Back to the future: using inhalers correctly.

The more things change, the more they stay the same. This old French saying seems to apply rather aptly to the situation faced by respiratory clinicians using inhaled therapy for their patients with obstructive lung disease. Since the development of the pressurized metered-dose inhaler (pMDI) in 1956, inhaled medication has become the standard of care for both asthma and chronic obstructive pulmonary disease.1,2 Since the mid-1970s it has become clear that more than 50% of adults, and even more children, do not use their pMDIs correctly.3 Data are available to show that poor inhaler technique leads to decreased asthma control with inhaled steroids4 and decreased bronchodilation with inhaled bronchodilators.5 The most common crucial error made when using a pMDI is incorrect timing of device actuation with taking a breath, sometimes referred to as poor hand-lung coordination.6 In addition to a constant call for patient education in inhaler use there have been multiple developments in inhaler technology to try to overcome this problem, including spacers for pMDI, dry-powder inhalers (DPIs) that are breath-actuated, breath-actuated pMDIs, and, most recently, soft mist inhalers.7 DPI is the most prevalent alternative to pMDI, since many of the newer potent inhaled steroids and long-acting agonists are only available in DPI. Although DPIs are considered simpler to use than pMDIs,8 a well done evidence-based guideline found no difference between available devices for aerosol therapy.9 That report has been criticized because it was based only on randomized controlled studies, which, by their very nature, will only include patients who demonstrate ability to use the devices being tested and are taught correct technique prior to study entry.10