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Why use a valved holding chamber (VHC) with all metered-dose inhalers (MDI)?

A valved holding chamber prevents MDI medication plumes from striking the mouth at 40 miles/hour
MDI medications taken without a valved holding chamber largely end up in the mouth and stomach
The “valve” allows a breath to be taken in through the chamber, but prevents exhaled air from flowing back into the chamber and washing out the medication
Most VHCs are equipped with a “whistle” or flow signal to warn users when they inhale at twice the ideal speed, the whistle means “slow down”

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Keep it Simple (3 Steps)–

With Flow-Vu® it is possible to see if the student is really breathing in and assess whether the breath takes several seconds and results in filling the lungs (chest rises slowly with no whistle heard)

This Photo by Unknown Author is licensed under CC BY-SA

This Photo by Unknown Author is licensed under CC BY-SA-NC

Old Air Out

Aim Up

Fill Up Slowly

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Target Inhalation Time

Target Inhalation Time is a concept based on how many seconds one should breathe in from an inhaler to have the maximum amount of medicine reach the lungs (along with good coordinated technique)

Target Inhalation Time is important whenever inhaling medicine from an inhaler, as, if it is done too quickly or too slowly means that less medicine than is in a puff of medicine, and that is intended to reach the lungs, will actually reach them.

Target Inhalation Time may be lower than normal when someone is having an asthma episode, and struggling to breathe because working lung volumes are reduced when obstructed.

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Optimal Inhalation Time�Varies By Age

�

Lungs become bigger as children grow taller. As such, little lungs fill up more quickly than big lungs. Below is an average inhalation time by age-range. MDI medication should flow into everyone’s lungs at the same rate �(a liter of air inhaled in 2 seconds).

This Photo by Unknown Author is licensed under CC BY-NC-ND

Elementary

2 to 3 seconds

Middle School

4 to 6 seconds

High School

6 to 10 seconds

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A quick and easy program available to School Nurses in Missouri that encourages coaching students with asthma on inhaler technique by providing resources.

This program, offered by Asthma Ready® Communities, provides asthma equipment to school nurses in Missouri who want to participate, at no cost to them or their district.

The equipment includes 2 AeroChambers with Flow-Vu ® Indicator (mouthpiece), and one Trainhaler. A survey (next slide) guides coaching efforts.

A Participating student receives complimentary AeroChamber Plus Flow-Vu ® Indicator (mouthpiece), and is coached on good inhaler technique, using the nurse’s Trainhaler, which is approved for multi-person use. (Clean between students with antiseptic wipe. At least 70% alcohol.)

Inhaler Technique Coaching Program

Monaghan Medical

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Using Inhaler Technique Coaching Program:

https://forms.office.com/r/Z5r315CiJN

Complete this survey to receive a replacement Flow-Vu AeroChamber

Aerochamber Use and Inhaler Technique Coaching Survey

https://forms.cloud.microsoft/pages/responsepage.aspx?id=vv3-4-n3G0ClGjVeAbBaiSaC3JS4Z_hEpJBdefjECkNURjNQODBVQjFXU0hXUDlSOVU5OTBRVEU2Ty4u&route=shorturl

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Go to this link to order start up kit: Link

Alternatively, you can contact Deb Cook Debcook1609@gmail.com to request you Inhaler Technique Starter Kit.

You will receive in the mail:

1 Trainhaler
2 AeroChambers with FlowVu

Coach student using quick survey link:

-Offers inhaler technique coaching resources—Written steps, and Video

(Can be used to help train student)

-Once survey is submitted, at the end of the month, a replacement

AeroChamber with FlowVu will be mailed to you.

Monaghan Medical, Alliance Tech Medical

Aerochamber Use and Inhaler Technique Coaching Survey

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How does a nurse fit this into an already busy schedule??

Make a calendar entry: Set aside 10-15 minutes of time a week, when there is a pocket of downtime, and work with one student, one time a week, until they are competent.

Around 2pm, for example

First time is the hardest: The first time coaching a student will take longer than subsequent sessions.

