Correct Use of Inhalers

Transcription

1 This Clinical Resource gives subscribers additional insight related to the Recommendations published in January 2017 ~ Resource # Correct Use of Inhalers As few as one-half to one-third of patients who are prescribed inhalers may be using them correctly, depending on the type of inhaler. 1 The different types of inhaler devices are likely to be equally effective in delivering medication when used correctly. 1,2 Therefore, take advantage of educational opportunities to assess inhaler technique and ensure adequate medication delivery. Education and repetitive demonstration are key to proper inhaler technique. 3 When choosing a device for a patient consider the availability of the desired medication in the desired device, patient s ability to use the device properly (e.g., cognition, dexterity, strength), patient preference, and cost. 1,2 There are nuances with each type of device. For example, metered-dose inhalers (MDIs) usually require priming and shaking prior to use and good hand-breath coordination (although the use of a spacer may help with this). 1 Dry-powder inhalers (DPIs) are breath-activated but do not require the same hand-breath coordination as MDIs. DPIs may not be best for patients who cannot produce an adequate inhalation (e.g., very young children) and must be stored in a dry area. 3 Detailed information for use and care of these inhalers is found in the product s packaging (e.g., patient information leaflets, MedGuides). Use CPT code to bill for inhaler teaching. We have therapeutic information about different inhalers in our charts, Inhalers for COPD and Comparison of Inhaled Asthma Meds, and a patient education handout, Tips for Correct Use of Inhalers. The chart below includes steps for use as well as links to instructional videos, information on how to obtain a demo inhaler to teach patients, and details about priming and cleaning the devices. Metered-Dose Inhaler (MDI) Breathing techniques: There are two different techniques used with MDIs when not using a spacer, open-mouth and closed-mouth. 3 All MDI manufacturers recommend a closed-mouth technique. 4 Data are not consistent on which technique is most effective or appropriate: 4 o Open-mouth technique may provide higher drug delivery to the lungs compared to closed-mouth. 5,6 o Other research suggests no advantages with open-mouth technique, but express concern about accurate aiming with the open-mouth technique. 7,8 Observe patient demonstrations regardless of technique used, in order to provide feedback to improve medication delivery. 3 The steps below outline the closed-mouth technique as recommended by current MDI manufacturers. General steps for use (closed mouth without spacer, includes changes needed for patients using a spacer): 3 1. Shake the inhaler well, if necessary (noted for each individual brand of inhaler in rows below). (If not using a spacer, move to step 3.) 2. If using a spacer: attach the spacer and the inhaler together, with the inhaler s canister in a vertical position 3. Breathe out fully through the mouth, away from the inhaler 4. Put the mouthpiece in the mouth and tighten the lips around it. (If not using a spacer, move to step 6.) OR 5. If using a spacer: put the mouthpiece of the spacer between the teeth and tighten the lips around it (or if you use a spacer with a mask, position the

2 (Clinical Resource #330106: Page 2 of 17) mask over the nose and mouth and make sure there s a tight seal against the cheeks and chin) 6. Press the canister down while inhaling deeply and slowly through the mouth (or if using a mask, take six normal breaths) 7. Remove the inhaler from the mouth. (If not using a spacer, move to step 9.) OR 8. If using a spacer: move the mouthpiece away from the mouth 9. Hold the breath for as long as comfortably possible, generally up to ten seconds and then breathe out (this step does not apply to mask use) 10. Wait before repeating, usually 30 to 60 seconds Instructional video: Brands (MDI) Additional Info a,b To request a demo inhaler Advair HFA fluticasone/salmeterol Shake before use? Yes Priming: Before first use: four sprays. If not used for >4 weeks, or if drop inhaler: two sprays. Cleaning: Weekly after evening dose. Wipe the area where the spray comes out with a dry cotton swab. Wipe the inside of the mouthpiece with a damp tissue. Allow to dry overnight. Aerospan flunisolide Alvesco ciclesonide Asmanex HFA mometasone Shake before use? Yes Priming: Before first use or if not used for >2 weeks: two sprays Cleaning: No Dose counter: No Priming: Before first use, or if not used for >10 days: three sprays Cleaning: Weekly. Wipe inside and out with a dry tissue. Shake before use? Yes Priming: Before first use, or if not used for >5 days: four sprays Cleaning: Weekly. Wipe inside and out with a dry lint-free tissue or cloth. Call Meda at

