II. Precautions

  1. Each Inhaler type has unique best usage recommendations
  2. Try to prescribe Inhalers with the same delivery methods to optimize compliance
  3. Inhaler Cleaning (prevent clogging)
    1. Clean Inhalers at least weekly
    2. Albuterol HFA
      1. Clogging may appear as white residue at MDI spray nozzle
      2. Remove Canister and avoid getting wet
      3. Rinse mouthpiece top and bottom under Running water for 30 seconds each, then dry
    3. Other Inhalers
      1. Discuss with pharmacist or follow manufacturer instructions
      2. Many of the devices (e.g. Symbicort) do not allow for removal of canister
      3. May wipe any mouthpiece with dry cloth to clean
      4. Avoid moisture around Dry Powder Inhalers
    4. References
      1. (2020) presc lett 27(9): 54

III. Technique: Aerosol Metered Dose Inhaler (e.g. Albuterol MDI, Proair, Qvar)

  1. Preparation
    1. Shake before use (mixes medication and propellant)
    2. Uncap Inhaler
    3. Prime once before first use
    4. Attach Inhaler Spacer
  2. Take a deep breath and then exhale all air out
  3. Place Inhaler with spacer to lips
  4. Start to breath in while pressing the Inhaler to release medication
  5. Inhale slowly and deeply and then hold breath for 10 seconds

IV. Technique: Hydrofluoroalkane Inhaler (HFA Inhaler)

  1. Prior to first use
    1. Shake new Inhaler for 45 seconds
    2. Prime Inhaler by spraying 3-4 puffs into air (do not inhale)
  2. Later uses
    1. Same technique as with CFC Inhalers
    2. Breath out, spray, and inhale deeply
    3. Hold breath for 10 seconds
    4. Wait one minute, while shaking Inhaler
    5. Repeat one more puff as above
  3. Other pointers
    1. Do not use "float test" (placing Inhaler in water) to see if has any medicine remaining
    2. Tally on the package the number of 2-puff doses used (expect about 100, 2-puff doses)

V. Technique: Dry Powder Inhaler (e.g. Advair, Flovent Diskus, Serevent, Asmanex, Spiriva)

  1. Precautions
    1. Never take the powders orally (and keep separate from oral medications)!
    2. Do not shake before use (contrast with MDI)
  2. Preparation
    1. Uncap the device
    2. Load the powder caps or other formulation as directed
    3. No Inhaler Spacer is needed
  3. Inhalation
    1. Exhale fully
    2. Place Inhaler with spacer to lips, holding it in level position
    3. Start to breath in while pressing the Inhaler to release medication
      1. Device punctures medication casing exposing the powder
    4. Inhale deeply, and in contrast to MDI, inhale rapidly
    5. Then hold breath for 10 seconds
    6. Then expire all air out and avoid exhaling on device (prevents wetting the powder)
  4. Device types
    1. Single-dose device (e.g. aerolizer, handihaler)
      1. One dose capsule inserted into device, punctured and inhaled once or twice
    2. Multi-dose device (e.g. Discus, Flexhaler, Twisthaler)
      1. Dose is advanced (specific to device) and then capsule punctured and inhaled

VI. Technique: Soft Mist Inhalers (e.g. Combivent Respimat)

  1. Spring-loaded device without propellant
  2. No shaking of suspension required
  3. Exhale, then press down on Inhaler while breathing in slowly and deeply and then hold breath for 10 seconds

VII. Preparations: Adjuncts

  1. Smart Inhaler Technology
    1. Add-on sensors (e.g. Hailie, Propeller) attach to Inhalers (or built in sensor for Proair Digihaler)
    2. Sensors relay Inhaler use and inspiratory flow to synchronized mobile applications
    3. May increase Inhaler compliance, but cost $160 and typically not covered by insurance
    4. (2019) Presc Lett 26(7): 41

VIII. References

  1. (2014) Presc Lett 21(2): 9
  2. (2017) Presc Lett 24(1): 3-4

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