Thread by @GailTanMD

🧵on basic #inhaler technique b/c we can all do better educating our #copd #asthma patients 🫁

Studies show inhaler error is common & many pts aren’t taught how to use their inhalers properly

↑💊 ≠ always the answer

#MedTwitter #MedStudentTwitter #Tweetorial
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Step 1: Actually ask how they use their inhaler😅

With so many types, it’s not surprising pts & providers get confused 😵‍💫

Esp in clinic, ⏰ is tight. But only takes a min to explain

Also pharmacists/RTs are amazing! I <3 using them when able

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Let’s first discuss the common inhaler devices. Which one was used in the clip above?

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pMDI pressurized metered dose inhaler
The classic L-shaped inhaler
V. common
Tricky to use

-contain canister with
-💊dissolved/suspended in
-propellant (compressed liquified💧gas💨)

Press👇→
releases drug+propellant→
pressure decreases→
💊💧vaporizes into aerosol💨→🫁

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You’ll often see pMDIs end in“HFA” which is a type of propellant

HFA inhalers replaced CFC-propelled inhalers after CFC was found to destroy the ozone 🌎💀

Still, HFA is a greenhouse gas that contributes to global warming☀️& we’ll discuss some propellant free inhalers next

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What about this inhaler device? Few examples below. Poll on next tweet

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DPI Dry Powder Inhaler

More user friendly
Single dose: place💊each time
Multi dose: usually preloaded

- contain just 💊as a powder
- propellant free, better for 🌎
-“breath-actuated” only need pt’s breath to activate

Inhalation→disperses 💊particles into aerosol💨→🫁

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How about this device?

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SMI soft mist inhaler (Respimat)

Newer
Technique similar to MDI

SMI
-contain liquid drug solution similar to MDI
-BUT propellant free
-⚡️from compressed spring
-💊💨released 4x slower than MDI

Press👇→⚡️from decompression of spring →creates slow velocity mist💨→🫁

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Pts should read the 💊insert for specifics, but the basics are the same!

Let’s 👀 common mistakes
❌Mistake #1: Not priming (if needed) or priming incorrectly
✔️“prime” by spraying a few “waste”sprays
✔️if 1st time use or not used for few days

Which should you shake before?
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Priming:

pMDI: SHAKE and SPRAY. Rmbr,💊is suspended in propellant so you need to mix

SMI: Just SPRAY. No shaking needed. 💊 in propellant free solution.

DPI: NO PRIMING. NO SHAKING. Woo! Just load💊. Usually w/ click of device (or drop capsule in inhaler if single dose)

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❌Mistake #2: Not maximizing lung space
✔️Exhale fully 😮‍💨 before inhaling

❌Mistake #3: Incorrect speed of inhalation

Knowing DPIs are breath actuated, how should you inhale a DPI?

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✔️FAST deep 🐇
DPIs
🙋🏻‍♀️Patient creates aerosol with inhalation
Inhale quick enough to create force to get the medicine into your 🫁

pMDIs & SMIs?
✔️SLOW deep 🐢
⚙️Device creates aerosol
Slow deep breath allows aerosol to 🔀 deep into 🫁 instead of throat

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❌Mistake 4: Poor timing/coordination with pressing down canister & inhaling (too soon or too late)
✔️pMDI & SMI: press & inhale at same time (or inhale a little before)
✔️ DPI: since breath actuated, no coordination needed😍

Which inhaler can you use a spacer?

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You see that MDIs require a bit of coordination that can be difficult esp for kids/elderly

Even with 💯technique, the💊 is propelled at such⚡️speed, a lot goes to throat/stomach not 🫁

Spacers attach to MDIs, slows💨,
acts as holding chamber, & reduces need for coordination
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Ideally EVERYONE using an MDI should use a spacer

❌Mistake 5: Not holding breath afterwards (~10 secs, the longer the better)

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❌Mistake 6: Taking second puff too soon. Wait ~60 seconds in between

One patient told me he did click-click-inhale. Seems obvious, but that’s why it’s impt to ask 😅. Click inhale. Click inhale.

Another patient developed white lesions on tongue/throat. What happened? ❌

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Inhaled steroids can cause oral thrush
✔️Patients should rinse their mouth after using ICS

❌Mistake 7: Not thinking about patient ability when prescribing

i.e. a patient with end stage COPD or 5 year old may not be able to take deep fast breath needed for a DPI

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In addition to inhalers, you’ll often see nebulizers so I’ll quickly mention

Nebulizers
aka “breathing machine”
turns💧💊→💨
delivers via face mask
EASY to use
no coordination
But..
longer treatment ~5-20 min
and bulky

Often used for pts who can’t use inhalers

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Summary
Device⚙️creates aerosol
-pMDI, SMI

Pt🙋🏻‍♀️creates aerosol (by inhaling)
-DPI

Coordination needed
-pMDI>SMI>DPI

pMDI
Expels💊FAST. Not ideal. Can go to throat instead of 🫁. Coordination needed. Spacers help👌

SMI
Expels💊SLOWER. More goes to 🫁

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Quick guide:

-Read 💊instructions
-Prime if needed
-Exhale fully first
-Inhale
-SLOW (MDI/SMI)
-FAST (DPI)
-Hold breath
-Wait 60 sec between puffs
-Rinse mouth if steroids

Not bad! Hope you now feel confident teaching your pts. Comment your tips & mistakes you’ve 👀

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