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Metered Dose Inhalers

Many patients and health care providers do not demonstrate proper metered dose inhaler (MDI) technique. Improper use reduces the delivery of the intended dose of medication and risks an unnecessary dosage increase. One survey of ambulatory nurses (Brenner et al., 2000) found that 58% considered nurses to be the primary patient educators of MDI technique. However, one-third of those nurses did not correctly demonstrate all the steps involved in using inhalers with or without a spacer (from the 1997 NHBI guidelines).

The most common errors involved inhalation and breath-holding. Proper technique requires: inhaling by mouth deeply and slowly for 3-5 seconds in order to maximize penetration of medication, followed by holding the breath for 10 seconds before exhaling to allow medication to reach target sites in the lungs. A frequently skipped step was priming (test spray) the inhaler at first use to assure patent opening. Almost all the nurses had received their last training more than two years prior (despite changes in delivery devices).

Even with proper technique, inhalers deliver 10% to 15% of medication into the smaller airways. Spacers can increase delivery about 12% by allowing more time to inhale. Many users, not just children, can benefit from spacers. Dry powder inhalers (DPI) are breath-activated and are smaller for carrying ease. However, powder medication may clump in high humidity and some persons cannot inspire quickly enough to get a full dose.

Patients need thorough orientation, periodic re-assessment and re-training; skills appear to deteriorate over time. A list can be used to check off each step of the procedure. NHLBI offers patient education tools at www.nhlbi.nih.gov/health/prof/lung/asthma. Nurses should review package inserts and practice their own skills with placebo equipment like those ordered for their patients to keep up with new devices, including spacers. A competent nurse is a more credible educator.

Calculating the number of doses remaining in a canister must be done by subtracting the number of doses taken from the original number indicated on the package (disregarding an extra dose or two for priming). Floating a canister in water is not accurate as surplus propellant wrongly suggests a depleted container holds medication.

(Togger D and Brenner P. Am J Nurs 2001;101(10):26-32)

Comment: School nurses are rarely the student's first educator about an inhaler, but they should assess technique in addition to response to medication. MDIs could be an excellent topic for classroom Science and Health lessons. -J.O.







		Metered Dose Inhalers Many patients and health care providers do not demonstrate proper metered dose inhaler (MDI) technique. Improper use reduces the delivery of the intended dose of medication and risks an unnecessary dosage increase. One survey of ambulatory nurses (Brenner et al., 2000) found that 58% considered nurses to be the primary patient educators of MDI technique. However, one-third of those nurses did not correctly demonstrate all the steps involved in using inhalers with or without a spacer (from the 1997 NHBI guidelines). The most common errors involved inhalation and breath-holding. Proper technique requires: inhaling by mouth deeply and slowly for 3-5 seconds in order to maximize penetration of medication, followed by holding the breath for 10 seconds before exhaling to allow medication to reach target sites in the lungs. A frequently skipped step was priming (test spray) the inhaler at first use to assure patent opening. Almost all the nurses had received their last training more than two years prior (despite changes in delivery devices). Even with proper technique, inhalers deliver 10% to 15% of medication into the smaller airways. Spacers can increase delivery about 12% by allowing more time to inhale. Many users, not just children, can benefit from spacers. Dry powder inhalers (DPI) are breath-activated and are smaller for carrying ease. However, powder medication may clump in high humidity and some persons cannot inspire quickly enough to get a full dose. Patients need thorough orientation, periodic re-assessment and re-training; skills appear to deteriorate over time. A list can be used to check off each step of the procedure. NHLBI offers patient education tools at www.nhlbi.nih.gov/health/prof/lung/asthma. Nurses should review package inserts and practice their own skills with placebo equipment like those ordered for their patients to keep up with new devices, including spacers. A competent nurse is a more credible educator. Calculating the number of doses remaining in a canister must be done by subtracting the number of doses taken from the original number indicated on the package (disregarding an extra dose or two for priming). Floating a canister in water is not accurate as surplus propellant wrongly suggests a depleted container holds medication. (Togger D and Brenner P. Am J Nurs 2001;101(10):26-32) Comment: School nurses are rarely the student's first educator about an inhaler, but they should assess technique in addition to response to medication. MDIs could be an excellent topic for classroom Science and Health lessons. -J.O.