Section 4:

Teaching inhaler technique

Teaching technique can improve patients’ ability to use their inhalers correctly. In the study cited by BTS/SIGN, correct usage score improved after teaching from a mean of 60% to 79%. Figures for no mistakes after teaching were 63% for pMDI, 65% for DPI, and 75% for breath-actuated MDI (the latter figure based on one study of 2,467 patients).1

Unfortunately many HCPs are unable to correctly demonstrate how to use the inhalers they prescribe.2 They may be unfamiliar with the use of specific devices, have inadequate time to teach, have poor training techniques and/or materials, or not provide follow up.3

With the increasing range of devices coming onto the market and the extensive range of treatment options available for each device, plus regular updates of national and international guidelines, it is important that HCPs periodically update their knowledge of both new inhalers and management standards.3,4

Checking and correcting inhaler technique using a standardised checklist takes only 2-3 minutes and leads to improved asthma control in adults and older children.2 GINA states that a physical demonstration is essential to improve inhaler technique. This is easier if the HCP has placebo inhalers (and a spacer if this has been prescribed). After training, inhaler technique ‘falls off’ with time, so checking and re-training must be repeated regularly. HCPs can provide highly effective inhaler skills training.2

The UK Inhaler Group Standards and Competency document

The UK Inhaler Group Inhaler Standards and Competency document provides a framework to set, assess and support the standards of those initiating inhaler therapies, and checking and teaching inhaler techniques to optimise drug administration.5

It states that all HCPs prescribing an inhaler should ensure that the patient knows how to use the device, and if initiating the device, they should also know how to use it and be competent in teaching its use. Prescribers should be able to demonstrate device techniques correctly and clearly. Assessing and teaching technique may involve watching the patient use their inhaler, instruction, reinforcement and repeating these steps. Device technique should be checked on the prescribed device or the relevant, single use, placebo device.5

While assessment criteria for each individual inhaler device may vary, there are basic steps that apply to all inhalers.5

The seven steps to using an inhaler device are:5

  1. Prepare the device
  2. Prepare or load the dose
  3. Breathe out, fully and gently, but not into the inhaler
  4. Place the inhaler mouthpiece in the mouth and seal the lips around the mouthpiece
  5. Breathe in:
    • pMDI: slow and steady over 4-5 seconds, press canister to release the medication6
    • BAI: slow and steadily over 4-5 seconds, the medication is released as patient breathes in6
    • DPI: Quick and deep over 2-3 seconds, the medication is released as patient breathes in6
  6. Remove inhaler from the mouth and hold the breath for up to 10 seconds
  7. Wait a few seconds then repeat as necessary

If these areas are covered, then specifics for each inhaler can be assessed, and technique optimised.

The HCP should also identify any concerns that may affect the patient’s ability to use their inhaler, such as:5

  • Lack of manual dexterity
  • Inability to coordinate inspiration and activation
  • Reduced ability to follow instructions
  • Impaired sight
  • Insufficient inspiratory flow rate (DPI)
  • Excessive inspiratory flow rate (pMDI)
  • Inability to hold breath for a minimum of 5 seconds

When a patient is first prescribed an inhaler, it can be difficult to ensure that they are confident in its use due to pressures of time within the initial consultation and possibly because patients themselves are stressed and anxious.3 Nonetheless, it is crucial that training is provided.1,2

  • Set aside uninterrupted time to complete the instruction
  • Perform the demonstration in a suitable environment
  • Have all the necessary equipment close at hand
  • Engage the patient’s attention
  • Explain what you will do and why
  • Demonstrate inhaler technique, naming and explaining each step
  • Repeat the demonstration without talking (talking is necessary in the previous step but interferes with correct timing of the inspiratory manoeuvre)
  • Repeat again, with verbal commentary
  • Have the patient demonstrate the manoeuvre, including correct identification of inhaler(s) and assembly of inhaler/spacer combination
  • Identify problems in the patient’s performance, repeat instruction, and have the patient demonstrate again
  • Ask the patient to tell you the most important parts of the procedure, and those he or she finds most difficult
  • Arrange for follow-up instruction. Assure the patient that some loss of skill over time is to be expected but can be corrected
  • Remind the patient to bring their inhalers and spacers to every appointment

Instruction should also be provided to parents/carers,3,5 particularly in the case of children, and adults with learning difficulties or dementia.

Job code: UK/RES-19014d DOP: April 2020

References

  1. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma, 2019. https://www.sign.ac.uk/sign-158-british-guideline-on-the-management-of-asthma.html [Accessed April 2020]
  2. Global Initiative for Asthma. Global strategy for asthma management and prevention, updated 2019. https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf [Accessed April 2020]
  3. Fink JB, Rubin BK. Problems with inhaler use: a call for improved clinician and patient education. Resp Care 2005;50(10):1360-74
  4. Staff writers. Inhaler devices, technique and errors: an overview. Practice Nurse 2019;49(09):18–24
  5. UK Inhaler Group. Inhaler Standards and Competency Document. https://www.respiratoryfutures.org.uk/media/69774/ukig-inhaler-standards-january-2017.pdf [Accessed April 2020]
  6. NICE NG80. Resources: Inhalers for asthma. Patient decision aid. https://www.nice.org.uk/guidance/ng80/resources/inhalers-for-asthma-patient-decision-ad-pdf-6727144573 [Accessed April 2020]