Rotacaps vs Inhaler vs Respules: Which Asthma Device Actually Gets the Dose Into Your Lungs

The same asthma drug can reach the lungs in very different amounts depending on the device it comes in. Budesonide with formoterol, for example, is on our shelves as an aerosol inhaler, a breath-actuated Synchrobreathe, Rotacaps for a capsule device, nebulizer respules and a Symbicort Turbuhaler. Choosing between them is usually treated as a matter of convenience. It is closer to choosing a dose.

The evidence on how people actually use these devices is sobering. A systematic review of 144 studies covering 54,354 patients and 59,584 directly observed inhaler demonstrations between 1975 and 2014 found that 31 percent used correct technique, 41 percent acceptable technique and 31 percent poor technique. There was no improvement between the first and second 20 years of that period (PMID: 27060726). Four decades of new devices and patient leaflets did not move the number. Roughly two in three people using an inhaler are losing part of every dose.

The five device types in one table

Device	How the dose is released	What the patient has to do	Examples we stock
Aerosol inhaler (pressurized metered dose inhaler)	Propellant spray when the canister is pressed	Coordinate the press with a slow, deep breath	Asthalin, Foracort, Seroflo, Budecort, Tiova inhalers
Breath-actuated inhaler (Synchrobreathe)	Aerosol fires automatically as you breathe in	Slow, deep breath; no timing needed	Foracort, Seroflo, Levolin, Maxiflo and Tiova Synchrobreathe
Capsule powder device (Rotacaps with Rotahaler or Revolizer)	Powder in a capsule, lifted out by your breath	Load and open a capsule; fast, deep breath	Foracort, Seroflo, Asthalin, Budecort and Tiova Rotacaps
Multi-dose powder device (Turbuhaler, Ciphaler)	Powder from a reservoir or blister strip	Twist or click to load; fast, deep breath	Symbicort Turbuhaler, Seroflo Ciphaler
Nebulizer with respules	Liquid turned into mist by a compressor	Breathe normally for several minutes	Budecort, Foracort, Levolin, Asthalin and Duolin respules

The question that sorts most people: slow breath or fast breath

Every device falls on one side of a simple divide. Aerosol inhalers, breath-actuated inhalers and spacers need a slow, steady breath lasting several seconds, because the spray is already moving fast and a hard breath slams it into the back of the throat. Dry powder devices need the opposite: a fast, forceful breath from the very start, because the patient's own breath is the only energy that lifts the powder out of the capsule or reservoir and breaks it into particles small enough to reach the lungs.

That divide explains the most common errors. The same review recorded these as the most frequent in each group (PMID: 27060726):

Device group	Error	Share of observed tests
Aerosol inhaler	Poor coordination of press and breath	45%
Aerosol inhaler	Wrong speed or depth of breath	44%
Aerosol inhaler	No breath hold after inhaling	46%
Dry powder device	Dose prepared incorrectly	29%
Dry powder device	Not breathing out fully before inhaling	46%
Dry powder device	No breath hold after inhaling	37%

People who own both types, a powder preventer and an aerosol reliever for example, often carry one technique across to the other device. A hard, fast breath through an aerosol inhaler and a gentle, slow breath through a Rotahaler both waste most of the dose.

Aerosol inhalers: how they fail and how to fix them

The pressurized metered dose inhaler is the cheapest and most common device, and the hardest to use well without a spacer. The spray leaves the canister in a fraction of a second, so pressing too early sends it into the mouth, and pressing too late means the breath is already over.

1. Remove the cap and shake the inhaler. Prime it as the leaflet instructs if it is new or has not been used for a while.
2. Breathe out gently, away from the mouthpiece.
3. Seal your lips around the mouthpiece.
4. Start a slow breath in, then press the canister once while continuing to breathe in slowly and deeply for three to five seconds.
5. Hold your breath for up to ten seconds, or as long as is comfortable, then breathe out slowly.
6. If a second puff is prescribed, wait as the leaflet directs and repeat.
7. After a steroid-containing inhaler, rinse your mouth with water and spit it out.

