Check and Correct: A Handbook for Better Inhaler Technique

19 Feb, 16

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Check and Correct Inhaler Technique

Delivery of respiratory medications by the inhalation route achieves a high concentration in the airways, more rapid onset of action, and fewer systemic adverse effects than systemic delivery. However, using an inhaler is a skill that must be learnt and maintained in order for the medication to be delivered effectively. Correct inhalation technique plays a vital role in effective asthma therapy alongside appropriate drug usage. However inhalers, both pMDIs and DPIs, are complicated to use, some requiring up to eight steps for a correctly performed inhalation manoeuvre.

Most patients (up to 70–80%) are unable to use their inhaler correctly. Studies have shown that approximately 50% of the patients make at least one error when using a DPI and around 76% make at least one error with a pMDI. Another study conducted by Arora et al. in 300 patients showed that maximum errors are observed in those using pMDI (94.3%), followed by DPI (82.3%) and pMDI+spacer (78%) while users of a Nebulizer (70%) committed the least number of errors while using it (p=0.005). Most people with incorrect technique are unaware that they have a problem.

Incorrect usage of inhalers is a significant problem for both asthma and COPD management because it may result in diminished therapeutic effect, resulting in poor control of symptoms, increased risk of exacerbations, increased adverse effectsand, thereby, insufficient disease management.

Therefore, it is necessary on the part of the physicians, respiratory therapists, and nurses to understand the issues related to performance and correct use of these medical devices and also to understand the difficulties faced by patients while using these devices.

The physician should check the patient’s inhaler technique at every clinic visit. If the technique is incorrect or if the patient is missing some steps, the physician should identify the errors with the help of a checklist and should give the patient a physical demonstration on using the inhaler correctly.

The steps to use the inhalers correctly along with the patient errors are mentioned below. We hope this will serve as a valuable handy resource for physicians for quickly checking and correcting their patients’ inhaler technique.

Checklist for assessing technique of using a pMDI	Checklist for assessing patient errors
Remove the mouthpiece cap.	Failure to remove the mouthpiece cap.
Shake the inhaler.	Failure to shake or inadequate shaking of the canister.
Breathe out fully through the mouth.	Failure to breathe out fully.
Place the mouthpiece of the inhaler in the mouth. Press down the canister and, at the same time, breathe in slowly and deeply.	Holding the device upside down (the mouthpiece should be on the bottom) Poor seal around the mouthpiece. Pressing down on the canister 2 or 3 times in a row (this should be done only once). Failure to synchronize hand actuation and inhalation. Failure to breathe in slowly and deeply through the pMDI or rapid inhalation Stopping inhalation as the device is fired.
Hold the breath for 10 seconds or for as long as possible.	Failure to hold the breath for a few seconds after inhalation.
Breathe out normally.	Failure to breathe out normally.

Checklist for assessing technique of using pMDI + spacer	Checklist for assessing patient errors
Assemble the spacer.	Incorrect assembly of spacer.
Remove the mouthpiece cap of the pMDI.	Failure to remove the mouthpiece cap.
Shake the inhaler.	Failure to shake or inadequate shaking of the canister.
Insert the inhaler into the opposite end of the spacer and actuate one dose.	Placing the inhaler in the wrong end of the spacer. Firing multiple puffs into the spacer.
Breathe out fully through the mouth.	Failure to breathe out fully.
Remove the mouthpiece cap from the spacer and immediately breathe in slowly and deeply.	Poor seal around the mouthpiece. Failure to breathe in slowly and deeply. Delay between actuation and inhalation. Exhaling instead of inhaling into the mouthpiece.
Hold the breath for about 10 seconds, or as long as is comfortable.	Failure to hold the breath for a few seconds after inhalation.
Breathe out normally.	Failure to breathe out normally.

