Version 5: Copyright © Meditrax July 2020 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trade-mark of Manrex Pty Ltd t/as Meditrax.

Essential Facts:OPTIMISING INHALED MEDICATION ADMINISTRATION

Incorrect inhaler technique

can prevent residents with asthma or chronic obstructive

pulmonary disease (COPD) from receiving the maximal benefit from

their medications.

Evidence has demonstrated that up to 90% of patients had incorrect technique when using metered

dose inhalers (MDIs) or dry powder inhalers (DPIs).

• Assess inspiratory effort for residents using DPIs (that is, is the resident able to inhale deeply enough for efficacy of the medication?

• Check the expiry date of devices containing medication and of medication placed into devices. Note for MDIs the expiry date will be on the canister inside the outer plastic casing.

• Regularly change over inhalers without counters based on number of doses given

• Ensure that the resident rinses their mouth out and expels the liquid for inhaled medications where this is recommended (see next page)

• Regularly assess the inhaler technique of residents who are self-administering inhaled medications

• All residents should use a spacer with MDIs to optimise delivery of medication into the airways and improve efficacy. This also overcomes the common issue of coordinating release of the dose with breathing in the dose.

• Metered dose inhalers (MDIs) are the most effective way to deliver bronchodilators for asthma or chronic obstructive pulmonary disease (COPD) and are much safer. Avoid using nebulisers as they generate a high level of aerosolised particles that can spread respiratory infections widely to staff and other residents.

• Wipe all inhaler devices clean after each use (see instructions in following pages) to minimise the risk of infections. Regularly maintain/replace devices to optimise medication delivery

• Use SABA relievers (see next page) prior to other inhalers if prescribed for administration at the same time, to maximise benefit

• Ensure staff are trained and competent in the administration of the various inhaler devices - see following pages for instructions

ASTHMA & COPD MEDICATIONS

Seebri Breezhaler #glycopyrronium 50mcg

Onbrez Breezhaler ^indacaterol150mcg • 300mcg

Spiriva Respimat # ‡tiotropium 2.5mcg

Spiriva Handihaler #tiotropium 18mcg

SABA RELIEVERS

Bricanyl Turbuhaler † ^terbutaline 500mcg

Airomir Autohaler ‡ ^ salbutamol 100mcg

Asmol Inhaler † ^ salbutamol 100mcg

Ventolin Inhaler † ^salbutamol 100mcg

Atrovent Metered Aerosol † ^ipratropium 21mcg

ICS/LABA COMBINATIONS LAMA MEDICATIONS

LAMA/LABA COMBINATIONS

ICS/LAMA/LABA

SAMA MEDICATION

Seretide MDI ‡fluticasone propionate/salmeterol 50/25 • 125/25 • 250/25 #

Fluticasone + Salmeterol Cipla Inhaler ‡fluticasone propionate/salmeterol 125/25 • 250/25 #

Seretide Accuhaler ‡fluticasone propionate/salmeterol100/50 • 250/50 • 500/50 #

Symbicort Turbuhaler ‡budesonide/formoterol100/6 • 200/6 • 400/12 #

DuoResp Spiromax ‡budesonide/formoterol 200/6 • 400/12 #

QVAR Autohaler ‡

beclometasone50mcg • 100mcg

Pulmicort Turbuhaler †budesonide 100mcg • 200mcg • 400mcg

Flixotide Accuhaler †fluticasone propionate100mcg* • 250mcg • 500mcg

Flixotide Inhaler † fluticasone propionate50mcg* • 125mcg • 250mcg*Flixotide Junior