3 (Clinical Resource #330106: Page 3 of 17) Brands (MDI) Additional Info a,b To request a demo inhaler Atrovent HFA ipratropium Priming: Before first use, or if not used for >3 days: two sprays Cleaning: Weekly. Remove dust cap and canister. Wash the mouthpiece with warm running water for at least 30 seconds. Shake to remove excess water and allow to air dry. Bevespi Aerosphere glycopyrrolate/formoterol Dulera mometasone/formoterol Flovent HFA fluticasone propionate Shake before use? Yes Priming: Before first use: four sprays. If not used for >7 days, and after weekly cleaning: two sprays. Cleaning: Weekly. Remove dust cap and canister. Wash the mouthpiece with warm running water for at least 30 seconds. Shake to remove excess water and allow to air dry overnight. Beyond-use date: 3 months after removal from foil pouch Shake before use? Yes Priming: Before first use, or if not used for >5 days: four sprays Cleaning: Weekly. Wipe inside and out with a dry tissue. Shake before use? Yes Priming: Before first use: four sprays. If not used for >7 days, or if inhaler is dropped: one spray. Cleaning: Weekly after evening dose. Wipe the area where the spray comes out with a damp cotton swab. Wipe the inside of the mouthpiece with a damp tissue. Allow to dry overnight. ProAir HFA albuterol Shake before use? Yes Priming: Before first use or if not used for >14 days: three sprays Cleaning: At least weekly. Remove the dust cap and canister. Wash the mouthpiece with warm running water for at least 30 seconds. Turn the mouthpiece upside down and repeat. Shake to remove excess water and allow to air dry. Replace canister. Shake well and spray two times into the air. Replace cap.

4 (Clinical Resource #330106: Page 4 of 17) Brands (MDI) Additional Info a,b To request a demo inhaler Proventil HFA albuterol Shake before use? Yes Priming: Before first use, or if not used for >14 days: four sprays Cleaning: At least weekly. Remove the dust cap and canister. Wash the mouthpiece with warm running water for at least 30 seconds. Shake to remove excess water and allow to air dry. Replace canister and cap. Dose counter: No Qvar beclomethasone dipropionate Manufacturer plans to discontinue. Priming: Before first use or if not used for >10 days: two sprays Cleaning: Weekly. Wipe inside and out with a dry tissue. Symbicort budesonide/formoterol Shake before use? Yes Priming: Before first use, if not used for >7 days, or if dropped: two sprays Cleaning: Weekly. Wipe inside and out with a dry cloth. Beyond-use date: Three months after removal from foil pouch Call AstraZeneca at Ventolin HFA albuterol Shake before use? Yes Priming: Before first use, if not used for >14 days, or if dropped: four sprays Cleaning: At least weekly. Remove the dust cap and canister. Wash the mouthpiece with warm running water for at least 30 seconds. Turn the mouthpiece upside down and repeat. Shake to remove excess water and allow to air dry. Replace canister. Shake the inhaler well and spray once into the air. Replace cap. Beyond-use date: 12 months after removal from foil pouch

5 (Clinical Resource #330106: Page 5 of 17) Brands (MDI) Additional Info a,b To request a demo inhaler Xopenex HFA levalbuterol Shake before use? Yes Priming: Before first use or if not used for >3 days: four sprays Cleaning: At least weekly. Remove the dust cap and canister. Wash the mouthpiece with warm running water for at least 30 seconds. Turn the mouthpiece upside down and repeat. Shake to remove excess water and allow to air dry. Replace canister and cap. Metered Dose Inhaler (MDI), Breath-Actuated: RediHaler Open cap Exhale fully, away from mouthpiece Holding inhaler upright, place mouthpiece in mouth. Close lips around it to form a good seal. Inhale deeply. Remove inhaler and hold breath for five to ten seconds. Exhale slowly, away from inhaler. Click the cap closed to prep inhaler for next inhalation. Cap must be closed before each inhalation or dose will not be delivered. If the cap remains open for more than two minutes, or it is left in the open position, close the cap before use. Qvar RediHaler beclomethasone dipropionate Cleaning: Clean the mouthpiece weekly with a clean dry cloth Contact sales representative. Soft-Mist Inhaler Hold the inhaler upright Turn the base in the direction of the arrows until it clicks Flip the cap until it snaps open Breathe out fully through the mouth, away from the inhaler Put the mouthpiece in the mouth and tighten lips around the end without covering the air vents Press the dose release button and inhale deeply and slowly through the mouth. Hold the breath as long as comfortably possible, up to ten seconds Instructional videos:

