Inhaler technique

The single most important fact? Most people using inhalers don’t use them correctly — and this can lead to poor disease outcomes as a result.^[1]

For millions of people with asthma and COPD, poor inhaler technique silently undermines treatment. In fact, These errors are linked to poorer disease control, increased hospital visits, medication overuse, and disease instability.^[2][3]

Let’s begin in the middle of a common story.

A patient is prescribed a new Dry Powder Inhaler (DPI) as part of a Maintenance and Reliever Therapy (MART) for worsening asthma symptoms. They’re given instructions at the GP practice and feel confident. Weeks later, they’re still struggling with their asthma symptoms. A routine review reveals the issue: the patient never exhaled before inhaling, and their inhalation was too slow and shallow. The medication never reached their lungs. It looked like treatment failure but in fact, it was a technique error.

In this article, we’ll explore:

• the seven steps to using an inhaler
• the importance of the ‘teach back’ approach (also known as inhaler coaching)

other top tips you can do in everyday practice.

Exploring the seven steps to using an inhaler

All healthcare professionals who work with people using inhalers should understand the fundamental difference between aerosol devices (e.g. pressurised metered dose inhalers (pMDI), soft mist inhalers (SMI) and DPI and their inspiratory requirements: aerosols (like pMDI) = inhale slow and steady, SMI = inhale slow and steady, DPI = inhale quick and deep.

Tools like the Seven Steps to Inhaler Use can help standardise your assessment across these inhaler types. Keep it device-specific.^[4]

Seven Steps to Inhaler Use:

1. prepare the inhaler device
2. prepare or load the dose
3. breathe out, fully and gently, but not into the inhaler
4. tilt the chin up slightly and place the inhaler mouthpiece in the mouth, sealing the lips around the mouthpiece
5. breathe in:

• Aerosol e.g. pMDI = slow and steady
• SMI = slow and steady
• DPI = quick and deep

6. remove inhaler from the mouth and hold the breath for up to 10 seconds
7. wait for a few seconds then repeat as necessary.

The importance of the ‘teach back’ approach

Improving inhaler technique doesn’t require extra clinics, just smarter integration into routine reviews.

Train the whole team (including community pharmacy) to become ‘inhaler coaches’

Doctors, nurses, pharmacists, and healthcare assistants should be confident checking and demonstrating technique (inhaler coaching). Refresher sessions and peer learning help reduce variation.^[5]

Observe, don’t just ask

Using the “teach-back” approach (patients being asked to show how the device must be used) appears to be particularly effective.^[6] Use placebo devices, training whistles or an in-check dial to observe the patient’s technique.^[5] After observing technique, inhaler coaches should demonstrate how to correct errors and observe again. For new devices, the inhaler coach may need to demonstrate or share a video. You can find videos on Right Breathe and Asthma + Lung UK.

Other top tips you can do in everyday practice:

Tailor the device to the patient

Consider inspiratory flow, dexterity, cognition, and lifestyle.^[5]

Minimise the number of devices

In the common case above the patient with poor asthma control moved from a pMDI (reliever) + DPI (preventer) to a DPI MART therapy.

The change seemed sensible as it follows national guidelines^[7], however by not offering the ‘teach back’ approach, poor control remained as the inhaler coach didn’t spot the patient wasn’t emptying their lungs before inspiration.

Avoid unreviewed switches

As systems move toward less costly and/or lower global warming inhalers, ensure all device switches are supported by technique checks and patient education. No blanket switches should occur.^[5]

Prescribe the medicine and device by brand

This allows the patient to receive the right medicine in a familiar device they’ve been coached on every time.^[8]

Empowering healthcare teams to integrate inhaler coaching into routine care, especially using structured methods like the Seven Steps and the teach-back approach, can transform patient outcomes.

Every interaction is an opportunity to ACT – Assess the person’s ability to use the device, Choose the right device to fit the right person and Train the person use it correctly.^[4]

Inhaler technique is not just a detail, it is a critical component of effective respiratory care. The evidence is clear: improper use of inhalers leads to poor disease control, unnecessary medication use, avoidable hospital visits, and even preventable deaths. Yet, correcting technique is both achievable and impactful.

[1] Chrystn H, Van Der Palen J, Sharma R et al. Prim Care Resp Med. 2017; 22

[2] Bosnic-Anticevich SZ, Cvetkovski B, Azzi EA, Srour P et al. Pulm Ther. 2018; 4(1)

[3] Chapstick T, Azeez F N, Deakin G et al. Resp Med. 2021

[4] UK Inhaler Group. Inhaler standard and competency document. available at: https://www.ukinhalergroup.co.uk/uploads/s4vjR3GZ/InhalerStandardsMASTER.docx2019V10final.pdf

[5] Primary Care Respiratory. Tailoring inhaler devices. Available at: https://www.pcrs-uk.org/sites/default/files/resource/Tailoring%20Inhaler%20Devices%20PF5%20101224.pdf

[6] Global strategy for prevention, diagnosis and management of COPD (GOLD). available at: https://goldcopd.org/2023-gold-report-2/

[7] BTS, NICE and SIGN. Algorithm C: Pharmacological management of asthma in people aged 12 years and over. Available at: https://www.nice.org.uk/guidance/ng245/resources/algorithm-c-pharmacological-management-of-asthma-in-people-aged-12-years-and-over-bts-nice-pdf-13556516367

[8] Kaplan A, Price D et al. Can Resp J. 2018