Inhaler prescribing looks simple and is not. There are over 120 inhaler device and drug combinations licensed in the UK, the terminology has shifted with AIR and MART therapy, and a correct-looking prescription can still fail because the patient cannot use the device. Choosing an inhaler is really choosing a drug, a device, a dose, a regimen, a behaviour and a follow-up plan at once, which is why errors are common. This guide sets out how RightBreathe, the BNF and national guidance each help, the mistakes clinicians most often make, and where the harder clinical reasoning sits.
In brief: RightBreathe is useful for identifying the inhaler device and product; the BNF is used for prescribing details such as dose, cautions and interactions; NICE, BTS and SIGN guidance covers asthma and COPD diagnosis and stepwise management; and a reasoning tool such as iatroX helps decide whether the underlying question is really diagnosis, escalation, technique or safety-netting.
Key takeaways
- There are over 120 licensed inhaler device and drug combinations in the UK, which makes selection genuinely complex.
- RightBreathe helps with device and product choice; the BNF with prescribing detail; national guidance with management.
- The 2024 asthma guidance shifted to AIR and MART, and no patient should have a SABA without a regular ICS.
- Common errors include ignoring technique, duplicating drug classes, and treating asthma and COPD the same.
- The inhaler decision often hides a diagnostic, escalation or safety-netting question that needs clinical reasoning.
Why inhaler prescribing is harder than it looks
Several things conspire to make this difficult. There are more than 120 device and drug combinations, so the choice space is large and unfamiliar. Brand and device confusion is common, because the same drug can come in different devices that require completely different techniques. Inhaled corticosteroid dose equivalence is not intuitive, since low, medium and high doses differ by molecule and device. The terminology has changed, with AIR and MART now central. Local formularies vary, so the "right" product differs by area. There is growing, legitimate pressure to consider the environmental impact of inhalers. And underneath all of it, the patient's own inspiratory flow and technique determine whether any of it works. A prescription that is perfect on paper is useless if the patient cannot generate the flow the device needs, or cannot coordinate the actuation.
What RightBreathe is best for
RightBreathe is the tool for the device and product question. It is a web-based NHS resource, created by NHS pharmacists and doctors and now maintained by the NHS London Procurement Partnership, that covers every UK-licensed inhaler and spacer for asthma and COPD. It is strongest for identifying device type, drug class, dose counter presence, spacer compatibility and product comparison, and it links to technique videos for every device, which is genuinely useful for supporting patients. One caveat worth knowing: RightBreathe references London prescribing pathways, which may not match your local formulary, so treat its pathway suggestions as a starting point and check your own area's preferred products. For the "which device and product" part of the decision, it is the best single resource.
What the BNF is best for
The BNF is the reference for the prescribing detail once you know roughly what you want. It is where you confirm the dose, the cautions, the contraindications, the interactions and the licensing particulars, and it is the authoritative national drug reference for those facts. RightBreathe tells you the product exists and what device it is; the BNF tells you how to prescribe it safely. For licensing specifics and any ambiguity about a particular product's licensed dose, the summary of product characteristics is the definitive source. Used together, RightBreathe and the BNF cover product selection and safe prescribing detail respectively.
What national guidance is best for
For diagnosis and management, national guidance leads. The 2024 joint NICE, BTS and SIGN asthma guideline covers diagnosis, monitoring and stepwise management, and it made significant changes that every prescriber needs to understand. NICE's COPD guideline covers COPD management, which follows a different logic. These guidelines, not a product database, are where you decide whether a patient needs to step up, step down, be reviewed, referred or acutely managed, and they set the framework within which RightBreathe and the BNF are used. Getting the guidance right is prior to getting the product right.
AIR and MART, explained
This is the change that catches people out, so it is worth being precise. When an ICS-formoterol inhaler is used as needed for symptom relief, that is Anti-Inflammatory Reliever therapy, or AIR. When the same ICS-formoterol inhaler is used both regularly for maintenance and as needed for relief, that is Maintenance And Reliever Therapy, or MART. The logic is that formoterol works as quickly as salbutamol, so an ICS-formoterol reliever treats the acute symptoms while also delivering the inhaled steroid that addresses the underlying inflammation. A crucial consequence follows: a patient on MART generally does not need a separate short-acting reliever, because their ICS-formoterol inhaler is the reliever. The guidance also makes clear that no patient should be prescribed a SABA without a regular ICS, and it supports patients self-titrating between AIR and MART. This is a genuine culture change from the old preventer-plus-blue-reliever model, and prescribing as if nothing has changed is now a mistake.
