Today a patient came into the clinic and said that his asthma inhaler wasn’t working.  He’d been diagnosed with mild asthma last week and his primary care physician gave him an albuterol inhaler to use when his asthma flairs and he starts coughing.  He had his inhaler with him, so I asked him to demonstrate how he uses it.  He promptly put the inhaler to his lips and sprayed the inhaler into his mouth and then took a big breath in.  I was able to see that he wasn’t getting the medication into his lungs efficiently, and since this is a common problem when using inhaled medication, I decided that the subject needed some attention. Using an inhaler can actually be quite challenging, and I find that most patients medications are only effective if they are used properly.  If you use the inhaler correctly the medication is delivered to the lungs where it works to control your symptoms.  If you are not using your inhaler correctly, little or no medication reaches your lungs and your asthma or reactive airway symptoms will not be adequately treated. Asthma inhaler types:  Most asthma inhalers are meter dose inhalers (MDI’s) and deliver a small spray of liquid medication such as albuterol (aka Proventil or Ventolin).  Since 2008, new inhaler canisters have come out that use a propellant that does not damage the ozone layer.  They are known as HFA inhalers and have a different taste compared to the previous inhalers and are also more expensive. The spray is also softer, but works just as well as the older inhalers. The other type of asthma inhaler is called a dry powder inhaler (DPI).  This type of inhaler has a small amount of powder that you breath in.  It has less taste, but the powder can fall out if you tip the device down towards to ground.  This type of inhaler is used commonly with medications such as the Advair diskus. Spacer devices:  A spacer is a device that is basically a small tube that allows the medicine to have a little extra time and space to get down into your lungs rather than be deposited in the back of your mouth or on your tongue.  It is not required to use a spacer, but it is highly recommended.  If you don’t have a spacer to use with your inhaler, you can make one using an empty cardboard toilet paper roll.  You put the spacer over the mouthpiece of the MDI and then put the other end of the spacer in your lips and inhale the medication from the metered dose inhaler through the spacer and into your lungs. Before using a metered dose inhaler MDI for the first time: 1)   Prepare the inhaler by shaking it for 5 seconds 2)   Prime the inhaler by pressing down on the canister with the index finger to release the medication.  Hold the inhaler away from your face to prevent the medication getting into your eyes.  Press the canister down again 3 more times 3)   After using for the first time, it does not need to be primed again unless you don’t use it for more than 2 weeks. Technique for using a metered dose inhaler (MDI): 1)   Shake the canister for 5 seconds 2)   If you have a spacer (recommended), insert the MDI into the spacer and hold the MDI upright with the index finger on the top of the medication canister and the thumb supporting the bottom of the inhaler.  Some people find that using the other hand to hold the spacer is easiest. 3)   Breathe out normally 4)   Close your lips around the spacer.  If your spacer has a mask, hold the mask tightly to the face.  If you do not have a spacer, close lips around mouthpiece or hold at a position about 4cm from your mouth. 5)   Keep your tongue away from the spacer opening/mouthpiece area 6)   Press down on the top of the medication canister with the index finger to release the medication 7)   At the same time as the canister is pressed, inhale deeply and slowly through your mouth until your lungs are completely filled – this should take about 4-6 seconds 8)   Hold your breath in for as long as possible – 10 seconds is recommended before breathing out. 9)   If a second puff of medication is recommended, wait about 15-30 seconds before repeating the procedure for the second puff. Remember to shake the canister before each puff 10)  Recap the mouthpiece 11)  Rinse your mouth with water rather than swallowing after the treatment.  This is recommended especially after using an inhaled cortisone medication to prevent developing thrush *Tip:  If you’re having difficulty timing your breath while spraying the medication, there are inhalers that automatically release the medication when you take a breath.  An alternative is to use a spacer or a dry powder inhaler (DPI). Cleaning your MDI:  Your inhaler must be cleaned at least once a week to prevent blockages.  The manufactures recommend cleaning the mouthpiece at least once per week. 1)   Remove the canister but do not wash the canister or put it in the water 2)   Run warm water through the top and bottom of the plastic mouthpiece for 60 seconds 3)   Shake off the excess water and allow the mouthpiece to dry completely overnight 4)   If you need to use your inhaler before it is dry, shake off all the water, replace the canister and test spray (away from your face) two times before using 5)   Remember to clean your spacer How to determine when your inhaler is empty:  You can’t always know when your inhaler is empty by shaking it because some propellant remains in the canister when all the medication is gone.  Some inhalers have a dose counter (Ventolin-HFA and Proventil) to track how much is used.  If your inhaler doesn’t have a counter but you use it regularly (2 puffs twice per day), you will need a refill in 30 days.  Write the date you will need a refill on the canister with a permanent maker to remind yourself. If you don’t use your inhaler very often, write the date you start using it on the canister in permanent maker and consider getting a refill in 3-4 months. Dry powder inhalers (DPIs):  These types of inhalers have a small dose of dry powdered medication in them.  They deliver a very fine powder to the lungs when you breathe in.  The advantage of using a DPI, is that you do not need to coordinate the squeezing of the canister with your breathing.  You must be able to breath in more forcefully with a DPI than with a spray type inhaler to ensure that the powder gets into the lungs.  These types of inhalers might be more difficult for patients who cannot breath in very deeply.  It’s also important not to exhale into the device before breathing in so that you don’t scatter the powdered medicine before it’s inhaled. How to use a DPI: 1)   For single use devices, load a capsule into the device as directed 2)   Breathe out slowly and completely (but not into the mouthpiece or you will scatter the powdered medication before you have a chance to breathe it in). 3)   Place the mouthpiece between your lips 4)   Breath in through the mouth quickly and deeply over 2-3 seconds 5)   Remove the inhaler from your mouth and hold your breath as long as possible – 10 seconds is recommended 6)   Breathe out slowly Cleaning a DPI:  Do not use soap and water.  The mouthpiece can be cleaned with a dry cloth. For more information about asthma, here is a list of resources: Center for disease control and Prevention  American Academy of Allergy, Asthma and Immunology American Lung Association   I hope that you have found this information useful.  Wishing you the best of health,

