Inhalers 101: Just Breathe

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So. Many. Inhalers.

There are MANY types of inhalers on the market. Each type functions differently and delivers different medications. Depending on the diagnosis, certain inhalers may or may not be the best fit for a patient. An inhaler is chosen based on a patient’s disease, a patient’s ability to coordinate an inhaler device, and the cost.

Inhalers are generally divided into metered-dose inhalers (MDI) and dry-powder inhalers (DPI). DPI deliver fine powder to the lungs; they require less coordination but more forceful inhalation. 

  • MDI types: HFA inhalers, RediHaler
    • Note: HFA refers to hydrofluoroalkane, which is an inactive ingredient that serves as the inhaler’s propellant (i.e., spray); RediHaler refers to a device in which the dose is ready for inhalation when the cap is opened
    • HFA examples:
      • SABA: Proair HFA / Proventil HFA / Ventolin HFA (albuterol), Xopenex HFA (levalbuterol)
      • SAMA: Atrovent (ipratropium)
      • ICS: Alvesco HFA (ciclesonide), Asmanex HFA (mometasone), Flovent HFA (fluticasone), QVAR HFA (beclomethasone)
      • ICS+LABA: Advair HFA (fluticasone+salmeterol), Dulera HFA (mometasone+formoterol), Symbicort (budesonide+formoterol)
    • RediHaler example:
      • QVAR RediHaler (beclomethasone)
    • MDI inhalers can be used with a spacer (e.g., AeroChamber) to ensure optimal medication dosing. The same idea can be performed with young children as well (e.g., AeroChamber with mask). 
  • DPI come as single-use devices (HandiHaler, Neohaler, Respimat) and multiple-use devices (Diskus, Ellipta, Flexhaler, Pressair, Twisthaler)
    • Single-use devices:
      • HandiHaler examples:
        • LAMA: Spiriva HandiHaler (tiotropium)
      • Neohaler examples:
        • LABA: Arcapta (indacaterol)
        • LAMA: Seebri (glycopyrrolate)
        • LABA+LAMA: Utibron (indacaterol+glycopyrrolate)
      • Respimat examples:
        • SABA+SAMA: Combivent (albuterol+ipratropium)
        • LABA: Striverdi (olodaterol)
        • LAMA: Spiriva Respimat (tiotropium)
        • LABA+LAMA: Stiolto Respimat (formoterol+glycopyrrolate)
    • Multiple-use devices:
      • Diskus examples:
        • ICS: Flovent Diskus (fluticasone)
        • LABA: Serevent Diskus (salmeterol)
        • ICS+LABA: Advair Diskus (fluticasone+salmeterol)
      • Ellipta examples:
        • ICS: Arnuity Ellipta (fluticasone)
        • ICS+LABA: Breo Ellipta (fluticasone+vilanterol)
        • ICS+LABA+LAMA: Trelegy Ellipta (fluticasone+vilanterol+umeclidinium)
        • LABA+LAMA: Anoro Ellipta (vilanterol+umeclidinium)
        • LAMA: Incruse Ellipta (umeclidinium)
      • Flexhaler examples:
        • ICS: Pulmicort Flexhaler (budesonide)
      • Pressair examples:
        • LAMA: Tudorza Pressair (aclidinium)
        • LABA+LAMA: Duaklir Pressair (formoterol+aclidinium)
      • Twisthaler examples:
        • ICS: Asmanex Twisthaler (mometasone)

As you can see above, inhalers deliver many types of medications: short-acting beta agonists (SABA), short-acting muscarinic antagonists (SAMA), long-acting beta agonists (LABA), long-acting muscarinic antagonists (LAMA), inhaled corticosteroids (ICS), and combinations of these (e.g., SABA+SAMA, ICS+LABA, LABA+LAMA, ICS+LABA+LAMA, etc.)

Teaching Inhaler Use

Many studies show that many patients (maybe more than 3 in 4) don’t use their inhalers correctly, an issue that appears to have made little improvement over time. What’s more, inhaler errors are associated with worse health outcomes. Furthermore, many clinicians appear to not know how to correctly use inhalers either. 

