Inhaler technique: pMDI, spacer and dry powder

Inhaled medication treats the airway only if the dose reaches it, and whether it does depends on a device technique that has to be taught, shown and watched rather than assumed -- the pressurized metered-dose inhaler shaken immediately before every actuation, breathed out fully away from the mouthpiece before use, fired at the start of one slow deep breath in and followed by a breath-hold, and used through a spacer or valved holding chamber whenever the patient cannot time the actuation to the breath and whenever the drug is an inhaled corticosteroid, because the chamber carries more of the dose to the lung and leaves less in the mouth and throat; the dry-powder inhaler the opposite maneuver -- loaded, never shaken, never breathed out into, its capsule pierced inside the device and never swallowed, and drawn on with one fast, forceful, deep breath that the patient must be able to generate, so the patient who cannot inhale forcefully needs a different device rather than more coaching; the mouth rinsed and the rinse spat out after any inhaled corticosteroid; the patient kept to as few device types as possible because each asks for a different breath, and moved to a new device only with retraining -- while the nurse checks technique by watching the patient use their own device against a device-specific checklist rather than by asking whether they know how, corrects it with a demonstration and a return demonstration, re-checks it at every contact because errors come back within weeks of being taught, reads the dose counter rather than the spray, the taste or the feel of a dose as the measure of what is left and what went in, and treats symptoms that stay uncontrolled, rising reliever use, hoarseness or oral thrush as reasons to check technique and adherence before anyone concludes that the medicine itself has failed.