Invest a Few Minutes in Inhaler Counseling

Asthma and chronic obstructive pulmonary disease (COPD) are common. Worldwide, roughly 730 million people have one of these diseases.^1,2 For years, researchers have known that patients often have poor inhaler technique, and numerous professional organizations have advocated for more counseling at every health care visit.^3,4 When clinicians select inhalers based on the patient’s skills and abilities, adherence increases.⁵ Although pulmonary inhalation devices have improved remarkably over recent decades and are the most frequently prescribed intervention for asthma and COPD, inhaler use skills have lagged.^6,7

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A recent study examined inhaler use among 279 patients hospitalized for an exacerbation.⁸ The researchers looked for critical technique errors and assessed the need to change the inhaler type at hospital discharge. Only 30% of patients had good inhaler adherence. Roughly half used metered dose inhalers, and 43% used dry powder inhalers (DPIs), which are associated with fewer critical errors and considered eco-friendly.^7-10 The most common critical error was failure to execute the “hold your breath” step correctly. Patients with a peak inspiratory flow of 30 L/min or greater, who represented more than 90% of the study cohort, were identified as candidates for DPIs preferentially. DPIs are breath actuated and eliminate the “hold your breath” step. More than half of the study participants made critical errors, and less than one-third needed but did not receive a device change at discharge.⁸

These findings are consistent with many other studies over the years.^6,11 Unless all health care professionals start to take this issue seriously, things won’t change. What can the pharmacy team do?

Recognize Clinical Inertia

When patients who are using inhalers have disease exacerbations, it’s time to question the treatment plan. Often, prescribers simply fail to step up therapy when patients who have respiratory diseases relapse. This is called clinical inertia, and it’s a problem in many disease states. Hospitalization, in particular, should signal a need to assess the patient’s current inhaler and possibly select a different inhaler that’s more suitable. This is especially important if the patient is rehospitalized within 30 days of discharge following an exacerbation admission.⁸

Know Common Errors

Research has identified the most common errors associated with inhaler use (see Table¹²), some of which are surprising.

Counseling and Recounseling

Inhaler technique often becomes sloppy over time. Even patients who are very confident in their abilities often have poor technique.¹³ For this reason, it’s essential to take the time to review inhaler technique whenever a new inhaler is prescribed and periodically thereafter. Some experts indicate patients need a review at every visit.³ If patients seem to be having trouble, pharmacists can ask pointed questions to find a remedy. Because so many children have asthma, including the school nurse on the treatment team and offering coaching at school can improve outcomes.¹⁴

At every counseling session, pharmacists need to discuss inhaling in accordance with the inhaler’s instructions and also assess whether a spacer is necessary if the medication leaves the device too quickly for the patient to effectively inhale it.¹⁵ Note that some patients may object to a spacer because it’s another device and an added cost. Most experts recommend using the teach-back method because it helps correct errors as they occur.¹⁶

Monitor Adherence

It’s easy to calculate how long an inhaler should last, and if patients ask for refills too soon or don’t refill their inhalers often enough, adherence is an issue.¹⁷ This is an area where pharmacy technicians can be especially helpful, alerting the pharmacist if it looks like there’s a problem. Pharmacy staff often know patients and their tendencies better than other health care providers and can encourage better adherence. They can also determine whether cost is a barrier.¹⁷

Personalizing inhaler selection can also improve adherence. Almost every area of medicine now talks about the need to personalize treatment. This is especially true in the care of patients who have asthma or COPD. Asking about manual dexterity, hand strength, facial weakness, visual acuity, and cognitive impairment is critical.¹⁸

With so many digital technologies now available to help with adherence, most patients will be able to find a tool to help them stay on track.¹⁹ One of the easiest ways to increase adherence is to program a cell phone to remind the patient to use the inhaler. Other adherence devices can be helpful. An old-fashioned but effective strategy is to provide a checklist that patients can use to ensure they follow the directions.

Finally, many providers overlook the need for maintenance and cleaning. Every inhaler needs to be inspected periodically to make sure that it’s still clean and in good shape.^14,18

Conclusion

It may seem like counseling on inhaler use could take too much time, but with practice, it can take minutes. Those few minutes may prevent a dangerous exacerbation, a hospitalization, or even death.