6 (Clinical Resource #330106: Page 6 of 17) Brands (Soft-Mist Inhaler) Additional Info a,b To request a demo inhaler Combivent Respimat albuterol/ipratropium Priming: Before first use, or if not used for >21 days: Spray inhaler into the air until a visible spray is seen. Spray three more times. If not used for >3 days: one spray. Cleaning: At least weekly. Wipe the mouthpiece inside and out with a damp tissue. Beyond-use date: Three months after assembly of device Call Boehringer Ingelheim at Spiriva Respimat tiotropium Priming: Before first use, or if not used for >21 days: Spray inhaler into the air until a visible spray is seen. Spray three more times. If not used for >3 days: one spray. Cleaning: At least weekly. Wipe the mouthpiece inside and out with a damp tissue. Beyond-use date: Three months after assembly of device Call Boehringer Ingelheim at Stiolto Respimat tiotropium bromide and olodaterol Priming: Before first use, or if not used for >21 days: Spray inhaler into the air until a visible spray is seen. Spray three more times. If not used for >3 days: one spray. Cleaning: At least weekly. Wipe the mouthpiece inside and out with a damp tissue. Beyond-use date: Three months after assembly of device Call Boehringer Ingelheim at Striverdi Respimat olodaterol Priming: Before first use, or if not used for >21 days: Spray inhaler into the air until a visible spray is seen. Spray three more times. If not used for >3 days: one spray. Cleaning: At least weekly. Wipe the mouthpiece inside and out with a damp tissue. Beyond-use date: Three months after assembly of device Call Boehringer Ingelheim at

7 (Clinical Resource #330106: Page 7 of 17) Dry-Powder Inhaler (DPI): Diskus After opening the inhaler with the thumb grip, hold the inhaler flat and level, and slide the lever from left to right until it clicks Breathe out fully through the mouth, away from the inhaler Put the mouthpiece in the mouth and tighten the lips around it Inhale quickly and deeply through the mouth Remove the device from the mouth and hold the breath as long as comfortably possible, up to ten seconds Instructional video: Brands (DPI; Diskus) Additional Info a,b To request a demo inhaler Advair Diskus fluticasone/salmeterol Cleaning: No Beyond-use date: One month after removal from foil pouch Contact a GlaxoSmithKline sales representative by calling Flovent Diskus fluticasone Serevent Diskus salmeterol Cleaning: No Beyond-use date: Six weeks after removal from foil pouch (50 mcg strength) and two months after removal from foil pouch (100 mcg and 250 mcg strength) Cleaning: No Beyond-use date: Six weeks after removal from foil pouch Contact a GlaxoSmithKline sales representative by calling Contact a GlaxoSmithKline sales representative by calling

8 (Clinical Resource #330106: Page 8 of 17) Dry-Powder Inhaler (DPI): Ellipta Slide the inhaler cover down to reveal the mouthpiece Breathe out fully through the mouth, away from the inhaler Put the mouthpiece between the lips Do not block the air vents with the fingers Breathe in deeply and slowly through the mouth Remove the inhaler from the mouth and hold the breath for three or four seconds or as long as comfortably possible Instructional video: Brands (DPI; Ellipta) Additional Info a,b To request a demo inhaler Anoro Ellipta umeclidinium/vilanterol Arnuity Ellipta fluticasone Breo Ellipta fluticasone/vilanterol Incruse Ellipta umeclidinium Trelegy Ellipta fluticasone/umeclidium/ vilanterol Cleaning: Wipe mouthpiece with a dry tissue before closing the inhaler if desired Beyond-use date: Six weeks after removal from foil tray Cleaning: Wipe mouthpiece with a dry tissue before closing the inhaler if desired Beyond-use date: Six weeks after removal from foil tray Cleaning: Wipe mouthpiece with a dry tissue before closing the inhaler if desired Beyond-use date: Six weeks after removal from foil tray Cleaning: Wipe mouthpiece with a dry tissue before closing the inhaler if desired Beyond-use date: Six weeks after removal from foil tray Cleaning: Wipe mouthpiece with a dry tissue before closing the inhaler if desired Beyond-use date: Six weeks after removal from foil tray Contact a GlaxoSmithKline sales representative by calling Contact a GlaxoSmithKline sales representative by calling Contact a GlaxoSmithKline sales representative by calling Contact a GlaxoSmithKline sales representative by calling Contact a GlaxoSmithKline sales representative by calling

