Asthma Inhalation Therapy: How to Avoid Inhaler Use Errors

Introduction

Inhalation therapy is the cornerstone in the management of chronic obstructive airway diseases, such as bronchial asthma [1]. It allows the delivery of medicinal substances directly to the lungs, providing a rapid and targeted action with minimal systemic side effects. However, despite the apparent simplicity, many patients make mistakes when using inhalers, which significantly reduces the effectiveness of treatment [1, 2]. Incorrect inhalation technique is a common problem that can lead to worsening disease control and a decline in quality of life [1]. In this article, we will examine the main errors, their consequences, and propose solutions for improving inhalation technique.

Prevalence and Consequences of Incorrect Inhaler Use

Incorrect use of inhalers is a global problem affecting patients with asthma and chronic obstructive pulmonary disease (COPD) worldwide [2]. Studies show that errors in inhalation technique occur with high frequency, regardless of the type of device—whether it is a metered-dose inhaler (MDI) or a dry powder inhaler (DPI) [1, 2]. Even a single critical error can significantly reduce drug delivery to the lungs, making therapy less effective [2].

The consequences of improper inhalation technique can be serious. Poor technique is directly linked to an unfavorable prognosis in both asthma and COPD [1]. This manifests as insufficient symptom control, an increased frequency of exacerbations, the need for more frequent emergency care visits, and hospitalizations. In the long term, this can lead to disease progression, decreased lung function, and a deterioration in the patient's overall quality of life [1]. Patients may mistakenly believe that their medication is ineffective, while the problem lies in the way it is applied.

Typical Errors in Inhalation Therapy

Errors in using inhalers are diverse and depend on the type of device. However, there are common shortcomings frequently found among patients [1]:

• Incorrect coordination of actuation and inhalation (for MDIs): This is one of the most frequent errors when using metered-dose inhalers. Patients may press the canister too early or too late relative to the start of inhalation, leading to the deposition of most of the drug in the oropharynx rather than the lungs.
• Inadequately deep or fast inhalation: MDIs require a slow and deep inhalation, while most DPIs require a fast and forceful one. A mismatch between the speed and depth of inhalation and the type of inhaler reduces the efficiency of drug delivery [1].
• Insufficient breath-holding after inhalation: After inhaling the medication, it is necessary to hold your breath for 5-10 seconds (or as long as comfortable) so that the drug has time to settle in the airways. The absence or too short duration of breath-holding leads to exhaling the medication [1].
• Failure to shake the inhaler (for MDIs): Before each use, a metered-dose inhaler must be thoroughly shaken to ensure an even distribution of the active substance in the propellant.
• Incorrect mouthpiece position: The mouthpiece must be tightly gripped with the lips to prevent drug leakage.
• Using an empty inhaler: Some patients do not track the number of remaining doses, continuing to use an inhaler that is already empty. Modern inhalers are often equipped with dose counters, but not all patients pay attention to them.
• Incorrect inhaler preparation: Certain types of DPIs require specific actions to be performed (e.g., turning the dispenser, opening the cap) before inhalation. Skipping these steps can result in the dose not being released or being released only partially.
• Non-observance of intervals between inhalations: If multiple inhalations are required, a small interval (usually 30-60 seconds) must be maintained between them to allow the lungs to recover and the next dose to be delivered more effectively.

All these errors result in a smaller amount of the medicinal substance reaching the target areas in the lungs, which reduces the therapeutic effect and may cause the sensation that the treatment is not working [1].

