Medication, generally asthma inhalers, play a very important role in the day-to-day management of asthma. It is important that you understand how your medicines or asthma inhalers work, and then take them as prescribed. Make sure that you are well-organised when it comes to your medication and ensure that you never run out.


What kind of inhaler should my child use?

Medicines used by pre-school children with asthma are no different from those used by older children.  The most effective way of treating asthma is by delivering the medicine directly to the lungs through an inhaler. The type of device used must suit the child’s age and ability. Your doctor, nurse or asthma educator will explain your choices. Here is a general guide only:

Age 0-3 years: A spacer device with a small mask may be used with medicines delivered by a Metered dose inhaler (MDI). The medicine remains suspended in the spacer for 15-30 seconds, allowing time for the child to take it in while taking six normal breaths. It is quite common for children to object to having a mask placed on their face, but rest assured – most children adapt in time.

3-5 years: At about three years a mouthpiece can replaced the mask. Liquid medicines may be used, but these are slower acting with more side effects.

5 years+: Children in this age group can continue to use spacers (without a mask) and the powder medicine devices – Accuhaler, Turbuhaler.

12 years+: There is no need to change medicine or device unless there is a problem.

At all ages, checks need to be made to see that the inhaler device is used properly and that the lowest dose is used to achieve good asthma control. Your doctor or asthma educator can offer you tips if you have problems giving your child inhalers.

Click below to watch a fun video from Asthma Waikato and Sailor the Pufferfish on using a spacer:

 

Preventer inhalers

Preventer inhalers are probably your most important asthma medication, because they treat the inflammation inside your airways, and reduce the likelihood of an asthma exacerbation. When you have asthma, your airway walls become leaky, and harmful triggers can get through and cause swelling. Preventer medicines help to seal up your airway walls. This helps break the cycle of swelling and mucus production, and makes room for air to flow freely. 

Preventer medicines work slowly and it may take you up to three months of regular use (generally twice a day) to notice the full benefit of the medicine. It can be dangerous to skip a few doses or stop your preventer when you feel well, as your asthma will often get worse.

Preventer inhalers are usually brown, orange. 

Corticosteroid Preventers

Most preventer medicines are steroids, which mimic the steroid we produce naturally in our bodies every day. An enormous body of research demonstrates that they are safe and effective for long term use.

Like all drugs, there can be side effects, which are less common in moderate doses. Side effects may include a husky voice, a sore throat or fungal growth in the mouth (thrush). The risk of side effects can usually be easily minimised by using a spacer (for people who use a Metered Dose Inhaler (MDI)) and rinsing the mouth after inhaler use.

More general side effects occur infrequently. These are due to tiny amounts of the drug being absorbed into the blood stream. The liver will clean up most of this but if very high doses of inhaled steroids are used there may be some side effects which include:

  • thinning of the bones called osteoporosis
  • thinning of the skin giving rise to easy bruising
  • a reduction in the body’s ability to respond to a severe medical illness.

For children, an additional problem can be minor growth suppression. This is unlikely when moderate doses are used.

Most experts agree that the risk of poorly treated asthma is far greater than the risk of serious side effect from inhaled corticosteroids. Anyone who is concerned about possible side effects from their medication should discuss the matter with their doctor.

Non-steroidal preventer medicines can be useful in mild asthma, especially in children. An extra dose can be taken before exercise if needed to prevent cough and wheeze. They are free of most side effects, apart from throat irritation. 

Reliever inhalers

Reliever inhalers bring short term relief from asthma by relaxing the tight bands of muscle around your airways. This helps air flow in and out of your lungs more freely. Relievers can help wheezing, coughing or tightness in the chest. They are only taken when you need them. Many people rely on their reliever inhaler to feel better immediately, but they do not treat the underlying cause of their asthma (swollen and inflamed airways) by regularly using their preventer. Relievers don’t have a lasting effect like preventers – their effect wears off in a few hours and they don’t change the swelling in the breathing tube.

Some side effects of reliever medicines include mild shaking, headaches, a racing heart, and restlessness.

The medicine Atrovent is also a reliever, although it relaxes the airway muscle in a different way. It is slower to take effect, however it may give longer relief. It is fairly free of side effects, although it may leave a bitter taste and cause some dryness of the mouth.

