What are the main types of inhaler?

The two main types of inhaler device (or 'puffers') available for asthma medicines are MDIs (metered dose inhalers, also called aerosol inhalers), and dry powder inhalers. In some cases these may also be used for people with COPD (chronic obstructive pulmonary disease). Inhalers allow the medicine to take the ‘direct route’ and go straight to the lungs, meaning a smaller dose of medicine is needed and it can start working quickly. Spacer devices are also recommended for use with MDIs, to maximise effectiveness.

Why are there different types of inhaler?

Asthma medicines can be divided into four main groups: preventers, relievers, symptom controllers, and combination inhalers. Different drug companies make products in each medicine group, and they come in different strengths and forms. For more information about the types of asthma medication, see Asthma medicines 

Metered dose inhaler (MDI)

In a metered dose or aerosol inhaler, the medicine and a liquid propellant are forced under pressure into a small canister, which is put into the coloured plastic case. When the inhaler is pressed, a measured dose of medicine is released through the mouthpiece. Exactly the same dose is released each time.

Preventer, reliever, symptom controller and combination medications are all available in MDIs. Using the MDI with a spacer (see further below) can make it easier to use the inhaler and improve the effectiveness, as more medicine gets into the lungs. Children over 10 years may be able to use an MDI. However, babies and young children can use MDIs with a spacer or a spacer and a mask. It is recommended that spacers are used with MDIs to receive maximum benefit from the medicine.

How to use your MDI

Common mistakes in using the MDI

• Breathing in too fast
• Breathing out so hard that you cough
• Pressing the puffer too early before you have started to breathe in (if you see a mist of medication from your mouth, then you are making this mistake)
• Tilting your head down - it should be tilting back slightly
• Activating the inhaler twice during a single inhalation 
• Giving the inhaler a 'test puff' into the air and wasting the medication
• Breathing in through the nose instead of the mouth.

How to look after your MDI

• Your inhaler can get clogged, especially where the medicine sprays out
• Clean your inhaler weekly to ensure it doesn't block (twice weekly if you use Tilade or Vicrom)
• To clean the inhaler, remove the plastic mouthpiece cap, remove the metal canister (don't put it in water), rinse the mouthpiece and case under warm water for at least 30 seconds
• Shake off any excess water, and leave the mouthpiece and cap to dry overnight
• Put the metal canister back in, and replace the cap.

Storing your MDI 

• Always keep the cap on your inhaler when it is not in use
• Store spare inhalers in cool places (not in car glove boxes)
• Carry a spare clean plastic casing in case the one you are using becomes blocked.

When to start a new inhaler

• By shaking the inhaler it is possible to hear if there are any contents left in the canister.
• Always have a spare inhaler ready, start this before the old one is completely empty.   
• It may help to write the start date on the preventer inhaler, so you can calculate how long it will last with daily use.

Spacers

Spacers are clear plastic tubes with a mouthpiece or mask on one end and a hole for your inhaler at the other. A valve in the spacer mouthpiece opens as you breathe in and closes as you breathe out. A spacer makes your MDI (metered dose inhaler) easy to use and more effective for people of all ages. Use your spacer with preventer, reliever, symptom controller and combination medicines.

Small volume spacers can be obtained for free from your doctor for children six years and under. Large spacers are free from your doctor for children over two years and adults.

How does a spacer help?

• Many adults and children are unable to use their metered dose inhaler effectively. The spacer reduces the need for perfect technique
• 50% more medicine enters the lungs when a spacer is used
• Less medicine gets left in the mouth and throat, which reduces the side effects of hoarseness or thrush in your mouth from preventer medicine
• A spacer can help when you are short of breath and an inhaler by itself is difficult to use
• A spacer is a smaller, convenient alternative to a nebuliser. Studies on adults and children show spacers work just as well as nebulisers in acute asthma
• Spacers with masks can help very young children inhale their medicine.

Cleaning a spacer

• Wash the spacer with warm water and dishwashing liquid
• Do not rinse
• Drip dry.

Priming: Wash your spacer before you use it for the first time. This is called 'priming'. It reduces static electricity inside your spacer so that the medicine does not stick to the sides of the spacer.

Regular cleaning: After priming, wash your spacer once per week (or more often if using Vicrom or Tilade).

How to use your spacer

• Shake the inhaler well (holding it upright)
• Fit the inhaler into the opening at the end of the spacer
• Seal lips firmly around the mouthpiece (or place the mask so it seals around the nose and mouth)
• Large volume spacers need to be tilted upwards at a 45 degree angle to ensure the valve works properly
• Press the inhaler once only
• Take 1-6 slow breaths in and out through your mouth. Do not remove the spacer from your mouth between breaths
• Remove the spacer from your mouth
• Repeat these steps for further doses
• Rinse mouth and spit out water or clean teeth after using a corticosteroid preventer.

Smartinhaler

Smartinhalers contain a micro-computer to help you use your inhaler effectively. Smartinhalers can be used with a special software programme. Together, the software and smartinhaler allow you to track and control your asthma. Smartinhalers are continually being developed for all major medications.

