"The inhaler does not work for me any more." It is one of the commonest things said in a chest clinic, and in the large majority of cases the inhaler is working perfectly — the medicine is simply not reaching the lungs. Studies of inhaler technique consistently find that most people using one make at least one error that substantially reduces the delivered dose.
This is worth taking seriously, because the alternative to a working inhaler is an attack.
1. Breathing in too fast, or not at all
Different devices need opposite things, which is where most of the confusion comes from.
A metered-dose inhaler — the small pressurised canister in a plastic boot — needs a slow, deep breath, started just before you press. Breathe in fast and the spray hits the back of your throat and stops there. You can often taste it, which is the sign that it did not go in.
A dry-powder inhaler — a Rotahaler, Revolizer, Multihaler and similar — needs the opposite: a quick, forceful breath, because your own effort is what lifts and breaks up the powder. Breathe in gently and much of the dose stays in the device.
If nobody has told you which type you have, that alone may be the problem.
2. Not holding your breath afterwards
After breathing in, hold for about ten seconds, or as long as is comfortable. This is what lets the particles settle onto the airway wall instead of being blown straight back out. Breathing out immediately wastes a large part of a dose that otherwise went in correctly. It is the single easiest fault to fix.
3. Not using a spacer
A spacer is the plastic chamber that a metered-dose inhaler fits into. It slows the spray down and lets the propellant evaporate, so far more of the drug reaches the lungs and far less lands in your mouth. It also removes the need to coordinate pressing and breathing, which is the hardest part.
For children a spacer is not optional — with a mask for the youngest. Many adults who find a plain inhaler difficult would do much better with one too. They are inexpensive and they work.
4. Confusing the preventer with the reliever
This is the most consequential mistake of all, and it is very common.
A reliever (usually salbutamol, often blue) opens a narrowed airway within minutes. It treats the symptom. It does nothing to the underlying inflammation.
A preventer (an inhaled steroid, alone or combined with a long-acting bronchodilator) reduces the inflammation that makes the airway narrow in the first place. It does nothing noticeable today. It is what keeps you well in three weeks' time.
People feel the reliever working and not the preventer, and conclude that the reliever is the real medicine. So the preventer gets stopped as soon as they feel well — which is exactly when it is doing its job. Then symptoms return, the reliever is needed more and more, and the conclusion drawn is that "the inhaler has stopped working".
Needing your reliever more than twice a week is not a sign that it has stopped working. It is a sign that your preventer needs reviewing.
5. An empty or expired device
Many inhalers do not reliably tell you when they are finished, and a nearly empty canister still sprays — it just sprays propellant. If yours has a dose counter, use it. If not, count roughly: an inhaler taken twice daily lasts about two months at 120 doses. Check expiry dates, and do not keep a reliever in a hot car or a humid bathroom for a year as your emergency supply.
Check your own technique in one minute
Do this honestly and you will find most problems yourself.
- Can you taste or feel the spray at the back of your throat? If yes, it is going too fast or you are not using a spacer.
- Do you breathe out fully before starting? Most people do not.
- Do you hold your breath for about ten seconds afterwards?
- For a metered-dose inhaler, do you press once, take one breath, then wait thirty seconds before the second puff? Two puffs in one breath wastes the second.
- After an inhaled steroid, do you rinse your mouth and spit? This prevents oral thrush and hoarseness.
- Do you know which of your inhalers is the preventer and which is the reliever, by name?
Bring your inhalers to the appointment
Not the names on a piece of paper — the actual devices. We will ask you to use them in front of us, and correct what we see. It takes two minutes and it is one of the most useful things that happens in a consultation about asthma or COPD. A change of technique often achieves what a change of drug was about to be prescribed for.
Frequently asked questions
How do I know whether my inhaler is the preventer or the reliever?
Ask, and have it written down. As a rough guide, a reliever is taken only when you need it and works within minutes; a preventer is taken every day whether or not you have symptoms. If in doubt, bring both devices in.
Can I use my reliever as often as I need it?
It is safe in an emergency, which is the point of it. But needing it more than about twice a week means your asthma is not controlled, and the answer is to review the preventer rather than to keep using more reliever.
Is a spacer really necessary for an adult?
Not always, but it delivers more of the dose to the lungs and removes the coordination problem. If your technique is imperfect — and most people's is — a spacer helps. For children it is essential.
Why do I have to rinse my mouth after the preventer?
Inhaled steroid left in the mouth can cause oral thrush and a hoarse voice. Rinsing and spitting after each dose prevents both and takes a few seconds.
My inhaler still sprays, so is it still full?
No. A nearly empty canister continues to spray propellant with little or no drug in it. Use the dose counter if there is one, or track roughly how long it should last.