How Do You Use Inhalers and Nebulizers?

Inhalers and nebulizers are ways of turning medications into aerosols for administration by inhalation. These devices are often used for asthma and other lung conditions.

Inhalers and nebulizers are medical devices used for delivering medication directly to the airway and lungs through inhalation. Inhalers and nebulizers convert medical solutions and/or powders into minute aerosol particles that can be easily breathed in.

Inhalers

There are two main types of inhalers:

• Metered dose inhaler (MDI): A handheld device that converts drug solutions or suspensions into sprays of breathable aerosol particles in measured doses using a pressurized canister.
• Dry powder inhaler (DPI): A handheld device that is used to puncture capsules or blisters containing medication in fine powder form that can be inhaled.

Inhalation accessory devices

An inhalation accessory device is attached to the metered dose inhaler’s mouthpiece to slow down the high-pressure spray and enable the medication to become a fine mist of aerosol particles.

Nebulizers

Nebulizers are electrical devices that transform drug solutions into fine, breathable aerosol particles. Nebulizers are useful for patients who are too young or too ill to use inhalers.

Many types of inhalers and nebulizers are used for different medications and it is important to read and follow the manufacturer’s instructions for use. It is also essential to clean and disinfect the inhalation devices periodically following instructions specific to each device.

Inhalation devices are used while sitting up straight. Following are the general steps for using inhalers and nebulizers:

Metered dose inhalers

Metered dose inhalers may be used directly or with an inhalation accessory device. Following are the usual steps in using a metered dose inhaler:

• Remove the cap from the inhaler.
• Shake the inhaler for a few seconds.
• Place the index finger on top of the canister and thumb on the bottom of the mouthpiece.
• Tilt the head back slightly and breathe out.
• Hold the inhaler upright about the width of two fingers from the mouth.
• Press the inhaler once and breathe in slowly and deeply for about three to five seconds.
• If possible, hold breath for at least 10 seconds.

If using a spacer,

• Attach it to the inhaler’s mouthpiece.
• Put the spacer’s mouthpiece in the mouth and close lips over it.
• If using a mask, fit it comfortably over the nose and mouth.
• Keep the spacer horizontal and press the canister once.
• Breathe in and out normally, three or four breaths.
• Repeat the above steps if more than one dose is prescribed.
• Replace the cap on the inhaler.
• Gargle and rinse the mouth with water or mouthwash (do not swallow) if inhaling steroid medications.

Inhalation accessory devices

Inhalation accessory devices are attached to the mouthpiece of the metered dose inhalers. Some spacing devices are used with a mouthpiece, but many of the devices can also be used with a mask. Inhalation accessory devices are of two types:

Spacers

Spacers are tubes that can be used with a mouthpiece or mask. Following are some of the types of spacers:

• Open tube spacers: An extension that provides extra space to slow down the spray. Some available open tube spacers are:
  • Microchamber
  • Microspacer
• Reverse-flow spacers: An extension piece that directs the flow of the drug away from the spacer’s mouthpiece and sounds an alert if the patient inhales too quickly. Following are some reverse-flow spacers:
  • Aerosol Cloud Enhancer (ACE)
  • InspirEase
  • OptiHaler

Valved holding chambers

Valved holding chambers have a one-way valve that keeps the mist of medication inside the spacer until the patient breathes in through the valve. Most devices can be used with a mask also and many of devices sound an alert if the patient inhales too quickly. Following are some of the valved holding chambers available:

• AeroChamber Plus, AeroChamber MAX
• Breathe Rite
• EasiVent
• E-Z Spacer
• Lever Haler
• Lite Aire
• OptiChamber Advantage
• Prime Aire
• Vortex

Dry powder inhalers

Dry powder inhalers are of many shapes and types, but all of them provide a method to puncture the blister or capsule containing the medicine in a closed chamber. The fine powder can be inhaled using the mouthpiece in the device.

