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3.1.5 Inhaler devices, peak flow meters and nebulisers

Prescribing Notes

Inhaler Devices

  • Choice of device should be considered on basis of ability to use the inhaler, patient-acceptability, carbon footprint and cost. The number of inhalers and different types of inhaler devices given to a patient should be minimised.
  • Good technique is essential in ensuring optimum use – refer to Asthma + Lung UK for inhaler videos demonstrating how to use each type of inhaler. RightBreathe provides useful information on all UK licensed inhalers and spacers.
  • On changing from a pressurised metered-dose inhaler (pMDI) to a dry powder inhaler, patients may notice a lack of sensation in the mouth and throat previously associated with each actuation. Coughing may also occur.


  • Spacer devices remove the need for coordination between actuation of a pMDI and inhalation. Spacer devices are particularly useful for patients with poor inhalation technique, elderly patients, those requiring high doses of inhaled corticosteroids, and for patients prone to candidiasis with inhaled corticosteroids.
  • The spacer device used should be compatible with the metered-dose inhaler. Spacer devices should not be regarded as interchangeable; patients should be advised not to switch between spacer devices. Refer to RightBreathe for information on available spacers including compatible inhalers and to Asthma+Lung UK for useful patient information on spacers including how to use and how to look after your spacer.

Peak Flow Meters

  • Measurement of peak flow may be of benefit in patients who are unable to detect deterioration in their asthma, and for those with more severe asthma. Refer to BNF for information on available peak flow meters and to Asthma + Lung UK for patient information.


  • Nebulisers are not currently prescribable in general practice (but they are free of VAT); patients should be appropriately assessed before nebulised therapy is deemed appropriate. A spacer should be tried before considering a nebuliser.
  • Dealing with requests to purchase nebulisers in community pharmacy:
    • Patients should be advised to only buy or use a nebuliser if it has been recommended by their specialist and their GP practice has agreed to prescribe the nebules.
    • Requests to purchase a nebuliser may indicate poor control or a deterioration of their condition. Consider referral to GP practice for review.
  • The use of nebulised therapy in acute exacerbations of asthma is not covered in this formulary.
  • On very rare occasions nebulised bronchodilators may be required when a patient with severe asthma or COPD is unable to use inhalers. Patients should be appropriately assessed before nebulised therapy is deemed appropriate.
  • If using nebulised salbutamol, 2.5mg unit dose vials (UDVs) should generally be used, which can be repeated if required. Side effects such as tachycardia are more common with the 5mg dose, particularly in elderly patients. In emergency situations, 5mg UDVs may be required.