Inhaling correctly with asthma and COPD: the guide

Inhaled medications are the basis of treating asthma and COPD — they bring the active ingredient to where it is needed: into the lungs. But a considerable proportion of patients inhale incorrectly — and the medication therefore works less well. Inhalation technique is the most common application error in airway therapy.

1. Why the correct inhalation technique is so important

With inhaled medications, the technique decides whether the active ingredient reaches the lungs at all. If you inhale incorrectly, a large part stays in the mouth and throat or is swallowed — and does not work there.^¹

• The most common application error: studies show that many patients — even long-term ones — do not use their inhalers correctly
• Consequence: the medication works less well, asthma or COPD control suffers, even though it is "actually" being treated
• Apparent treatment failure: often it is not the medication but the technique — before the dose is increased, the technique should be checked
• Easy to learn: the correct technique is no magic — with guidance and a little practice it works reliably

The good news: inhalation technique can be learned and improved. Even small corrections can make a big difference. That is why it is worth checking your own technique regularly — even if you have been inhaling for a long time.

2. Controller and reliever: what is inhaled when?

Before it comes to technique, it is important to understand what you inhale. With asthma and COPD there are two fundamentally different kinds of inhaled medication:^¹

• Controller (maintenance medication): anti-inflammatory (e.g. inhaled cortisone such as budesonide) — must be used regularly, even without complaints, and works preventively over days/weeks
• Reliever (as-needed/emergency medication): a fast-acting bronchodilator (e.g. salbutamol) — quickly widens the bronchi in an acute case and relieves acute shortness of breath
• Combination preparations: some inhalers contain both (e.g. cortisone plus a long-acting bronchodilator)

This distinction is important: the controller is inhaled regularly according to a plan, the reliever as needed. Both require the correct inhalation technique. More on the controller principle in the guide to cortisone and on the pages about budesonide and salbutamol.

3. The different inhaler types

There are various inhaler systems that differ clearly in their use. It is important to know your own type and its correct technique:

• Metered-dose inhaler (spray, "propellant inhaler"): releases a puff at the press of a button — requires the coordination of triggering and inhaling (its own chapter)
• Dry powder inhaler: contains the active ingredient as a powder that is carried along by inhaling forcefully — no spray coordination needed, but a forceful breath (its own chapter)
• Spacer (inhalation aid): a chamber placed between the metered-dose inhaler and the mouth that makes use considerably easier (its own chapter)
• Nebulizer: converts liquid medication into a fine mist that is inhaled through a mask/mouthpiece — mainly in the clinic or in severe cases

The exact technique depends on the device type. When it is prescribed, have your specific device explained to you in detail and the use demonstrated — and practise it. In the following we go through the most common types.

4. Using a metered-dose inhaler (spray) correctly

The metered-dose inhaler is widespread, but also error-prone — because triggering the puff and inhaling have to be coordinated. Here is how to do it right:

1. Shake: shake the metered-dose inhaler well before use, remove the protective cap.
2. Sit or stand upright and breathe out fully — not into the device.
3. Close around the mouthpiece: close your lips firmly around the mouthpiece, head slightly back.
4. Breathe in slowly and deeply and at the same time trigger the puff — the coordination is crucial.
5. Keep breathing in slowly and deeply until the lungs are filled.
6. Hold your breath (about 10 seconds, or as long as comfortably possible), so the active ingredient settles in the lungs.
7. Breathe out slowly — not into the device.
8. For a further puff: wait about 30 seconds, then repeat.

The hardest part is the coordination of triggering and inhaling. Anyone who has problems with this (e.g. children, older people, during an acute attack) benefits enormously from a spacer (next chapter), which makes this coordination unnecessary. With cortisone-containing sprays, rinse your mouth afterwards.

5. The spacer: the underestimated inhalation aid

The spacer (inhalation aid) is one of the most effective and most underestimated aids for inhaling with a metered-dose inhaler. It is a chamber placed between the spray and the mouth:^¹

• No coordination needed: the puff is released into the chamber, from which you then inhale calmly — this solves the biggest problem with the metered-dose inhaler
• More active ingredient in the lungs: a larger part of the medication actually reaches the lungs instead of the mouth-throat area
• Fewer side effects in the mouth: with cortisone sprays, less stays in the mouth — this reduces oral thrush and hoarseness
• Especially valuable for: children (with a mask), older people, people with coordination problems and during an acute attack
• Use: shake the spray, insert it into the spacer, release one puff and then calmly breathe in and out from the spacer (several breaths)

6. Using a dry powder inhaler correctly

With a dry powder inhaler, the active ingredient is drawn into the lungs as a fine powder by your own breath. The technique differs from the metered-dose inhaler — here no spray coordination is needed, but a forceful, deep breath:

1. Prepare: prepare/load the inhaler depending on the model (e.g. activate the dose) — hold it upright so the powder does not fall out.
2. Breathe out: breathe out fully before inhaling — but NOT into the inhaler (moisture would clump the powder).
3. Close around the mouthpiece and breathe in forcefully, deeply and quickly — the powder is carried along by the breath.
4. Hold your breath (about 10 seconds), then breathe out slowly — not into the inhaler.
5. Check: depending on the model, check whether the dose has been taken (dose counter).

