Today a patient came into the clinic and said that his asthma inhaler wasn’t working. He’d been diagnosed with mild asthma last week and his primary care physician gave him an albuterol inhaler to use when his asthma flairs and he starts coughing. He had his inhaler with him, so I asked him to demonstrate how he uses it. He promptly put the inhaler to his lips and sprayed the inhaler into his mouth and then took a big breath in. I was able to see that he wasn’t getting the medication into his lungs efficiently, and since this is a common problem when using inhaled medication, I decided that the subject needed some attention.
Using an inhaler can actually be quite challenging, and I find that most patients medications are only effective if they are used properly. If you use the inhaler correctly the medication is delivered to the lungs where it works to control your symptoms. If you are not using your inhaler correctly, little or no medication reaches your lungs and your asthma or reactive airway symptoms will not be adequately treated.
Asthma inhaler types: Most asthma inhalers are meter dose inhalers (MDI’s) and deliver a small spray of liquid medication such as albuterol (aka Proventil or Ventolin). Since 2008, new inhaler canisters have come out that use a propellant that does not damage the ozone layer. They are known as HFA inhalers and have a different taste compared to the previous inhalers and are also more expensive. The spray is also softer, but works just as well as the older inhalers.
The other type of asthma inhaler is called a dry powder inhaler (DPI). This type of inhaler has a small amount of powder that you breath in. It has less taste, but the powder can fall out if you tip the device down towards to ground. This type of inhaler is used commonly with medications such as the Advair diskus.
Spacer devices: A spacer is a device that is basically a small tube that allows the medicine to have a little extra time and space to get down into your lungs rather than be deposited in the back of your mouth or on your tongue. It is not required to use a spacer, but it is highly recommended. If you don’t have a spacer to use with your inhaler, you can make one using an empty cardboard toilet paper roll. You put the spacer over the mouthpiece of the MDI and then put the other end of the spacer in your lips and inhale the medication from the metered dose inhaler through the spacer and into your lungs.
Before using a metered dose inhaler MDI for the first time:
1) Prepare the inhaler by shaking it for 5 seconds
2) Prime the inhaler by pressing down on the canister with the index finger to release the medication. Hold the inhaler away from your face to prevent the medication getting into your eyes. Press the canister down again 3 more times
3) After using for the first time, it does not need to be primed again unless you don’t use it for more than 2 weeks.
Technique for using a metered dose inhaler (MDI):
1) Shake the canister for 5 seconds
2) If you have a spacer (recommended), insert the MDI into the spacer and hold the MDI upright with the index finger on the top of the medication canister and the thumb supporting the bottom of the inhaler. Some people find that using the other hand to hold the spacer is easiest.
3) Breathe out normally
4) Close your lips around the spacer. If your spacer has a mask, hold the mask tightly to the face. If you do not have a spacer, close lips around mouthpiece or hold at a position about 4cm from your mouth.
5) Keep your tongue away from the spacer opening/mouthpiece area
6) Press down on the top of the medication canister with the index finger to release the medication
7) At the same time as the canister is pressed, inhale deeply and slowly through your mouth until your lungs are completely filled – this should take about 4-6 seconds
8) Hold your breath in for as long as possible – 10 seconds is recommended before breathing out.
9) If a second puff of medication is recommended, wait about 15-30 seconds before repeating the procedure for the second puff. Remember to shake the canister before each puff
10) Recap the mouthpiece
11) Rinse your mouth with water rather than swallowing after the treatment. This is recommended especially after using an inhaled cortisone medication to prevent developing thrush
*Tip: If you’re having difficulty timing your breath while spraying the medication, there are inhalers that automatically release the medication when you take a breath. An alternative is to use a spacer or a dry powder inhaler (DPI).
Cleaning your MDI: Your inhaler must be cleaned at least once a week to prevent blockages. The manufactures recommend cleaning the mouthpiece at least once per week.
1) Remove the canister but do not wash the canister or put it in the water
2) Run warm water through the top and bottom of the plastic mouthpiece for 60 seconds
3) Shake off the excess water and allow the mouthpiece to dry completely overnight
4) If you need to use your inhaler before it is dry, shake off all the water, replace the canister and test spray (away from your face) two times before using
5) Remember to clean your spacer
How to determine when your inhaler is empty: You can’t always know when your inhaler is empty by shaking it because some propellant remains in the canister when all the medication is gone. Some inhalers have a dose counter (Ventolin-HFA and Proventil) to track how much is used. If your inhaler doesn’t have a counter but you use it regularly (2 puffs twice per day), you will need a refill in 30 days. Write the date you will need a refill on the canister with a permanent maker to remind yourself.
If you don’t use your inhaler very often, write the date you start using it on the canister in permanent maker and consider getting a refill in 3-4 months.
Dry powder inhalers (DPIs): These types of inhalers have a small dose of dry powdered medication in them. They deliver a very fine powder to the lungs when you breathe in. The advantage of using a DPI, is that you do not need to coordinate the squeezing of the canister with your breathing. You must be able to breath in more forcefully with a DPI than with a spray type inhaler to ensure that the powder gets into the lungs. These types of inhalers might be more difficult for patients who cannot breath in very deeply. It’s also important not to exhale into the device before breathing in so that you don’t scatter the powdered medicine before it’s inhaled.
How to use a DPI:
1) For single use devices, load a capsule into the device as directed
2) Breathe out slowly and completely (but not into the mouthpiece or you will scatter the powdered medication before you have a chance to breathe it in).
3) Place the mouthpiece between your lips
4) Breath in through the mouth quickly and deeply over 2-3 seconds
5) Remove the inhaler from your mouth and hold your breath as long as possible – 10 seconds is recommended
6) Breathe out slowly
Cleaning a DPI: Do not use soap and water. The mouthpiece can be cleaned with a dry cloth.
For more information about asthma, here is a list of resources:
Center for disease control and Prevention
American Academy of Allergy, Asthma and Immunology
American Lung Association
This document is for informational purposes only, and should not be considered medical advice for any individual patient. If you have questions please contact your medical provider.
I hope that you have found this information useful. Wishing you the best of health,
Scott Rennie, DO