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An inhaler is only as good as the technique used with it. When the steps go wrong, most of the dose lands in the mouth and throat instead of the lungs — so the medicine seems "not to work", even at the right dose. The good news: the errors are common, predictable, and fixable. This guide covers the steps every inhaler shares, why a spacer should be your default with a puffer, what changes for other devices (how fast you breathe in), and how to check your own technique. For the exact steps for your device, tap it on the Puffers & Inhalers page.
Why technique matters more than you think
Inhaler technique is one of the most under-recognised reasons that breathing treatment underperforms. Study after study finds that a large share of people make at least one error that reduces how much medicine reaches the lungs, and that these errors are linked to worse symptom control and more flare-ups.1,2
Technique also drifts over time — someone taught perfectly at diagnosis often slips within months — which is why a periodic check matters as much as the first lesson.3
The steps every inhaler shares
Devices differ in how you load and fire them, but almost all share the same core sequence. Get these right and you are most of the way there:
1 · Where possible, always use a spacer
If you use a pressurised puffer (pMDI), the single best step you can take is use it with a spacer whenever you can. A spacer is a clear chamber that clips onto the puffer: you fire one puff into it and then breathe the mist out of the chamber, so the timing no longer has to be perfect. Spacers give the best deposition of the medicine in the lungs of any puffer method — they get more drug where it is needed, leave far less in the mouth and throat, and cut the side-effects of steroid puffers — they are recommended for most puffer users, and for everyone during a flare-up.4
Do one puff at a time — never fire two puffs into the spacer together.
Shake the puffer, fit it into the spacer, seal your lips around the mouthpiece and fire one puff into the chamber.
Breathe in and out through the spacer with six normal-size breaths — relaxed, tidal breaths, not big forced ones.
If a second puff is prescribed, fire the next puff and take another six normal breaths. Continue one puff at a time.
Six relaxed breaths per puff clears the mist from the chamber and suits everyone — including children, older adults and anyone who is breathless or unwell. (An older, capable adult may instead take one slow, deep breath per puff and hold it for about 6 seconds, but the six-breath method is the reliable default.) See Puffer with a Spacer for the full step-by-step, including how to clean and prime the chamber.
2 · Other devices
If you do not have a spacer, or you use a different type of inhaler, the speed of the breath at step 4 becomes critical — and it changes by device. Get this the wrong way round and even perfect handling delivers little medicine.
- Pressurised puffers used without a spacer (pMDIs), Aerosphere, Autohaler, Rapihaler
- Respimat soft-mist inhaler
- Breathe in slowly and gently — like sipping through a straw — over 4–5 seconds, then hold for about 6 seconds
- A fast, hard breath fires the spray against your throat
- Turbuhaler, Easyhaler, Spiromax, Genuair, Accuhaler, Ellipta, Breezhaler, HandiHaler, Zonda
- Breathe in quickly, deeply and forcefully from the start — you create the "pull" that lifts the powder into your lungs
- A slow, gentle breath leaves the powder in the device
- With capsule devices you should hear the capsule rattle
- Never use a spacer with a dry-powder inhaler
Timing your inhaler around airway clearance
If you also do airway clearance (chest physiotherapy to move mucus), when you take each inhaler matters. Bronchodilators open the airways first; preventers and maintenance combinations work best once the airways are clear.
- SABA (short-acting reliever, e.g. salbutamol) and LABA (long-acting bronchodilator)
- Take these before airway clearance therapy
- They open the airways so mucus moves more easily and clearance is more effective
- LABA/LAMA combinations and triple therapy (ICS/LABA/LAMA)
- Take these after airway clearance is finished
- Preventer (ICS) and maintenance medicine deposits onto cleared airways rather than landing on mucus that is about to be cleared away
If you use nebulised medicines too (e.g. hypertonic saline and antibiotics)
When several inhaled and nebulised treatments are prescribed together — common in bronchiectasis and cystic fibrosis — the order matters. Open the airways first, loosen and clear the mucus next, and give the antibiotic last so it lands on clear airways:
Always follow the exact order and timing your team gives you — regimens vary by person and condition.
