How nurses can help patients optimise inhaler use

This week marked World Asthma Day (5 May) and poor inhaler technique remains one of the most persistent and under addressed failures in respiratory care, with evidence suggesting that as many as 90% of patients make at least one critical error. Executive respiratory nurse advisor Jane Leyshon outlines how nurses and healthcare providers can help patients optimise their inhaler use 

Despite advances in inhaler technology and increased choice, poor inhaler technique remains a significant barrier to effective respiratory treatment.

According to multiple systematic reviews and observational studies, around 50-90% of patients commit at least one critical error when using their inhalers.

Not only does this poor technique result in inadequate control of disease and a lower quality of life, but it also increases a patient’s risk a full-blown exacerbation and hospitalisation, said Jane Leyshon, executive respiratory nurse advisor at the National Services for Health Improvement, at a Nursing in Practice 365 event in London last week (30 April).

Because, if technique is poor: ‘It doesn’t matter how good the drug in your inhaler is. If it can’t get it into the lungs, it’s not going to do anything,’ she said in her session at the event.

Wide variety of inhalers

Ms Leyshon highlighted that there are 148 inhalers and 52 spacers available on the UK market adding that: ‘Some might say that’s a good thing. One size does not fit all. So now we’ve got all the sizes, all the shapes, we should be able to get them to fit the people in front of us.’

‘But,’ she contended, ‘We’re not winning. We’re not getting there. Research has shown that 40 years on from when I started in respiratory, we’re still having the same issues… In fact, all of these choices might be confusing both us and the patients.’

There are four main types of inhaler, Ms Leyshon explained:

Pressurised metered-dose inhalers (pMDIs)

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These are traditional inhalers that use a propellant to deliver medication as an aerosol spray, similar to a perfume or deodorant. The user must press the canister and inhale at the same time, requiring coordination.

Breath-actuated MDIs

These are similar to pMDIs in that they also contain a propellant, but the dose is released automatically when the patient inhales, removing the need for coordination between pressing and breathing in.

Soft mist inhalers

These devices do not use a propellant. Instead, they create a slow-moving, fine mist that’s generated by the mechanics of twisting the inhaler.

Dry powder inhalers (DPIs)  

These contain medication in a powder form, either in capsules or preloaded doses. The drug is only released when the patient takes a deep, fast, forceful breath in, meaning the patient must generate enough inspiratory effort to draw the medication into the lungs. These inhalers can sometimes be single use only.

Ms Leyshon said: ‘So really, inhalers fit into two types for me: the sort where the drug is fired out at you, and the sort where you have to generate the power and the force to get it in.’

‘And we need to remember that when we’re thinking about the inhaler for a patient, what is their inspiratory effort like? What can they manage?’

Ms Leyshon uses an In-check DIAL peak flow meter to check a patient’s inspiratory ability and to assess whether the individual has ‘the adequate breath to make the inhaler work.’

Accounting for a patient’s inspiratory ability is a key part of choosing the right inhaler for them and, in effect, optimising their inhaler technique.

Common errors in inhaler use

Beyond inhaler choice and inspiratory ability, Ms Leyshon highlighted the most common errors seen in inhaler technique. They were:

• Incorrect preparation or loading of the device
• Poor coordination between actuation and inhalation
• Failure to exhale before use
• Inability to inhale at correct speed or depth
• Failure to hold breath after inhalation

Ms Leyshon noted that inhaler errors are often basic and typically stem from inadequate instruction from healthcare providers.

Additionally, she said that many clinicians are unfamiliar with the different types of devices and can end up prescribing based on habit rather than patient need.

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Moreover, insufficient follow-up with patients after initiating or changing therapy is a crucial factor influencing poor technique.

Seven steps for assessing inhaler technique

Ms Leyshon called for improved follow-up with patients and more frequent assessment of inhaler technique.

She recommends asking patients after they’ve initiated or changed therapy, or at times when they report inadequate symptom control, to demonstrate how they use their inhaler device.

‘While this can be a little awkward and some patients can feel patronised or frustrated at being asked the same questions time and time again, it can be unsafe to assume that all patients have a good inhaler technique,’ she said.

Ms Leyshon listed seven steps for assessing inhaler technique:

1. Prepare the inhaler device
2. Prepare or load the dose
3. Breathe out fully and gently, but not into the inhaler
4. Tilt chin up slightly and place the inhaler mouthpiece in the mouth, sealing the lips around the mouthpiece
5. Breathe in:
   • Slow and steady for pMDIs and breath-actuated MDIs
   • Slow and steady for soft mist inhalers
   • Quick and deep for DPIs
6. Remove inhaler from mouth and hold breath for up to 10 seconds
7. Wait for a few seconds and then repeat as necessary

Ms Leyshon highlighted that it can often be easier to change an inhaler device than a person’s behaviour, so use this assessment as an opportunity to evaluate what might work best for that individual patient.

When selecting a device, it’s not only essential to consider inspiratory flow but also to look at a patients’ lifestyle.

‘If you’re a 20-year-old, would you want to carry a spacer around with you when you’re active and going partying with your friends? It’s not really cool, is it?

‘So think about lifestyle. Think about what the person needs to do with that inhaler, where they’re going to be using it. And think about personal preference.

‘See what might fit with their abilities, and then maybe say to them, look, we’ve got these two different options that are available…And let them have some input into it,’ she said adding, ‘We can’t make changes for people. We need to make changes with people.’

Related Article: Over one million switched to combined asthma inhalers since NICE update

Combination inhalers

On 5 May, the National Institute for Health and Care Excellence (NICE) highlighted the impact combination inhalers are having for some patients following the landmark guideline published jointly in 2024 by NICE, the British Thoracic Society and the Scottish Intercollegiate Guidelines Network.

The guideline says that healthcare professionals should move away from relying on traditional blue reliever inhalers – short-acting beta2-agonists or SABA – alone and instead use combination inhalers that contain both an inhaled corticosteroid and a fast-acting reliever for both maintenance and immediate symptom relief.

A version of this article was first published on our sister title, The Pharmacist.

Continue your learning by registering for our upcoming Nursing in Practice Virtual event on 4 June where the theme is Respiratory and Women’s Health, tailored for nursing professionals looking for practical, CPD-accredited learning and expert-led sessions to support high-quality patient care.