Inhaler Guide

What is an Inhaler

Inhalers are commonly associated with asthma, but asthma inhalers aren’t the only ones available. These devices are used for treating many lung diseases like COPD, cystic fibrosis, and more. Inhalers can deliver medication in an aerosol or dry powder form which can be orally inhaled. There is a wide range of medication that is available as inhalers which may differ depending on the condition or the disease type.

While inhalation therapy has been around for a long time and can be traced back to 4,000 years ago in India, inhalers as devices were only introduced in the 19th century. The first type of inhaler was actually a glass bulb nebulizer. These were large devices typically used in physician’s offices that generated a mist of medication that could be inhaled, much like the nebulizers in use today which went on to be developed from this technology. In 1938, a hand bulb nebulizer was introduced which was much smaller in size but still had some flaws along with being inconvenient to use. But the modern inhaler technology of compact inhaler devices would not have been possible without these early devices. The first breakthrough inhaler device was the metered-dose inhaler (MDI) that was launched in 1956, which was the first truly effective and portable inhaler device. While improvements have been made to the device over the years, especially with the introduction of a pressurized canister resulting in pMDIs (pressurized metered-dose inhalers), the basic mechanism remains the same and a lot of similarities can be seen in the designs.

Improvements have been made over time and now inhalers even come with dose counters. There are many different types of inhalers available today and they are used widely across the world. Inhalers are one of the highest recommended devices for diseases that affect the lungs since they are one of the most effective forms of delivering medication. As for the future of inhalers, research continues to find ways to make them even more effective.

Why To Use Inhalers

Inhalers are used for treating and managing symptoms of both acute and chronic diseases which includes asthma, COPD (Chronic Obstructive Lung Disease), emphysema, and bronchitis. If you are diagnosed with a respiratory condition like these, your doctor might prescribe you an inhaler to manage the symptoms. If you are wondering why you have to use a special device for medication instead of just having pills taken orally, this is because, with inhalers, the medicine goes directly to the parts of the body where it needs to have an effect - the airways and the lungs. Because of this, a less dosage of medicine is also required than compared to pills, leading to fewer side effects. Doctors can prescribe you inhalers depending on your condition and how severe it is. You might be prescribed inhalers as a long-term treatment option that you might have to use regularly (eg. for asthma) or only for a few days if you have a treatable illness like pneumonia. Inhalers can also have medication that is quick-acting so you can get immediate relief when needed. This is especially important for those diagnosed with asthma because an asthma attack can be quite serious and it is in this situation when a quick-acting asthma inhaler comes in handy, which can make a lot of difference.

Types of Inhalers

There is now a wide variety available today when it comes to inhaler types. There are mainly three types of inhalers that are classified based on the way that they work.

1. Pressurized Metered-Dose Inhalers (pMDIs)

This is the most commonly used inhaler which consists of a pressurized canister that contains medication mixed with aerosol propellants that are released as a spray with the press of a button. Chances are when you think of asthma inhalers, the device you picture is a metered-dose inhaler. Metered-dose inhalers are also commonly referred to as an inhaler pump or asthma pumps since they act just like a pump. So, if you hear someone talking about inhaler pumps or a pump for asthma, you should know that they are most likely talking about the metered-dose inhaler.

While simple in nature, a metered-dose inhaler requires some coordination of actuation and inhalation (hand with breath) which can be difficult to perform for most people who use it across all age groups and especially with kids and the elderly. If there is poor coordination, the proper dose of the medication may not reach the lungs and instead, a larger proportion of the medication might get deposited in the mouth or throat, which can lead to fungal infections. This is also why doctors recommend rinsing your mouth after using inhalers. This challenge of coordination can be overcome by using a spacer.

A spacer, which is a tube-like device that is attached to the inhaler where medication can be sprayed into. Spacers are generally recommended to make the use of metered-dose inhalers easier and more effective to use so the medication can be inhaled properly without much of the dose going to waste. When it comes to an inhaler with spacer, the need for coordination reduces as there is more time to inhale the medication and receive the proper dosage.

