PL Detail-Document #300206 This PL Detail-Document gives subscribers additional insight related to the Recommendations published in PHARMACIST S LETTER / PRESCRIBER S LETTER February 2014 Correct Use of Inhaler Devices At least one-half of patients who are prescribed s may be using them incorrectly. 1 Health care providers may also have a knowledge gap when it comes to the correct use of the different devices. 2 This can lead to suboptimal control of respiratory conditions such as asthma and COPD. 2 The different types of devices are likely to be equally effective in delivering medication when used correctly. 1,2 Some things to think about when choosing a device for a patient include the availability of the desired medication in the desired device, the patient s ability to use the device properly (e.g., cognition, dexterity, strength, etc), the patient s preference, and cost. 1,2 There are also nuances of each type of device that should be kept in mind. Metered-dose s (MDIs) usually require priming and shaking prior to use and good hand-breath coordination (although the use of a spacer such as a valved holding chamber may help with this). 1 Dry-powder s (DPIs) are breath-activated and do not require the same hand-breath coordination as MDIs. DPIs may not be best for patients who cannot produce an adequate inhalation such as very young children, they must be stored in a dry area, and the medicine that comes with one type of should not be used with another type of. 3 For patients who use multiple inhaled medications, having to use different types of s can increase the risk for confusion. 1 It s also important to remember to instruct patients about ways to avoid side effects associated with delivery of medications via devices, such as rinsing the mouth after the use of an inhaled corticosteroid and directing any priming sprays away from the face. The following chart includes steps for using MDIs, the newer softmist, and subtypes of DPIs, as well as links to instructional videos, information on how to obtain a demo to teach patients, and details about priming and cleaning the devices. Keep in mind that detailed information for use and care of these s is found in the product s packaging (i.e., patient information leaflets or MedGuides). The CPT code 94664 can be used to bill for teaching patients correct technique. We have therapeutic information about different s in our PL Charts, Inhalers for COPD and Comparison of Inhaled Asthma Medications and a PL Patient Education Handout, Tips for Correct Use of Inhalers. If cost is an issue, see our PL Chart to help patients save money. Metered-Dose Inhaler (MDI) General steps for use (closed mouth, without spacer): 3 Take off the cap Look inside the mouthpiece for foreign objects Shake the well, if necessary (noted for each individual brand of in rows below) Breathe out fully through the mouth, away from the Put the mouthpiece in the mouth and tighten the lips around it Press the canister down while inhaling deeply and slowly through the mouth Remove the from the mouth Hold the breath for as long as comfortably possible, generally up to 10 seconds Breathe out continued
(PL Detail-Document #300206: Page 2 of 17) Wait before repeating, usually 30 to 60 seconds Instructional video: http://www.cdc.gov/asthma/_video/in_mouth.htm General steps for use (with spacer): 3 Take off the cap Look inside the mouthpiece for foreign objects Shake the well, if necessary (noted for each individual brand of in rows below) Attach the spacer and the together, with the s canister in a vertical position Breathe out fully through the mouth, away from the 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 mask over the nose and mouth and make sure there s a tight seal against the cheeks and chin) Press the canister down and inhale deeply and slowly through the mouth Move the mouthpiece away from the mouth Hold the breath for as long as comfortably possible, generally up to 10 seconds Breathe out Wait before repeating, usually 30 to 60 seconds Instructional video: http://www.cdc.gov/asthma/_video/with_spacer.htm General steps for use (open mouth, without spacer): 3 Take off the cap Look inside the mouthpiece for foreign objects Shake the well, if necessary (noted for each individual brand of in rows below) Breathe out fully through the mouth, away from the Place the two fingers width away from the lips With the mouth open and tongue flat, tilt the mouthpiece of the device toward the upper back of the mouth Press the canister down and inhale deeply and slowly through the mouth Move the mouthpiece away from the mouth Hold the breath for as long as comfortably possible, generally up to 10 seconds Breathe out Wait before repeating, usually 30 to 60 seconds Instructional video: http://www.cdc.gov/asthma/_video/two_inches.htm
