Inhaler – Types, Proper use of inhalers, side effects



An inhaler is an aerosol device that is used to deliver medication to the lungs. By converting medicine into a breathable mist or small granules, an inhaler allows an individual to draw medication deep into the lungs, where it is most effective. This technique is effective in the treatment of asthma, chronic obstructive pulmonary disease (COPD) and other respiratory problems.

Inhalers come in two main types:

  • Metered-dose inhalers. Use a small canister of compressed air to deliver a specific dose of medication as a fine mist that is easily inhaled. 

  • Dry powder inhalers. Rely on a sharp inhalation from the user to deliver small granules of medication in measured doses.

Learning to use a metered-dose inhaler properly may be difficult. Some dry powder inhalers require a powerful force when inhaling that people with lung problems may not be capable of providing. A physician can determine the best type of inhaler for a specific patient.

People who use inhalers regularly must keep careful track of how much medication they have used. It is often not obvious how much medication remains in the device, especially with metered-dose inhalers. Inhalers should be washed every day. Physicians recommend that people who use an inhaler carry it with them wherever they go, if they use it for rescue medication.

Some infants, young children and elderly people find it difficult to use inhalers. For these patients, a physician may recommend use of a nebulizer – a device that uses pressurized air to deliver liquid medication in a mist form through a mask that fits over the nose and mouth. This delivery method generally makes it easier for the patient to inhale the medication. However, nebulizers are not as commonly used as inhalers because they are inconvenient (due to their dependence on an electrical outlet). They are also much more time consuming to use. Nebulizers take around 15 minutes to use, whereas inhalers take only a matter of seconds.

About inhalers

Inhalers are small, portable containers that dispense inhaled medication for the treatment of respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD).

Inhaled medications are beneficial because they can be applied directly to the inner tissue of the lungs, bypassing the processing that normally takes place in the digestive organs (with pills or other ingested medication). Because the medication takes such a direct route, side effects are generally much less severe with inhaled medications.

In addition, inhalers are able to deliver medications to the specific area where it is needed most – lung tissues. This allows a person to take a lower dose of medication in an aerosolized form than they would with a tablet or capsule (because the dose is not diluted as it travels through the rest of the body).

A device known as a spacer may be used with some inhalers to increase their effectiveness. A spacer is a small tube that fits over the mouthpiece of an inhaler. When the inhaler is used, the medicine is sprayed into the spacer, where it becomes an even finer mist. It is then inhaled out of the spacer and into the lungs.  Spacers can also make it easier for young children or the elderly to use certain inhalers.

For individuals who have difficulty using inhalers, a physician may recommend a nebulizer. Nebulizers use pressurized air to convert liquid medicine into a mist but the medicine can be inhaled gradually with several breaths.

Inhalers are used to deliver several different types of medications, including:

  • Short-acting bronchodilators. Medications that quickly relieve asthma symptoms by opening breathing passages. These are considered “rescue” medications because they are designed to instantly relieve the symptoms of an asthma attack. They are usually not taken long-term.

  • Long-acting bronchodilators. Medications that open airways less quickly than short-acting bronchodilators but for longer periods of time. They are designed to minimize inflammation and prevent asthma flare-ups before they occur and are usually taken long-term.

  • Corticosteroids. Medications that reduce the inflammation associated with breathing problems by enhancing the body’s ability to counteract symptoms. They are used to treat asthma symptoms over long periods of time.

  • Mast cell stabilizers. Medications effective at treating mild or moderate inflammation in the bronchial tubes. Formerly common, these medications are now rarely used in asthma treatment.

  • Corticosteroid plus long-acting bronchodilator. Medications that combine corticosteroids with long-acting bronchodilators to be used in the long-term treatment of asthma and other lung-related problems.

Metered dose inhalers (MDIs) that administer the drug albuterol (a type of bronchodilator) are currently being phased out of the U.S. market. The U.S. Food and Drug Administration ordered their removal from the market by 2009 because they contain an environmentally dangerous propellant known as chlorofluorocarbon (CFCs), which damages the ozone layer. A new type of inhaler, known as the hydrofluoroalkane-based (HFA) inhaler, offers the same albuterol in a different delivery vehicle (one that does not damage the environment). This will not lead to any significant change as far as the patient is concerned.

Types and differences of inhalers

There are two main types of inhalers generally used to deliver inhaled medication to the lungs:

  • Metered-dose inhalers. By pushing down on a small, pressurized canister, a metered amount of aerosolized medication is released from the inhaler through the use of chemical propellant, usually chlorofluorocarbon (CFCs). This process converts the medication into a fine mist that can be inhaled deep into the lungs.

    When the canister is depressed, a puff of medication is released into the mouth of the user. Once in the mouth, the user can inhale the mist into the lungs, allowing the medication to come into direct contact with the inner lining of the lungs, where symptoms associated with asthma and COPD frequently appear.

    This type of inhaler usually includes between 50 and 200 individual doses. To properly use a metered–dose inhaler, the timing of the “push” needs to coincide with the proper inhalation. This takes some practice, but it is important to use these inhalers correctly. With an incorrect breathing technique, the medication will be blocked by the tongue or back of the throat and will be unable to penetrate into the lungs.

