Inhaler Use in Hospice Setting

When it comes to inhaler use in hospice, there are four factors that determine proper drug deposition with inhaled medications. These are:

  1. Inhalation flow
  2. Proper use/coordination of the inhaler
  3. Aerosol velocity
  4. Drug particle size

Two of these factors ‐ inhalation flow and proper use/coordination of the inhaler ‐ may decline over time making it very important to assess a COPD patient’s ability to correctly use an inhaler to ensure adequate dosing. Age and gender appear to be the key determinants of inspiratory flow, not the degree of expiratory airway obstruction. For dry powder inhalers (DPIs), the inhalation must be deep and forceful to disperse the medication adequately. While most COPD patients are able to generate sufficient inspiratory flow for optimal drug delivery with DPIs, predictors of inadequate peak inspiratory flow (PIF) include advanced age, the female gender, and exacerbations. Therefore, it is necessary to assess the patient’s PIF rate to determine suitability for both inhaled medication initiation and throughout the disease progression.

The inspiratory effort required for several common devices are listed below:

  • Turbohaler device (Symbicort): 30-60 L/min
  • Twisthaler device (Asmanex): 28 L/min
  • Diskhaler device (Serevent): >30 L/min
  • Aerolizer device (Foradil): 60 L/min
  • Diskus device (Advair): 60 L/min
  • Flexhaler device (Pulmicort): 60L/min
  • Handihaler device (Spiriva): 30L/min
  • Neohaler device (Arcapta): 60L/min
  • Pressair device (Tudorza): 35L/min

Metered dose inhalers (MDIs) require that the actuation of the inhaler be carefully coordinated with inspiration. Spacer devices slow down the particles and make coordination of actuation and inhalation less critical.

Consider switching to nebulized medication if there is any question regarding the ability of a patient to properly use an inhaler. This will ensure proper dosing and should improve patient comfort.

How HospiceMed Does It

In addition to having access to a pharmacist 24/7, pharmacist recommendations are provided to HospiceMed clients at time of ordering through eRx, our web based app that nurses use for ordering medications. For example, when a nurse orders an inhaler such as Advair, the following recommendation pops up on their screen:

If you would like to learn more about how your agency can use HospiceMed's eRx tools, contact us.


Elliot D, Dunne P, Guide to Aerosol Delivery Devices for Physicians, Nurses, Pharmacists, and Other Health Care Professionals. American Association for Respiratory Care 2011. Available at:

Laube BL, Janssens HM, Jongh FHC, Devadason SG, Dhand R, Diot P, Everard ML, Horvath I, Navalesi P, Voshaar T, Chrystyn H, What the pulmonary specialist should know about the new inhalation therapies Eur Respir J 2011; 37: 1308–1331 DOI: 10.1183/09031936.00166410

Malberg LP, Rytila P, Happonen P, Haahtela T, Inspiratory Flows Through Dry Powder Inhaler in Chronic Obstructive Pulmonary Disease: Age and Gender Rather than Severity Matters. August 2010 Volume 2010:5; Pages 257 – 262 DOI:

By | 2018-01-04T20:00:00+00:00 July 1st, 2016|Pharmacist Corner|0 Comments

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