There is no strong evidence that certain interventions are better than others in teaching inhaler technique. The National Asthma Education and Prevention Program (NAEPP) recommends that patients be taught inhaler use as follows:

  • The clinician should first demonstrate the steps on the checklist.
  • The patient then practices in front of the clinician so that errors may be corrected.
  • The patient’s technique should be evaluated periodically and corrections made as necessary.
  • Patients should be positively reinforced for correct inhaler technique. Instructions should be reviewed and repeated over time to reinforce the correct inhaler technique. 

There are MANY online resources available. Here are just a few: 

HFA inhalers

Examples: 

  • SAMA: Atrovent (ipratropium)
  • ICS: Alvesco HFA (ciclesonide), Asmanex HFA (mometasone), Flovent HFA (fluticasone), QVAR HFA (beclomethasone)
  • ICS+LABA: Advair HFA (fluticasone+salmeterol), Dulera HFA (mometasone+formoterol), Symbicort (budesonide+formoterol)
  • SABA: Proair HFA / Proventil HFA / Ventolin HFA (albuterol), Xopenex HFA (levalbuterol)

How to use an HFA inhaler: 

  1. Remove mouthpiece, check for foreign objects
  2. Shake the inhaler well immediately before use
  3. Prime if necessary
  4. Breathe out normally, getting as much air out as possible
  5. Place mouthpiece between lips and teeth, sealing lips around mouthpiece
  6. Breathe in slowly and press canister down when you start breathing
  7. Hold breath as long as possible, up to 10 seconds
  8. Remove inhaler and breathe out slowly
  9. Wait 30-60 seconds between puffs
  10. If it is a steroid inhaler, rinse mouth and spit

RespiClick and RediHaler inhalers function similarly as HFA inhalers.

  • Examples of RespiClick include Proair RespiClick (albuterol) and Airduo RespiClick (fluticasone+salmeterol)
  • Examples of RediHaler include QVAR RediHaler (beclomethasone)

Diskus inhalers

Examples: 

  • ICS: Flovent Diskus (fluticasone)
  • ICS+LABA: Advair Diskus (fluticasone+salmeterol)
  • LABA: Serevent Diskus (salmeterol)

How to use Diskus inhalers: 

  1. Hold the Diskus level with one hand (like a hamburger).
  2. Place the thumb of the other hand on the thumb grip.
  3. Push your thumb away from you until the Diskus clicks. This will open the Diskus so you can see the mouthpiece.
  4. Hold the Diskus level and slide the lever away from you until the Diskus clicks. This will load the medication. Keep the Diskus level so you don’t lose the medication.
  5. Hold the Diskus level and away from your mouth and gently breathe out. Never exhale into to Diskus.
  6. Seal your lips around the mouthpiece.
  7. Inhale rapidly and deeply. Continue to take a full, deep breath.
  8. Hold your breath for up to 10 seconds. This allows the medication time to deposit in the airways.
  9. Resume normal breathing.
  10. Close the Diskus by placing your thumb on the thumb grip. Pull your thumb toward you until the discus clicks. The mouthpiece will be hidden and the lever will be reset.

How to identify when Diskus inhalers are empty: 

  1. The Diskus has a dose indicator on the top of the device. Numbers on the dose indicator show how many doses are left in the Diskus.
  2. When there are 5 doses left in the Diskus the numbers on the dose indicator will turn red. This means the Diskus is almost empty.
  3. When the red number is at 0 the Diskus is empty. Plan to get a new Diskus before the dose indicator gets to 0.

How to clean Diskus inhalers: 

  • Keep the Diskus closed when not in use. Keep the Diskus dry. The Diskus does not need to be cleaned routinely. If the mouthpiece is dirty, wipe it with a cloth.

