Correct inhaler technique: the enduring unmet need

Incorrect inhaler technique has been ubiquitous within asthma management for decades. It’s been associated with several negative clinical outcomes, which often result in a significant economic burden on healthcare systems. Why are patients still failing to use their inhalers correctly?

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An age-old issue

For years we’ve known that incorrect inhaler technique has been associated with negative respiratory health outcomes such as inadequately controlled asthma, increased exacerbation rates, and a rise in hospital visits.1,2 Accompanying these clinical outcomes is also a significant economic burden on international healthcare systems, which when paired with lost productivity costs, can be equivalent to hundreds of millions of dollars in a single year.3 Yet despite this being recognized as a long-standing global issue, incorrect inhaler technique is still ubiquitous within individuals living with asthma. Thanks to a recent study conducted in partnership with the University of Colorado School of Medicine and Children’s Hospital Colorado, it has been demonstrated that the vast majority of people with asthma still may be using their inhalers incorrectly.4,5


Inadequate technique

As we know, for many rescue and controller medications, two inhalations are required for a complete dose. With the majority of these inhalers, the correct technique steps required prior to any inhalation to achieve a successful dose are estimated to take between 30 to 60 seconds to complete. This is accordance with guideline and patient information leaflet criteria. In the study of 7,558 asthmatic adults and children in the US, researchers measured this time interval between the two consecutive actuations using electronic medication monitors; trialing a new method of screening for inadequate inhaler technique.5


Across both rescue and controller medications, 84% of patients were found to not take the required minimum of 30 seconds to complete the steps. 67% took less than 15 seconds, while only 16% of patients took the ‘acceptable’ time interval of 30 seconds to complete the inhalation steps. When stratified by rescue versus controller and metered-dose inhaler (MDI) versus dry-powder inhaler (DPI) use, the results were similar, yet varied with age. Participants aged 4 to 11 had the highest levels of ‘acceptable’ inhaler use, in contrast to those aged 18 to 29, who had the lowest.5


Lacking physician knowledge

Only aggravating the situation further is the often-inadequate knowledge of healthcare professionals (HCPs) regarding correct inhaler technique. A 2018 systematic review analyzed 55 studies, spanning across a period of almost 40 years, that assessed the inhaler technique of 6,304 HCPs. It was found that correct inhaler technique was demonstrated in only 15.5% of cases on average, across both pressurized MDIs (pMDIs) and DPIs, and decreased over time from 20.5% in the early period (1975–1995), to 10.8% in the late period (1996–2014).6 In terms of pMDIs, the most common HCP errors were failure to breathe out completely before inhalation, lack of post-inhalation breath-hold, and lack of coordination. With regards to DPI use, the most frequent technique errors were similarly not breathing out completely prior to inhalation, and a lack of breath-hold.6


A need for training

But why is knowledge of correct inhaler technique lacking in HCPs? These results emphasize an evident need for efficient strategies to improve the inhaler technique training of HCPs. With tailored, recurring educational programs focused on improving individual HCPs’ inhaler technique knowledge and skills, the likelihood of correct technique in patients could be increased.7 Discover more about the current challenges in asthma management in our article, and keep abreast of the latest news in respiratory care with our updates.


  1. Price DB et al. J Allergy Clin Immunol Pract. 2017; 5(4): 1071–1081.e9.
  2. Bosnic-Anticevich SZ et al. Pulm Ther 2018; 4(1): 1–12
  3. Lewis A et al. BMC Health Serv Res 2016; 16: 251.
  4. 84% of people with asthma may be using their inhalers incorrectly, Propeller Health study finds. Available at: Accessed: June 2019.
  5. Anderson WC et al. J Allergy Clin Immunol Pract 2019 Feb 15. pii: S2213–2198 (19) 30170–30179.
  6. Plaza V et al. J Allergy Clin Immunol Pract. 2018; 6(3): 987–995.
  7. How Common Are Inhaler Device Errors Among HCPs? Available at: Accessed: June 2019.

November 2019 RESP 41998