Fluticasone Cipla Inhaler †fluticasone propionate 125mcg • 250mcg

Alvesco Inhaler †ciclesonide80mcg • 160mcg

Trelegy Ellipta cfluticasone furoate/umeclidinium/vilanterol100/62.5/25

ICS PREVENTERS

Singulair Tablet amontelukast4mg • 5mg • 10mg

Tilade Inhaler †nedocromil sodium 2mg

Intal Inhaler † sodium cromoglycate1mg • 5mg**Intal Forte all units in mcg

all units in mcg

NON STEROIDAL PREVENTERS

2018

This chart was developed independently by the National Asthma Council Australia with support

from Boehringer-Ingelheim, GSK Australia, Mundipharma and Teva Pharma Australia

RESOURCES TREATMENT GUIDELINES

Australian Asthma Handbook: asthmahandbook.org.auCOPD-X Plan: copdx.org.au

INHALER TECHNIQUEHow-to videos, patient and practitioner information

nationalasthma.org.au

Inhalers/MDIs should be used with a compatible spacer

QVAR Inhaler †beclometasone50mcg • 100mcg

Montelukast Tablet amontelukast4mg • 5mg • 10mgGeneric medicine suppliers

Bretaris Genuair #aclidinium 322mcg

Incruse Ellipta #umeclidinium 62.5mcg

Brimica Genuair caclidinium/formoterol 340/12

Anoro Ellipta cumeclidinium/vilanterol62.5/25

Spiolto Respimat ctiotropium/olodaterol 2.5/2.5

Ultibro Breezhaler cindacaterol/glycopyrronium110/50

Symbicort Rapihaler ‡budesonide/formoterol50/3 • 100/3 • 200/6 #

Flutiform Inhaler ‡fluticasone propionate/formoterol50/5 • 125/5• 250/10

Breo Ellipta ‡fluticasone furoate/vilanterol 100/25 # • 200/25

Oxis Turbuhaler ‡formoterol6mcg • 12mcg

Serevent Accuhaler ‡salmeterol 50mcg

LABA MEDICATIONS

PBS PRESCRIBERS † Asthma unrestricted benefit ‡ Asthma restricted benefit a Asthma authority required ^ COPD unrestricted benefit # COPD restricted benefit C COPD authority required Check TGA and PBS for current age and condition criteria© National Asthma Council Australia

ICS, inhaled corticosterioid | L

AB

A, long-acting beta

2 agonist | LA

MA

, long-acting muscarinic antagonist | SA

BA

, short-acting beta2 agonist | SA

MA

, short-acting muscarinic antagonist

Version 5: Copyright © Meditrax July 2020 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trade-mark of Manrex Pty Ltd t/as Meditrax.

Ask residents to rinse their mouth out (and expel the

liquid) after administration of ICS preventers, SAMA medications, ICS/LABA combinations, LAMA medications, ICS/LAMA/LABA

combinations, and LAMA/LABA combinations.

It is not necessary to rinse the mouth out after

administration of SABA relievers, Non-steroidal preventers, or

LABA medications.

Accessed 8 April 2020 from nationalasthma.org.au - note this 2018 version does not include newer inhaled medications e.g. Arnuity Ellipta (ICS preventer) and Braltus Zonda (LAMA medication)

Metered Dose Inhaler (MDI) and RapihalerAiromir, Alvesco, Asmol, Atrovent, Cipla, Flixotide, Flutiform, Intal, Pavtide, Qvar, Rapihaler, SalplusF, Seretide, Symbicort, Tilade, Ventolin.

1. Remove cap.2. Check dose counter if available.3. Hold inhaler upright and shake well. (NB - Qvar does not require shaking)4. Ask resident to breathe out gently away from inhaler.5. Place mouthpiece between teeth and ask resident to close lips to form a good seal (without biting). Ensure

resident keeps chin up to keep inhaler upright – not aimed at roof of mouth or tongue.6. Ask resident to breathe in slowly through mouth, and at the same time press down firmly on canister.7. Ask resident to continue to breathe in slowly and deeply.8. Ask resident to hold breath for 5-10 seconds, or as long as comfortable.9. While resident is holding breath, remove inhaler from mouth.10. Ask resident to breathe out gently away from inhaler.11. If more than one dose is needed, repeat all starting from Step 2.12. Wipe mouthpiece clean and replace cap.

When is it empty?• Symbicort Rapihaler, Seretide, Cipla and Flutiform MDI have dose counters.• If using an MDI which does not have a dose counter (Ventolin and Asmol for example), it is difficult to know

when the device is empty. The number of puffs used per day and therefore the life of the medicine should be monitored, recorded and calculated. This should take into account priming.

