Asthma advice: Inhaler technique

Introduction

Greet, introduce yourself, confirm the patient’s name and date of birth. Obtain consent and wash hands.

In explanation stations, it is very important to follow exactly what the station instruction sheet says. Some stations may ask you to take a brief history and/or examination, and then proceed to explanation or demonstration. Even if it is not written in the instructions, it is often useful to establish a very brief history on the patient’s understanding of their condition. Use the instructions as a framework to decide how to approach this station.

History

Establish the patient’s understanding of their condition and why they need to use a peak flow meter. Then proceed to fill any gaps in their knowledge. This should be summarised using only a few sentences.

This is a good time to establish the patient’s ICE (Ideas, Concerns and Expectations). Expectations are most important; if you know what the patient hopes to gain from the consultation you can tailor your approach.

Inhaler technique

There are various ways to approach this part. The ‘tell, show, do’ approach works well. This involves talking to the patient through the steps (listed below), moving to you demonstrating the correct technique to the patient and then finally asking the patient to perform the correct inhaler technique.

The correct technique will now be described below.

Whilst it is most likely that you will need to demonstrate using a blue metred dose inhaler, it is possible that you may be given a different type, so be familiar with how they all work.
It is crucial that you explain as you talk through the steps. However, this can sometimes lead to confusion. Hence, it can be helpful to say “please interrupt me at any point if any of this isn’t making sense or you don’t understand something.”

Preparing the inhaler

Begin by checking the expiry date. This can be identified by simply removing the metal canister containing the medicine, from the plastic casing, and then replacing it once finished. Advise the patient that they will need to get a new prescription if out of date. Some inhalers also show a number (a counter) giving the number of puffs that are still left – make sure you look for this on the inhaler when you pick it up. Next, shake the inhaler for 5 seconds and remove the cap. This mixes the medicine (e.g. salbutamol) with the propellant inside.

A metered dose inhaler.

A typical metered dose inhaler.

Using the inhaler

Ensure that you are either standing or sitting upright when demonstrating. This is important because it allows you to breathe in deeply. Hold the inhaler upright and breathe out. Form a tight seal around the mouthpiece with your tongue below the mouthpiece so it does not obstruct the spray. Begin taking a slow, deep breath in and simultaneously press the canister at the top down, taking in as much air as is comfortable. Hold your breath for 10 seconds to allow the medication to spread as deep into the airways as possible, before breathing out. Breathe normally afterwards and place the cap back on the inhaler.

They should also follow the recommendations provided with the inhaler about cleaning it. Inform the patient that if they need another dose from their blue inhaler, there should be at least a 30 second gap since the previous dose.

If the patient has been prescribed a preventer (brown) inhaler containing steroids, ensure you advise them to rinse their mouth after use to prevent opportunistic infections to occur, such as oral thrush.

A fungal infection around the mucous membranes of the mouth, most commonly caused by Candida Albicans. It is an opportunistic infection, therefore usually seen in those that are immunocompromised.

Ending the demonstration

Once you have finished demonstrating and explaining, check for understanding and ask the patient to demonstrate the process back to you.

Ask if the patient has any questions about this part before moving on. Some important advice or answers to the questions they may ask include:

You can use your inhaler up to a maximum of ten puffs in an attack (with 30 seconds between each puff). If this doesn’t provide relief, either call 999 or go to your closest A&E. If 15 minutes have passed and the ambulance hasn’t arrived, then take another 10 puffs. Once the patient has had a go at using the inhaler, it is equally important to reinforce the parts they did well, as well as giving them potential areas that they could improve on.

Conclusion

Summarise broadly what you have spoken about today with the patient, clarify if there is anything they do not understand and whether they have any further questions.

Thank patient, wash your hands and remember to offer leaflets that provide more information about asthma, inhalers and peak flow at the end of the consultation.

Communication

The importance of communication in this station cannot be overstressed. Examiners use it to differentiate good from exceptional candidates. A good candidate will be able to remember the necessary instructions, however a great candidate will be able to fluently communicate these in a simple, memorable way. Listed below are some of the most effective techniques:

Explicit categorisation

Organising the discussion into different categories to help structure the consultation. For example: “There are three things I’d like to discuss with you. Firstly I’d like to speak to you about what exactly asthma is, secondly, I will show you how to use the correct technique for your inhaler to help you breathe easier and finally I will explain how best to monitor your asthma using something we call a peak flow meter.”

Signposting

Transition statements can help you to move from one topic to another. For example: “We have talked and demonstrated how to use your inhaler correctly, now I’d like to show you how to use a peak flow meter to help us monitor how well controlled your asthma is.”

Avoid medical jargon

Ensure you use language that the patient will be able to understand. If you must use a medical term, be sure to explain what it means.

List form

Instructions
When assessing each other, please click on each list item as you go along. Doing so will turn the list item green. Make careful note of any steps missed at the end.
We recommend completing any examination or procedure in under 10 minutes, but you can adjust the timer to suit your needs.
:

  1. Introduction: “Hello, I’m SimpleOSCE and I am a medical student, could I confirm your full name and DOB? I’ve been asked to talk to you about your asthma, specifically how to use your inhaler and then how to record how well you’re doing with your asthma. Are you happy to proceed?”
  2. Wash hands.
  3. Check patient’s current knowledge and understanding of asthma.
  4. Fill in any gaps in their knowledge in a simple manner.
  5. Explain and/or demonstrate the following (5-10):

  6. Check expiry date of the medication.
  7. Shake the inhaler for a few seconds and remove cap
  8. Breathe out before forming a tight seal around the mouthpiece.
  9. Take a slow, deep breath in and simultaneously press the canister down.
  10. Hold breath for 10 seconds before breathing out and replacing cap.
  11. If applicable, wash mouth after using a steroid inhaler.
  12. Check that the patient has understood steps 5-10 and/or request a demonstration.
  13. Ask and answer any questions.
  14. Thank patient, wash hands and offer leaflets that provide more information on asthma, inhaler and PEFR at the end of the consultation.
  15. Communication mark 1: Good patient manner.
  16. Communication mark 2: Clear explanations with minimal jargon.
  17. Communication mark 3: Good communication technique (e.g. categorisation and signposting).
Overall: 0/28