    Some of these types of inhalers are breath activated, so that the medication is automatically released as the patient draws a deep breath.

    The CFC propellant used by these inhalers is harmful to the ozone layer. As a result, they are being phased out in favor of metered-dose inhalers with hydrofluoroalkane (HFA), an ozone-friendly propellant. HFA may have a different taste and smell. However, the size, shape and effectiveness of the inhaler are the same.

  • Dry powder inhalers. This type of inhaler does not use a chemical propellant to release the medication. Instead, it relies on the force of the patient’s rapid intake of breath. As the patient inhales, a measured dose of small granules of medication is pulled into the lungs.

    Because there is no need for coordination between the hand and the lungs, dry powder inhalers are generally considered easier to use than metered-dose inhalers. Still, some types of dry powder inhalers require a large amount of effort to inhale the medicine. For this reason, these inhalers may not be usable by children or the elderly. There are several types of dry powder inhalers:

    • Turbohaler. Uses a rotated knob to dispense each dose.

    • Diskhaler. Uses a raised lid to dispense each dose from replaceable disks.

    • Rotahaler. Uses a rotated sleeve to dispense each dose through a mesh screen.

    • Spinhaler. Uses a sliding sleeve and a small propeller to deliver each dose.

    • Diskus. Uses a lever to deliver each dose.

Sometimes a device called a spacer is used with a metered-dose inhaler. A spacer is a holding chamber that is added to the mouthpiece of the inhaler to increase its effectiveness. When the inhaler is activated, the spacer allows the puff of medication to turn into a very fine mist before the individual inhales. The finer the mist, the deeper the medication can be inhaled into the lungs. A spacer also prevents the medication from being blocked by the tongue or back of the throat, which can happen when a metered-dose inhaler is used alone. Spacers cannot be used with dry powder inhalers.

Conditions treated with inhalers

Inhalers dispense medications that are frequently used to treat conditions where it is beneficial to apply medication directly and deeply into the lungs. These conditions include:

  • Asthma. A condition where the airways become blocked and/or narrowed, causing shortness of breath and difficulty breathing. Asthma can be triggered by environment factors, including allergens, cold air and exercise. Inhalers can deliver medication rapidly to the airways, quickly relieving an asthma attack.
  • Chronic obstructive pulmonary disease (COPD). Condition whereby airflow in and out of the lungs is disrupted. Includes emphysema and chronic bronchitis.
  • Allergies. Some allergies cause symptoms to appear in the lungs and airways (such as coughing and shortness of breath). Inhalers can quickly deliver medication to treat these symptoms.

Potential side effects of inhalers

Side effects related to inhaler use are usually minor. Patients may develop tongue or throat irritation as the result of the powder passing through the mouth and throat. The powder may also leave an unpleasant taste in the patient’s mouth. In addition, swallowing any medication that remains in the mouth after inhaler use can lead to minor stomach upset and heartburn.

More serious side effects associated with the use of inhalers include:

  • Thrush mouth. Usually caused by inhaled corticosteroids, this condition is a yeast infection that occurs at the back of the throat. Symptoms include a white film that covers the back of the throat and the tonsils. An antifungal mouthwash is often used to treat this condition.
  • Asthma exacerbations. While metered-dose inhalers are very commonly used to treat asthma, the CFCs (chlorofluorocarbons) that discharge the medication in metered-dose inhalers will occasionally exacerbate an individual’s asthma. In these cases, a physician can recommend a dry powder inhaler that does not use CFCs. Because of the danger CFCs pose to the ozone layer, they generally are being phased out in most countries. An ozone-friendly propellant is replacing CFCs. Known as HFAs (hydrofluoroalkanes), this propellant has a different taste but the effectiveness of the inhaler remains the same.

Patients can lower their risk for side effects by thoroughly rinsing their mouth after using an inhaler and using their inhaler exactly as prescribed by their physician.

Lifestyle considerations with inhalers

There are some considerations that must be taken into account by those individuals who use inhalers regularly. The most important of these is determining when the inhaler is empty. Depending on the type and brand, inhalers can have between four and 200 doses, although the inhaler may still “puff” even after its medication has run out.

Patients should keep careful track of how often they use their inhalers so they know when to refill their prescription. This is easier to do with preventive medicine, which is used regularly. Simply divide the number of puffs in the container by the number of puffs each day. The result is the number of days the inhaler will last. For instance, if a medicine is to be used with two puffs, taken twice a day, then an inhaler with 200 doses should be replaced in 50 days.

This formula does not work as well with inhalers used to relieve symptoms of an asthma attack. One method is to keep track of the number of puffs on a calendar, and tally the number each month. Or, patients can purchase an add-on device for MDIs, which keeps track of the total number of puffs delivered by the inhaler.

It was once thought that placing a metered-dose inhaler in a container of water could indicate how much medication was left (depending on whether it floated or sank). However, that test is now not recommended and may even be dangerous as moisture can prevent the discharge of medication from the inhaler.

