Are you using your asthma inhaler correctly?

Why technique matters more than the medicine

An inhaler is not a perfume spray. The drug particles have to travel past the tongue and the back of the throat, stay suspended in the air you breathe in, and settle deep in the small airways where the inflammation actually lives. If the timing of the press and the breath do not match, most of the dose lands on the tongue and the back of the throat, gets swallowed, and does nothing for the lungs.

This is why a patient can be on a perfectly appropriate inhaled corticosteroid and still wheeze at night. At the clinic we routinely see symptom control improve dramatically after a ten-minute technique correction, with no change in prescription at all.

The correct 5-step technique for a metered dose inhaler (MDI)

This applies to the familiar pressurised canister-in-a-plastic-boot inhalers such as Asthalin, Seroflo, Foracort and Budecort.

• Shake and prepare. Shake the inhaler for 5 seconds and remove the cap. Sit or stand upright — never lying down. If it is a new inhaler or has not been used for a week, fire one puff into the air first.
• Breathe out fully. Exhale gently and completely, away from the mouthpiece, until your lungs feel empty. This is the step patients skip most often, and it is the one that makes the most difference — you cannot draw a deep breath in if your lungs are already half full.
• Seal and press together. Place the mouthpiece between your teeth and close your lips tightly around it. Start a slow, deep breath in and, just after you begin breathing in, press the canister once. The press and the breath must overlap.
• Keep breathing in slowly. Continue that same slow, deep breath for 4–5 seconds. Slow is essential — a sharp, fast suck makes the particles slam into the back of the throat instead of flowing into the airways.
• Hold for 10 seconds. Take the inhaler out, close your mouth and hold your breath for up to 10 seconds, then breathe out gently. This lets the fine particles settle onto the airway lining instead of being blown straight back out.

The seven mistakes we see every single week

• Not breathing out before the puff — the single most common error.
• Pressing the canister before, or long after, starting to breathe in.
• Breathing in fast and hard instead of slow and deep.
• Not holding the breath afterwards, so the particles are exhaled again.
• Tilting the head back, which closes off the airway angle.
• Using an empty inhaler. Patients often keep using a canister for weeks after the drug has run out because it still hisses — the propellant lasts longer than the medicine. Count your doses or use a dose counter.
• Not rinsing the mouth after a steroid inhaler, which leads to oral thrush and a hoarse voice.

When you should be using a spacer

A spacer is a plastic chamber that sits between the inhaler and your mouth. You fire the puff into the chamber and then breathe it in over a few normal breaths, which removes the need for perfect press-and-breathe coordination entirely.

A spacer roughly doubles the amount of drug reaching the lungs and significantly reduces throat irritation and thrush. We strongly recommend one for all children, for anyone over 60, during an acute attack when you are too breathless to coordinate, and for any adult who repeatedly struggles with the timing. A spacer is inexpensive and, honestly, under-prescribed in India.

Dry powder inhalers work differently

Rotahalers, Revolizers and similar dry powder devices need the opposite of a slow breath — they need one quick, forceful, deep suck to break up the powder, and they must never be used with a spacer. If you have been switched between device types, ask to be re-taught, because the technique does not transfer.

How to check whether your technique is actually working

Good signs: you need your reliever (blue) inhaler less than twice a week, you sleep through the night without coughing, you can climb stairs or walk fast without wheezing, and you have had no course of oral steroids in the past year.

Warning signs that technique or treatment needs review: reliever use on most days, waking at night with cough or tightness, symptoms after mild exertion, or more than one flare-up a year. Any of these deserves a review with a pulmonologist rather than simply increasing the dose.

Frequently asked questions

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