(PL Detail-Document #300206: Page 3 of 17) Brands (MDI) Additional Info a,b To request a demo Advair HFA fluticasone/salmeterol Priming: Before first use: 4 sprays. If not used for more than 4 weeks, or if is dropped: 2 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 ***Not yet available as of January 2014*** Alvesco ciclesonide Atrovent HFA ipratropium Priming: Before first use or if not used for more than 2 weeks: 2 sprays Cleaning: No Priming: Before first use, or if not used for 10 days or more: 3 sprays Cleaning: Weekly. Wipe inside and out with a dry tissue. Priming: Before first use, or if not used for more than 3 days: 2 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. Information not yet available Not available Call Boehringer Ingelheim at 866-441-4671 Dulera mometasone/formoterol Priming: Before first use, or if not used for more than 5 days: 4 sprays Cleaning: Weekly. Wipe inside and out with a dry tissue. Not available
(PL Detail-Document #300206: Page 4 of 17) Brands (MDI) Additional Info a,b To request a demo Flovent HFA fluticasone propionate Priming: Before first use: 4 sprays. If not used for more than 7 days, or if is dropped: 1 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 Priming: Before first use or if not used for more than 14 days: 3 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 2 times into the air. Replace cap. Call Teva at 866-444-3653 Proventil HFA albuterol Priming: Before first use, or if not used for more than 14 days: 4 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. Not available QVAR beclomethasone dipropionate Priming: Before first use or if not used for more than 10 days: 2 sprays Cleaning: Weekly. Wipe inside and out with a dry tissue. Call Teva at 866-444-3653
(PL Detail-Document #300206: Page 5 of 17) Brands (MDI) Additional Info a,b To request a demo Symbicort budesonide/formoterol Priming: Before first use, if not used for more than 7 days, or if dropped: 2 sprays Cleaning: Weekly. Wipe inside and out with a dry tissue. Beyond-use date: 3 months after removal from foil pouch Call AstraZeneca at 800-236-9933 Ventolin HFA albuterol Priming: Before first use, if not used for more than 14 days, or if dropped: 4 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 well and spray once into the air. Replace cap. Beyond-use date: 12 months after removal from foil pouch Xopenex HFA levalbuterol Priming: Before first use or if not used for more than 3 days: 4 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 well and spray once into the air. Replace cap. Not available
(PL Detail-Document #300206: Page 6 of 17) Soft-Mist Inhaler Hold the 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 Put the mouthpiece in the mouth and tighten the 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 10 seconds Instructional video: http://www.combivent.com/how/index.php Brands (Soft-Mist Inhaler) Additional Info a,b To request a demo Combivent Respimat Albuterol/ipratropium Priming: Before first use, or if not used for more than 21 days: Spray into the air until a visible spray is seen. Spray 3 more times. If not used for more than 3 days: 1 spray. Cleaning: At least weekly. Wipe the mouthpiece inside and out with a damp tissue. Beyond-use date: 3 months after assembly of device Call Boehringer Ingelheim at 866-441-4671
(PL Detail-Document #300206: Page 7 of 17) Dry-Powder Inhaler (DPI): Diskus Open the using the thumb grip Hold the flat and level, and slide the lever from left to right until it clicks Breathe out fully through the mouth, away from the 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 Hold the breath as long as comfortably possible, up to 10 seconds Use the thumb grip to close the Instructional video: http://www.advair.com/asthma/about-advair/if-you-are-taking-advair/using-advair-diskus.html Brands (DPI; Diskus) Additional Info a,b To request a demo Advair Diskus fluticasone/salmeterol Cleaning: No Beyond-use date: 1 month after removal from foil pouch Flovent Diskus fluticasone Serevent Diskus salmeterol Cleaning: No Beyond-use date: 6 weeks after removal from foil pouch (50 mcg strength) and 2 months after removal from foil pouch (100 mcg and 250 mcg strength) Cleaning: No Beyond-use date: 6 weeks after removal from foil pouch
(PL Detail-Document #300206: Page 8 of 17) Dry-Powder Inhaler (DPI): Ellipta Slide the cover down to reveal the mouthpiece Breathe out fully through the mouth, away from the 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 from the mouth Hold the breath for 3 or 4 seconds or as long as comfortably possible Close the Brands (DPI; Ellipta) Additional Info a,b To request a demo Anoro Ellipta umeclidinium/vilanterol ***Not yet available as of January 2014*** Cleaning: Wipe mouthpiece with a dry tissue before closing the if desired Beyond-use date: 6 weeks after removal from foil pouch Breo Ellipta fluticasone/vilanterol Cleaning: Wipe mouthpiece with a dry tissue before closing the if desired Beyond-use date: 6 weeks after removal from foil pouch
