Inhalers with spacer and mask, and nebulisers, in children

What it is

Most inhaled medicines for children come in a pressurised metered-dose inhaler. Children cannot coordinate pressing and breathing in, so the inhaler is fitted to a spacer (holding chamber). Children under about four use a spacer with a face mask that covers nose and mouth; older children use a spacer with a mouthpiece. A nebuliser turns the medicine into a mist the child breathes normally and is sometimes easier for very young or very ill children. The nurse checks the order, gives the medicine with the right technique, watches the response and teaches the family until they can do it alone.

Indications

• Prescribed inhaled medicines (quick relief or long-term control) in a child who cannot use an inhaler alone.
• Teaching the family and checking technique at every visit.
• Wheezing episodes treated in the service while the child is reassessed after each dose, as AIEPI describes.
• Nebuliser when prescribed, or when the child cannot use a spacer, for example in severe distress.

Contraindications and precautions

• Verify the order (medicine, route, frequency) and the child's identity before every dose.
• A child with signs of respiratory distress receives oxygen during the treatment cycles and is reassessed often.
• Dry powder inhalers are not used with a spacer.
• Do not test whether a canister is empty by putting it in water; use the dose counter.
• Store the inhaler at room temperature, away from heat; never puncture the canister.

Equipment

• The prescribed inhaler, with its dose counter checked.
• A spacer of the right size: with a mask for small children, with a mouthpiece for older ones.
• Nebuliser, tubing, medicine cup and mask or mouthpiece, if prescribed.
• Water to rinse the mouth; tissues.
• Pulse oximeter and watch to count respiratory rate before and after.

Step by step (and why)

1. Wash your hands and check the order and identity — every inhaled medicine is a medicine.
2. Count respiratory rate, look at effort and measure SpO2 — the baseline shows whether the dose works.
3. Remove the cap, check the mouthpiece, shake the inhaler and fit it to the spacer — shaking mixes the medicine.
4. Small child: hold as for bottle feeding and seal the mask over nose and mouth — a leak lets the medicine escape.
5. Press once and let the child take at least five normal breaths — the spacer holds the puff while the child breathes.
6. Older child: sitting up, breathe out, lips sealed, press once, slow deep breath, hold it — a slow breath carries the medicine into the airways.
7. Repeat one puff at a time as ordered, waiting between puffs of a quick reliever — puffs sprayed together are wasted.
8. Remove and cap the inhaler; rinse the mouth and the mask area with water — this reduces local side effects.
9. Reassess breathing after each dose and record the response — the plan changes if the child is not better.
10. Wash the spacer or nebuliser parts as instructed and let them air-dry — cleaning prevents germs from growing.

Complications

• Little or no improvement because of poor technique, a mask leak or an empty canister.
• Fast or pounding heartbeat, tremor or agitation after a quick-relief medicine (report it).
• Local side effects in the mouth when it is not rinsed after inhaled medicine.
• Germs can grow in nebuliser parts that are not cleaned and dried, causing lung infections.

Next step: when to call for help

• No improvement after the treatment cycle, or the child looks worse: tell the nurse in charge and the doctor at once.
• Cyanosis, very fast breathing, chest indrawing, drowsiness or difficulty speaking: call for help immediately.
• Before discharge, watch the caregiver give a full dose and correct the technique; bring the inhaler to every visit.
• Teach the family to watch the counter and get a refill before the inhaler runs out.

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Cuadro de procedimientos AIEPI (Atención Integrada a las Enfermedades Prevalentes de la Infancia) (Ministerio de Salud y Protección Social de Colombia, 2016); How to use an inhaler - with spacer (MedlinePlus, U.S. National Library of Medicine, 2024); How to use a nebulizer (MedlinePlus, U.S. National Library of Medicine, 2024); Asthma (fact sheet) (World Health Organization, 2025).

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