Some relievers are available in tablet form, and are used for children who can’t manage inhalers and spacers or when inhaled treatment does not seem to work. Side effects are more likely than in inhaled medicine, because the medicine is affecting more parts of the body and the dose is higher. Side effects might include a fast heartbeat, tremor, headache, and hyperactivity.

Combination inhalers (preventers)

Combination inhalers contain both preventer and long acting reliever medicine in one device. Combination inhalers should be taken regularly as prescribed, but not used in emergency situations.

Examples of combination inhalers are Seretide, Symbicort and Vannair. 

Prednisone 

Prednisone is used in severe episodes of asthma. It works slowly over several hours to reverse the swelling of the airways. Prednisone needs to be continued for several days after your asthma symptoms settle to make sure that the swelling doesn’t return. Your doctor may use your peak flow record and symptom diary as a guide to reduce and stop the Prednisone tablets. If you stop too early your asthma may get worse again.

A short course of Prednisone is safe with no lasting side effects. If you need Prednisone tablets more than twice a year, your asthma is not under control. Talk to your doctor about your options. You may need to review your Self Management Plan or visit a specialist.

The tablet most commonly used is Prednisone, which comes in sizes of 1mg, 5mg, and 20mg. Others less often used are Betnesol (0.5mg soluble tablet), Cortisone (5 & 25mg), Dexamethasone (1 & 4mg), Medrol (4mg), and Prednisolone (very similar to Prednisone).

The dose varies such a lot depending on the person – from 2-3mg to 40mg per day. The doctor will all the time be attempting to bring the dose down to the lowest possible in order to reduce the likelihood of side effects.

Many people are accustomed to taking short courses (a few days or weeks) of steroid tablets for attacks of asthma. However some people have asthma that causes problems all the time, despite looking after themselves well and using their inhalers properly. These people may need to use steroid tablets continuously (every day or on alternate days) to control their asthma.

A respiratory specialist should first be seen to check that all other possible treatments have been explored, before someone engages on long term steroid treatment.

When steroid tablets are taken in short bursts (under about three weeks), there are usually no problems. There can be increased appetite, mood change (a high mood more often than a depressed one), and occasionally fluid retention and indigestion.

Unwanted side effects happen the longer you take the steroid and the higher the dose used. The main ones are:

  • Increased appetite and weight gain.
  • Thinning of the bones, which can lead to bone fractures if very severe.
  • Slowing of growth in children.
  • The body’s own natural production of the steroid cortisol is reduced; this can be a problem when steroid tablets are stopped or when the body needs a surge of more steroid to cope with an acute illness.
  • Easy bruising of the skin and slow healing of cuts.
  • Puffiness or roundness of the face.
  • Indigestion or stomach ulcers.
  • Fluid retention with swelling of the ankles.
  • Cataracts in the eyes.

Doses of Prednisone below 7mg a day are unlikely to give problems other than possible skin thinning. 10mg/day or more will most likely give some of these effects after a few years. The higher the dose the more likely side effects are, so the doctor will be weighing up the risks of poor asthma control against the risk of steroid side effects and will keep the dose as low as possible.

You can help keep the dose down by:

  • taking your other asthma medicines as usual;
  • using your inhaler right – ask your nurse or doctor to check your technique, use a spacer with an MDI (metered dose inhaler) or see if an alternative device could be of help;
  • measuring your peak flow every day, and follow a Self Management Plan, starting extra treatment early;
  • letting the doctor know if your peak flow reading drops or you feel unwell.

The timing and frequency of taking the tablets can also influence side effects. Fewer side effects occur if:

  • the steroid tablets can be taken every other day, instead of each day (even if a slightly bigger dose is needed to keep the asthma under control);
  • the daily dose is taken as a single dose in the morning. Morning is the time the body normally products its cortisone for the day;
  • taken during or after meals.

Bone strength

Long-term steroid tablet treatment can weaken bones. This can’t be prevented altogether, but can be reduced if:

  • you stay as fit and active as possible;
  • There are now some other medications that can keep the bones stronger; your doctor can discuss this with you or refer you to a specialist in the bone field. a special sort of x-ray may be needed to measure the density of the bone (it is quite easy and doesn’t hurt) before deciding on the best treatment to use and even whether treatment is needed at all.

