Beyond the drug – why inhalation technique and device choice matter

2026: ERS Barcelona

ERS Inhalasjonsteknikk

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Inhalation technique is a critical step to effective treatment. During recent decades, scientists and engineers have developed innovations resulting in highly sophisticated inhalation devices for improving drug delivery to the lungs¹. Unfortunately, patients’ inhalation technique has not improved at the same speed.² Still, doctors are “trained to focus on the drugs, not the device” – says Professor Usmani

Do doctors underrate the impact of device use?

Strikingly, a systematic review found that fewer than one in six could correctly demonstrate inhalation technique.³ Pulmonologists, general practitioners and non-physician practitioners were asked what they considered more important when prescribing maintenance treatment for a newly diagnosed COPD – device or medication class. Only 1 in 10 listed the device as more important, all others prioritized medication class.⁴

It is critical to address this mismatch to improve efficacy of inhalation treatment in airway diseases.

Fundamentally different techniques required

The inhalation technique is of utmost importance when using a pressurized metered dose inhalers (pMDIs) or the dry powder inhalers (DPIs) but they require fundamentally different inhalation technique.⁵ For pMDIs, a slow and deep 5 seconds inhalation is required. If the pMDI is a suspension the inhaler needs to be shaken. Furthermore, it is important that the patient lifts the chin up, breathe out gently, and take a 5 second slow and deep inhalation.

On the other hand, DPIs require a distinct and fast inspiration to activate the inhalator, break the drug from the larger drug carrier particles, and finally carry the drug to the lung – “pull, break and carry”. Some patients may not have the sufficient inspiratory muscle strength to do this procedure. However, DPIs require varying levels of inspiratory effort depending on the device.

Internal resistance of DPIs determines the minimum inspiratory effort required

“We often think high resistance equals high flow, but this is wrong “, Professor Usmani says. DPIs with low internal resistance demand a higher inspiratory flow to create the pressure drop required to pull, break and carry the drug. Conversely, high-resistance DPIs requires low flow.⁵

Reassess inhaler choice following hospitalization

When patients are discharged from hospital and subsequently readmitted, several factors may need to be considered. These include whether the medication was appropriate, whether the patient received effective physiotherapy, whether they had proper inhaler technique and whether they were given the right treatment on discharge. During an admission for an infection or exacerbation, respiratory muscles may be compromised – Says Professor Usmani

If patients are then given an inhaler that requires a high inspiratory flow while their muscles are weak and recovering, they may be unable use the inhaler effectively. In one small subgroup of patients with suboptimal peak inspiratory flow (sPIF), discharged with either DPI or nebulised treatment, readmission rates (<30 and >90 days) were significantly higher when treated with a DPI than with nebulized therapy.⁶

The objective is to understand inhalers and communicate that effective treatment is not simply a matter of adherence. It also depends on education, collaboration, training, mastery and correct inhaler use.

– Professor Usmani

The sustainable inhaler choice

“The best inhaler is the inhaler that a patient can use properly” – says Professor Usmani. However, many guidelines, especially in the Nordics, have implemented a powder preferred approach due to lower carbon footprint. (Note: pMDIs with reduced carbon footprint are entering the market)

The largest study on non-clinical switching in the United States included approximately a quarter of a million patients who were switched from a pMDI to a DPI. This approach was a cost-driven switch and not required clinically. Following the device switch, there was a 5% increase in all-cause emergency-department visits, an 8% increase in all-cause hospitalisations and a 10% increase associated with the switch.⁷

The findings supported the hypothesis that non-clinical switching increases costs and carbon footprint.⁸

Carbon minimal inhalers – the future of inhaled therapies

Reducing the carbon footprint of the health care sector is, for good reasons, high on the political agenda. However, for individual patients, the device selection should always be driven by the clinical need.

Scientists and industry have joined forces to develop pMDIs containing propellants with lower carbon footprint, comparable to the available DPIs. Currently two devices are already approved, and more are expected to reach the marked in 2027. No device is universally suitable, and these innovations open up more possibilities to meet individual clinical needs while keeping a low carbon footprint.

Patient’s need first

Which inhaler is the best? There is no universal answer, other than that the ideal inhaler is the one that the patient can use, will use, and understands how to use correctly. The patient’s ability, preferences and clinical needs is the foundation for choosing the “best” inhaler device.

ID 24291-09.09.2026