The commonest reason an inhaled regimen is not working is that the drug is not reaching the lung, and the commonest reason for that is technique. Stepping up therapy without checking is how a patient ends up on three inhalers, none of which they are using properly.
Ask the patient to demonstrate with their own device, not a placebo, and watch the whole sequence: shake, exhale away from the device, seal the lips, inhale, hold. The errors cluster - firing before inhaling, inhaling fast through a dry powder device or slow through a metered dose inhaler, no breath hold, and a spacer that has never been used. Count how many doses are left, because an empty canister still puffs propellant.
Do it at every review and after every change of device. Changing the drug is a prescribing decision anyone can make; changing the technique is the one that actually alters the dose delivered, and it costs two minutes.
- Have the patient demonstrate with their own inhaler at every review, not describe it.
- Watch for firing before inhalation, wrong inspiratory flow and absent breath hold.
- Prescribe and check a spacer for every metered dose inhaler, especially in children and older patients.
- Check how many doses remain; an empty canister still sprays.
- Recheck technique whenever the device brand or type changes, even for the same drug.
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