to inconsistent dosing andpoorly functioning inhalers. All aerosol inhalers, such asmetered dose inhalers (MDIs),should be shaken before use.

• Using an aerosol device thatisn’t working properlyThe patient should check thatthe spray is functioningcorrectly before using it forthe first time or if they havenot used it for a while (usuallyfive to seven days). Theprotective cap should beremoved, the inhaler shakenand sprayed twice into the air.

• Not breathing out beforeinhaling

Breathing out fully, or as muchas is comfortable, reduces

the amount of air in theairways and increases

the available spacefor air from the

next breath.The result is adeeper thannormalinhalation,maximisingthe chanceto carry allof the

medication

to the site of action. It isimportant that people don’tbreathe out into the inhaler, as this may introduce moistureinto the device or disperse thepowder if it’s a dry powderinhaler (DPI), both of whichwill reduce the clinical effect.

• Incorrect positioning of thepatient and DPI inhalerPatients should be instructednot to hold a DPI with themouthpiece pointingdownwards during or afterthe loading of a dose as thedrug can escape. It should bekept horizontal or upright.Patients should keep their chinup or head slightly tilted backwhen using the inhaler.

• Incorrect co-ordination ofMDI actuation and inhalationTo deliver the medication tothe lungs, the patient mustcoordinate breathing in withpressing the canister.

Starting to breathe in tooearly can mean the breath inhas finished before thecanister has been pressed,particularly if the inhalation is very fast. The result is themedication is deposited intothe mouth, with little or none

recommendations that canimprove the administrationand effectiveness of the drug.This can help to avoid thefollowing common errors:

• Not shaking the inhalerdevice before useWhen the canister of anaerosol device is pressed, avolume of liquid is releasedinto the inhaler’s nozzle,which then rapidly evaporatesto produce the aerosol ‘mist’. If the contents of the canister– both the propellant and themedication – are not mixedthoroughly, then too much ortoo little of one component

will be released.Not shaking the

canisterproperly

can lead

systemic availability, whichminimises adverse effects.Despite this being thepreferred method of efficientdelivery of medication to thelungs, evidence suggests thatmany people are unable to usetheir inhalers effectively.

Common errors In most cases, incorrect inhaler

technique can beresolved with

simple

Inhaled therapies are themainstay of deliveringmedicines for people withrespiratory diseases such asasthma. When compared withsystemic administration, ifused correctly, inhalers delivera smaller amount of the drugdirectly to the site of action inthe lungs, with a faster onsetof effect and with reduced

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C P D M O D U L E

Welcome to our CPD module series for communitypharmacy technicians. Written in conjunction with thePharmacy Magazine CPD series, it will mirror the magazine’sprogramme throughout the year. The series has beendesigned for you to use as part of your continuingprofessional development. Reflection exercises have beenincluded to help start you off in the CPD learning cycle.

CURRENT THINKING ON...

OPTIMISING INHALERTECHNIQUE

MODULE NUMBER: 60

AIM: To help pharmacy technicians assess patientinhaler technique and provide the knowledge toidentify and correct it.

OBJECTIVES: After completing this module, you shouldbe able to: l Recognise common errors with inhaler use anddiscuss possible solutions toimprove a patient’sinhaler techniquel Understand thatinhaler devices areas important asdrugs inmanaging thediseasel Describe bestpractice in the useof different inhalerdevicesl Discuss the steps of aconsultation to assess a patient’s inhaler technique.

CPD

SUPPORT

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LUATE

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CT

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Contributing author: Dr Anna Murphy, consultant respiratory pharmacist, University Hospitalsof Leicester NHS Trust and honorary visiting professor, De Montfort School of Pharmacy, Leicester.

Tech matters CPD P44-45_Q8.LN_G_fever 10/09/2015 13:55 Page 44

reaching the lungs. The time between pressing

the canister and the final partof the medication leaving theinhaler device is less than halfa second, so any delaybetween pressing the canisterand starting to breathe inmeans that lung deposition is significantly reduced as theaerosol will already have been released.

In both cases, the risk oflocal side effects is increased.Training aids are availablewhich can be used toencourage slow inhalationwith MDI devices.Alternatively, using a spacerdevice or breath-actuatedinhaler will help to overcomethis problem.

• Delay in inhaling the drugthrough a spacer deviceMedication stays suspended ina spacer only for a short time,so if patients fail to take eachdose immediately after loadingthe spacer, a proportion of thedose is deposited onto theinner surface of the device andis therefore lost.

• Inspiratory flow – breathingin too quickly or too slowlyThe total lung deposition of aninhaled drug is stronglyaffected by the speed ofinhalation and the requiredspeed varies depending on thetype of inhaler used. Aerosolssuch as MDIs need a slow andsteady inhalation to increaselung deposition. DPIs require aquick and deep inhalation togenerate a large internalturbulent force to break upthe formulation and optimisethe particle size and lungdeposition. The inhalationshould be forceful from thestart of inhalation.

• Not continuing to breathe inafter pressing the canisterInhaling deeply maximises the

opportunity for the drugparticles to reach the smallairways. If no additional air is inhaled, the drug will remainin the larger airways, limitingits effect. Patients shouldtherefore continue to breathein after pressing the canister.

