1. Inhaler technique is it important?

2. Compton et al (2006) Review of evidence from 6 European countries ( Spain, Italy, France, Germany, Netherlands, UK) found  Up to 50% of patients are unable to take their inhaler correctly  Up to 40% of children make errors even with a spacer

3. BTS/SIGN 2011  Proportion of patients making no mistake with their inhaler MDI 23-43% MDI 23-43% DPI 53-59% DPI 53-59% MDI and spacer 55-57%

4. BTS/SIGN 2011  Teaching inhaler technique however improved the score  MDI from 23-43% to 63%  DPI from 55-57% to 75%

5. BTS/SIGN 2011 Recommend Prescribe inhalers only after patients have received training in the use of the device And have demonstrated a satisfactory technique

6. BTS/SIGN Guidelines 2012 In stable asthma (B2 agonists) In stable asthma (B2 agonists)  Children aged 5-12 pMDI & Spacer are as effective as any other inhaler  In adults pMDI & Spacer are as effective as any other hand held inhaler but patients may prefer some types of DPI

7. NICE guidelines on inhalers in children (2002) Tell us the importance of ensuring the child is able to use the device effectively and consider the portability of the device

8. BTS/SIGN Guidelines 2012 Inhaled steroids in stable asthma Inhaled steroids in stable asthma  Children aged 5-12 pMDI & Spacer is as effective as any DPI  In adults pMDI & Spacer is as effective as any DPI

9. BTS/SIGN 2011 Children under 5  MDI and spacer  And in under 2 use MDI spacer and face mask

10. BTS/SIGN 2011 Care of spacers  Spacer should be compatible with the inhaler  Administer in single actuations  Minimal delay between actuation and inhalation  Tidal breathing is as effective as single breaths  Spacers should be cleaned monthly rather than weekly ( manufacturers recommendation ) as this reduces the effectiveness  Should be washed in detergent not rinsed and allowed to air dry

11. BTS/SIGN 2011  Adolescents with asthma prescribed MDI and spacer do not use the spacer as they feel they are too inconvenient  Adolescents inhaler choice should be considered to improve adherence to treatment

12. BTS/SIGN 2011  The choice of drug may be determined by the choice of drug  If the patient is unable to use the device satisfactorily an alternative should be found  The patients ability to use their inhaler should be assessed by a competent health care professional  The medication needs to be titrated against clinical response to ensure optimum efficacy  Reassess inhaler technique as part of a structured clinical review

13. GINA 2009  Poorly controlled asthma is expensive  Ensuring adequate effective preventer medication will give cost savings

14. Therefore

15. The cheapest inhaler is one the patient can and will take