Choosing an inhaler device to suit the individual
Choose a device type that is best for the individual, considering potential problems.
Table. Types of inhaler devices for delivering asthma and COPD medicines Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/75
- How this recommendation was developed
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
Based on clinical experience and expert opinion (informed by evidence, where available).
- Correct use of inhaler devices
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
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.Close
- 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.Close
- 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).24, 25
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
- 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.29, 27, 30, 31, 32, 33,34
- 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.36, 37 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.40Close
- Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
- 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
- Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23098685
- Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
- Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18083019
- Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24779482
- Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ primary care respiratory medicine. 2014; 24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
- Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
- National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
- Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762
- Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415
- Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
- Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol. 2007; 119: 1537-8. Available from: http://www.jacionline.org/article/S0091-6749(07)00439-3/fulltext
- Giraud, V., Allaert, F. A., Roche, N.. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respiratory medicine. 2011; 105: 1815-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21802271
- Basheti, I. A., Reddel, H. K., Armour, C. L., Bosnic-Anticevich, S. Z.. Counseling about turbuhaler technique: needs assessment and effective strategies for community pharmacists. Respiratory care. 2005; 50: 617-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15871755
- Lavorini, F.. Inhaled drug delivery in the hands of the patient. Journal of aerosol medicine and pulmonary drug delivery. 2014; 27: 414-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25238005
- Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert opinion on drug delivery. 2014; 11: 365-78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24386924
- Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from: http://erj.ersjournals.com/content/32/4/1096.full
- Schuh, S., Johnson, D. W., Stephens, D., et al. Comparison of albuterol delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma. The Journal of pediatrics. 1999; 135: 22-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10393599
- Schultz A, Sly PD, Zhang G, et al. Incentive device improves spacer technique but not clinical outcome in preschool children with asthma. J Paediatr Child Health. 2012; 48: 52-6. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2011.02190.x/full
- National Asthma Council Australia. Kids' First Aid for Asthma. National Asthma Council Australia, Melbourne, 2011. Available from: http://www.nationalasthma.org.au/first-aid
- Schultz A, Le Souëf TJ, Venter A, et al. Aerosol inhalation from spacers and valved holding chambers requires few tidal breaths for children. Pediatrics. 2010; 126: e1493-8. Available from: http://pediatrics.aappublications.org/content/126/6/e1493.long
- Ram FS, Brocklebank DD, White J, et al. Pressurised metered dose inhalers versus all other hand-held inhaler devices to deliver beta-2 agonist bronchodilators for non-acute asthma. Cochrane Database Syst Rev. 2002; Issue 2: CD002158. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002158/full
- British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
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- Mitchell JP, Nagel MW. Valved holding chambers (VHCs) for use with pressurised metered-dose inhalers (pMDIs): a review of causes of inconsistent medication delivery. Prim Care Respir J. 2007; 16: 207-14. Available from: http://www.nature.com/articles/pcrj200734
- Leach CL, Davidson, Hasselquist BE, Boudreau RJ. Influence of particle size and patient dosing technique on lung deposition of HFA-beclomethasone from a metered dose inhaler. J Aerosol Med. 2005; 18: 379-85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16379614
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