Asthma Management Handbook

Choosing an inhaler device to suit the individual

Recommendations

Choose a device type that is best for the individual, considering potential problems.

Table. Types of inhaler devices for delivering asthma and COPD medicines Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/75

Table. Considerations for choice of inhaler device type when prescribing inhaled medicines

Clinical situation

Consideration

Acute asthma (all patients) Recommend use of spacer when using reliever via pMDI for acute asthma

Any patient using a pMDI for an inhaled corticosteroid

Recommend use of a spacer every time (except for breath-acuated pMDIs)

Infants and small children

Use a spacer with a facemask

Poor manual dexterity (e.g. weak hands or osteoarthritis)

Consider either of:

  • a Haleraid device with relevant pMDIs (available for salbutamol, fluticasone, fluticasone/salmeterol)
  • a breath-actuated inhaler

Difficulty connecting spacer to pMDI (e.g. elderly patient with weakness or poor coordination)

Consider a breath-actuated inhaler or a spacer with a flexible (universal) connector port

Inability to form a good seal around the mouthpiece of the inhaler or spacer (e.g. person with cognitive impairment or facial weakness)

Consider a spacer plus age-appropriate facemask

Difficulty speaking or reading English

Give a physical demonstration

Use videos

Use an interpreter or provide written instructions in the person’s first language

Using multiple inhalers

Choose the same type for each medicine, if possible, to avoid confusion

If not possible, train person in the correct inhaler technique for each of their devices, emphasising any key differences (e.g. speed of inhalation, shake pMDIs but not dry-powder inhalers)

Source: National Asthma Council Australia. Inhaler technique for people with asthma or COPD. Melbourne: NAC; 2016. Available from: http://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

For patients who may find it difficult to use an inhaler (e.g. older patients with osteoarthritis or weakness), check the person’s technique to work out which inhaler type will be easiest to use.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only approximately 10% of patients use correct technique.12

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,3, 4, 5, 6, 7 even among regular users.8 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.9

Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.3, 10, 8, 11, 12 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.8

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.13, 14

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:9

  • failing to shake the inhaler before actuating
  • holding the inhaler in wrong position
  • failing to exhale fully before actuating the inhaler
  • actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
  • actuating the inhaler too late while inhaling
  • actuating more than once while inhaling
  • inhaling too rapidly (this can be especially difficult for chilren to overcome)
  • multiple actuations without shaking between doses.

Common errors for dry powder inhalers include:9

  • not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
  • failing to exhale fully before inhaling
  • failing to inhale completely
  • inhaling too slowly and weakly
  • exhaling into the device mouthpiece before or after inhaling
  • failing to close the inhaler after use
  • using past the expiry date or when empty.

Other common problems include:

  • difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
  • inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
  • inability to generate adequate inspiratory flow for the inhaler type
  • failure to use a spacer when appropriate
  • use of incorrect size mask
  • inappropriate use of a mask with a spacer in older children.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.9 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.15, 3, 16, 17 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.16 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).1, 14

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct technique.13, 3, 4 

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Administration of inhaled medicines in children: 0–5 years

To use inhaler devices correctly, parents and children need training in inhaler technique and in the care and cleaning of inhalers and spacers.

Children need careful supervision when taking their inhaled medicines (e.g. at preschool), especially when using a reliever for acute asthma symptoms. 

During acute wheezing episodes, delivery of short-acting beta2 agonist to airways is more effective with a pressurised metered-dose inhaler plus spacer than with a nebuliser.18 In older children, salbutamol has also been associated with a greater increase in heart rate when delivered by nebuliser than when delivered by pressurised metered-dose inhaler plus spacer.19

Dry-powder inhalers are usually ineffective for preschool children because they cannot generate sufficient inspiratory air flow.18

Preschool children cannot use pressurised metered-dose inhalers properly unless a spacer is attached (with mask when necessary), because it is difficult for them to coordinate inspiratory effort with firing the device.18 Note that breath-actuated pressurised metered-dose inhalers cannot be used with a spacer.

Even when using pressurised metered dose inhalers and spacers, drug delivery is very variable in young children.20 The inhaler design may improve spacer technique,20 but will not necessarily improve clinical outcomes. The amount of medicine delivered by inhaler devices to the lower airways varies from day to day in preschool children.18 This variation might explain fluctuations in effectiveness, even if the child’s parents have been trained to use the device correctly.

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the inhaler, fire one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).21 Fewer breaths may suffice; in children with asthma aged 2–7 years (not tested during an acute asthma episode), the number of tidal breaths needed to inhale salbutamol adequately from a spacer has been estimated at 2 breaths for small-volume spacers, 2 breaths for a spacer made from a 500-mL modified soft drink bottle, and 3 breaths for a large (Volumatic) spacer.22

When using a spacer with face mask (e.g. for an infant too young or uncooperative to be able to use a mouthpiece), effective delivery of medicine to the airways depends on a tight seal around the face. When masks are used for inhaled corticosteroids, there is a risk of exposure to eyes and skin if the seal over the mouth and nose is not adequate. Parents should be advised to wash the child's face after administering inhaled corticosteroids by mask.