9 (Clinical Resource #330106: Page 9 of 17) Dry-Powder Inhaler (DPI): Flexhaler Hold the inhaler upright and remove the cap Holding the inhaler in the middle, twist the grip as far as it will go in one direction, then back in the other direction until it clicks Breathe out fully through the mouth, away from the inhaler Put the mouthpiece in the mouth and tighten the lips around it Breathe in deeply and forcefully through the mouth Instructional video: Brands (DPI; Flexhaler) Additional Info a,b To request a demo inhaler Pulmicort Flexhaler budesonide Priming: Before first use. Twist the grip in one direction, then back in the other direction until a click is heard one time. Cleaning: Weekly, clean the outside of the device with a dry tissue Call AstraZeneca at Dry-Powder Inhaler (DPI): Diskhaler Pull the mouthpiece all the way out, press in the raised ridges on the outside edges of the mouthpiece, and pull the whole tray out Place one medicine disk onto the wheel, flat side up Push the tray back into the body of the inhaler as far as it will go Lift the half-circle flap on top of the inhaler to a straight-up position and then click the flap back into place Breathe out fully through the mouth, away from the inhaler Place the mouthpiece in the mouth, keeping the inhaler level Tighten the lips around the mouthpiece without covering the small holes on its sides Breathe in steadily and deeply through the mouth and hold the breath for a few seconds Instructional video:

10 (Clinical Resource #330106: Page 10 of 17) Brands (DPI; Diskhaler) Additional Info a,b To request a demo inhaler Relenza Diskhaler zanamivir Cleaning: No Dose counter: No Dry-Powder Inhaler (DPI): HandiHaler Remove the inhaler cap by pressing the piercing button Pull the lid away from the inhaler to expose the mouthpiece Expose the center chamber by pulling the mouthpiece up and away from its base Place one capsule (removed from its foil blister) in the center chamber of the inhaler and close the mouthpiece until it clicks Continue to hold the inhaler with the mouthpiece pointed up, press the button on the side once, then release it Breathe out fully through the mouth, away from the inhaler Place the inhaler in a horizontal position and place the mouthpiece in the mouth, tightening the lips around it Breathe in deeply through the mouth and hold the breath for a few seconds Remove the mouthpiece from the mouth Repeat the steps starting with Breathe out fully through the mouth a second time Open the mouthpiece, remove the used capsule, and discard it Instructional video: Brands (DPI; HandiHaler) Additional Info a,b To request a demo inhaler Spiriva HandiHaler tiotropium Cleaning: After each use: empty the remains of the capsule from the inhaler into the trash. Before closing the mouthpiece or cap, turn the inhaler upside down and tap it firmly yet gently to remove any residue. As needed: open the cap and mouthpiece. Open the base by lifting the piercing button. Rinse the inhaler with warm running water while pushing the piercing button several times. Leave it open to air dry for 24 hours. Dose counter: No Call Boehringer Ingelheim at

11 (Clinical Resource #330106: Page 11 of 17) Dry-Powder Inhaler (DPI): Neohaler Remove one capsule from its foil blister and place the capsule into the capsule chamber Click the inhaler closed Hold the inhaler upright and press the buttons on the sides, both at one time, until a click is heard, then release Breathe out fully through the mouth, away from the inhaler Place the mouthpiece in the mouth and breathe in rapidly and steadily through the mouth and hold the breath as long as comfortably possible, up to 10 seconds. Open inhaler to see if any powder remains in the capsule. If yes, close inhaler and repeat steps starting with Breathe out fully through the mouth. Open the mouthpiece, remove the used capsule, and discard it Instructional video: Brands (DPI; Neohaler) Additional Info a,b To request a demo inhaler Arcapta Neohaler indacaterol Cleaning: Wipe with a clean dry lint-free cloth between uses if desired Dose counter: No Utibron Neohaler indacaterol/glycopyrrolate Cleaning: Wipe the mouthpiece inside and out with a clean dry lint-free cloth between uses if desired Dose counter: No

12 (Clinical Resource #330106: Page 12 of 17) Dry-Powder Inhaler (DPI): Podhaler After removing the lid, stand the inhaler upright on its base, hold the body of the inhaler, and unscrew the mouthpiece. Set the mouthpiece aside. Tear off one blister card, roll back the foil, take the capsule out of the blister, and place it in the capsule chamber of the inhaler Put the mouthpiece back on the inhaler and screw it closed Hold the inhaler with the mouthpiece pointing down and press the button on the end of the inhaler all the way down one time Breathe out fully through the mouth, away from the mouthpiece Place the mouthpiece in the mouth and breathe in deeply through the mouth Remove the inhaler from the mouth and hold the breath for about five seconds Take a few normal breaths, and then repeat the steps starting with Breathe out fully through the mouth. Open the mouthpiece, remove the used capsule from the inhaler, and discard it Replace the mouthpiece and wipe it with a clean dry cloth Instructional video: Brands (DPI; Podhaler) Additional Info a,b To request a demo inhaler Tobi Podhaler tobramycin Cleaning: No. However, one extra device is included with every 28-day supply in case the device becomes wet, dirty, or broken; is dropped; or malfunctions. Dose counter: No Call Novartis at Dry-Powder Inhaler (DPI): Pressair After removing the cap, hold the inhaler with the mouthpiece facing the mouth and the button on the top Press the button all the way down and release it. If the control window does not turn green, repeat. Breathe out completely through the mouth, away from the inhaler Place the mouthpiece in the mouth, tighten the lips around it, and breathe in quickly and deeply through the mouth, until the lungs are filled Remove the inhaler from the mouth and hold the breath for as long as is comfortably possible Instructional video:

