Australian Asthma Handbook

Australian Asthma Handbook

The National Guidelines for Health Professionals

Management Adults and Adolescents Principles of management Selecting inhalers for adults and adolescents
Management / Adults and Adolescents

Selecting inhalers for adults and adolescents

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Before selecting inhalers

Choose initial treatment Understand options among treatment regimens Understand options among treatment regimens
Recommendation

When prescribing inhaled asthma medicines, consider which type of inhaler the person prefers and will be able to use correctly.

Factors to consider in shared decisions with patients include:

  • the person’s ability to use the device after training (e.g. based on age, developmental stage, cognitive function, inspiratory effort capability, and dexterity)
  • minimising the number of inhalers required for multiple medicines
  • minimising number of types of inhaler
  • the environmental impact of the device in use and when discarded.
Considerations for choice of inhaler Table
Available inhaler types for asthma medicines according to pharmacological class and active ingredient Table
In-use shelf life of asthma inhalers Table

Recommendation type: Consensus recommendation

Clinical outcomes do not differ significantly between inhaler devices when they are used correctly, but incorrect inhaler technique and poor adherence are associated with worse outcomes.[Rigby 2024]

Inhalers for asthma medicines differ according to procedures for preparing doses before inhaling, required manual dexterity, required inspiratory flow rate, cleaning requirements, and environmental impacts.[Rigby 2024]

Rigby D. Inhaler device selection for people with asthma or chronic obstructive pulmonary disease. Aust Prescr 2024; 47: 140-147.

Rigby D. Inhaler device selection for people with asthma or chronic obstructive pulmonary disease. Aust Prescr 2024; 47: 140-147.

National Asthma Council Australia information paper: Inhaler technique for people with asthma or COPD

National Asthma Council Australia information paper: Reducing the environmental impact of asthma treatment. Information for health professionals

Inhaler types for asthma medicines include:

  • pressurised metered-dose inhalers – preferably used with a spacer
  • breath-actuated metered-dose inhalers
  • dry powder inhalers – multi-dose or capsule
  • soft mist inhalers.
Recommendation

Train the patient to use their inhaler by physically demonstrating using a placebo inhaler and providing a list of correct steps for the specific inhaler type.

Recommendation type: Consensus recommendation

Incorrect inhaler technique for inhaled asthma medicines is very common in Australia and worldwide.[NACA 2018] Adults and adolescents are unlikely to use inhalers correctly unless they are given clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.[NACA 2018] When inhalers are used incorrectly, the full dose may fail to reach the target area in the lung.  Poor inhaler technique can result in poor symptom control and exacerbations.[NACA 2018]

Patients need training to use inhalers correctly – just reading the manufacturer’s leaflet is ineffective. The best way to train patients to use their inhalers correctly is one-to-one training by a health professional (e.g. nurse, pharmacist, GP) that involves both verbal instruction and physical demonstration. Australian randomised controlled trials have shown that adults with asthma are more likely to use their inhaler correctly after a health professional demonstrated the correct technique using a placebo inhaler as well as explaining and providing written instructions, than after receiving only written and verbal instructions or after written instructions only.[NACA 2018]

An effective method is to assess the individual’s technique by comparing each step to a checklist specific to the type of inhaler, and then provide written instructions highlighting the steps that were incorrect (e.g. a sticker attached to the device). This helps patients maintain correct technique longer.[NACA 2018]

National Asthma Council Australia. Inhaler technique in people with asthma or COPD. National Asthma Council Australia, Melbourne, 2018.

National Asthma Council Australia information paper: Inhaler technique for people with asthma or COPD (2018) 

National Asthma Council Australia’s inhaler demonstration videos

NPSMedicinewise Checklist for correct use of common inhaler types

National Asthma Council Australia’s videos demonstrating correct use of inhalers

Recommendation

For patients using ICS via a pMDI, advise use of a spacer.

The use of a spacer with a pMDI reduces oropharyngeal deposition and increases deposition in the lungs.[Lavorini 2009] Avoidance of oropharyngeal deposition may reduce the risk of local side-effects such as dysphonia and oral candidiasis.[Lavorini 2009]

Lavorini F, Fontana GA. Targeting drugs to the airways: The role of spacer devices. Expert Opin Drug Deliv 2009; 6: 91-102.

National Asthma Council Australia information paper: Inhaler technique for people with asthma or COPD 

National Asthma Council Australia’s inhaler demonstration videos

National Asthma Council Australia’s Spacer use and care

National Asthma Council Australia’s fact sheet on spacers for pressurised metered-dose inhalers

Technical information on pMDIs and spacers

Recommendation

For patients using reliever via pMDI, advise use of a spacer.

The use of a spacer with a pMDI is essential when symptoms are frequent or worsening.

Advise single-breath technique, except during acute asthma.

The use of a spacer, one actuation at a time, minimises local adverse effects and optimises deposition of the medicine in the lungs.[GINA 2025]

Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention, 2025. Available from: www.ginasthma.org

National Asthma Council Australia information paper: Inhaler technique for people with asthma or COPD (2018)

How to use a metered dose inhaler (puffer) with a spacer for adults

National Asthma Council Australia’s Spacer use and care

National Asthma Council Australia’s fact sheet on spacers for pressurised metered-dose inhalers

There are two methods for inhaling reliever from a pMDI plus spacer.

The standard, recommended method (single-breath technique) is to take a single slow deep breath after each actuation into the spacer, then hold the breath for 5 seconds, then exhale away from the spacer. 

