Best practice guidance for inhalers in care homes
For prescribers and all staff responsible for administering inhalers in care homes.
You can download a full pdf version of this document by following the link on the right.
What is an inhaler?
It’s a device holding a medicine that someone takes by breathing in (inhaling)1. Inhalers are the main treatment for asthma or chronic obstructive pulmonary disease (COPD).
Background
In the UK, over a 7-year period, half a million people died from lung disease such as asthma, COPD and pneumonia2. According to a new study from Asthma + Lung UK, the UK has the worst death rate from lung diseases such as asthma and chronic obstructive pulmonary disease (COPD) in Western Europe, apart from Turkey.
It’s estimated that the annual cost of asthma and COPD to the NHS in the UK is £3 billion and £1.9 billion, respectively3.
Correct technique in using medicine delivery devices, such as metered dose inhalers, helps manage asthma and COPD effectively. Care home staff and residents would benefit from specific training relating to inhaler use.
Aim
This guidance will help to support care home staff, care agency staff and pharmacists to provide high quality care for using inhalers for asthma or COPD patients.
There are many different types of inhalers which can be confusing. This guide gives information on the:
- medicines inside inhalers
- types of inhaler device
- general information about inhalers.
It also highlights some of the issues and signposts to currently available support and resources.
Good practice points
Every patient should have an individualised care plan within the care home which includes overall aims and a monitoring plan and when to contact their GP.
When asking about asthma symptoms, use specific questions, such as the Royal College of Physicians ‘3 Questions.’4 These include:
- have you had difficulty sleeping because of your asthma symptoms including a cough)?
- have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness, or breathlessness)?
- has your asthma interfered with your usual activities, for example housework, work/school?
Monitor the inhaler technique and apply good inhaler spacer device care to ensure effective treatment and management of asthma or COPD.
Prescribe a suitable device for individual patients taking into consideration dexterity and those with impaired cognition such as dementia. Some devices need more co-ordination than others.
Some of the inhaler medicine may hit the back of the throat which can sometimes cause problems such as thrush in the mouth. This tends to be more of a problem with higher doses of steroid inhalers.
Using a spacer device means less medicine hits the throat. This can help to alleviate throat problems especially when prescribing a higher dose of inhaled steroid.
Tell patients to rinse their mouth and drink water after using a steroid inhaler.
Check inhaler technique at every opportunity and before changing or increasing a patients’ medication.
Everyone with asthma or COPD should have a review with their doctor or respiratory nurse as appropriate or at least once a year.5-6
The use of inhalers in asthma and COPD
Reliever inhalers
This type of inhaler:
- contains bronchodilator medicines which can ease symptoms of breathlessness, wheeziness, or tightness in the chest
- relaxes the muscle in the airways. This opens the airways wider, and symptoms usually quickly ease
If someone needs a reliever three times a week or more to ease symptoms, a preventer inhaler would be more suitable.
Preventer inhalers
This type of inhaler:
- may be steroid inhalers and/or long-acting bronchodilators
- used every day to prevent symptoms from developing and should be taken on a regular basis.
- take 3 to 7 days for the steroid in a preventer inhaler to build up its effect
A preventer inhaler will only be used in some patients.
The choice of inhaler is personal preference, ability to use the device and the drugs available in it. There are several different types of inhaler devices.
See appendix 1 for types of inhaler devices.
See appendix 2 for spacer devices.
Inhaler choices and the environmental impact
The relationship between inhaler choices and the climate is becoming increasingly important, as we work to lessen our environmental footprint and combat climate change (global warming).
Some inhalers use a propellant (gas) to carry the medicine into the lungs. These types of inhalers are called pressurised metered dose inhalers (pMDIs).
The propellants in pMDIs are powerful greenhouse gases. They’re thousands of times more potent than carbon dioxide, and contribute to climate changes. pMDIs account for 70% of inhalers prescribed in the UK and contribute to 3% of the NHS overall carbon emissions.7
The good news is, there are other inhalers with a much lower-carbon footprints than pMDIs. For this reason, the NHS encourages professionals to provide people over the age of 12 the choice to switch to a lower-carbon inhaler where clinically appropriate.
Inhalers with much lower-carbon footprints
These include:
- dry powder inhalers (DPIs) which generally don’t rely on propellants. Patients must inhale quickly and deeply which may not be suitable for everyone
- soft mist inhalers (SMIs) which use pressurised water vapour instead of propellants.
Reducing the climate impact of inhalers
You can do this in several ways.
Optimise care
Ensure residents get regular reviews and medication check. This is an opportunity to identify poor control, reduce overuse of reliever (rescue) inhaler, meaning lower carbon footprint.
