Technique decays. A patient taught correctly at diagnosis will, within a year, commonly have drifted into firing before inhaling, inhaling too fast from a dry powder device, or not holding their breath at all. Nothing in the consultation reveals this unless you ask them to demonstrate, and asking whether they are using it properly reliably produces yes.
The second half of the habit matters as much. Ask them to show you with the device they actually have with them, not a demonstration inhaler from the drawer. Substitution at the pharmacy is common, devices differ in whether they need a slow deep breath or a fast forceful one, and a patient switched from a pressurised metered-dose inhaler to a dry powder device without retraining is frequently using the wrong technique for the right drug.
Before escalating therapy in apparently uncontrolled asthma or COPD, this is the first thing to check, ahead of adding a drug. A substantial proportion of what looks like treatment failure is delivery failure.
- Ask for a demonstration with the patient's own device, every visit
- Check the technique matches the device type — slow and deep for pressurised inhalers, fast and forceful for dry powder
- Ask whether the pharmacy has changed the device, not just the brand
- Check a spacer is being used where indicated, and how it is cleaned
- Correct technique before adding a drug for apparent loss of control
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