REFERENCES

1. Global Asthma Network. The global asthma report 2018. August 31, 2018. Accessed June 6, 2025. https://globalasthmareport.org/2018/index.html

2. Adeloye D, Song P, Zhu Y, Campbell H, Sheikh A, Rudan I; NIHR RESPIRE Global Respiratory Health Unit. Global, regional, and national prevalence of, and risk factors for, chronic obstructive pulmonary disease (COPD) in 2019: a systematic review and modelling analysis. Lancet Respir Med.2022;10(5):447-458. doi:10.1016/S2213-2600(21)00511-7

3. Global strategy for asthma management and prevention. Accessed June 6,2025. https://ginasthma.org/wp-content/uploads/2022/07/GINA-Main-Report-2022-FINAL-22-07-01-WMS.pdf

4. 2022 global strategy for prevention, diagnosis, and management of COPD. Global Initiative for Asthma. Updated 2022. Accessed June 6, 2025. https://goldcopd.org/2022-gold-reports/

5. Amin AN, Ganapathy V, Roughley A, Small M. Confidence in correct inhaler technique and its association with treatment adherence and health status among US patients with chronic obstructive pulmonary disease. Patient Prefer Adherence. 2017;11:1205-1212. doi:10.2147/PPA.S140139

6. Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team (ADMIT). Systematic review of errors in inhaler use: has patient technique improved over time?. Global Initiative for Chronic Obstructive Lung Disease.Chest. 2016;150(2):394-406. doi:10.1016/j.chest.2016.03.041

7. Cataldo D, Hanon S, Peché RV, et al. How to choose the right inhaler using a patient-centric approach? Adv Ther. 2022;39(3):1149-1163. doi:10.1007/s12325-021-02034-9

8. Robio MC, Teppa PJA, Hermosa JLR, et al. Insights from real-world evidence on the use of inhalers in clinical practice. J Clin Med. 2025;14(4):1217. doi:10.3390/jcm14041217

9. Molimard M, Raherison C, Lignot S, et al. Chronic obstructive pulmonary disease exacerbation and inhaler device handling: real-life assessment of 2935 patients. Eur Respir J. 2017;49(2):1601794. doi:10.1183/13993003.01794-2016

10. Leving MT, Kocks J, Bosnic-Anticevich S, Dekhuijzen R, Usmani OS. Relationship between peak inspiratory flow and patient and disease characteristics in individuals with COPD–a systematic scoping review. Biomedicines.2022;10(2):458. doi:10.3390/biomedicines10020458

11. Kocks JWH, Chrystyn H, van der Palen J, et al. Systematic review of association between critical errors in inhalation and health outcomes in asthma and COPD. NPJ Prim Care Respir Med. 2018;28(1):43. doi:10.1038/s41533-018-0110-x

12. Price DB, Román-Rodríguez M, McQueen RB, et al. Inhaler errors in the CRITIKAL study: type, frequency, and association with asthma outcomes. J Allergy Clin Immunol Pract. 2017;5(4):1071-1081.e9. doi:10.1016/j.jaip.2017.01.004

13. Volerman A, Toups MM, Hull A, Press VG. Does inhaler technique align with confidence among African-American children and their parents?. Ann Allergy Asthma Immunol. 2019;123(1):100-101. doi:10.1016/j.anai.2019.04.012

14. Volerman A, Kan K, Carpenter D, Press VG. Strategies for improving inhalation technique in children: a narrative review. Patient Prefer Adherence. 2021;15:665-675. doi:10.2147/PPA.S267053

15. Holley S, Morris R, Knibb R, et al. Barriers and facilitators to asthma self-management in adolescents: a systematic review of qualitative and quantitative studies. Pediatr Pulmonol. 2017;52(4):430-442. doi:10.1002/ppul.23556

16. Press VG, Arora VM, Trela KC, et al. Effectiveness of interventions to teach metered-dose and Diskus inhaler techniques: a randomized trial. Ann Am Thorac Soc. 2016;13(6):816-824. doi:10.1513/AnnalsATS.201509-603OC

17. Mahdavi H, Esmaily H. Impact of educational intervention by community pharmacists on asthma clinical outcomes, quality of life and medication adherence: a systematic review and meta-analysis. J Clin Pharm Ther. 2021;46(5):1254-1262. doi:10.1111/jcpt.13419

18. Gardenhire DS, Burnett D, Strickland S, Myers TR. A guide to aerosol delivery devices for respiratory therapists. American Association for Respiratory Care. 2017. Accessed June 6, 2025. https://www.aarc.org/wp-content/uploads/2015/04/aerosol_guide_rt.pdf

19. Bosnic-Anticevich S, Bakerly ND, Chrystyn H, Hew M, van der Palen J. Advancing digital solutions to overcome longstanding barriers in asthma and COPD management. Patient Prefer Adherence. 2023;17:259-272. doi:10.2147/PPA.S385857