This format includes Asthalin, Foracort 200, Seroflo 250, Budecort 200 and Tiova.

Spacers: the cheapest upgrade in asthma treatment

A spacer, or valved holding chamber, is a tube the aerosol is sprayed into before it is inhaled. It removes the timing problem entirely, slows the spray down, and lets the large particles that would have landed in the throat settle on the chamber wall instead. Less drug in the throat means less hoarseness and thrush from steroid inhalers, and more of the dose reaches the airways.

The strongest evidence for spacers comes from acute asthma. A Cochrane review of 39 trials in 1,897 children and 729 adults compared a reliever given by aerosol inhaler with a spacer against the same drug given by nebulizer. Hospital admission rates did not differ significantly. Children treated with a spacer left the emergency department sooner: the mean stay was 103 minutes with a nebulizer and 33 minutes shorter with a spacer. In adults length of stay was similar, and lung function results were similar in both groups (PMID: 24037768).

A spacer costs a few dollars, needs no power and delivers a reliever at least as well as a nebulizer for most attacks. Anyone using an aerosol inhaler for a steroid, and every child using an aerosol inhaler, should have one. Wash it in warm water with a little detergent and let it air dry rather than wiping it, because wiping builds up static that holds the drug on the chamber wall.

Synchrobreathe and other breath-actuated inhalers

A breath-actuated inhaler contains an ordinary aerosol canister, but the spray fires automatically when the patient starts to breathe in through the mouthpiece. It removes the press-and-breathe coordination step, which is the most common aerosol error. Cipla's version is called Synchrobreathe, and we stock Foracort 200, Foracort 400, Seroflo 250, Levolin, Maxiflo and Tiova in this format.

Two limits are worth knowing. The patient still needs a slow, deep breath and a breath hold afterwards; the device fixes timing, not the rest of the technique. And breath-actuated inhalers are designed to be used straight from the mouth rather than through a spacer, so for young children and anyone who needs a spacer, a standard aerosol inhaler with a chamber is usually the better choice.

Rotacaps with a Rotahaler or Revolizer

Rotacaps are capsules of dry powder that are loaded one at a time into a small device, the Rotahaler or the Revolizer, which opens or pierces the capsule so the powder can be inhaled. There is no propellant and no timing to get right, and there is a visible check that the dose has been taken.

1. With dry hands, take a capsule out of the strip only when you are about to use it. Powder in a capsule left out in humid air clumps and disperses poorly.
2. Load and open the capsule exactly as the leaflet for your device shows. The two devices load differently.
3. Breathe out fully, away from the device. Breathing into it pushes moisture onto the powder.
4. Seal your lips around the mouthpiece and breathe in quickly and deeply from the very start of the breath.
5. Hold your breath for up to ten seconds, then breathe out away from the device.
6. Open the device and look at the capsule. If powder remains, inhale again from the same capsule, then discard it.
7. After a steroid-containing capsule, rinse and spit.

The capsule check is the real advantage of this format. An aerosol inhaler gives no feedback on whether the dose went in. A capsule that is still half full after inhaling tells the patient the breath was too weak or the capsule was not opened properly.

The limitation is flow. Because the breath does the work, anyone who cannot inhale forcefully, a young child, someone in the middle of a severe attack, or someone with advanced lung disease, may leave much of the dose behind. That makes powder devices a poor choice for a reliever that has to work during an attack.

Inhaler capsules are for inhaling, not swallowing

Capsules for inhalation look like oral capsules, and people swallow them. In 2008 the FDA issued a public health advisory after receiving reports of patients swallowing tiotropium and formoterol inhalation capsules instead of placing them in the device, and advised prescribers to ask patients who were not improving whether they were swallowing the capsules rather than inhaling them. A swallowed capsule does almost nothing for the lungs. Tiotropium taken by mouth, for example, has an oral bioavailability of only 2 to 3 percent according to its US label.