Factors Influencing Inhalation Quality

The effectiveness of inhalation therapy depends on a multitude of factors that can contribute to the occurrence of errors [1]:

• Patient-related factors:
  • Insufficient understanding of instructions: Patients may not fully understand how to use the inhaler correctly, especially if the instructions are complex or have not been explained properly.
  • Cognitive impairments: Elderly patients or individuals with certain cognitive disorders may experience difficulties in remembering and executing the sequence of actions.
  • Age: Children and very elderly individuals often require a special approach and assistance when using inhalers.
  • Insufficient motivation or conviction: If a patient does not believe in the effectiveness of the treatment or does not see a direct link between correct technique and improvement, their motivation to adhere to the rules decreases.
  • Low health literacy: Limited knowledge about their disease and treatment methods can hinder the correct use of the inhaler.
• Device-related factors:
  • Complexity of the inhaler design: Some inhalers have a more complex activation mechanism or require multiple steps to prepare the dose, increasing the likelihood of error.
  • Absence of a dose indicator: Without a clear dose counter, it is difficult for the patient to determine when the inhaler will run out.
• Healthcare provider-related factors:
  • Insufficient patient education: Doctors and nurses may not devote enough time or attention to teaching patients the correct inhalation technique.
  • Lack of regular technique checks: The inhalation technique should be periodically re-evaluated, as patients may forget details or develop bad habits over time.
  • Lack of standardized training protocols: Differences in training approaches can lead to incomplete information.

Ways to Improve Inhalation Technique and Treatment Effectiveness

Improving inhalation technique is a key element in achieving optimal asthma control. This requires a comprehensive approach that includes the following measures [1]:

• Individualized training and retraining: This is the most important step. Healthcare workers must regularly demonstrate the correct technique for using the inhaler, using placebo devices so that the patient can practice without wasting medication. Training should be individualized, taking into account the patient's age, cognitive abilities, and preferences.
• Regular technique assessment: At every visit to a doctor or nurse, it should be checked how the patient is using their inhaler. This allows for the timely identification and correction of emerging errors [1].
• Choosing a suitable inhaler: It is important to select the type of inhaler that the patient can use most effectively. For example, for patients with poor coordination or low inspiratory capacity, DPIs or MDIs with a spacer may be preferable [1].
• Using auxiliary devices: Spacers (spacer chambers) significantly simplify the use of MDIs, especially for children and the elderly, improving coordination and reducing drug deposition in the oropharynx.
• Clear and simple instructions: Providing patients with written or visual instructions (e.g., brochures, videos) can help them remember the correct sequence of actions.
• Involving family and the community: Involving family members in the education and support process can significantly improve treatment adherence. Studies show that community participation (patients, their families, clinicians) in the development of treatment strategies can enhance therapy efficacy and adherence [3]. This allows educational programs and support methods to be adapted to the real needs of patients.
• Feedback and motivation: It is important to explain to patients why correct technique is so important and show them how improving technique affects their well-being and asthma control.

Conclusion

Inhalation therapy is a powerful tool in combating asthma, but its effectiveness directly depends on the correct use of the inhaler. Common mistakes can negate all treatment efforts, leading to poor symptom control and a deteriorated quality of life. Awareness of these errors, their causes, and the active participation of both patients and healthcare workers in the training and control of inhalation technique are the keys to successful asthma management. Regular training, an individualized approach, and constant feedback will help patients maximize the potential of inhalation therapy and live a full life without limitations caused by asthma.

Sources

• [1] Plaza, V., Giner, J., & Quirce, S. (2020). Common errors in inhalation therapy: Impact and solutions. https://pubmed.ncbi.nlm.nih.gov/32710522/
• [2] Budhathoki, S., & Shrestha, S. (2022). Inhaler Competence in Nepalese Patients with Asthma and Chronic Obstructive Pulmunory Disease: A Systematic Review. https://pubmed.ncbi.nlm.nih.gov/36550701/
• [3] Krishnan, J. A., et al. (2025). Community Advisors' Effect on a Randomized Pragmatic Clinical Trial for Asthma Treatment: Retrospective Analysis. https://pubmed.ncbi.nlm.nih.gov/41418289/

Disclaimer: The information presented in this article is for reference purposes only and should not be used for self-diagnosis or self-treatment. Always consult a qualified medical specialist to obtain an accurate diagnosis and an individualized treatment plan.