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The use of inhaler devices in adults

Dean Hess, RRT, PhD
Rajiv Dhand, MD, FCCP, FACP, FAARC
Section Editor
Bruce S Bochner, MD
Deputy Editor
Helen Hollingsworth, MD


Inhaler devices are the major method for delivery of asthma medication, but their effectiveness can be compromised if the patient uses the inhaler device incorrectly [1]. The magnitude of this problem has been well documented; in several studies less than half of the patients used their inhaler correctly [2-9].

The use of inhaler devices by adults will be presented here. More general discussions of the delivery of inhaled medication via nebulizers and what patients need to know about their asthma are presented separately (table 1). (See "Delivery of inhaled medication in adults" and "What do patients need to know about their asthma?".)


Inhaler devices are used to deliver a variety of inhaled medications, including beta-agonists, anticholinergics, glucocorticoids, tobramycin, and insulin. Three main types of inhaler devices are available, the pressurized metered dose inhaler (MDI), the dry powder inhaler (DPI), and the soft mist inhaler (SMI) [10,11].

Metered dose inhalers with CFC and HFA — MDI devices consist of a pressurized canister, a metering valve and stem, and a mouthpiece actuator (picture 1). The pressurized canister contains the drug suspended in a mixture of propellants, surfactants, preservatives, flavoring agents, and dispersal agents. Following adoption of the Montreal protocol, an international agreement to ban chlorofluorocarbons (CFCs), the CFC-free propellant hydrofluoroalkane (HFA)-134a has replaced CFC-containing devices [12-24]. Delivery of most aerosol medications to the lungs is comparable between HFA and traditional CFC devices, although a few of the HFAs deliver a greater portion of the dose than the comparable CFC MDI [21,25-30].

Dry powder inhalers — DPIs are breath-actuated devices that deliver micronized drug particles with a mass median aerodynamic diameter (MMAD) of less than 5 µm, which usually are aggregated with carrier particles (such as lactose or glucose) of greater diameter [31,32]. Drug is delivered to the airways by the inhalation of air over a punctured capsule, blister, or reservoir [31,32]. Inspiratory flow rates of 30 to 60 L/min are required to disaggregate and aerosolize the drug when using a DPI device [33-35].