2. Dry Powder Inhalers (DPIs)

Dry powder inhalers are quite different from metered-dose inhalers in the way they deliver the medication. Instead of the medication being an aerosol, these inhalers contain the medicine in a dry powder form which can be inhaled. If you are wondering why dry powder inhalers were designed, this was because of the coordination issues mentioned for metered-dose inhalers. They also gained attention when popular aerosol propellants CFCs were banned for environmental reasons as many metered-dose inhalers at the time still used them to deliver the spray (MDIs have now switched to another propellant called HFAs). Dry powder inhalers themselves can be of many types. These include DPIs that deliver a single dose, multi-dose or contain a reservoir-type system that stores the dry powder in bulk.

However, dry powder inhalers have their own advantages and limitations. Their advantages include being easier to use and being environmentally friendly. But since the formulation comes in a dry powder form, it is prone to contamination and damage in humid conditions or if there is a large change in temperature leading to a lesser dosage of medication being delivered.

You can read more about dry powder inhalers here >

3. Breath-Actuated Inhalers (BAIs)

Breath-actuated inhaler refers to inhalers that can release the medication when you breathe in. Breath-actuated metered-dose inhalers combine the benefits of MDIs like the compactness, portability, and the ability to have multiple doses while overcoming the major disadvantage of pMDIs, the need for coordination. Once ready for use, you can simply breathe in and the breath-actuated metered-dose inhaler will release the medication. Among all the types of inhalers for asthma, studies have found this one to be easier to use both in hospital settings and by patients on their own.

While it has its advantages, the breath-actuated inhalers do have their limitations too. Since they are activated by inhaling, if the force of inhalation isn’t strong enough, which can be the case for some people with breathing conditions, the medication isn’t released. BAIs can be used with a minimal inspiratory flow (force of inhalation) of around 23-35 L/min, making them suitable for use across all age groups including children and the elderly.

Why Proper Use of Inhalers Matters

While we have discussed the many options available thanks to the development of different inhaler types over the years, talking about proper inhaler use is equally important. There have been many studies over the years about incorrect inhaler use which show why knowing the correct technique to use inhalers is important. Improper inhaler use has also been linked with poor control of diseases, more frequent emergency room visits, and even with greater risk of hospitalization. This is because if your inhaler is used incorrectly, the proper medication fails to reach the airways and lungs and they don’t receive the treatment that they are supposed to receive. So, no matter what inhaler types you end up using for your treatment, be sure to also be aware of proper inhaler techniques so you can get the full effect of the medicine.

How To Use Inhalers

Since there are many types of inhalers that work in different ways, the techniques to use them also differ. Let’s go through the techniques for some of the most common inhaler types:

How To Use Metered-Dose Inhaler (MDI)

With metered-dose inhalers being the most widely used among all inhaler types, this might be the kind you might be familiar with. Here are the steps to use a metered-dose inhaler:

Step 1: Take off the cap of the inhaler and shake the inhaler well.

Step 2: Hold the inhaler in an upright position and stand up or sit up straight.

Step 3: Exhale and breathe out all the air in your lungs as you tilt your head slightly backwards.

Step 4: Hold the mouthpiece between your teeth, close your lips around to achieve a proper seal.

Step 5: Start breathing in slowly through the mouth and press down the canister fully to release one spray. Continue breathing in slowly and deeply. This coordination is important to follow to ensure the proper dose of the medication is delivered.

Step 6: Remove the inhaler from your mouth.

Step 7: Hold your breath for ten seconds, or as long as you comfortably can, and breathe out slowly.

