 We'll show several of the more common devices and how a patient can use these devices appropriately. First for the metered dose inhaler. The first device is called the metered dose inhaler or an MDI. This is one of the more common types of inhalers and must be used appropriately to effectively deliver the medication into the lungs. If used incorrectly, most of the medication will be deposited into the mouth or the back of the throat or in the stomach instead of the lungs. Because of this, it is very important that each patient learn how to use this inhaler device properly and practice good inhaler technique. There are three techniques that a patient can use to deliver the medications from the MDI to the lungs. These methods are called one, the closed mouth technique, secondly, the open mouth technique, and third, the spacer technique. These techniques differ only in the way the MDI is positioned in the mouth before it is used. Most patients use the closed mouth technique, however using the open mouth technique or the spacer actually improves the amount of medication delivered into the lungs. With these two techniques, less medication is deposited into the mouth and the throat or swallowed into the stomach and more of the medication gets to the targeted site, the lungs. MDIs have three main parts, the pressurized container, the metering valve, and the actuator. And this is how the three components are put together. To prepare the inhaler for use, first you must remove the cap and check for debris and then shake the inhaler. These are the first two steps that should be completed every time the inhaler is used, regardless of which technique is used to deliver the medication. The closed mouth technique may be used for fast-acting bronchodilators such as albuterol, but should not be used for inhaled steroids such as beclevant or flowvant. If you use this technique with these types of inhaled steroids, the medication can be deposited into the back of the throat and may cause a fungal infection in the back of the mouth or throat known as thrush. It is always advisable to use a spacer with an inhaled steroid to decrease the chance of developing this type of infection. Also, be sure to rinse, gargle, and spit after you use a steroid to prevent this type of infection. Today I was going to stop by and see if you could recommend something for my sore throat. I started using Floven a few weeks ago for my asthma, and ever since then my throat's been really sore and I can't hardly swallow. Okay. Have you been rinsing and spitting after each use? No, ma'am. I'm sure I haven't. Okay. You may have developed an infection in the back of your throat called thrush. If you haven't been rinsing and spitting, it's really important to do that to prevent this infection from happening. I would suggest that you call your doctor for an appointment and have your throat checked, because if it is thrush, you may need to get an antifuncle medication to treat it. I'll do that. I'll call my doctor now. Is there anything else that I can do to keep this from happening again in the future? Well, have you been using your spacer with your Floven? No, ma'am. I'm sure I haven't. Okay. You need to use your spacer with your Floven inhaler because the spacer will keep the medication from just stopping in the back of your throat and will help it get deep into your lungs where it needs to go. So it's very important to always use your spacer. If your doctor or pharmacist tells you to use the closed mouth technique with your fast-acting inhaler, you would follow these steps. Prepare the inhaler for use as described previously. Tilt the head back slightly. Breathe out completely, emptying the lungs just before use. Put your lips around the mouth of the inhaler and seal your lips. As you start to breathe in, press down on the inhaler to release a puff of medication. Press down only one time. Breathe in very slowly and deeply over three to five seconds. Hold your breath for at least 10 seconds or as long as possible. Normally, then wait at least one minute before the next puff. The most common mistakes with the use of the MDIs are forgetting to breathe out before using the medication and breathing in too quickly after releasing the dose. If you breathe in too quickly, the medication particles actually move too fast and ricochet off the back of the mouth and throat instead of being pulled into the lungs. More medicine is deposited in the mouth and throat and part of the dose is wasted. Be sure to count to five while breathing in to avoid this mistake. If your doctor has prescribed more than one puff of the MDI, be sure to at least wait one minute between puffs. If you are using a fast-acting bronchodilator, the medicine will actually begin working within this minute and the smooth muscle in the airways will actually begin to relax. This allows for a deeper penetration of the subsequent doses of the medication and a more effective response. Prepare the inhaler for use in the same way described for the closed mouth technique. Tilt the head back slightly. Breathe out completely, emptying the lungs just before use. Position the inhaler one to two inches in front of the mouth and keep the mouth open. As you start to breathe in, press down on the inhaler to release a puff of medication. And remember, press down only one time. Breathe in very slowly and deeply over three to five seconds. Hold your breath for at least ten seconds or as long as you possibly can. Exhale normally and then wait at least one minute between puffs. For many patients, it is difficult to inhale the full amount of the medication quickly and difficult to handle the small inhaler device. A device called a spacer can be attached to the end of the MDI to allow more time for the patient to inhale. And a larger device for the patient to hold. A similar device called a holding chamber can also be attached to the end of the MDI. This device simply holds the medication in the chamber so that a patient can inhale the medication using several breaths. This can be especially helpful in patients