Asthma Inhaler Technique: The Mistakes Most People Make
Lungs & Breathing

Asthma Inhaler Technique: The Mistakes Most People Make

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Inhaled medication only works if it reaches the small airways. Studies repeatedly find that a majority of inhaler users make at least one error serious enough to reduce the delivered dose, and poorly controlled asthma is often a technique problem rather than a drug problem.

Know which device you have

Metered dose inhaler (MDI). The familiar pressurised canister in an L-shaped plastic actuator. Requires coordination between pressing and breathing.

Dry powder inhaler (DPI). Rotahaler, Revolizer, Turbuhaler, Accuhaler and similar. Requires a fast, forceful inhalation to disperse the powder. No coordination with a press is needed.

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Soft mist inhaler. Releases a slow-moving cloud over about 1.5 seconds.

The techniques are different, and crucially the breathing is opposite between the first two.

Correct MDI technique

  1. Remove the cap and check the mouthpiece is clear.
  2. Shake the inhaler for about five seconds.
  3. If it is new or unused for two weeks, prime it by firing two puffs into the air.
  4. Sit or stand upright. Breathe out gently and fully, away from the inhaler.
  5. Place the mouthpiece between your teeth and seal your lips around it. Do not bite it or block it with your tongue.
  6. Begin a slow, deep breath in, and press the canister once just as you start inhaling.
  7. Keep inhaling slowly for four to five seconds until your lungs feel full.
  8. Remove the inhaler and hold your breath for up to ten seconds, or as long as is comfortable.
  9. Breathe out gently.
  10. Wait about 30 seconds before a second puff, and shake again.

Correct DPI technique

  1. Load the dose as the device requires: insert and twist a capsule, rotate the base, or slide the lever. Hold the device upright while loading.
  2. Breathe out gently and fully, away from the device. Breathing into a powder inhaler makes the powder clump.
  3. Seal your lips around the mouthpiece.
  4. Breathe in fast, hard and deep, in one steady effort.
  5. Hold your breath for up to ten seconds.
  6. Breathe out away from the device and check the capsule is empty if your device uses one.

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The common errors

  • Not breathing out first. Without emptying, there is little room to draw the dose deep.
  • Inhaling too fast with an MDI. A rapid breath deposits the drug in the throat instead of the lungs.
  • Inhaling too slowly with a DPI. A gentle breath fails to disperse the powder at all.
  • Firing before or after the breath starts. Coordination errors waste most of the dose.
  • Not shaking an MDI. The drug and propellant separate, so the first puffs are propellant-heavy.
  • Two puffs in quick succession without a pause.
  • Not holding the breath afterwards. Much of the dose is exhaled straight back out.
  • Blocking the mouthpiece with the tongue or teeth.
  • Breathing out into a DPI mouthpiece.
  • Assuming the canister is not empty. Most MDIs have no reliable float test. Use the dose counter, or track the date you started.
  • Not rinsing after an inhaled steroid. Rinse, gargle and spit after steroid doses to prevent oral thrush and hoarseness.
  • Using a reliever more and more often without review. Needing a reliever more than twice a week means the asthma is not controlled.

Use a spacer with an MDI

A spacer, a plastic chamber between inhaler and mouth, removes the coordination problem almost entirely. It increases lung deposition, reduces throat deposition and side effects, and is recommended for most MDI users, not only children.

With a spacer: shake, insert the inhaler, seal your lips on the mouthpiece, fire one puff, then take four or five slow breaths in and out through the spacer, or one slow deep breath with a ten-second hold. One puff at a time, never several into the chamber.

Wash the spacer monthly in warm soapy water and let it air dry without wiping, because wiping creates static that traps the drug.

Preventer versus reliever

The preventer, usually an inhaled corticosteroid or a steroid and long-acting bronchodilator combination, is taken daily whether or not you have symptoms. It reduces the underlying airway inflammation and takes days to weeks to reach full effect.

The reliever opens airways within minutes. It treats symptoms and does nothing for inflammation. Relying on it alone is associated with worse outcomes, and modern guidance for many patients uses a combination inhaler as both preventer and reliever. Follow the specific plan your doctor has written.

Ask to be checked

Have your technique observed at least once a year, and whenever your device changes. Errors creep back in, and a two-minute demonstration at a clinic or pharmacy is one of the highest-value things in asthma care.

Seek urgent help if

Breathlessness is severe, you cannot complete a sentence, the reliever is not working or is needed every one to two hours, lips or fingertips look blue, or you feel drowsy or confused.

Asthma treatment must be individualised. Do not change or stop a preventer inhaler based on feeling well, without speaking to your doctor.