By: Jack (Hongkai) Bao, PharmD Candidate c/o 2018

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Inhalers are one of the most prescribed therapies used to treat respiratory disorders in patients. Anticholinergics, β-agonists, and corticosteroids are all packaged into a miniature device that patients must use correctly every time to ensure delivery of their medication. To complicate matters, a myriad of inhaler types are available: metered-dose inhalers (MDIs), dry-powder inhalers (DPIs), and soft-mist inhalers (SMIs). Each type of inhaler possesses its own nuances and must be precisely used each and every time to deliver the correct dose. Complexities arise when a specific medication is available in only one type of inhaler, such as a DPI, but a patient is only familiar with an MDI. Fortunately, when used correctly, different types of inhalers are equally effective in delivering medication.¹

Patients and healthcare providers both run into trouble when demonstrating correct inhaler technique. Whether healthcare providers are counseling patients on proper inhaler technique or their patients are using inhalers on their own, both parties are prone to errors. In fact, a few as one-half to one-third of all patients who are prescribed inhalers use them correctly.¹ Consequently, it is crucial to properly educate both patients and providers on the specificities of each unique device. Interestingly enough, a study in 2009 evaluated inhaler techniques among 142 internal medicine residents in Korea and found that a large majority of residents had inadequate inhaler technique.² This quickly changed after a single teaching session, where overall skills improved significantly.² This study demonstrated the importance of proper education whether directed towards the provider or patient; additional time spent on counseling inhaler users can ultimately improve health-related outcomes.

Healthcare providers themselves must be cognizant of patient preferences and ensure that dispensed inhalers are patient specific. For instance, it would be more convenient to dispense the same type of inhalers that patients have used their entire lives rather than dispensing new ones. In addition, emphasizing a few major key points about an inhaler rather than counseling patients on every detail will benefit the patients much more. These points may include the names and types of medication in inhalers or the necessity of shaking inhalers before use.  Also, as some inhalers need to be primed before use, it is crucial to mention this to anyone who may handle these devices. And lastly, because all inhalers have different expiration dates, providers must mention this to patients so that they may replace their outdated inhalers as needed.

While using an inhaler, it is important to keep it clean. This ensures that drug is not being accumulated and blocking the mouthpiece, preventing the inhaler from working properly. Generally, most manufacturers recommend cleaning an MDI at least once a week.³ They recommend taking apart the inhaler by removing the canister and cap and running warm tap water through the top and bottom for at least 30 to 60 seconds.³ Following this, a patient must shake off excess water and allow the mouthpiece to try completely overnight.³ Before using the inhaler again, a patient should administer 2 test sprays.³ Instructions for cleaning DPIs and SMIs are much more simple. DPIs generally should not be washed with water, unlike MDIs. Usually a wet cloth is used to simply wipe the mouthpiece.³ SMIs, unlike its competitors, do not require any cleaning at all.

Other points that providers can stress to patients include differentiating between their inhalers if they use more than one. Questions such as, “which inhaler do you use during an emergency” or “which inhaler do you use to prevent or control your asthma symptoms” are great for differentiating between rescue inhalers and controller inhalers.³ Providers can also advise patients to keep their emergency inhalers with them at all times and to track the frequency of use. If patients require constant use of their emergency inhaler (>2 times/weekly), it may indicate inadequate maintenance control of their asthma and a subsequent revision of therapy may be necessary.⁴ Lastly, it is always beneficial to use a teach-back approach when educating patients on inhaler technique. Asking patients to show how they use their inhalers offers opportunity for correction if necessary.

SOURCES:

1. Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest. 2005;127(1):335-71.
2. Kim SH, Kwak HJ, Kim TB, et al. Inappropriate techniques used by internal medicine residents with three kinds of inhalers (a metered dose inhaler, Diskus, and Turbuhaler): changes after a single teaching session. J Asthma. 2009;46(9):944-50. doi: 10.3109/02770900903229701.3.
3. Bailey W, Gerald LB. Patient education: Asthma inhaler technique in adults (Beyond the Basics). UpToDate. Updated 06/06/2016. Accessed 01/06/2016.
4. Clinical Resource, Correct Use of Inhalers. Pharmacist’s Letter/Prescriber’s Letter.Accessed 01/05/2017.

Published by Rho Chi Post