Repeat the steps to take the number of puffs as prescribed by your doctor with a gap of at least 1 minute in between. Many people find it difficult to coordinate their breathing with the release of medicine as described in step 5. Children especially might not be able to follow it so doctors recommend using pMDIs with a spacer that can be attached to the inhaler before use. The medication remains suspended in the chamber of the spacer after being sprayed, allowing more time to inhale the medicine comfortably at a slower rate over a period of time so it can be inhaled completely.

How To Use Dry Powder Inhaler (DPI)

Dry powder inhalers have become more popular over the past few decades. Like metered-dose inhalers, they can also be small in size and easy to carry around. But with DPIs, you will find many different types of models as some load medicine in single doses for one-time use, some contain multiple doses of medicine, and others have a chamber that holds the medication in bulk and releases a particular amount of dosage with each use. Here is how you can use a dry powder inhaler:

Step 1: Load the medication dosage according to the instructions for your device. Since there are many types of dry powder inhalers available, the method might vary.

Step 2: Ensure that the medication is properly loaded and the inhaler is ready for use.

Step 3: Sit or stand upright and breathe out fully through your mouth.

Step 4: Put the mouthpiece between your teeth and close your lips around it to form a proper seal.

Step 5: Breathe in quickly and deeply. In some devices, you might hear and feel the vibration of the medication capsule as the medication gets released from it.

Step 6: Take out the inhaler and hold your breath for about ten seconds, or as long as you comfortably can.

Step 7: Check to see if there is any powder remaining in the chamber of the inhaler in case of a capsule device. If there is, repeat steps 3 to 6.

In case of the multi-dose DPI Inhalers, since they are already pre-loaded with medication, you may skip Step 1 and 2. Also, in case of multi-dose DPI Inhalers, generally the entire dosage is administered at once and step 7 may be skipped.

How To Use Breath-Actuated Metered-Dose Inhaler (BA-MDI)

Breath-actuated metered-dose inhalers have similarities in the formulation with metered-dose inhalers but using them is different because you don’t need to press to spray the medication. Here are the steps to use a breath-actuated metered-dose inhaler:

Step 1: Shake the inhaler well and remove the cap of the inhaler. Check if the mouthpiece is clean.

Step 2: Sit or stand up straight and breathe out completely.

Step 3: Hold the inhaler in an upright position and place it between your teeth.

Step 4: Close your lips around it to form a seal.

Step 5: Breathe in slowly and deeply. Continue breathing in after the medication has been released.

Step 6: Take out the inhaler and close the cap. Hold your breath for around ten seconds, or as long as comfortable.

Repeat this process if you have to take more than one dose.

These techniques only cover some of the most commonly found inhaler types. No matter what inhaler you have, you can find the proper technique listed down in the patient leaflet that comes with the inhaler. And if you’re not sure about your inhaler technique, you can always get in touch with your doctor. Breathefree also has a Digital Educator Initiative where you can get a demonstration of proper inhaler technique, free of cost.

How To Clean Your Inhaler

While inhalers don’t typically require much maintenance, keeping your inhaler clean is important. These are devices that you will be using almost every day so it is recommended to clean them regularly as otherwise, you might find yourself inhaling dirt and debris along with your medication - which is something you want to avoid. Cleaning your inhaler is also especially important if you have recently suffered from a respiratory infection. If you used your inhaler through a bout of a cold or the flu, there might still be germs in it later so you should give it a thorough cleaning. The cleaning methods differ depending on which types of inhaler you use but the care instructions are typically mentioned in the patient leaflet that comes with the box.

It is important to clean inhalers regularly to prevent inhaling dirt and debris along with the medication. In the case of pressurized metered-dose inhalers, it is recommended that they be cleaned once a week.

pMDIs can be cleaned using two methods please refer your inhaler pack leaflet to know which method to follow for your inhaler.

Here are the steps to clean a pMDI.

Method 1:

Step 1: Take the mouthpiece cap off. Do not take the metal canister out of the actuator.

Step 2: Wipe the inside and the outside of the mouthpiece with a clean & dry cloth.

