Inhaler Technique
Author – Kalyani Shinkar Editor – Mohona Sengupta
Last updated 26/03/24
Table of Contents
Introduction
Explaining inhaler technique effectively is a frequent scenario encountered both in clinical practice and OSCEs. It involves effectively communicating and demonstrating the correct method for using inhalers, which is crucial for patients managing respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), and other lung conditions. This article outlines the different inhaler types, includes a step-by-step guide on how to explain effective inhaler technique in an OSCE scenario, and provides information regarding asthma.
Types of Inhalers
Inhalers are medical devices used to deliver medication directly to the lungs, providing quick relief or long-term control of symptoms in the treatment of respiratory conditions. There are many different types of inhalers, which can be classified on how they deliver medications, such as metered-dose, dry powder, or soft mist inhalers. Another way in which they can be classified is the type of medication they deliver e.g. reliever, preventer, or SMART (single maintenance and reliever therapy) inhalers.
| Metered-Dose Inhaler (MDI) | Dry Powder Inhaler (DPI) | Soft Mist Inhalers |
|---|---|---|
An MDI is a handheld device that delivers a specific amount of medication in aerosol form.The medication is often contained within a pressurised canister that is activated by pressing down on the canister.
MDIs require proper coordinating between pressing down on the canister to release the medication and inhaling the medication to ensure effective delivery to the lungs.
They are the most commonly used types of inhalers. Thus, explaining how to use MDIs is a common OSCE scenario. | Dry powder inhalers deliver medication in the form of a dry powder, which is breathed in during inhalation.
Unlike MDIs, DPIs do not require the patient to press on a canister to release the medication. Instead, the medication is dispersed on inhalation. | Soft mist inhalers are a newer type of inhaler that convert liquid medication into a fine mist, which is inhaled through a mouthpiece.
The medication is delivered as a slow-moving mist, thereby making it easier for some patients to inhale.
It can be used for patients who have difficulty using MDIs or DPIs. |
| Reliever (Blue Inhaler) | Preventer (Brown Inhaler) | SMART Inhaler |
|---|---|---|
Relievers contain a bronchodilators (e.g. salbutamol)
As the name suggests, they provide immediate relief of patients’ symptoms (e.g. shortness of breath, wheezing, chest tightness) by relaxing their airways
They should be used on a ‘as and when needed’ basis
Safety netting – patients should not be using a reliever more than 3 times a week. If they do, this suggests their asthma is not well controlled and requires reviewing. | Preventers contain corticosteroids (e.g. beclomethasone)
They are also known as maintenance or controller inhalers
They prevent patients from experiencing symptoms and exacerbations in the long term by reducing inflammation in the airways
They should be taken regularly even if the patient is not experiencing any symptoms
Compliance with preventer inhalers can be poor, as they may not provide immediate or obvious benefits like reliever inhalers do. However, they play an important role in managing chronic respiratory conditions and their importance in managing patients’ conditions should therefore be explained effectively.
Safety netting – patients should rinse their mouth with water after use to reduce the risk of developing oral candidiasis (a type of fungal infection that affects the mouth) | SMART (single maintenance and reliever therapy) inhalers are combination inhalers that contain both a reliever medication and preventer medication in a single device
Examples of SMART inhalers include Symbicort, Fostair, Duoresp, and Spiromax
Safety netting – patients should rinse their mouth with water after use to reduce the risk of developing oral candidiasis (a type of fungal infection that affects the mouth) |
Inhaler Technique
This guide demonstrates how to effectively describe the technique for using a metered-dose inhaler (MDI), which is often tested in an OSCE setting.
A good method for explaining effective inhaler technique is the ‘tell, show, do’ method. This begins with talking through the steps involved, showing the correct inhaler technique, and then lastly asking the patient to execute the correct inhaler technique themselves to ensure patient understanding.
Inhaler Technique OSCE Scenario: Introduction
Make sure to read the instructions carefully before entering the station. You can use the instructions as a framework on how to approach the station. There may be some variations to the station; for instance, in addition to explaining inhaler technique, you may be required to take a brief history on the patient’s understanding of asthma or explain the patient’s recent asthma diagnosis.
Start by introducing yourself, confirm patient details, gain consent, and wash your hands.
