Inhalers: A Demonstration is Worth One Thousand Words

INTRODUCTION

Asthma and chronic obstructive pulmonary disease (COPD) are common conditions that affect many individuals’ daily functioning. Worldwide, roughly 340 million people have asthma, and 390 million people have COPD.^1,2 It’s well-known that patients often have suboptimal inhaler technique, and numerous professional organizations have advocated for more counseling at every point in the healthcare system.^3,4 Although several new and improved pulmonary inhalation devices are available, inhaler use skills have lagged.⁵

Two systematic reviews analyzed studies of inhaler technique among patients and healthcare professionals from 1975 to 2014.^5,6 Each review divided the studies into an earlier (1975 to 1994) and a later (1995 to 2014) period to assess changes over time. The review of 54,354 patients over 144 studies found that approximately 30%, 40%, and 30% percent of patients had correct, acceptable, and poor technique, respectively. There was no significant difference in inhaler use skill between the earlier and later time periods.⁵ The review of 6,304 healthcare professionals over 55 studies found that correct inhaler technique among healthcare professionals declined from around 20.5% in the earlier time period to just 10.8% in the later time period.⁶

Using inhalers correctly is essential to disease control. A systematic literature review found an association between inhaler use errors and worsened disease outcomes for patients with asthma and COPD in almost all included studies.⁷ Longitudinal studies found that reductions in inhaler use errors improved disease outcomes.

Ultimately, most patients receive their inhalers from a pharmacy. Research shows that community pharmacists can positively impact inhaler technique, asthma control, quality of life, and medication adherence with educational interventions.⁸ Pharmacy personnel are strategically positioned to improve outcomes for people with asthma and COPD by

• Being familiar with the various inhalers available, understanding how to use them, and knowing the counseling points for each
• Recognizing patient-specific factors that could impact inhaler administration
• Understanding the importance of educating and evaluating patients on inhaler technique, and planning how to best deliver this care
  

Medication Classes Found in Inhalers

Several pharmacologic classes of medications (and combinations of these classes) are available in inhaler products:

• Short-acting beta-agonists (SABA) and long-acting beta-agonists (LABA) relax airway smooth muscles by stimulating beta_2-adrenergic receptors.⁴ Patients with asthma and/or COPD can use beta agonist medications as needed for relief of acute symptoms, and on a regular schedule for symptom prevention.^3,4
• Short-acting muscarinic antagonists (SAMA) and long-acting muscarinic antagonists (LAMA) cause bronchodilation by inhibiting muscarinic receptors in the airway smooth muscles.⁴ Patients with COPD can use SAMA and LAMA medications as maintenance therapy.^4,9 Patients with asthma who are already using a LABA and an inhaled corticosteroid (ICS) can add on a LAMA maintenance medication if needed.³
• ICS reduce airway inflammation and are used as daily maintenance medications to prevent asthma exacerbations.³ Patients with COPD may also use ICS in combination with LABA or LABA plus LAMA as a daily maintenance medication. Prescribing information for corticosteroid inhalers advises patients to rinse their mouths with water after inhalation and to spit the water out afterward to reduce the risk of fungal infection in the mouth and pharynx.^10-12

TYPES OF INHALER DEVICES

Pressurized Metered Dose Inhalers

A pressurized metered dose inhaler (pMDI) has two components: a plastic actuator with mouthpiece, and a pressurized canister which may contain^13,14

• the active medication
• a spray-generating propellant to move the medication out of the inhaler
• co-solvents to allow the inhaler ingredients to mix well
• surfactants to stabilize the mixture and prevent drug particles from clumping together or sticking to the canister

The propellant is typically hydrofluoroalkane (HFA), a replacement for the chlorofluorocarbon (CFC) propellants used in many early inhalers.¹³ The Montreal Protocol of 1987 called for phasing out CFCs due to their ozone-depleting properties. The liquid inside a pMDI canister may be formulated as a solution or as a suspended micronized powder. Each time a patient actuates the inhaler (i.e., presses the button to release a spray), a metering chamber in the canister measures the correct liquid volume for that dose. The device releases large particles (about 45 micrometers) from the mouthpiece in a cloud of vapor, and particle size decreases to between 0.5 and 5.5 micrometers as the aerosol evaporates.

Pause and ponder: How do you think the ban on chlorofluorocarbons impacted the inhaler market?