13 (Clinical Resource #330106: Page 13 of 17) Brands (DPI; Pressair) Additional Info a,b To request a demo inhaler Tudorza Pressair aclidinium bromide Call AstraZeneca at Cleaning: If desired. Clean the outside of the mouthpiece with a dry tissue or paper towel. Beyond-use date: 45 days after removal from sealed pouch Dry-Powder Inhaler (DPI): RespiClick Hold the inhaler upright and open the cap fully, until you hear a click Breathe out completely through the mouth, away from the inhaler Place the mouthpiece in the mouth and tighten the lips around it, without blocking the vent above the mouthpiece Breathe in quickly and deeply through the mouth, until the lungs are filled Remove the inhaler from the mouth and hold the breath for as long as is comfortably possible, up to 10 seconds Instructional video: Brands (DPI; RespiClick) Additional Info a,b To request a demo inhaler AirDuo RespiClick fluticasone/salmeterol ArmonAir RespiClick fluticasone ProAir RespiClick albuterol Cleaning: Wipe mouthpiece with a dry cloth or tissue if it appears to need cleaning. Beyond-use date: 30 days after removal from foil pouch Cleaning: Wipe mouthpiece with a dry cloth or tissue if it appears to need cleaning. Beyond-use date: 30 days after removal from foil pouch Cleaning: Wipe mouthpiece with a dry cloth or tissue if it appears to need cleaning. Beyond-use date: 13 months after removal from foil pouch Call Teva Select option #3 Call Teva Select option #3 Call Teva Select option #3

14 (Clinical Resource #330106: Page 14 of 17) Dry-Powder Inhaler (DPI): Twisthaler Hold the inhaler upright and remove the cap by twisting it in a counterclockwise direction Breathe out fully through the mouth, away from the inhaler Place the mouthpiece in the mouth and tighten the lips around it, holding the inhaler in a horizontal position Do not cover the ventilation holes and breathe in quickly and deeply through the mouth Remove the inhaler from the mouth and hold the breath as long as comfortably possible, up to ten seconds Replace the cap, turning it in a clockwise direction and gently pressing it down, until a click is heard Instructional video: Brands (DPI; Twisthaler) Additional Info a,b To request a demo inhaler Asmanex Twisthaler mometasone Cleaning: Wipe mouthpiece with a dry cloth or tissue as needed. Beyond-use date: 45 days after removal from foil pouch Call Merck at Magnair Nebulizer System To assemble the device: Lift the clasp to open the top of the handset Insert aerosol head into handset, lining up the small tab with the notch on the handset (avoid touching the center of the aerosol head) Close the handset Attach the mouthpiece, making sure the blue valve is pressed down Connect the controller to the handset using the connection cord Controller can be used with batteries or the AC adapter o For battery use: Open the battery door, insert four AA batteries, and close the battery door. (Keep spare batteries with you.) o For AC adapter use: Plug the small end of the AC adapter into the inlet on the battery door and plug end of the AC adapter into the wall. 1. Open the foil pouch and remove one vial (keep the other vial in the pouch; discard if not used within seven days) 2. Make sure the aerosol head is installed before attaching medication cap to avoid losing part of the dose 3. Insert the vial into the bottom of the medication cap until it clicks 4. Place the medication cap on the top of the headset 5. Turn the medication cap clockwise until you hear a click, ensuring the notch on the medication cap lines up with the blue line on the handset body 6. Insert mouthpiece into your mouth (do not tilt, loosen or remove medication cap, or unclasp the handset until the treatment is finished)

