News Reader.info

The article looks at selecting an inhaler and how the devices should be used

Heslop, K. (2009) Respiratory inhaled therapy 2: choosing an inhaler. Nursing Times; 105: 13.The second article in a two-part series takes a detailed look at what issues healthcare

professionals should consider when selecting an inhaler for a patient. It looks at the differences between the different types and explains how they should be used. Part one looked at the

use of pressurised metered dose inhalers (Heslop, 2008).

Keywords: Respiratory illness, Inhaled therapy, Patient education

Karen Heslop, MSc, PGDip in Cognitive Behavioural Therapy, BSc, is respiratory nurse consultant, Royal Victoria Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust.

Medication for respiratory conditions is generally administered via the inhaled route rather than orally or intravenously, because delivering the drug directly to its site of action will

mean more rapid onset of action and minimise systemic adverse effects (Brocklebank et al, 2001).

However, specific inhalation techniques are necessary if each type of inhaler is to be used properly. A less than optimal technique can result in decreased drug delivery, which may lead to

symptoms persisting and affecting the patient’s quality of life. Inhalers should only be prescribed after patients have received training from a competent healthcare professional in their

use and demonstrated a satisfactory technique when checked (British Thoracic Society and Scottish Intercollegiate Guidelines Network, 2008).

Before they can select a device for a patient, a healthcare professional needs a thorough understanding of how different devices work, how they should be cleaned and what drugs can be used

with each one.

To a large extent, the decision will depend on the patient. They must be able to use the inhaler, and children and elderly patients may find some types more difficult than others. Lifestyle

and circumstances will make a highly portable device especially important to some. The patient’s preference must be taken into account because, if they do not like a device, they may not use

it.

The effectiveness of the device in an exacerbation of asthma or COPD should also be considered. For example, a pMDI with a large volume spacer is as effective as a nebuliser at treating mild

and moderate exacerbations of asthma (BTS and SIGN, 2008).

Some devices will require patients to have a greater inspiratory flow than others. With pMDIs (with or without spacers), a gentle slow breathing technique is required. For dry powder

devices, 30-60L/min is sufficient, but deposition improves with higher inspiratory flow (Borgström et al, 1994).

There are devices that can measure inspiratory flow - such as the Turbohaler Trainer and the In-Check device - and some that help patients improve technique for maximum deposition.

There is a risk of infection when using inspiratory flow meters between patients, so infection control guidelines must be followed.

Some inhalers have dose counters, which will indicate when the medication is running out, which can be helpful. Patients who need more than one drug may benefit from a combined inhaler such

as Symbicort or Seretide, particularly if they pay for their prescriptions.

The cost of the device to the health service should also be considered. The most expensive device may not be the one that costs most but the one that is not being used correctly so more drug

is required.

Conditions such as arthritis, poor eyesight or cognitive impairments can affect patients’ ability to use inhalers. Aids are available to help patients use pMDIs and Turbohalers.

The instructions for this device were described in a previous article (Heslop, 2008).Easi-Breathe

Before prescribing treatment, healthcare professionals need to consider which inhaler would be most appropriate. However, choosing a device can be problematic and there are many issues to

consider. If a patient struggles to use any inhaler, an alternative device should be sought.

Borgström, L. et al (1994). Lung deposition of budesonide inhaled via Turbohaler: a comparison with terbutaline sulphate in normal subjects. European Respiratory Journal; 7: 69–73.

Brocklebank, D. et al (2001) Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technology

Assessment; 5: 26, 1–149.

British Thoracic Society and Scottish Intercollegiate Guidelines Network (2008) British guideline on the management of asthma. Thorax; 63: 5 (Supp IV), iv 1–iv 121.

Heslop, K. (2008) How to use pressurised metered dose inhalers. Nursing Times; 104: 47, 78–80.