/min:
      • pMDI+spacer
      • breath-actuated MDI
      • DPI
    • insufficient inspiratory flow:
      • pMDI+spacer
      • breath-actuated MDI
  • Conscious inhalation not possible:
    • pMDI+spacer.
pMDI=pressurised metered dose inhaler; MDI=metered dose inhaler; DPI=dry powder inhaler.

Inhaler choice in adults

For adults requiring inhalers, many types of inhalation devices are now available. Current evidence indicates that there is no difference in the clinical effectiveness of one device over another provided they are used properly.5 We need to be cognizant that impaired cognitive functioning, manual dexterity, and failing eyesight may contribute to an inability to use inhaler devices correctly.

Despite repeated instructions, inhalers are not always used correctly, and patients make mistakes when using both pMDIs and DPIs. A better match made between the patient and device could be accomplished if the prescriber is aware of the following factors:

  • patient characteristics (disease, severity, fluctuation in airflow obstruction)
  • class of medication that is indicated
  • where in the lung the medication should be delivered to
  • how this can be best achieved by a given device in this specific patient.

Dekhuijzen and colleagues6 propose the 3W-H approach, which is evidence-based and very practical. This process enables the prescriber to make a rational choice in only a few minutes by just considering the following four simple questions:

  • Who? (consider the asthma and COPD disease characteristics)
  • What? (think about the medication to be used)
  • Where? (think about the target in the lung for the medication)
  • and How? (consider the patient, the molecule, the dose required and the actual device

A further simple and practical approach to inhaler device choice in adults has been proposed by Usmani and colleagues.7 This takes into account that placebo devices are not always available for use with patients, so inspiratory flow rate is first considered as a deciding factor for choosing a suitable inhaler.


Algorithm for choosing an appropriate inhaler device.7Download a PDF of this algorithm.

Getting the device right for the patient is an important clinical need, but we also need to be aware of patient factors. If people are not engaged with us, then they are less likely to use their inhaler.7

There are additions to devices, such as dose counters, and more intuitive devices with fewer operational factors, but we need to ensure that these features contribute to making the person comfortable in using their inhaler, rather than be dazzled by yet another new device.

The use of nebulisers is not routinely recommended unless there is a clinical need. This type of device can give out high doses of medication and can cause problems, such as hypokalemia, and can lead patients to rely on them rather than seeking appropriate medical help.3, 8


The optimal device for both children and adults is dependent on many factors. Given that there is little difference in terms of clinical effectiveness, in the end it generally comes down to what medication is required within its product licence, the required inspiratory flow rate, and whether a person can and will use it.

Read the next article in the series, which focuses on therapeutic options for the management of asthma and COPD.


  1. NICE. Guidance on the use of inhaler systems (devices) in children under the age of 5 years with chronic asthma. NICE Technology Appraisal 10. NICE, 2000. Available at: www.nice.org.uk/ta10.
  2. Vincken W, Levy M, Scullion J et al. Spacer devices for inhaled therapy: why use them, and how? ERJ Open Res 2018;4 (2): 00065-2018.
  3. NICE. Inhaler devices for routine treatment of chronic asthma in older children (aged 5–15 years). NICE Technology Appraisal 38. NICE, 2002. Available at: www.nice.org.uk/ta38.
  4. van Aalderen W, 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 Prim Care Respir Med 2015; 25 14088.
  5. Brocklebank D, Ram F, Barry P et al. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature.Health Technol Assess 2001; 5: 1–149.
  6. Dekhuijzen P, Vincken W, Virchow J et al. Prescription of inhalers in asthma and COPD: Towards a rational, rapid and effective approach. Respir Med 2013; 107: 1817–1821.
  7. Usmani O, Capstick T, Chowan H et al. Choosing an appropriate inhaler device for the treatment of adults with asthma or COPD. Originally developed for Guidelines 2016; also published on Guidelines for Nurses 2016. Available at: www.GuidelinesforNurses.co.uk/WPG/inhaler-choice
  8. Asthma UK. Getting emergency treatment through a nebuliser. www.asthma.org.uk/advice/nhs-care/emergency-asthma-care/nebulisers (accessed 12 April 2019).