(PL Detail-Document #300206: Page 9 of 17) Dry-Powder Inhaler (DPI): Aerolizer Remove the cover Hold the base of the and twist the mouthpiece in the direction of the arrow to open Remove one capsule from its foil blister Place the capsule in the capsule chamber in the base of the Twist the mouthpiece back to close Hold the upright and press both buttons on the sides one time, at the same time, then release them Breathe out fully through the mouth, away from the Tilt the head back slightly Hold the horizontally with the buttons on the sides and place it between the lips Breathe in quickly and deeply through the mouth Remove the from the mouth Hold the breath for as long as comfortably possible Open the chamber to see if any powder remains in the capsule. If yes, close the chamber and repeat the steps starting from Breathe out fully through the mouth. Open the mouthpiece, remove the used capsule, and discard it Replace the cover Instructional video: http://www.nationaljewish.org/healthinfo/medications/lung-diseases/devices/instructional-videos Brands (DPI; Aerolizer) Additional Info a,b To request a demo Foradil Aerolizer formoterol Cleaning: No Beyond-use date: 4 months from the date of dispensing Not available
(PL Detail-Document #300206: Page 10 of 17) Dry-Powder Inhaler (DPI): Flexhaler Hold the upright and remove the cap Holding the 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 Put the mouthpiece in the mouth and tighten the lips around it Breathe in deeply and forcefully through the mouth Remove the from the mouth Replace the cap Instructional video: http://www.pulmicortflexhaler.com/pulmicort-flexhaler-instructions.aspx Brands (DPI; Flexhaler) Additional Info a,b To request a demo 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 800-236-9933
(PL Detail-Document #300206: Page 11 of 17) Dry-Powder Inhaler (DPI): Diskhaler Remove the cover Check inside the mouthpiece for foreign objects 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 of the body of the Place one medicine disk onto the wheel, flat side up Push the tray back into the body of the as far as it will go Lift the half-circle flap on top of the to a straight-up position Click the flap back into place Breathe out fully through the mouth, away from the Place the mouthpiece in the mouth, keeping the level Tighten the lips around the mouthpiece without covering the small holes on its sides Breathe in steadily and deeply through the mouth Remove the from the mouth Hold the breath for a few seconds Replace the cover Brands (DPI; Diskhaler) Additional Info a,b To request a demo Relenza Diskhaler zanamivir Cleaning: No
(PL Detail-Document #300206: Page 12 of 17) Dry-Powder Inhaler (DPI): HandiHaler Remove the cap by pressing the piercing button Pull the lid away from the 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 Close the mouthpiece until it clicks Continue to hold the with the mouthpiece pointed up Press the button on the side once then release it Breathe out fully through the mouth, away from the Place the in a horizontal position and place the mouthpiece in the mouth tightening the lips around it Breathe in deeply through the mouth 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 Close the mouthpiece and cap Instructional video: https://www.spiriva.com/using-spiriva/how-to-use-spiriva.html Brands (DPI; HandiHaler) Additional Info a,b To request a demo Spiriva HandiHaler tiotropium Cleaning: After each use: empty the remains of the capsule from the into the trash. Before closing the mouthpiece or cap, turn the 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 with warm running water. Leave it open to air dry for 24 hours. Call Boehringer Ingelheim at 866-441-4671
(PL Detail-Document #300206: Page 13 of 17) Dry-Powder Inhaler (DPI): Neohaler Open the mouthpiece of the Remove one capsule from its foil blister Place the capsule into the capsule chamber Click the closed Hold the upright 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 Place the mouthpiece in the mouth Breathe in rapidly and steadily through the mouth Hold the breath for as long as comfortably possible Open the to see if any powder remains in the capsule. If yes, close the and repeat steps starting with Breathe out fully through the mouth. Open the mouthpiece, remove the used capsule, and discard it Close the mouthpiece Instructional video: http://www.arcapta.com/info/about-arcapta/taking-arcapta-indacaterol-inhalation-powder.jsp Brands (DPI; Neohaler) Additional Info a,b To request a demo Arcapta Neohaler indacaterol Cleaning: Wipe with a clean dry lint-free cloth between uses if desired Call Novartis at 888-669-6682
