Even as asthma—a chronic inflammatory airway disease—affects nearly 7.9 percent of children in India, the country lacks standard national guidelines for the cleaning, drying, and maintenance of spacer devices used by young asthma patients.
This critical gap in asthma care has been highlighted by a recent study by researchers from AIIMS Jodhpur, who found that 40 percent of spacer devices were contaminated with pathogenic bacteria, including Pseudomonas aeruginosa. The findings raise concerns about infection risks from devices designed to support effective asthma treatment.
Although the contamination did not directly affect asthma control, the study titled “Bacterial Contamination of Spacer Devices Used by Asthmatic Children: A Cross-Sectional Study” draws attention to an overlooked risk linked to inadequate maintenance practices and the absence of standardized national guidelines for spacer hygiene.
In India, as in many countries, inhaled corticosteroids delivered through metered-dose inhalers (MDIs) remain the cornerstone of asthma management. Spacer devices are widely recommended for children, as they enhance drug delivery, reduce deposition of medication in the mouth and throat, and improve coordination during inhalation.
However, poor upkeep can undermine their safety. “Inadequate maintenance can turn spacer devices into reservoirs of infection. At present, parents and caregivers largely depend on manufacturer instructions, which vary widely and often do not clearly specify cleaning frequency, drying methods, or replacement timelines,” said Dr. Jagdish Prasad Goyal, lead author of the study and faculty member at the Department of Pediatrics, AIIMS Jodhpur.
The research showed that drying spacers with a cloth was significantly associated with the growth of pathogenic bacteria, compared to air drying. This finding underscores the need for clear, evidence-based recommendations. While asthma symptoms were not directly worsened, researchers cautioned that the real danger lies in potential infections and future exacerbations.
Published in Indian Pediatrics, the study underlines the urgent need for standardized national guidelines on spacer hygiene, similar to existing protocols for inhaler technique. Without uniform guidance, millions of children using spacer devices may remain exposed to avoidable microbial risks.
Other researchers involved in the study included Dr. Robin Kumar, Kalyana Prabhakaran, Prawin Kumar, Vibhor Tak, and Kumar S. Abhishek, all from AIIMS Jodhpur.
Conducted between January 2021 and December 2023 at the Pediatric Chest Clinic of AIIMS Jodhpur, the study enrolled 180 children aged 5 to 17 years who had been using an MDI with a spacer for at least three months. Using sterile microbiological techniques, researchers analyzed samples from the inner surfaces of spacer devices and correlated contamination with cleaning practices, drying methods, and asthma control.
The results showed that 40 percent of spacers harbored pathogenic bacteria, while the remaining 60 percent contained non-pathogenic organisms. Pseudomonas aeruginosa was the most frequently isolated pathogen, accounting for 28 percent of cases—a clinically significant finding given its association with respiratory infections, particularly in vulnerable groups.
Interestingly, no significant association was found between bacterial contamination and washing methods. Most caregivers (82.2 percent) cleaned spacers using tap water alone, while only 17.8 percent used soap and water. Cleaning frequency, whether daily or weekly, also did not show a statistically significant link with contamination.
In contrast, drying practices emerged as a critical factor. Spacer devices dried with a cloth showed a markedly higher prevalence of pathogenic bacteria compared to those that were air-dried, suggesting cloth drying as an important and modifiable risk factor.
Despite the high contamination rate, asthma control remained largely stable. Based on Asthma Control Test (ACT) and Childhood Asthma Control Test (C-ACT) scores, 92.2 percent of children had well-controlled asthma. Poor asthma outcomes were more strongly associated with incorrect inhaler technique and poor medication adherence than with spacer contamination.
The study also noted positive trends: over three-fourths of children demonstrated correct inhaler technique, and more than 80 percent showed good medication compliance—likely reflecting the benefits of a dedicated pediatric asthma care team.
“In the absence of evidence-based national recommendations, caregivers and clinicians are forced to rely on inconsistent manufacturer advice, which may not adequately address infection risks,” the study concluded.
