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Inhaler devices for respiratory medicines

Inhalers for chronic obstructive pulmonary disease (COPD) and asthma are devices which deliver medicine to prevent and control symptoms and help reduce exacerbations (flare ups). The variations between different inhaler devices can sometimes be confusing, but understanding them will help you make an informed choice about your care.

11 min read

Why are there different types of inhalers?

Inhalers are classified generally as

  • pressurised metered-dose inhalers (pMDIs)
  • breath-actuated metered dose inhalers (bMDIs)
  • dry powder inhalers (DPIs, single or multidose), and
  • soft mist inhalers.

Inhalers can contain either a single medication or a combination of medications.

An inhaler can deliver:

  • a bronchodilator, which helps to open up your airways and increase air flow
  • a corticosteroid, which helps to reduce inflammation in your airways
  • a combination of different bronchodilators
  • a combination of bronchodilator and corticosteroid

Which is better?

The choice of inhaler device depends on a number of considerations.1 The type of inhaler or other device you use will depend on the medicine you are taking and your ability to use the device properly, as well as your own personal preference – so that you get the most benefit from your inhaled medicines.

Are you physically capable of carrying out each step of the inhaler technique correctly?

For example:

  • are you able to coordinate breathing in with pressing the inhaler at the same time?
  • are you able to form a good seal with your lips over the mouthpiece?
  • are you able to open, correctly handle, and prepare (prime) the device?
  • are you able to take a deep breath to inhale the medicine?

Can you remember all the necessary steps to use the inhaler correctly, and to remember when to take their inhaler?

Using your inhaler and devices such as spacers correctly is very important in order to ensure that the right amount of medicine is delivered to your lungs and to help minimise side effects.


References

1. Price D, Bosnic-Anticevich S, Briggs A, et al. Inhaler competence in asthma: Common errors, barriers to use and recommended solutions. Respir Med 2013;107:37-46 [PubMed].

Using your pressurised metered-dose inhaler (pMDI)

A pMDI needs to be set up (primed) before first use or if it has not been used for several days. Ask your pharmacist to do this if you need help.

Use should be checked by a qualified health professional before you begin and at follow-up visits.

Improper inhaler use is a leading cause of poor asthma control and poor treatment outcomes.1 If used properly, an MDI is as effective as any other form of delivery and can be less costly.2,3

Your pharmacist, nurse or doctor can also show you how to use your inhaler and other devices.

Using your inhaler correctly means you are less likely to get side effects, such as oral thrush or a sore throat. Remember to rinse your mouth after use if your inhaler contains corticosteroid medicine.

You can also watch these videos and download instructions on how to use an inhaler correctly.

For more information, see the Consumer Medicine Information for your brand of medicine, available on our Medicine Finder page or from your pharmacist or prescriber.

References

1. Sanchis J, Gich I, Pedersen S. Systematic review of errors in inhaler use: Has patient technique improved over time? Chest 2016;150:394-406 [PubMed].

2. Brocklebank D, Ram F, Wright J, et al. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess. 2001:5:1-149 [PubMed].

3. Ram FSF, Wright J, Brocklebank D, et al. Systematic review of clinical effectiveness of pressurised metered dose inhalers versus other hand held inhaler devices for delivering β(2)agonists bronchodilators in asthma. BMJ 2001;323:901 [PubMed].

Do I need a spacer device?

Ask about a spacer if you have any trouble using your pressurised metered-dose inhaler (pMDI). For example, if you are having trouble pressing down on the canister and breathing in at the same time, or breathing in slowly and deeply when you use it.

Attaching a spacer makes it easier to inhale the medicine from a pMDI by allowing the medicine to ‘float’ in the spacer until you can breathe it in. This helps to get the medicine into your lungs more effectively and also reduces the chance of some side effects, such as oral thrush.1

You may find that you particularly need to use a spacer in order to inhale your medicine effectively during an asthma attack or flare-up (exacerbation) of chronic obstructive pulmonary disease (COPD).

If you are using a pMDI with a spacer, watch these videos on how to use them correctly.

Cleaning your spacer

There are many types of spacers - some do not require washing before use, and others do.

Download a fact sheet on spacer use and care from National Asthma Council Australia.

