Watch the inhaler before you change the inhaler

A patient whose asthma or COPD is not controlled on a device they cannot use does not have refractory disease. Yet the commonest response to poor control is to step up therapy, which adds a second device the patient will also use incorrectly.

Ask the patient to demonstrate, every time, with their own device. Four errors account for most failures. With a pressurised metered-dose inhaler: no shake, actuation not coordinated with a slow inhalation, and no breath hold. With a dry powder inhaler: an inhalation that is not forceful enough to disaggregate the powder, and — the one nobody sees — exhaling into the device before inhaling, which blows the dose out. The two device types need opposite inhalation techniques, which is why a patient given both often uses both wrongly.

Then check the count. A pressurised inhaler with no dose counter gives no indication of being empty, and patients keep using one long past its last dose because it still sprays propellant. And in Indian practice, ask what they actually have at home rather than what is on the prescription — substitution at the pharmacy means the device in the cupboard is often not the one you taught.

• Ask for a demonstration with the patient's own device at every review
• Slow and deep for a metered-dose inhaler, hard and fast for a dry powder inhaler — never teach both the same way
• Check that the patient exhales away from the device, not into it
• Check the dose counter, and warn that a spraying inhaler can still be empty
• Add a spacer before adding a drug; it fixes most coordination failures

Why it matters

Most apparently refractory airways disease is a device problem, and stepping up treatment adds a second device to get wrong.

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