SAN FRANCISCO — Clinical sites should have designated personnel responsible for routinely educating patients about how to properly use a metered-dose inhaler.

“Improper administration of metered-dose inhalers (MDIs) has been strongly correlated with a patient’s ability to control their asthma,” Joshua Blair, PA-S, in the Department of Physician Assistant Studies at the New York Institute of Technology and colleagues reported at the American Academy of Physician Assistants 2015 meeting.

“A provider’s ability to educate their patients on the proper use of an MDI is essential for improving asthma control,” he added.

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They surveyed 111 physician assistants and 60 nurse practitioners, who prescribed MDIs at least monthly, at their respective New York State conferences to determine frequently missed steps in MDI use and to determine subgroups of participants who performed better than others. 

Participants were asked to perform a demonstration about how they would teach an adult patient with asthma to administer an MD. They were then evaluated using Plaza’s previously validated nine-step criterion and assigned a score on a 100-point scale. 

The nine steps of properly administering an MDI were as follows: 


  1. Removing the cap and shaking the inhaler
  2. Deep exhalation
  3. Inserting the mouthpiece into the mouth
  4. Slow inspiration
  5. Coordinated firing into the inspiration
  6. Firing the canister once only
  7. Continued deep, slow inspiration
  8. Holding breath for at least 5 seconds
  9. Waiting a few seconds before repeating the maneuver

Physician assistants and nurse practitioners performed equally well in regard to demonstrating MDI administration, the researchers found, but several subgroups performed better. These practitioners included: asthmatic practitioners, those who prescribed MDIs more frequently (daily or weekly), and those who regularly educated their patients on MDI use themselves. 

The most frequently missed steps were step nine (44.1%), “wait a few seconds before repeating the maneuver;” step four (38.6%), “begin slow inspiration;” and step eight (33.3%), “hold the breath for at least five seconds.” 

The researchers offered several suggestions for improving these areas of patient education, including designing an inhaler that fires with the negative pressure caused by inhalation and the development of an audio component with the MDI that would communicate proper administration instructions to those with limited experience. 


  1. Blair J et al. “Metered-Dose Inhalers: A Comparison of Administration Amongst Healthcare Providers in New York State.” Presented at: AAPA 2015. May 23-27, 2015.