The alternative method (tidal breathing) is used during acute exacerbations, when people usually cannot coordinate actuation and breathing. Up to 2 actuations are released into the spacer at the same time, and the patient takes multiple breaths, breathing in and out through the spacer mouthpiece.

The tidal breathing method is usually used in EDs to deliver SABA in acute asthma, but patients should revert to the preferred single-breath technique after discharge.

Technical information on pMDIs and spacers

Recommendation

Do not prescribe or recommend nebulised medicines.

Nebulisers should only be used when necessary to deliver salbutamol in a patient with severe or life-threatening acute asthma.

Recommendation type: adapted from GINA

The use of a pMDI with spacer delivers inhaled asthma medicines to the lungs more quickly and at least as effectively as a nebuliser.[Newman 2002]

The association between SABA use and increased risk of exacerbations is stronger for nebulized salbutamol than salbutamol delivered by pMDI.[Paris 2008]

The use of nebulisers is unnecessary except in some cases of severe acute asthma.

The use of nebulisers may increase the risk of viral transmission.[Hui 2009, Biney 2024, Goldstein 2021] Healthcare workers should follow infection control procedures including use of personal protective equipment such as face masks.

Biney IN, Ari A, Barjaktarevic IZ, et al. Guidance on mitigating the risk of transmitting respiratory infections during nebulization by the COPD Foundation Nebulizer Consortium. Chest 2024; 165: 653-668.

Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, 2025. Available from: www.ginasthma.org

Goldstein KM, Ghadimi K, Mystakelis H, et al. Risk of transmitting coronavirus disease 2019 during nebulizer treatment: a systematic review. J Aerosol Med Pulm Drug Deliv 2021; 34: 155-170.

Hui DS, Chow BK, Chu LC, et al. Exhaled air and aerosolized droplet dispersion during application of a jet nebulizer. Chest 2009; 135: 648-654.

Newman KB, Milne S, Hamilton C, Hall K. A comparison of albuterol administered by metered-dose inhaler and spacer with albuterol by nebulizer in adults presenting to an urban emergency department with acute asthma. Chest 2002; 121: 1036-1041.

Paris J, Peterson EL, Wells K, et al. Relationship between recent short-acting beta-agonist use and subsequent asthma exacerbations. Ann Allergy Asthma Immunol 2008; 101: 482-487.

Consideration

For patients using a separate inhaler for ICS and for reliever, prescribe the same type of device, if possible.

Recommendation type: Consensus recommendation

Ideally, each patient should be prescribed only a single inhaler type, because this may reduce errors and improve adherence.[Braido 2015, Bosnic-Anticevich 2018, Doyle 2010, Levy 2016]

Braido F, Lavorini F, Blasi F et al. Switching treatments in COPD: implications for costs and treatment adherence. Int J Chron Obstruct Pulmon Dis 2015; 10: 2601-2608.

Bosnic-Anticevich S, Callan C, Chrystyn H et al. Inhaler technique mastery and maintenance in healthcare professionals trained on different devices. J Asthma 2018; 55: 79-88.

Doyle S, Lloyd A, Williams A et al. What happens to patients who have their asthma device switched without their consent? Prim Care Respir J 2010; 19: 131-139.

Levy ML, Dekhuijzen PN, Barnes PJ et al. Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT). NPJ Prim Care Respir Med 2016; 26: 16017.

Rigby D. Inhaler device selection for people with asthma or chronic obstructive pulmonary disease. Aust Prescr 2024; 47: 140-147.

National Asthma Council Australia information paper: Inhaler technique for people with asthma or COPD

Practice point

If more than one type of inhaler is available for the required medicine, involve the patient in deciding between inhalers.

Practice point

If the use of multiple inhaler types is unavoidable, patients need clear instructions for each to avoid confusion between different handling requirements. For example, aways shake versus never shake, slow and steady inhalation versus quick and deep inhalation, wash inhaler versus keep inhale dry.

Practice point

Assess each patient’s inhaler technique repeatedly, even for patients who have been using the inhaler for many years.

To assess:

  • Have the patient demonstrate their inhaler technique, while checking against a checklist of steps for the specific device.
  • Demonstrate correct technique using a placebo device and correct any specific errors identified.
  • Have the patient repeat the demonstration to check they can now use the device correctly. If necessary, repeat instruction until the patient has all steps correct.
  • Provide the checklist as a reminder, and write down or highlight any steps that were done incorrectly (e.g. on a sticker attached to their inhaler or on a pictorial instruction sheet).

Resources

National Asthma Council Australia’s information paper: Inhaler technique for people with asthma or COPD Link
Practice point

For patients using maintenance ICS treatment, rinsing out the mouth with water after each dose may reduce the risks of dysphonia and oropharyngeal candidiasis.

Practice point

After a patient has attended ED for acute asthma, recheck inhaler technique and explain that those using a spacer should revert to the recommended single-breath technique – not multiple breaths after each actuation or multiple actuations (tidal breathing).

Practice point

For adults and adolescents who are unable to seal their lips firmly around an inhaler mouthpiece, the use of a pMDI with spacer and adult-sized mask is preferable to using a nebuliser.

Resources

National Asthma Council Australia’s video[JH11.1]: How to use a metered dose inhaler (puffer) with a spacer for adults Link
National Asthma Council Australia’s fact sheet on spacers for pressurised metered-dose inhalers Link

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