If you are required to take a brief history, you can explore the patients’ ideas, concerns, and expectations (ICE), which can further structure your approach to the station.
It can also be useful to ask the patient’s understanding of inhaler technique to make your explanation more specific to the patient.
Steps
- Check the Inhaler
- Check the correct medication is in the inhaler
- Check the expiry date of the medication, which can be done by removing the canister containing the medication from the plastic casing, and replacing it once finished
- Shake the inhaler well to check that there is some medication remaining (some inhalers have a number to show how many puffs are remaining)
- Remove the cap and check the mouthpiece is clean/there is nothing obstructing the mouthpiece (this is relevant if the patient has not used their inhaler for 5 or more days)
- Shake the inhaler for 5 seconds (this helps to mix the medication inside)
- Stand or sit up straight (this helps the medication to reach the lungs more effectively)
- Hold the inhaler upright
- Breathe out slowly away from the inhaler until lungs feel empty
- Form a tight seal with lips around the mouthpiece, making sure no air escapes
- Explain that the next steps need to happen simultaneously in one smooth action. Whilst pressing the canister to release a puff of medication, start breathing in slowly and deeply until lungs feel full
- Hold breath for 10 seconds or for as long as they comfortably can
- Breathe out slowly
- If the patient has been prescribed more than 1 puff, wait for at least 30 seconds before administering another puff. Then repeat steps 2-9.
- Ask the patient to demonstrate their inhaler technique to check patient understanding.
- Sensitively identify any areas for improvement if applicable
- Close the consultation:
- Ask the patient if they have any questions or concerns (can suggest the patient contact their GP practice if they have any future questions or concerns)
- Provide them with a leaflet or signpost them to useful resources (e.g. Asthma + Lung UK)
- Provide safety netting advice
- Blue (salbutamol) inhaler – advise patients to contact their GP practice if they are using their blue inhaler more than 3 times a week. This suggests their asthma is not well controlled and requires reviewing.
- Brown (corticosteroid) inhaler – advise patients to rinse their mouth with water after use to reduce the risk of developing oral candidiasis
- Asthma attack – advise the patient to call 999 or go to their nearest A&E in the event of an asthma attack
Viva Questions
What are the signs of an asthma attack?
Signs of an asthma attack can vary between individuals and range from mild to severe. They include:
- Persistent or worsening symptoms (e.g. cough, shortness of breath, wheezing, and chest tightness) that are not relieved by their relieve inhaler e.g. salbutamol
- Increased respiratory rate
- Difficulty speaking in full sentences
- In severe cases:
- Drowsiness, confusion, or dizziness
- Fatigue/exhaustion
- Blue lips or fingers
- Fainting
How are asthma attacks managed in the hospital?
Asthma attacks in the hospitals are generally managed through a combination of medications and supportive care. A useful way to remember the general approach is with the ‘OSHIMTE’ mnemonic:
- Assessment: Before initiating treatment, patients need to have an A-E assessment, which includes evaluating for any signs of respiratory compromise, oxygen saturation, respiratory rate, peak expiratory flow, (PEFR), and overall clinical status. The PEFR is important to assess the severity of the asthma attack:
- Mild: PEFR>75% best or predicted
- Moderate: PEFR 50-75% best or predicted
- Severe: <33-50% best or predicted
- Life-threatening <33% best of predicted
- Oxygen – If O2 sats are <94%, oxygen should be administered via an oxygen mask
- Salbutamol (or other bronchodilators) – These are often administered via a nebuliser
- Hydrocortisone (oral or IV corticosteroids e.g. hydrocortisone, prednisolone, dexamethasone)
- Ipratropium bromide (anticholinergic) – These may be added to bronchodilator therapy to further dilate the airways and improve airflow. Similar to bronchodilators, these are often administered via a nebuliser.
- Magnesium Sulphate (IV) – This works as a bronchodilator and may be considered in severe asthma attacks that are not responding adequately to standard therapy.
- Theophylline – This works as a bronchodilator by inhibiting the enzyme phosphodiesterase, primarily phosphodiesterase-4 (PDE-4).
- Escalation to ITU – In cases of respiratory failure or severe respiratory distress, escalation to ITU for mechanical ventilation may be required. Non-invasive ventilation e.g. bilevel positive airway pressure (BiPAP) or invasive ventilation (endotracheal intuation and mechanical ventilation) may be used depending on the patient’s condition.