The most important difference: with the metered-dose inhaler you breathe in slowly, with the dry powder inhaler forcefully and quickly. A breath that is too weak is the most common mistake with the dry powder inhaler — the powder then does not reach deep enough into the lungs. Here too: never breathe out into the device, and with cortisone rinse your mouth afterwards.

7. The most common inhalation mistakes

These mistakes occur most often — and can all be avoided:

• With the metered-dose inhaler: poor coordination of triggering and inhaling (a spacer helps).
• Not breathing out before inhaling — the lungs are then not ready to take it in.
• Breathing out into the device — clumps the powder in the dry powder inhaler.
• Breathing in too weakly with the dry powder inhaler — the powder does not reach the lungs.
• Breathing in too fast/hastily with the metered-dose inhaler — the active ingredient settles in the throat.
• Not holding the breath after inhaling — the active ingredient cannot settle.
• Not shaking the metered-dose inhaler — the active ingredient is then not evenly distributed.
• Not rinsing the mouth after cortisone (risk of oral thrush/hoarseness).
• Operating the wrong device type incorrectly — each design has its own technique.
• Continuing to use an empty device — without noticing that no active ingredient is released any more.

8. Rinsing the mouth: why it matters

A simple but important step — above all after inhaling cortisone (e.g. budesonide). Part of the active ingredient stays in the mouth and throat and can cause side effects there:

• Oral thrush (fungal infection): whitish coatings in the mouth/throat, encouraged by the cortisone
• Hoarseness and voice changes
• The solution: after inhaling cortisone, rinse your mouth with water (and spit it out, do not swallow) or eat/drink something; schedule the inhaling before brushing your teeth
• A spacer additionally reduces the amount that stays in the mouth

This small routine prevents the most common local side effects of inhaled cortisone. With pure bronchodilators (relievers), rinsing the mouth is less critical, but does no harm. More on this on the page about budesonide.

9. Inhaling in children

In children with asthma, correct inhalation is especially important — and especially challenging, because coordination is difficult. Here the spacer is almost always the solution:

• Spacer with a mask for small children/infants: the child simply breathes calmly through the mask while the spray is released into the spacer
• Spacer with a mouthpiece for older children who can already cooperate
• Calm and playful: avoid stress, build the inhaling into a routine
• Rinse the mouth / drink something after cortisone — with small children, possibly let them drink something after inhaling
• Practise the technique with the parents: involve and train the carers (daycare, school)

Parents should have the technique shown to them in detail and check it regularly. A well-fitting spacer with a mask is what makes inhaling reliably possible for small children in the first place. The paediatrician discusses the age-appropriate dose and device choice.

10. Inhaling in older people

Older people too often have difficulties with the inhalation technique — through declining coordination, strength or cognitive limitations:

• Coordination problems with the metered-dose inhaler: a spacer helps, because it makes the coordination unnecessary
• Too weak a breath with the dry powder inhaler: with clearly limited breathing strength, a metered-dose inhaler with a spacer is often more suitable
• Adjust the device choice: the doctor can choose a device suited to the individual's abilities
• Check the technique regularly: even long-term users often make mistakes
• Involve support: relatives or care staff can help with inhaling

Choosing the right inhaler type is especially important in older people — not every device suits everyone. If use is difficult, this should be discussed with the doctor instead of doing it "somehow". Often there is a more suitable system.

11. Care and hygiene of the inhaler

A clean inhaler works better and is more hygienic. The care is simple, but often forgotten:

• Clean regularly: clean the mouthpiece according to the manufacturer's instructions (often wipe dry; some parts with water — observe the manufacturer's instructions)
• Metered-dose inhaler: clean the mouthpiece regularly so it does not clog
• Clean the spacer: clean regularly according to the instructions (often with mild washing-up liquid, let it air-dry — do not rub it dry, this can build up static)
• Keep dry powder inhalers as dry as possible — no moisture into the device
• Keep an eye on the fill level/dose counter: reorder in good time, replace empty devices
• Note the shelf life — also after opening (manufacturer's instructions)

A dirty or clogged mouthpiece can impair the release of the active ingredient. The exact cleaning instructions are in the instructions for use of the respective device — the devices differ here.

12. When the technique should be checked

The inhalation technique should be checked regularly — not only at the start:

• At the first prescription: have the technique shown in detail and practise it
• At every change of device: a new inhaler type often requires a different technique
• With poor disease control: check the technique before the therapy is changed
• Regularly (e.g. yearly): mistakes creep in even with experienced users
• In children and older people: check more often
• At the pharmacy or doctor: have the technique shown and checked

A short check of the technique costs little time, but can clearly improve the effect of the therapy. Do not be shy about asking at the pharmacy or doctor and having the use shown to you — that is a normal and sensible part of the treatment.

13. How brite helps you with inhaling

An inhalation therapy has a few pitfalls: the controller has to be taken regularly (even without complaints), rinsing the mouth after cortisone is easily forgotten, and high reliever use is a warning sign. This is exactly where brite comes in:

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