Keep Rotacaps in their strip next to the device, never in a pill organizer with tablets. If a capsule has been swallowed, check with a pharmacist before taking another dose that day.

Turbuhaler and Ciphaler: multi-dose powder devices

Multi-dose powder devices hold a month or more of doses inside, in a reservoir or on a sealed strip, and load one dose at a time with a twist or a lever. The Symbicort Turbuhaler uses a reservoir. Cipla's Seroflo 250 Ciphaler and Seroflo 500 Ciphaler use a sealed strip.

• Load the dose exactly as shown. For a Turbuhaler that means holding it upright while twisting the base one way and back.
• Do not shake a powder device after loading, and never breathe out into it; moisture clumps the powder.
• Breathe in fast and deep, as with a capsule device.
• Many people feel or taste nothing with a Turbuhaler, because each dose is a tiny amount of powder. That is normal and not a sign the dose was missed, which is why the dose counter matters.

Multi-dose devices suit people who find capsules fiddly, including those with arthritis or poor eyesight, provided they can produce a strong enough breath.

Respules and nebulizers: when they earn their place

Respules are single-dose plastic ampoules of liquid drug that are emptied into a nebulizer, which turns the liquid into a mist breathed in normally over several minutes through a mouthpiece or mask. They need no technique at all, and that is their whole advantage.

That advantage is real for infants and young children who cannot manage a spacer and mask, for some people with severe physical or cognitive limitation, and in hospital during severe attacks when oxygen is being given at the same time. Nebulized budesonide is also one of the few inhaled steroid options licensed for very young children in some countries. We stock Budecort, Foracort, Levolin, Asthalin and Duolin respules.

The disadvantages are just as real. A nebulizer session takes several minutes and needs power, a compressor and regular cleaning. As the Cochrane review above showed, it is not more effective than an aerosol inhaler with a spacer for a reliever. Budesonide suspension is labeled for use with a jet nebulizer, and the Pulmicort Respules label states that ultrasonic nebulizers are not suitable for it. A face mask leaves steroid on the skin around the nose and mouth, so wipe the face after steroid respules. The ipratropium in Duolin can widen the pupil and blur vision if mist reaches the eyes, so a well-fitting mask or a mouthpiece matters.

Matching the device to the person

Situation	Usually works	Usually fails
Children under 5	Aerosol inhaler with spacer and mask; nebulizer if a spacer is not tolerated	Powder devices and breath-actuated inhalers
Older children and adults with good technique	Any device; powder devices are convenient	Whichever device is used without being taught
Arthritis or weak grip	Breath-actuated inhaler or multi-dose powder device	Pressing an aerosol canister
Relief during an attack	Aerosol reliever with a spacer	Powder devices, because inspiratory flow falls as an attack worsens
Severe COPD with weak inspiration	Aerosol or breath-actuated inhaler with good technique; low-resistance capsule devices if flow is adequate	Devices that need a strong, fast breath

Inspiratory flow is the limiting factor in that last row. The US label for the Spiriva HandiHaler, a low-resistance capsule device, states that it releases powder at flows as low as 20 liters per minute. In 26 patients with severe COPD the median peak flow through the device was 30 liters per minute, with a range of 20.4 to 45.6, and the device's standard delivered dose is measured at 39 liters per minute. Even a device designed for weak breathers is working close to its floor in severe disease.

Switching device is switching dose

The amount of drug that reaches the lungs differs between the aerosol, powder and nebulized versions of the same molecule, and for budesonide those differences are meaningful (PMID: 11475468). Labeling adds a second layer of confusion. Some products state the metered dose, what leaves the capsule or valve, and others state the delivered dose, what leaves the mouthpiece. Symbicort Turbuhaler 160/4.5 is labeled by delivered dose and corresponds to a metered 200 mcg of budesonide with 6 mcg of formoterol, the figure Foracort 200 prints. Same drug, described two ways.