Priming• If an MDI hasn’t been used for more than 7 days, it should be primed. Shake it and then release a test spray.

Shake it again for 5 seconds and release a second test spray.

Cleaning• Rapihaler and Flutiform - do not wash any part of the device or get it wet. After

each use, wipe with a clean, dry tissue.• MDI - wipe clean after each use and periodically (e.g. weekly or depending

frequency of use), wash as follows. Remove the metal canister (do not wash this). Wash the plastic casing and cap with running warm water through the top and bottom for at least 30 seconds. Shake off excess water and allow to completely air dry.

• Intal and Tilade must be washed every day to avoid clogging. People who take these have two puffers at a time so there is always a clean and dry one available. Wash the white or yellow plastic case daily. Allow it to dry 24 hours before using again.

Version 5: Copyright © Meditrax July 2020 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trade-mark of Manrex Pty Ltd t/as Meditrax.

Respiratory Device Management: Technique and MaintenanceSpacer (used with MDIs and Rapihalers)

Assemble spacer (if necessary) and remove inhaler cap.

1. Check dose counter if available.2. Hold inhaler upright and shake

well.3. Insert inhaler upright into

spacer.4. Put mouthpiece between teeth

without biting and ask resident to close lips to form a good seal.

5. Ask resident to breathe out gently, into the spacer.

6. Keep spacer horizontal and press down firmly on inhaler canister once.

7. For single breath technique, ask resident to breathe in slowly and deeply as the canister is pressed and to hold breath for 5-10 seconds or as long as is comfortable then to breath out gently into the spacer. For multi-breath technique, ask resident to breathe in and out normally through the spacer for 3-4 breaths.

8. Remove spacer from mouth.9. Remove inhaler from spacer.10. If more than one dose is

needed, repeat all steps starting from step 1.

12. Wipe mouthpiece of spacer and replace inhaler cap.

A tightly fitting face mask can be

used for people who cannot form a close seal around the mouthpiece.

Cleaning

• Some spacers require washing and priming (by firing 10 puffs into it) prior to first use (e.g. Able Spacer Universal, Breath-A-Tech, Volumatic). Spacers made from antistatic polymers (e.g. Able A2A, AeroChamber Plus, Breathe Eazy, La Petite E-Chamber, La Grande E-Chamber, OptiChamber Diamond) do not need to be washed or primed before first use.

• All spacers should be cleaned about once a month and after a resident has recovered from a respiratory infection.

• Pull spacer apart if possible.• Wash in warm soapy water

(detergent).• After washing, DO NOT rinse

the spacer .• Allow to drip dry.• DO NOT dry with a cloth, as this

can cause static to build up.• DO NOT place a spacer into a

dishwasher.• Note spacers should be checked

every 6-12 months for cracks or other damage and replaced as needed.

AutohalerAiromir, Qvar

1. Remove cap.2. Hold inhaler upright and shake well. Do not block vents at base.3. Push lever up.4. Ask resident to breathe out gently away from inhaler.5. Place mouthpiece between teeth without biting and ask resident to close

lips to form a good seal.6. Ask resident to breathe in slowly and deeply, and to continue breathing in

after a click is heard.7. Ask resident to hold breath for about 5-10 seconds or as long as

comfortable.8. While resident holds breath, remove inhaler from mouth.9. Ask resident to breathe out gently away from inhaler10. Push lever down.11. If more than one dose is needed, repeat all steps starting

from Step 2.12. Wipe mouthpiece clean and replace cap.

CleaningClean the inhaler mouthpiece with a clean, dry tissue after each use before replacing the cover.

TurbuhalerBricanyl, Oxis, Pulmicort, Symbicort

1. Unscrew and remove cover.2. Check dose counter.3. Keep inhaler upright while twisting grip at the base – twist around and then back until a

click is heard.4. Ask resident to breathe out gently away from inhaler.5. Place mouthpiece between teeth without biting and ask resident to close lips and form a

good seal. Do not cover air vents.6. Ask resident to breathe in strongly and deeply.7. Ask resident to hold breath for about 5-10 seconds or as long as comfortable.8. Remove inhaler from mouth.9. Ask resident to breathe out gently away from inhaler.10. If more than one dose is needed, repeat all steps starting from step 2.11. Wipe mouthpiece clean and replace cover.

