Section 3:

Guideline recommendations for choosing an inhaler device and assessing inhaler technique

The BTS/SIGN guideline emphasises the importance of careful selection of inhaler devices:1

  • Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique.
  • In children aged 5-12 and adults, a pMDI + spacer is as effective as any other hand-held inhaler, but some [adult] patients may prefer some types of DPI.
  • Choice of reliever inhaler for stable asthma should be based on patient preference and assessment of correct use. Many patients will not be prepared to carry a spacer.
  • The choice of device may be determined by the choice of drug. If the patient is unable to use a device satisfactorily an alternative should be found.
  • The patient should have their ability to use the prescribed inhaler device (particularly for any change in device) checked by a competent healthcare professional.
  • Reassess inhaler technique as part of the structured clinical review
  • Generic prescribing of inhalers should be avoided as this might lead to people with asthma being given an unfamiliar inhaler device that they are not able to use properly.
  • Prescribing mixed inhaler types (i.e. both DPI and pMDI) may cause confusion and lead to increased errors in use. Using the same type of device to deliver preventer and reliever treatments may improve outcomes.

To ensure effective inhaler use, GINA recommends the 4 ‘C’s’:

  • Choose the most appropriate device for the patient before prescribing. Consider medication, physical problems, e.g. arthritis, patient skills, and cost. For ICS by pMDI prescribe a spacer
  • Check inhaler technique at every opportunity. Ask the patient to show you how they use their inhaler. Check technique against a device-specific checklist
  • Correct using a physical demonstration (e.g. with a placebo device)
  • Confirm that you can demonstrate correct technique for each of the inhalers you prescribe.2

The NICE Patient Decision Aid

NICE has produced a patient decision aid to help select the most appropriate type of inhaler, based on the patient’s ability to produce sufficient inspiratory effort and co-ordinate inhalation and activation of the device (Figure 1).3 NICE states that everyone (with asthma) should be able to choose the inhaler that they find easiest to use.3


BAI –breath-actuated metered dose inhaler; DPI –dry powder inhaler; pMDI –pressurised metered dose inhaler
*Using multiple breath technique

Job code: UK/RES-19014d DOP: April 2020


  1. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma, 2019. [Accessed April 2020]
  2. Global Initiative for Asthma. Global strategy for asthma management and prevention, updated 2019. [Accessed April 2020]
  3. NICE NG80. Resources: Inhalers for asthma. Patient decision aid. [Accessed April 2020]