• Smartinhalers used for preventer medications contain a reminder alarm, to help you remember to take your preventer
• Smartinhalers contain a 'fuel gauge' to show you how much medication is left in your inhaler
• 'Personal asthma manager' software includes an action plan and educational material, and creates a report of your medication usage and peak flow
• Smartinhalers are not subsidised, so you will need to purchase the device and computer programme
• You need to have a computer and computer knowledge.

Dry powder inhalers

Dry powder inhalers are breath activated inhalers. The most common dry powder inhaler in New Zealand is the Turbuhaler.

TURBUHALER

The Turbuhaler is breath activated and has no propellant or carrier added to the medicine. This means you will hardly notice any powder in your mouth. Preventers, relievers, symptom controllers and combination medicines are all available in the Turbuhaler. Adults and children from 5-7 years of age upwards should be able to use the Turbuhaler.

Using the Turbuhaler

Cleaning the Turbuhaler

Do not allow the device to get wet when cleaning. Wipe the mouthpiece with a dry cloth. Do not wash the mouthpiece. Keep the cap on when not in use. The device may clog if exhaled or dribbled into routinely or if stored in an environment of high humidity with the cap unsealed.

When to start a new Turbuhaler

There is a window under the mouthpiece on the outside of the Turbuhaler. When a red mark or number appears at the top of the window, there are approximately 20 doses left.

ACCUHALER

Accuhaler is a breath activated device. Doses of the medicine are set into a foil strip inside the Accuhaler, and there is a dose counter.

The case is opened to reveal a lever which activates the dose. The medicine is taken by breathing in through the mouthpiece. You must not breathe back into the Accuhaler.

• There are no propellants involved
• Rinse mouth and spit out water or clean teeth after using a corticosteroid preventer.

HANDIHALER

The HandiHaler delivers the medication Spiriva which is used by some people with COPD (chronic obstructive pulmonary disease).

How to use the HandiHaler

• Spiriva capsules come in a blister strip. Separate blister strips to create two strips of five capsules.
• Peel back the foil from one blister strip to exposure one capsule
• Open the HandiHaler protective cover and mouthpiece. Place the capsule in the centre chamber
• Close the mouthpiece firmly until a click is heard, leaving the protective cover open
• Holding the Handihaler upright, pierce the capsule by pressing the green button in completely once
• Sit upright, tilt head back (into 'sniff' position) and breathe out gently. Do not breathe into the device. Insert the mouthpiece into the mouth, ensuring that the lips are firmly sealed
• Breathe in slowly and deeply. The sound of the capsule vibrating in the chamber will be heard. Remove the device from the mouth and hold the breath for 10 seconds or as long as possible. Breathe out gently through the nose
• Check to see if any powder remains in the capsule. If so, repeat the process from 'sit upright'
• Open the mouthpiece. Tip out and dispose of the used capsule. Close the mouthpiece and protective cover to prevent dust/dirt settling on the mouthpiece and being inhaled.

Cleaning the HandiHaler

• Clean the device once a month
• Open the protective cap, mouthpiece and base
• Rinse the whole device with warm water and air-dry thoroughly for 24 hours
• Clean outside of mouthpiece with a damp tissue when needed.

Breath activated aerosol inhaler

AUTOHALER

The Autohaler is an aerosol inhaler which contains less propellant than a metered dose inhaler because it is breath activated. Adults and children over 12 years of age should be able to use the device. The Autohaler overcomes the problem of trying to press the inhaler and breathe in at exactly the right time.

To use the Autohaler, lift the small lever up before shaking the device well to prepare the metered dose for release. Sit upright, tilting the head back and breathe out gently. Place the inhaler in your mouth, making sure the air vents at the bottom of the device are not blocked by hands. Keep the device upright and breathe in fully. Do not stop when the 'whoosh' is heard and felt.

Remove the device from the mouth and hold the breath for 10 seconds or as long as is comfortable. Breathe out gently through the nose. Push the grey lever down gently. If another puff is needed, repeat the process. Rinse mouth and spit out water or clean teeth after using a corticosteroid preventer.

To clean the Autohaler, wipe the mouthpiece only with a damp cloth or tissue. Do not push a drying cloth or anything else into the device. Do not wash or soak the entire device in water. To store, always keep the cap on your inhaler when not in use. Store in a cool place (not your car glove box).

Nebulisers

Nebulisers are an alternative way to take medicine. Nebulisers produce a fine mist of the medicine, which is breathed in through a mask or mouthpiece. They are either powered by an electrical air pump or oxygen. It takes about 10-15 minutes to breathe in the dose of medication.

A nebuliser is mainly used for reliever medicine. With so many improved inhaler devices and spacers, there is now less need for nebulisers. Research proves that spacers are just as effective in acute asthma for adults and more effective for children than nebulisers.

Deciding on the right inhaler for you

Inhaled asthma medicines are an important part of asthma care. Because inhalers come in many different shapes and sizes, you can find the one that suits you best, in conjunction with your doctor or asthma educator.

Original material provided by the Asthma Foundation of New Zealand. Reviewed by everybody, October 2010.