Estimates of inhaler errors include up to 90% of patients using pressurised metered dose inhalers (pMDIs). In the image, (left to right) a MDI, Turbohaler, Autohaler and Accuhaler Illustration by Javier Trigo Show
Asthma and chronic obstructive pulmonary disease (COPD) are common conditions in the UK and inhaled medications are the cornerstone of their management[1] The goal of asthma treatment is for patients to be symptom free and to be able to lead a normal, active life. More information on asthma, its diagnosis, treatment and management has been covered in previous articles[2] If used correctly, inhalers
deliver a smaller effective amount of the drug directly to the site of action in the lungs, with a faster onset of effect and with reduced systemic availability that minimises adverse effects (when compared with systemic administration). Despite this being the preferred method of medication delivery to the lungs, evidence suggests that many patients are unable to use their inhalers
effectively[6]
There is increasing evidence to suggest that correct inhaler technique plays an important role in improving medicine adherence[13] Correct technique depends on the inhaler type, therefore, patients need to understand the right steps for their own inhaler. It is a good idea for healthcare professionals to learn how to correctly use each inhaler device and to be aware of common errors so they can confidently demonstrate this to patients. Types of inhaler deviceBroadly speaking, there are two classes of inhaler
devices[6]
What are the common problems with inhaler technique and what are their solutions?Despite the development of several new types of inhaler device over the past 40 years, there has been no sustained improvement in how patients use
them[6] All types of inhaler devices have similar efficacy when tested under strict clinical trial
conditions[22] Incorrect inhaler technique is common, regardless of the type of device prescribed. Patients may be given
different inhaler types, receive minimal training (if any) and sometimes receive incorrect training on how to use the device. Therefore, it is important to understand the differences between these two types of inhalers, especially regarding how fast the patient inhales (inspiratory
flow)[25] Examples of common inhaler technique errors and recommendations for improvement are described in ‘Table 2: Common inhaler technique errors and suggested solutions’.
How can healthcare professionals talk to patients effectively about inhaler technique?Training of patients by healthcare professionals has been shown to be an effective means of improving
technique[28] A recent study suggested that up to 25% of patients have not received any verbal instruction for the use of their prescribed
inhaler[10] Figures 1–5 provide a summary of the techniques for the commonly used inhaler devices, and common errors with patient technique, that healthcare professionals can use as a guide before training patients. Figure 1. How to use a metered dose inhaler (MDI) Illustration by Javier Trigo 1: Cap should be removed and inhaler shaken to ensure consistent delivery of dose. Device should be primed if patient is using for the first time, or if not used for a while. Common errors in technique made by patients:
For solutions to these common errors, please see
Figure 2. How to use a metered dose inhaler (MDI) with spacer Illustration by Javier Trigo 1: Cap should be removed and the patient should check to see if the mouthpiece is clean. Inhaler
should be shaken to ensure consistent delivery of dose. Device should be primed if patient is using for the first time, or if not used for a while. Common errors in technique made by patients:
For solutions to these common errors, please see Figure 3: How to use an Accuhaler Illustration by Javier Trigo 1: Holding the device horizontal or upright, the patient should open the inhaler by moving sliding lever in the correct direction. Common errors in technique made by patients:
For solutions to these common errors, please see
Figure 4: How to use a turbohaler Source: Illustrations by Javier Trigo 1: The patient should unscrew the cap (turning anticlockwise) and remove. Holding the inhaler upright, the dose can be loaded by turning the coloured base to the right, as far as it will go. Common errors in technique made by patients:
For solutions to these common errors, please see It is a good idea for healthcare professionals to learn how to correctly use each inhaler device (see additional resources for useful videos) and to be aware of common errors (see Table 2 and Figures 1–5), so they can confidently demonstrate this to patients. Healthcare professionals should also learn the rationale for each step of the instructions, so they can clearly explain its importance to patients during counselling (see ‘Box 1: How to engage with patients to confirm inhaler technique’ and ’Box 2: Inhaler technique checklist’). Box 1: How to engage with patients to confirm inhaler technique
Box 2: Inhaler technique reminder checklist
Additional resources:
Anna Murphy is consultant respiratory pharmacist, University Hospitals of Leicester NHS Trust and honorary visiting professor, De Montfort school of pharmacy, Leicester. Reading this article counts towards your CPD You can use the following forms to record your learning and action points from this article from Pharmaceutical Journal Publications. Your CPD module results are stored against your account here at The Pharmaceutical Journal. You must be registered and logged into the site to do this. To review your module results, go to the ‘My Account’ tab and then ‘My CPD’. Any training, learning or development activities that you undertake for CPD can also be recorded as evidence as part of your RPS Faculty practice-based portfolio when preparing for Faculty membership. To start your RPS Faculty journey today, access the portfolio and tools at www.rpharms.com/Faculty If your learning was planned in advance, please click: If your learning was spontaneous, please click: References[1] Health and Social Care Information Centre. Prescriptions dispensed in the Community. England 2003–2013. Health and Social Care Information Centre, London: 2014. Available at: http://www.hscic.gov.uk/searchcatalogue?productid=14988&q=title%3a%22Prescriptions+Dispensed+in+the+Community%22&sort=Relevance&size=10&page=1#top (accessed July 2016). [2] Murphy A. Asthma: the condition and its diagnosis. Clinical Pharmacist 2010;2:203. Available at: http://www.pharmaceutical-journal.com/learning/learning-article/asthma-the-condition-and-its-diagnosis/11012933.article (accessed July 2016). [3] Murphy A. Asthma: treatment and monitoring. Clinical Pharmacist 2010;2:209. 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Ann Allergy Asthma Immunol 2004;93:439–446. doi: 10.1016/s1081-1206(10)61410-x [30] Ovchinikova L, Smith L & Bosnic-Anticevich S. Inhaler technique maintenance: gaining an understanding from the patient’s perspective. J Asthma 2011;48:616–624. doi: 10.3109/02770903.2011.580032 [31] Basheti IA, Armour CL, Bosnic-Anticevich SZ et al. Evaluation of a novel educational strategy, including inhaler based reminder labels, to improve asthma inhaler technique. Patient Educ Couns 2008;72:26–33. doi: 10.1016/j.pec.2008.01.014 Last updated 12 February 2021 19:06 CitationThe Pharmaceutical Journal, PJ, July 2016, Vol 297, No 7891;297(7891):DOI:10.1211/PJ.2016.20201442How should you instruct the patient to use the inhaler?As you start to inhale, press the button on the side of the inhaler. When your lungs are full, hold your breath for 10 seconds to keep the medicine in your lungs. Take the inhaler out of your mouth and breathe out slowly. Put the cap back on the mouthpiece.
What does a spacer do for an inhaler?The spacer connects to the inhaler mouthpiece, and the medicine goes into the spacer tube first. This allows you to breathe in the medicine more easily. Using a spacer wastes a lot less medicine than spraying the medicine directly into your mouth.
What are teaching hints that can be used to help patients use inhalers correctly?The patient should keep their chin up or head slightly tilted back when using the inhaler. It should be placed correctly in the mouth and the lips should form a tight seal over the mouthpiece. To deliver the medication to the lungs from a pMDI, the patient must coordinate breathing in with pressing the canister.
What are the 7 steps for assisting a person with an asthma inhaler?7 Steps to Using an Inhaler. Prepare the inhaler device.. Prepare or load the dose.. Breathe out, fully and gently, but not into the inhaler.. Place inhaler mouthpiece in the mouth and seal the lips around the mouthpiece.. Breathe in: ... . Remover inhaler from the mouth and hold the breath for up to 10 seconds.. |