References

1. Yang I, Dabscheck E, George J, et al. The COPD-X plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease v2.47. Milton, QLD: Lung Foundation Australia, 2016. [Online] (accessed October 2016).

Using your breath-actuated metered-dose inhaler (bMDI)

Using your inhaler(s) and other devices correctly is very important. This helps to ensure that the right amount of medicine is delivered to your lungs and prevent side effects.

A breath-actuated metered-dose inhaler is activated by your breath – when you breathe in using the mouthpiece, the medicine is released in a fine spray.

With this type of inhaler, you don't have to push the canister to release a dose of medicine. But, you do need to shake the inhaler so that the medicine is mixed well before you inhale it.

You can also watch these videos and download instructions on how to use an inhaler correctly.

Using your inhaler correctly means you are less likely to get side effects, such as oral thrush or a sore throat. Remember to rinse your mouth after use if your inhaler contains corticosteroid medicine.

For more information, see the Consumer Medicine Information for your brand of medicine, available on our Medicine Finder page or from your pharmacist or prescriber.

Using your dry powder inhaler (DPI)

There are two types of DPI:

  • Type 1: the medicine is contained within the inhaler device at all times, until inhaled, or
  • Type 2: the medication comes in a separate capsule that must be placed into the inhaler device at the time of use.

To use a DPI, you need to be able to breath in quickly and deeply.

If you do not inhale fast enough or long enough, part of the dose may not be emitted from the inhaler, or the particles of medicine produced may be too big to enter the lungs.1,2

A DPI may not be suitable for people who are very short of breath (for example, because of an asthma attack or a flare-up (exacerbation) of COPD.

What else should I know about my DPI?

  • DPIs can't be used with spacer devices. If a spacer is required, you will need to use a pMDI to inhale your medicine. Ask your health professional about this.
  • Many DPIs have a counter to show the number of doses remaining in the device, which is useful for keeping track of when a new DPI will be required.
  • Do not swallow the capsules that come with your DPI if you use the type that needs capsules. They are only intended to be inhaled from your device and won’t work if they are swallowed.
  • DPIs need to be kept dry in order to work effectively. Always keep the cap on your DPI when it’s not being used and don’t keep it in a moist environment such as your bathroom.
  • Do not breathe out into your DPI – this will moisten the tubes inside the DPI and reduce the dose of medicine that is delivered to you when you next use the device.
  • Turbuhaler requires setting up (priming) before it is first used. Your pharmacist or practice nurse may be able to do this for you.

Using your inhaler correctly means you are less likely to get side effects, such as oral thrush or a sore throat. Remember to rinse your mouth after use if your inhaler contains corticosteroid medicine.

You can also watch these videos and download instructions on how to use an inhaler correctly.

For more information, see the Consumer Medicine Information for your brand of medicine, available on our Medicine Finder page or from your pharmacist or prescriber.

References

1. Lavorini F, Magnan A, Christophe Dubus J, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med 2008;102:593-604 [PubMed].

2. Haughney J, Price D, Barnes NC, et al. Choosing inhaler devices for people with asthma: Current knowledge and outstanding research needs. Respir Med 2010;3:125-31 [PubMed].

Using your soft mist inhaler (SMI)

A soft mist inhaler delivers the medicine as a fine mist, but does not contain any ‘propellant’ like pressurised metered-dose inhalers (pMDIs).

The mist is produced more slowly and for slightly longer than with other inhalers, which may be helpful for people who have difficulty with handling pMDIs, or for people who can’t breathe in fast enough to get a DPI to work properly.1

Like pressurised metered dose inhalers (pMDIs), soft mist inhalers such as Respimat are a press-and-breathe device. This means that you need to coordinate breathing in with pressing the dose-release button.

What else should I know about my SMI?

  • Soft mist inhalers do not need to be used with spacer devices.
  • Soft mist inhalers use a cartridge that must be placed inside the device.
  • Respimat requires setting up (priming) before first use. Your pharmacist or practice nurse may be able to show you how this is done, or do this for you.

Using your inhaler correctly means you are less likely to get side effects, such as oral thrush or a sore throat.

You can also watch these videos and download instructions on how to use an inhaler correctly.

For more information, see the Consumer Medicine Information (CMI) for your brand of medicine, available on our Medicine Finder page or from your pharmacist or prescriber.

