PITFALLS IN INHALER TECHNIQUE

One of the major areas where mistakes are made is in the use of asthma inhalers. Most physicians, pharmacists and asthma patients do not use inhalers properly. Many studies have shown that the majority of asthmatics do not use ideal technique, and that even after having their inhaler technique corrected, within six months their technique is once again inadequate. Below you will find selected comments regarding common inhaler problems.

GENERAL COMMENTS

Whenever you go to see your physician, asthma specialist, respiratory technologist, always take your inhaler(s) with you. Specifically ask to have them review your technique. Having a third party view your inhaler technique will often pick up errors that you do not know you are making. It also serves as an incentive to take your anti-inflammatory regularly to maintain correct technique. When I see an asthmatic having difficulty with basic technique I suspect that they have not been taking their anti-inflammatory medication regularly.

In young children, you must use a puffer (MDI) with a spacer device that has a facemask. The infant should take six good breaths for every puff. I frequently tell parents to wait 10 breaths before removing the mask. The mask must fit tightly on the infants face for only a good seal will allow medication to be deposited in the lungs. As soon as the infant is able to understand, the mouth should be kept open all the time the spacer mask is on the face. If the infant breathes through the nose, the particles are deposited in the nose and do not get to the lungs.

In adults (any child over five years of age can use adult technique), if you are using a puffer, you must take your medication one puff at a time. After you have shaken your puffer up, you FIRMLY depress the canister and breathe your medication in and hold that breath in your lungs for 10 seconds. YOU TAKE YOUR MEDICATION ONE PUFF AT A TIME. No matter what type of inhaler you use (puffer, dry powder) every inhalation should be held in the lungs for 10 seconds. Note, this is 10 full seconds, not to the count of 10, and you should watch the clock to ensure your timing is correct. Many adults progressively hold the medication in for shorter and shorter periods (because everybody is in a hurry). Most individuals can hold their breath for 10 seconds, but if they cannot, they should hold their breath for as long as possible. Particularly, when starting inhalers initially, the holding of the breath for 10 seconds makes people feel light headed (like they are going to pass out). If this occurs, sit down in a chair while you are counting your 10 seconds. Note, with every type of inhaler you should be in the standing position while you are actually breathing the medication in, as you take a larger breath of air into your lungs in the standing position.

After using any anti-inflammatory corticosteroids (preventers, controllers) the throat and mouth should be rinsed thoroughly (gargle deeply, rinse, and spit out) or in young children using a spacer with face mask, the face should be washed off, in both instances with plain water. After using a bronchodilator (openers, relievers) it is normal to experience mild tremor and an increase in pulse rate as these effects are directly related to the mechanism of action of bronchodilators. In fact, if you experience no tremor at all, it is very likely you have inadequate inhaler technique (or you are having a severe asthmatic attack and require multiple puffs of your opener).

SPECIFIC INHALERS

THE PUFFER (MDI, metered dose inhaler)

-Always shake inhaler prior to use (some don’t require this now, but always shake to be sure)

-Always dump first dose if the puffer has not been used in several days (the medication in this dose has disappeared and all you will get is propellant)

-Always use spacer (i.e. Aerochamber TM, Optichamber TM,and others) with inhaled anti-inflammatory corticosteroids (the preventer and controller medication - Flovent HFA TM, QVAR, TM, etc.); the spacer improves deposition in the lungs and reduces deposition in the mouth). Combination inhalers – steroid and bronchodilator (Advair TM, Zenhale TM) and pure steroids should be used with a spacer if possible. The exception is Alvesco TM (ciclesonide) which does not need a spacer as the steroid is not active until it is in the lungs.

- When using a spacer, begin your breath in as soon as the canister has been depressed and the breath in should be slow and steady (taking approximately 2 to 3 seconds total); many patients breathe in too quickly. If your spacer whistles – you are breathing in too fast – no whistle should be heard.

- Never double puff (i.e. depress canister once, then immediately depress again) because the second puff contains only propellant; wait at least 20 seconds between puffs to allow proper medication-propellant mixing

-Most individuals will not take a spacer with them all the time, as it requires too much room. This means using your bronchodilator (opener, quick reliever) is done without a spacer. This is a less efficient method. The newer HFA inhalers (i.e. Airomir TM-salbutamol HFA-Ventolin HFA TM) have the particle discharge velocity slowed down so you can put your lips around the end of the puffer while inhaling and these newer HFA inhalers can be used at lower temperatures.

-When using a puffer alone, the breath in should start at the same time as you depress the canister and the breath in should be continued fairly quickly ( approx. 1 second duration) until the lungs are full

-You do not have to rinse your mouth after using bronchodilators (openers), although the common side effects of bronchodilators (tremor and increased pulse rate) can be reduced with rinsing or reducing the number of puffs.

DRY POWDER INHALERS ( Turbuhaler TM (Symbicort,Pulmicort,Bricanyl,Oxese), Diskus TM (Advair,Flovent,Ventolin)

-Do not contain propellants or lubricants, are more environmentally friendly, and operate at all temperatures

-Bricanyl TMand Pulmicort TM contains only medication; Oxese TM, Symbicort TM, and all Diskus TM contain lactose as a carrier agent (can be a problem with severe milk allergy).

-You should not get these inhalers wet.

-The Turbuhaler TM if it's cap is sealed tightly is waterproof and very durable, if dropped into water when opened should be discarded, and a red dot/area appears fully in a small window when it is empty. Symbicort TM has a dose indicator.

-The Diskus TM contains 60 individually foil packaged doses, if dropped in water should be thoroughly dried prior to use, has a visible counter telling you exactly how many doses are left (this is useful to ensure compliance)

-All dry powder inhalers require you to breathe out completely (exhale completely) before you seal your lips on the mouthpiece, require a very tight seal with your lips on the mouthpiece, and require a very hard and long breath in to suck the powdered medication particles into the lungs. It is absolutely mandatory to generate a high flow rate through the inhaler to get optimal particle deposition in the lungs. When used properly the lung deposition with the Turbuhaler TM and the Diskus TM is better than the puffer-spacer combination.

-The dry powder inhalers cannot be used by individuals who are unable to generate a high flow rate through the device (i.e. young children usually 5 years old or less, the elderly, individuals who are weak for any reason, etc.)

-It is critical that the patient never blow air into the inhaler as they are sealing their lips around the mouthpiece as this blows the medication out of the inhaler

-Once again, every inhalation must be held in the lungs for 10 full seconds prior to exhaling

While these comments seem very obvious, I can assure you that the vast majority of asthmatics, even though they think there inhaler technique is good, will have one or more mistakes in inhalation technique when it comes down to actually performing the specific technique.