Inhaler Technique – OSCE Guide

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Explaining effective inhaler technique is a common OSCE scenario and requires you to both describe and demonstrate the skill. This step-by-step guide describes how to explain inhaler technique in an OSCE setting.


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

Check the patient’s current understanding of inhaler technique, allowing you to better tailor your explanation.

Position the patient so that they are sitting comfortably.

Ask the patient if they have any pain or shortness of breath before beginning your explanation of inhaler technique.


Explanation

Overview

Provide a general overview of the patient’s inhaler:

  • “You have been started on ….(name of inhaler)…for your asthma.”
  • “This is what the inhaler looks like.”
  • “This is the mouthpiece, this is the canister containing the medication and this is the dose counter.”

Different types of inhaler

Reliever (e.g. salbutamol inhaler)

Explain what a reliever inhaler is and when it should be used:

  • “(Name of inhaler) is a reliever. This is useful to help relieve sudden asthma attacks. It works by relaxing the airways so that you can breathe more easily. You shouldn’t need this more than three times a week if your asthma is well controlled. Ask your GP for a review if you are using this more frequently. I would like you to inhale (x puff(s)) when you feel short of breath.”

Preventer (e.g. beclomethasone inhaler)

Explain what a preventer inhaler is and when it should be used:

  • “(Name of inhaler) is a preventer – it helps to reduce the swelling in the airways and stops them from tightening up. You use this inhaler to reduce the risk of having asthma attacks. I would like you to inhale …(x puff(s))…(x time(s) a day)…everyday. It’s really important that you don’t miss doses, as regular use is key to keeping your asthma under control.” 

Remind the patient to rinse their mouth after use due to the increased risk of oral candidiasis:

  • “You should rinse your mouth after you use this inhaler as otherwise, you might develop a sore and inflamed mouth.”

SMART (Single Maintenance and Reliever Therapy) regime (e.g. Symbicort, Fostair, Duoresp, Spiromax)

Explain what a SMART inhaler is and when it should be used:

  • “Symbicort is used as both a preventer and a reliever. You need to use this regularly …(x puff(s))…twice a day to prevent symptoms and …(x puff(s))…each time you have an attack.”

Remind the patient to rinse their mouth after use due to the increased risk of oral candidiasis:

  • “You should rinse your mouth after you use this inhaler as otherwise, you might develop a sore and inflamed mouth.”

Check the patient’s understanding

Ask the patient to summarise the key points back to you to check their understanding:

  • “To make sure you’ve understood everything I’ve said could you tell me what type of inhaler you have and when it should be used? Don’t worry if you can’t remember everything right away, we can always go back over the important information.”
  • Salbutamol inhaler (pMDI)
    Salbutamol inhaler (pMDI)

Demonstrate effective inhaler technique

The guide below focuses on correct inhaler technique using a pressurised metered-dose inhaler (pMDI), which is most commonly used in OSCE scenarios. 2

Ensure you clearly explain and demonstrate each of the following steps to the patient using a dummy inhaler.

Things to do before using the inhaler

There are several things you should advise the patient to do before they begin to use their inhaler.

Device test

If the inhaler hasn’t been used for 5 days or more, the patient should be advised to test the device before using it:

1. Remove the cap and shake the inhaler well.

2. Point the mouthpiece away from you and press the canister to release a puff into the air.

Dose counter

Some pMDI’s have a dose counter which shows the number of remaining doses left in the inhaler. Advise the patient to check the inhaler is not empty and to seek a replacement whilst they still have several doses left.

Expiry date

The expiry date shows when the medication within the inhaler will expire and no longer be effective. The expiry date is typically located on the metal canister of the inhaler. Advise the patient to seek a replacement in advance of their inhaler expiring and to avoid using it after the expiry date.

Procedure

Preparation

1. Hold the inhaler upright.

2. Remove the cap from the inhaler and inspect to make sure there is nothing inside the inhaler mouthpiece.

3. Shake the inhaler well.

Inhalation

4. Sit or stand up straight and slightly tilt your chin up. This position helps the medication to better reach the lungs.

5. Breathe out gently and slowly away from the inhaler until your lungs feel empty.

6. Put your lips around the mouthpiece of the inhaler to create a tight seal.

7. Start to breathe in slowly and steadily whilst at the same time pressing the canister on the inhaler once.

8. Continue to breathe in slowly until your lungs feel full.

9. Remove the inhaler from your mouth and seal your lips.

10. Hold your breath for 10 seconds, or as long as you are comfortably able to.

11. Breathe out gently, away from your inhaler.

Final steps

12. Once you have finished using your inhaler, replace the cap. If you’ve used an inhaler that contains steroids, rinse your mouth with water to reduce the chance of side effects.

Multiple doses

If you’ve been prescribed a second puff, wait 30 seconds to a minute for repeating steps 3-12.


Assess the patient’s inhaler technique

Ask the patient to use their own inhaler as demonstrated and observe their technique.

Provide feedback based on what you observe to allow the patient to refine their technique.

Point out the positives“You are doing X&Y very well”… then introduce room for improvement …“but doing A&B may help your inhalers work more effectively for you.”

Continue to repeat the cycle of observation and feedback until the patient is able to use their inhaler effectively.


Spacer devices

Spacers are used to improve drug deposition in the lungs. They are also useful for reducing the side effects of high dose inhaled corticosteroids by decreasing the amount of drug deposited in the mouth. Commonly used spacers include Volumatic and AeroChamber.

Ensure you clearly explain and demonstrate each of the following steps for effectively using a spacer to the patient:

1. Prepare the inhaler as previously explained.

2. Attach the inhaler mouthpiece to the spacer device.

3. Breathe out gently and slowly away from the spacer until your lungs feel empty.

4. Place your lips around the spacer mouthpiece to create an effective seal.

5. Release one dose of the inhaler into the spacer device.

6. Breathe deeply, both in and out, through the spacer mouthpiece several times.

7. Administer a second dose if required.

Spacer device care instructions

The spacer device should be washed with detergent (washing up liquid is fine) once a month and left to air-dry.

It should never be wiped dry as this can cause static within the device and drug particles will stick to sides of the spacer as a result.

Spacers should be replaced at least once a year.

  • Spacer device
    Spacer device 3

Closing the consultation

Check if the patient has any questions regarding inhaler technique.

Advise the patient to use their inhalers as directed.

Explain the potential side effects they may experience when using their inhalers:

  • Palpitations and tremor: salbutamol can cause tachycardia and tremor, particularly at higher doses.
  • Oral thrush: steroid inhalers can cause candidiasis, particularly if the patient doesn’t wash their mouth out effectively after each use.

Advise that if the patient has an asthma attack that does not respond to their salbutamol inhaler after 10 puffs (with 30 seconds between each puff) they should call 999 for urgent medical assessment.

Provide an information leaflet for the relevant inhaler device.

Arrange a follow-up appointment to re-assess the patient’s inhaler technique.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


References

  1. James Heilman, MD. Adapted by Geeky Medics. Oral candidiasis. Licence: CC BY-SAAvailable from [LINK].
  2. Asthma UK. How to use a pMDI inhaler. Accessed on 12th June 2020. Available from: [LINK].
  3. Tradimus. Adapted by Geeky Medics. Spacer device. Licence: CC BY-SA. Available from: [LINK].

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