Babies are unlikely to inhale enough medicine while crying.19 The use of a spacer and face mask for a crying infant may require patience and skill: the child can be comforted (e.g. held by a parent, in own pram, or sitting on the floor) while the mask is kept on, and the actuation carefully timed just before the next intake of breath. Most infants will tolerate the spacer and mask eventually. The child may be more likely to accept the spacer and mask if allowed to handle them first (and at other times), if the devices are personalised (e.g. with stickers), or if the mask has a scent associated with the mother (e.g. lip gloss). The use of a spacer with a coloured valve allows parents to see the valve move as the child breathes in and out.

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Administration of inhaled medicines in children: 6 years and over

School-aged children (depending on the child’s age, ability, and with individualised training) can correctly use a range of inhaler types,23 including manually actuated pressurised metered-dose inhalers with spacers,24 breath-actuated pressurised metered-dose inhalers (e.g. Autohaler), and dry-powder inhalers (e.g. Accuhaler, Turbuhaler).2425

A pressurised metered-dose inhaler and spacer is an appropriate first choice for most children.23

Parents and children need training to use inhaler devices correctly, including inhaler technique, and care and cleaning of inhalers and spacers.

School-aged children are unlikely to use their inhaler device correctly without careful training.26

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Choosing inhaler devices for older adults

Problems for older patients using inhalers

Inhaler devices should be used in favour of nebulisers wherever possible, just as for younger adults.27 The use of nebulisers increases the risk of transmitting infections to other patients or to health workers. The use of ipratropium bromide via nebulisers with loose-fitting masks has been associated with pupil dilatation, blurred vision and acute glaucoma.28 In practice, many patients do not maintain their nebuliser adequately (e.g. change bowl as often as recommended).

Incorrect inhaler technique is common among older people with asthma or COPD, whether using a pressurised metered-dose inhaler or a dry-powder inhaler, particularly with those with more severe airflow limitation.2927, 3031, 32, 33,34

Common problems for older people include:30333536, 3738

  • inadequate inspiratory flow (particularly among those with COPD), which limits ability to use dry-powder inhalers or pressurised metered-dose inhalers properly
  • difficulty connecting a pressurised metered-dose inhaler to a spacer
  • inability to coordinate breathing in with actuating a pressurised metered-dose inhaler
  • inability to actuate a pressurised metered-dose inhaler due to osteoarthritis or weakness of the hands
  • inability to achieve a firm seal around the mouthpiece when using inhalers alone or with a spacer (particularly for patients with cognitive impairment, facial weakness, or who are missing teeth).

Tips for correct use of inhalers

Patients with osteoarthritis may find it easier to use an aid (e.g. Haleraid hand-grip device) to help them actuate their inhaler, or use a breath-actuated inhaler. Mechanical difficulties can usually be overcome by checking each individual’s technique and helping the person identify which inhaler they can use best among those available for the required medicine.

For some patients, a breath-actuated pressurised metered-dose inhaler (e.g. Autohaler) or breath-actuated dry-powder inhaler (e.g. Turbuhaler or Accuhaler) may be easier to use than pressurised metered-dose inhalers.3637 However, some patients (e.g. those with severe COPD) may be unable to achieve a high enough inspiratory rate to actuate dry-powder inhalers (e.g. Accuhaler or Turbuhaler).37 With a breath-actuated inhaler, adequate lung doses of inhaled corticosteroids may be achieved despite poor technique.39

Older people with asthma can acquire and retain appropriate technique after specific instruction, but this instruction needs to be repeated regularly to reinforce correct inhaler technique,27 just as for young people. People with cognitive impairment are likely to have problems retaining skills after instruction in the use of an inhaler.40

About half of all older people with asthma or COPD are prescribed more than one inhaler device.41 As the number of prescribed devices increase, the frequency of error also increases.42

Table. Considerations when choosing inhaler devices for older patients

Problem

Solution

Reduced maximal inspiratory flow

Consider pMDI alone or with spacer

Avoid dry-powder inhalers

Reduced manual dexterity (e.g. due to osteoarthritis)

Consider a Haleraid with a pMDI, where relevant (salbutamol, fluticasone, fluticasone/salmeterol)

Consider pMDI with small-volume spacer or breath-actuated dry-powder inhaler

Inability to coordinate actuation and inhalation

Consider pMDI with spacer, breath-actuated pMDI or breath-actuated dry-powder inhaler

Avoid pMDI without spacer

Inability to form effective seal with lips around mouthpiece

Use spacer plus face mask

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References

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  2. Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
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