Extra steroid doses

Because the body’s own natural steroid production is switched off when you take steroid tablets for a long time, it may not be able to respond quickly enough if suddenly your body needs an extra boost of steroid. So you will need to take extra doses of the steroid tablet instead. This can happen during illnesses.

If you are taking long-term steroid treatment you may need extra steroid during illnesses such as bad ‘flu, operations, asthma attacks and dental work or during any important health problem. See your doctor straight away if you become ill.

Your doctor may be able to help you plan ahead for certain problems.

If you are vomiting or unable to swallow tablets, contact your doctor urgently. You must not be without steroid medicine, particularly if you are unwell.

Stopping long-term steroid treatment

For the same reason, it can be quite dangerous to stop long-term treatment suddenly – the body can find itself seriously short of steroid.

Anyone taking regular steroid tablets should wear a Medic-Alert bracelet. Then, if an accident occurs, and extra steroid is needed, the doctors will know.

When long-term treatment is to be stopped, this must be done very gradually. The dose must be slowly reduced, often over several months. This allows the body time to start making its own cortisone again, Slow reduction will also stop unpleasant side effects, such as severe muscle aches, arthritis and depression.

Slow reduction of steroid treatment must be done by your doctor, and the asthma carefully watched so it doesn’t worsen.

Do you use a MDI?

Metered dose inhalers (MDIs) are sometimes called aerosol inhalers. When the inhaler is pressed, a measured dose of medicine is released through the mouthpiece. It is recommended that MDIs are used with a spacer no matter what your age.

Using your MDI

Ask your doctor, nurse or asthma educator to check your inhaler technique regularly, even if you have been using your inhaler for a long time. 

Girl Using Spacer

You should always try to use a spacer with your inhaler to receive maximum benefit from the medicine, especially if using MDI preventer medication.

However, if you need to use your inhaler without a spacer follow these steps:

  1. Take off the cap and hold the inhaler upright
  2. Shake the inhaler to mix the medication with the propellant
  3. Sit upright, tilt head back slightly (as if you are sniffing – ‘sniff position’) and breathe out gently
  4. Hold the device upright, insert the mouthpiece into your mouth ensuring that your lips firmly seal the mouthpiece
  5. At the beginning of a slow deep breath, breathe in through the inhaler and activate the aerosol once
  6. Breathe in fully, remove the MDI from the mouth and hold your breath for ten seconds or as long is comfortable
  7. Breathe out gently through your nose
  8. Rinse your mouth and spit out or clean your teeth after using a corticosteroid preventer to reduce side effects.

Cleaning your inhaler

Clean your MDIs weekly to ensure they do not block (twice weekly if you use Tilade or Vicrom.)

  1. REMOVE the plastic mouthpiece cap
  2. REMOVE the metal canister (don’t put it in water)
  3. RINSE the mouthpiece and cap under warm water for at least 30 seconds
  4. SHAKE off any excess water and leave the mouthpiece and cap to dry overnight.
  5. Put the metal canister back in, and replace the cap.

If you need to use your inhaler before it is dry:

  1. Shake off any excess water from the plastic casing and put the metal canister back inside
  2. Test spray the inhaler by firing two puffs into the air.

Do you have a dry powder inhaler?

Dry powder inhalers are breath activated inhalers. In New Zealand, the most common dry powder inhaler is the Turbuhaler, which is a breath activated inhaler with no propellant or carrier added to the medicine.

Some Kiwis also use the Accuhaler, which is also a breath activated device. Doses of the medicine are set into a foil strip inside the Accuhaler.

What is the Turbuhaler?

The Turbuhaler is most common dry powder inhaler used in New Zealand. It has no propellant or carrier added to the medicine. You will hardly notice any powder in your mouth. The recommended age of use is 5-7 years through to adult.

Using your turbuhaler

  1. Unscrew and remove the cap
  2. Hold the Turbuhaler upright. Turn the grip as far as it will go and then back to the original position – listen for the click. (Repeating will not double the dose)
  3. Sit upright, and breathe out gently
  4. Insert the mouthpiece into the mouth holding the inhaler horizontally ensuring that the lips are firmly sealed
  5. Breathe in steadily and deeply
  6. Remove the Turbuhaler from the mouth, then breathe out gently through the nose
  7. Replace the cap securely
  8. Rinse mouth and spit out or clean teeth after using a corticosteroid preventer

There is a window under the mouthpiece on the outside of the Turbuhaler called the ‘Empty Soon Indicator.’ When a red mark or a number appears at the top of the window, there are approximately 20 doses left.