15 (Clinical Resource #330106: Page 15 of 17) 7. Press the on/off button 8. Breathe in and out normally through the mouthpiece until you hear the beeping sound (about two to three minutes) 9. The controller will automatically shut off Instructional video: Brands (nebulizer system: Additional Info a,b Magnair) Lonhala Magnair glcopyrrolate Cleaning: do not use antibacterial soap, this can damage the aerosol head 1. Disconnect handset from connection cord and separate medication cap from the handset body 2. Remove medication vial from medication cap and remove mouthpiece 3. Loosen the blue valve on the mouthpiece 4. Remove aerosol head from headset without touching the center of the aerosol head and set aside for separate cleaning 5. Rinse handset parts under warm running water for about ten seconds 6. Wash handset parts with clear liquid dishwashing soap for about ten seconds 7. Rinse handset parts to remove all soap for about ten seconds 8. Rinse both sides of the aerosol head under warm running water for about ten seconds 9. Holding the handle, swish the aerosol head back and forth in warm soapy water for about ten seconds 10. Rinse aerosol head to remove all soap for about ten seconds 11. If any handset parts are still dirty, soak in warm soapy water for about five minutes, then rinse well in warm running water 12. Shake parts to remove water. Allow all parts to air dry on a lint-free towel. 13. Do not reassemble until all parts are completely dry and ready to use again. Dose counter: No Beyond-use date: Seven days after opening foil pouch To request a demo inhaler Contact your sales representative. To find yours, call a. Note that instructions for inhaler device use and care are specific to the listed brand name product. Instructions for use/care of generic inhaler devices may differ. b. Beyond-use date: the date after which a medication should not be used. This may be sooner than the manufacturer s expiration date, if a medication is less stable after it is mixed, removed from protective packaging, etc.

16 (Clinical Resource #330106: Page 16 of 17) U.S. product information used for preparation of the above chart: Advair Diskus (December 2017); Advair HFA (December 2017); Aerospan (November 2017); AirDuo Respiclick (March 2018); Alvesco (March 2018); Anoro Ellipta (October 2017); Arcapta Neohaler (April 2013); ArmonAir Respiclick (March 2018); Arnuity Ellipta (May 2017); Asmanex HFA (March 2018); Asmanex Twisthaler (March 2018); Atrovent HFA (August 2012); Bevespi Aerosphere (August 2017); Breo Ellipta (December 2017); Combivent Respimat (June 2016); Dulera (December 2017); Flovent Diskus (July 2017); Flovent HFA (July 2017); Incruse Ellipta (October 2017); Lonhala Magnair (January 2018); ProAir HFA (July 2016); ProAir RespiClick (September 2016); Proventil HFA (September 2017); Pulmicort Flexhaler (October 2016); QVAR (October 2017); QVAR Redihaler (November 2017); Relenza Diskhaler (August 2016); Serevent Diskus (September 2016); Spiriva HandiHaler (February 2018); Spiriva Respimat (February 2017); Stiolto Respimat (June 2016); Striverdi Respimat (June 2016); Symbicort (December 2017); Tobi Podhaler (October 2015); Trelegy Ellipta (September 2017); Tudorza Pressair (June 2017); Utibron Neohaler (January 2017); Ventolin HFA (March 2018); Xopenex HFA (February 2017). Users of this resource are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and internet links in this article were current as of the date of publication.

17 (Clinical Resource #330106: Page 17 of 17) Project Leader in preparation of this clinical resource (330106): Beth Bryant, Pharm.D., BCPS, Assistant Editor (Original); Melanie Cupp, Pharm.D., BCPS (April 2018 update) References 1. Barrons R, Pegram A, Borries A. Inhaler device selection: special considerations in elderly patients with chronic obstructive pulmonary disease. Am J Health Syst Pharm 2011;68: Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: evidence-based guidelines. Chest 2005;127: Gardenhire DS, Burnett D, Strickland S, Myers TR. A guide to aerosol delivery devices for respiratory therapists, 4th edition. American Association for Respiratory Care. (Accessed April 8, 2018). 4. Gregory KL, Wilken L, Hart MK. Guide to aerosol delivery devices for physicians, nurses, pharmacists, and other health care professionals. 3 rd edition. (Accessed April 8, 2018). 5. Dolovich M, Ruffin RE, Roberts R, Newhouse MT. Optimal delivery of aerosols from metered dose inhalers. Chest 1981;80: Thomas P, Williams T, Reilly PA, Bradley D. Modifying delivery technique of fenoterol from a metered dose inhaler. Ann Allergy 1984;52: Unzeitig JC, Richards W, Church JA. Administration of metered-dose inhalers: comparison of open- and closed-mouth techniques in childhood asthmatics. Ann Allergy 1983;51: Chhabra SK. A comparison of closed and open mouth techniques of inhalation of a salbutamol metered-dose inhaler. J Asthma 1994;31: Cite this document as follows: Clinical Resource, Correct Use of Inhalers. Pharmacist s Letter/Prescriber s Letter. January Evidence and Recommendations You Can Trust 3120 West March Lane, Stockton, CA ~ TEL (209) ~ FAX (209) Copyright 2017 by Therapeutic Research Center Subscribers to the Letter can get clinical resources, like this one, on any topic covered in any issue by going to PharmacistsLetter.com, PrescribersLetter.com, PharmacyTechniciansLetter.com, or NursesLetter.com