Updated for 2026: The Rescue Inhaler Rule Has Been Turned Around

If you read only one update on this site, make it this one. What I wrote in 2012 described the standard of the time, and that standard has since been reversed. The old model was simple and everybody knew it. Albuterol is your rescue inhaler, you carry it, you puff it when you are tight. A steroid inhaler is the controller, added later if things get bad enough. That is no longer what the global asthma guidance recommends for adults and adolescents. GINA now says plainly that adults and adolescents should not be treated with a short acting reliever alone (1). The reason is that albuterol relieves the symptom without touching the inflammation causing it. You feel better, the underlying disease keeps going, and the pattern of leaning harder on the reliever while the airways get angrier is exactly what precedes the attacks that put people in hospital.

What Replaced It

A combination inhaler containing both a steroid and formoterol, used as the reliever. Formoterol is a long acting bronchodilator that happens to work fast, so the same puff that opens you up also delivers an anti inflammatory dose. Treating the symptom and the cause in one action. At the milder end that inhaler is used only when needed, no daily maintenance at all. Further up, the same inhaler is used both on a schedule and as the reliever, which goes by maintenance and reliever therapy, or MART (1). The effect on serious attacks is large, roughly a sixty percent reduction in severe exacerbations compared with reliever-only treatment. Different analyses land slightly differently within that range, but the direction and the size are consistent (1). There is a second track for people who cannot get a steroid and formoterol combination. In that case you may still use albuterol as your reliever, but never on its own. It must be paired with a separate steroid inhaler taken regularly. If you are an adult carrying only an albuterol inhaler and nothing else, that is worth raising at your next visit. It was correct advice once. It is not the current advice.

Technique, Which Is Still Where Most of the Benefit Is Lost

None of the above matters if the medicine ends up on the back of your throat. Use a spacer with a metered dose inhaler. Not sometimes, routinely. Shake the suspension inhalers before every puff, which includes albuterol and the budesonide-formoterol and fluticasone-salmeterol combinations. One slow steady breath in, then hold it. If you are too breathless for that, five or six normal tidal breaths through the spacer will do instead. Children under three need a mask, three to five a mouthpiece (1).

What a Video Visit Is Actually Good For Here

This one surprises people. Inhaler technique is better assessed on video than almost anything else I do. I can watch you use it. In a clinic room I would ask you to demonstrate with a placebo device in an unfamiliar setting. On video you are holding your own inhaler and your own spacer, in your own kitchen, doing what you actually do every morning. I catch more real errors that way, and I have changed more outcomes by fixing a grip and a breath than by changing a drug. I can also count your reliever use, review your action plan, and check whether your prescription still matches current guidance. What I cannot do from here is listen to your chest or measure your lung function. Spirometry and peak flow need equipment.

Get Emergency Care If

You cannot finish a sentence. You are using neck and shoulder muscles to breathe. Peak flow under half your personal best. Lips or fingertips turning blue. Repeated reliever doses are not touching it, or you have gone past the maximum daily dose of a steroid and formoterol reliever. That last one is a genuine emergency signal rather than a dosing footnote. Blowing through the daily maximum means the attack is winning.

The Bottom Line

Albuterol alone is no longer the answer for adults and adolescents. If that is all you carry, ask about a steroid and formoterol combination. And use a spacer, because the best inhaler in the world does nothing from the back of your throat.

Sources

1. Update on Asthma Management Guidelines. Missouri Medicine. 2024 Sep-Oct;121(5):364-367. https://pmc.ncbi.nlm.nih.gov/articles/PMC11482852/ 2. Global Initiative for Asthma. GINA 2025 Report and Summary Guide. https://ginasthma.org/

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Board Certified in Obesity Medicine and Family Medicine

This blog is for educational purposes only and does not constitute individual medical advice. Always consult your own physician before making changes to your health, medications, or treatment plan.