When control is poor, the technique is a commoner explanation than the molecule, and asking whether the patient uses the inhaler correctly reliably produces the answer yes. The only useful version of the question is to hand them their own device and watch.
What to look for depends on the device, and the two families fail differently. A pressurised metered-dose inhaler needs a slow, deep inhalation started just before actuation and a ten-second hold; the common failures are firing before or after the breath, and inhaling too fast. A dry powder inhaler needs the opposite - a forceful, deep inhalation - and fails when the patient exhales into the device, loading it wrongly, or is too breathless to generate the flow. A pMDI without a spacer in anyone who struggles with coordination is a dose largely deposited in the oropharynx.
Two checks that take ten seconds each and are almost never done: ask the patient to show you the dose counter, because an empty or nearly empty device explains a great deal, and ask them to rinse and spit after inhaled steroid, then check for oral candidiasis. Re-demonstrate at every review where control has slipped, not only at the first prescription; technique decays within months.
- Hand the patient their own device and watch a full actuation before changing any drug
- Match the breath to the device: slow and deep for a pMDI, hard and fast for a dry powder inhaler
- Add a spacer for any pMDI where coordination is imperfect, including in adults
- Check the dose counter and look in the mouth at the same visit
- Re-demonstrate at every review where control has slipped - technique decays
Why it matters
Escalating therapy for a device problem adds cost and side effects without touching the reason control was lost.
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