Inhaler Technique and Spacers for Older Adults

Know which device you have

Inhalers look alike but work differently:

• Pressurised metered-dose inhaler (pMDI): a metal canister in a plastic holder that sprays a measured puff when pressed.
• Breath-actuated pMDI: releases the dose when you breathe in.
• Dry powder inhaler (DPI): delivers powder drawn in by a fast, deep breath. Types include capsule devices, blister packs and reservoirs.
• Soft mist inhaler: produces a slow mist from a cartridge.

Technique differs between them, so a person who changes device needs fresh teaching. Keep a list of what each inhaler is for: preventers (taken daily, often containing a steroid) and relievers (taken for breathlessness). Follow the doctor's plan; see COPD at home guide and asthma in older adults. For when a nebuliser is used instead, see nebuliser or inhaler: understanding the difference.

Pressurised inhaler with a spacer (recommended for most older adults)

A spacer is a plastic chamber that holds the puff so you can breathe it in without precise timing. It improves delivery, cuts throat side effects and is usually advised for pMDIs.

1. Wash hands, sit or stand upright. 2. Check the inhaler: dose counter, expiry, the mouthpiece clean and free of fluff. Remove the cap. 3. Shake the inhaler for a few seconds if the leaflet says so. 4. Prime a new inhaler or one not used for a while, as the leaflet says, by spraying one to four puffs into the air. 5. Attach the inhaler to the spacer, with the canister upright. 6. Breathe out gently, away from the spacer. 7. Put the spacer mouthpiece between the teeth and seal the lips around it, or place a mask snugly over nose and mouth if a mask is used. 8. Press the canister once to release a single puff into the spacer. 9. Breathe in slowly and deeply through the mouth for about three to five seconds, or breathe in and out gently for four to five breaths through the spacer without removing it. If the spacer has a whistle, it warns when you breathe in too fast. 10. Hold your breath for about ten seconds, or as long as is comfortable, after taking the mouthpiece away. 11. Wait 30 to 60 seconds before the next puff. Shake again and repeat for each puff, one puff at a time. Do not spray several puffs into the spacer together. 12. If using a steroid preventer, rinse the mouth with water, gargle and spit, and wipe the face if a mask was used. Replace the cap.

Pressurised inhaler without a spacer

Only if the person can coordinate well; otherwise ask for a spacer.

1. Remove the cap and shake. 2. Breathe out gently. 3. Place the mouthpiece between the teeth, lips sealed, tongue under the mouthpiece. 4. Start to breathe in slowly and, as you begin, press the canister once. 5. Keep breathing in slowly and deeply for three to five seconds. 6. Hold the breath for about ten seconds. 7. Wait 30 to 60 seconds before the next puff. 8. Rinse the mouth after steroid inhalers.

Common error: breathing in fast or stopping the breath as the puff hits the throat.

Dry powder inhalers

These need a fast, strong, deep breath to draw the powder out. Details vary by device, so follow the leaflet and the teaching.

1. Prepare the dose exactly as the device instructs, such as loading a capsule, twisting a base or sliding a lever. Do this while the device is upright and do not shake it. 2. Breathe out gently, away from the device. Never blow into it, because moisture can clump the powder. 3. Seal the lips around the mouthpiece without blocking the air vents. 4. Breathe in quickly and deeply through the mouth, as if sipping a thick drink through a straw. 5. Hold the breath for about ten seconds. 6. Breathe out slowly, away from the device. 7. Close the device. 8. Rinse the mouth after a steroid-containing inhaler.

Some DPIs produce a taste, a click or a sweet flavour to confirm delivery, while others give none. If your parent's breath is too weak to use a DPI, the doctor may change to a different type. Never press on without a good inhalation.

Soft mist and other inhalers

Follow the leaflet exactly: they usually require loading a cartridge, turning the base, then a slow, steady breath in as the button is pressed. Ask for a demonstration.

Common errors

• Not removing the cap or not shaking a pMDI.
• Breathing out into the device, especially a dry powder inhaler.
• Pressing too early or late, or several puffs at once into a spacer.
• Breathing in too fast with a pMDI or too slowly with a DPI.
• Not holding the breath.
• Not waiting between puffs.
• Not rinsing the mouth after steroids, which can lead to thrush or hoarseness.
• Using an empty inhaler and not reading the dose counter; pMDIs can feel as if they work when empty.
• Storing or washing incorrectly, for example getting a DPI wet.
• Using the wrong device for the situation or mixing up reliever and preventer.
• Taking extra doses without the doctor's guidance.

Tips for stiff hands, poor sight and weak breath

• Hand grip aids: devices exist that make it easier to press a canister; ask the pharmacist or an occupational therapist. Using both hands, or a chair arm to brace, can help.
• Spacers with masks for people who cannot seal their lips or who are very weak.
• Large-print labels and colour-coded caps to tell relievers from preventers, and a written schedule.
• Dose counters and reminder alarms, and a pill organiser style chart. See giving medicines safely at home.
• Weak breath: the doctor may choose a device that needs less inspiratory effort, or a nebuliser; see nebulisers: types, use and cleaning.
• Tremor: brace the elbows on a table; a spacer helps.
• Memory problems: a carer should supervise or give the inhaler; use simple steps on a card. See dementia and medicines: managing safely.
• Dentures: keep fitted for a good lip seal, unless the doctor advises otherwise.

Checking technique

Ask the doctor, nurse or pharmacist to watch your parent at every review, which is as much part of care as the prescription. A physiotherapist can also help. Some clinics use a training device that checks the speed of the breath. Use the teach-back method: your parent demonstrates while the professional watches and corrects.

Care of inhalers and spacers

• Keep the mouthpiece clean: wipe weekly with a dry cloth; follow the leaflet for washing any plastic holder, and dry fully.
• Wash the spacer weekly in warm soapy water and let it drip dry without wiping; replace when cracked or as advised. See a cleaning schedule for breathing equipment.
• Storage: keep inhalers in a cool, dry place away from direct sun and heat, which can damage pressurised canisters; never leave in a hot car or on a sunny window sill. Keep DPIs dry; do not store in a bathroom.
• Expiry and counters: check the expiry date and the dose counter, and replace before it runs out. Keep a spare reliever, especially for travel and the pollution season. See a pollution season plan for older adults.
• Do not puncture or burn canisters.
• Disposal: return empty or expired inhalers to a pharmacy where possible.
• Counterfeit risk: buy from a reliable pharmacy; see spotting fake or poor-quality care products.

Medicines to be careful with

Do not stop or change preventer inhalers because your parent feels well, and do not use a reliever more than prescribed. If a reliever is needed more often, call the doctor. Do not share inhalers. Side effects such as shaking, a racing heartbeat, a sore mouth, hoarseness or a cough should be reported. See medicine side effects families should watch for.

When to ask a professional

Ask for an inhaler technique check at every review, a spacer if using a pMDI, and a device the person can manage. Ask the pharmacist to label devices and explain the difference between relievers and preventers. Call the doctor if the reliever is needed more often, if symptoms worsen despite good technique, or if side effects occur. Call 112 for severe breathlessness, blue lips, confusion, chest pain or no relief from the reliever as the action plan states.