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Monday, December 13, 2010

Many patients do not use inhalers properly

Studies show most asthmatics do not use their inhalers correctly. In fact, this may be a greater problem than you suspect. I recently wrote about his at

Proper inhaler use is essential

(August 10, 2010)

Chances are most asthmatics have a metered dose inhaler (MDI) tucked away somewhere in their possession. Yet studies (like these) show too many of us do not use our MDIs correctly.

Of course improper use of your medicines will inevitably mean you're not getting as much of the medicine as you should, and may result in difficulty controlling your asthma.

Take your MDI and squirt it into your mouth. When you do this you'll note most of the medicine impacts hard on the back of your throat. You can taste it strongly. Of course then it has to make a hard turn to get into your lungs.

Studies show even with proper use only 9 percent of the medicine reaches the air passages of your lungs. Thus, with improper use, you won't be getting much medicine at all.

It's evident: proper inhaler use is essential.

So, to get the most out of your MDI, you'll have to be aware of the following facts:

1. Prime the pump: According to, "Asthma for Dummies," by Dr. William E. Berger, "Loss of prime occurs when the inhaler's propellant evaporates or escapes from the metering chamber after days or weeks of non-use. If you haven't used an inhaler recently, waste a puff of medication (often less than a full dose) to be sure you're getting a full dose.

The MDI Albuterol should be primed after three days of nonuse. To see recommendations for priming other inhalers click here.

2. Tail off: Berger notes that many asthmatics try to squeeze every last drop out of an MDI. Studies show that after so many puffs all that's left in an MDI is propellant. Most MDIs have a counter so you know how many puffs are in a canister. Do not try to get more out of it.

3. Correct use: There's more than one way to properly use an MDI, yet the most effective way is to use a spacer (see below). Since many guys don't carry a spacer, experts recommend you shake the inhaler well, and place the inhaler one to two inches from your mouth before inhaling. These one to two inches help reduce upper airway impaction of medicine. For a more detailed instruction on correct MDI use, click here.

4. Spacers and holding chambers: To see a spacer, click here. However inconvenient and bulky, spacers have two major advantages: they improve coordination and reduce your risk for systemic side effects.

Large inhalent particles are trapped inside the spacer instead of sticking to your upper airway.

When you inhale, the spacer allows you to generate a smooth, laminar flow, which improves the amount of medicine that gets to the air passages of your lungs by up to 70 percent.

In fact, studies like this one prove proper use of an inhaler with a spacer is equally as effective as a nebulizer breathing treatment.

Likewise, due to less impaction in your mouth, your risk of side effects is greatly reduced. Follow this with a good rinse, and you'll reduce the risk of side effects even more.

Asthma experts note the exception here is adults who are having an acute exacerbation of asthma. In this case airflow may be so obstructed generating enough force to properly use the inhaler may pose a problem.

For children, on the other hand, an inhaler with spacer and mask is the most effective means of inhaling the medicine even during an acute attack. This is because other methods have been proven pretty ineffective with most children. I wrote about this more extensively here.

The latest craze in asthma treatment is dry powdered inhalers (DPI) like Advair. The neat thing about DPIs is they eliminate the need for spacers. The reason is because the medicine is inhaled by the force you create, and this eliminates any coordination problems

The problem with DPIs is they cost too much, and adequate distribution of the medicine is determined by the flow you create, so it's still important to be taught proper technique. (For a neat article on DPIs, click here)

Another problem with DPIs is each device is different, so for each one you may need to learn a different technique. To refresh yourself on the proper use of your DPI, check out this link.

Actually, while many newer meds are now available as DPIs, most research shows that MDIs used properly with a spacer work better than DPIs. (For a great post comparing the MDI with the DPI click here.)

So, for this reason, and because of the chemical composition of bronchodilators like Albuterol and xopenex, the MDI will not be available as a DPI anytime soon.

To learn how to properly use an inhaler with a spacer click here.

When I was a kid spacers were hard to come by, and my doctor recommended I use a used toilet paper roll as a spacer. I couldn't find a toilet paper roll recommended here online, but I did find this and, better yet, this. In nations where spacers are unavailable or expensive, these old ideas still work.

Still, while spacers work best, one study showed that fewer than 20 percent of asthmatics use them. Recently, my asthma blogging friends and I came up with some theories why this might be:

1. Grew up in the no spacer era (old habits die hard)
2. Carrying a spacer is inconvenient
3. Laziness
4. Never showed proper inhaler technique (do you have a
good doctor?)
5. Don't know what a spacer is (I get this a lot where I work)
6. Don't know advantages of spacers
7. Spacers make being discreet with inhaler use impossible
8. Personal preference
9. Don't need 70 percent more medicine
10. It works just fine without a spacer
11. Can't afford one

I'll be honest. When I was a bronchodilatoraholic kid, I spent many nights running the inhaler under warm water trying to get the last drop out. I also cringed at the idea of wasting my holy Ventolin by priming it.

I think most asthmatics are like me, and use their spacer sometimes. We may use it at home, yet when we travel we use it as is. Not many people, I think, like to carry that bulky spacer around -- yet we all should.


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