Published: 2017-07-26

Incorrect inhaler techniques in Western India: still a common problem

Mandeep Kaur Sodhi


Background: To assess and evaluate the incorrect use of inhalers in patients with asthma and chronic obstructive pulmonary disease (COPD) in the outpatient department of pulmonary medicine at RUHS college of medical sciences Jaipur, Rajasthan, India.

Methods: Patients visiting the outpatient department of respiratory medicine were asked to demonstrate the inhaler technique and were assessed by the physician.

Results: The study included 200 patients with Asthma or COPD.  Among patients with COPD, 80 (63.4%) were males and 46 (36.5%) were females. In the asthma group, there were 50 (67.5%) females and 24 (32.4%) males. Patients with COPD were in the age group between 46-82 years with a mean age of 64 years while patients with asthma were in the age group between 18-70 years with a mean age of 44 years. Only 28 (14%) patients could perform all steps correctly in use of inhaler devices. 172 patients (86%) were unable to use inhalers properly. Most common error for metered dose inhalers (MDIs) was in step 7 that is (i.e.) not holding breath for 10 seconds which was seen in 46 patients (51.7%). The most common error seen for dry powder inhalers (DPIs) was in step 5 i.e. exhalation to residual volume before inhalation seen in 50 patients (47.1%).

Conclusions: This study revealed that majority of patients use the inhaler devices incorrectly. Proper education regarding inhaler use is crucial for effective treatment with use of these inhaler devices.


Asthma, Chronic obstructive pulmonary disease, Dry powder inhalers, Incorrect technique, Metered dose inhalers

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Global strategy for asthma management and prevention. Global initiative for asthma (Gina) 2017. Available at: Accessed: May 2017.

Global strategy for the diagnosis management and prevention of COPD. Global initiative for chronic obstructive lung disease (GOLD) 2014. Available from: Accessed: May 1 2017.

Gandevia B. Historical review of the use of Para sympatholytic agents in the treatment of respiratory disorders. Postgrad Med J. 1975;51(7):13-20.

Camps PWL. A note on the inhalation treatment of asthma. Guy’s Hosp Report. 1929;79:496-8.

Laube BL, Janssens HM, De Jongh FHC, Devadason SG, Dhand R, Diot P, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J. 2011;37:1308-31.

Wright J, Brocklebank D, Ram F. Inhaler devices for the treatment of asthma and chronic obstructive airways disease (COPD). Qual Saf Health Care. 2002;11(4):376-82.

Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011;105(6):930-8.

Hesselink AE, Penninx BWJH, Wijnhoven HAH, Kriegsman DM, Van Eijk JT. Determinants of an incorrect inhalation technique in patients with asthma or COPD. Scan J Prim Health Care. 2001;19:255-60.

Pedersen S, Frost L, Arnfred T. Errors in inhalation technique and efficiency in inhaler use in asthmatic children. Allergy. 1986;41:118-24.

Goren A, Noviski N, Avital A, Maayan C, Stahl E, Godfrey S, et al. Assessment of the ability of young children to use a powder inhaler device (turbuhaler). Pediatr Pulmonol. 1994;18:77-80.

Molimard M, Rahersion C, Lignot S, Depont F, Abouelfath A, Moore N. Assessment of handling of inhaler devices in real life: an observational study in 3811 patients in primary care. J Aerosol Med. 2003;16:249-54.

Diamond SA, Chapman KR. The impact of a nationally coordinated pharmacy-based asthma education intervention. Can Respir J. 2001;8:261-5.

Chorao P, Pereira AM, Fonseca JA. Inhaler devices in asthma and COPD. An assessment of inhaler technique and patient preferences. Respir Med. 2014;108(7):968-75.

Santus P, Picciolo S, Proietto A, Falcone F, Mangiacavallo A, Pellegrino G, et al. Doctor-patient relationship: a resource to improve respiratory diseases management. Eur J Int Med. 2012;23:442-6.

National Institute of Health. Guidelines for the diagnosis and management of asthma summary report. National asthma education and prevention program. Expert panel report 3: NIH Publication. 2007;59-60.

Jolly GP, Mohan A, Guleria R, Poulose R, George J. Evaluation of metered dose inhaler use technique and response to educational training. Indian J Chest Dis Allied Sci. 2015;57:17-20.

Poudel RS, Piryani RM, Shrestha S, Prajapati A. Benefit of hospital pharmacy intervention on the current status of dry powder inhaler technique in patients with asthma and COPD: a study from the central development region, Nepal. Integr Pharm Res Pract. 2017;6:7-13.

Souza ML, Meneghini AC, Ferraz E, Vianna EO, Borges MC. Knowledge of and technique for using inhalation devices among asthma patients and COPD patients. J Bras Pneumol. 2009;35:824-31.

Plaza V, Sanchis J. Medical personnel and patient skill in the use of metered dose inhalers: a multicentric study. CESEA Group. Respiration. 1998;65(3):195-8.

Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J. 2002;19(2):246-51.

Onyedum CC, Desalu OO, Nwosu NI, Chukwuka CJ, Ukwaja KN, Ezeudo C. Evaluation of Inhaler techniques among asthma patients seen in Nigeria: an observational cross-sectional study. Ann Med Health Sci Res. 2014;4(1):67-73.

Van Beerendonk I, Mesters I, Mudde AN, Tan TD. Assessment of the inhalation technique in outpatients with asthma or chronic obstructive pulmonary disease using a metered-dose inhaler or dry powder device. J Asthma. 1998;35:273-9.

Adeyeye OO, Onadeko BO. Understanding medication and use of drug delivery device by asthmatic in Lagos. West Afr J Med. 2008;27:155-9.

Pothirat C, Chaiwong W, Phetsuk N, Pisalthanapuna S, Chetsadaphan N, Choomuang W. Evaluating inhaler use technique in COPD patients. Int J Chron Obstruct Pulmon Dis. 2015;10:1291-8.

Poudel RS, Shrestha S, Bhatta P, Piryani RM. Do face-to-face training and telephonic reminder improve dry powder inhaler technique in patients with COPD? Int J Telemed Appl. 2017:2017.

Hindle M, Chrystyn H. Relative bioavailability of salbutamol to the lung following inhalation using metered dose inhalation methods and spacer devices. Thorax. 1994;49:549-53.

Price D, Bosnic-Anticevich S, Briggs A, Chrystyn H, Rand C, Scheuch G, et al. Inhaler error steering committee. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013;107:37-46.