References

1. Anderson P. Use of Respimat(®) Soft Mist™ Inhaler in COPD patients. Int J Chron Obstruct Pulmon Dis 2006;1:251-9 [PubMed].

Using your nebuliser

A nebuliser is a pump that turns medicine into a fine mist that can then be inhaled through a tube (mouthpiece) or face mask that fits over your nose and mouth.

For most people, inhalers and spacer devices are an easier, faster and more convenient way to inhale medicines – including during a flare-up/ exacerbation. An inhaler with a spacer also reduces the risk of getting side effects from your medicines.

A nebuliser is useful for people who:

  • are unable to use an inhaler or other device because of confusion, hand weakness or coordination problems1
  • have severe difficulty breathing in a hospital setting or ambulance2 (eg, severe exacerbations of COPD).
  • are young children or infants in emergency situations.3

Looking after your nebuliser

If you use a nebuliser at home, make sure it is properly cleaned and maintained according to the manufacturer’s instructions. This will ensure that you get the dose of medicine you need. Using a nebuliser that isn’t well cleaned or maintained also increases your risk of getting an infection from the machine.

To correctly clean and maintain your nebuliser it is important to:

  • clean all of the separate parts after each use
  • replace the tubing and mask (or mouthpiece) frequently (usually about every 3 months)
  • check, clean and replace the filters regularly, usually about every 6 to 12 months
  • have the nebuliser machine pump serviced every 6 to 12 months to make sure it is producing the right pressure.

What else should I know about my nebuliser?

Two medicines can be inhaled through a nebuliser at the same time, but some solutions may not mix well together.

If you are using a nebuliser at home:

  • Check with your doctor, pharmacist, practice nurse or the consumer medicine information (CMI) for your medicine to find out whether you can mix your nebulised medicines and how this should be done.
  • Using a face mask with a nebuliser may cause your eyes and skin to react to the inhaled medicine. To reduce the chance of side effects, protect your eyes and wash your face after use, or use a mouthpiece rather than a mask.

Using your inhaler correctly means you are less likely to get side effects, such as oral thrush or a sore throat.

You can also watch these videos and download instructions on how to use an inhaler correctly.

For more information, see the Consumer Medicine Information (CMI) for your brand of medicine, available on our Medicine Finder page or from your pharmacist or prescriber.

References

1. O'Donohue WJ, Jr. Guidelines for the use of nebulizers in the home and at domiciliary sites. Report of a consensus conference. National Association for Medical Direction of Respiratory Care (NAMDRC) Consensus Group. Chest 1996;109:814-20 [PubMed].

2. National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE, 2010, updated 2016. [Online] (accessed 25 January 2017).

3. National Asthma Council Australia. Australian Asthma Handbook, verson 1.2. 2016, [Online] (accessed 20 January 2017).

4. Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2013. [PubMed].

How to care for your inhalers

Inhalers need to be stored correctly.1

  • Keep the cap on when not in use - this will help to keep the mouthpiece clean.
  • Store your inhalers at the correct temperature (usually room temperature, between 15 degrees and 30 degrees). Check the Consumer Medicine Information or packaging for storage instructions. Extreme temperatures can affect the medicines in inhalers.

Inhalers should be cleaned properly1. Check the consumer medicine information (CMI) for how to clean your inhaler and keep it working well.

The most important thing to remember is to never wash the metal canister or put it in water - only wash the plastic parts.

  • Remove the metal canister from the plastic casing of the inhaler and remove the mouthpiece cover.
  • Rinse the plastic casing thoroughly under warm running water for at least 30 seconds.
  • Shake off excess water and allow to completely air dry.
  • For pMDIs, put the metal canister into the plastic casing, test it by releasing a single puff into the air and replace the mouthpiece cover.
  • Metered-dose inhalers containing inhaled corticosteroids (ICS) should never be washed. Wipe dry with a tissue.

Cleaning your dry powder inhaler:

  • Wipe the mouthpiece with a dry cloth at least once a week.
  • Do NOT use water to wipe the dry powder inhaler because the powder is sensitive to moisture.

Cleaning your soft mist inhaler:

  • Clean the mouthpiece, including the metal part inside the mouthpiece, with a damp cloth or tissue only, at least once a week.
  • If the outside of your inhaler gets dirty, wipe it with a damp cloth.

