Please can you provide some guidance on the correct inhalation technique
for MDI plus spacer?  Thanks.

-- gumbo

If I may say so, you seem to have touched upon a very important issue by
saying that pursed lips breathing is difficult to keep up. I've seen
enough photos of asthmatics sitting in disused mines (where the air is
supposed to be so healthy) in deck chairs and doing PLB for hours on
end.  Then there are photos of some extremely healthy-looking professor
of respiratory medicine doing a demonstration.  Nowhere does the extreme
effort needed to curb an actual attack come over.

For a better description of PLB see
http://www.perf2ndwind.org/html/breathing.html:

"....Your problem now is working on getting
air out of your lungs. You now need to breathe out 2 or 3 times longer
than you breathe in. If you panic and breathe too fast, or breathe in
and out at the same rate, you will cause more air trapping and get more
short of breath. In our studies, patients who did good pursed lip
breathing (PLB) slowed down to about 10 breaths a minute at rest."

(According to Dr. Celli
(http://www.postgradmed.com/issues/1998/04_98/celli.htm) the actual
effect of PLB is not because of back pressure to keep the airways open,
but is due to some other effect. A reflex?)

Professor D. Hillsman writes
(http://www.ohiou.edu/isarp/conf_02/papr_4.htm) on prolonging the exhale
for COPD but also with some emphasis on asthma:

"The commonest and usually best deflation strategy is a non-forced, or
minimally forced, prolongation of the expiratory time by approximately
25%. This will minimize the problem of Dynamic Bronchial Compression
(DBC) as discussed below.

Repeated over several breaths all Dynamic Hyperinflation should be
corrected, and the patient comfortable within 10 or so breaths."

And "Patients should be thoroughly instructed in recognizing and
avoiding the Rescue Breathing Pattern which is a common psychological
based reason for acute dyspnea attacks. Anxiety is a common trigger for
hyperventilation, and anxiety based on the dyspnea sensation is a
particularly powerful emotional stimulus to induce hyperventilation. In
the COPD patient this can trigger Dynamic Hyperinflation.

Typically a COPD patient will experience mild exertion dyspnea, become
anxious, hyperventilate, and promptly convert a mild dyspnea situation
into a severe dyspnea attack."

This on the one hand says precisely what is to be done and also avoids
any tactless use of the word panic.

Another breathing technique which is poorly explained is diaphragmatic
breathing, see Hillsman's objections to merely "belly puffing"

It seems that to be done correctly diaphragmatic breathing should give
the feeling that the diaphragm is directly wired to the feeling of
suction in the nose and closed mouth.  The tongue is laid against the
front teeth and there is sensation of air flowing through the nose and
probably operating a reflex to open the lung airways (nasopulmonary
reflex). Correct diaphragmatic breathing should give rise to a yummy
feeling the lower abdomen

In conclusion I do reckon that this sort of diversification could make
asthma advice much more effective.  If folks remain in good contact with
their docs, the defusing effect (reduction in fear) should not impair
safety.

A last point would be that if breathing exercises - like f. i. 4 secs.
inhale, 3 secs. hold and then 6 secs. exhale - are done before going to
bed at night, the rhythm may maintained all night and this may serve to
avoid asthmatic hyperventilation. You may sleep sweetly with less
asthmatic episodes.  Richard Friedel