Inhaler Devices

1. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK1
Inhaler techniques.
Additional information/guidelines can be found at:
http://www.asthma.org.uk/using_your_inhaler.html
http://www.asthma.org.uk
http://www.lunguk.org
http://www.ginasthma.com

2. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK2
Inhalation therapy
The inhaled route is the preferred route of
administration for most anti-asthma therapy
By this route
the active ingredient can be delivered to the
smallest airways
the dose required is much smaller than needed
for an equivalent effect via oral route
minimises risk of systemic side effects
onset of action faster

3. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK3
Inhalation therapy 2
Devices available to deliver inhaled
medication include pressurised metered-
dose inhalers, breath-actuated metered dose
inhalers, dry powder inhalers and nebulisers.
Spacer (or holding chamber) devices make
inhalers easier to use.

4. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK4
Drugs Administered Via Inhalers.
Corticosteroids. (Anti inflammatory)
Beclometasone
Beta agonists ( Bronchodilators) Salbutamol
& Terbutaline.
Anti muscarinic bronchodilators. Ipratropium
bromide
Combination therapy. The above drugs may
be administered separately or combined into
one inhaler device.

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Metered dose aerosol inhaler
Metered dose aerosol (MDI)
Convenient, low dose form of therapy
Advantages
Low dose Portable
Cheap Fixed dose
Can feel & hear dose being delivered

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Metered dose aerosol inhaler
Disadvantages
Requires good hand/breath co-ordination
Not good for those with decreased dexterity
Jet aerosol can cause deposition of the drug in the
oropharynx – reduces dose available to the airways
and predisposes to local side effects (i.e. oral
candidiasis)
25-30% of patients unable to use properly
Don’t know how much is left in device

7. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK7
Using a metered dose inhaler
Remove cap and check
mouthpiece is clear
Shake inhaler
Breathe out gently
Place mouthpiece in mouth
and seal with lips
At the start of breathing in,
press canister
Continue to breath in as deep
as possible
Hold breath for up to 10
seconds
Wait half a minute before
repeating a dose

8. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK8
Using a spacehaler device
Remove cap
Shake inhaler
Breathe out gently
Put mouthpiece in mouth
and at the start of
inspiration, which should
be slow and deep, press
canister down and
continue to inhale deeply
Remove from mouth, and
hold breath for 10
seconds

9. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK9
Using an Easi-breathe inhaler
Shake inhaler
Hold inhaler upright. Open the cap
Breathe out gently. Keep inhaler
upright, put mouthpiece in mouth and
close lips and teeth around it (the
airholes on the top must not be
blocked by your hand)
Breathe in steadily through the
mouthpiece. Don’t stop breathing
when the inhaler puffs continue
taking a deep breath.
Remove from mouth and continue to
hold breath for 10 seconds.
After use, hold inhaler upright and
immediately close cap.

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Dry Powder Inhaler devices
Dry powder devices
require no special co-ordination
work well even with low inspiratory flow rates
suitable for younger children
should avoid exhaling through the device as this
will dampen the dry powder
any air holes in the device must not be covered
during inspiration
Includes accuhaler, disk inhaler and turbohaler
devices

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Dry Powder Inhaler devices
Advantages
Easy to use
No co-ordination needed
Patient breath actuated
Know how many doses left
Disadvantages
Air can escape if you don’t form a good seal around the
mouthpiece
Expensive in comparison to MDI’s
May need a higher respiratory effort

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Using Accuhaler Device
Hold the outer casing of the
accuhaler in one hand whilst
pushing the thumb grip away
until a click is heard
Hold accuhaler with mouthpiece
towards you, slide lever away
until it clicks. This primes the
dose.
Holding the accuhaler horizontal,
breathe out gently away from the
device, put mouthpiece in mouth
and suck in steadily and deeply.
Remove from mouth and hold
breath for about 10 seconds.
To close, slide thumb grip back
towards you as far as it will go till
it clicks.

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Using a Turbohaler
1.Unscrew and lift off cover.
Hold turbohaler upright and
twist grip forwards and
backwards as far as it will go.
You should hear a click.
2.Breathe out gently, put
mouthpiece between lips and
breathe in as deeply as
possible. Even when a full
dose is taken there may be no
taste
3.Remove from mouth and hold
breath for 10 seconds

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Spacer devices
Spacer devices and expansion chambers
reduce jet effect
overcome hand-breath co-ordination problems
disperses aerosol discharge within a chamber
may breathe in and out of chamber without breath
holding - this may suit small children.
Less effort.
Decreases local side effects
Increases drug concentration delivered to the small airways
so maximises treatment without having to increase dose
Work at least as well as nebulisers at treating most asthma
attacks in children and adults

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Volumatic device
Remove cap, shake inhaler and
insert into device
Place mouthpiece in mouth or
mask over mouth and nose
Depress canister and leave device
in same position.
Take a deep breath (this will make
a clicking sound as the valve
opens and closes) and hold your
breath for ten seconds (or for as
long as is comfortable) then
breathe out slowly.
If you find it difficult to take deep
breaths, breathing in and out of
the mouthpiece several times is
just as good
Remove device from mouth
Wait 30 seconds before repeating

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Aerochamber
Remove cap
Shake inhaler and insert in back of
aerochamber
Place mouthpiece in mouth
Press the canister once to release a
dose of the drug
Take a slow deep breath in. If you hear
a whistling sound you are breathing
too quickly
Hold breath for about 10 seconds,
then breathe out through the
mouthpiece
If you find it difficult to take deep
breaths, breathing in and out of the
mouthpiece several times is just as
good
Remove mouthpiece from mouth and
breathe out

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Maintenance & Hygiene
Spacer devices should be cleaned once a month in
warm soapy water and left to “drip dry” on a clean
draining board.
After using corticosteroids via an inhaler patients
should be encouraged to clean their teeth. The
steroid particulate can damage teeth enamel as
well as cause oral thrush.
Therefore all patients are encouraged to brush
teeth after use of an inhaler or rinse mouth with
water

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Nebuliser Therapy
http://www.brit-thoracic.org.uk/page261.html

A nebuliser is a device which converts drug solution into an
aerosol for direct inhalation via a mask or mouthpiece
The solution is contained within a reservoir through which
oxygen or compressed air is passed.
It may be powered by electricity (mains or battery) or by a
compressed oxygen or air supply.
A flow rate of 6-8 litres/minute is required to drive the
nebuliser.
normal breathing over 5-10 minutes is usually sufficient for
drug delivery

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Advantages of nebulisers:
patients whose condition makes MDI use difficult
shortness of breath
weakness
Simple to apply
Effective in use
Large doses can be administered
Can be used for delivering drug direct to lungs even
if not available in inhaler form
e.g. antibiotics

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Disadvantages of nebulisers
Not very portable
Requires compressed gas, so only suitable for
clinical environment unless bulky compressor
used
inefficient
only about 10% of the prescribed dose reaches
the lung.

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Jet nebuliser
Jet of gas forced
through narrow
opening (venturi)
negative pressure in
reservoir
mist of droplets of
drug solution
5- 10 microns size
Larger droplets fall
back into reservoir
Compressed gas
Reservoir of
drug
droplets Venturi
baffle
Aerosol of drug
for inhalation

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Used for
Emergency treatment
acute asthma
COPD
Long term bronchodilator treatment
Preventive drugs for asthma
Antibiotics
cystic fibrosis
Bronchiectasis
HIV/AIDS
Symptom relief in palliative care