To maximize lung deposition of medication from a pMDI, patients should take a slow, deep breath lasting about four to six seconds and actuate the inhaler at the start of (or immediately after starting) this breath.¹³ If patients mistime the actuation or inhale too quickly, medication is more likely to deposit on the tongue or the back of the throat and patients will swallow it instead. This phenomenon—also known as oropharyngeal deposition—can reduce the effective medication dose and increase adverse effects (e.g., oral thrush and hoarseness with inhaled corticosteroids).¹³ Table 1 lists the medications available as pressurized metered dose inhalers.

Table 1. Pressurized Metered Dose Inhalers^9,10,15-24

HFA = hydrofluoroalkane; ICS = inhaled corticosteroid; LABA = long-acting beta-agonist; LAMA = long-acting muscarinic antagonist; SABA = short-acting beta-agonist; SAMA = short-acting muscarinic antagonist

Spacers and Valved Holding Chambers

A spacer is a tube or bag, often made of plastic, that a patient connects to a pMDI before use.²⁵ Medication particles traveling through these devices slow down before reaching the mouth. This also allows the aerosol propellant more time to evaporate, leaving smaller particles to be inhaled. Lower velocity and smaller particle sizes reduce oropharyngeal deposition, so more medication reaches the lungs. However, patients still need to time inhalation with actuation, and they should avoid exhaling into the spacer to prevent dilution (weakening) of the dose.

Valved holding chambers (VHC) are like spacers, but they have a one-way valve between the chamber and the mouthpiece.²⁵ VHCs trap the aerosols in the chamber, allowing time for patients with poor hand-breath coordination to inhale their medication. The one-way valve blocks exhalations from reaching the aerosols in the chamber, allowing patients to use multiple inhalations or tidal (restful) breathing if needed. For doses requiring multiple medication puffs, healthcare providers should counsel patients to prepare, actuate, and inhale each puff separately rather than spraying multiple puffs into the spacer or VHC at once.¹³

Due to gravity, impaction, and electrostatic charge, some medication is lost in a spacer or VHC before reaching the patient.²⁵ Washing a spacer or VHC with detergent (a water-soluble cleansing agent) and letting it air dry before first use can reduce the electrostatic charge and limit drug particle loss to the device walls. Some spacers and VHCs are made with anti-static material, but often come at a higher cost to the patient.

The Global Asthma Network (which aims to improve asthma care, particularly in low- and middle-income countries) advises that people can make effective spacers from 500 ml plastic bottles if commercial spacers are unavailable or too expensive.¹ A cost-effectiveness analysis determined home-made spacers (most of which were made from plastic water bottles) to be more cost-effective than commercial spacers in Columbia (a middle-income country).²⁶ The study found lower overall treatment costs and no difference in hospital admission rates.

Breath-Actuated pMDIs

A breath-actuated pMDI of beclomethasone dipropionate HFA (Qvar Redihaler) is available to overcome the problem of hand-breath coordination.²⁷ This inhaler is available in 40 mcg/actuation and 80 mcg/actuation. As the name implies, it actuates when the patient takes a breath, but it does not rely on a high inspiratory flow rate to deliver the medication. An inspiratory flow rate of just 20 L/min activates the inhaler, which then uses the HFA propellant to assist with dose delivery. Other breath-activated inhalers (discussed below) require up to 88 L/min for activation, which may be difficult for individuals with asthma or COPD who are already having trouble breathing. Young children and adults have tidal breathing inspiratory flow rates of 8 to 16 L/min and 13 to 18 L/min respectively.²⁷ Therefore, a breath-activated pMDI may require only a bit more inspiratory effort than the patients’ usual breathing.

Soft Mist Inhalers

Soft mist inhalers (SMIs) do not contain a propellant.²⁵ Instead, these inhalers use a spring to create pressure and spray the drug solution through a nozzle, forming two jets of liquid that collide to create a slow-moving mist. The mist’s low velocity increases drug deposition in the lungs rather than the oropharynx. An SMI’s aerosol cloud lasts about six times longer than a pMDI’s, increasing the window for effective inhalation in patients who have trouble coordinating actuation and inhalation. Table 2 shows the medications available as soft mist inhalers.