PrimingPrior to first use, the inhaler needs to be primed. Take off the cap and while holding upright turn the base left then right. Repeat this action again. The device is now ready to be used and the dose can be loaded.

When is it empty?The Symbicort Turbuhaler base has a dose counter that counts to zero. Once it gets to 20 the numbers change from black to red. Other Turbuhalers have a red line which will appear in the window on the side of the device, indicating there are 20 doses left. This is a good time to organise a new device.

CleaningWipe the inhaler with a clean, dry tissue after use. Do not wash any part of the device or get it wet.

AccuhalerFlixotide, Seretide, Serevent

1. Check the dose counter.2. Open cover, using thumb grip.3. Load dose – keep horizontal while sliding lever until it clicks. Do not shake.4. Ask resident to breathe out gently away from inhaler.5. Place mouthpiece in mouth without biting and ask resident to close lips to form a good seal. Keep inhaler

horizontal.6. Ask resident to breathe in steadily and deeply.7. Ask resident to hold breath for about 5-10 seconds or as long as comfortable.8. While resident holds breath remove inhaler from mouth.9. Ask resident to breathe out gently away from inhaler.10. If more than one dose is needed, repeat all steps starting from step 3. 11. Wipe mouthpiece clean and close cover to shut.

When is it empty?Accuhalers are empty when the dose counter indicates zero. The last 5 doses appear in red.

CleaningWipe the inhaler with a clean, dry tissue after use. Do not wash any part of the device or get it wet.

Respiratory Device Management: Technique and Maintenance

Version 5: Copyright © Meditrax July 2020 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trade-mark of Manrex Pty Ltd t/as Meditrax.

GenuairBretaris, Brimica

DO NOT SHAKE at any time

1. Check the dose counter.2. Remove cap by squeezing arrows on each side and pulling outwards.3. Hold inhaler horizontally with large coloured button facing straight up.

Without tilting inhaler, press and release the button.4. Check that the control window has changed to green.5. Ask resident to breathe out gently away from inhaler.6. Put mouthpiece in mouth and ask resident to close lips to form a good seal. Keep inhaler

horizontal.7. Ask resident to breathe in strongly and deeply, and to keep breathing after click is heard.8. Ask resident to hold breath for about 5-10 seconds or as long as comfortable.9. While holding breath, remove inhaler from mouth.10. Ask resident to breathe out gently away from inhaler.11. Check the control window has changed to red.12. Wipe mouthpiece clean and replace cap.

When is it empty?The button will lock in the middle position when the last dose has been loaded. After the last dose is inhaled the device cannot be used again.

CleaningClean the inhaler mouthpiece with a clean, dry tissue before replacing the cover.

BreezhalerOnbrez, Seebri, Ultibro

1. Remove cap.2. Tilt the mouthpiece to open.3. Remove capsule from the blister and place in chamber. 4. Close mouthpiece until it clicks.5. Press side piercing buttons in once and release – Do not shake. Do not pierce more than

once.6. Ask resident to breathe out gently away from the inhaler.7. Place mouthpiece between teeth without biting and ask resident to close lips and form a

good seal.8. Ask resident to breathe in rapidly and steadily, so capsule vibrates.9. Ask resident to continue breathing in as long as comfortable.

10. Ask resident to hold breath for about 5-10 seconds, or as long as comfortable. While holding breath, remove inhaler from resident’s mouth.

11. Ask resident to breathe out gently away from inhaler.12. Open mouthpiece and remove used capsule.13. If more than one dose is needed, repeat all steps starting from

Step 3.14. Wipe mouthpiece clean and replace cap.

CleaningClean the mouthpiece as needed with a clean tissue. Do not wash the inhaler with water or take it apart. Store in a cool dry place.