Ellipta inhalers

Examples: 

  • ICS: Arnuity Ellipta (fluticasone)
  • ICS+LABA: Breo Ellipta (vilanterol+fluticasone)
  • ICS+LABA+LAMA: Trelegy Ellipta (fluticasone+vilanterol+umeclidinium)
  • LABA+LAMA: Anoro Ellipta (vilanterol+umeclidinium)
  • LAMA: Incruse Ellipta (umeclidinium)

How to use Ellipta inhalers: 

  1. Wait to open the cover until you are ready to take your dose.
  2. Slide the cover down. You will hear a click. This will open the Ellipta so you can see the mouthpiece. This will also load the medicine. The counter will count down one number.
  3. Your inhaler is ready to use.
  4. Hold the Ellipta level and away from your mouth and gently breathe out. Never exhale into the Ellipta.
  5. Seal your lips around the mouthpiece.
  6. Inhale rapidly and deeply. Continue to take a full, deep breath. Do not block the air vent with your fingers.
  7. Hold your breath for up to 10 seconds. This allows the medication time to deposit in the airways.
  8. Resume normal breathing.
  9. Close the Ellipta. The mouthpiece will be hidden by the cover when closed.
  10. If the medicine you are taking is Breo Ellipta, rinse your mouth after taking the medicine.

How to identify when Ellipta inhalers are empty: 

  • The Ellipta has a dose indicator on the side of the device. Numbers on the dose indicator show how many doses are left.
  • When there are 9 doses left in the Ellipta there will be a red square next to the number. This means the Ellipta is almost empty. 
  • When the red square appears without the number, the Ellipta is empty. Plan to get a new Ellipta before the dose indicator becomes a red square.

How to clean Ellipta inhalers: 

  • If the mouthpiece is dirty, wipe it with a cloth. Do not put the Ellipta in water. Keep the Ellipta closed when not in use. 

Common errors with Ellipta inhalers: 

  • Shaking the inhaler
  • Opening and closing the mouthpiece without inhaling a dose
  • Leaving the mouthpiece open
  • Covering vent with the hand
  • Exhaling into or near the mouthpiece
  • Not closing the cover after inhaling

Tips for using Ellipta inhalers: 

  • Do not open the mouthpiece until you are ready to inhale the dose; if the mouthpiece is closed, the dose is lost. 
  • Always close the cover after use. 
  • If you are using this inhaler for a corticosteroid preventer medication, rinse your mouth with water and spit after inhaling the last dose to reduce the risk of side-effects. 

Flexhaler inhalers

Examples: 

  • ICS: Pulmicort Flexhaler (budesonide)

How to use Flexhaler inhalers: 

  1. Remove the cap from the Flexhaler by unscrewing the cap.
  2. Hold the Flexhaler with the mouthpiece up. This will load the medication correctly.
  3. Turn the bottom all the way to the right and back to the left. You will hear it click. This will load the medication.
  4. Hold the Flexhaler away from your mouth and gently breathe out.
  5. Seal your lips around the mouthpiece.
  6. Inhale rapidly and deeply. Continue to take a full, deep breath.
  7. Resume normal breathing.
  8. Repeat steps 1-7 when more than one puff is prescribed.
  9. Rinse your mouth and spit out the water after inhaling the medication.
  10. Keep the Flexhaler cap on when not in use. This will keep the Flexhaler clean and dry.

How to identify when Flexhaler inhalers are empty: 

  • The Flexhaler has a dose counter window below the mouthpiece. It will let you know approximately how many doses are left. As you use the Flexhaler the numbers will count down by 10. The Flexhaler will count down to 0 in the center of the window when the Flexhaler is empty. Plan to get a new Flexhaler before you see the 0 in the window.

How to clean Flexhaler inhalers: 

  • Wipe the mouthpiece with a clean cloth at least once a week or if it appears dirty. Do not put the Flexhaler in water.

HandiHaler inhalers

Examples: 

  • LAMA: Spiriva HandiHaler (tiotropium)

How to use HandiHaler inhalers: 

  1. Each capsule for the HandiHaler is individually wrapped. The wrapping is called a blister card. When you are ready to use the capsule, separate one blister pack from the blister card. (To do this, tear along the perforation). Take the capsule out of the blister pack. (To do this, find the corner of the blister pack with the arrow. Peel back this corner of the blister pack until you see the capsule.)
  2. Open the cover of the HandiHaler by pressing the green button on the side on the device. Lift the cover. 
  3. Open the mouthpiece of the HandiHaler by lifting the mouthpiece ridge.
  4. Place the capsule in the hole in the center of the HandiHaler.
  5. Close the mouthpiece. You will hear a click when the mouthpiece is closed.
  6. Leave the cover of the HandiHaler open.
  7. Hold the HandiHaler with the mouthpiece up. Press the green button on the side of the HandiHaler once firmly. This will pierce the capsule, so you can inhale the medication when you breathe in.
  8. Hold the HandiHaler away from your mouth and gently breathe out. Do not blow into the HandiHaler.
  9. Seal your lips around the mouthpiece.
  10. Inhale slowly and deeply but a rate sufficient to hear the capsule vibrate. Continue to take a full, deep breath.
  11. Resume normal breathing.
  12. You can repeat steps 8 to 11 again to make sure you inhale the medication.
  13. Open the mouthpiece and throw away the used capsule.
  14. Do not touch the capsule once it has been pierced.

