The Wall Street Journal

Many Asthma Patients Use Their Inhalers Incorrectly, Research Shows
They hold it wrong, breathe at the wrong time, or forget to shake the device

Inhaler Users’ Biggest Mistakes
Many people who take medicine for asthma and other lung disease patients are using inhalers incorrectly, new studies show. WSJ’s Sumathi Reddy explains on Lunch Break with Tanya Rivero. Photo: iStock

By Sumathi Reddy
March 6, 2017
When it comes to proper inhaler use, mistakes are the norm.

The process of using the medicine-delivery devices requires multiple steps and studies have found that patients make at least one mistake as much as 70% to 90% of the time. The result: only about 7% to 40% of drugs is delivered to the lungs.

Metered-dose inhalers are among the most commonly used devices for treating respiratory diseases. The devices deliver specific amounts of medication to the lungs with each spray breathed in.

“We see all kinds of errors in the clinic,” said Nick Hanania, an associate professor of medicine-pulmonary at Baylor College of Medicine in Houston, Texas.


People get less medicine by using their metered-dose inhalers improperly.

Not shaking it. Guidelines recommend shaking it before each puff. Doctors say often patients shake before the first puff but not subsequent ones. Shaking is what mixes the propellant and medicine.
Orientation. Inhalers should be held upright. Some patients hold them at angles or lean in too far which can cause the medicine to stick to the tongue or mouth instead of going down the airway to the lungs.
Coordination with breath. Patients are instructed to start inhaling slowly before activating the inhaler. Some patients wait too long before activating it or activate it before breathing.
Breathing in too quickly. Some patients take short breaths and stop, rather than breathing in slowly and deeply.
Holding the breath. Patients are supposed to hold their breath for five to 10 seconds before exhaling to let the medication settle in the lungs. Many exhale too quickly.
Spacing. Not everyone waits the recommended 15 to 30 seconds before taking the next puff.
Dr. Hanania said his patients with respiratory conditions like chronic obstructive pulmonary disease (COPD) and asthma frequently do everything from forgetting to shake their inhaler to exhaling too quickly to forgetting to hold their breath at the proper moment.

To zero in on the most common errors and how they affect the amount of medicine delivered to patients’ lungs, Dr. Hanania and electrical engineers at Rice University co-authored a recent study that looked at metered-dose inhaler use.

In the first experiment—presented and published last year as part of the annual pulmonary conference CHEST—Dr. Ashutosh Sabharwal, a professor of electrical and computer engineering at Rice and senior author of the two studies, and Dr. Hanania and other researchers put sensors on the metered-dose inhalers used by 23 asthma and COPD patients. They were able to track the number of shakes made, the force of each shake, breathing rates, when the inhaler was activated, and other parameters.

The data recorded by the sensors showed that everyone made at least one error and 74% of patients made at least three. About half of the patients didn’t shake the inhaler before use properly or at all. There was also a large variation in how fast or deeply patients breathed.

In a study published in the Journal of Aerosol Medicine and Pulmonary Drug Delivery last month the researchers modeled how much medicine was reaching the lungs by measuring the airflow characteristics from eight patients. ​They then used the data to program a​ lung simulator​ with a robotic finger ​to ​generate​ the different patterns of human inhalation.

The researchers made some of the errors made by the human patients to see how they impacted the delivery of medication. The key finding: coordination was the biggest and most serious error. When using a MDI patients are instructed to start breathing and then to press or activate the inhaler. “Even half-a-second late in inhaling and you press the inhaler too soon you get only 20% of the medication,” said Dr. Sabharwal.

The second most damaging error wasn’t breathing deeply enough, which can cause 5 to 10% less medicine to reach the lungs.

The study was funded with National Institutes of Health funding from Cognita Labs, which Dr. Sabharwal is co-founder of. The Houston-based company developed the sensor used in the pilot study presented at the CHEST meeting.

He said coordinating the pressing and breathing and exhaling is particularly difficult for certain populations, such as children, the elderly and individuals with cognitive impairments. Spacer devices—a tube that is attached to the inhale to aid in medicine delivery—are often recommended for such patients.

Inhaler checks with patients often go by the wayside because of lack of time, says MeiLan Han, associate professor of the division of pulmonary and critical care medicine at the University of Michigan Health System in Ann Arbor.

She noted that a recent update of recommendations from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) emphasized the importance of rechecking inhaler technique use with patients.

One of the factors being evaluated now she said are ways to keep COPD patients from being hospitalized. “Now I’m trying to make a conscious effort to talk to the patient about their inhalers,” she said.

Write to Sumathi Reddy at

Corrections & Amplifications
An earlier version of this article incorrectly spelled Dr. Ashutosh Sabharwal’s name. (March 7, 2017)

Appeared in the March 7, 2017, print edition as ‘Inhalers Aren’t Always Effective INHALER.

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By | 2017-11-09T15:06:07+00:00 June 22nd, 2017|News|0 Comments

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