How feedback on an RT magazine cover image showing a metered-dose inhaler (MDI) without a spacer led our editor to research proper inhaler techniques.

By Marian Benjamin

The cover of the May 2005 issue of RT magazine brought a flurry of e-mails from readers who wondered why in the world I had printed an image of a boy using a metered-dose inhaler (MDI) without a spacer. All wrote to say that they spend hours educating their patients on the correct way to use their medication. One RT wrote, “This is a very sensitive subject with us. We spend countless hours teaching our patients the correct way to use their medications. To us this [cover] only reinforces bad practices.” Feeling chastened, I decided that it was time to learn more about the importance of spacers.

Marian Benjamin

Metered-dose inhalers are the most commonly used inhalation devices,1 but studies have shown that as little as 7% to 23% of any drug delivered by MDIs actually enters the respiratory tract.2 This is true not only for pediatric patients, who may not be cooperative,3 but for adults as well. The reasons for this vary from noncompliance to the inability of the inhaler to deliver the drug to the lung. A major culprit is MDI misuse—inhaler not held correctly, device not actuated at the beginning of inspiration, no slow inspiratory flow, etc. Education on the proper use of inhalers would seem to be the answer; yet, according to one reader, most patients are never shown the correct technique. “Most state that they were given an inhaler by a pharmacist or doctor with instructions to take two puffs as needed, four times a day, or twice daily, without any instructions as to how to take the puffs,” he wrote. And written instructions are not enough. Providing the package insert or printed sets of instructions is not sufficient.4 Verbal instructions and demonstrations need to be included.

Even when properly educated, patients may fall into their “bad ways” and not realize the full effect of their medication. The bulk of the medication may still be deposited on the oropharynx, swallowed, or dispersed in the air (as on May’s cover!). In children especially, proper technique is difficult. More than half have coordination problems using the MDI correctly or problems with fast inhalation. It is for these reasons that, until recently, MDIs were rarely prescribed for young children. With the advent of spacers, that is changing. A spacer acts as a holding chamber for the medication and allows the patient to breathe normally through the spacer mouthpiece. Often, a single brief demonstration regarding its proper use is sufficient.5 Best of all, in adults as well as in children, studies have shown that the amount of drug delivered directly to the lungs could double with the use of spacers.2

Respiratory therapists are uniquely positioned to offer MDI-use education, and, clearly, assuring that their patients receive the full benefit of their medications is a top priority.


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Marian Benjamin is the former editor of RT. For more information, contact [email protected].


  1. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J. 2002;19(2):246-51.
  2. Cochrane MC, Bala MV, Downs KE, Mauskopf J, Ben-Joseph RH. Inhaled corticosteroids for asthma therapy. Chest. 2000;1172():642-50.
  3. Battistini A, Pisi G, Attanasi G. Response to bronchodilator administered directly with spray or with spacer. Pediatr Med Chir. 1997;19(4):237-42.
  4. Fink JB. Inhalers in asthma management: is demonstration the key to compliance? Respir Care. 2005;50(5):598-600.
  5. Cunningham SJ, Crain EF. Reduction of morbidity in asthmatic children given a spacer device. Chest. 1994;106(3):753-7.