18 Video Instructions for Different Inhaler Devices Inhaler devices deliver medicine directly into the lungs. This is different from most pills or shots, which send medicine into the whole body. There are specific instructions for the various types of inhalers. It s important for you to know how to correctly use the inhaler that s prescribed for you, so the medicine works best. Below are links to videos that show how to use different types of inhalers. Your pharmacist or other health care professional can demonstrate correct use as well. Bring your inhaler(s) to the pharmacy or to appointments with your prescriber, so you can demonstrate how you use it, and get tips if you need help. Metered-dose inhalers (e.g., Advair HFA, Aerospan, Alvesco, Atrovent HFA, Dulera, Flovent HFA, ProAir HFA, Proventil HFA, QVAR, Symbicort, Ventolin HFA, Xopenex HFA): Metered-dose inhaler (with spacer) Metered-dose inhaler (open mouth technique) Soft-mist inhaler (Combivent Respimat) Dry-powder inhalers: Aerolizer (Foradil) Prepared for the subscribers of Pharmacist s Letter / Prescriber s Letter to give to their patients. Copyright 2014 by Therapeutic Research Center ~

19 Video Instructions for Different Inhaler Devices Diskus (e.g., Advair, Flovent, Serevent) Flexhaler (Pulmicort) HandiHaler (Spiriva) Neohaler (Arcapta) Pressair (Tudorza) Twisthaler (Asmanex) [January 2014] Prepared for the subscribers of Pharmacist s Letter / Prescriber s Letter to give to their patients. Copyright 2014 by Therapeutic Research Center ~

20 Instrucciones en Video Para Diferentes Inhaladores Los inhaladores envían medicamentos directamente a los pulmones. Esto es diferente de la mayoría de las píldoras o inyecciones, que envían medicamentos en todo el cuerpo. Es importante que usted use el inhalador correctamente, para que el medicamento funcione mejor. A continuación se presentan los enlaces a los vídeos que muestran cómo utilizar distintos tipos de inhaladores. Su farmacéutico u otro profesional de atención médica pueden demostrar el uso correcto. Llevar sus inhaladores a la farmacia o a las citas con su médico con el fin de demostrar cómo se utiliza, así como obtener sugerencias si necesita ayuda. Inhaladores de dosis prefijada (e.g., Advair HFA, Aerospan, Alvesco, Atrovent HFA, Dulera, Flovent HFA, ProAir HFA, Proventil HFA, QVAR, Symbicort, Ventolin HFA, Xopenex HFA): Inhaladores de dosis prefijada (con un espaciador) Inhaladores de dosis prefijada (técnica con la boca abierta) Inhalador de suave neblina (Combivent Respimat) Inhaladores de medicamento pulverizado: Aerolizer (Foradil) Prepared for the subscribers of Pharmacist s Letter / Prescriber s Letter to give to their patients. Copyright 2014 by Therapeutic Research Center ~

21 Instrucciones en Video Para Diferentes Inhaladores Diskus (e.g., Advair, Flovent, Serevent) Flexhaler (Pulmicort) HandiHaler (Spiriva) Neohaler (Arcapta) Pressair (Tudorza) Twisthaler (Asmanex) [Enero 2014] Prepared for the subscribers of Pharmacist s Letter / Prescriber s Letter to give to their patients. Copyright 2014 by Therapeutic Research Center ~

22 Tips for Correct Use of Inhalers Inhalers send medicine directly to your lungs. This is different from most pills or shots, which send medicine to the whole body. Instructions are not the same for all of the different types of inhalers. Be sure you understand how to use each of your inhalers. How can I learn to use my inhaler? Your pharmacist or prescriber can show you how to use your inhaler. Bring your inhalers to the pharmacy or to prescriber appointments. You can show them how you use it. Then they can give you tips, in case you are having any problems. Ask your pharmacist or prescriber these questions: Do I need to shake my inhaler before using it? Do I need to prime my inhaler with test sprays? If so, how and when? Should I clean my inhaler? If so, with what (e.g., dry cloth, damp cloth, running water)? Are all inhalers the same? No, they are not. See the differences between three common types of inhalers. Have your health care provider fill in the names of the inhalers you re using below. Metered-dose Inhalers: Dry-powder Inhalers: Soft-mist Inhalers: Shake most before use Do not shake Do not shake Prime most before first use No need to prime Prime before first use Slow deep breath Quick deep breath Slow deep breath (Inhaler: ) (Inhaler: ) (Inhaler: ) What do I need to know if I use more than one inhaler? It is important to use your inhalers in the right order. This will help them work better. Bronchodilators relax and open your airways. (Inhaler name: ) o Always use the bronchodilator first. Steroids decrease swelling in your airways. (Inhaler name: ) o After using your steroid inhaler, rinse your mouth with water and spit it out. Don t run out of your inhaler. Make sure you have enough medicine in your inhaler. o Most inhalers have counters to keep track of how many doses are left. o If your inhaler does not have a counter, be sure to keep track of how many doses you have used. Don t remove inhalers from original packaging until you need them. o Some expire a few weeks or months after removal from the foil pouch. o Your pharmacist will tell you the last date you should use these inhalers. Don t wait until the last minute to reorder your inhaler. o Give yourself enough time so you don t go without these important medicines. How should I store my inhaler? Keep inhalers at room temperature. If you are going out and may need your inhaler, keep it with you (on your person). Do not leave your inhaler in your car. It might get too hot or too cold. [This handout may not cover all possible information. It does not replace the need for professional medical care. Always follow the instructions from your healthcare provider.][december 2016; ] Prepared for the subscribers of Pharmacist s Letter / Prescriber s Letter to give to their patients. PharmacistsLetter.com ~ PrescribersLetter.com

