How do I teach a patient proper metered-dose inhaler (MDI) technique?

Teaching Proper Metered-Dose Inhaler (MDI) Technique

Teach MDI technique through direct physical demonstration with a placebo device, having the patient practice the technique in front of you with immediate feedback—this is significantly more effective than written instructions, videos, or verbal counseling alone. 1, 2, 3

Step-by-Step MDI Technique to Teach

When instructing patients on MDI use, demonstrate and have them practice these specific steps 4:

For Standard MDI (Adults and Children ≥5 years)

1. Shake the inhaler and remove the cap 4

2. Exhale completely (away from the inhaler) - this is one of the most commonly missed steps 1

3. Position the inhaler with mouthpiece between lips and teeth, creating a tight seal 4

4. Begin slow, deep inhalation at approximately 30 L/min (taking 3-5 seconds for the full breath) 4, 5

5. Actuate the inhaler once during the slow inhalation (not before, not after) 4

6. Continue inhaling slowly and deeply after actuation—patients commonly stop breathing when they press the canister 4

7. Hold breath for 10 seconds after full inhalation 4

8. Exhale slowly away from the device 4

9. Rinse mouth and spit (especially for inhaled corticosteroids to reduce systemic absorption and oral thrush) 4

Age-Specific Modifications

Children <4 Years Old

• Use a valved holding chamber (VHC) with face mask - MDI alone is not appropriate for this age group 4
• Ensure tight face mask fit and allow 3-5 inhalations per actuation 4
• Note: Face mask reduces lung delivery by 50% compared to mouthpiece, but is necessary for proper administration 4

Children 4+ Years and Adults with Coordination Difficulty

• Use a spacer or VHC with mouthpiece 4
• Actuate only once into the spacer per inhalation 4
• Inhale slowly (30 L/min over 3-5 seconds) immediately after actuation 4
• Hold breath for 10 seconds 4
• VHC decreases oropharyngeal deposition and improves lung delivery in patients with poor technique 4

Most Effective Teaching Method

Physical demonstration with hands-on practice is essential 1, 2, 3:

• A 2-minute pharmacist counseling session with physical demonstration achieved competency in proper technique, while written materials, CDC videos, and YouTube videos all failed to produce competent technique 1
• Physical demonstration resulted in 80% of patients maintaining correct technique at 8 weeks, compared to only 10% with written/verbal instruction alone 3
• Practical demonstration improved technique scores by 3 points versus 2 points for written instruction (p<0.001) 2

Implementation Strategy

Initial Teaching Session

1. Demonstrate the technique yourself using a placebo device, narrating each step 2, 3
2. Have the patient immediately practice with their own inhaler (or placebo) while you observe 1, 2
3. Provide immediate corrective feedback on errors 1, 2
4. Repeat demonstration and practice until all steps are performed correctly 2

Follow-Up Assessment

• Reassess technique at every visit, especially for patients with poorly controlled asthma 4, 6
• Have patients physically demonstrate their technique—verbal assessment alone misses most errors 6
• Technique deteriorates over time; only 19% of providers routinely reassess even in poorly controlled asthma 6
• Repeat education is necessary as median technique scores drop from 8 to 7 after one month without reinforcement 2

Common Pitfalls to Address

Most frequently missed critical steps 1, 2:

• Failing to exhale before inhalation - emphasize this explicitly
• Not holding breath for 10 seconds after inhalation - count it out with them
• Stopping inhalation at actuation - stress continuing to breathe in slowly after pressing 4
• Inhaling too rapidly - demonstrate the slow 3-5 second inhalation; consider using a 2Tone Trainer device that provides audible feedback when inhalation is too fast 5

Practical Barriers and Solutions

Time constraints are the most commonly cited barrier (84% of providers) 6:

• Designate a consistent educator (respiratory therapist, pharmacist, or trained nurse) rather than expecting physicians to perform all education 6, 1
• Brief, repeated practice sessions are more effective than lengthy one-time instruction 6

Lack of demonstration devices (67% cite this barrier) 6:

• Obtain placebo MDIs for in-office demonstration
• Consider video tutorials as adjunct only, never as replacement for hands-on teaching 1

Alternative Devices for Patients Unable to Master Standard MDI

If coordination remains problematic despite proper teaching 4:

• Breath-actuated MDI: Requires tight seal and slightly faster inhalation than standard MDI; eliminates need to coordinate actuation with inhalation 4
• Dry powder inhaler: Requires rapid, deep inhalation (60 L/min over 1-2 seconds); not suitable for children <4 years who cannot generate sufficient inspiratory flow 4