Asthma Management Handbook

Training patients in inhaler technique

Recommendations

Make sure your own knowledge of correct technique is up to date.

How this recommendation was developed

Consensus

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

Train patients to use their inhaler devices correctly (including use of spacers, where recommended).

How this recommendation was developed

Evidence-based recommendation

Based on literature search and formulated by multidisciplinary working group

Key evidence considered:

  • The Inhaler Error Steering Committee, 20131
  • Lavorini et al. 20082
  • Gillette et al. 20163
  • Bjermer L et al. 20144
  • Melani et al. 20115
  • Basheti et al. 20086
  • Bosnic-Anticevich et al. 20107
  • Capanoglu et al. 20158
  • Crane et al. 20149
  • Chorao et al. 201410
  • Wieshammer et al. 200811
  • Sestini et al. 200612
  • Broeders et al. 200313
  • Levy et al. 201614

Last reviewed version 2.0

Assess each patient's inhaler technique at every opportunity, even for patients who have been using the inhaler for many years.

  • Have the patient demonstrate their inhaler technique, while checking against a checklist of steps for the specific device.
  • Demonstrate correct technique using a placebo device and correct any specific errors identified.
  • Have the patient repeat the demonstration to check they can now use the device correctly. If necessary, repeat instruction until the patient has all steps correct.
  • Provide the checklist as a reminder, and write down or highlight any steps that were done incorrectly (e.g. on a sticker attached to their inhaler or on a pictorial instruction sheet).

Note: Watch the person use their inhaler – don’t just ask if they think they know how to use it properly.

Checklists of steps, and videos demonstrating correct technique, for various types of inhalers are available on National Asthma Council Australia’s website.

How this recommendation was developed

Evidence-based recommendation

Based on literature search and formulated by multidisciplinary working group

Key evidence considered:

  • Basheti et al. 201315
  • National Asthma Council Australia, 201816
  • The Inhaler Error Steering Committee, 201317
  • Basheti et al. 200818
  • Basheti et al. 20176
  • Bosnic-Anticevich et al. 20107
  • Capanoglu et al. 20158
  • Crane et al. 20149
  • Giraud et al. 201110
  • Lavorini 201419
  • Newman 201420
  • Hesso et al 201621

Last reviewed version 2.0

 

Keep your advice and explanations relevant to the person and appropriate to their age, cultural background and education.

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

For people instructed to use a spacer with their inhaler, ask whether they sometimes or often use the inhaler alone. Strongly encourage the use of spacers and emphasise that using the spacer is an important part of correct technique for best results.

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

More information

Correct use of inhaler devices

Checking and correcting inhaler technique is essential to effective asthma management.

Most patients with asthma or COPD do not use their inhalers properly,22, 23,2424, 25 and most have not had their technique checked or corrected by a health professional.

Incorrect inhaler technique when using maintenance treatments increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD.22, 23, 5, 14, 26, 27

Poor asthma symptom control is often due to incorrect inhaler technique.28, 29

Incorrect inhaler technique when using inhaled corticosteroids increases the risk of local side effects like dysphonia and oral thrush.

The steps for using an inhaler device correctly differ between brands. Checklists of correct steps for each inhaler type and how-to videos are available from the National Asthma Council website.

Last reviewed version 2.0

Close
Administration of inhaled medicines in children: 1-5 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. 

Types of inhalers suitable for preschool children

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 actuating the device.30 Note that breath-actuated pressurised metered-dose inhalers cannot be used with a spacer.

Dry-powder inhalers are usually ineffective for preschool children because they cannot generate sufficient inspiratory air flow.30

Drug delivery is very variable in young children with any type of inhaler, including pressurised metered dose inhalers and spacers.31 Filter studies have shown high day-to-day variability in delivered doses in preschool children.30 This variation might explain fluctuations in effectiveness, even if the child’s parents have been trained to use the device correctly.

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

Pressurised metered-dose inhalers plus spacers for relievers

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.30 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.32

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the inhaler, actuate one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).33 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.34

Face masks for infants

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.32 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.