ElliptaAnoro, Arnuity, Breo, Incruse, Trelegy

1. Check the dose counter.2. Slide cover down until a click is heard. Do not shake.3. Ask resident to breathe out gently away from inhaler.4. Place mouthpiece in mouth and ask resident to close

lips and form a good seal – Do not block air vent with fingers.

5. Ask resident to breathe in steadily and deeply.6. Ask resident to hold breath for 5-10 seconds or as long

as comfortable.7. While resident is holding breath, remove inhaler from

mouth.8. Ask resident to breathe out gently away from inhaler.9. Wipe mouthpiece clean and slide the cover upwards as far as it will go, to cover the

mouthpiece.

After foil packing is opened, discard Arnuity, Breo and Trelegy Ellipta after one month, and Incruse Ellipta after 6 weeks. Write date to discard on label provided.

CleaningWipe the inhaler mouthpiece with a clean, dry tissue before closing the cover.

Respiratory Device Management: Technique and Maintenance

Version 5: Copyright © Meditrax July 2020 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trade-mark of Manrex Pty Ltd t/as Meditrax.

RespimatSpiriva, Spiolto

**Loading before use (discard 3 months after loading cartridge)1. Keep the cap closed.2. Remove clear base: press safety catch while firmly pulling off base with other

hand.3. Insert the narrow end of the cartridge into the inhaler.4. Place the inhaler on a firm surface and push down firmly until it snaps into place.5. Put the clear base back into place until it clicks.6. Turn the clear base in the direction of the arrows on the label until it clicks (half a turn).7. Open the cap until it snaps fully open.8. Point the inhaler toward the ground. Then press the dose-release button.9. Close the cap.10. Repeat steps 6–9 until there is a cloud coming out when the dose-release button is

pressed.11. Repeat steps 6–9 three more times.

**Administration1. Hold inhaler upright with the cap closed2. Turn base in direction of arrows on label until it clicks (half a turn).3. Open the cap until it snaps fully open.4. Ask the resident to breathe out gently away from inhaler.5. Place mouthpiece in mouth and ask resident to close lips to form a good seal. (Do not cover air

vents.)6. Ask resident to breathe in slowly and deeply through mouth and, at the same time, press down on

the dose button.7. Ask resident to continue to breathe in slowly and deeply.8. Ask resident to hold breath for 5-10 seconds or as long as comfortable.9. While resident is holding breath, remove inhaler from mouth.10. Ask resident to breathe out gently away from inhaler.11. Wipe mouthpiece clean and close cover to click shut.12. Two inhalations is the usual dose for medicines used with Respimat. Repeat from step 1 to get the full

dose.

When is it empty?When the dose counter has reached the red zone, there are 7 days left. When the dose counter gets to ‘0’, the device locks and cannot be turned at the base, and button cannot be pressed.

CleaningClean the mouthpiece with a clean, dry tissue before replacing the cover.

Respiratory Device Management: Technique and Maintenance

TURNOPENPRESS

Version 5: Copyright © Meditrax July 2020 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trade-mark of Manrex Pty Ltd t/as Meditrax.

Zonda

Braltus (tiotropium)

1. Pull the cap upwards.2. Hold the base of the inhaler firmly and open the mouthpiece by pulling it upwards.3. Remove a capsule from the bottle immediately before use and close the bottle tightly. Place one capsule in the capsule-shaped compartment in the base of the inhaler. Do not store the capsule in the inhaler. Do not place a capsule directly into the mouthpiece.4. Close the mouthpiece until a click is heard, leaving the cap open.5. Hold the inhaler with the mouthpiece upwards, and firmly press the piercing button completely in to pierce the capsule (do this only once) then release the button.6. Ask the resident to breathe out gently and fully away from the mouthpiece.7. Place mouthpiece between teeth and ask resident to close lips to form a good seal (without biting).8. Ask resident to breathe in slowly and deeply through mouth, so capsule vibrates.9. Ask resident to continue breathing in then hold breath for 5-10 seconds or as long as comfortable.10. While resident is holding breath, remove inhaler from mouth.11. Ask the resident to breath out gently, away from the inhaler.12. Repeat steps 7 – 11 to empty the capsule completely and take the full dose.13. Open mouthpiece and remove used capsule.14. Wipe the mouthpiece clean and close the mouthpiece and cap.

