Table 4– Detailed instructions on how to use pressurised metered-dose inhalers (pMDIs), breath-actuated (BA)-pMDIs, pMDIs with spacers, dry powder inhalers (DPIs), nebulisers and soft mist inhalers
pMDIs: for patients with good actuation–inhalation coordination
 1) Shake four or five times if suspension formulation.
 2) Take the cap off.
 3) Prime the inhaler (refer to the PIL for specific instructions).
 4) Exhale slowly, as far as comfortable (to empty the lungs).
 5) Hold the inhaler in an upright position.
 6) Immediately place the inhaler in the mouth between the teeth, with the tongue flat under the mouthpiece.
 7) Ensure that the lips have formed a good seal with the mouthpiece.
 8) Start to inhale slowly, through the mouth and at the same time press the canister to actuate a dose.
 9) Maintain a slow and deep inhalation, through the mouth, until the lungs are full of air. This should take an adult 4–5 s.
 10) At the end of the inhalation, take the inhaler out of the mouth and close the lips.
 11) Continue to hold the breath for as long as possible, or up to 10 s before breathing out.
 12) Breathe normally.
 13) If another dose is required, repeat steps 4–12.
BA-pMDIs: for patients ≥6 yrs old
 1–7) Same as above for pMDIs alone.
 8) Start to inhale slowly, through the mouth. The patient should sense that a dose has been released, either by taste or a noise when the dose is released (the noise is quiet for the Easi-Breathe®).
 9) Maintain a slow and deep inhalation, through the mouth, until the lungs are full of air. This should take a child ∼2–3 s and an adult 4–5 s.
 10–13) Same as above for pMDIs alone.
pMDI + spacer with facemask: for patients ≤3 yrs old or anyone who cannot breathe consciously through the mouth
 1–3) Same as above for pMDIs alone.
 4) Insert the mouthpiece of the pMDI into the open end of the spacer and ensure a tight fit. If a reverse flow spacer is used (table 6), insert the valve stem of the pMDI into the port on the mouthpiece of the spacer.
 5) Place the facemask over the nose and mouth and be sure the fit is tight to the face.
 6) Actuate one dose into the chamber of the spacer.
 7) The patient should inhale and exhale normally into the spacer at least 10 times.
 8) Take the facemask off the patient's face.
 9) If another dose is required, repeat steps 1–8.
pMDI + spacer with mouthpiece: for patients ≥3 yrs old (caregiver should determine if child can perform this technique correctly)
 1–4) Same as above for spacer with facemask.
 5) Place the mouthpiece of the spacer in the patient's mouth with the teeth over the mouthpiece and the lips sealed around it.
 6) Actuate one dose into the chamber of the spacer.
 7) Instruct the patient to inhale and exhale using normal (tidal) breaths into the spacer at least 5 times. With some spacers, the inhalations and exhalations can be monitored by observing the movement of the valves.
 8) If another dose is required, repeat steps 4–7.
 9) If ICSs are used, rinse mouth afterwards.
pMDI + spacer with mouthpiece: for patients ≥6 yrs old (caregiver should determine if child can perform this technique correctly)
 1–4) Same as above for spacer with facemask.
 5) Place the mouthpiece of the spacer in the patient's mouth with the teeth over the mouthpiece and the lips sealed around it.
 6) Instruct the child to exhale slowly, as far as comfortable (to empty their lungs).
 7) Actuate one dose into the chamber of the spacer and start to inhale slowly through the mouthpiece. Some spacers will make a whistling noise if inspiration is too fast.
 8) Maintain a slow and deep inhalation through the mouth, until the lungs are full of air. This should take a child 2–3 s and an adult 5 s.
 9) At the end of the inhalation, take the inhaler out of the mouth and close the lips.
 10) Continue to hold the breath for as long as possible for up to 10 s before breathing out.
 11) Breathe normally.
 12) If another dose is required, repeat steps 1–11.
 13) If ICSs are used, rinse mouth afterwards.
DPIs: for patients ≥5–6 yrs old (caregiver should determine if child can perform this technique correctly)
 1) Take the cap off (some do not have a cap).
 2) Follow the dose preparation instructions in the PIL.
 3) Do not point the mouthpiece downwards once a dose has been prepared for inhalation because the dose could fall out.
 4) Exhale slowly, as far as comfortable (to empty the lungs). Do not exhale into the DPI.
 5) Start to inhale forcefully through the mouth from the very beginning. Do not gradually build up the speed of inhalation.
 6) Continue inhaling until the lungs are full.
 7) At the end of the inhalation take the inhaler out of the mouth and close the lips. Continue to hold the breath for as long as possible, or up to 10 s.
 8) Breathe normally.
 9) If another dose is required, repeat steps 1–8.
Jet nebulisers: for patients of any age who cannot use a pMDI with a valved holding chamber, with or without a facemask, or if the drug is only available as nebuliser liquid
 1) Assemble the tubing, nebuliser cup and mouthpiece (or mask).
 2) Pour the medication solution into the nebuliser cup.
 3) Do not exceed the fill volume recommended by the manufacturer.
 4) Connect to power source; flow of 6–8 L·min−1, or compressor.
 5) Place the mouthpiece in the mouth and close the lips around it (or cover the nose and mouth with an appropriate facemask).
 6) Keep the nebuliser vertical during treatment.
 7) Inhale and exhale using normal (tidal) breaths, with occasional deep breaths, until the nebuliser starts to sputter or no more aerosol is produced.
 8) If the treatment must be interrupted, turn off the unit to avoid waste.
 9) At the completion of the treatment, take the mouthpiece out of the mouth.
 10) Dismantle and clean nebuliser following manufacturer's instructions.
 11) With technology that differs from that of a traditional jet nebuliser, clinicians should thoroughly review operating instructions prior to patient use and instruction.
Mesh nebulisers: for use with drugs licensed with this type of nebuliser
 1) Assemble the device according to the manufacturer's instructions.
 2) Follow manufacturer's instructions to test the nebuliser function prior to the first use of a new device and after each cleaning to verify proper operation.
 3) Pour the medication solution into the medication reservoir. Do not exceed the volume recommended by the manufacturer.
 4) Turn on the power.
 5) Hold the nebuliser in the position recommended by the manufacturer.
 6) Put the mouthpiece into the mouth and close the lips around it.
 7) Inhale and exhale using normal (tidal) breaths, with occasional deep breaths.
 8) At the completion of the treatment, take the mouthpiece out of the mouth.
 9) Clean nebuliser following the manufacturer's instructions.
Soft mist inhalers
 Assemble and use the device according to the manufacturer's instructions.
  • PIL: patient information leaflet; ICSs: inhaled corticosteroids. See Appendix for all product/drug manufacturer details.