When individuals are first prescribed inhaled medication it is essential to teach them about the correct use of their inhaler to ensure optimal drug delivery
In this article…
- The importance of using inhalers correctly
- Detailing different types of inhalers and how to use them
- Correctly using training aids
5 key points
- Failure to use inhalers correctly reduces their benefit
- Patients should be taught how to use their inhaler when they are first prescribed inhaled medication
- Their technique should be checked at subsequent consultations
- Individuals’ abilities should be taken into account when selecting inhaler devices
- Placebo inhalers can be useful to demonstrate correct inhaler technique
- This article has been double-blind peer reviewed
Inhalation is the preferred method of delivering medication for respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). The drug is delivered directly to the affected organ allowing a lower dose to be used.
The need for teaching
Incorrect use of inhalers reduces any potential benefit of the medication, so respiratory guidelines recommend that patients are carefully taught how to use prescribed inhalers (BTS/SIGN, 2008).
Most pressurised metered dose inhalors (pMDIs) involves users co-ordinating correct timing and appropriate inspiratory flow rate (IFR). Some pMDIs (Autohaler, Easibreathe) and all dry powder inhalers (DPIs) do not require timing, but do demand that the inspiration produce a certain IFR or peak inspiratory flow (PIF).
Written instructions alone on how to use an inhaler are insufficient. When patients are first prescribed inhaled medication they must be taught how to usetheir inhaler, and their technique should be checked at subsequent consultations.
It is crucial that healthcare professionals who teach inhaler technique can perform it correctly themselves (Crompton, Barnes et al, 2006). However, recent study showed that 93% of those tested were unable to demonstrate both the various stages of inhaler use and the correct IFR (Baverstock et al, 2010). The techniques and IFRs are not the same for all inhaler devices, so healthcare professionals must learn how to use all the inhalers they prescribe. For all inhalers the instructions in the patient information leaflet should be followed.
Pressurised metered dose inhalors
These consist of a pressurised canister containing the medication. When the inhaler is activated by pressing the canister, releasing a measured aerosol dose of the drug. The user must inhale slowly at a low IFR, otherwise most of the respirable dose will stick to the back of the throat rather than reaching the lungs (Box 1). This requires a degree of co-ordination that may be beyond the ability of some, such as children or older people.
Box 1. Using pMDIs
- Remove the cap
- Shake the inhaler
- Breathe out gently
- Place mouthpiece between lips
- Actuate the inhaler and breathe in slowly and deeply at a low IFR
- Hold breath for 5-10 seconds then breathe out
- Wait a few seconds then repeat the above process
- Replace inhaler cap
For those who find pMDI technique difficult or need a high dose of corticosteroid, a spacer device can be attached to the inhaler. After the canister is pressed the medication remains in suspension in the spacer for a short time allowing the user to inhale the drug by either taking one deep gentle breath in, or through tidal breath (inhale and exhale at normal, resting rate - this is usually at a rate of one press of the inhaler and five tidal breath).
A spacer with a mask attached is available for children and adults who have difficulty sealing their lips around a mouthpiece. The mask must be closely applied to the face while the pMDI is activated. Manufacturers recommend washing spacer devices in warm soapy water when new, and then weekly, leaving to air dry to reduce static.
Spring-loaded pMDIs (Autohaler/Easibreathe)
These inhalers must be primed before each use. The Autohaler is primed by pushing a lever on top of the inhaler upwards and the Easibreathe by closing the cap on the mouthpiece. The devices are activated when the user inhales, which removes the need to co-coordine activation and inspiration, although an appropriate IFR and continued breathe in is still vital.
Fine mist pMDI (Respimat)
This device requires an initial priming and activation in accordance with the manufacturer’s instructions. The outer case is turned before each use and the cap is removed. The lips should then be sealed around the mouthpiece before the device is activated. A long, gentle breath in is required.
Dry powder inhalers
A wide range of DPIs is available; the list below is not exhaustive but explains the principles for using some of those most commonly prescribed in the UK (Box 2).
Box 2. Using DPIs
- Remove cap
- Prime device for delivery
- Breathe out gently, place mouthpiece between lips
- With Accuhaler breathe in steadily and deeply
- With Turbohaler and Handihaler breathe in as deeply as possible
- Hold breath for 5-10 seconds
- Wait a few seconds then repeat the process if a second dose is required
- Replace inhaler cap
With DPIs the drug is held within sealed blisters, capsules or a reservoir. The inhaler is prepared by, for example:
- Pressing a trigger, which moves an opened blister to the inhalation port (Accuhaler);
- Loading and piercing the capsule (Handihaler;
- Twisting the base of the reservoir (Turbohaler).
Inhalation breaks up the powder into an aerosol of respirable size particles,drawing the drug out of the inhaler into the lungs. This means a more forceful inspiration is required when using a DPI, although thePIF needed varies according to the design of the inhaler.
Placebo inhalers (available from inhaler manufacturers) can help with demonstrating correct inhaler technique. These placebo devices are for single-person use.
A range of devices is available to help train healthcare professionals and patients. These include: 2Tone Trainer Turbutest, In-CheckDial, Mag-Flo inhaler flow indicator, Aerosol Inhalation Monitor, Inhalation Manager, SmartMist and Multimedia training tools (Lavorini et al, 2010).
Individuals’ ability to use inhalers and their attitude to the disease, therapy and acceptability of the selected device should be taken into account when selecting the selection of a device if compliance with therapy is to be achieved. Compliance and inhaler technique should be assessed at every consultation.
Box 3.Competencies required by nurses
- Ability to carry out loading and activation procedure for the various inhalers
- Knowledge of appropriate IFRs for pMDIs and PIFs for DPIs
- Ability to understand and teach how to use each inhaler
- Ability to recognise poor inhaler technique
Box 4. Details to document
- Diagnosis and disease severity
- Type of inhaler and appropriate IFR/PIF (this may change if inhaler is changed)
- Checklist of correct inhaler use (Boxes 1 and 2)
- Details of reinstruction and re-checking where necessary
- If inhaler device has been changed, reason for this
Baverstock M et al (2010) Do healthcare professionals have sufficient knowledge of inhaler technique in order to educate their patients effectively in their use? Thorax; 65: (suppl.4), A119.
British Thoracic Society, Scottish Intercollegiate Guidelines Network (2004) British guideline on the management of asthma. Thorax; 63: (suppl.4), 1-121.
Crompton G et al (2006)The need to improve inhalation technique in Europe: a report from the Aerosol Drug Management Improvement Team. Respiratory Medicine; 100:1479-94.
Lavorini F et al (2010) The ADMIT series – Issues in inhalation therapy. Training tools for inhalation devices. Primary Care Respiratory Journal; 19: 4, 335-41.