Breathing easier: Safe use of inhaled medicines


Inhalation is the best way to take a medicine used to treat asthma or chronic obstructive pulmonary disease (COPD). (See the Sidebar for information about asthma and COPD.) The medicine acts faster to control breathing if inhaled directly into the lungs. Also, inhaled medicines can often be taken in a lower dose than an oral tablet of the medicine. This can help to reduce the risk of bad side effects.

 Inhalers for asthma and COPD contain either a single type of medicine or a combination of medicines, including:      

• A bronchodilator to relax the muscles around the airways and increase air flow
• A corticosteroid to reduce inflammation in the airways and possible lung damage
• A combination of bronchodilators
• A combination of a bronchodilator and a corticosteroid

Types of inhalers

“Rescue” inhalers contain short-acting bronchodilators used to relieve asthma attacks or sudden breathing problems. They provide temporary relief of symptoms such as wheezing, coughing, chest tightness, and other breathing side bardifficulties. They are also used before exercise to prevent breathing problems. Within minutes after inhalation, these medicines quickly open the airways to make breathing easier. The most common rescue inhaler medicines in the US can be found below on table 1.

“Maintenance” (controller) inhalers contain long-acting bronchodilators and corticosteroids to control asthma and COPD. They are typically used once or twice daily, even in the absence of breathing problems. These medicines open the airways and reduce swelling for at least 12 hours. They are taken every day to control chronic breathing problems. The most common maintenance inhaler medicines in the US can be found below on Table 2.

There are also different types of inhalers that deliver doses in a unique way.

Pressurized metered-dose inhalers (MDI) have been used for decades. An MDI typically consists of a small canister of medicine fitted into a plastic body with a mouthpiece. Each dose is delivered by pressing the canister into the plastic body while inhaling as the mouthpiece is sealed between the lips. MDIs that allow the use of a spacer make it easier to inhale the dose. The oval plastic spacer fits on the MDI, and on the other end is a mouthpiece. The dose is first released into the spacer, and then it is inhaled slowly so less medication is wasted.

Dry-powder breath-activated inhalers are preloaded with the medicine already inside the device. Prior to use, a single dose of the powder needs to be “readied” or “loaded,” often by turning or twisting the inhaler body until a “click” signals the dose is ready to be inhaled. Simply take a deep breath while the lips are sealed around the mouthpiece, and a single dose will be delivered (breath-activated).

Some dry-powder inhalers utilize a single-dose capsule that must be inserted into the inhaler and punctured using the device, after which the dose is inhaled.

Soft mist inhalers are a propellant-free liquid inhaler that provides a slow-moving, soft aerosol cloud of medicine to help people inhale the medicine even if they can’t take a very deep breath.common inhalers chart

Errors with inhalers

Inhaled medicines will work only if they are delivered correctly into the lungs using the inhaler. Little or no medicine reaches the lungs if the inhaler is used incorrectly. The correct use of an inhaler depends on its type, and each type of inhaler has its own directions. The companies that make inhalers provide detailed instructions for consumers. Some inhalers come with a Medication Guide for consumers. Many companies also provide a short video online to help visualize the correct technique. Unfortunately, up to 94% of people with asthma and COPD use their inhalers incorrectly.1-3

Common mistakes made with inhalers that have been around for many years include:4,5

• Not forming a seal around the mouthpiece with the lips
• Not holding the breath long enough after inhaling a dose (hold for about 10 seconds or as long as comfortable)
• Using an “empty” inhaler, believing it still contains medicine
• Forgetting to exhale completely before each dose, or exhaling into the inhaler

Common errors made when using an MDI (with and without a spacer) include:4,5

• Not shaking the canister or container before each dose
• Failing to prime the inhaler, so that only a partial dose is inhaled
• Inhaling at the wrong time (not in sync with pressing the inhaler)
• Aiming the inhaler at the roof of the mouth or tongue, rather than the throat
• Inhaling a foreign body that has entered an uncapped inhaler without notice
• Damaged or sticky spacer valves that limit the delivery of the medicine