• Not holding the breath afterinhalationHolding the breath increaseslung deposition through theprocess of sedimentation,

meaning the air is still enoughfor the drug particles to settleon the surface of the lungs. A10 second breath is thought tobe ideal, but if this is notpossible, encourage thepatient to hold for as long as iscomfortable after inhaling.

• Multiple actuations withoutwaiting in betweenVery rapid actuations canreduce the dose delivered peractuation, limiting the drug’seffectiveness. However,salbutamol MDIs can beactuated immediately after therequired breath holding for 10seconds without affecting thedose delivered. Patients shouldbe advised according to thetype of inhaler they use.

• Using an empty inhaler Patients frequently fail todetect when their inhaler is

empty, particularly when usingreliever MDIs. They shouldtherefore be encouraged toregularly check their inhalersto ensure there is a sufficientamount of the drug remainingto be effective.

• Poor maintenance of inhaleror spacer deviceSpacers should be reviewedevery six to 12 months to checkthat the structure is intact (e.g.no cracks), the outer casing isclean and the valve isfunctioning effectively.

Improving inhalertechniqueTraining of patients by healthprofessionals has been shownto be an effective means ofimproving inhaler techniqueand should be repeated atregular intervals. It is essentialthat those providing the

training are themselves ableto demonstrate correcttechnique for each inhalertype. This ensures patientsunderstand the right steps fortheir own inhaler. Pharmacytechnicians can use thechecklist of step-by-stepinstructions outlined in Table1 to achieve optimal inhalertechnique.

How to engage withpatients When assisting patients usinginhaler treatments, you should:

• Introduce yourself to thepatient

• Ask the patient if you candiscuss their inhaler treatmentwith them. Do not ask: “Canyou use your inhaler?” It isbetter to say: “Can you showme how you use your inhaler

so we can see if we canimprove the amount ofmedicine getting into yourlungs?” Don’t rely on thepatient’s assurance that theyknow how to use their inhaler– most are unaware that theirinhaler technique could beimproved

• Discuss the inhaler with thepatient, explaining whatmedicine it contains and howit should help their lungcondition

• Describe the steps of usingthe inhaler device (see Table 1for checklist)

• Demonstrate the optimalinhaler technique to thepatient yourself

• Ensure the patient knowshow to keep their inhalerclean and in good workingorder, making sure they knowhow to recognise when theirinhaler is empty or nearlyempty

• Ask the patient if they haveany questions or concernsabout their medicine and thesteps to optimise delivery ofthe drug to their lungs.

Inhaler technique must be re-checked and educationreinforced regularly in order to maintain optimal delivery of the drug.

Education is key The NICE guideline for peoplewith chronic obstructivepulmonary disease and theBritish Thoracic Societyguideline for asthma bothrecommend that prior toprescribing a new inhaler, thepatient should receive trainingand education in the use ofthe device.

Inadequate inhalertechnique will lower drugdeposition to the lungs, wastemedication and may lead topoor disease control, reducedquality of life, increasedemergency hospital admissionsand higher treatment costs.

Pharmacy technicians canreally make a difference in thisarea by ensuring that everypatient with an inhaler knowshow to use their devicecorrectly, either by providingtraining or by referring to apharmacist.

SEPTEMBER 2015 T R A I N I N G M AT T E R S 45

reflectionexercise

Go to www.tmmagazine.co.uk to answer the CPD questions. When you pass, you’ll be able to download a certificate to showcase your learning.You can also add this to your online, personalised learning log.

Think about the last time you counselled a patientabout their inhaler technique. How confident are youthat you correctly assessed their inhaler technique?What went well and what could you improve?

Next month: We focus on cardiovascular MURs.

USEFUL RESOURCES:

l ‘7 steps to success’ inhaler device reminder cards aredesigned for healthcare professionals to use withpatients and can be purchased from:simplestepseducation.co.ukl The Greater Manchester Inhaler TechniqueImprovement Programme has created a series of videosand podcasts about inhaler technique. See:wires.wessexahsn.org.uk/video-series/inhaler-technique l Guides on the Electronic Medicines Compendiumwebsite: medicines.org.uk/guides/pages/how-to-use-your-inhaler-videos l More information and resources are available fromAsthma UK: asthma.org.uk

Step 1 Prepare the device. Remove the mouthpiece cover, open the device and hold the inhaler upright

Step 2 Prepare the dose. Shake all aerosols and Easyhaler devices and load dose for DPIs

Step 3 Breathe out gently as far as is comfortable (not into the inhaler)

Step 4 Put the mouthpiece in the mouth and close lips around it

Step 5 Breathe in. Check the coordination of breathing and actuation of MDI. Think about the type of inhaler device – is it an aerosol device or DPI?••Breathe in slowly and steadily for all aerosol devices, including through a spacer device. Use a training aid if necessary••Breathe in quickly and deeply for all DPIs

Step 6 Remove inhaler from the mouth and hold breath for up to 10 seconds

Step 7 Repeat dose (if applicable) and replace mouthpiece cover or close device

Table 1: 7 steps to success: inhaler technique reminder checklist

C P D M O D U L E

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Tech matters CPD P44-45_Q8.LN_G_fever 10/09/2015 13:55 Page 45