The importance of good inhaler technique

Unfortunately, many patients struggle to use inhalers, and many HCPs struggle to teach technique.^[1],[2]

It has also been found that many patients with COPD cannot use their inhaler correctly, with more than two thirds of patients making at least one error in using an inhalation device.^[3] This then results in poorer symptom control and reduced disease control.^[3],[4] It’s therefore imperative that HCPs address this crucial aspect of respiratory disease management if we are to improve asthma control, COPD outcomes and quality of life for our patients.

Choosing the right inhaler

At diagnosis, one important decision on treating and managing a patient’s respiratory disease is choosing the proper medication via a suitable inhaler. The best drug in the world won’t work if it isn’t delivered correctly. There are many aspects to choosing the most appropriate device.

Some decisions will be based on:^[5]

• Age
• Cognitive ability
• Manual dexterity
• The patient’s previous experience/exposure to devices
• Personal preference

From the prescriber’s perspective, the device needs to:

• Contain the appropriate medication
• Meet formulary recommendations

The involved HCP also needs to feel confident in the patient’s ability to use the device following instruction.

Teaching inhaler techniques

Individuals or parents (where the patient is a child) need to know how to:

• Use the inhaler with the correct technique
• Administer the drug through the spacer (if using a pMDI)
• Care for their devices
• Tell when an inhaler device needs replacing.

I usually refer patients to the inhaler devices section on Asthma+ Lung UK. There are videos that show patients how to use their prescribed device.

Elderly patients have particular problems with generating the correct inspiratory flow and volume.^[6] They may have co-ordination problems, or poorer manual dexterity and hand strength, and are less likely to retain instructions because of cognitive decline.^[7]

If using a video link to perform a respiratory review, it should be possible to ask the patient to demonstrate their inhaler technique to you. A quiet, well-lit area with a good wi-fi connection and adequate sound is ideal. Then as the HCP, you can comment accordingly, correcting incorrect technique appropriately in a non-judgemental, supportive manner.

If, however, the review is by telephone, then although you cannot see the patient using their inhaler, you can assess control by using validated tools such as Royal College of Physicians (RCP) 3 questions, the Asthma Control Test (ACT) or the COPD Assessment Tool (CAT). If control is good, you can assume that the patient receives adequate medication with satisfactory inhaler technique.

You can also ask the patient to describe their technique to you, and you, in turn, can discuss the correct technique with them. At this point, I would also recommend the patient read the instruction leaflet in their prescription, send them an instruction leaflet and or refer them to the Asthma + Lung UK website, as previously mentioned.

Effective inhaler techniques

The efficacy of inhaled therapies is dependent on a variety of factors including the physiochemical properties of inhaled drugs (e.g., solubility), the device and formulation characteristics (e.g., particle size), and also the influence of patient characteristics.^[8]

Some of the main inhaler features to consider when choosing an inhaler device include:^[9]

• Efficacy and safety
• Clinical setting
• Economic constraints
• Patients’ ability to use the prescribed inhaler
• Age of patient
• Patients’ acceptability of the device
• Patient preference
• Pulmonary deposition

In general terms, there are three categories of inhalers:

• Pressurised metered dose inhaler (pMDI)
• Dry powder preparations (DPI)
• Soft mist inhalers (SMIs)

pMDIs deliver a pre-defined dose of medication which is inhaled slowly, deeply and steadily, followed by a short breath-hold of up to 10 seconds.^[9]

DPIs administer the drug in the form of a fine powder, energy from the patient’s inhalation is used to disperse the powder formulation into smaller particles and therefore require to be inhaled quickly and deeply.^[5]

Soft mist inhalers do not require a propellant or the patient’s inspiratory flow to generate the aerosol, and is instead generated by a spring. Patients are advised to breath slowly and steadily when using a soft mist inhaler.^[10]

In conclusion

Most people think that they can use their inhaler correctly, but inhaler technique errors are common in practice.^[11] Unfortunately, a sub-optimal technique results in poorer symptom control and reduced disease control.^[3],[4]

As HCPs, we have a duty of care to ensure that no matter what barriers there are to preventing us from seeing patients face-to-face, which is the ideal, we should endeavour to address inhaler technique as a critical part of a respiratory assessment/review. It doesn’t matter who checks the technique as long as someone does it, and no inhaler should be prescribed without ensuring that the person receiving it can use it effectively.^[12]

Good adherence to inhaled therapy improves with repeated instruction on how and when to use their treatment,^[13] and therefore, it must be an integral part of the review.  We need to know it, show it, teach it and review it.

[1] Sanchis J, Gich I, Pedersen, S. Systematic Review of Errors in Inhaler Use. Chest 2016; 150(2):394-406.

[2] Prasad S, Moore M, Sathyamurthy. Confidence and aptitude of healthcare professionals at demonstrating inhaler technique. Thorax 2018;73:A204.

[3] Global Initative for Chronic Obstructive Lung Disease. Global Strategy for Prevention, Diagnosis and Management of COPD. Available at: https://goldcopd.org/2023-gold-report-2/. Accessed June 2023

[4] Melani S, Bonavia M, Cilenti V et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respiratory Medicine 2011; 105(6):930-938.

[5] Usmani O. S. Choosing the right inhaler for your asthma or COPD patient. Therapeutics and clinical risk management, 2019;15:461–472.

[6] Janssens W, VandenBrande P, Hardeman E, et al. Inspiratory flow rates at different levels of resistance in elderly COPD patients. European Respiratory Journal 2008;31(1):78-83

[7] Barbara S, Kritikos V, Bosnic-Anticevich S. Inhaler technique: does age matter? A systematic review. European Respiratory Review 2017;26:170055

[8] Borghardt J M, Kloft C, Sharma A. Inhaled Therapy in Respiratory Disease: The Complex Interplay of Pulmonary Kinetic Processes. Canadian Respiratory Journal 2018;2732017

[9] 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

[10] Leeds Teaching Hospitals Trust Inhaler Device Guide. 2018. Available at http://www.cpwy.org/doc/2003.pdf. Accessed April 2021

[11] Bosnic-Anticevich, S. Inhaler device handling: have we really started to address the problem? European Respiratory Journal 2017;49(2):1700120

[12] The UKIG Standards for Inhaler Technique. Available at: https://www.ukinhalergroup.co.uk/uploads/s4vjR3GZ/InhalerStandardsMASTER.docx2019V10final.pdf. Accessed June 2023

[13] Takemura M, Kobayashi M, Kimura K et al. Repeated Instruction on Inhalation Technique Improves Adherence to the Therapeutic Regimen in Asthma.Journal of Asthma 2010;47(2):202-208

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.