Some common mistakes when using the turbuhaler are:

  • Not holding the inhaler upright when priming
  • Covering the air inlets with lips
  • Breathing in through the nose instead of the mouth
  • Shaking the inhaler to see how much is left
  • Storing inhaler in a damp environment with the cap off

Using your Accuhaler

  1. Open the device by holding the outer case. Using the thumb grip, slide the cover open as far as it will go
  2. Face the mouthpiece towards the person using the device
  3. Push the lever away from the mouthpiece until you hear the ‘click’
  4. Sit upright, tilting the head back (as if you are sniffing – ‘sniff’ position) and breathe out gently
  5. Insert the mouthpiece into the mouth ensuring that your lips firmly seal the mouthpiece
  6. Breathe in fully, remove Accuhaler from the mouth and hold breath for 10 seconds or as long as is comfortable
  7. Breathe out gently through the nose
  8. Slide the thumb grip back over the mouthpiece
  9. Repeat if second dose required
  10. Rinse mouth and spit out or clean teeth after using a corticosteroid preventer

Some common mistakes are exhaling into the device, breathing in through your nose instead of your mouth, or not ‘clicking’ the lever after opening the cover.
You will know that it is time for a new inhaler when the number of doses remaining is displayed (with the last five numbers in red.)

Using a nebuliser

A nebuliser works by turning liquid medicine into a fine mist which you can breathe easily into the lungs. A nebuliser can be useful for people with asthma, however many clinical trials have found spacers (used with a reliever) to be equally as effective. Spacers are also cheaper, not dependent on a power supply, and they are less frightening, especially for children.

Only a small number of people need a nebuliser, and should be used under the directions of their doctor.Those who might benefit from a nebuliser are usually:

  • some older adults with chronic respiratory disease who get better relief of symptoms with a nebuliser;
  • people with disabilities or people who are unable to use hand held inhalers and spacers;
  • people using medication that needs to be nebulised e.g. those with cystic fibrosis requiring nebulised antibiotics; or
  • people who are recommended a nebuliser by their doctor.

A nebuliser consists of:

  • an electrical air pump (or compressor) to pump the air at a high pressure
  • the nebuliser bowl where the medicine is placed
  • a length of plastic tubing connecting the pump (or compressor) and the nebuliser bowl
  • a mouthpiece or facemask used to breathe in the medicine.

NOTE: Oxygen from a cylinder or hospital wall supply can be used instead of a compressor and air.

What medicines can be used in a nebuliser?

  • Preventers
  • Relievers
  • Antibiotics

Other drugs such as

  • Morphine
  • Pulmozyme
  • Lignocaine

Some of the medicines can be mixed together instead of being given separately. Your doctor or pharmacist can tell you about this.

How to use a nebuliser

  • Delivery is increased if you are able to use a mouthpiece, as it avoids the natural filtering system of the nose. A mask may be needed for children under three or during a bad attack. It must fit closely.
  • Use slow ‘normal’ breathing – rapid breathing is not as effective.
  • If a steroid preventer (Pulmicort) is used with a mask you should wash your face afterwards.
  • Do not leave medicine in the nebuliser bowl between uses.

Whoever supplies you with a nebuliser should tell you and show you:

  • How to attach the tubing, nebuliser bowl, facemask or mouthpiece.
  • How and where to put the medication.
  • How to fit the mask on or use the mouthpiece.
  • How to maintain and clean the equipment.

People who are purchasing on their doctor’s recommendation need to know:

  • Where replacement tubing, nebuliser bowls, facemasks/mouthpieces can be obtained from.
  • Where and how often the nebuliser should be serviced.
  • A yearly service is usually recommended. If it takes your nebuliser longer than 10 minutes to deliver one 2.5ml dose a service is advised. A service agent can check that the compressor is producing the correct flow and pressure, and check on the electrical safety of the nebuliser. If the nebuliser is used every day you will need more frequent flow and pressure checks. Contact your local Asthma Society for the names of service agents.