Cleaning:Wipe the mouthpiece after use with a dry cloth or tissue. Do not rinse with water.

Note:Discard the Zonda device after 30 uses. A new device is provided with each new pack of capsules.

Nebuliser

• A nebuliser is a machine used to turn liquid medication into a vapour which can be inhaled. It pumps pressurised air through the liquid, to form a mist, which can be inhaled by a mask or mouthpiece.

• Research shows that using a MDI with spacer is as effective as a nebuliser. Nebulisers generate a high level of aerolised particles that spread widely and they are therefore NOT SUITABLE for residents with acute infection, due to the risk of spread of infective organisms. When nebulisers are the only appropriate therapy, administer in a negative pressure or single room using contact, droplet and airborne precautions. If this is not possible then efforts should be made to move the resident to a negative pressure or single room as soon as possible.

• Certain drugs, if the vapour escapes the mask, may make contact with the eye and increase the risk of glaucoma (ipratropium and budesonide). Cover eyes during administration.

• Most nebulisers need the pump serviced and filters replaced regularly, usually every 6-12 months depending on use. The bowl, tubing and mast/mouthpiece also need to be replaced every 3 months.

Budesonide (Pulmicort) nebules/respules should be given with a high-flow nebuliser (8L/minute). Cover resident’s eyes during nebulisation and wash face afterwards. A mouthpiece is preferred over a mask to reduce risk of facial

irritation.

Some medications for nebulisation can be mixed (e.g. salbutamol with ipratropium). Pulmicort Respules can be used in a nebuliser with terbutaline, salbutamol, sodium cromoglycate, ipratropium and normal saline.

Respiratory Device Management: Technique and Maintenance

Version 5: Copyright © Meditrax July 2020 “This material is copyright and the property of Meditrax the proprietor of the copyright. The material is loaned to the user on the condition that it is not copied in whole or part without the prior written consent of the owner of the copyright. When the purpose of the loan has expired, the material is to be returned to Meditrax.” Meditrax is a registered trade-mark of Manrex Pty Ltd t/as Meditrax.

Spiromax

DuoResp

1. Check dose counter 2. Hold upright with red mouthpiece cover at the bottom. Do not shake. 3. Open cover downwards until it clicks. 4. Breathe out gently (away from inhaler) 5. Put mouthpiece between teeth (without biting) and close lips to form

good seal. (Do not cover air vents). 6. Breathe in strongly and deeply. 7. Remove inhaler from mouth (without breathing out). 8. Hold breath for 5-10 seconds or as long as comfortable.

9. Ask resident to breathe out gently (away from the inhaler). 10. Wipe mouthpiece clean and close cover.11. If more than one dose is needed, repeat all steps starting from step 2.

Each time the mouthpiece is closed, the dose counts down. Therefore, do not open and close unless taking a dose- to monitor when inhaler is empty.

Note: Mouthpiece cover will ‘click’ even when the device is empty.

CleaningKeep the device dry and clean. The mouthpiece may be wiped after each use with a dry cloth or tissue.

HandihalerSpiriva

1. Open cap.2. Flip open mouthpiece.3. Peel back foil, remove capsule and put

capsule in chamber.4. Close mouthpiece until it clicks.5. Press green piercing button once and

release. Do not shake. Do not pierce more than once.6. Ask resident to breathe out gently away from the inhaler.7. Place mouthpiece between teeth without biting and ask resident

to close lips and form a good seal.8. Ask resident to breathe in slowly and deeply, so capsule vibrates.9. Ask resident to continue breathing in as long as comfortable.10. While resident is holding breath, remove inhaler from mouth.11. Ask resident to breathe out gently away from inhaler.12. Repeat steps 6-11 to take the full dose.13. Open mouthpiece and remove used capsule.14. Wipe mouthpiece clean and replace cap.

CleaningAfter each use wipe the mouthpiece with a dry tissue. Once a month open the dust cap and mouthpiece, lift up the green lever and rinse with warm water. Allow to air dry for 24 hours.