A patient whose asthma or chronic obstructive pulmonary disease is not controlled on a reasonable regimen has three possible problems: the wrong drug, the wrong adherence, or the wrong technique. The consultation almost always investigates the first and almost never the third.
Ask the patient to demonstrate with their own device, not a placebo, and watch the whole sequence: shake, exhale fully first, seal, actuate at the start of a slow deep breath for a metered-dose inhaler or a sharp fast one for a dry powder device, hold for ten seconds. The two commonest failures are not exhaling before the breath, and actuating after the inhalation has started. Neither is visible in the history.
And note that the technique differs between device types in ways that interfere. A patient switched from a dry powder device to a metered-dose inhaler will often keep the fast sharp breath, and get almost nothing. Any switch of device type deserves a demonstration at the moment it is made, not at the next review.
- Ask for a demonstration with the patient's own device, not a placebo trainer.
- Check exhalation before the breath, and timing of actuation - the two commonest errors.
- Re-demonstrate whenever the device type changes, at the moment of the change.
- Slow deep breath for a metered-dose inhaler; fast and forceful for a dry powder device.
- Check for a spacer where one is indicated, and whether the patient actually uses it.
Why it matters
Technique failure looks exactly like drug failure in the history, and only one of them is fixed by a new prescription.
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