# Inhaler Use Training

## Overview

This module describes how to coach a patient on using a metered dose inhaler correctly.

## Indications

1. Patients new to using a metered dose inhaler

2. Patients familiar with using the device often need to have a technique check and refresher

## Contraindications

1. None

## Patient information and consent

“We’re going to run through the steps to use an asthma pump. I want to see how you do it and give you some tips that might help. It’s important to get the technique correct to ensure that the medication gets to all the parts of the lungs that it needs to.”

## Preparation

Ask the patient to bring their inhalers along to every hospital visit. Ideally, all patients should use a spacer. If they do not have an inhaler yet, make sure you have an inhaler and spacer or demonstration device ready. Disinfect the inhaler/spacer mouthpiece with an alcohol swab before every demonstration.

## Site & Positioning

Patients should sit or stand up straight with their head tilted slightly back, so as to get as much medication into the small airways as possible, reducing the volume clinging to the mouth and upper airways.

## Procedure

### Using a metered dose inhaler

1. Remove the cap.

2. Do not shake the inhaler, which may create bubbles. Rather tilt the inhaler gently upside down and right way up a few times.

3. Hold the inhaler with your thumb at the bottom and index finger on top.

4. Sit/stand up straight and tilt your head back slightly.

5. Breathe out deeply all the way.

6. Put the inhaler in your mouth with your lips sealed around it.

7. Press the inhaler once while also breathing in slowly and deeply.

8. Hold your breath for ten seconds.

9. Breathe out normally.

10. Repeat if necessary.

### Using a spacer device

Wash the spacer before the first use to remove static, and everytime it gets dirty. Wash it gently with a cloth in soapy water, rinse with clean water, and allow to dry. Never scrub or wipe dry a spacer device. For infants and toddlers, you may want to attach a face mask to the spacer.

1. Remove the cap.

2. Do not shake the inhaler, which may create bubbles. Rather tilt the inhaler gently upside down and right way up a few times.

3. Attach the spacer to the inhaler.

4. Hold the inhaler with your thumb at the bottom and index finger on top.

5. Sit/stand up straight and tilt your head back slightly.

6. Breathe out all the way.

7. Put the spacer in your mouth with your lips sealed around it.

8. Press the inhaler once. Wait for 5 seconds before EITHER inhaling once and holding for ten seconds, OR take 10 slow breaths, keeping your lips sealed around the spacer.

9. Breathe out normally.

10. Repeat if necessary.

## Troubleshooting

The patient is a toddler and they throw tantrums whenever the parents try to administer their medication.

Don’t try to bribe a toddler with sweets or toys. They may start to expect this! Instead, first get them comfortable with the mask by playing with it. The parent then puts the mask to their own face to demonstrate that it is safe and then checks if the child will allow them to hold the mask to their face before practicing taking breaths. If all else fails, the parents may administer the inhaler using a spacer and mask while they are asleep.

My patient is complaining of a white, painful tongue and throat.

Inhaled corticosteroids can cause oral candidiasis (oral thrush). Patients should gargle water after using inhaled corticosteroids to reduce this risk. Parents may reduce the risk of skin irritation in children using inhaled corticosteroids via mask by wiping down the child’s face with a wet cloth.

My patient does not wait between puffs.

Pressing the inhaler twice or more in one go causes the medication particles to clump and actually reduces the amount that gets to the lungs. Patients should wait 30 seconds between puffs.

Powder is escaping from the patient’s nose or mouth after inhalation.

The patient either has not taken a deep enough inspiration or has not sealed their mouth tight enough when removing the inhaler.

I have no face mask to use for a toddler/infant.

Use a paper cup with a slot cut out of the base to fit the spacer mouthpiece.

I do not have a spacer to supply to my patient.

The patient may use a clean 500 ml plastic drink bottle with a slot cut out of the base to fit the inhaler mouthpiece.

## Risks

Steroid inhalers have an excellent safety profile, but they may cause:

1. Oral candidiasis

2. Sore mouth or throat

3. Hoarse voice & coughing

4. Nosebleeds

## References

1. Buddiga P. Use of Metered Dose Inhalers, Spacers, and Nebulizers. Medscape. 2020

2. Mash B. How to Use Inhalers and Spacers. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010: 91-92.