Table 2. Soft Mist Inhalers^28-31

LABA = long-acting beta-agonist; LAMA = long-acting muscarinic antagonist; SABA = short-acting beta-agonist; SAMA = short-acting muscarinic antagonist

Dry Powder Inhalers

Dry powder inhalers (DPI) are breath-actuated and breath-powered inhaler devices. To improve powder flow and accurate dose metering, manufacturers combine the active medication with a carrier powder or formulate it into spherical agglomerates (small sphere-shaped particles).³² Patients’ inspiratory flow and the resistance inside the inhaler generate turbulent energy that disaggregates (separates) the medication. Quick inhalation optimizes this process. The resulting tiny drug particles (less than 5 micrometers) can reach the lungs, while the larger carrier particles land in oropharynx and are swallowed.

DPIs typically require an inspiratory flow rate of at least 30 to 60 L/min, which some patients may have difficulty achieving.²⁵ There is also a possibility of decreased medication delivery from a DPI during disease exacerbations (periods of worsening), when patients’ ability to generate a forceful inspiration may be impaired.³² Table 3 lists available dry powder inhalers.

Table 3. Dry Powder Inhalers^15,33-46

ICS = inhaled corticosteroid; LABA = long-acting beta-agonist; LAMA = long-acting muscarinic antagonist; SABA = short-acting beta-agonist

INHALER TECHNIQUE EDUCATION

Consider that participants in most randomized controlled trials receive thorough education on inhaler use, must demonstrate competence to be included, and receive ongoing evaluations of their technique.⁴ This is the context in which inhaler efficacy is established. Ideally, all patients would have access to similar standards of care to ensure maximum benefit of inhaled medications. Inhaler technique support can also improve adherence. If patients are using inhalers incorrectly and not seeing clinical improvement, they may discontinue them due to perceived lack of efficacy.⁴⁷ A survey of patients with COPD found significantly greater adherence and confidence in treatment among patients whose inhaler technique had been checked by a healthcare professional within the past two years.⁴⁸

Healthcare providers must consider patient preferences, health literacy, and language barriers when choosing appropriate education methods.⁴⁷ A survey of inhaler-using adults seen at a pulmonary clinic or outpatient pharmacy compared education preferences between English and non-English speakers.⁴⁹ Both groups shared a preference for in-person, active learning methods but had low interest in participating in education sessions outside of regular clinic visits. The aforementioned survey of patients with COPD found that 83% thought a demonstration was “very helpful” for learning inhaler technique.⁴⁸ Only 58% and 34% thought the same about a video or leaflet, respectively.

Pharmacists Can Improve Inhaler Use

Pharmacists are best placed to provide in-person, active demonstrations to patients where they already come to pick up their medications. Research shows that pharmacists can provide effective inhaler use education (if and when their workflow allows for it). A 2017 systematic review of critical inhaler errors in asthma and COPD found that pharmacist-led inhaler education interventions produced statistically significant improvements in patients’ inhaler technique in seven out of eight studies.⁵⁰

Published studies of pharmacist-led interventions provide examples of counseling methods that have proven effective. A pre- and post-intervention study of 211 patients with COPD in Vietnam examined the efficacy of face-to-face inhaler training with a pharmacist. Training followed this format⁵¹:

• Patients demonstrated technique on a placebo inhaler device
• Pharmacists corrected each mistake and explained why the correction was important
• Pharmacists demonstrated every step verbally and physically with a placebo inhaler
• Patients performed the technique again
• Patients and pharmacists repeated this process until patients could complete all steps correctly

This procedure took about six minutes for initial training and three minutes for follow-up trainings.⁵¹ Pharmacists provided training monthly for three months, once at six months, and once at 12 months. They also included label stickers on inhalers with a summary of the steps for use. The percentage of patients using correct inhaler technique increased by over 40% from baseline to six months but declined somewhat between six and 12 months. Researchers concluded that patients benefit from an initial intensive period of repeated training sessions, followed by long-term follow-up at least every three months.⁵¹

Another study of 72 subjects examined the efficacy of different inhaler training methods by assigning patients to do one of the following⁵²:

• Read an MDI package insert pamphlet
• Watch a Centers for Disease Control and Prevention video demonstrating technique
• Watch a YouTube video demonstrating technique
• Receive direct instruction from a pharmacist

Only two minutes were allotted for the interventions (to mimic what might be feasible in a community pharmacy setting).⁵² The pharmacist-led counseling sessions were loosely scripted based on a checklist of proper inhaler technique. After a pharmacist explained and demonstrated inhaler use, subjects could ask questions if time permitted. Study investigators (including the pharmacists performing the direct instruction sessions) used a standardized checklist to assess all participants immediately following the training. There was a statistically significant difference between pharmacist-led instruction and each of the other interventions but not between any of the three other intervention groups. More than 70% of patients in the pharmacist-led intervention group demonstrated correct inhaler use after training compared with less than 20% of patients in the other intervention groups.⁵²

Pause and Ponder: Why might a live demonstration provide better training than a video demonstration of the same time duration?

