rxPassport Pharmacy Newsletter
July 2014
Technique, Technique, Technique.
Often forgotten, but without it our patients are unlikely to reach optimal asthma or COPD outcomes.
We often correlate long-term use of inhalers with correct technique, but for the most part this is not the case. One study demonstrated that more than 98% of patients claimed to know how to use their inhaler, but when their technique was observed, 94% of them committed at least one error.1 Overall, it is estimated that only 10% of patients are accurately using their inhalers.1 Despite recommendations from the Canadian Thoracic Guidelines (CTS) asthma guidelines for healthcare professionals to review inhaler technique at every visit2, inhaler technique remains a significant reason for uncontrolled asthma and COPD.3,4
Practice Tip:
Often respiratory medications are intensified due to poor response, but poor response could be due to lack of proper inhaler technique and suboptimal drug delivery to the lungs. As front-line healthcare providers, pharmacists are equipped with the skills and accessibility to reinforce proper inhaler technique.
Patient Case
Meet JR, a 4-year old boy visiting your pharmacy with his mother. He was prescribed salbutamol and fluticasone puffers for his new asthma diagnosis. His mother briefly mentions she is in between jobs and hopes the medications are not very expensive. Could they administer these medications without a valved-holding chamber?
Metered Dose Inhalers (MDI) MDI are often the most difficult inhaler to use due to the need to coordinate actuation and breathing.1 Drug delivery occurs via an aerosol propellant, and for it to be delivered to the lungs, technique is crucial. To improve drug delivery, a valved-holding chamber (VHC) is recommended. VHCs extend the distance between the inhaler and the patient’s mouth, while also trapping the medication in the chamber to provide the patient with more time to inhale the full contents of an MDI dose.
VHCs are more than just a spacer
In addition to reducing the need for coordinating actuation and breathing, VHCs also decrease oropharyngeal deposition, which is an important characteristic for when inhaled corticosteroids are prescribed.5,6 This may help to reduce common side effects of inhaled corticosteroids, such as dysphonia (voice changes) and oral candidiasis (thrush), that occur due to oropharyngeal deposition.
Various factors come into play when selecting an appropriate VHC:
  • Electrostatic charge on the plastic chamber decrease drug delivery as medication particles will adhere to the walls of the chamber and be unavailable for inhalation.6,7 To overcome this, many VHCs are now made to be anti-static.
    • Individual manufacturers have recommendations on how to clean their specific VHC product with detergent to reduce electrostatic charge, and thus improve drug delivery. Please refer to the manufacturer’s manual for cleaning recommendations.
  • Mouthpieces are the preferred option over masks, and it is recommended to switch patients from a mask to mouthpiece as soon as possible. The nose is more effective at filtration than the mouth, and thus the drug delivery through the mouth will maximize aerosol particles that reach the lungs.5
  • Masks are recommended for young children or cognitively-impaired adults.
    • Even the smallest leak can greatly reduce the amount of drug available to the patient, and thus a tightly fit mask is crucial to optimize drug delivery.8,9
    • Transparency allows caregivers to observe the drug contents being inhaled.9
    • Pharmacists need to stress the significance of purchasing the appropriate facemask size for infants; cost concerns may lead patients purchasing oversized products, aiming to extend use of the VHC.
Practice Tip: Selecting the appropriate mask
Due to the importance of the seal between the mask and face, it is crucial to select the appropriate mask for the patient. Always consider the patient’s age and size when selecting the mask. Generally:
  • Most infants (up to 18 months of age) require a small mask
  • Children (18months to 5 years) require a medium mask
  • Older children (>5 years) and adults require a large mask if they cannot use VHC with the mouthpiece
  • Inhalations: Patients using a VHC can inhale 2-3 tidal breaths (regular breaths) as opposed to the single maximal inhalation required when using MDI without a VHC.10 However, it is crucial to ensure patients are using their VHC correctly. See below for VHC-specific recommendations on proper technique:
Back to the Case:
The pharmacist recommends purchasing a VHC with a mouthpiece, and educates JR’s mother on how to use the MDI with the VHC.
The VHC will optimize drug delivery to JR, and hopefully improve his asthma control and reduce the impact of his symptoms. The mouthpiece is a cheaper alternative, and provides better drug delivery than the mask. Furthermore, the VHC will reduce the risk of oral candidiasis and dysphonia, which can be associated with inhaled fluticasone therapy.