How to care for the nebuliser

Keep the nebuliser covered in a dust free place when not in use. Wipe over with a damp cloth when necessary. If a filter is fitted it will need replacing or cleaning depending on the manufacturer’s instructions. The tubing does not require washing. If you do notice some condensation in the tubing, take off the nebuliser bowl, turn on the nebuliser and remove the condensation by shaking the tubing. Replace the tubing if any dirt is seen in it, or cracks appear. Do not keep tubing and bowl in direct sunlight. The nebuliser bowl needs to be rinsed in warm water after every use. This is because the medicine comes in a salt solution and some may get left in the bowl. This can crystallise and block up the outlets. After rinsing the bowl, drip dry or connect up tubing to it, switch on nebuliser, blow air through for a few seconds. Don’t wipe the bowl dry. Once a week wash bowl with dishwashing liquid and water. Disposable nebuliser bowls need replacing every 1-2 months if used regularly. Durable bowls are more expensive to buy but last 12 months. As the bowl gets worn the medication is less effective since larger particles of medicine are produced that cannot enter the small breathing tubes. Facemasks or mouthpieces need to be washed daily with dishwashing liquid and water. They need replacing if they crack, or the facemask doesn’t fit snugly. The elastic on the face mask is easy to replace yourself.

Trialling a nebuliser

Your doctor may suggest it is worth using a loaned/hired nebuliser for several weeks to see if it is of benefit to you. In each area hire/loan pools are operated by different agencies. Your doctor or the local Asthma Society will know where you can find one near you.

Only a doctor can prescribe the nebuliser medication and give approval for you to hire a nebuliser. Specialists at the hospital may arrange for some of their patients to have a nebuliser on loan from the hospital. You may be asked to keep taking peak flow recordings during your nebuliser trial.

Often an inhaler with a spacer is as effective for most people, provided adequate doses of medication are given. Because a nebuliser is a machine and costs a lot more money than an inhaler and spacer, it does not necessarily mean it is the best choice for you.

What to look for in a nebuliser

There are many different makes of nebulisers. All have advantages and disadvantages. You have to look at how you are going to use a nebuliser then pick the most suitable model.

Aspects you should consider are:

  • DURABILITY. If you are using the nebuliser three to four times a day you require a sturdy model, while for occasional use in attacks durability is not so vital. Check the details of the guarantee.
  • POWER SUPPLY. Some people may require the nebuliser for travel in the car as well as at the home, a model that runs on electrical supply (240v) as well as the car battery (12v) would be suitable. Some models have a battery that can be recharged.
  • PORTABILITY. If the nebuliser needs to be moved from room to room check the weight as some are heavy. This may cause difficulties for older adults and people with disabilities. Ultrasonic nebulisers are the most portable but are expensive.
  • SERVICE AVAILABILITY. The nebuliser should be serviced yearly. Check if your model can be serviced in your area and if a loan machine will be given to you while yours is being checked.
  • PRICE. This varies greatly from approximately $200-$700. Being more expensive does not mean they are better, they may just have features that you don’t need.

When asthma is worsening

The medicines that you take daily through a nebuliser should give relief for three to four hours. If this is not happening tell your doctor. The best way to tell if your asthma is getting worse is by using a peak flow meter to check. Follow your Self-Management Plan. This will guide you and tell you what to look for when your asthma is getting worse and when to seek help.

After having a dose wait 15 minutes – if your peak flow hasn’t risen a lot and/or you still feel wheezy, have another nebuliser and let the doctor know. If no improvement (i.e. your peak flow readings are still low and/or you’re still breathless) after the second nebuliser treatment, get someone to ring immediately for an ambulance – dial 111.

Is your asthma under control?

Take the asthma control test to find out

Useful Asthma Resources

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Understanding Your Inhaler Resource

Understanding your Inhaler

An information booklet with tips on how to clean, use and store your inhaler.

Controlling Your Asthma

Controlling your Asthma

An information booklet with seven steps to help you learn to control your asthma and lead the life you want.

What Is Asthma

What is Asthma

An information booklet on symptoms, triggers, management strategies, medicines and steps to take in an asthma emergency.​

Children And Asthma

Children and Asthma

An information booklet on symptoms, inhaler use, medicines, physical activity and asthma friendly schools.