What is the proper technique for using an inhaler (inhalation device)?

Proper Inhaler Technique for Effective Medication Delivery

Proper inhaler technique is crucial for effective medication delivery and significantly impacts morbidity, mortality, and quality of life in patients with respiratory conditions. Poor inhaler technique is associated with increased risk of hospitalization, emergency room visits, and poor disease control 1.

General Principles for All Inhalers

1. Before using any inhaler:

   • Breathe out completely (exhale) away from the inhaler
   • Keep the inhaler in the correct position (usually upright)
   • Create a proper seal around the mouthpiece with lips

2. After inhaling medication:

   • Hold breath for about 10 seconds or as long as comfortable
   • Breathe out slowly
   • For inhaled corticosteroids, rinse mouth with water and spit it out (don't swallow)

Specific Techniques by Inhaler Type

Metered Dose Inhalers (MDIs)

1. Remove cap and shake inhaler well
2. Hold inhaler upright
3. Breathe out completely away from inhaler
4. Position mouthpiece 1-2 inches from open mouth OR place directly between lips creating a seal
5. Start breathing in slowly and deeply through mouth
6. While breathing in, press down firmly on canister once
7. Continue breathing in slowly until lungs are full
8. Hold breath for 10 seconds
9. Wait at least 30-60 seconds before repeating for additional doses
10. Replace cap after use

Important: For patients who struggle with MDI coordination, a spacer or valved holding chamber is strongly recommended 2, 3.

Dry Powder Inhalers (DPIs)

1. Keep inhaler in correct position (varies by device)
2. Load the dose according to specific device instructions
3. Breathe out completely away from inhaler
4. Place mouthpiece between lips creating a tight seal
5. Breathe in QUICKLY and DEEPLY (unlike MDIs which require slow inhalation)
6. Hold breath for 10 seconds
7. Do not exhale into the device
8. Close the device properly after use

Example for Diskus:

1. Open cover by sliding lever
2. Slide lever until it clicks to load dose
3. Breathe out away from inhaler
4. Create tight seal around mouthpiece
5. Inhale quickly and deeply
6. Hold breath for 10 seconds
7. Close device to prepare for next use

Soft Mist Inhalers

1. Hold upright with cap closed
2. Turn base in direction of arrows until it clicks
3. Open cap completely
4. Breathe out completely
5. Close lips around mouthpiece
6. While taking slow, deep breath, press dose release button
7. Continue breathing in slowly
8. Hold breath for 10 seconds
9. Close cap after use

Common Errors to Avoid

1. Not exhaling before inhalation - reduces lung capacity for medication
2. Poor coordination between actuation and inhalation with MDIs - approximately 40% of patients fail to coordinate properly 4
3. Breathing too rapidly with MDIs - reduces medication deposition in lungs
4. Not holding breath after inhalation - most common error with MDIs 5
5. Incorrect inhaler position - reduces medication delivery
6. Not waiting between multiple doses - reduces effectiveness
7. Not rinsing mouth after using corticosteroid inhalers - increases risk of thrush

Special Considerations

For Children

• Children under 4 years should always use a spacer or valved holding chamber with MDIs 3
• Face mask attachments are necessary for very young children
• Spacers reduce medication delivery to lungs by approximately 50% but improve overall delivery compared to poor technique 3

For Elderly Patients

• Older age is strongly associated with inhaler misuse 1
• Consider devices requiring less coordination or strength
• Regular technique assessment is essential

Importance of Education and Follow-up

A high proportion of patients with COPD have poor inhaler technique, which negatively affects outcomes 2. Proper education significantly improves technique:

1. Initial demonstration - Healthcare providers should demonstrate correct technique
2. Patient practice - Have patient demonstrate technique back
3. Regular reassessment - Check technique at each visit
4. Device selection - Match device to patient's abilities and preferences
5. Consistency - Use of multiple devices with similar inhalation techniques is associated with lower exacerbation rates 2

Poor inhaler technique is associated with increased risk of hospitalization, emergency room visits, courses of oral steroids and antimicrobials, and poor disease control 1. Choosing the right device for each patient, providing proper education, and regularly checking inhaler technique are essential components of respiratory disease management 2.