Last reviewed version 2.0

Close
Administration of inhaled medicines in children: 6 years and over

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

School-aged children (depending on the child’s age, ability, and with individualised training) can learn to use a range of inhaler types, including manually actuated pressurised metered-dose inhalers with spacers, breath-actuated pressurised metered-dose inhalers (e.g. Autohaler), and dry-powder inhalers (e.g. Accuhaler, Turbuhaler).3, 8, 35, 36, 37

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

A pressurised metered-dose inhaler and spacer is an appropriate first choice for most children.35

School-aged children are unlikely to use their inhaler device correctly without careful training and repeated checking.38

Last reviewed version 2.0

Close

References

  1. 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
  2. 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
  3. Gillette, C., Rockich-Winston, N., Kuhn, J. A., et al. Inhaler technique in children with asthma: a systematic review. Acad Pediatr. 2016; 16: 605-15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27130811
  4. Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration. 2014; 88: 346-52. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25195762
  5. 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
  6. Basheti, I A, Armour, C L, Bosnic-Anticevich, S Z, Reddel, H K. 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
  7. 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. J Asthma. 2010; 47: 251-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20394511
  8. 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. J Asthma. 2015; 52: 838-45. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26037396
  9. 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 Prim Care Respir Med. 2014; 24: 14034. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25188403
  10. Chorao, P., Pereira, A. M., Fonseca, J. A.. Inhaler devices in asthma and COPD – an assessment of inhaler technique and patient preferences. Respir Med. 2014; 108: 968-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24873873
  11. Wieshammer, S., Dreyhaupt, J.. Dry powder inhalers: which factors determine the frequency of handling errors?. Respiration. 2008; 75: 18-25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17911976
  12. Sestini, P, Cappiello, V, Aliani, M, et al. Prescription bias and factors associated with improper use of inhalers. J Aerosol Med. 2006; 19: 127-136. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16796537
  13. Broeders, M E, Molema, J, Hop, W C, Folgering, H T. Inhalation profiles in asthmatics and COPD patients: reproducibility and effect of instruction. J Aerosol Med. 2003; 16: 131-141. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12823907
  14. Levy ML, Dekhuijzen PN, Barnes PJ, et al. Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT). NPJ Prim Care Respir Med. 2016; 26: 16017. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27098045
  15. Basheti, I. A., Bosnic-Anticevich, S. Z., Armour, C. L., Reddel, H. K.. Checklists for dry powder inhaler technique: a review and recommendations. Respir Care. 2013; 59: 1140-1154. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24129338
  16. National Asthma Council Australia,. Inhaler technique in adults with asthma or COPD. An information paper for health professionals. NACA, Melbourne, 2018. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
  17. The Inhaler Error Steering Committee,, Price, D., Bosnic-Anticevich, S., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013; 107: 37-46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23098685
  18. 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
  19. Lavorini, F.. Inhaled drug delivery in the hands of the patient. J Aerosol Med Pulm Drug Deliv. 2014; 27: 414-8.
  20. Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert Opin Drug Deliv. 2014; 11: 365-78. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24386924
  21. Hesso, I., Gebara, S. N., Kayyali, R.. Impact of community pharmacists in COPD management: Inhalation technique and medication adherence. Respir Med. 2016; 118: 22-30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27578467
  22. The Inhaler Error Steering Committee,, Price, D., Bosnic-Anticevich, S., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013; 107: 37-46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23098685
  23. 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
  24. Basheti, I A, Armour, C L, Bosnic-Anticevich, S Z, Reddel, H K. 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
  25. 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
  26. 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
  27. 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
  28. Harnett, C. M., Hunt, E. B., Bowen, B. R., et al. A study to assess inhaler technique and its potential impact on asthma control in patients attending an asthma clinic. J Asthma. 2014; 51: 440-5.
  29. Hardwell, A., Barber, V., Hargadon, T., et al. Technique training does not improve the ability of most patients to use pressurised metered-dose inhalers (pMDIs). Prim Care Respir J. 2011; 20: 92-6. Available from: http://www.nature.com/articles/pcrj201088
  30. 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
  31. 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
  32. 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
  33. National Asthma Council Australia. Kids' First Aid for Asthma. National Asthma Council Australia, Melbourne, 2011. Available from: http://www.nationalasthma.org.au/first-aid
  34. 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
  35. Ram, F S F, Brocklebank, D D M, 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: .
  36. Nikander, K, Turpeinen, M, Pelkonen, A S, et al. True adherence with the Turbuhaler in young children with asthma. Arch Dis Child. 2011; 96: 168-173.
  37. Pedersen, S., Mortensen, S.. Use of different inhalation devices in children. Lung. 1990; 168 Suppl: 653-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/2117175
  38. Sleath, B, Ayala, G X, Gillette, C, et al. Provider demonstration and assessment of child device technique during pediatric asthma visits. Pediatrics. 2011; 127: 642-648.