Inhaled medication is the cornerstone of treatment for many people with lung conditions, especially those with asthma and COPD. There are many considerations for choosing an inhaler: drug, dose, technique, cost and environmental impact.
However, the most important thing is that the patient can use it correctly. Using a device incorrectly could be the reason why some people with respiratory conditions struggle to control their symptoms.
With over 125 inhaler devices available, choosing the right one for your patient can present a challenge!
See here for the PCRS guide to making safe, greener changes to inhalers.
Make sure that you understand how each device works before you show a patient how to use it. You can order placebo devices from pharmaceutical companies for your patient to practice with.
Click here to see our inhaler technique videos
About inhaler devices
There are 3 main types of inhaler device
1. Pressurised metered dose inhalers (pMDIs)
pMDIs hold medication in a pressurised canister. They require a slow, steady inhalation and should always be used with a spacer.
This is because the technique to use pMDIs can be hard for patients to get right. A spacer ensures that there is better deposition of the medication in the airways.
Your patient can use either of the following techniques, whichever they prefer:
Spacers should be replaced at least yearly. Click here to watch a video about looking after your spacer
Spacers are available with and without facemasks. Facemasks should not be used for adults unless they have a condition meaning they cannot use a spacer with a mouthpiece.
Children under the age of 5 will generally use a spacer with a facemask, although as soon as they can drink through a straw they may be able to use a spacer with a mouthpiece. This is preferable as it minimises medication coming into contact with the skin around the mouth, which can cause rashes.
Remind parents to protect their child’s skin by wiping around their child’s mouth after they’ve used a spacer with a facemask, especially when giving inhaled corticosteroids.
pMDIs do not usually have dose counters, so it’s important to remind your patient to keep track of how many doses they are using.
2. Dry powder inhalers (DPIs)
DPIs are breath actuated devices, which means they are primed to release a dose of medication as soon as the patient breathes in. These devices require a quick, deep inhalation. They are not used with spacer devices.
Evidence shows that most patients find DPIs easier to use than pMDIs. Because DPIs are not used with spacers, it means your patient doesn’t have to take their spacer out and about with them.
Older people, some children (particularly under 12) or people with more severe lung conditions may not have sufficient inspiratory effort to use the DPI effectively. Therefore, it is crucial to assess your patient’s ability to use a DPI, using either a placebo device or an inhaler checking device.
Many DPIs contain lactose which may not be suitable for people with lactose intolerance. You can check inhaler ingredients at EMC or RightBreathe.
DPIs should not be stored in bathrooms or anywhere they might become damp as this the powder is sensitive to moisture.
Some DPI devices have a strong after taste and can be off putting for some patients. Advising your patient to rinse their mouth after use can help prevent this problem.
Most DPIs come with a built-in dose counter.
Avoid giving your patients a combination of DPI and pMDI inhalers. Using both types can confuse patients, leading to incorrect inhalation techniques, reduced drug delivery, and potentially reducing disease control.
3. Soft mist inhalers
SMIs produce a fine, slow-moving mist that improves the deposition of the drug in the airways compared to MDIs and DPIs. Aerosol generation in SMIs does not depend on the patient’s inspiratory effort, so it is useful for patients with a weak inspiratory flow.
SMIs can also be used with a spacer if necessary.
SMIs require less coordination between actuation and inhalation than pMDIs or DPIs , meaning they are easy to use. The slow-moving mist is gentle and less likely to cause throat irritation or coughing compared to the forceful spray of MDIs or the dry powder of DPIs.
There are fewer drug formulations available in SMI form than pMDI or DPI inhalers. Some SMI devices can be difficult for people with limited dexterity eg arthritic patients so it’s important to ensure that you demonstrate the technique to your patient. Remind them that they can take their inhalers to a pharmacist who can also show them how to use it.
SMIs come with a built-in dose counter. SMIs turn red when they are almost empty and lock themselves after all the medicine has been used.
The SMI device can usually be refilled with cartridges containing the medication. The device itself should be replaced every 6 months.
Lower carbon inhaler devices
It’s important to consider the carbon footprint of inhalers. pMDIs contain propellants which contain powerful greenhouse gases and contribute to climate change. See here for more information.
Dry powder inhalers and soft mist inhalers do not contain propellants.
pMDIs make up 70% of inhalers prescribed in the UK, causing 3% of the NHS’s overall carbon emissions. For this reason, it’s important to give your patient the option of using a lower-carbon inhaler.
Whilst it’s important to offer your patient the option of a lower carbon inhaler, this is a decision that must be taken collaboratively with your patient. It must be made clear to them that they can change back to their pMDI if the alternative you are suggesting doesn’t suit them.
Batch prescription changing is never acceptable. This is because if your patient doesn’t know how to use or does not like their inhaler then they are likely to use it less which will affect their disease control.
The National Institute for Clinical Excellence (NICE) have produced a patient decision aid on inhalers and climate change which you can share with your patients.
More information on how to support your patient who is thinking about changing their inhaler can be found at Greener Practice, including a video and leaflet explaining why Salamol is now being used in preference to Ventolin.