It may take 10-15 minutes the first time,
but after that, it will usually take much less time, because of familiarity, and improvement with practice.

Benefit: If good inhaler technique becomes habit, then asthma control starts to increase, leading to fewer unplanned episodes.

“An ounce of prevention saves a pound of cure,” According to Benjamin Franklin.
Consider also reviewing medication use (which inhaler medications used and how often) while working with student (an additional important component to asthma control).

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When is it better to stick with a mask, instead of using a mouthpiece?

Young Child. When they cannot: 1) Create a good seal OR 2) Coordinate inhaler technique—slow inhalation with coordination of actuation. ^1,2,3,4

Young children have difficulty creating a seal with their lips around a mouthpiece—without a good seal, the dose of medicine will be inadequate, and more guaranteed with a well-fitted mask that creates a tight seal. ^1,2,3

Children less than age 4, typically, but most children are able to create a seal around the mouthpiece and coordinate breath by around age 5 or 6.^1,2,3

***When a child is being taught to transition from mask to mouthpiece, it may take several coaching sessions before they catch on.***

An Adult or Child (any age) who cannot actively participate in medication taking.⁴ If they cannot coordinate good inhaler technique, they will not receive good medication delivery with a mouthpiece. Below are a couple of examples that reduce or eliminate one’s ability to actively participate in inhaler technique.

Cognitive or neuromuscular limitations
Severe asthma episodes: When you can’t speak in full sentences, it is hard to coordinate inhaler technique to get a full dose of medicine from an inhaler.

NIH / National Heart, Lung, and Blood Institute. (2007) Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma Guidelines for the Diagnosis and Management of Asthma—EPR3 Guidelines (2007) www.nhlbi.nih.gov/guidelines/asthma
Csonka, P., Tapiainen, T., Makela, M.J., Lehtimaki, L. “Optimal administration of bronchodilators with valved holding chambers in preschool children: a review of literature.” European Journal of Pediatrics (2021) Apr. 20; 180(10):3101-3109. https://pmc.ncbi.nlm.nih.gov/articles/PMC8055476/
Volerman, A., Balachandran, U., Siros, M., Akel, M., Press, V.G., “Mask Use with Spacers/Valved Holding Chambers and Metered Dose Inhalers among Children with Asthma.” Annals of the American Thoracic Society. (2021” Jan;18(1):17–22 https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.202005-522CME
American Academy of Allergy, Asthma, and Immunology (AAAAI) “Spacers and Valved Holding Chambers (VHCs) for Metered Dose Inhaler (MDIs).” (2026) https://www.aaaai.org/tools-for-the-public/conditions-library/asthma/spacers-and-valved-holding-chambers-(vhcs)-for-use.

For those children using masks, the recommendations indicate that the transition from a spacer/VHC with a mask to a spacer/VHC with a mouthpiece should occur sometime between 3 and 6 years of age. This recommendation about the transition stems from evidence that young children cannot create a tight seal around the mouthpiece of a spacer (6) and cannot control their breathing to coordinate inhalation with the actuation of the inhaler (23); until they are able to, children should instead use a mask with the spacer/VHC. However, the age range at which children should ultimately be transitioned to using a spacer with a mouthpiece is quite large and does not account for other factors that may influence the ability of a child to use an MDI with a spacer/VHC and a mouthpiece rather than with a mask (23, 30).

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Good Seal with the Right Size Mask

Tight fit and good seal between the mask and the face are essential for drug delivery.^1,2,3,5
Choose the right size facemask—one size does not fit all
It should cover the mouth and nose comfortably. Look at the mask’s perimeter and make sure it is touching the face all around and there is no leak between the mask and the face.