References

1. Queensland Health Statewide Respiratory Clinical Network and the Australian Lung Foundation. Better Living with chronic obstructive pulmonary disease: a patient guide. Queensland Health, 2012. [Online] (accessed 5 December 2016

Common mistakes with inhaler technique

  • Not breathing out first before use. Breathing out fully (or as much as is comfortable) just before using an inhaler creates more space in the lungs for the next breath. This enables you to breathe in deeper and for longer when you inhale your asthma or COPD medicine – giving it the best chance of reaching the small airways deep inside your lungs, and being most effective.
  • Breathing in too fast using a pMDI. Use a slow steady breath. The amount of drug reaching the lungs is strongly affected by how fast you breathe it in. Breathing in too fast can increase the amount of medicine that hits the back of the throat instead of going down into your lungs.
  • Breathing in too slow using a DPI. Dry powder inhalers require a quick and deep breath to inhale the powder down into the lungs.
  • Inhaling too late after pressing the canister of a pMDI (unless you're using a spacer). Even a short delay breathing in after you press the canister can mean that some of the medicine will end up being sprayed in your mouth and not be carried down to your lungs where it's needed.
  • Not holding your breath after taking your inhaler. If you've been advised to hold your breath after using your inhaler, then this is an important step. Holding your breath gives more time for the medicine to get into your lungs. Aim for 10 seconds if you can, or if not, for as long as you feel comfortable.
  • Not shaking a pMDI before using it. Shake your inhaler before use if it is a pMDI. If you don’t shake the inhaler, the medicine and the ‘propellant’ don’t mix together, releasing too much or not enough of either. You should wait about 30 seconds after shaking it for this to happen.
    (Note: dry powder inhalers (eg Accuhaler, Breezhaler, Ellipta, Genuair, Handihaler, Turbuhaler) do not need shaking)
  • Not priming the MDI pump. You need to give the device a pump before use to make sure it releases a full dose. The ‘propellant’ in the inhaler can evaporate or escape from the metering chamber if not used for days or weeks.
    (Note: Soft mist inhalers need priming for the first dose only. DPIs do not need priming)
  • Using an empty inhaler. Remember to check your dose counter. Most inhalers have a counter that can be checked. This will make sure you are getting medicine and not just propellant.
  • Using an inhaler that is past its expiry date. Check the expiry date on your inhaler and make sure that you have one ready for use if you only use it occasionally.
  • Delaying inhaling when using a spacer device. Take deep steady breaths after pressing the canister. If you delay breathing, larger particles of medicine fall on the inside of the spacer instead of the upper airway. Observe the one way valve for movement with each breath to ensure drug is moving from the spacer.
  • Other simple mistakes include failing to pierce the capsule when loading a single-dose dry powder inhaler, or loading an inhaler the wrong way (such as loading a Turbuhaler when it is horizontal).

References

Price D, Bosnic-Anticevich S, Briggs A, et al. Inhaler competence in asthma: Common errors, barriers to use and recommended solutions. Respir Med 2013;107:37-46 [PubMed].

Smith H. Inhalation devices for asthma and chronic obstructive pulmonary disease. SA Pharm J 2012;79:23-6.

Boise E, Rotella M. ABCs of asthma inhaler and device training. Int Forum Allergy Rhinol 2015;5 Supp1:S71-5 [PubMed].

Rau JL. Practical problems with aerosol therapy in COPD. Respir Care 2006;51:158-72 [PubMed].

Sleath B, Ayala GX, Gillette C, et al. Provider demonstration and assessment of child device technique during pediatric asthma visits. Pediatrics 2011;127:642-8 [PubMed].

When to check your inhaler technique

You might want to make sure you are using your inhaler correctly if:

  • taking your inhaled medicine doesn’t seem to improve your breathing
  • a mist of medicine particles comes out of the top of the inhaler when you use it
  • a mist of medicine particles comes out of your mouth when you breathe out after using your inhaler
  • taking your inhaler medicine is felt mostly on your tongue.

Each time you start a new device or your medication is changed, ask your health professional to show you how to use your inhaler correctly.

If you are not sure that you are using your inhaled medicines properly, talk to your doctor, pharmacist, or nurse. They can show you how to use your inhalers and other devices, check your technique, or recommend a different type of device for you.

Find more resources about inhalers and how to use them:

11 min read