Inhale, Exhale: Best Practices Related to Inhaler Use in the PACE Population

Inhalers are used frequently in the elderly population, including PACE participants, to treat chronic obstructive pulmonary disease or asthma. Each inhaler works a little differently, and proper administration technique is important to ensure participants receive the appropriate amount of medication to make a difference in their disease state and improve lung function. With any type of inhaler, it’s important for PACE pharmacy providers and other members of the PACE center’s multidisciplinary to provide careful, clear instructions to participants and their caregivers.

Inhalers in the PACE Population: Metered Dose Inhalers (MDI)

These devices come in the form of a pressurized canister containing the medication mixed with propellants and other agents to assist the medication in properly reaching the lungs. Hydrofluoroalkane (HFA) is the propellant used in these inhalers. They work well in participants who have lesser inspiratory flow because they do not rely only on the participant’s own breath for actuation to the lungs. However, timing is important for these devices to allow for the release of the medication at the same time as the participant inhales. Spacers and holding chambers are devices that may be used with an MDI to give the medication time to slow before reaching the mouth. These devices decrease the amount of medication lost to the mouth and pharynx and also allow for stepwise administration, rather than simultaneous medication release and inhalation. Spacers and holding chambers may be helpful for participants who have trouble coordinating inhalation with activation. Priming must be performed prior to each initial use and if the inhaler has not been used for two weeks or longer. This is done by shaking the inhaler for five seconds and then pressing down on the canister to release a puff of air four times. Cleaning of the inhaler should be done by rinsing the mouthpiece with warm water weekly after removing the canister. It should be left to dry overnight before the next use.

Inhalers in the PACE Population: Dry Powder Inhalers (DPI)

Diskus® devices, Twisthalers®, and Handihalers® are all DPIs, designed to administer medication in a solid form via the PACE participant’s breath. They contain a capsule, blister, or reservoir containing medication mixed with lactose or glucose that is inhaled. Because the medication is actuated by breath alone, a deep and steady rapid inhale is required to properly aerosolize the medication. This means participants who cannot breathe deeply, such as those suffering from COPD, may not be good candidates for these inhalers. HandiHaler and other single-use inhalers must be loaded with a capsule prior to each use. The capsules should be removed one at a time from their packaging only when a participant is ready to administer the medication. Each inhaler can be opened to reveal a hole where the capsule should be placed. The inhaler should be closed until a click sounds, which indicates the puncture of the capsule to release the medication. Once the capsule has been punctured, the device should not be tilted, since doing so can result in a loss of medication. The punctured capsule should be disposed of after each use. Diskus and other multi-use inhalers already contain all doses of the medication. These medications are loaded in different ways, depending on the medication. With Diskus, Breo®, Twisthaler, and Respiclick®, each dose is loaded prior to use by opening the inhaler fully until a click is heard. With Pressair®, you press a button, while with Flexhaler®, you twist the inhaler in one direction and then the other. It should then be inhaled immediately without tilting the device, since doing so may cause loss of medication. Cleaning should be done on the outside of the mouthpiece with a damp cloth, only if necessary. No water should be used inside the inhaler. [Tweet “A look at #inhaler best practices for PACE participants. #postacutecarepharmacy”]

Inhalers in the PACE Population: Soft Mist Inhalers (SMI)

The Respimat® is a common SMI, which releases medication without propellant but in a form that remains aerosolized for six times longer than an MDI. Because the particles of medication are released at a lower velocity, less medication is lost to the mouth and pharynx. In addition, because the medication remains in the air longer, the need to carefully time inhalation and medication release is lessened.
The first use requires loading of the canister by removing the clear base and inserting the narrow end of the cartridge into the inhaler firmly by pressing it down on a hard surface until it clicks. The base can then be replaced and turned for half a turn until it clicks and is ready to be primed by opening the cap fully and pressing the button. Turning, opening, and pressing the button should be repeated until a mist is released.

Inhalers in the PACE Population: Administration Tips for All Inhalers

Participants should be instructed to exhale normally prior to the use of any inhaler. Then, after the inhaled medication is used, participants should hold their breath for at least five to 10 seconds to ensure the medication properly deposits in the lungs.

After use of any medication containing a corticosteroid (such as fluticasone, budesonide, betamethasone, and mometasone), the mouth should be thoroughly rinsed with water to prevent oral thrush.

Between puffs of the same medication, wait at least 15 to 30 seconds. When using multiple inhaled medications, the fastest-acting bronchodilator should be used first, followed by other bronchodilators.

Corticosteroids should be administered last, once the airways have been dilated by the fast-acting inhaler. Each administration of a different medication should be spaced by at
least 60 seconds.

Table of guidelines related to inhaler use.

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