Step 3: Replace the mouth piece cap.

Do not wash or soak any part of the inhaler in water

Method 2:

Step 1: Gently pull out the metal canister from the actuator of the inhaler. Remove the mouthpiece cap from the actuator.

Step 2: Immerse the actuator and the mouthpiece cap in warm water. Do not Put the Metal Canister in water.

Step 3: Next rinse the actuator & the mouthpiece cap thoroughly under running tap water.

Step 4: Shake well to remove excess water.

Step 5: Leave to air-dry. Avoid excess heat.

Step 6: When the actuator is dry, replace the metal canister into the actuator so that it fits firmly & then close the mouthpiece cap.

Refer to the video guide on How to clean your pMDI device.

Spacers can be cleaned by first separating the two halves by gently rotating and pulling them apart and then rinsing the two halves in clean water or a soap solution. The water should not be boiling as it can damage the spacer. Once done, you can shake to remove excess water and wipe it dry with a soft cloth or leave it to air dry. It is recommended to replace spacers every 6 months.

For dry powder inhalers, you can refer to the information leaflet that accompanies the device for specific cleaning instructions and how frequently to clean it as they might vary depending on the type of device. Dry powder inhalers need to stay away from water while use as it can cause the powdered medication to lump together.

Here are few videos to guide you for cleaning and maintaining your inhaler.

How to clean a pressurized metered dose inhaler (pMDI)?

How to clean a breath actuated inhaler (BAI)?

Short-Term Effect of Inhalers

The effect of the inhalers in a short term depends on the type of inhaler and why the inhaler has been prescribed. Inhalers can be used for short-term respiratory conditions to provide relief from some symptoms as well as for treatment for long-term conditions like COPD and asthma that don’t have a cure. With asthma inhalers, there are usually two kinds of inhalers provided - a maintenance asthma inhaler that is to be used daily and a rescue or quick-relief asthma inhaler that, as its name suggests, is only to be used for emergencies like an asthma attack and provides immediate relief. If you have the need to use a rescue inhaler, you might see the short-term effects quickly but if you have been prescribed an inhaler for the long term, you might only notice the symptoms improve gradually. Rescue asthma inhalers contain fast-acting bronchodilators which relax the airways and make it easier to breathe. However, these contain a high dosage of medication and should not be used frequently. If you find yourself using your rescue asthma inhaler more than twice a week, you should get in touch with your doctor.

Long-Term Effect of Inhalers

If you have a chronic breathing condition like asthma or COPD, you might have been prescribed inhalers for long-term use to be taken daily. When inhalers become a part of your day-to-day life, you might also wonder what the long term effects are. So, do your COPD or asthma inhalers make a change in the long run? The short answer is yes.

There have been studies that show that when used for the maintenance of symptoms for a long period of time, the regular use of inhalers can improve lung function and reduce the risk of hospitalizations. So, if you have been prescribed COPD or asthma inhalers to manage the symptoms and you use them according to the schedule using the proper inhaler technique, you can also expect to see some improvement in your breathing condition over the long term. Studies have even shown that for those with asthma, the narrowing of the airways can even reduce, resulting in symptoms getting better with long-term inhaler use. You should also know that there is no best inhaler for asthma, the long-term effect can be seen with any type of inhaler if it is used properly.

In some cases, the inhaler medication may need to be adjusted as your breathing condition can also change over time. The dosage of the medication might need to be adjusted or the medication might need to be changed if you don’t notice much improvement in your symptoms or your symptoms get worse. If you experience this, it is important to get in touch with your doctor. Your doctor will be able to test whether your inhaler is having the desired effect and what the next steps should be.

Dos and Don’ts of Inhaler Use

When it comes to treating your breathing problems such as asthma and COPD, inhalers are your best friends. Here are some tips that will help you use your inhaler efficiently and keep your breathing problem under control. Follow the instructions mentioned in the patient information leaflet to ensure that you’re using the inhaler in the right way (Click here to learn how to use inhalers)

Do-

• Label your Controller and Reliever inhalers to avoid confusion.