The most common mistakes
If your inhaler seems less effective, it is usually one of these — not the medicine:
- Not breathing out fully before the dose
- Breathing in too fast with a puffer, or too gently with a dry-powder inhaler
- Firing a puffer at the wrong moment — before or after the breath, not at the start of it
- Not holding your breath afterwards, so the medicine is breathed straight back out
- Firing two puffs in a single breath
- Not shaking a puffer, or not priming a new or unused device
- Forgetting to rinse and spit after a steroid inhaler
- Running the device empty — not tracking the dose counter
- Breathing out into a dry-powder inhaler and clumping the powder
Technique is the usual explanation — but not always. Treat these as signs that your condition itself may be worsening, not a handling fault to practise away:
- You need your reliever more often than usual, or it does not last as long as it used to
- You are waking at night with breathlessness, coughing or wheeze
- You are more breathless doing your usual activities, or your sputum has changed in colour or amount
Have your technique checked and contact your GP or treating team — see Recognising a Flare-Up. If you are struggling to breathe, your reliever is not helping, or you cannot speak in full sentences, call 000.
How to check your own technique
- Read the leaflet for your device and follow the device-specific page on this site — the loading steps genuinely differ.
- Ask to be watched. Have your pharmacist, GP or physiotherapist watch you use it and give feedback — self-rating is unreliable, and watching catches the errors.3
- Re-check periodically — at least yearly, after any hospital or flare-up, and whenever your device changes.
- Match your device to your ability. If you cannot breathe in forcefully enough for a dry-powder inhaler, a puffer with a spacer or a soft-mist device may suit you better — raise this with your prescriber.
Poor inhaler technique is prevalent, persistent and clinically consequential — and it is a modifiable, allied-health-addressable "treatable trait" that should be verified before any escalation of therapy.
- A systematic review of 144 studies over 40 years found no improvement in technique over time; roughly a third of patients make critical errors.2
- Critical errors are associated with poorer control, more exacerbations and higher healthcare use.2,3
- Physical demonstration plus teach-back beats verbal or written instruction alone; effect decays, so repeat.3
- Matching device to inspiratory ability and minimising the number of different device types a patient uses reduces error.3,5
Peak inspiratory flow (PIF) matters. Dry-powder inhalers are flow-dependent and need a fast, forceful inspiration to disaggregate the powder; a substantial minority of patients — especially older adults and those with severe COPD or during an exacerbation — cannot generate a sufficient PIF, favouring a pMDI-plus-spacer or soft-mist device.5 pMDIs and soft-mist inhalers instead require a slow, coordinated inspiration. Getting the inspiratory profile right for the device class is the single highest-yield correction.
The physiotherapy contribution. Confirming technique and adherence is a prerequisite before labelling asthma or COPD "uncontrolled" and escalating pharmacotherapy — including referral for biologic therapy, where demonstrated technique and adherence are eligibility requirements. It sits naturally within a cardiorespiratory assessment alongside breathing-pattern retraining and airway clearance.
Role of the physiotherapist
Inhaler-technique review is core cardiorespiratory physiotherapy, not an add-on. As part of an assessment we watch you use your own device, correct the specific errors, match the device to what you can physically do, and re-check over time — because technique drifts. We also place it in context: good technique works alongside breathing retraining, airway clearance and rehabilitation, so the whole picture improves, not just the prescription.
Most people lose some accuracy over time. We can watch you use your own inhaler and check your technique at your appointment.
References & evidence base
- Sanchis J, Corrigan C, Levy ML, Viejo JL; ADMIT Group. Inhaler devices — from theory to practice. Respir Med 2013;107(4):495–502.
- Sanchis J, Gich I, Pedersen S; ADMIT Group. Systematic review of errors in inhaler use: has patient technique improved over time? Chest 2016;150(2):394–406.
- Usmani OS, Lavorini F, Marshall J, et al. Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes. Respir Res 2018;19(1):10.
- Vincken W, Levy ML, Scullion J, et al. Spacer devices for inhaled therapy: why use them, and how? ERJ Open Res 2018;4(2):00065-2018.
- Laube BL, Janssens HM, de Jongh FHC, et al. What the pulmonary specialist should know about the new inhalation therapies (ERS/ISAM Task Force). Eur Respir J 2011;37(6):1308–1331.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Always follow the leaflet for your specific device and your prescriber's instructions.
Everything starts with an assessment — your symptoms, breathing, exercise tolerance and daily function measured properly, so what follows is built on your lungs rather than an average.
Corrections: If something on this page is wrong, out of date or unclear, we want to know. Email reception@inspireclinic.au with the page name and what you believe is incorrect. Substantive corrections are made promptly, and the guide’s version and last-updated date are changed to reflect it.