Following are some of the types of dry powder inhalers:

• Diskus: A disk shaped device containing a coiled blister strip which is rotated with a wheel to puncture each blister.
• Aerolizer: A plastic device with a button to puncture capsules of formoterol fumarate, a type of bronchodilator medication.
• HandiHaler: A spherical plastic device with a button to puncture capsules containing tiotropium bromide, a bronchodilator.
• Twisthhaler: The Twisthaler uses a twisting mechanism to deliver measured doses of dry powder mometasone furoate, an inhaled corticosteroid.
• Flexhaler: A device that uses a twisting motion to puncture capsules of dry powder budesonide, a synthetic anti-inflammatory corticosteroid.

Following are the primary steps in using a dry powder inhaler:

• Load the dry powder inhaler with the medication.
• Use the piercing mechanism to puncture the capsule/blister.
• Tilt the head back slightly.
• Position the inhaler horizontally.
• Exhale before placing the mouthpiece into the mouth, and close lips around it.
• Inhale deeply and hold breath for 10 seconds.
• Remove the mouthpiece from the mouth and exhale.
• Gargle and rinse the mouth with water or mouthwash (do not swallow) if inhaling steroid medications.
• Replace the cover on the mouthpiece for storage.

Nebulizers

Nebulizers are a little more complicated than inhalers to assemble and use. Nebulizers need a power source, either a wall socket or batteries, depending on the type of device. Nebulizers are of three types:

• Pneumatic jet nebulizer: Has a separate electrical compressor plugged into a wall socket, and a tubing connected to the compressed air outlet. A medication cup is connected to the tubing, with an inhalation mouthpiece or mask that fits on top of the medication cup.
• Ultrasonic nebulizer: A compact, single unit that comes in both types, either outlet or battery-operated. The medication cup fits into the device, and the mouthpiece or mask is connected to the top of the cup.
• Mesh nebulizer: Mesh nebulizer is a portable battery-operated device with a medication cup, and a mouthpiece or mask to fit over it.

All three types of nebulizers are used as follows:

• Assemble all the removable parts of the device.
• Fit the cup in its appropriate place.
• Pour the prescribed dose of medication into the cup.
• Fit the cup end of the mouthpiece/mask on top of the cup.
• Turn on the device to start generating a mist of medication.
• Place the mouthpiece in the mouth and close lips over it.
• If using a mask, fit it comfortably over the nose and mouth.
• Take slow deep breaths until the medication in the cup empties.
• Gargle and rinse the mouth with water or mouthwash (do not swallow) if inhaling steroid medications.
• Clean the nebulizer and store in a cool, dry and dust-free place.

The drugs used in inhalers and nebulizers are primarily for treatment of respiratory illnesses, most often bronchodilators or corticosteroids. Following are medications used in inhalation devices:

Metered dose inhalers

• Albuterol sulfate (Ventolin HFA, Proventil HFA, ProAir HFA)
• Beclomethasone dipropionate (QVAR)
• Ciclesonide (Alvesco)
• Fluticasone propionate (Flovent HFA)
• Fluticasone propionate/salmeterol xinafoate (Advair HFA)
• Ipratropium bromide (Atrovent HFA)
• Ipratropium bromide/albuterol sulfate (Combivent Respimat)
• Levalbuterol tartrate (Xopenex HFA)
• Mometasone/formoterol (Dulera)

Dry powder inhalers

• Budesonide (Pulmicort Flexhaler)
• Budesonide/formoterol (Symbicort)
• Fluticasone propionate (Flovent Diskus)
• Fluticasone propionate/salmeterol xinafoate (Advair Diskus)
• Formoterol fumarate (Foradil Aerolizer)
• Mometasone furoate (Asmanex Twisthaler)
• Salmeterol xinafoate (Serevent Diskus)
• Tiotropium bromide (Spiriva HandiHaler)

Nebulizers

• Albuterol sulfate (Proventil, AccuNeb)
• Arformoterol tartrate ((Brovana)
• Budesonide (Pulmicort Respules)
• Cromolyn sodium (Intal)
• Formoterol fumarate (Perforomist)
• Ipratropium bromide (Atrovent)
• Levalbuterol hydrochloride (Xopenex)