• Breathe out fully before inhaling the medication

• After removing the inhaler from the mouth, hold your breath for about 10 seconds, or as long as it is comfortable.

• If another dose is required, wait for at least 1 minute before taking the second dose.

• Keep a check on the number of doses left in your inhaler.

• In case of dose counters, when the color of the dose counter changes from green to red, indicating fewer doses, consider buying a new inhaler.

• Follow the cleaning and washing instructions mentioned in the patient
  information leaflet.

• Always keep your Reliever inhaler and doctor’s prescription handy while travelling
  while traveling.

• Talk to your doctor and clarify any doubts you might have about the inhalers.

Do not-

• Do not exhale into your inhaler.

• In case of dose counters, do not tamper with the numbers on the dose counter.

• Do not use the inhaler beyond the expiry date.

• Do not exceed the recommended dose.

Myths and Facts About the Use of Inhalers

While most of the people across the world have accepted inhalers

as the most effective way to treat breathing problems, there are still many myths that surround these devices. It is because of these myths that some people are often a little worried when they are told that inhalation therapy is the best for them. However, using inhalers is safe and effective, so you can keep using them without any worry.

These are some of the common myths that people have when it comes to inhalers:

• Myth #1- Inhalers cause addiction

Despite common belief, using inhalers regularly does not mean you will get addicted to it. The medication used in inhalers is not habit forming. Early discontinuation may cause the symptoms to reappear. Simply put, inhalers are a necessity to treat breathing problems such as asthma and COPD, and do not cause addiction. Inhalers should be used for as long as prescribed by your doctor.

• Myth #2- Using inhalers stunt children’s growth

This is a very common misconception with inhalers. Inhalers have next to no side effects, as the medication delivered to the lungs is in very small doses. In fact, when taken regularly and in the prescribed doses, inhalers are the safest kind of medication to use for treating breathing problems. Contrary to popular belief, children who have regularly used inhalers to treat their breathing problem have grown up to normal adult height.

• Myth #3- Inhaled steroids are harmful

When you use the inhaler, the medication reaches the problem area – the lungs - directly. Therefore, the amount of medication delivered to the lungs through the inhaler is very small. Such small amounts do not cause any harm. Inhalers can be safely taken by everyone, including children and pregnant women. In addition, the kind of steroid used in the inhaler medication is not the same as the one used by athletes and body builders, for improving their performance. Thus, the chances of you having any kind of side effects is minimal. In fact, you are far less likely to come to any harm from using your inhaler regularly than not taking it.

• Myth #4- Inhalers are the last resort

Inhalers are not the last but the first resort medicine for treating breathing problems such as Asthma and COPD. Across the globe, inhalers are considered to be the most effective, safe and convenient way of treating most of the breathing problems. Inhalers make it possible for the medicines to reach the problem areas – the lungs and airways – directly to provide immediate and long-term relief. Inhalation therapy is the most effective way to treat your breathing problems such as asthma and COPD, so you can continue doing all that you love and enjoy, and lead a normal active life without any worry.

Questions For Your Doctor

Depending on your needs, your doctor will prescribe the correct asthma inhaler for you. When you have been prescribed an inhaler, your doctor will cover a few basic points about how to use them. But if you want to understand inhaler use in more detail, here are some questions that you can ask them:

• What is the proper technique for using the inhaler?
• Are there any other types of inhalers that I can try if I have difficulty using this one?
• How can I know if my inhaler technique is correct?
• How do I know if my inhaler is working?
• How often is too often when it comes to using rescue inhalers?
• What should I do if I feel my rescue inhaler is not working?
• What should I do if I miss a dose?
• What happens if I take in extra puffs of my inhaler accidentally?
• What should I do if I don’t have my inhaler with me and feel the symptoms getting worse?