The document provides information on different types of inhalers and inhalation therapy for asthma treatment. It discusses the benefits of inhalation therapy including targeted delivery to the lungs, lower required doses, and faster onset compared to oral administration. Metered dose inhalers, dry powder inhalers, nebulizers and spacer devices are covered in terms of their use and advantages. Specific drugs administered via inhalers like corticosteroids and bronchodilators are also mentioned.

1. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 1
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, UK 2
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, UK 3
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, UK 4
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.

5. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 5
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

6. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 6
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, UK 7
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, UK 8
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, UK 9
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.

10. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 10
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

11. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 11
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

12. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 12
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.

13. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 13
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

14. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 14
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

15. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 15
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

16. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 16
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

17. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 17
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

18. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 18
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

19. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 19
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

20. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 20
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.

21. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 21
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

22. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 22
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