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Literature review current through: Nov 2017. | This topic last updated: Jun 22, 2017.
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  1. Schecker MH, Wilson AF, Mukai DS, et al. A device for overcoming discoordination with metered-dose inhalers. J Allergy Clin Immunol 1993; 92:783.
  2. Goodman DE, Israel E, Rosenberg M, et al. The influence of age, diagnosis, and gender on proper use of metered-dose inhalers. Am J Respir Crit Care Med 1994; 150:1256.
  3. Toogood, JH. Helping your patients make better use of MDIs and spacers. J Respir Dis 1994; 15:151.
  4. Sander N, Fusco-Walkert SJ, Harder JM, Chipps BE. Dose counting and the use of pressurized metered-dose inhalers: running on empty. Ann Allergy Asthma Immunol 2006; 97:34.
  5. Wieshammer S, Dreyhaupt J. Dry powder inhalers: which factors determine the frequency of handling errors? Respiration 2008; 75:18.
  6. Souza ML, Meneghini AC, Ferraz E, et al. Knowledge of and technique for using inhalation devices among asthma patients and COPD patients. J Bras Pneumol 2009; 35:824.
  7. Sleath B, Ayala GX, Gillette C, et al. Provider demonstration and assessment of child device technique during pediatric asthma visits. Pediatrics 2011; 127:642.
  8. Minai BA, Martin JE, Cohn RC. Results of a physician and respiratory therapist collaborative effort to improve long-term metered-dose inhaler technique in a pediatric asthma clinic. Respir Care 2004; 49:600.
  9. Allen SC, Warwick-Sanders M, Baxter M. A comparison of four tests of cognition as predictors of inability to learn to use a metered dose inhaler in old age. Int J Clin Pract 2009; 63:1150.
  10. Dolovich MB, Dhand R. Aerosol drug delivery: developments in device design and clinical use. Lancet 2011; 377:1032.
  11. Laube BL, Janssens HM, de Jongh FH, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J 2011; 37:1308.
  12. Hawksworth RJ, Sykes AP, Faris M, et al. Albuterol HFA is as effective as albuterol CFC in preventing exercise-induced bronchoconstriction. Ann Allergy Asthma Immunol 2002; 88:473.
  13. Langley SJ, Sykes AP, Batty EP, et al. A comparison of the efficacy and tolerability of single doses of HFA 134a albuterol and CFC albuterol in mild-to-moderate asthmatic patients. Ann Allergy Asthma Immunol 2002; 88:488.
  14. Cheng YS, Fu CS, Yazzie D, Zhou Y. Respiratory deposition patterns of salbutamol pMDI with CFC and HFA-134a formulations in a human airway replica. J Aerosol Med 2001; 14:255.
  15. Richards J, Hirst P, Pitcairn G, et al. Deposition and pharmacokinetics of flunisolide delivered from pressurized inhalers containing non-CFC and CFC propellants. J Aerosol Med 2001; 14:197.
  16. Boccuzzi SJ, Wogen J, Roehm JB. Use of hydrofluoroalkane propellant delivery system for inhaled albuterol in patients receiving asthma medications. Clin Ther 2000; 22:237.
  17. Huchon G, Hofbauer P, Cannizzaro G, et al. Comparison of the safety of drug delivery via HFA- and CFC-metered dose inhalers in CAO. Eur Respir J 2000; 15:663.
  18. Magnussen H. Equivalent asthma control after dose reduction with HFA-134a beclomethasone solution aerosol. Comparative Inhaled Steroid Investigation Group (CISIG). Respir Med 2000; 94:549.
  19. Shapiro G, Bronsky E, Murray A, et al. Clinical comparability of ventolin formulated with hydrofluoroalkane or conventional chlorofluorocarbon propellants in children with asthma. Arch Pediatr Adolesc Med 2000; 154:1219.
  20. Brindley A. The chlorofluorocarbon to hydrofluoroalkane transition: the effect on pressurized metered dose inhaler suspension stability. J Allergy Clin Immunol 1999; 104:S221.
  21. Bronsky E, Ekholm BP, Klinger NM, Colice GL. Switching patients with asthma from chlorofluorocarbon (CFC) albuterol to hydrofluoroalkane-134a (HFA) albuterol. J Asthma 1999; 36:107.
  22. Ramsdell JW, Klinger NM, Ekholm BP, Colice GL. Safety of long-term treatment with HFA albuterol. Chest 1999; 115:945.
  23. Bleecker ER, Tinkelman DG, Ramsdell J, et al. Proventil HFA provides bronchodilation comparable to ventolin over 12 weeks of regular use in asthmatics. Chest 1998; 113:283.
  24. Leach CL. The CFC to HFA transition and its impact on pulmonary drug development. Respir Care 2005; 50:1201.