Dry-powdered inhalers (DPI)
Dry-powdered inhalers are breath-activated and do not require the same amount of hand-breath coordination as MDIs. Due to slight differences in appearance and technique, pharmacists should emphasize the common errors for patients that are using several inhalers.
Consider contacting individual drug manufacturers to obtain a placebo inhaler to provide demonstrations for patients at your pharmacy.
Practice Tip
Ask patients to come to the pharmacy once a year with their inhalers to complete a medication review. This will be a perfect opportunity to re-educate patients on proper inhaler technique.
Inhaler techniques
Refer to this PDF for written instructions on how to use the different inhalers available.
Click here for video demonstrations
Table 1 includes common errors patients may commit while using their inhalers, and how we can prevent them from occurring.

*Click to enlarge
By: Monica Sanh, PharmD Candidate
With appreciation to Mike Boivin
In this issue:
Patient Case
Metered Dose Inhalers (MDI)
VHCs are more than just a spacer
Dry-powdered inhalers (DPI)
Inhaler techniques
Interactive Poll
How often do you review inhaler technique with your asthma or COPD patients?
Only for new prescriptions
Every 6-12 Months
Every 2-3 months
At every refill
Participate Now
Practice Tip:
Consider asking the patient/caregiver to demonstrate how they use their inhaler. This will help you identify where they may be making mistakes, and provide an opportunity to educate them on proper inhaler technique.
1. CTS Asthma Guidelines: View Resource
2. GINA Asthma Guidelines: View Resource
3. GOLD COPD Guidelines: View Resource
Read Monica's Blog Entry
1. Self TH, Wallace JL, George CM, Howard-Thompson A, et. Schrock SD. Inhalation therapy: help patients avoid these mistakes. The Journal of Family Practice. 2011; 60(12): 714-720
2. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children, and adults: Executive summary. Can Respir J. 2012; 19(6): 81-88
3. Restrepo RD, Alvarez MT, Wittnebel LD, Sorenson H, Wettstein R, Vines DL, et al. Medication adherence issues in patients treated for COPD. International Journal of COPD. 2008; 3(3): 371-384
4. AL-Jahdali H, Ahmed A, AL-Harbi A, Khan M, Baharoon S, Salih SB, et al. Improper inhaler technique is associated with poor asthma control and frequent emergency department visits. Allergy, Asthma & Clinical Immunology. 2013; 9(8)
5. Laude BL, Janssens HM, de Jongh FHC, Devadason SG, Dhand R, Diot P et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J. 2011; 37(6): 1308-1331
6. Hess DR. Aerosol Delivery Devices in the Treatment of Asthma. Respiratory Care. 2008; 53(6): 699-725
7. Wildhaber JH, Devadason SG, Eber E, Hayden MJ, Everard ML, Summers QA, et al. Effect of electrostatic charge, flow, delay and multiple actuations on the in vitro delivery of salbutamol from different small volume spacers for infants. Thorax. 1996; 51: 985-988
8. Janssens HM et. Tiddens HAWM. Facemasks and Aerosol Delivery by Metered Dose Inhaler-Valved Holding Chamber in Young Children: A Tight Seal Makes a Difference. Journal of Aerosol Medicine. 2007; 20: 59-65
9. Amirav I et. Newhouse MT. Review of Optimal Characteristics of Face-Masks for Valved-Holding Chambers (VHCs). Pediatric Pulmonology. 2008; 43: 268-274
10. Schultz A, Le Souef TJ, Venter A, Zhang G, Devadason SG, et. Le Souef PN. Aerosol Inhalation From Spacers and Valved Holding Chambers Requires Few Tidal Breaths for Children. Pediatrics. 2010; 126(6): 1493-1498
11. Gardenhire DS, Ari A, Hess D et Myers TR. A Guide to Aerosol Delivery Devices for Respiratory Therapists, 3rd Edition. American Association for Respiratory Care.
12. Price D, Bosnic-Anticevich SB, Briggs A, Chrystyn H, Rand C, Scheuch G, et al. Inhaler competence in asthma: Common errors, barriers to use and recommended solutions. Respiratory Medicine. 2013; 107: 37-46
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