Inhaler technique is the single most important determinant of whether an inhaled medicine reaches the lungs in sufficient quantity to work. Yet studies consistently show that between 70% and 90% of inhaler users make at least one critical error — a figure that has remained stubbornly stable for decades despite advances in device design, according to a systematic review published in the Journal of Allergy and Clinical Immunology.
Community pharmacists are uniquely positioned to identify and correct technique errors. Unlike GP consultations, which are time-pressured and appointment-based, pharmacy interactions happen at the point of dispensing — exactly when the patient has the device in hand.
Why technique matters more than the drug
NICE guideline NG80 (Asthma: diagnosis, monitoring and chronic asthma management) and the BTS/SIGN guideline on asthma management both emphasise that poor inhaler technique should be assessed and corrected before stepping up treatment. The clinical logic is straightforward: if a patient is not getting the drug into their lungs, increasing the dose or adding a second controller medicine will not help — and may add unnecessary side effects and cost.
The National Review of Asthma Deaths (NRAD, 2014) found that inadequate inhaler technique was a contributing factor in a significant proportion of asthma deaths reviewed. The report recommended that inhaler technique should be checked at every opportunity by every healthcare professional.
Common errors by device type
Metered-dose inhalers (MDIs)
MDIs are the most commonly prescribed inhaler type in the UK. They require coordination between pressing the canister and breathing in — a skill that many patients never master.
Critical errors pharmacists check for:
| Error | Why it matters | How to correct |
|---|---|---|
| Not shaking before use | Dose may be subtherapeutic | Shake 4-5 times before each actuation |
| Breathing in too fast | Drug impacts on the oropharynx instead of reaching the lungs | Slow, steady breath in over 3-5 seconds |
| Poor coordination (press-breathe timing) | Most of the dose is lost to the mouth and throat | Use a spacer, or switch to a breath-actuated device |
| Not holding breath | Drug is exhaled before deposition | Hold breath for 10 seconds (or as long as comfortable) after inhalation |
| Not waiting between puffs | Second dose is subtherapeutic | Wait 30-60 seconds between actuations |
Spacer use. NICE recommends that all patients using an MDI with an inhaled corticosteroid should use a spacer. Spacers eliminate the need for press-breathe coordination, reduce oropharyngeal deposition (and therefore oral thrush and dysphonia), and increase lung deposition. Despite this, spacer prescribing remains inconsistent. Pharmacists should check whether a spacer has been prescribed and, if not, suggest it to the prescriber.
Dry powder inhalers (DPIs)
DPIs (Turbohaler, Accuhaler, Ellipta, Easyhaler, NEXThaler) are breath-actuated and do not require coordination. However, they require a forceful inspiratory effort — which can be a problem for patients with severe airflow limitation, young children or elderly patients.
Critical errors:
- Breathing in too slowly. DPIs need a fast, deep breath to disaggregate the powder. Coach patients to "breathe in hard and fast, like sucking through a straw."
- Exhaling into the device. Moisture from exhaled breath can clump the powder. Always breathe out away from the mouthpiece before inhaling.
- Not holding the device in the correct orientation. Some DPIs (e.g. Turbohaler) must be held upright during loading.
Soft mist inhalers (Respimat)
The Respimat produces a slow-moving aerosol mist that is easier to coordinate with breathing than an MDI. The main errors are failing to prime the device (first use or after non-use for more than 3 days) and not breathing in slowly enough.
What a pharmacy technique review involves
A structured inhaler technique review typically takes 5–10 minutes and follows these steps:
- Ask the patient to demonstrate their technique with their own device. Do not describe technique first — you need to see their actual habits, not a coached performance.
- Observe and note errors using a standardised checklist (available from the UK Inhaler Group at rightbreathe.com or Asthma + Lung UK).
- Correct errors one or two at a time. Trying to fix everything at once is counterproductive — focus on the critical errors first.
- Demonstrate the correct technique yourself, then ask the patient to repeat.
- Check understanding — can the patient explain the key steps back to you?
- Document the review in the patient's PMR and communicate findings to the prescriber if a device switch or spacer addition is needed.
When to recommend a device switch
If a patient consistently fails to achieve adequate technique with their current device — particularly coordination with an MDI — pharmacists can recommend to the prescriber:
- MDI → MDI + spacer (simplest change, maintains the same drug)
- MDI → breath-actuated MDI (e.g. Autohaler, Easi-Breathe)
- MDI → DPI (if inspiratory flow is adequate)
- DPI → soft mist inhaler (if inspiratory flow is inadequate for DPI)
The choice should consider the patient's manual dexterity, inspiratory capacity, preference and — increasingly — the environmental impact. DPIs have a significantly lower carbon footprint than MDIs (which use hydrofluorocarbon propellants), and NICE has recommended considering environmental impact alongside clinical factors when choosing inhalers.
NHS services that support technique reviews
New Medicine Service (NMS). Inhaled corticosteroids for asthma are NMS-eligible. The structured follow-up contacts provide an ideal opportunity to check technique. See: New Medicine Service Explained
Pharmacy First consultations. While Pharmacy First focuses on acute conditions, pharmacists conducting consultations for respiratory symptoms may identify patients whose asthma control is poor due to technique errors.
Structured medication reviews (SMRs). PCN pharmacists conducting SMRs routinely review inhaler technique as part of the respiratory medicines optimisation pathway.
The evidence for pharmacy technique reviews
A Cochrane review of inhaler technique education interventions found that technique training improved correct technique scores and, in some studies, improved clinical outcomes including reduced exacerbations. The evidence is strongest for face-to-face demonstration and teach-back methods — exactly the approach used in pharmacy.
Asthma + Lung UK estimates that poor inhaler technique contributes to approximately 60% of the £1.1 billion annual NHS cost of asthma care in the UK. Even modest improvements in technique across the pharmacy network could have substantial impact on both patient outcomes and healthcare costs.
Pharmacists interested in respiratory or clinical roles can explore current opportunities through PharmSee's job search, which tracks vacancies across 11 sources including NHS Jobs, where respiratory specialist posts are regularly listed.
Sources
- NICE NG80: Asthma — diagnosis, monitoring and chronic asthma management (updated 2024).
- BTS/SIGN Guideline on the management of asthma (SIGN 158), 2019.
- National Review of Asthma Deaths (NRAD), Royal College of Physicians, 2014.
- Sanchis J et al. Systematic review of errors in inhaler use. Journal of Allergy and Clinical Immunology, 2016.
- UK Inhaler Group. rightbreathe.com.
- Asthma + Lung UK. Inhaler technique resources, 2024.
- PharmSee pharmacy data: pharmsee.co.uk.