Reviewing inhaler technique
Checking resident’s inhaler technique is crucial for:
- optimal disease control
- cutting down waste doses
- reducing their impact on the environment.
Offer inhalers with lower carbon footprints
When clinically appropriate and suitable for residents, switch to inhalers with lower carbon footprints. This is the outcome of a personalised, shared decision-making consultation with the patients and their healthcare professionals8.
Proper disposal of inhalers
You must return all used and unwanted inhalers in the care home to community pharmacy for proper disposal. The pharmacy or dispensary will send it for recycling or incineration. This type of disposal minimises the impact of the leftover greenhouse gases, which s is better for the climate, compared to putting inhalers in landfill9.
Key considerations
These include:
Care home population
Residents in care homes often have a range of needs and abilities. Choose inhaler devices that are appropriate for each resident10. Think about things like manual dexterity, hand-eye coordination, grip strength, resident preference, and possibly cognitive limitations.
Staff training
Make sure care home staff are properly trained on appropriate inhaler technique demonstrations, and green inhaler options.
Inhaler carbon footprint comparison tool
More information
Health advice resources from Asthma + Lung UK
Asthma + Lung UK helpline details
Community pharmacy and the management of people with asthma
Managing medicines in care homes
Patient information leaflets for individual inhalers
References
2.Lung conditions kill more people in the UK than anywhere in Western Europe
3.Respiratory high impact interventions
4.BTS/SIGN Asthma quick reference guidelines 2019
5.Asthma: diagnosis, monitoring and chronic asthma management
6.COPD in over 16’s: diagnosis and management
7.How inhalers affect the environment
8.How to reduce the carbon footprint of inhaler prescribing
Factors to consider when choosing an inhaler
Appendix 1: inhaler devices
Different inhaler devices suit different people. Inhaler devices can be divided into four main groups.
Watch the videos on how to use the various types of inhaler
Use the respiratory inhaler identification chart to help you identify the different types of inhalers and their manufacturers.
| Pressurised metered dose inhalers (MDIs) | Breath-activated inhalers |
| The standard MDI is the most widely used inhaler. However, many people don’t use it to its best effect. | These are alternatives to the standard MDI. Some are still pressurised MDIs, but they don’t require pressing a canister on top. These would be useful for patients who have difficulty breathing and pressing the inhaler at the same time.
Examples of breath-activated MDIs include the Autohaler and Easi-breathe inhaler. |
| How to use a metered dose inhaler | How to use a breath-activated inhaler |
|
You must push up (on) the autohaler lever before each dose, and push down again (off) afterwards or it won’t operate. The Easi-breathe doesn’t have a lever. |
| Dry powder inhalers | Multidose liquid inhalers |
| Some breath-activated inhalers are also called dry-powder inhalers. These require breathing in fairly hard to get the powder into the lungs.
Examples include:
Each type has a slightly different method of use. Precise instructions are on patient information leaflets. Make sure you’re competent in its use before using on a resident. |
These types of inhaler devices have medication in a liquid form which is converted to a fine mist then inhaled.
The slow-moving mist eases the effort to inhale it, enabling the resident to breathe more slowly and normally. Examples include Spiriva Respimat and Spiolto Respimat. |
Appendix 2: spacer devices
A spacer is usually a plastic container, with a mouthpiece at one end and a hole for the inhaler at the other. Spacers only work with a metered dose inhaler.
Spacers are important because they:
- help to deliver asthma medicine to the lungs
- allow more medicine into your lungs than when just using the inhaler on its own
- make metered dose inhalers easier to use and more effective
- help to reduce the possibility of side effects from the higher doses of preventer medicines by reducing the amount of medicine that is swallowed and absorbed into the body
- are convenient and compact and work at least as well as nebulisers at treating most asthma attacks in children and adults.
There are different types of spacers available. These include:
- Volumatic
- Nebuhaler
- Aerochamber
- Able spacer
- Space Chamber and Space Chamber Plus.
The different brands of spacer fit different metered dose inhalers and are available on prescription. See the relevant patient information leaflet on how to use each spacer with the appropriate inhaler device.
Handy hints for using a spacer
Care home staff should be appropriately trained on how to use an inhaler and spacer properly
Ensure that the spacer prescribed fits your inhaler.
Tell the patient to put one puff of the inhaler into the spacer.
If the patient finds it difficult to take deep breaths, breathing in and out of the mouthpiece several times for at least 10 seconds is just as good.
Repeat the step above for each dose/puff needed and allow 30 seconds between each puff.
Wash the spacer once a month. Leave it to drip-dry as this helps to prevent the medicines sticking to the sides. Don’t put them through a dishwasher.
Replace spacers at least once each year, especially if used daily.