  25. Escribano A, Tutuncu A, Löhr I, et al. Clinical comparability between the CFC and HFA budesonide pressurised metered-dose inhalers in paediatric patients with asthma: a randomised controlled trial. Curr Med Res Opin 2006; 22:1085.
  26. Singh D, Tutuncu A, Lohr I, et al. Budesonide administered using chlorofluorocarbon and hydrofluoroalkane pressurized metered-dose inhalers: pharmacokinetics, pharmacodynamics and clinical equivalence. Int J Clin Pharmacol Ther 2007; 45:485.
  27. Shapiro GS, Klinger NM, Ekholm BP, Colice GL. Comparable bronchodilation with hydrofluoroalkane-134a (HFA) albuterol and chlorofluorocarbons-11/12 (CFC) albuterol in children with asthma. J Asthma 2000; 37:667.
  28. Newman S, Salmon A, Nave R, Drollmann A. High lung deposition of 99mTc-labeled ciclesonide administered via HFA-MDI to patients with asthma. Respir Med 2006; 100:375.
  29. Nave R, Zech K, Bethke TD. Lower oropharyngeal deposition of inhaled ciclesonide via hydrofluoroalkane metered-dose inhaler compared with budesonide via chlorofluorocarbon metered-dose inhaler in healthy subjects. Eur J Clin Pharmacol 2005; 61:203.
  30. Leach CL, Colice GL. A pilot study to assess lung deposition of HFA-beclomethasone and CFC-beclomethasone from a pressurized metered dose inhaler with and without add-on spacers and using varying breathhold times. J Aerosol Med Pulm Drug Deliv 2010; 23:355.
  31. Newman SP, Busse WW. Evolution of dry powder inhaler design, formulation, and performance. Respir Med 2002; 96:293.
  32. Islam N, Gladki E. Dry powder inhalers (DPIs)--a review of device reliability and innovation. Int J Pharm 2008; 360:1.
  33. Broeders ME, Molema J, Vermue NA, Folgering HT. Peak inspiratory flow rate and slope of the inhalation profiles in dry powder inhalers. Eur Respir J 2001; 18:780.
  34. Chavan V, Dalby R. Effect of rise in simulated inspiratory flow rate and carrier particle size on powder emptying from dry powder inhalers. AAPS PharmSci 2000; 2:E10.
  35. Kanabuchi K, Kondo T, Tanigaki T, et al. Minimal inspiratory flow from dry powder inhalers according to a biphasic model of pressure vs. flow relationship. Tokai J Exp Clin Med 2011; 36:1.
  36. Dalby R, Spallek M, Voshaar T. A review of the development of Respimat Soft Mist Inhaler. Int J Pharm 2004; 283:1.
  37. Panos RJ. Efficacy and safety of eco-friendly inhalers: focus on combination ipratropium bromide and albuterol in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2013; 8:221.
  38. Wilkes W, Fink J, Dhand R. Selecting an accessory device with a metered-dose inhaler: variable influence of accessory devices on fine particle dose, throat deposition, and drug delivery with asynchronous actuation from a metered-dose inhaler. J Aerosol Med 2001; 14:351.
  39. Nikander K, Nicholls C, Denyer J, Pritchard J. The evolution of spacers and valved holding chambers. J Aerosol Med Pulm Drug Deliv 2014; 27 Suppl 1:S4.
  40. Fink JB. Aerosol device selection: evidence to practice. Respir Care 2000; 45:874.
  41. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-4051). www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on June 13, 2011).
  42. Dempsey OJ, Wilson AM, Coutie WJ, Lipworth BJ. Evaluation of the effect of a large volume spacer on the systemic bioactivity of fluticasone propionate metered-dose inhaler. Chest 1999; 116:935.
  43. Sheth P, Bertsch MD, Knapp CL, Myrdal PB. In vitro evaluation of nonconventional accessory devices for pressurized metered-dose inhalers. Ann Allergy Asthma Immunol 2014; 113:55.
  44. O'Callaghan C, Barry P. Spacer devices in the treatment of asthma. BMJ 1997; 314:1061.
  45. Barry PW, O'Callaghan C. Inhalational drug delivery from seven different spacer devices. Thorax 1996; 51:835.
  46. Bisgaard H, Anhøj J, Klug B, Berg E. A non-electrostatic spacer for aerosol delivery. Arch Dis Child 1995; 73:226.
  47. Hess DR. Aerosol delivery devices in the treatment of asthma. Respir Care 2008; 53:699.
  48. Guidelines for the Diagnosis and Management of Asthma. National Asthma Education and Prevention Program, NIH publication no. 97-4051 USDHHS, 1997.
  49. Pickering H, Pitcairn GR, Hirst PH, et al. Regional lung deposition of a technetium 99m-labeled formulation of mometasone furoate administered by hydrofluoroalkane 227 metered-dose inhaler. Clin Ther 2000; 22:1483.