Inhalers should be cleaned every day. To clean the device, remove the metal cartridge (on those inhalers that have one) and rinse the applicator under running water. The hole in the mouthpiece, through which the medication is dispensed, should be washed particularly well.

After washing, the device should be air-dried. The protective cap for the inhaler should always remain on when the inhaler is not in use. The metal cartridge should be gently replaced once the applicator is completely dry.

In addition, patients should note the color of their inhalers. Inhalers used to prevent asthma symptoms, for instance, will be of a different color than an inhaler used to relieve an asthma attack. Often, a blue or white inhaler is used for rescue medication.

Individuals should contact their physician if they find that their inhaler is not working properly. Patients should also consult their physician if their symptoms are persisting.   In addition, patients who must use short-acting bronchodilators frequently (such as twice a week) to control asthma, should alert their health care provider. Their long-term treatment regimen may have to be altered. If breathing becomes difficult, an individual should always dial 911.

Proper use of inhalers

It is extremely important to use an inhaler properly to get the full effects of the medicine it dispenses. Improper use of an inhaler can prevent an adequate amount of medicine from reaching the lungs. Improper breathing techniques can cause much of an inhaler’s medication to remain in the mouth, where it is not effective. As a result, physicians may ask patients to demonstrate their inhalation technique at each office visit. This helps the physician ensure that the patient is using the device properly.

Properly using an inhaler depends on the type being used. Breathing techniques are different for each of the two main types of inhalers:

  • Metered-dose inhalers. Using a metered-dose inhaler usually requires some practice to get the timing down right. To properly use the inhaler:

    1. Carefully read the directions of the inhaler, making sure medication is inserted into the device (if needed).

    2. Remove the cap from the inhaler.

    3. Shake the inhaler before each use and always check the mouthpiece for bits of dirt or other foreign objects.

    4. Hold the inhaler in an upright position 1 to 2 inches from the open mouth while tilting the head back slightly.

    5. Exhale fully to clear the lungs of as much air as possible.

    6. Press down on the inhaler canister firmly with the index finger while breathing in fully and slowly (for as long as it feels comfortable – at least five to 10 seconds). Hold the breath for as long as possible before exhaling.

    7. Wait 30 to 60 seconds before repeating any other doses. Make sure to stay within physician-directed limits for the number of repeated doses allowed.

    8. Replace the cap on the inhaler and rinse out the mouth with water or brush teeth thoroughly.

  • Dry powder inhaler. This type of inhaler is easier to use than the metered-dose inhaler. Still, it is important to follow these guidelines for proper use:

    1. Carefully read the directions of the inhaler, making sure a new blister packet of medication is inserted into the device (if it requires one).

    2. Be sure to note how the inhaler dispenses the medication (by puncturing the blister pack). Some types use a lever, others a trigger. Also be sure to hold the inhaler in the correct position (indicated in the instructions).

    3. Exhale deeply away from the inhaler. Never blow into the device.

    4. Place the mouthpiece of the inhaler between the lips, close the mouth tightly around the device and inhale deeply and forcefully.

    5. Wait 30 to 60 seconds before repeating any other doses. Make sure to stay within physician-directed limits for the number of repeated doses allowed.

    6. Rinse out the mouth with water or brush teeth thoroughly after each use.

Child and elderly use issues with inhalers

The use of an inhaler may be too difficult for children and some elderly persons because of the lowered respiratory ability of these groups. While some types of dry powder inhalers require only slight inhalations to activate, others require a sharp intake of breath that not everyone can produce.

In addition, the hand-lung coordination required to use a metered-dose inhaler can be difficult for both children and the elderly. A physician can help suggest the best type of inhaler for a given individual.

Spacers make it easier for anyone with lowered respiratory function to use a metered-dose inhaler. A spacer is a holding chamber that is added to the mouthpiece of the inhaler, allowing the puff of medication to turn into a very fine mist. The finer the mist, the deeper the medication can be inhaled into the lungs. By using a spacer, children and the elderly can have an easier time inhaling medications deep into their lungs. Child-sized spacers are available.

For young children, a pediatric-spacer is available with a built-in mask that fits over the nose and mouth so the child can breathe in the medicine more easily. Another type of device uses a kind of bellows or balloon that allows children to breath in medication with several breaths and encourages them to breathe in evenly and slowly.

Children who carry their own inhalers should also be trained in how to properly use the device. Parents must make sure their child understands how an inhaler works, and under what circumstances an inhaler should be used. This information should also be communicated to school officials, daycare personnel or any other caregivers.

Questions for your doctor about inhalers

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to inhalers:

  1. Am I a good candidate for an inhaler?
  2. What type of inhaler do you recommend for me?
  3. Can you show me the proper way to use an inhaler?
  4. Will I have to use an inhaler for the rest of my life?
  5. Will I have to use the inhaler every day?
  6. Will I have to carry the inhaler with me at all times?
  7. How will I know if the inhaler is working or if I am using the device properly?
  8. How will I know when the medication in my inhaler is getting low?
  9. How often should I clean my inhaler? What is the best way to clean it?
  10. My child is having difficult using the inhaler. Would he or she benefit from using a spacer?
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