Checklist for assessing technique of using a Revolizer	Checklist for assessing patient errors
Hold the Revolizer at the base and pull back the mouthpiece till both arrows meet.	Arrows not matching
Insert the rotacap into the rotacap chamber with its transparent end facing down.	Did not insert the transparent side of the rotacap into the rotacap chamber.
Close the mouthpiece firmly.	Did not lock the Revolizer correctly.
Breathe out fully through the mouth.	Failure to breathe out fully.
Place the mouthpiece of the inhaler in the mouth and breathe in rapidly and deeply through the mouth, for as long as possible.	Poor seal around the mouthpiece. Failure to inhale forcefully and deeply. Exhaling into the mouthpiece, instead of inhaling.
Hold the breath for 10 seconds or for as long as is comfortable.	Failure to hold the breath for a few seconds after inhalation.
Breathe out normally.	Failure to breathe out normally.

Checklist for assessing technique of using a Rotahaler	Checklist for assessing patient errors
Ensure that the fin of the Rotahaler is not directly below the rotacap hole.	Placing the fin below the rotacap hole.
Insert the rotacap into the rotacap hole with its transparent end facing down.	Failure to insert the transparent end of the rotacap into the rotacap hole.
Press the rotacap firmly so that the top end is in level with the top of the hole.	Did not press the rotacap firmly.
Holding the mouthpiece firmly with one hand, rotate the base so as to separate the two halves of the rotacaps.	Two halves not separated.
Breathe out fully through the mouth.	Failure to breathe out fully.
Place the mouthpiece of the inhaler in the mouth and breathe in rapidly and deeply through the mouth.	Poor seal around the mouthpiece. Failure to forcefully and deeply inhale through the device. Exhaling into the mouthpiece, instead of inhaling.
Hold the breath for 10 seconds or for as long as is comfortable.	Failure to hold the breath for a few seconds after inhalation.
Breathe out normally.	Failure to breathe out normally.

Checklist for assessing technique of using an Autohaler	Checklist for assessing patient errors
Remove the mouthpiece cover and shake the Autohaler	Failure to remove the mouthpiece cover. Failure to shake or inadequate shaking.
Push the lever up.	Not raising the lever to the vertical position.
Breathe out fully through the mouth.	Failure to breathe out fully.
Place the mouthpiece of the Autohaler in the mouth and breathe in slowly and deeply.	Poor seal around the mouthpiece. Failure to breathe in slowly and deeply. Stopping the inhalation after hearing the click sound after the device is fired.
Hold the breath for 10 seconds or for as long as possible.	Failure to hold the breath for a few seconds after inhalation.
Breathe out normally.	Failure to breathe out normally.
Return the lever to the down position.	Failure to return the lever to the down position.

Checking and correcting inhaler technique using a standardized checklist takes only 2–3 minutes and leads to improved asthma control. A physical demonstration is essential to improve inhaler technique.

This is easiest if the health-care provider has placebo inhalers and a spacer. Even after training, inhaler technique falls off with time, so checking and re-training must be repeated regularly. This is particularly important for patients with poor symptom control or a history of exacerbations. Pharmacists and nurses can provide highly effective inhaler skills training

National and international guidelines stress the need to teach asthma and COPD patients the correct use of inhalers. Patient education is crucial in proper use of delivery devices and effectiveness of aerosol therapy. Whatever the chosen inhaler, education from health-care providers has a major role in improving inhaler technique and compliance. Proper education to patients on correct usage may not only improve control of the symptoms of the disease but might also allow dose reduction in the long term.

Remember

Don’t rely on self-reports regarding inhaler technique; despite claims of proficiency, most patients make at least one mistake.
Check inhaler technique at every opportunity.
Ask the patient to show you how they use their inhaler (don’t just ask if they know how to use it).
Identify any errors using a device-specific checklist.
Show the patient how to use the device correctly with a physical demonstration, e.g. using a placebo inhaler
Check technique again, paying attention to problematic steps. You may need to repeat this process two to three times.
Only consider an alternative device if the patient cannot use the inhaler correctly after several repeats of training.
Re-check inhaler technique frequently. After initial training, errors often recur within 4–6 weeks.

References

Global Initiative For Asthma, Global Strategy For Asthma Management and Prevention; Updated 2015 (ginasthma.org/local/uploads/files/GINA_Report_2015_Aug11.pdf); Accessed on 11th Feb 2015
Respiratory Medicine 2014; 108: 992-998
The Journal of Family Practice 2011; 60(12): 714-721
Respiratory Medicine 2011; 105: 930-938
Respiratory Medicine 2008;102: 593-604

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