The article looks at selecting an inhaler and how the devices should be used ABSTRACT HESLOP, K. (2009) Respiratory inhaled therapy 2: choosing an inhaler. _Nursing Times_; 105: 13. The

second article in a two-part series takes a detailed look at what issues healthcare professionals should consider when selecting an inhaler for a patient. It looks at the differences between

the different types and explains how they should be used. Part one looked at the use of pressurised metered dose inhalers (Heslop, 2008). KEYWORDS: Respiratory illness, Inhaled therapy,

Patient education AUTHOR KAREN HESLOP, MSC, PGDIP IN COGNITIVE BEHAVIOURAL THERAPY, BSC, is respiratory nurse consultant, Royal Victoria Hospital, Newcastle upon Tyne Hospitals NHS

is to be used properly. A less than optimal technique can result in decreased drug delivery, which may lead to symptoms persisting and affecting the patient’s quality of life. Inhalers

should only be prescribed after patients have received training from a competent healthcare professional in their use and demonstrated a satisfactory technique when checked (British Thoracic

Society and Scottish Intercollegiate Guidelines Network, 2008). There are four main types of inhaler device: * Pressurised metered dose inhalers (pMDIs) are activated when the patient

breathes slowly and deeply, and include Easi-Breathe and Autohaler; * Dry powder devices are activated by inspiration and include Turbohaler, Diskhaler, Accuhaler and HandiHaler. Inspiration

disperses the powder drug particles, which are transported in a carrier such as lactose. * Nebulisers convert a liquid into an aerosol, which is administered through a mask or mouthpiece.

They are used in the treatment of severe exacerbations of asthma or COPD, cystic fibrosis and bronchiectasis. They can also be used to deliver antibiotics directly into the lungs of patients

with pulmonary infections. * Soft-mist inhalers are the newest device; they are propellant free and produce slow-moving aerosols over an extended duration. SELECTING AN INHALER Before they

can select a device for a patient, a healthcare professional needs a thorough understanding of how different devices work, how they should be cleaned and what drugs can be used with each

one. To a large extent, the decision will depend on the patient. They must be able to use the inhaler, and children and elderly patients may find some types more difficult than others.

Lifestyle and circumstances will make a highly portable device especially important to some. The patient’s preference must be taken into account because, if they do not like a device, they

may not use it. The effectiveness of the device in an exacerbation of asthma or COPD should also be considered. For example, a pMDI with a large volume spacer is as effective as a nebuliser

at treating mild and moderate exacerbations of asthma (BTS and SIGN, 2008). Some devices will require patients to have a greater inspiratory flow than others. With pMDIs (with or without

spacers), a gentle slow breathing technique is required. For dry powder devices, 30-60L/min is sufficient, but deposition improves with higher inspiratory flow (Borgström et al, 1994). There

are devices that can measure inspiratory flow - such as the Turbohaler Trainer and the In-Check device - and some that help patients improve technique for maximum deposition. There is a

risk of infection when using inspiratory flow meters between patients, so infection control guidelines must be followed. Some inhalers have dose counters, which will indicate when the

medication is running out, which can be helpful. Patients who need more than one drug may benefit from a combined inhaler such as Symbicort or Seretide, particularly if they pay for their

prescriptions. The cost of the device to the health service should also be considered. The most expensive device may not be the one that costs most but the one that is not being used

correctly so more drug is required. Conditions such as arthritis, poor eyesight or cognitive impairments can affect patients’ ability to use inhalers. Aids are available to help patients use

pMDIs and Turbohalers. HOW TO USE THE DEVICES PMDI The instructions for this device were described in a previous article (Heslop, 2008). Easi-Breathe * Shake inhaler, hold upright and open

cap. * Breathe out gently, put mouthpiece in mouth and close lips and teeth around it (the air holes on the top must not be blocked by the hand). * Breathe in steadily through mouthpiece. Do

not stop when the inhaler puffs. Hold breath for about 10 seconds. * Hold inhaler upright and immediately close the cap. TURBOHALER * Unscrew the cover and lift it off. Check the window to

ensure the device contains enough medication. * Hold the Turbohaler upright in one hand. With the other, twist the grip fully in one direction as far as it will go, then twist back as far as

it will go. A click should be heard. * Breathe out gently. Then place the mouthpiece between your lips and breathe in through your mouth as deeply and hard as you can. * Take the Turbohaler

out of the mouth and breathe out slowly. * Replace the cover. DISKHALER * Take off the mouthpiece cover. * To load a disk, pull out the white tray gently. Place the disk on the wheel so

that the numbers face upwards, slide the tray back in. * Hold the corners of the tray and slide the tray out and in. This will rotate the disk. Stop when the highest number is reached. *

Keep the Diskhaler level. Lift up the back of the lid until it is fully upright. This will pierce the blister. Close the lid. * Breathe out as far as is comfortable. * Keep the Diskhaler

level and raise it to your mouth. Place the mouthpiece between your teeth and close your lips firmly around it. * Suck in through your mouth, quickly and deeply. * Hold your breath and

remove the Diskhaler from your mouth. Hold your breath for 10 seconds. * Turn the disk to the next number by gently pulling out the tray and pushing it in once. ACCUHALER * Hold the outer

case in one hand and put the thumb of your other hand on the thumb grip and push until you hear a click. * Hold the inhaler with the mouthpiece towards you. Slide the lever away from you, as

far as it will go - until it clicks. This opens a blister. A counter records how many doses remain. * Breathe out as far as possible. Put the mouthpiece to your lips. Suck in quickly and

deeply. * Remove the Accuhaler from your mouth and hold your breath for about 10 seconds. * Close the Accuhaler by sliding the thumb grip back towards you, as far as it will go. It will

click when it is shut. HANDIHALER * Open the dust cap of the HandiHaler by pressing the green piercing button. Pull the dust cap upwards and pull up the mouthpiece ridge. * Remove a capsule

from a blister and insert it in the centre chamber. * Close the mouthpiece until you hear a click, leaving the dust cap open. Be sure that the mouthpiece sits firmly against the grey base. *

Hold the device with the mouthpiece upwards and press the green piercing button until it is flush against the base, and release to pierce the capsule. Breathe out completely. * Hold the

device by the grey base, being careful not to block the air intake vents. Raise the inhaler to your mouth and close your lips tightly around the mouthpiece. * Keep you head upright and

breathe in slowly and deeply. You should hear or feel the capsule vibrate. * Breathe in until your lungs are full. Hold your breath for as long as is comfortable and remove the inhaler from

your mouth. * To ensure you get the full dose, breathe out completely and inhale again without pressing the piercing button. * Open the mouthpiece, tip out the used capsule and discard.

Close the mouthpiece and dust cap. SUMMARY Before prescribing treatment, healthcare professionals need to consider which inhaler would be most appropriate. However, choosing a device can be

problematic and there are many issues to consider. If a patient struggles to use any inhaler, an alternative device should be sought. BORGSTRÖM, L. ET AL (1994). Lung deposition of

budesonide inhaled via Turbohaler: a comparison with terbutaline sulphate in normal subjects. _European Respiratory Journal_; 7: 69–73. BROCKLEBANK, D. ET AL (2001) Comparison of the

effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. _Health Technology Assessment_; 5: 26, 1–149. BRITISH THORACIC

SOCIETY AND SCOTTISH INTERCOLLEGIATE GUIDELINES NETWORK (2008) British guideline on the management of asthma. _Thorax_; 63: 5 (Supp IV), iv 1–iv 121. HESLOP, K. (2008) How to use pressurised

metered dose inhalers. _Nursing Times_; 104: 47, 78–80.