The PRAXIS Nexus The PRAXIS Nexus

Don’t Forget to Check the Technique!

Posted on February 14, 2023   |   

This post was written by Michael W. Hess, MPH, RRT, RPFT.

Inhaled medications have been with us for a very long time; longer, perhaps, than we usually recognize. The first known description of a medicinal inhaler device (outside of pipes and such used for smoking and similar activities) was actually created in 1654 by an English physician by the name of Christopher Bennet.​1​ Just over three hundred years later, an American scientist named George Maison invented a dose-metering valve at the behest of his daughter, who sought a more convenient way to take her asthma medication. That invention, and the subsequent development of the metered-dose inhaler (MDI), set the stage for decades of convenient, portable, and effective inhaled therapy for a variety of respiratory conditions.​2

At least, it was supposed to.

Unfortunately, the reality has not quite kept up with the promise. Without question, MDIs and their cousins the dry powder inhaler (DPI) and soft mist inhaler (SMI) are portable, fitting into pockets far more easily than most nebulizers. Many find them to be quite convenient due to that portability. However, their efficacy is often limited by their relative complexity. The steps involved in preparing and using an inhaler vary from device to device, but are certainly more complicated than what is usually portrayed in popular media. The fact that patients cannot simply “puff and go” has led to roughly two-thirds of inhaler users not using their inhaler correctly, an error rate that has stayed largely unchanged since it was first studied in the 1970s.​3​ Frequent misuse has been demonstrated to lead to worse outcomes and more healthcare-related expenditures.​4​ This is particularly true in cases where people are prescribed multiple inhalers, often having different inhalation demands.​5

The problem is not limited to patients, either. A meta-analysis of 55 studies again beginning in 1975 found that a mere 15.5% of health care professionals overall demonstrated proper inhaler technique.​6​ The study also suggests that the problem is getting worse. The group found that during the first 20 years of studies, just over 20% of clinicians showed proper technique, but that rate had fallen to 11% during the second 20 years. This could be attributable to the increasing variety of inhaler devices on the market, but suffice it to say, if people are not instructed correctly, they will not be able to use their devices correctly, and their health will unfortunately suffer.

Organizations like the Global Initiative for Chronic Obstructive Lung Disease (GOLD) have long recognized the importance of proper inhaler technique, recommending assessment of technique and adherence in COPD management algorithms.​7The most recent GOLD report goes a step further, including for the first time a dedicated table on principles for choosing the appropriate drug/device combination. These principles are largely based on the evidence-based guidelines published nearly 20 years ago (yet sadly still under-utilized) by the American College of Chest Physicians and the American College of Asthma, Allergy, and Immunology.​8​ One critical addition recognizes that many clinicians are not well versed in many devices, recommending that prescribers should only order medications that come in devices they are familiar with, ensuring they are able to appropriately match the device’s characteristics with the patient’s preferences and abilities, as well as enabling them to teach its operation.

Fortunately, various resources are available to help clinicians improve their inhaler knowledge base. The COPD Foundation maintains an entire series of instructional videos covering the myriad inhalers and nebulizers on the market today. These videos, produced by respiratory therapists intimately familiar with each device, walk viewers through each step of priming and actuating these devices. The nebulizer section also includes how to clean each device, an often-overlooked component of education. Because these videos are free, they can also serve as an ongoing reference for people prescribed inhaled medications. This is critical; I have personally seen cases where without ongoing assessment and re-instruction inhaler technique competence can drop rapidly. Even with physical demonstration, inhaler technique can be noticeably worse within 4 months.​9

With the increasing demands placed on health care professionals at all levels, it is easy to see why many do not feel they have the time to teach good technique. Unfortunately, this is really one of those corners that cannot be cut. When someone has poor technique and does not know it, they run the risk of worsening outcomes, not to mention feeling like additional treatment may be futile. I encourage everyone out there who touches the COPD community to take advantage of resources like our video library, become more knowledgeable about inhalers, and help your patients breathe easier!

