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An estimated 1.2 million people in England have a diagnosed COPD, and the majority use at least one inhaler. Yet studies consistently show that between 50% and 80% of inhaler users make at least one critical error in their technique — errors that can reduce drug delivery to the lungs by as much as 90%. The community pharmacist, who sees these patients monthly at prescription collection, is uniquely positioned to identify and correct these problems.
Why device selection matters
COPD treatment guidelines from NICE (NG115) and GOLD (Global Initiative for Chronic Obstructive Lung Disease) recommend choosing an inhaler device based on the patient's ability to use it correctly, not solely on the drug it contains. A technically perfect prescription of a dry powder inhaler is clinically useless if the patient cannot generate the inspiratory flow rate needed to actuate it.
The three main device categories each demand different skills from the patient:
| Device type | How it works | Key patient requirement | Common examples |
|---|---|---|---|
| Metered dose inhaler (MDI) | Pressurised canister, manual actuation | Coordinate hand-breath timing | Ventolin Evohaler, Clenil, Fostair MDI |
| Dry powder inhaler (DPI) | Breath-actuated, no propellant | Generate sufficient inspiratory flow (≥30 L/min for most devices) | Turbohaler, Ellipta, HandiHaler, Easyhaler |
| Soft mist inhaler (SMI) | Slow-moving aerosol mist | Less coordination needed, but multi-step loading | Respimat |
Spacer devices attached to MDIs can reduce the coordination requirement substantially. NICE recommends offering a spacer to any patient who has difficulty with MDI technique.
The pharmacist's role in device selection
Community pharmacists cannot change a prescribed inhaler without the prescriber's agreement, but they can — and should — assess whether the patient can use the device they have been given. This assessment is part of the Medicines Use Review (MUR) service, the New Medicine Service (NMS), and any ad-hoc consultation at the dispensing counter.
Key checks include:
- Inspiratory flow assessment: can the patient breathe in hard and fast enough for a DPI? A simple check: ask the patient to inhale through the empty device and listen for the characteristic click or whistle. Devices like the In-Check DIAL allow pharmacists to measure peak inspiratory flow against the resistance profile of specific inhalers.
- Hand strength and dexterity: can the patient load the device, remove the cap, and hold it steady? Arthritis, tremor, and reduced grip strength are common in COPD patients and can make certain devices impractical.
- Cognitive load: how many steps does the device require? The Ellipta (three steps) is simpler than the HandiHaler (six steps). Patients with cognitive impairment or who manage multiple devices may benefit from consolidation onto a single device type.
- Technique observation: watching the patient use the device is the single most effective intervention. Verbal instruction alone corrects fewer errors than demonstration plus teach-back.
Common technique errors by device type
| Device | Most common error | Clinical consequence |
|---|---|---|
| MDI (without spacer) | Firing before or after the breath, not during | Drug deposits in mouth/throat instead of lungs |
| MDI (with spacer) | Multiple puffs into spacer before inhaling | Drug settles on spacer walls |
| Turbohaler | Not holding upright during loading | Dose not loaded into chamber |
| Ellipta | Exhaling into device before inhaling | Moisture clogs powder |
| HandiHaler | Not piercing capsule fully | No drug released |
| Respimat | Not turning base until click | Dose not primed |
Structured inhaler reviews in community pharmacy
NICE quality standard QS10 (COPD) states that people with COPD should have their inhaler technique checked at every review. In practice, the most systematic community pharmacy touchpoint is the annual COPD review, but pharmacists can also intervene at each dispensing.
A structured approach:
- Ask the patient to demonstrate their technique with their own device
- Identify errors against the device-specific checklist
- Correct using physical demonstration (placebo devices are ideal)
- Use teach-back: ask the patient to repeat the corrected technique
- Document the intervention and flag to the GP if a device switch is needed
When to recommend a device switch
The pharmacist should contact the prescriber to recommend a device change when:
- The patient consistently fails to generate adequate inspiratory flow for a DPI despite training
- Arthritis or tremor prevents reliable device loading
- The patient is on three or more different device types, increasing the risk of technique confusion
- A hospitalisation for COPD exacerbation suggests current therapy is not reaching the lungs
Where to explore further
Pharmacists can use PharmSee's job search to explore respiratory pharmacist roles across the NHS, or browse pharmacy listings by area to understand local COPD service provision. The salary section provides context on how respiratory specialist roles compare to generalist pharmacist positions.
Caveats
Inhaler technique assessment is a clinical skill that benefits from formal training. The UK Inhaler Group (UKIG) provides device-specific technique checklists and training resources. The error rates cited above are drawn from published systematic reviews and may vary by population. Any recommendation to change a patient's inhaler device should be communicated to the prescriber and documented.
Sources
- NICE NG115: Chronic Obstructive Pulmonary Disease in Over 16s (2018, updated 2019)
- GOLD 2026 Report: Global Strategy for the Diagnosis, Management and Prevention of COPD
- UK Inhaler Group: Inhaler Standards and Competency Document
- Crompton GK et al., "The need to improve inhalation technique in Europe", Respiratory Medicine (2006)
- PharmSee vacancy database, 1,715 active roles as at 15 April 2026