with small or tight lungs such as children. Some holding chambers will actually whistle if the patient breathes in too quickly or over a time shorter than three to five seconds. This can be helpful in reinforcing the habit of breathing in slowly to get more medication into the lungs. Hi Suzanne. I see that your doctor has prescribed a medication for your asthma. And the medication that he has prescribed is called Albuterol. And that medication is used to actually relieve the tightness you feel in your chest when you're having an asthma attack. It works very quickly. But in order for the medication to work the best possible it has to get down into your lungs. And we do that by using what we call a meter dose inhaler. But if you use this incorrectly you'll get more in your throat and in your stomach than you will in your lungs. So I'm going to teach you how to use this today so that you get the most medication possible into your lungs. There's actually three ways you can use this medication. And the only difference between the three techniques is where you place the inhaler when you're using it. And so there's parts of the techniques that are the same regardless of where you're putting the inhaler or which technique you're using. The first thing you always want to do when you get your medication is open the cap of the inhaler. And that exposes the mouthpiece that you'll use in order to deliver the medication into your body. And you always want to inspect it to make sure that it's clean and there's nothing in there that might have got. If it was in your purse or something sometimes you'll get dirty when make sure it's clean and ready to use. The next thing you want to do is actually shake the inhaler. And this is a very important step. It's probably one of the most important steps you do. Because if your inhaler was in your purse and it was laying on its side like this, all of the medication actually falls to the bottom of the inhaler and it'll be stuck on the side of the inhaler. And if you pick it up to use it and you forget to shake it, you're going to be using propellant with no active medication in it. So you have to really shake it up in order to get the medication distributed with the propellant. Now just think about if you were going to spray paint something in your garage and you went out and you forgot to shake the spray paint. You would actually get globs of paint on whatever you're painting and it wouldn't be even and pretty. And that's the same type of thing you're doing here. When you shake this you're mixing the propellant with the medication so that it's ready to be inhaled into the lungs. And that's the same regardless of where you put the inhaler or which technique you use to deliver it. The next thing you're going to do is with all three techniques you're going to breathe out and you're going to empty your lungs of air and that's going to cause you to take a reflex deep breath in which will help you get a lot of medication down into the lungs. So that's the first three steps that we're always going to do. Now the next thing you have to remember is the first technique I'm going to go over with you is the closed mouth technique. You have to think about where am I going to place the inhaler. With the closed mouth technique it's exactly what it sounds like. You're going to place the inhaler between the lips and you're going to wrap the lips around the mouthpiece but when you use the closed mouth technique. And then you're going to press down on the inhaler and actually dispense one puff of the medication. And while you're doing that you're going to breathe in very slowly over three to five seconds. And that's the hardest part because a lot of my patients they like to breathe in real fast like that. And it's not very effective when you breathe in fast. Actually the medicine goes really fast and it hits the back of the throat and it comes back out in your mouth and you don't get enough down your lungs. It gets all in your mouth and on your throat but it doesn't get down your lungs. So you have to breathe in very slowly over three to five seconds. And then after you breathe in you have to hold the medication in your lungs for at least ten seconds. So I need you to hold your breath for ten seconds or more. If you can go longer I'd love for you to go longer. Because when you're holding your breath the medicine is actually in contact with your lungs and it's finding where it's supposed to work and it's working. And when you breathe back out you're actually excelling the medication back out into the environment and it's not where it needs to be acting anymore you're releasing it into the environment. So the longer it is in contact with your lungs the better that you have the delivery of the medication to the lung tissue where it needs to be. Then after you breathe out you need to wait at least one minute in between puffs to make sure that the medication that you just breathe in starts working. And especially with your medication which is called a bronchodilator, the albuterol it actually starts opening up those airways and the muscles in your lungs start relaxing and the airways actually start widening. And when you use the second puff the medicine is going to get deeper down into your lungs and it will have a better effect than the first puff did. So it's very important to wait between puffs and never use two puffs at one time. So now I'm going to show you how to do all these steps for closed mouth technique and I want you to show me and we'll see if you got it right. That ten seconds seems longer than what you would think isn't it? But that's very important that you hold their breath for at least ten seconds before you breathe out. Now if I was going to use a second puff of the medicine I would wait one minute before I use that second puff. Now let's see if you can do that. Very good. You held it for eleven seconds actually so that's very good. Any questions about the closed mouth technique? It doesn't seem too hard. I don't think I can do it. The closed mouth technique would be