A change of device is therefore a change the prescriber should know about, and asthma control over the following weeks is the real test of whether the new device is delivering. How the fluticasone and budesonide combinations compare on dose is set out in our Advair vs Symbicort comparison.

Counters, storage and cleaning

• An aerosol inhaler keeps spraying propellant after the labeled number of doses has been used, so a canister that still puffs is not proof that it still contains drug. Use the dose counter, or count doses and write the start date on the canister if there is no counter.
• Clean the plastic actuator of an aerosol inhaler as the leaflet instructs and let it dry fully. A blocked actuator is a common cause of a weak spray.
• Keep powder devices and capsules dry. A bathroom cabinet is the worst place to store them.
• Keep aerosol canisters away from heat and never puncture them.
• Once a respule foil pouch is opened, use the ampoules within the time printed on the pack, protected from light.
• Rinse and dry the nebulizer cup after every use and replace tubing and cups on the manufacturer's schedule.

What we stock in each format

Drug	Aerosol inhaler	Breath-actuated	Rotacaps	Multi-dose powder	Respules
Budesonide with formoterol	Foracort 100, 200, 400	Foracort 200, 400	Foracort 100, 200, 400	Symbicort 80, 160, 320	Foracort 0.5 mg, 1 mg
Fluticasone with salmeterol	Seroflo 50, 125, 250	Seroflo 250	Seroflo 100, 250, 500	Seroflo 250 Ciphaler, 500	None
Budesonide	Budecort 100, 200	None	Budecort 200, 400	None	Budecort 0.5 mg, 1 mg
Salbutamol	Asthalin	None	Asthalin	None	Asthalin
Levosalbutamol	Levolin	Levolin	Levolin 100	None	Levolin 0.31 mg, 0.63 mg, 1.25 mg
Tiotropium	Tiova	Tiova	Tiova	None	None

The capsule devices are sold separately: the Rotahaler at $6.00 and the Revolizer at $12.00.

When technique is not the problem

Checking technique is the first step when asthma is poorly controlled, because problems are common, cheap to fix and easy to overlook. It is not the only step. If technique has been checked and corrected and a reliever is still needed more than a couple of times a week, or night waking continues, the controller treatment, adherence, triggers and even the diagnosis need reviewing with a prescriber. Our guides to budesonide with formoterol, Advair vs Symbicort and montelukast cover the controller options, and our asthma treatment overview shows how they fit together.

Ask a pharmacist, nurse or prescriber to watch you use your inhaler at least once a year and whenever the device changes. Most technique errors are invisible to the person making them.

Medical disclaimer

This article is educational and does not replace advice from a qualified healthcare professional. Inhaled asthma and COPD medicines are prescription medicines in the United States, United Kingdom, Canada and Australia. Device instructions vary between manufacturers, and the leaflet supplied with your device takes priority over any general description here. A change of device can change the dose reaching the lungs and should be discussed with your prescriber. Worsening breathlessness, or a reliever that is no longer working, needs urgent medical assessment.

References

• Sanchis J, Gich I, Pedersen S. Systematic review of errors in inhaler use: has patient technique improved over time? Chest 2016. PubMed PMID: 27060726.
• Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2013. PubMed PMID: 24037768.
• Clinical pharmacokinetics of inhaled budesonide. PubMed PMID: 11475468.
• US Food and Drug Administration, Public Health Advisory on the correct use of Spiriva and Foradil capsules, 2008.
• FDA prescribing information, Spiriva HandiHaler: device performance and clinical pharmacology sections.
• FDA prescribing information, Pulmicort Respules: dosage and administration.
• Global Initiative for Asthma, inhaler device selection for children 5 years and younger.

Related reading on asthma treatment

For how the two main combination inhalers compare, see Advair vs Symbicort. For the long-acting muscarinic bronchodilator used in COPD and severe asthma, see our tiotropium guide. Reliever choice is covered in salbutamol vs levosalbutamol. The full range is on our asthma and respiratory medicines page.