The 2022 GINA report emphasizes the importance of providing patients with ongoing inhaler technique training and assessment. The report recommends that pharmacists, nurses, and other healthcare workers³

• physically demonstrate using placebo inhalers (and spacers or VHCs, if applicable)
• check against a device-specific checklist as patients demonstrate technique
• supply a take-home handout with steps for inhaler use (ideally including pictures)
• check and re-train patients at every opportunity, as errors frequently recur four to six weeks after training

Pause and ponder: In your workplace, would it be feasible to provide two minutes of counseling with every inhaler refill? How might you identify patients who most need inhaler use training?

Of note, devices exist to evaluate patients’ inspiratory flow and inhalation technique when prescribing, training, or assessing.⁴⁷ Although these may not be feasible to use in most community pharmacy settings (and are outside the scope of this continuing education module), they may be very useful in other settings (e.g., a pulmonary clinic). Devices include the AIM (Aerosol Inhalation Monitor), the In-Check DIAL, and the 2-Tone trainer.⁴⁷

Inhaler Administration Counseling

pMDIs

Most pMDIs require users to prime (release sprays into the air) before first use (see Table 4).^17-20 When priming a pMDI, users should spray it in the air away from the face. If the inhaler requires shaking, they should also be sure to shake well before each priming spray. Most pMDIs require shaking prior to actuation but some, including Atrovent HFA and Alvesco, do not.^9,10 Patients should always avoid spraying pMDIs into their eyes; the package insert for Atrovent HFA instructs users to close their eyes during inhaler actuation.⁹

Table 4. Priming Requirements for pMDIs^10,15-24

^aAlso need to be primed if dropped; ^bAlso need to be primed after cleaning; HFA = hydrofluoroalkane

The following are general administration instructions for pMDIs^17-20:

1. Check for a firm fit of the canister in the actuator
2. Remove cap from mouthpiece and check mouthpiece for any foreign objects
3. If product requires shaking, shake well (typically for 5 seconds)
4. Facing away from the inhaler, exhale completely
5. Holding inhaler upright with mouthpiece down, place mouthpiece in mouth
6. Form a tight seal with lips, keep tongue below mouthpiece, and tilt head back slightly
7. While breathing in deeply and slowly through the mouth, press down on the canister until it stops moving and has released a puff and remove finger from the canister
8. Continue to breathe in as long as possible, then remove the mouthpiece
9. Hold breath as long as is comfortable (up to 10 seconds)
10. Breathe out gently, away from the inhaler
11. Replace cap right away

Patients should never use the canister of one inhaler with the actuator of another inhaler.^9,23,24 Patients should clean pMDIs at least once a week. Cleaning instructions for pMDIs vary by product (see Table 5).

Table 5. pMDI Cleaning Requirements^10,15-24

HFA = hydrofluoroalkane

All available MDI inhalers have dose counters built into either the canister or the actuator. For most products, the dose counter’s numbers or background will change to red when the inhaler is running low, reminding patients to refill their medication. Healthcare providers should counsel patients not to use inhalers after the dose counter reads zero, even if the canister does not feel empty and still operates. People should not put canisters in water to see if they float as a means of gauging whether medication remains (an old trick that is no longer recommended) or try to alter dose counters. They should also never use a sharp object to unblock an actuator or throw a pMDI into a fire or incinerator. All pMDI inhalers require storage at room temperature, and most should be stored with the mouthpiece down so that the tip of the canister valve is facing down. This keeps the gasket inside of the canister wet so that it does not become brittle and allow outside moisture to enter the canister.⁵³

In addition to general counseling for pMDIs, specific counseling points for breath-actuated pMDIs include four points⁵⁴:

• There is no button to press; opening the cap prepares the dose. If patients leave the cap open for more than two minutes, they will need to close and reopen the cap before inhaling their dose.
• Do not shake (especially not with the cap open, as this may actuate the inhaler). Do not prime or use with a spacer or VHC.
• Clean weekly with a clean, dry tissue or cloth
• Do not take the inhaler apart

SMIs

To set up an SMI (Respimat inhaler), remove the clear base, label the cartridge with the discard date (three months from first use), and insert the narrow end of the cartridge into the inhaler.^28-31 With the inhaler on a firm surface, push down until the cartridge clicks into place (this often takes more force than patients expect). Replace the clear base so that it clicks into place. Do not take the inhaler apart after assembly. To actuate the inhaler, patients should remember the acronym TOP:

• Turn the clear base half a turn in the direction of the arrows until it clicks
• Open the cap fully
• Press the dose-release button and close the cap.