  1. Stein SW, Thiel CG. The History of Therapeutic Aerosols: A Chronological Review." J Aerosol Med Pulm Drug Deliv. 2017;30(1):20-41. href="doi:10.1089/JAMP.2016.1297/ASSET/IMAGES/LARGE/FIGURE15.JPEG
  2. Schultz RK, Paul S. Drug delivery characteristics of metered-dose inhalers. Journal of Allergy and Clinical Immunology. 1995;96(2):284-287. doi:10.1016/S0091-6749(95)70207-5
  3. Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team (ADMIT). Systematic Review of Errors in Inhaler Use. Chest. 2016;150(2):394-406. doi:10.1016/j.chest.2016.03.041
  4. Usmani OS, Lavorini F, Marshall J, et al. Critical inhaler errors in asthma and COPD: A systematic review of impact on health outcomes. Respir Res. 2018;19(1):1-20. doi:10.1186/S12931-017-0710-Y/TABLES/2
  5. Bosnic-Anticevich S, Chrystyn H, Costello RW, et al. The use of multiple respiratory inhalers requiring different inhalation techniques has an adverse effect on COPD outcomes. Int J Chron Obstruct Pulmon Dis. 2017;12:59. doi:10.2147/COPD.S117196
  6. Plaza V, Giner J, Rodrigo GJ, Dolovich MB, Sanchis J. Errors in the Use of Inhalers by Health Care Professionals: A Systematic Review. J Allergy Clin Immunol Pract. 2018;6(3):987-995. doi:10.1016/J.JAIP.2017.12.032
  7. 2023 GOLD Reports - Global Initiative for Chronic Obstructive Lung Disease - GOLD.
  8. Dolovich MB, Ahrens RC, Hess DR, et al. Device Selection and Outcomes of Aerosol Therapy: Evidence-Based Guidelines. Chest. 2005;127(1):335-371. doi:10.1378/chest.127.1.335
  9. Bosnic-Anticevich SZ, Sinha H, So S, Reddel HK. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. J Asthma. 2010;47(3):251-256. doi:10.3109/02770900903580843


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  • Thanks Mike. More great info
  • Thanks, Mike! It can help even those HCPs and patients who feel they know an inhaler backward and forward to check in on technique (watch our videos!) You never know if a slight modification could make all the difference.
  • My last visit to the doctor he tried to sell me on the medication his sales rep left samples of. My doctor had been out helping Covid patients in the hospital. During our appointment he wore a mask, half hanging off his face. He was wearing shoes that looked 20 years old. He was demonstrating how to use the inhaler, he dropped it on his old shoe that had just been in the Covid ward then handed it to me and said " try it " I said 'no thanks' ( it was a sign )
    I dont trust most doctors and I definitely dont Trust Big Pharma. They spend too much time worried about money. They make all these same medications, with the same basic ingredients put them in hard to use contraptions with different names, charge a small fortune and nothing changes.
    I use my nebulized medication, take it once in the AM, once in the PM, yes it takes 10 minutes but simple enough. I use a rescue inhaler with chamber when needed. I have bad COPD , I havent had any exacerbation since my first in 2018 and only once needed antibiotics and steroid since.
    I do take a couple puffs of strong marijuana a couple times a day, helps me cough up all the mucous, what else it may or may not do I dont know. They need to study more about Lung's and come up with new ways to look at and treat issues like they were forced to do with Covid Lung's.
    Sorry so negative but the shoe thing was funny wasnt it?

    • Hi, Mermaid! It is very unfortunate how your doc handled that situation. I also wholeheartedly agree that we need much more research about lung problems. The Foundation, along with our other advocacy partners, has been pushing for this for many years, and we are finally starting to see some progress. Baby steps, to be sure, but progress nonetheless.

      You can help us out, actually! Our annual IMPACT advocacy event is coming up next month. If you are interested in telling Congress about the importance of research funding for things like COPD, I invite you to sign up at Hope to see you (virtually) there!
  • Who are the people who test these inhalers before they reach market, how much testing is done?
    I have been using nebulizer for 4 years twice a day and It took me two years to find a mouthpiece I think worked best and now you cant find them! So I have used the same mouthpiece for 2 years ( not good for business) and there may be a better one but the market is flooded with too much medication and mouthpieces to stop and see what really works and then when it does, it disappears.
    If I was a doctor, Id tell the patient to screw around with it until they know its getting where it needs to be, probably more effective.
  • It takes many years for any new drug to reach the market, sometimes even longer for inhaled meds because of the extra process of testing the device. Can you describe the kind of mouthpiece you are looking for? Generally speaking, for nebulizers, there are only a couple of different types. Different manufacturers may have some quirks, certainly.

