Inhalers, asthma and getting the technique right

Inhaled medication only works if it reaches the lungs, and studies of technique consistently find that a large proportion of patients use their devices incorrectly.

Why technique matters so much

An inhaler delivering the drug to the mouth and throat rather than the airways delivers no benefit and produces local side effects.

Poor technique is one of the main reasons treatment appears to fail, leading to escalation to stronger and more expensive medication when the existing one was never being delivered.

Studies show that technique deteriorates over time even in people taught correctly, which is why periodic re-checking matters.

Which makes an inhaler technique check one of the highest-value five minutes available in a pharmacy or clinic, and one that is rarely requested.

The main device types

Which require different techniques.

Pressurised metered dose inhalers require a slow, steady inhalation coordinated with actuation, followed by a breath hold.

Coordination is the difficulty, and a spacer solves it.

Dry powder inhalers require a quick, forceful inhalation, which is the opposite instruction and is the source of much confusion when someone switches device.

Soft mist inhalers require a slow inhalation.

A breath hold of around ten seconds after inhalation applies to all of them, and is frequently omitted.

Spacers

Cheap and underused.

A spacer used with a metered dose inhaler removes the need for coordination, reduces deposition in the mouth and throat, and improves drug delivery to the lungs.

It reduces oral thrush and hoarseness from inhaled steroids.

It is recommended for children and for anyone with coordination difficulty, and is beneficial for most adults.

Practical points: use one puff at a time, inhale immediately after actuation, and clean it monthly by washing in warm soapy water and allowing it to air dry rather than rinsing and wiping, which creates static.

Preventer and reliever

A distinction that is frequently misunderstood.

Preventer inhalers, usually containing an inhaled corticosteroid, reduce airway inflammation and must be taken regularly to work, whether or not symptoms are present.

Reliever inhalers relieve symptoms quickly and treat nothing.

Over-reliance on relievers is a recognised marker of poor control and of risk — using more than a defined number of reliever inhalers a year is a warning sign that should trigger a review.

Asthma guidance in several countries has shifted substantially towards combination anti-inflammatory reliever therapy rather than short-acting reliever alone, on the basis of trial evidence showing reduced exacerbations.

Which means anyone using an old regimen should ask whether current guidance suggests something different.

Practical management

What good asthma care includes.

A personalised written action plan, which reduces exacerbations and hospital admissions in trials and which a minority of patients have.

An annual review with technique check.

Peak flow monitoring where appropriate.

Identification and management of triggers.

Influenza vaccination.

Smoking cessation, including exposure to others' smoke.

Attention to nasal symptoms, since upper and lower airway disease are linked.

And checking whether other medications are contributing, since non-steroidal anti-inflammatories and beta blockers affect some patients.

Recognising deterioration

The signs that matter.

Needing the reliever more often.

Symptoms waking you at night.

Symptoms limiting activity.

Falling peak flow readings.

And an attack that does not respond to the usual reliever, which is an emergency.

Asthma deaths are frequently preceded by recognisable warning signs over days or weeks, and reviews consistently find under-treatment with preventers and over-reliance on relievers among the contributing factors.

The cost side

Where inhalers differ from other medicines.

Generic substitution is not straightforward, because the device matters as much as the drug — switching brands without retraining leads to worse control, which is more expensive than any saving.

Which is why inhaler switches should be accompanied by technique training rather than done by dispensing substitution.

Environmental considerations have entered this area, since metered dose inhalers contain propellants with significant global warming potential, and switching to dry powder devices where clinically appropriate reduces this substantially — a change several health systems are actively pursuing.

Return used inhalers to a pharmacy for disposal rather than putting them in household waste.

Getting the technique checked

Practically.

Ask a pharmacist to watch you use your inhaler, which they will do without an appointment.

Ask at every annual review.

Ask when any device changes.

Watch a demonstration video specific to your exact device, since instructions differ.

And ask about a spacer, which is inexpensive and improves delivery for most people using a metered dose inhaler.

General information only, not medical advice. Consult a clinician or pharmacist about inhaler technique and asthma management, and seek emergency care for an attack that does not respond to your reliever.