Before first use, repeat the actuation steps until a mist is visible. ^28-31 Then repeat three more times. To take an inhalation

1. Turn the base and open the top
2. Fully exhale away from the inhaler
3. Put mouthpiece in mouth and form a tight seal with lips, keeping mouthpiece above the tongue and pointing towards the back of the throat; be sure not to block air vents with lips or fingers
4. While taking a slow, deep breath through the mouth, press the dose-release button and breathe in as long as possible
5. Remove inhaler from mouth and hold breath as long as is comfortable (up to 10 seconds)
6. Breathe out slowly away from the inhaler
7. Close cap

Pharmacists should counsel patients to prime the device with one puff if not used for more than three days or four visible puffs if not used for more than 21 days. ^28-31 Patients should clean the SMI’s mouthpiece (including the metal part inside) once a week with a damp cloth or tissue. These inhalers have dose indicators and automatically lock when empty. Patients should not spray the device into their eyes or use the SMI with a spacer or VHC. SMIs require room temperature storage.

DPIs

To administer DPIs^33-36

1. Open cover or remove cap and check mouthpiece for foreign objects

1. Prepare dose (see Table 6)
2. Fully exhale away from the inhaler
3. Put mouthpiece in mouth and form a tight seal with lips, keeping tongue below mouthpiece; be sure not to block air vents with lips or fingers
4. Breathe in quickly and deeply, generating a forceful breath right from the start of inhalation
5. After breathing in all the way, remove inhaler from mouth and hold breath for as long as is comfortable (up to 10 seconds)
6. Breathe out slowly away from the inhaler
7. Cover mouthpiece

Table 6. Preparing and Administering DPI Doses^{15,33-37,39-46}

Patients may or may not taste or feel the powder from a DPI upon inhalation. It is fine if they do, and they should not take an extra dose if they don’t. Patients cannot use spacers, VHCs, or masks with DPIs. Manufacturers formulate most DPIs with lactose powder as an ingredient, so patients with severe milk protein allergies should not use them.

Individuals should not wash DPIs. If cleaning is necessary, using a dry tissue or cloth is appropriate. Patients should store DPIs at room temperature and protect them from heat and humidity; they are more sensitive to humidity than are other inhalers. They should not store the Tudorza Pressair inhaler on a vibrating surface.

DEVICE SELECTION TO MATCH PATIENT NEEDS

Individualizing delivery device selection is crucial for optimizing outcomes of aerosol drug therapy. Healthcare professionals must consider patient-, drug-, device-, and environmental-related factors. A good starting point may be to observe a patient’s natural inhalation.⁵⁵ For example, if the patient instinctively takes slow, deep breaths, a pMDI or SMI might be a good fit. If the patient tends to inhale quickly and deeply, a DPI may be ideal. Table 7 discusses other important factors to consider.

Table 7. Inhaler Suggestions Based on Patient-Specific Factors^25,27,56-58

COPD = chronic obstructive pulmonary disease; DPI = dry powder inhaler; pMDI = pressurized metered dose inhaler; SMI = soft mist inhaler; VHC = valved holding chamber

Patients often use multiple inhaled medications for asthma and COPD. Prescribing the same inhaler type for all a patient’s inhaled medications eliminates confusion over varying administration techniques.⁵⁹ Clinicians can also prescribe combination products where appropriate to simplify treatment regimens.

Consider the Cost

Affordability is another vital consideration and will depend on the patient’s insurance status. While most inhalers are brand-name only, a few generic inhalers are available (see examples in Tables 1-3). Prioritizing patient preference when selecting inhalers can improve adherence.⁶⁰ Central to patient satisfaction are issues such as simplicity of use, treatment time, comfort, portability, cleaning requirements, taste, and effect on the throat. If a patient remains unable to use a device effectively after several training visits, consider switching to another inhaler type.

