Inhaler device technique: top ten tips

I’ve previously covered why inhaler technique is important here on Together in Respiratory, and now let’s look at some practical tips for working with respiratory patients and their devices. As healthcare professionals, I believe that it is important that we remember that we have a duty of care to ensure no inhaler device is prescribed without instruction and the patient can use it effectively.

Here are ten top tips for inhaler device technique.

1. 1. Educate yourself. Spend time understanding how to use the different types of devices. You could ask other respiratory interested colleagues to discuss and demonstrate their use, or explore the online inhaler technique videos on Asthma + Lung UK or other validated sites.
   2. Know the principles of pressurised metered dose inhaler (pMDI) technique. Slow and steady inhalation followed by breath holding for approximately 10 seconds.^[1] Be aware that slow and steady inhalation will minimise deposition in the upper airways and enhance delivery of the drug to
      the lungs.^[2]
   3. Know the dry powder inhaler (DPI) technique. Quick and deep to ensure the drug is disaggregated from the carrier. Energy from a fast inhalation will disperse the powder into smaller particles, resulting in adequate delivery to the lungs.^[3],[4]
   4. Know the soft mist inhaler (SPI) technique. This does not require a propellent and the patient is simply advised to breathe slowly and steadily.^[5]
   5. When choosing a device for a patient make sure you recognise their previous experience with inhalers (if appropriate). Ask them about their preferences, give them some choice in the selection process and work in partnership with them. If the patient does not like the device you are considering they are much less likely to take it. Poor adherence leads to poor clinical outcomes.^[6]
   6. Be aware of what drugs are available in each device. Use the British National Formulary or MIMS – the Monthly Index of Medical Specialities to get a good understanding. You do not need to memorise every drug but you should know what treatment the patient is going to require, what is available via which device and what the license recommendations are.
   7. Know your drug formulary for your place of work. You will probably be limited on what you can prescribe or recommend. There is no point in teaching a particular device to a patient to then realise that it is not formulary compliant or you are unable to prescribe.
   8. Try to have consistency in your inhaler choice. For example, if the patient can use a pMDI, then ensure that all their devices are compatible and the patient uses the same technique. Similarly, for DPIs, try to prescribe the same type for regular and also reliever/emergency use. This will help patients to learn one technique, rather than trying to remember which inhaler needs a slow and steady inhalation as opposed to a quick and deep technique one.
   9. Repeated instruction on inhaler technique is essential. Patients forget what they have been taught or can develop bad habits. Never assume that because you taught them how to use their inhaler at the last consultation, they are still able to use their device correctly and effectively. Checking inhaler technique is an essential part of a respiratory review and should always be addressed.^[7],[8] If you’re working with patients remotely, you might find this article on remote consultations helpful.
   10. Have a selection of placebo devices available so that you can physically demonstrate their use. If you don’t have, or can’t access a placebo, you can ask the patient to bring their own devices to the consultation – however they frequently forget them! Work with your local pharmacists, and ask them to demonstrate technique to patients when they go to pick up their prescriptions. To reinforce good technique, signpost patients to sites like Asthma + Lung UK to remind them on how they should use their device.

Inhaler technique remains an essential part of treating and managing patients with respiratory disease and therefore we all need to develop, and refresh ourselves on these essential skills to improve patient care. Remember, the best device is the one the patient can and will use.

We need to know it, show it, teach it and review it.

Any advice given and opinions expressed in this article are those of the author and do not reflect the view of Chiesi Limited (Chiesi). All content in this article is for informational and educational purposes only. Although Chiesi strives to always provide accurate information, it is not responsible for and does not verify for accuracy any of the information contained within. No advice in this article is intended to be a substitute for your own professional judgment in the clinical management of your patients.

[1] Lavorini F, Janson C, Braido F et al. What to consider before prescribing inhaled medications: a pragmatic approach for evaluating the current inhaler landscape. Therapeutic advances in respiratory disease. 2019;13:1753466619884532

[2] Laube B, Janssens H, de Jongh F et al. European Respiratory Journal 2011:37(6);1308-1417

[3] Lavorini, F, Pistolesi M, Usmani, O.S. Recent advances in capsule-based dry powder inhaler technology. Multidisciplinary Respiratory Medicine. 2017;12:11

[4] Science Direct. Dry Powder Inhaler. 2017. Available at: https://www.sciencedirect.com/topics/medicine-and-dentistry/dry-powder-inhaler

[5] Leeds Teaching Hospitals Trust Inhaler Device Guide. 2018. Available at http://www.cpwy.org/doc/2003.pdf

[6] Melani A, Bonavia M, Cilenti V et al Respiratory Medicine 2011;105(6):930-938.

[7] NICE. Asthma: diagnosis, monitoring and chronic asthma management. 2021. Available at: https://www.nice.org.uk/guidance/ng80/chapter/Recommendations#monitoring-asthma-control

[8] NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. 2019. https://www.nice.org.uk/guidance/ng115/chapter/Recommendations#managing-stable-copd