Monaghan Medical

NIH / National Heart, Lung, and Blood Institute. (2007) Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma Guidelines for the Diagnosis and Management of Asthma—EPR3 Guidelines (2007) www.nhlbi.nih.gov/guidelines/asthma
Csonka, P., Tapiainen, T., Makela, M.J., Lehtimaki, L. “Optimal administration of bronchodilators with valved holding chambers in preschool children: a review of literature.” European Journal of Pediatrics (2021) Apr. 20; 180(10):3101-3109. https://pmc.ncbi.nlm.nih.gov/articles/PMC8055476/
Volerman, A., Balachandran, U., Siros, M., Akel, M., Press, V.G., “Mask Use with Spacers/Valved Holding Chambers and Metered Dose Inhalers among Children with Asthma.” Annals of the American Thoracic Society. (2021” Jan;18(1):17–22 https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.202005-522CME
Amirav, I., Newhouse, M.T. “Aerosol therapy with valved holding chambers in young children: Importance of the Facemask Seal.” Pediatrics (Sept. 2001) 108(2):389-94 https://www.researchgate.net/publication/11858937_Aerosol_Therapy_With_Valved_Holding_Chambers_in_Young_Children_Importance_of_the_Facemask_Seal

Medium

intermediate

Large

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Transition Young Child to Mouthpiece When:

The child can seal lips tightly around the mouthpiece.

The child can inhale slowly and deeply.

The child understands basic cueing.

The child shows competent technique with coaching.

**This may take a few coaching sessions**

The child is observed actively participating in the Metered Dose Inhaler medication delivery process.

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Ideas for obtaining valved holding chambers with masks for your office

Check with local pharmacies or medical supply companies to see about possibilities for equipment donation

Check with regional health systems—some have charitable arms or can provide community education and equipment.

Grants for school health office supplies

Request support from school / district parent groups (like PTA), or civic organizations like the Lyons Club or Kiwanis Club to cover the cost of chambers with masks.

Can purchase with from Monaghan at preferred pricing rates—Purchasing Document will be included with the presentation on the MO Healthy Schools Asthma Page.

Can purchase valved holding chambers with and without masks through supply companies. Ex: School Health Corporation, and School Nurse Supply Inc.

I have had some districts unable to use this because they couldn’t get the documentation they needed. Not a problem to get an invoice to pay your bill.

If your purchasing process allows you to pay for something and then request reimbursement, that might be the best way to get these items. Monaghan is not able to be a vendor to individual school districts, but you can use this form to order directly from them. They just don’t have the capacity to become a formal vendor. This is something they created for us to be able to share with school districts and clinics that we train. But the ordering has to follow the purchase and agreement terms listed on this form, that will be shared.

Not sure if it was the 1099, but some districts have to have, but I know of one district that couldn’t use this form by itself to make a purchase, and had to have Monaghan become a vendor before they could purchase. Monaghan is not able to work in that capacity with individual school districts, and if you need that (form them to be a vendor to use them, you can also get chambers with masks from your local DME company). But I also know of at least one district that has not had any problem ordering from Monaghan, without needing them to send them anything to become a vendor. Monaghan creates and designs the products, and they typically have other vendors who sell those products to schools. Like a medical sales and distribution company.

If you have any questions about that, or are looking to find a company who can sell chambers with masks and become a vendor, feel free to reach out to me or anyone from our team here at SNACS-S.

Has anyone ordered from Monaghan before, who is on this call?

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Using the AeroChamber Plus* Flow-Vu* with a ComfortSeal* Mask - Trudell Medical International

Steps from video

Remove the cap from the inhaler
A) Insert the inhaler in the back of the

chamber

B) Apply he mask to the face and ensure

an effective seal.

(The Flow-Vu Inhalation Indicator only

moves if you have a good seal)

A) Press the inhaler at the beginning of the

inhalation as the Flow-Vu Inhalation

Indicator moves toward the user.

B) Use the Flow-Vu Inhalation Indicator to

count 5 to 6 breaths

Administer one puff at a time. Follow

instructions supplied with inhaler on how

long to wait between puffs. (Wait one

minute between puffs)

Using a chamber with a mask: AeroChamber Plus Flow-Vu

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Using a chamber with a mask: Valved Holding Chamber with Mask

Using an Inhaler with a Spacer Mask

Children’s Hospital of Atlanta:

Using an Inhaler with a Spacer Mask

Steps from video

Prime the inhaler before use
Stand or sit up straight
Take off the cap and shake the inhaler
Insert the inhaler into the end of the chamber / spacer
Breathe out all the way
Place mask firmly on the face, covering the nose and mouth.
Press down on the inhaler and breathe in and out slowly 6 times.
Shake the inhaler before taking each pump if more than one puff is ordered. Allow 30 seconds to one minute between each puff
Wipe face after using any inhaled steroid medicine
Clean your spacer once a week. Pull the pieces apart and soak them in warm, soapy water. Let them dry before putting them back together.

