Counseling on the Use of Inhaled Medications

Asthma and chronic obstructive pulmonary disease (COPD) are life-long, potentially life-threatening diseases that represent the leading chronic respiratory diseases in the world. Inhalation of medications is an effective method for rapidly delivering short- or long-acting bronchodilators and corticosteroids to prevent, control, and treat respiratory symptoms that accompany these diseases. Inhalation of medications may also reduce the risk of adverse drug effects because the medications can often be provided in lower doses than an oral form of the drug. 

 

Types of inhalers

Rescue inhalers that deliver short-acting bronchodilators to relieve sudden respiratory symptoms, and maintenance inhalers that deliver long-acting bronchodilators and corticosteroids to prevent and control respiratory symptoms, are the cornerstone of managing asthma and COPD. Inhalation devices that deliver these medications are available in four basic types:

Pressurized metered-dose inhalers (MDIs), which have been around for decades, typically consist of a small canister of medication fitted into a plastic body with a mouthpiece. Each dose is delivered by pressing the canister into the plastic body while inhaling through the mouthpiece. Use of a spacer that connects to the MDI makes it easier to inhale the dose, which is first released into the spacer and then inhaled slowly.

Dry-powder, breath-activated inhalers are preloaded with the medication(s) inside the device. Prior to use, a single dose of the medication is loaded into the mouthpiece, often by turning or twisting the inhaler body until a “click” signals the dose is ready to be inhaled. Patients simply take a deep breath while their lips are sealed around the inhaler, and a single dose is delivered (breath-activated).

Dry-powder, capsule inhalers utilize capsules as the dose-holding system, which are inserted into the device by the manufacturer or by the patient prior to use, and punctured by the device before each dose is inhaled directly from the inhaler.

Soft mist inhalers are a propellant-free liquid inhaler that provides a slow-moving, soft aerosol cloud of medicine to help patients inhale the medication, even if they can’t take a very deep breath. 

 

Errors with inhalers

The correct use of an inhaler depends on its type; thus, each manufacturer provides detailed instructions for use, some with a Medication Guide for consumers and/or a short online video to help visualize the technique. Unfortunately, up to 94% of patients with asthma and COPD use their inhalers incorrectly.2-4 Problems are not limited to one type of device, nor are they limited to patients—even healthcare professionals have made errors. Misuse leads to reduced efficacy and poor outcomes. For example, in a study published in 2015, Bonds et al. found that only 7% of patients who used MDIs demonstrated proper technique; 93% made at least one mistake, and of those, 63% missed 3 or more steps in the 11-step process. While most of these errors typically result in diminished drug delivery rather than no delivery at all, other errors have resulted in omitted doses, overdoses, and exacerbation of the underlying disease and respiratory symptoms.

 

Common errors made by patients using any inhaler include:

• Not holding their breath long enough after inhaling a dose (hold for about 10 seconds or as long as comfortable)
• Using an empty inhaler, often believing an inhaler still provides doses even after the dose counter is at zero because the patient can still see or feel a “spray”
• Forgetting to exhale completely before each dose or exhaling into the inhaler
• Not using maintenance inhalers when asymptomatic

 

Common errors made by patients using an MDI (with and without a spacer) include:

• Not shaking the canister or container before each dose
• Inhaling at the wrong time (not in sync with pressing the inhaler)
• Aiming the inhaler at the roof of the mouth or tongue, rather than the throat
• Inhaling an unnoticed foreign body that has entered an uncapped inhaler
• Damaged or sticky spacer valves that limit the delivery of the medicine

 

Common errors made by patients using a dry-powder, breath-activated inhaler include:

• Failing to load a dose before inhaling
• Loss of some medication by holding the inhaler mouthpiece upside down during or after loading a dose
• Failure to inhale strongly enough to draw the medication out of the device

 

Common errors made by patients using a dry-powder inhaler that requires loading and piercing of a capsule prior to each dose include:

 

• Not piercing the capsule
• Forgetting to remove the spent capsule and not using a new capsule for each dose
• Failing to take a second breath (if indicated) to receive the full dose
• Swallowing the capsule instead of inhaling its contents
• Placing the capsule into the inhaler mouthpiece instead of the chamber designed to hold the capsule, which can result in swallowing or choking on the capsule during inhalation

 

Errors with newer inhalers

Over the past few years, several new devices for the administration of inhaled medications have been introduced. Some of the devices are used to administer newly marketed medications, while others contain previously available drugs in a different administration format. They were designed to address some of the problems with older inhalers and to improve the ability to use the inhalers correctly. Specifically, the newer inhalers include:

• A dose counter, which allows patients to see when the supply of medication is low. This was previously available on some dry-powder inhalers but not on MDIs.
• A longer duration of spray at a lower speed to help patients receive the full dose despite problems with coordinating the spray with the breath and the depth of the breath (e.g., Respimat soft mist inhalers).
• The inability to activate a dose when all of the medication has been used. Once the last dose has been taken and the inhaler is empty, the mechanism to prepare another dose is locked, preventing the use of an empty inhaler.

Despite these new design enhancements to improve correct use, unfamiliarity with the newer inhalers on the market has been the source of several recently reported errors.