Before a patient with COPD or asthma is escalated to a new device, a new drug or a biologic, the single most informative thing available costs ninety seconds: ask them to take their inhaler exactly as they do at home, with their own device, and watch.
What you are looking for is specific. Did they shake it if it needs shaking, and prime it if it has not been used for a while? Did they breathe out fully first, away from the mouthpiece? Is the seal at the lips complete? For a pressurised metered-dose inhaler, is the breath slow and deep and does actuation coincide with the start of it; for a dry powder device, is the breath fast and forceful instead? Did they hold their breath afterwards, and for how long? Did they rinse their mouth if the device contains a steroid?
Two further questions catch the rest. Ask them to show you how they know when the inhaler is empty, which many patients cannot answer, and count the devices they are carrying, since patients on three inhalers with different techniques frequently use one technique for all of them. Escalating therapy over poor technique adds cost and side effects and fixes nothing, and a device the patient cannot use is not a treatment failure of the drug.
- Ask for a demonstration with the patient's own device, not a placebo trainer
- Check the breath itself: slow and deep for a metered-dose inhaler, fast and forceful for dry powder
- Ask how they know when it is empty; dose counters are often unread or absent
- Simplify to one inhaler type where possible when a patient carries several with different techniques
- Add a spacer for any pressurised metered-dose inhaler where coordination is imperfect, which is most people
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