How To Use My Inhaler?
It Is Not All The Same
Dear Dr. Mahler:
It is confusing to me how to use the different inhalers prescribed for my COPD. I was diagnosed a few years ago, and my primary care started me on ProAir as needed and Spiriva HandiHaler in the morning. They helped my breathing, but I was still short of breath walking from my car to the grocery store.
I was referred to a pulmonary doctor who recommended adding Symbicort and replacing ProAir with Combivent Respimat for “rescue.” Unfortunately, the nurse who does inhaler teaching was not in the office that day. This morning, my husband watched me use the inhalers, and suggested that I wasn’t inhaling the right way. I got mad at him and told him to “Shut up.”
After I calmed down, I thought about his comment and realized that I really wasn’t sure about how to inhale correctly. It seems so simple, but I not getting the relief that I want. Please help me.
I have been quite inactive during the current COVID pandemic. I retired two years ago working as a secretary in the school district office.
Many thanks.
Karen from Carson City, NV
Dear Karen,
Your question is important because the inhaled medication needs to get deep into the lungs to provide benefit. Certainly, knowing how to inhale correctly can be challenging with the different types of inhalers.
Here is a brief review of the three different types of handheld inhalers:
pressurized metered-dose inhalers (pMDIs)
slow mist inhalers (SMIs)
dry powder inhalers (DPIs)
For all of the three handheld inhalers, the first step is to exhale slowly and completely empty air out of the lungs.
Pressurized metered-dose inhalers (pMDIs)
A pressurized metered-dose inhaler (pMDI)
Make it stand out
With a pMDI, the propellant inside the cannister provides pressure.
Just after you start to breathe in, press down on the canister to release the aerosol (medication). Then, inhale “slow and steady” filling your lungs with air. This allows the medication to reach the lower part of the lungs. Then, hold your breath as long as possible.
Two of your inhalers – ProAir and Symbicort – are pMDIs.
Slow mist inhalers (SMI)
Slow mist inhaler (SMI)
With a SMI, turning the base tightens a spring inside the device to create pressure.
Just after you start to breathe in, press down on the button to release the mist (medication). Then, inhale “slow and steady” filling your lungs with air. This allows the medication to reach the lower part of the lungs. Then, hold your breath as long as possible. This is identical to using a pMDI.
One of your inhalers – Combivent Respimat – is a SMI.
Dry powder inhalers (DPI)
Different dry powder inhalers
With a DPI, you need to create turbulent energy inside the device to break up the powder into small particles. To do this, you should breathe in “hard and fast” and then hold your breath as long as possible. This is DIFFERENT than using a pMDI or SMI.
One of your inhalers – Spiriva HandiHaler – is a DPI.
In my practice if a patient is using a DPI, the respiratory therapist measures the individual’s peak inspiratory flow to determine whether the person has the ability to generate the turbulent energy to successfully break up the powder.
Karen – hopefully this information helps you understand the differences in the three inhalers that you are using. If you continue with your current inhalers – it will be important to inhale “slow and steady” with Symbicort and Combivent, and “hard and fast” with Spiriva.
To make it simple, you may wish to ask your doctor about prescribing inhalers that require the same inhalation.
Finally, I wish to emphasize the importance of using the medications daily as prescribed. Dr. Jorgen Vestbo and colleagues reviewed the effects of adherence (using the inhaler exactly as recommended) in 4,880 patients who participated in the TORCH study. In the study, good adherence was defined as greater than 80% use of the study medication.
Plot of survival if patients were either adherent or not adherent to study treatment
The figure shows that patients who were adherent to the inhaled medication had a 11.3% probability of death at three years compared with 26.4% in those who were not adherent. In addition, good adherence was significantly associated with a reduced risk of admission to the hospital for a COPD flare-up (exacerbation).
Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.
Sincerely,
Donald A. Mahler, M.D.