    As far as meds go, it's important to remember that each person responds a little differently to each med, even if they are in the same class. It can absolutely take some trial and error to find the right combination for you. However, I think it is more important for clinicians to take the time to teach properly rather than just abandon each person to literally their own devices and force them to do their own trial and error. The issue is that many health care professionals simply don't know how to use the devices either, which is another problem we're working on!
    • When pulmonoligis have no idea how oxygen works, and no idea how to train us on using it and inhalers, we are in big trouble. Maybe we need to start this in medical school, as my doctors had no idea what would work for me to leave my home and keep oxygen levels safe. They just figured I could get a portable machine and go anywhere! They never even explained to me what level to keep my home oxygen concentrater at, I have figured this all out on my own. Hell, they never even mentioned rehab until I learned about on one of these forums. I am very, very unhappy with doctors at this point, as I feel they just want to tell me to take a pill and that their time is too limited to explain anything.
    • Hard to disagree with any of that, Kimoco. Their time is VERY limited, and there are not (yet) a lot of RTs out there in these offices. There are many misconceptions about oxygen equipment, lots of different kinds of inhalers out there, and many don't remember to refer people to pulmonary rehab (if there's even one in your area, due to budget cuts). I would definitely like to see more training on these devices somewhere, most likely in residency or fellowship training after medical school. But you're right, it has to happen somewhere...or we need more RTs to help support the team!
  • Thank you MIke for all the awesome information. I have had COPD for 20+ years. I learn so much from all of you. I do a lot of research and if I can help you or anyone else in any way please let me know.
  • My pulmono0logists may be amazing at research and diagnostics, but they never once explained how to use the medication they ordered. They have no clue how oxygen machines work and what can be used for a specific need.

    I am a very computer literate person who still has my mental capacity in order so I can research and teach myself. But there are likely many who are not in my position. I think there should be a requirement for all patients who need these devices get appointments with Respiratory therapists, who are more likely to be able to demonstrate, educate and train us on these items.
    • There's no question that you're right: people who are prescribed 02 for home use should be seen by and RT and shown how to use the equipment, More importantly, they should be told WHY they are being prescribed 02 and what the consequences can be if it's not used as prescribed. Most people think it's to help their breathing, and it may do that, but maybe not. The major reason 02 is prescribed is to keep the 02 saturation levels in the blood sufficient to deliver 02 to all parts of the body so things continue to work like they're supposed to. We do that by breathing, but the key is that we have to be able to get enough 02 from room air by itself and if we can't, that's why we're prescribed 02. So in most important respects being prescribed 02 isn't at all about breathing, it's all about how much 02 you can deliver to the blood that sends the 02 all the places it needs to go.
    • Hi, Kimoco! We in the respiratory therapy community are working hard to get RTs in more offices and more settings, like even primary care. Docs are quite busy due to requirements from the health care system, and you're right, RTs are often a little more "up" on these devices than pulmonologists (especially when it comes to inhalers). Before I worked at the Foundation, I had just that kind of role in a primary care office, and it did really show me how badly this is needed!
  • Thanks for your reply Mike but I think Congress is slow...and have enough to try and deal with. I think there needs to be some kind of database for Pulmonologist and Respiratory Therapist to share thoughts and there may already be. I just remember the beginning of Covid when they were treating patients for Respiratory Distress per protocol and they were dying until a few brave doctors thought out of the box risked their positions and credibility to save lives. And through technology ( Twitter, to be exact) they spread the word. otherwise the death toll would have been a lot worse. I know doctors are in a bad position because they rightly fear being sued etc. But lets say a doctor himself or through a patient stumbles on to something or figures something out thats helpful, spread the word! Technology is good for some things. Sorry for getting off subject. We can send a rocket to the moon, lets figure out an inhaler that works
    • You bring up some great points! I know at least on the RT side, we do indeed have a site not unlike this one called AARConnect (hosted by our professional organization, the American Association for Respiratory Care, or AARC). In the early days of the pandemic, there was a LOT of discussion about what was working and what wasn't, and that's how things like prone positioning (laying on your belly instead of your back) and preferring noninvasive ventilators to breathing tube-based ones ended up becoming the "new and improved" standard practices rather than the old playbook. I would have to image docs have something similar. The risk with Twitter is that there are a LOT of random ideas flying around there, not always backed by science, and it can be hard to separate the signal from the noise. And I say that as someone who LOVES the #medtwitter community!

      Our own Dr. David Mannino is fond of saying that if we could develop an inhaler that was as easy and efficient to use as a cigarette, we would be in pretty good shape. Hope springs eternal!
  • Fantastic information! It is very frustrating when patient's come in without spacers and have no idea what I am talking about when I ask if they have one. The PCP's do not realize the importance of spacers. When they do write scripts for them, the Pharmacist tells a lot of patients they are not needed. Worse than that, doctors assume the pharmacist will explain how to use the inhaler and spacer and the pharmacist assumes the doctor has done this, in reality, no one has explained to the patient how to properly use them. I had one patient who was swallowing the pill that went in her DPI and then just sucking on the mouthpiece, because no one explained how to use it. It's sad.

    • Agreed all around. One of our big projects this year is to work with GOLD on a brand-new event aimed at primary care providers at the GOLD conference this November. We plan to have an entire session on the importance of inhaler selection and technique, and that's really the tip of the iceberg when it comes to what we want to do to improve clinician education. We've gone 50 years without significant changes in the rate of critical errors for inhalers, we can't afford to go 50 more!