COPD Exacerbation: Inhaler Technique and Smoking
Your Role — Doctor
General Practice
Your 62-year-old patient with COPD has had three exacerbations in the past year and attends after a recent course of steroids and antibiotics. You suspect poor inhaler technique and ongoing smoking are contributing. The patient is defensive about smoking and believes the inhalers 'don't work'. You need to review inhaler technique, explore smoking, and motivate change without lecturing.
- •Explore the patient's understanding of COPD and their experience of the recent flare-ups, showing empathy for how frightening breathlessness can be.
- •Ask the patient to describe or demonstrate how they use their inhalers; identify and gently correct technique errors, and consider a spacer.
- •Explore smoking sensitively without judgement — ask permission to discuss it, elicit the patient's own reasons for and against quitting.
- •Offer concrete support: nicotine replacement or other stop-smoking medication, referral to a stop-smoking service, and explain the benefit of stopping even at this stage.
- •Agree a realistic shared plan (inhaler review, pulmonary rehab, vaccinations, a rescue plan) and arrange follow-up.
The Interlocutor
Played by the actor / assessor
You are 62 and have COPD. You've had several bad chest infections this year and hate feeling breathless. You've smoked since you were 16 and feel it's too late to bother stopping now. You think the inhalers don't really help, and you feel a bit told-off by doctors about smoking, which makes you defensive.
- •Describe how the recent flare-up left you frightened and unable to walk to the shops.
- •When asked to show how you use your inhaler, describe taking a quick puff without breathing in deeply or holding your breath — you didn't know there was a technique.
- •Be defensive if smoking is raised bluntly ('here we go again'), but soften if the doctor is respectful and non-judgemental.
- •Say you feel it's too late to quit after all these years, and you enjoy it — it's one of your few pleasures.
- •If the doctor explains the benefits clearly and offers real support, agree to try nicotine patches and a stop-smoking referral, and to have your inhaler technique checked.
Sample Role-play
Hello Mrs Doyle, I'm Dr Amin. I'm sorry to hear you've had another rough patch with your chest. How are you feeling now compared to a couple of weeks ago?
A bit better, but honestly it terrified me. I couldn't even walk to the corner shop without stopping to catch my breath.
That sounds really frightening — being that breathless is horrible, and I'm glad you came in. I'd like to work out together why these flare-ups keep happening, so we can cut down how often they hit you. Would that be okay?
Yes, but I'll tell you now, those inhalers don't do a thing for me.
That's really useful to know — if they're not helping, we need to sort that out. Sometimes it's the medicine, but often it's about how the inhaler is used, which is easy to get slightly wrong. Would you mind showing me how you normally take it?
I just press it and take a quick puff, like this. That's all there is to it, isn't there?
Thank you for showing me — that explains a lot. The trick is to breathe out first, then as you press, breathe in slowly and deeply, and hold your breath for about ten seconds so the medicine reaches deep into your lungs. A little device called a spacer can make it much easier. Shall we practise together and get you one?
Nobody ever showed me that. Alright, I'll give it a go.
Wonderful. There's one other thing that would make a big difference, and I want to raise it respectfully — would it be alright to talk about smoking?
Here we go. Look, I've smoked for forty-odd years, it's too late now, and it's one of the only things I enjoy.
I hear you, and I'm not here to lecture you. What I can tell you honestly is that it's never too late — stopping now genuinely slows the damage and cuts these flare-ups, whatever your age. Can I ask, is there any part of you that has thought about cutting down?
I suppose these chest infections are scaring me. I just don't think I can do it on my own.
You wouldn't have to. Most people who succeed use support — I can prescribe nicotine patches to take the edge off the cravings, and refer you to our stop-smoking service who'll coach you through it. Combined, that gives you a real chance. Would you be willing to try that?
Alright. If it'll stop me ending up breathless like that again, I'll try the patches and see the service.
That's a brave decision and I'm really pleased. So: we'll fix your inhaler technique with a spacer today, start the patches, refer you for stop-smoking support and pulmonary rehab, and make sure your vaccinations are up to date. Let's meet again in a month. Well done for taking this on.
Useful Phrases
Clinical Background
COPD exacerbations accelerate lung-function decline and increase mortality. Key modifiable factors: inhaler technique (commonly poor), smoking, vaccination status (influenza, pneumococcal, COVID), and pulmonary rehabilitation. Smoking cessation is the single most effective intervention at any stage. Use pharmacotherapy (NRT, varenicline/bupropion) plus behavioural support. Motivational interviewing — eliciting the patient's own reasons — outperforms directive advice for behaviour change.
Common Mistakes to Avoid
- ✕Raising smoking bluntly or with visible judgement, triggering defensiveness and disengagement.
- ✕Assuming the inhalers are ineffective without checking technique first.
- ✕Advising the patient to 'just stop smoking' without offering concrete pharmacological and behavioural support.