(PL Detail-Document #300206: Page 14 of 17) Dry-Powder Inhaler (DPI): Podhaler Hold the and unscrew the lid. Set the lid aside. Stand the upright on its base Hold onto the body of the and unscrew the mouthpiece. Set the mouthpiece aside. Tear off one blister card Roll back the foil that covers one capsule Take the capsule out of the blister and place it in the capsule chamber of the Put the mouthpiece back on the and screw it closed Hold the with the mouthpiece pointing down Press the button on the end of the all the way down one time Breathe out fully through the mouth, away from the mouthpiece Place the mouthpiece in the mouth Breathe in deeply through the mouth Remove the from the mouth Hold the breath for about 5 seconds Take a few normal breaths, then repeat the steps starting with Breathe out fully through the mouth. Open the mouthpiece, remove the used capsule from the, and discard it Replace the mouthpiece and wipe it with a clean dry cloth Brands (DPI; Podhaler) Additional Info a,b To request a demo Tobi Podhaler tobramycin Cleaning: No. However, one extra device is included with every 28-day supply in case the device becomes wet, dirty, broken, or dropped. Call Novartis at 888-669-6682
(PL Detail-Document #300206: Page 15 of 17) Dry-Powder Inhaler (DPI): Pressair Remove the cap by pressing the arrows on the sides and pulling it off Check that no foreign objects are in the mouthpiece Hold the with the mouthpiece facing the mouth and the button on the top Press the button all the way down and release it Breathe out completely through the mouth, away from the Place the mouthpiece in the mouth and tighten the lips around it Breathe in quickly and deeply through the mouth, until the lungs are filled Remove the from the mouth Hold the breath for as long as is comfortably possible Replace the cap Instructional video: http://www.tudorza.com/instructional-video.aspx Brands (DPI; Pressair) Additional Info a,b To request a demo Tudorza Pressair aclidinium bromide Cleaning: If desired. Clean the outside of the mouthpiece with a dry tissue or paper towel. Beyond-use date: 45 days after removal from foil pouch Forest representative at 800-678- 1605, ext 66298
(PL Detail-Document #300206: Page 16 of 17) Dry-Powder Inhaler (DPI): Twisthaler Hold the upright and remove the cap by twisting it in a counterclockwise direction Breathe out fully through the mouth, away from the Place the mouthpiece in the mouth and tighten the lips around it, holding the in a horizontal position Do not cover the ventilation holes Breathe in quickly and deeply through the mouth Remove the from the mouth Hold the breath as long as comfortably possible, up to 10 seconds Replace the cap, turning it in a clockwise direction and gently pressing it down, until a click is heard Instructional video: http://www.nationaljewish.org/healthinfo/medications/lung-diseases/devices/instructional-videos Brands (DPI; Twisthaler) Additional Info a,b To request a demo Asmanex Twisthaler mometasone Cleaning: Wipe mouthpiece dry after each use Beyond-use date: 45 days after removal from foil pouch Not available a. Note that instructions for device use and care are specific to the listed brand name product. Instructions for use/care of generic 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. U.S. product information used for preparation of the above chart: Advair HFA December 2012, Alvesco January 2013, Atrovent HFA August 2012, Dulera October 2013, Flovent HFA July 2013, ProAir HFA May 2012, Proventil HFA June 2012, QVAR July 2012, Symbicort August 2013, Ventolin HFA August 2012, Xopenex HFA September 2013, Combivent Respimat August 2012, Arcapta Neohaler September 2012, Asmanex Twisthaler January 2013, Anoro Ellipta December 2013, Breo Ellipta May 2013, Flovent Diskus September 2011, Foradil Aerolizer November 2012, Pulmicort Flexhaler July 2010, Relenza Diskhaler October 2013, Serevent Diskus January 2012, Spiriva HandiHaler June 2013, Tobi Podhaler November 2013, Tudorza Pressair June 2013.
(PL Detail-Document #300206: Page 17 of 17) Users of this PL Detail-Document 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. Project Leader in preparation of this PL Detail- Document: Stacy A. Hester, R.Ph., BCPS, Assistant Editor 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;68:1221-32. 2. Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: evidence-based guidelines. Chest 2005;127:335-71. 3. Gardenhire DS, Ari A, Hess D, Myers TR. A guide to aerosol delivery devices for respiratory therapists, 3 rd edition. American Association for Respiratory Care. http://www.aarc.org/resources/aerosol_resources/. (Accessed January 14, 2014). Cite this document as follows: PL Detail-Document, Correct Use of Inhaler Devices. Pharmacist s Letter/Prescriber s Letter. February 2014. Evidence and Recommendations You Can Trust 3120 West March Lane, Stockton, CA 95219 ~ TEL (209) 472-2240 ~ FAX (209) 472-2249 Subscribers to the Letter can get PL Detail-Documents, like this one, on any topic covered in any issue by going to www.pharmacistsletter.com, www.prescribersletter.com, or www.pharmacytechniciansletter.com