Neohaler inhalers

Examples: 

  • LABA: Arcapta (indacaterol)
  • LAMA: Seebri (glycopyrrolate)
  • LABA+LAMA: Utibron (indacaterol+glycopyrrolate)

How to use Neohaler inhalers: 

  1. Each capsule for the Neohaler is individually wrapped. The wrapping is called a blister card. When you are ready to use the capsule, separate one blister pack from the blister card. Tear along the perforation to do this. Take the capsule out of the blister pack. To do this, find the corner of the blister pack. Peel back this corner of the blister pack to expose the foil. Push the capsule through the foil. Do not swallow the capsule.
  2. Pull off the cover of the Neohaler.
  3. Open the inhaler of the Neohaler.
  4. Hold the base of the Neohaler and tilt the mouthpiece to open the inhaler.
  5. Place the capsule in the hole in the center of the Neohaler.
  6. Close the inhaler. You will hear a click when the mouthpiece is closed.
  7. Leave the cover of the Neohaler off.
  8. Hold the Neohaler with the mouthpiece up. Press both buttons on the sides of the Neohaler once firmly. This will pierce the capsule, so you can inhale the medication when you breathe in.
  9. Hold the Neohaler away from your mouth and gently breathe out. Do not blow into the Neohaler.
  10. Seal your lips around the mouthpiece. Hold the inhaler with the buttons to the left and right, not up and down.
  11. Inhale rapidly and deeply but a rate sufficient to hear the capsule vibrate. Continue to take a full, deep breath.
  12. Resume normal breathing.
  13. Open the inhaler to see if there is still powder in the capsule. If there is powder in the capsule repeat steps 8-12.
  14. Open the mouthpiece and throw away the used capsule.
  15. Keep the cover on the Neohaler when not in use. This will help keep the Neohaler clean and dry.

Pressair inhalers

Examples: 

  • LAMA: Tudorza Pressair (aclidinium)
  • LABA+LAMA: Duaklir (formoterol+aclidinium)

How to use Pressair inhalers: 

  1. Hold the Pressair with the mouthpiece facing you – but not inside your mouth. The green button should be facing straight up.
  2. Before you put the inhaler into your mouth, press the green button all the way down.
  3. Release the green button. Do not continue to hold the green button. This will load the medicine, so you can inhale the medicine when you breathe in.
  4. Check the Control Window to make sure your dose is ready for you to inhale. Make sure the control window has changed from red to green.
    • If the control window is green, the medicine is ready to inhale.
    • If the control window is still red, press and release the green button again. Check the control window to make sure it has changed from red to green.
  5. Hold the Pressair away from your mouth and gently breathe out. Do not blow into the Pressair.
  6. Seal your lips around the mouthpiece. Do not breathe out into the inhaler.
  7. Inhale rapidly and deeply. You will hear a “click” sound. Continue to take a full, deep breath in to make sure you get the full dose. Do not hold the green button down while you are breathing in.
  8. Take the Pressair out of your mouth.
  9. Resume normal breathing.
  10. Check the control window to see if it turned to red from green.
    • If the window is red, you have inhaled your full dose of medicine.
    • If the control window is still green, inhale again rapidly and deeply.
    • If you are unable to inhale the medicine correctly after several tries, check with your health care provider.
  11. Keep the cover on the Pressair when not in use. This will help keep the Pressair clean and dry.