INHALER USE MISTAKES

A literature review and meta-analysis of inhaler use errors in patients with asthma and COPD found that 50% to 100% of patients made at least one error when using their inhaler. Error rates were higher for patients⁶¹

• using MDIs compared to those using DPIs
• with COPD compared to those with asthma
• with a longer history of device use compared to patients new to inhaler treatment
• using multiple inhalers compared to those using only one inhaler

Errors are also common in patients using SMIs. A systematic literature review and meta-analysis of patients with COPD, bronchitis, or emphysema found that nearly 60% made at least one error when using a SMI.⁶² Other factors associated with higher error rates include^50,61

• older age
• lower education level
• female gender
• lower socioeconomic status
• having two or more comorbidities

Pause and ponder: In your workplace, would it be feasible to provide training and technique assessment with every inhaler refill? If not, how might you identify and prioritize patients who most need inhaler use training?

While perfect inhaler use is ideal, patients often have complex medication regimens and healthcare professionals often have heavy workloads. It’s vital to prioritize the most essential steps in the inhaler use process, including those that have a proven impact on patient outcomes. The CRITIKAL study used data from the iHARP asthma review service (a multicenter cross-sectional study of adults with asthma) to identify inhaler use errors associated with worsening asthma control.⁶³ Investigators used data from 3660 patients to pinpoint these critical errors which included⁶³

• not opening the cover or removing cap from mouthpiece
• insufficient inspiratory effort
• incorrect position of head
• not breathing out before inhalation
• not holding breath after inhaling medication, or holding for less than three seconds
• not sealing lips around mouthpiece
• incorrectly priming, timing, or inhaling the second dose (if needed)

Demonstration Devices

Demonstration devices are placebo inhalers, meaning they contain no active medication. They may be available free of charge from device manufacturers. These are ideal for training since the lack of active drug allows for repeated cycles of education and patient demonstration (“teach-back”). Many demonstration inhalers are specifically marked as “only for use by a single patient” to prevent the possible spread of disease.⁶⁴ Keep demonstration inhalers in a separate area of the pharmacy, and do not send them home with patients to avoid any confusion.⁶⁵

We collected the following information by calling inhaler manufacturers directly. Typically, anyone in a healthcare provider’s office or pharmacy is allowed to order demonstration devices on behalf of a prescriber or pharmacy. To order demonstration devices

1. Determine the patient population and disease state you will be addressing
2. Generate a list of common devices your patients use
3. Identify the manufacturer of each device and visit the manufacturer’s website or the website for the specific product
4. Obtain the email and phone number for customer service representatives and note days and times available (keep in mind the time zone)
5. Reach out to the company’s local representative or customer care representative to request demonstration devices
6. Provide all information required (generally your full name, title, state license number, phone number, address of the pharmacy or office you plan to have the devices delivered to and the facility’s secondary contact information [e.g., fax, email])

When making a demonstration device request, pharmacy staff should allow several weeks for processing and device delivery. The number of devices available also varies. For example, one inhaler manufacturer provides 15 or 20 demonstration devices in response to requests, while another requires a manager review of any request for more than three devices.

Appendix 1 provides contact information for the manufacturers of several inhaler devices. Demonstration device availability can change over time; some companies have demonstration devices in stock only periodically and will advise calling back another time. Companies may also stop carrying demonstration devices for their older products. The GOLD report identifies a lack of placebo inhalers as a common barrier to educating patients.⁴ However, if efforts to obtain demonstration devices are unsuccessful, pharmacists can teach patients using their own devices instead.

Manufacturers may also provide patient assistance programs and co-pay assistance to help with affordability. Patients with commercial or private health insurance are often eligible to participate in co-pay assistance programs and receive a savings card to help lower the cost of the prescription. Healthcare providers can also request additional educational materials and pamphlets to hand out. Referring patients who may be struggling with affording their medications to the manufacturer for assistance and to investigate the patients’ benefits to determine discounts available is highly recommended.

CONCLUSION

Pharmacy personnel are well positioned to help patients maximize the benefit of their inhaled medications. An awareness of available inhalers and the requirements and techniques for their use can help healthcare professionals identify whether patients and their devices are a good match. Recognizing the importance of ongoing training and assessment, pharmacy staff can encourage brief yet frequent counseling sessions with patients as they refill their inhaled medications. Pharmacy personnel should proactively order inhaler demonstration devices from manufacturers (if available) to facilitate patient education.

Appendix I. Inhaler Manufacturer Contact List (Current as of July 1, 2022)

HFA = hydrofluoroalkane

All information was obtained by calling companies directly and was up to date as of July 1, 2022.

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