When control is poor, the reflex is to step up the inhaler. Before doing that, ask the patient to take a dose in front of you with their own device — not to describe how they do it, and not with a placebo trainer.
What you are looking for is specific. Did they shake it. Did they exhale before the dose rather than into the device. Did the actuation and the breath coincide. Did they hold their breath afterwards, and for how long. Did they take a second dose within a few seconds of the first. With a dry powder device, was the inspiration fast and deep or slow and polite. With a spacer, did they use tidal breathing or one enormous breath.
Most inhaler technique problems are one of these, and none of them is visible from a repeat prescription list or from asking whether they are managing all right. A minute of watching also tells you whether the device suits the patient at all — a dry powder inhaler in someone who cannot generate the flow is a prescription for a placebo, and stepping it up doubles nothing.
- Ask for a demonstration with the patient's own device at every review where control is poor
- Check inspiratory effort matches the device type before changing the drug
- Watch the breath-hold; it is the step most often dropped
- Record what you observed, not that technique was 'checked'
Why it matters
Stepping up a drug the patient is not actually inhaling changes the prescription and nothing else.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for pulmonology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free