Common errors made when using a dry-powder breath-activated inhaler include:4,5

• Failing to load a dose before inhaling
• Loss of medicine by holding the inhaler mouthpiece upside down during or after loading a dose
• Failure to inhale strongly enough to draw the medicine out of the device

Common errors made when using a dry-powder inhaler that requires loading and piercing of a capsule prior to each dose include:4,5

• Not inserting the capsule into the device
• Not piercing the capsule once it is placed in the device
• Forgetting to remove the spent capsule, and failing to use a new capsule for each dose
• Failing to take a second breath (if indicated) to receive the full dose
• Swallowing the capsule instead of inhaling its contents
• Placing the capsule into the inhaler mouthpiece instead of the chamber designed to hold the capsule, which can result in swallowing or choking on the capsule during inhalation

Newer inhalers

Several newer inhalers that are designed in a way to address some of the problems with older inhalers, and to improve the ability to use the inhalers correctly and safely. Specifically, the newer inhalers feature:

• A dose counter, which allows people to see when the supply of medicine is low. This feature was previously available on some dry-powder inhalers, but not on MDIs.
• A longer duration of spray at a lower speed to help people receive the full dose despite problems with coordinating the spray with the breath, and the depth of the breath (e.g., Respimat slow mist inhalers).
• The inability to release a dose when all of the medicine has been used. Once the last dose has been taken and the inhaler is empty, the mechanism to prepare another dose is locked, preventing use of an empty inhaler.

Errors with newer inhalers

Unfamiliarity with these newer inhalers has been the source of some recently reported errors. A patient discharged from the hospital on Spiriva HandiHaler was readmitted 3 days later after taking 3 Spiriva capsules by mouth each day. He was unaware that the capsule was to be placed in the device so its contents could be inhaled. A color-blind patient was unable to tell if the indicator window on a Tudorza Pressair inhaler was red or green. The window turns green when the inhaler is loaded with a dose and ready to use, and red when the dose has been completely inhaled. Errors have happened to healthcare providers, too. In the pharmacy, an order for Incruse Ellipta was mistaken as “Increase Ellipta,” and the pharmacist dispensed Breo Ellipta, the only “Ellipta” inhaler with which he was familiar.

To promote the proper use of these newer inhalers, we have compiled a list of safety tips below. This summary chart is intended to be used as a quick reference. It supplements, but does not replace, the information provided by the inhaler manufacturers.

inhaler example chart 1

 inhaler chart 2


 inhaler chart 3

 inhaler chart 4

ISMP gratefully acknowledges ISMP Canada for providing much of the content for
this article, especially the safety tips on the summary chart.4

1) Bonds RS, Asawa A, Ghazi AI. Misuse of medical devices: a persistent problem in self management
of asthma and allergic disease. Ann Allergy Asthma Immunol. 2015;114(1):74-6.
2) Rootmensen GN, van Keimpema AR, Jansen HM, de Haan RJ. Predictors of incorrect inhalation
technique in patients with asthma or COPD: a study using a validated videotaped scoring method.
J Aerosol Med Pulm Drug Deliv. 2010;23(5):323-8.
3) Lavorini F, Magnan A, Dubus JC, et al. Effect of incorrect use of drug powder inhalers on management
of patients with asthma and COPD. Respir Med. 2008;102(4):593-604.
4) ISMP Canada. Safety considerations with newer inhalation devices. ISMP Canada Safety Bulletin.
5) National Asthma Council Australia. Inhaler technique in adults with asthma or COPD. 2008.
6) Centers for Disease Control and Prevention. Asthma in the US growing every year. CDC Vital Signs.
May 3, 2011.
7) Centers for Disease Control and Prevention. Smoking and COPD. January 18, 2016.

Created on June 3, 2016

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