How to Use an Inhaler With a Spacer — Step by Step

Why does using a spacer matter?

When you press a metered-dose inhaler (MDI) without a spacer, the medication is released as a fast-moving aerosol that often hits the back of your throat before you can inhale it. A spacer -- also called a valved holding chamber (VHC) -- holds the aerosol cloud so you can inhale it at your own pace, improving drug delivery to the lungs.

The National Asthma Education and Prevention Program's EPR-3 guidelines recommend spacer use because it improves drug delivery, reduces throat irritation from inhaled corticosteroids (ICS), and is especially helpful for people who find it hard to coordinate pressing and inhaling simultaneously. 1Ref 1National Asthma Education and Prevention Program (2007).Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma—Summary Report 2007.Spacer/valved holding chamber recommended with MDI use: improves drug delivery to the lungs, reduces throat irritation from ICS, especially important for patients with poor coordination; slow inhalation technique; mouth rinse after ICS to prevent oral thrush A 2013 Cochrane systematic review of 39 randomized controlled trials confirmed that an MDI with spacer is at least as effective as a nebulizer for acute bronchodilator delivery in adults and children with asthma, with fewer adverse effects and shorter ED stays in children. 2Ref 2Cates CJ, Welsh EJ, Rowe BH (2013).Holding chambers (spacers) versus nebulisers for delivery of beta-agonist relievers in the treatment of an asthma attack.Cochrane systematic review of 39 RCTs: MDI with spacer at least as effective as nebulizer for acute bronchodilator delivery in adults and children with asthma, with shorter ED stays and fewer adverse effects in children

Step-by-step: how to use a spacer with an MDI inhaler

1. Shake the inhaler. Remove the cap from both the inhaler and the spacer. Shake the inhaler firmly for five seconds.

2. Attach the inhaler to the spacer. Fit the mouthpiece of the MDI into the wide opening at one end of the spacer.

3. Breathe out gently. Exhale away from the spacer until your lungs feel comfortably empty. Do not force it.

4. Put the spacer mouthpiece in your mouth. Seal your lips around it. If your spacer has a mask (common for young children), press it firmly over your nose and mouth.

5. Press the inhaler once. Press down on the canister to release one dose into the spacer chamber.

6. Breathe in slowly and deeply over 3-5 seconds, then hold your breath for up to 10 seconds before exhaling. Inhaling too quickly triggers the whistle valve and reduces lung deposition. 1Ref 1National Asthma Education and Prevention Program (2007).Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma—Summary Report 2007.Spacer/valved holding chamber recommended with MDI use: improves drug delivery to the lungs, reduces throat irritation from ICS, especially important for patients with poor coordination; slow inhalation technique; mouth rinse after ICS to prevent oral thrush

7. Wait 30-60 seconds before a second puff if prescribed. Rinse your mouth after using an inhaled corticosteroid to reduce the risk of oral thrush. 1Ref 1National Asthma Education and Prevention Program (2007).Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma—Summary Report 2007.Spacer/valved holding chamber recommended with MDI use: improves drug delivery to the lungs, reduces throat irritation from ICS, especially important for patients with poor coordination; slow inhalation technique; mouth rinse after ICS to prevent oral thrush

How do I know my technique is working?

A few simple checks:

• Listen for the whistle. Most spacers have a one-way valve. Whistling during inhalation means you are breathing in too fast -- slow your inhalation until the whistle stops.
• Check the plume. Pressing the inhaler before putting it to your mouth should produce a visible mist in the spacer chamber. If you see nothing, the canister may be empty.
• Symptom control. If your asthma is well controlled, you should rarely need your rescue inhaler more than twice a week (outside of exercise). The GINA 2024 strategy report uses this symptom frequency as a key marker of asthma control. 3Ref 3Global Initiative for Asthma (GINA) Science Committee (2024).Global Strategy for Asthma Management and Prevention.GINA 2024 strategy report: spacer use with MDI recommended; daytime symptom frequency twice per week or less as a marker of well-controlled asthma

If you are unsure your technique is effective, ask a Gale clinician or pharmacist to observe and correct your technique at your next visit.

How often should I clean my spacer?

Most spacers should be cleaned once a week:

1. Disassemble the spacer and remove the valve if possible. 2. Wash all parts in warm water with a small amount of dish soap. 3. Do not rub the inside -- static charge helps hold the medication particles. Swirl gently. 4. Allow to air dry completely before use. Do not towel-dry. 5. Replace your spacer every six to twelve months, or sooner if the valve looks damaged. 1Ref 1National Asthma Education and Prevention Program (2007).Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma—Summary Report 2007.Spacer/valved holding chamber recommended with MDI use: improves drug delivery to the lungs, reduces throat irritation from ICS, especially important for patients with poor coordination; slow inhalation technique; mouth rinse after ICS to prevent oral thrush

Which spacer should I use?

Most MDIs fit a standard spacer mouthpiece. A valved holding chamber (VHC) -- a spacer with a one-way valve -- is generally preferred because the valve gives you more time to inhale. Young children and infants typically use a spacer with a face mask rather than a mouthpiece.

Your Gale clinician or pharmacist can confirm which spacer is compatible with your specific inhaler brand. Spacers are available over the counter at most pharmacies and are usually covered by insurance when prescribed.

Common mistakes to avoid

• Not shaking the inhaler -- medication settles and you may get mostly propellant.
• Pressing the canister more than once per breath -- extra puffs waste medication and do not improve delivery.
• Inhaling too fast -- slow, steady inhalation is more effective than a quick gasp. 1Ref 1National Asthma Education and Prevention Program (2007).Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma—Summary Report 2007.Spacer/valved holding chamber recommended with MDI use: improves drug delivery to the lungs, reduces throat irritation from ICS, especially important for patients with poor coordination; slow inhalation technique; mouth rinse after ICS to prevent oral thrush
• Skipping the mouth rinse after a steroid inhaler -- oral thrush is preventable with a simple water rinse. 1Ref 1National Asthma Education and Prevention Program (2007).Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma—Summary Report 2007.Spacer/valved holding chamber recommended with MDI use: improves drug delivery to the lungs, reduces throat irritation from ICS, especially important for patients with poor coordination; slow inhalation technique; mouth rinse after ICS to prevent oral thrush
• Using an empty inhaler -- do a float test or keep a dose counter. Most modern MDIs have a built-in counter.