SABA overuse as a safety signal
Excessive short-acting reliever use is not just a prescribing quirk; it is a warning. Overuse of SABAs is associated with an increased risk of asthma attacks and death, so a patient collecting frequent salbutamol canisters is signalling poorly controlled asthma that needs review, not just a repeat prescription. When you see high reliever use, the response is to review control, technique and adherence, consider whether the patient should move to AIR or MART, and treat it as the red flag it is. Reissuing the reliever without asking why it is being used so much misses the point of the signal.
The common inhaler prescribing mistakes
Held against all of this, the recurring errors are clear:
- Treating inhalers as interchangeable. Device, technique and inspiratory flow all matter; switching device without checking the patient can use the new one causes failure.
- Not checking technique. The correct prescription still fails if technique is wrong, so review, demonstration and community pharmacy support matter as much as the choice.
- Duplicating drug classes. Prescribing two LABAs or two ICS across separate inhalers, or muddling triple therapy, is a genuine safety issue.
- Misunderstanding MART and AIR. Leaving a MART patient on a separate SABA, or not explaining self-titration, undermines the regimen.
- Ignoring exacerbation history. Steroid or antibiotic courses, emergency attendances, night symptoms and rescue use should change the plan.
- Treating COPD and asthma as the same. The diagnosis, the escalation logic and the role of inhaled steroids all differ, and COPD decisions should follow COPD guidance.
- Missing red flags. Haemoptysis, weight loss, hypoxia, chest pain or unexplained breathlessness need investigation, not another inhaler.
- Forgetting environmental considerations. Lower-carbon options matter, but never at the expense of the patient's control or ability to use the device.
A practical workflow
Putting it together, a safe sequence is: first, confirm the diagnosis and assess control, because the product is downstream of that. Second, check what the patient is currently prescribed and actually using. Third, check technique and adherence, since these explain many apparent failures. Fourth, use RightBreathe for device and product selection. Fifth, use the BNF for the prescribing detail. And sixth, use a reasoning tool to sense-check the diagnosis, escalation and safety-netting before you finalise. The product choice is one step near the end, not the whole task.
Where iatroX fits
The most useful thing to notice is that an inhaler question is often not really about the inhaler. Is this asthma, COPD, overlap, heart failure, anxiety, infection, poor technique or non-adherence? Does the patient need step-up, step-down, review, referral or acute management? What should you safety-net? These are diagnostic and reasoning questions, and they are where iatroX helps: Ask iatroX answers grounded in NICE, CKS, SIGN and the SmPC with the source attached, and its reasoning support helps work through the differential and the escalation logic before you change an inhaler. Use RightBreathe for the device, the BNF for the prescribing detail, and iatroX for the clinical reasoning behind the change. Try it at Ask iatroX, and for how these tools sit together in practice, see the hidden GP software stack and what GP templates can and cannot do.
Frequently asked questions
Is RightBreathe a prescribing guideline? No. RightBreathe is a resource for identifying inhaler devices and products and supporting technique, not a management guideline. Use national guidance for diagnosis and stepwise management, the BNF for prescribing detail, and note that RightBreathe's pathway suggestions reference London and may not match your local formulary.
What is MART? Maintenance And Reliever Therapy: using a single ICS-formoterol inhaler both regularly for maintenance and as needed for relief. Because formoterol acts as fast as salbutamol, the reliever also delivers inhaled steroid, and a patient on MART generally does not need a separate short-acting reliever.
Why is SABA overuse a concern? Because overuse of short-acting relievers is linked to an increased risk of asthma attacks and death. High reliever use signals poorly controlled asthma and should prompt review of control, technique, adherence and whether to move to AIR or MART, not simply a repeat prescription.
Should all inhalers be prescribed by brand? Prescribing by brand or specified device is generally recommended for inhalers, because the device and technique are integral to the treatment and substitution can change what the patient receives. Follow national and local guidance on this, and check the specific product.
When should a patient with breathlessness be referred rather than given an inhaler? When there are red flags, such as haemoptysis, weight loss, hypoxia, chest pain or unexplained breathlessness, or diagnostic uncertainty, or failure to respond as expected. These need investigation and reasoning, not another inhaler, which is where checking the differential matters.