TABLE 1—

Correct techniques for different types of inhaler and the errors patients are known to make

Device	Correct technique	Errors in technique
“Press and breathe” pMDI	Remove mouthpiece cap	Failure to remove mouthpiece cap*
	Shake inhaler (suspensions only)	Inhaler not shaken
	Hold inhaler upright	Inhaler upside down*
	Breathe out	No exhalation
	Place mouthpiece between lips
	Fire while breathing in deeply and slowly	Firing device before start of inhalation
		Firing device at or after end of inhalation*
		Inhaling through nose*
	Continue to inhale after firing	Stopping inhalation as device is fired*
		Fast inhalation
	Hold breath (10 s)	No/short breath-hold
Breath-actuated pMDI	Remove mouthpiece cap	Failure to remove mouthpiece cap*
	Shake inhaler (suspensions only)	Inhaler not shaken
	Hold inhaler upright	Inhaler upside down*
	Prepare device (e.g. lift lever)	Failure to prepare device correctly*
	Breathe out	No exhalation
	Place mouthpiece between lips	Poor seal around mouthpiece
		Using “open mouth” inhalation technique*
	Breathe in deeply and slowly	Weak inhalation, failure to trigger device*
		Inhaling through nose*
	Continue to inhale after firing	Stopping inhalation as device is fired*
		Fast inhalation
	Hold breath (10 s)	No/short breath-hold
“Press and breathe” pMDI plus spacer		Inappropriate handling (static charge)
	Remove mouthpiece cap	Failure to remove mouthpiece cap*
	Shake inhaler (suspensions only)	Inhaler not shaken
	Hold inhaler upright	Inhaler upside down*
	Insert pMDI into spacer
	Breathe out	No exhalation
	Fire while breathing in deeply and slowly	Long delay before inhalation
		Multiple actuation
		Weak inhalation, failure to open valve*
		Inhaling through nose*
	Continue to inhale after firing	Stopping inhalation as device is fired*
		Fast inhalation
	Hold breath (10 s)	No/short breath-hold
DPIs	Remove cover (device specific)	Failure to remove cover*
	Load dose (device specific)	Incorrect dose loading*
	Pierce capsule (single-dose devices)	Failure to pierce capsule*
	Breathe out	Breathing out into device*
	Place mouthpiece between lips	Inhalation vents blocked^¶
		Poor seal round mouthpiece
		Using “open-mouth” inhalation technique*
	Inhale deeply and quickly	Not inhaling quickly enough*
		Insufficient “acceleration”
		Inhaling through nose*
	Hold breath (10 s)	No/short breath-hold
	Store in cool dry place	Inappropriate storage
Respimat® Soft Mist^TM Inhaler^#	Hold upright and turn base	Failure to prime device/load dose*
	Open mouthpiece cap	Failure to open mouthpiece cap*
	Breathe out	No exhalation
	Put mouthpiece between lips	Mouthpiece vents blocked^¶
	Press dose release button while breathing in deeply and slowly	Firing device before start of inhalation
		Firing device at or after end of inhalation*
		Inhaling through nose*
	Continue to inhale after firing	Stopping inhalation as device is fired*
		Fast inhalation
	Hold breath (10 s)	No/short breath-hold

pMDI: pressurised metered-dose inhaler; DPI: dry powder inhaler. *: crucial error, likely to result in zero lung deposition of drug; ^#: manufactured by Boehringer Ingelheim GmbH & Co. KG, Ingelheim, Germany; ^¶: error that may be crucial.