appropriate for your fast acting inhaler, your albuterol. That would be fine. But if your doctor ever prescribes a steroid inhaler for your asthma I don't want you to use the closed mouth technique for that. That would be something like flow vent or beck flow vent, something like that because the steroids can actually get, with the closed mouth technique get deposited on your throat and it increases your risk of thrush. So we want to use one of the other two techniques, specifically a spacer technique if you're using a steroid. But with this medication you can use that closed mouth technique and you will get some medication down your lungs. There's actually a way you could hold your inhaler where you'll get a little bit more medicine down your lungs and it's called the open mouth technique. Now the open mouth technique is exactly like the closed mouth technique except where you place the inhaler. So you're going to remove the cap, you're going to shake the inhaler, you're going to breathe out, but you're going to place the inhaler instead of in your mouth with your lips wrapped around the mouthpiece you're going to actually place it approximately two finger widths or one to two inches in front of your mouth and you go hold it there when you press down. Now I can tell you that a lot of my patients they instinctively change that. They'll have it right here just where they're supposed to but right before they press down they move in, or they move in the inhaler. So I want you to be real careful if you're using the open mouth technique to keep your hands steady and keep your inhaler at least two inches in front of your lips, okay? And then you're going to breathe in very slowly over three to five seconds. You're going to hold your breath for ten seconds. Then you're going to let your breath out and then you're going to wait at least one minute before you use a second puff of the medication. So the only difference is where you're putting the inhaler. Now the reason this helps is it actually gives the distance between the back of your throat and the inhaler mouthpiece is farther and so you actually have time for the particle size of your medicine to get small enough that it goes into your lungs instead of long to your mouth and throat and into your stomach. And so it's actually the timing and the space that you need that the two inches is perfect, okay? So let me show you how to do this and I'm going to let you practice again, okay? So remove the cap, shake. Now I like to see you do it. That was perfect except for one thing. Can you think of something you did wrong? I don't know. You missed it? Okay. You forgot to breathe out, okay? Okay. So remember the breathing out is very important because it helps empty the lungs and then it gives you that reflex that you take a very deep breath in and you get it back and fill your lungs with the medicine, okay? So let's try it one more time and we want to watch one more puff. We'll pretend we waited one minute in between puffs. Okay. Okay. Do I do it after? Okay. Yeah, you breathe out. What I usually do is I position the inhaler and then I breathe out to the side and then put my head back and press down. Okay. Very good. That was perfect. That's the open mouth technique, okay? Okay. And again, you can use your albuterol using the open mouth technique and you're going to get a little bit more of the medicine down into your lungs than you did with the closed mouth technique, okay? But it's still not optimal to use with steroids. I would rather you use a spacer with steroids and the reason is that steroids, when you're using the open mouth technique, you can get a vapor of the mist that can get into your eyes and it can actually cause side effects in your eyes. And so the spacer actually eliminates the risk of having side effects in your eyes, okay? So the third technique we're going to talk about is the spacer technique and that's when you use something, either a spacer such as this or a holding chamber such as this in order to deliver the medicine. Now the best thing, the gold standard, is the holding chamber. It's a Cadillac, okay? Because it has all kinds of bells and whistles to help make sure that you use the medication appropriately. But very similar technique, you're going to remove the cap and you're going to shake the inhaler to mix the medication. And then you're going to insert the inhaler into this end of the holding chamber designed to adapt with the adapter for the inhaler, okay? You're going to insert that in here just like that. Now this other end, you just remove the cap and this is the mouthpiece for this, okay? You're going to put it up and get it positioned just like you would for the OP mouth technique and you're going to breathe out to the side, okay? And then you're going to press down and the nice thing about holding chamber is it actually holds the medicine in here until you pull or breathe in and pull on the chamber to release the medication into the lungs, okay? And then you're going to breathe in really slowly and this one is really smart. It whistles at you if you breathe in too fast and it's saying slow down, okay? Then you're going to take it away and you'll hold your breath for 10 seconds before you repeat the next puff, okay? So let me show you how that would be. That's how you use a spacer. You would wait one minute before you use the second puff, okay? Okay. Let's see you do that. I'm going to remove the cap and shake it really good. Very good, okay? And just to show you how it does whistle at you if you go too fast, I'm just going to release the dose. So that would be if you were trying to breathe it in too fast and it's telling you that it's ricocheting off the back of your throat and that it's actually not getting down into your lungs. It's telling you to slow down. So if you ever hear that sound, remember to breathe in slower and count to five while you're breathing in. Okay. That's very good. Do you have any questions about how to use a meter-dose inhaler? Okay, well, great. You can always call me if you have any questions later.