Respimat inhalers

Examples: 

  • LABA: Striverdi (olodaterol)
  • LAMA: Spiriva Respimat (tiotropium)
  • LABA+LAMA: Stiolto Respimat (formoterol+glycopyrrolate)
  • SABA+SAMA: Combivent (albuterol+ipratropium)

How to use Respimat inhalers: 

  • Prepare
    1. Hold the orange cap in one hand and press the safety catch on the side of the inhaler. With the other hand pull off the clear base. Don’t touch the piercing element located inside the bottom of the clear base.
    2. Write the discard date on the inhaler. The discard date is 3 months from the date you prepare the new Respimat.
    3. Take the Respimat cartridge out of the box.
    4. Push the narrow part of the cartridge into the inhaler.
    5. Push the cartridge on a firm surface to make sure it is correctly inserted. The base of the cartridge will not sit flush with the inhaler.
    6. Do not remove the cartridge once it is inserted into the inhaler.
    7. Put the clear plastic base back onto the inhaler. Do not remove the plastic base once it is attached to the inhaler.
  • Priming (If you have not used the Respimat inhaler for more than 21 days prime the inhaler as described below. If you have not used the inhaler for more than 3 days prime it once.)
    1. Hold the Respimat inhaler upright, with the orange cap at the top and closed.
    2. Turn the clear base in the direction of the white arrows for a half turn until it clicks.
    3. Flip the orange cap until it snaps fully open.
    4. Point the inhaler towards the ground.
    5. Press the dose release button.
    6. Close the orange cap.
    7. Repeat the Priming procedure 3 more times. Now the inhaler is ready for use.
  • Inhaling a dose
    1. Hold the Respimat upright.
    2. Turn the clear base in the direction of the white arrows for a half turn until it clicks.
    3. Flip the orange cap until it snaps fully open.
    4. Hold the Respimat away from your mouth and gently breathe out.
    5. Seal your lips around the end of the mouthpiece without covering the air vents.
    6. Point the Respimat inhaler to the back of your throat.
    7. While inhaling slowly and deeply through your mouth press the dose release button. Continue to breathe in slowly and deeply.
    8. Hold your breath for up to 10 seconds. This allows the medication time to deposit in the airways.
    9. Resume normal breathing.
    10. Close the orange cap until you use the inhaler again.
  •  

How to identify when Respimat inhalers are empty: 

  • The Respimat has a dose indicator on the side of the device. The dose indicator shows about how many doses are left in the Respimat.
  • When the pointer enters the red area of the scale there is enough medicine for 7 days. Plan to get a new Respimat at this point.
  • When the pointer gets to the bottom of the red area, there are no doses left. The inhaler locks.

How to clean Respimat inhalers: 

  • Wipe the mouthpiece including the metal part inside the mouthpiece with a damp cloth at least once a week. Keep the Respimat closed when not in use.

Twisthalers

Examples: 

  • ICS: Asmanex Twisthaler (mometasone)

How to use Twisthaler inhalers: 

  1. Hold the Twisthaler straight up with the pink portion on the bottom. This is important to make sure you get the right amount of medicine.
  2. Remove the cap from the Twisthaler by twisting off the cap.
  3. As you lift off the cap the dose counter on the pink portion will count down by one. This action gets the medicine ready for you to inhale.
  4. Hold the Twisthaler away from your mouth and gently breathe out.
  5. Seal your lips around the mouthpiece.
  6. Inhale rapidly and deeply. Continue to take a full, deep breath.
  7. Take the Twisthaler out of your mouth. Hold your breath for 10 seconds.
  8. Resume normal breathing. Do not breathe out into the Twisthaler.
  9. Close the Twisthaler by twisting on the cap. The indented arrow on the case should line up with the dose counter when the Twisthaler is closed. Keep the cap on the Twisthaler when not in use. This will keep the Twisthaler clean and dry.
  10. Repeat steps 4-9 when more than one puff is prescribed.
  11. Rinse your mouth and spit out the water after inhaling the medication.

How to identify when Twisthaler inhalers are empty: 

  • The Twisthaler has a dose counter on the pink base. The dose counter will show the doses of medicine left. When the dose counter shows 01, there is 1 dose left.
  • When the Twisthaler is empty the dose counter will show 00 and the pink base will not turn. Start using a new Twisthaler.

tl;dr

How to use…

Other great resources:

Blog post based on Med-Peds Forum talk by Kat Duprey, PharmD (our awesome clinical pharmacist!)

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