23 Consejos para el uso correcto de los inhaladores Inhaladores mandan medicina directamente a sus pulmones. Esto es diferente de la mayoría de píldoras o inyecciones, en cual mandan medicina en todo el cuerpo. Instrucciones no son las mismas para todos los diferentes tipos de inhaladores. Asegúrese que comprenda como usar cada uno de sus inhaladores. Cómo puedo aprender cómo usar mi inhalador? Su farmacéutico o prescriptor podría ensenarle como usar su inhalador. Traiga sus inhaladores a la farmacia o citas con su prescriptor. Usted puede mostrarles como lo usa. Entonces ellos pueden darle consejos en caso que usted este teniendo problemas. Pregúntele a su farmacéutico o prescriptor estas preguntas: Necesito agitar mi inhalador antes de usarlo? Necesito cebar mi inhalador con aerosoles de prueba? Si es así, cómo y cuándo? Debería de limpiar mi inhalador? Si es así, con que (por ejemplo, tela seca, tela húmeda, agua corriente)? Todos los inhaladores son iguales? No, ellos no son. Mire las diferencias de tres tipos comunes de inhaladores. Haga que su profesional de atención de la salud escriba los nombres de sus inhaladores que usted este usando. Inhaladores de dosis fija: Inhaladores de polvo seco: Inhaladores de rocío fino: Agite la mayoría antes de usar No agite No agite Ceba la mayoría antes del No ocupa cebar Ceba antes del primer uso primer uso Respiro profundo y despacio Respiro profundo y rápido Respiro profundo y despacio (Inhalador: ) (Inhalador: ) (Inhalador: ) Qué debo saber si uso más de un inhalador? Es importante de usar sus inhaladores en la orden correcta. Esto le ayudaran que funcionen mejor. Los broncodilatadores relajan y abren sus vías respiratorias (Nombre de inhalador: ) o Siempre use el broncodilatador primero. Los esteroides disminuyen la hinchazón en las vías respiratorias. (Nombre de inhalador: ) o Después de usar su inhalador de esteroides, enjuáguese la boca con agua y escúpalo. Que no se le acaban su inhalador. Asegúrese que tenga suficiente medicina en su inhalador. o La mayoría de los inhaladores tienen contadores para realizar un seguimiento de cuántas dosis quedan. o Si su inhalador no tiene un contador, asegúrese de mantener cuantas dosis has usado. No remueva los inhaladores de sus paquetes originales hasta que los ocupe. o Algunos expiran unas pocas semanas o meses después de la eliminación de la bolsa de aluminio. o Su farmacéutico le dirá el último día de cuándo deberá dejar de usar estos inhaladores. No espere hasta el último minuto para volver a ordenar su inhalador. o Dese suficiente tiempo para que usted no pase sin estas importantes medicinas. Prepared for the subscribers of the Letter to give to their patients. PharmacistsLetter.com ~ PrescribersLetter.com ~ NursesLetter.com

24 Consejos para el uso correcto de los inhaladores Cómo debo de guardar mi inhalador? Mantenga los inhaladores a temperatura ambiente. Si va a salir y podría necesitar su inhalador, manténgalo con usted (en usted). No deje su inhalador en su carro. Podría ponerse muy caliente o muy frio. [Este panfleto puede no tener toda la información posible. También no reemplaza la necesidad de atención médica profesional. Siempre siga las instrucciones de su profesional de atención de la salud.][diciembre 2016; ] Prepared for the subscribers of the Letter to give to their patients. PharmacistsLetter.com ~ PrescribersLetter.com ~ NursesLetter.com