In addition, patients will require close monitoring of response to treatment by assessing parameters such as respiratory rate, work of breathing, oxygen saturation, PEFR, and level of consciousness. .
Following treatment, patient education regarding asthma management, including proper inhaler technique, triggers avoidance, and adherence to preventer inhalers, is vital before discharge. A written asthma action plan should be provided to guide self-management and reduce the likelihood of future asthma attacks. It is also recommended that patients are reviewed in primary care 48-72 hours following discharge from hospital.
What are the important differences between using a metered dose inhaler (MDI) and using a spacer?
When using a spacer, after pressing the canister to release medication into the spacer, the patient can take 1 deep breathe (similar to an MDI) OR take 5 normal breaths in and out whilst keeping their mouth over the mouthpiece. NB – the spacer has a one-way valve, which prevents the medication from exiting the spacer
Some patients may be worried about the long-term effects of using corticosteroids (e.g. weight gain, growth suppression in children, testicular atrophy). What are the chances that patients taking inhaled corticosteroids may experience systemic side effects?
Whilst inhaled corticosteroids can potentially cause systemic side effects, the risks of this are low, especially compared with oral or IV corticosteroids, as inhaled corticosteroids are much less likely to get absorbed into the bloodstream. However, the risks of experiencing systemic side effects increases with high doses of inhaled corticosteroids or long-term use, but are still much less common compared to oral or IV corticosteroids.
More common side effects associated with the use of inhaled corticosteroids include throat irritation, hoarse voice, hoarseness, sore throat, coughing, and oral candidiasis.
What is the mechanism of action of salbutamol?
Salbutamol is a bronchodilator that works to relieve symptoms of respiratory conditions, such as asthma or COPD. It acts as a selective agonist (activator) of beta-2 adrenergic receptors located in the smooth muscle cells lining the bronchioles (small airways) in the lungs. This leads to smooth muscle relaxation, which causes the bronchodilation and increased airflow into and out of the lungs. In addition to bronchodilation, salbumatol can stimulate mucous clearance from the airways by increasing ciliary activity of the respiratory epithelium.
What is the pathophysiology of asthma?
Asthma is a common chronic respiratory condition that affects millions of people worldwide. The pathophysiology of asthma is complex and involves multiple genetic, environmental, and immunological factors.
In asthma, the airways are ‘sensitive’ and react if they come into contact with an asthma trigger. The airways react in 3 different ways:
- Inflammation (the lining of the airways become inflamed)
- Bronchoconstriction (the muscles surrounding the airways tighten)
- Mucous hypersecretion (sticky mucous and phlegm builds up in the airways)
These 3 things can cause the airways to become narrow, reducing airflow in and out of the lungs. This leads to symptoms such as shortness of breath, coughing, wheezing, and chest tightness.
Name 5 common risk triggers for asthma exacerbation?
Asthma exacerbations, also known as asthma attacks, are episodes of worsening asthma symptoms characterised by increased inflammation and bronchoconstriction. There are several possible triggers for asthma exacerbations. Common triggers include:
- Allergens (e.g. pollen, pet dander, dust mites, mould)
- Environmental pollutants/Irritants (e.g. tobacco smoke, air pollution, chemical fumes)
- Respiratory infections
- Exercise (can cause exercise-induced asthma in certain individuals)
- Poor medication adherence
Identifying and managing these risk factors through patient education, environmental control measures, medication adherence, and personalised asthma management plans can help to reduce the frequency and severity of asthma exacerbations. Regular monitoring and asthma reviews are also essential in optimising asthma management and reducing the risk of exacerbations.
What is the benefit of using a spacer with an inhaler?
Spacers can be used with metered dose inhalers (MDIs) to enable more effective delivery of medication into the lungs. The main benefits spacers provide are:
- Improved Medication Delivery: Spacers can be beneficial in patients who struggle to coordinate between pressing on the canister to activate the inhaler whilst simultaneously inhaling the medication. This is particularly applicable to young children.
- Reduction of Side Effects: Spacers reduce the occurrence of side effects associated with inhaler use, such as throat irritation or coughing, by reducing the amount of medication that is deposited in the mouth and throat.