  50. Dickens GR, Wermeling DP, Matheny CJ, et al. Pharmacokinetics of flunisolide administered via metered dose inhaler with and without a spacer device and following oral administration. Ann Allergy Asthma Immunol 2000; 84:528.
  51. Leach C. Effect of formulation parameters on hydrofluoroalkane-beclomethasone dipropionate drug deposition in humans. J Allergy Clin Immunol 1999; 104:S250.
  52. Weers J, Clark A. The Impact of Inspiratory Flow Rate on Drug Delivery to the Lungs with Dry Powder Inhalers. Pharm Res 2017; 34:507.
  53. National Asthma Education Program. Teach your patients about asthma. A clinician's guide. National Institutes of Health, Bethesda, 1992, Pub. #92-2737.
  54. Manzella BA, Brooks CM, Richards JM Jr, et al. Assessing the use of metered dose inhalers by adults with asthma. J Asthma 1989; 26:223.
  55. Blake KV, Harman E, Hendeles L. Evaluation of a generic albuterol metered-dose inhaler: importance of priming the MDI. Ann Allergy 1992; 68:169.
  56. Ross RN. Loss of bronchodilator medication in priming a conventional metered dose inhaler: a cost of treating asthma. Med Interface 1997; 10:141.
  57. Cyr TD, Graham SJ, Li KY, Lovering EG. Low first-spray drug content in albuterol metered-dose inhalers. Pharm Res 1991; 8:658.
  58. Everard ML, Devadason SG, Summers QA, Le Souëf PN. Factors affecting total and "respirable" dose delivered by a salbutamol metered dose inhaler. Thorax 1995; 50:746.
  59. Berg E. In vitro properties of pressurized metered dose inhalers with and without spacer devices. J Aerosol Med 1995; 8 Suppl 3:S3.
  60. Dompeling E, Oudesluys-Murphy AM, Janssens HM, et al. Randomised controlled study of clinical efficacy of spacer therapy in asthma with regard to electrostatic charge. Arch Dis Child 2001; 84:178.
  61. Anhøj J, Bisgaard H, Lipworth BJ. Effect of electrostatic charge in plastic spacers on the lung delivery of HFA-salbutamol in children. Br J Clin Pharmacol 1999; 47:333.
  62. van der Veen MJ, van der Zee JS. Aerosol recovery from large-volume reservoir delivery systems is highly dependent on the static properties of the reservoir. Eur Respir J 1999; 13:668.
  63. Wildhaber JH, Janssens HM, Piérart F, et al. High-percentage lung delivery in children from detergent-treated spacers. Pediatr Pulmonol 2000; 29:389.
  64. Piérart F, Wildhaber JH, Vrancken I, et al. Washing plastic spacers in household detergent reduces electrostatic charge and greatly improves delivery. Eur Respir J 1999; 13:673.
  65. Kacmarek, DM, Hess, D. The interface between patient and aerosol generator. Respir Care 1991; 36:952.
  66. Rau JL, Restrepo RD, Deshpande V. Inhalation of single vs multiple metered-dose bronchodilator actuations from reservoir devices. An in vitro study. Chest 1996; 109:969.
  67. Barry PW, O'Callaghan C. The effect of delay, multiple actuations and spacer static charge on the in vitro delivery of budesonide from the Nebuhaler. Br J Clin Pharmacol 1995; 40:76.
  68. Smith KJ, Chan HK, Brown KF. Influence of flow rate on aerosol particle size distributions from pressurized and breath-actuated inhalers. J Aerosol Med 1998; 11:231.
  69. Azouz W, Chetcuti P, Hosker HS, et al. The inhalation characteristics of patients when they use different dry powder inhalers. J Aerosol Med Pulm Drug Deliv 2015; 28:35.
  70. Kawamatawong T, Khiawwan S, Pornsuriyasak P. Peak inspiratory flow rate measurement by using In-Check DIAL for the different inhaler devices in elderly with obstructive airway diseases. J Asthma Allergy 2017; 10:17.
  71. Manuyakorn W, Direkwattanachai C, Benjaponpitak S, et al. Sensitivity of Turbutester and Accuhaler tester in asthmatic children and adolescents. Pediatr Int 2010; 52:118.
  72. Chrystyn H. Is inhalation rate important for a dry powder inhaler? Using the In-Check Dial to identify these rates. Respir Med 2003; 97:181.
  73. Combivent Respimat prescribing information. http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021747s013lbl.pdf (Accessed on December 19, 2016).
  74. Rickard KA. Not running on empty. Ann Allergy Asthma Immunol 2006; 97:558.
  75. Cain WT, Oppenheimer JJ. The misconception of using floating patterns as an accurate means of measuring the contents of metered-dose inhaler devices. Ann Allergy Asthma Immunol 2001; 87:417.
  76. Ogren RA, Baldwin JL, Simon RA. How patients determine when to replace their metered-dose inhalers. Ann Allergy Asthma Immunol 1995; 75:485.