Cleaning Note: Never wipe the inside of the spacer. There is a special lining that helps the medicine get into the lungs.

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Preschool children will usually respond to the following instructions after the mask is in place.

�1. Make sure the mask is in place over the child's nose and mouth and has a good seal.�2. Coach the child to “aim up” so the child lifts their chin.�3. Next, encourage the child to take deep breaths - “OK. Blow out ALL your air (nose exhalation valve leans forward while breathing out), “blow out like you are blowing out candles on a cake [or similar instructions].” �4. Next, press down to actuate the MDI and say, “Breathe in, breathe in, breathe in… Now hold it, hold it, hold it. Good work!”
�***If the effort is not great, just keep the mask in place and repeat this sequence one or more times to clear the drug from the chamber. By three or four years of age most young children can learn to empty their lungs intentionally, take a slow breath to fill their lungs with medication and then hold their breath a few seconds.***

Asthma Ready Communities. Delivering Asthma Education for Caregivers - Infants and Young Children Edition. https://youtu.be/hJqQrmy76Lw [Inhaler with mask coaching starts 2:01:52 and ends 2:02:59]

Coach a child to take bigger breaths using the Valved Holding Chamber with mask

(May help in transitioning child to mouthpiece)

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Links for Inhaler Technique videos

Watch Inhaler Technique Coaching Example

https://www.youtube.com/watch?v=Ge3kQerMDDQ

Watch short videos about inhaler technique and why spacers are important

Videos about Inhaler Technique with Mask:

Using the AeroChamber Plus* Flow-Vu* with a ComfortSeal* Mask - Trudell Medical International
Using an Inhaler with a Spacer Mask
https://youtu.be/hJqQrmy76Lw [Inhaler with mask coaching starts 2:01:52 and ends 2:02:59]

Flyers encouraging spacer use (can be shared with students / families)

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References:

1. NIH / National Heart, Lung, and Blood Institute. (2007) Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma Guidelines for the Diagnosis and Management of Asthma—EPR3 Guidelines (2007) www.nhlbi.nih.gov/guidelines/asthma (Accessed January 11^th, 2026)
2. Csonka, P., Tapiainen, T., Makela, M.J., Lehtimaki, L. “Optimal administration of bronchodilators with valved holding chambers in preschool children: a review of literature.” European Journal of Pediatrics (2021) Apr. 20; 180(10):3101-3109. https://pmc.ncbi.nlm.nih.gov/articles/PMC8055476/
3. Volerman, A., Balachandran, U., Siros, M., Akel, M., Press, V.G., “Mask Use with Spacers/Valved Holding Chambers and Metered Dose Inhalers among Children with Asthma.” Annals of the American Thoracic Society. (2021” Jan;18(1):17–22 https://www.atsjournals.org/doi/full/10.1513/AnnalsATS.202005-522CME (Accessed January 11^th, 2026)
4. American Academy of Allergy, Asthma, and Immunology (AAAAI) “Spacers and Valved Holding Chambers (VHCs) for Metered Dose Inhaler (MDIs).” (2026) https://www.aaaai.org/tools-for-the-public/conditions-library/asthma/spacers-and-valved-holding-chambers-(vhcs)-for-use. (Accessed January 11^th, 2026)
5. Amirav, I., Newhouse, M.T. “Aerosol therapy with valved holding chambers in young children: Importance of the Facemask Seal.” Pediatrics (Sept. 2001) 108(2):389-94 https://www.researchgate.net/publication/11858937_Aerosol_Therapy_With_Valved_Holding_Chambers_in_Young_Children_Importance_of_the_Facemask_Seal (Accessed January 11^th, 2026)