Metered dose inhaler MDI: Overview, Uses and Top Manufacturer Company

H2: Introduction

Metered dose inhaler MDI is a handheld, pressurized inhalation medical device designed to deliver a measured (metered) amount of medication to the lungs with each actuation (“puff”). It is widely used across outpatient care, emergency departments, inpatient wards, and community settings because it can provide rapid, portable, and repeatable medication delivery when used with correct technique.

A useful terminology note: in many clinical and regulatory contexts, “MDI” is shorthand for pressurized metered-dose inhaler (pMDI) to distinguish it from other inhaler families such as dry powder inhalers (DPIs) or soft-mist inhalers (SMIs). This article uses the term Metered dose inhaler MDI in the broad, common sense (a pressurized, canister-based metered inhaler), but the practical point remains: different inhaler types have different technique requirements, and swapping device types without retraining can cause avoidable under-treatment.

For clinicians and trainees, Metered dose inhaler MDI sits at the intersection of pharmacology and procedure: the same medication can have very different effects depending on how the device is operated. For hospitals, this clinical device also creates operational questions about formulary standardization, staff competency, infection prevention, patient education, and supply continuity.

It also intersects with broader systems issues that are easy to overlook at the bedside: medication reconciliation when patients bring in home inhalers, differences between brand and generic device handling, pressurized-container storage policies, and (in many health systems) increasing attention to propellant-related environmental impact as organizations pursue sustainability targets. These system factors don’t replace clinical decision-making, but they do shape how reliably patients receive inhaled therapy in real-world care.

This article provides general educational and operational information—not medical advice. You will learn how Metered dose inhaler MDI works, common use cases and limitations, what to check before use, basic operation steps that are broadly applicable, safety and human-factors risks, how to “interpret” device-related outputs (such as dose counters and technique indicators), troubleshooting expectations, cleaning and infection control principles, and a practical global market overview to support procurement and service planning.

H2: What is Metered dose inhaler MDI and why do we use it?

Definition and purpose (plain language)

A Metered dose inhaler MDI is a pressurized canister-and-actuator system that releases a fixed, pre-measured amount of aerosolized medication each time it is actuated. The goal is to deliver medication to the airways and lungs efficiently, using inhalation as the route of administration.

In many health systems, an inhaler product is a drug–device combination: the medication formulation and the device must work together. Because of that, instructions for use and performance characteristics can vary by manufacturer.

In operational terms, an MDI’s “promise” is consistency: the device is designed so that each actuation dispenses a defined volume from a metering chamber/valve. However, the delivered lung dose is influenced by patient technique, accessory use, and the clinical context (e.g., acute dyspnea vs stable baseline breathing). That is why many institutions treat inhaler technique as a clinical skill rather than “just giving a medication.”

Common clinical settings

Metered dose inhaler MDI is encountered in a wide range of settings, including:

• Primary care and specialty clinics (e.g., chronic respiratory disease follow-up)
• Emergency department (ED) for acute symptoms when appropriate under local protocols
• Inpatient wards for ongoing therapy during hospitalization
• Perioperative and procedural areas where patients may need inhaled therapy
• Long-term care and home care where portability and simplicity can matter

Additional settings where MDIs frequently appear (depending on country and model of care) include ambulance/prehospital services, school health programs, community pharmacies running inhaler-technique checks, and telehealth workflows where clinicians must coach technique remotely. Even when the prescriber and diagnosis are unchanged, technique coaching may need to be adapted to the setting—for example, what is feasible in a calm clinic room may not be feasible during an ED surge without standardized teaching aids and a clear team role assignment.

Some facilities also use Metered dose inhaler MDI with specific adapters or techniques in critical care environments; this is highly protocol- and product-dependent.

Key benefits for patient care and workflow (general)

When compared with some other delivery methods, Metered dose inhaler MDI can offer practical workflow advantages:

• Portability and speed: minimal setup compared with some aerosol systems
• Dose repeatability: each actuation is intended to deliver a consistent metered amount (within labeling specifications)
• Scalability: easier to stock and dispense than many larger pieces of hospital equipment
• Patient self-administration potential: appropriate in some care models with supervision and education
• Reduced reliance on powered equipment: no compressor or electrical supply is required for standard use

These advantages only translate into clinical value when technique is correct and the right medication/device is selected.

From a hospital operations perspective, another frequently cited advantage is that MDIs can reduce reliance on shared aerosol-generating equipment in some workflows. In certain infection prevention strategies, facilities may prefer MDI-with-spacer pathways over nebulization where clinically appropriate and supported by local policy. This is not a blanket rule—patient condition and protocol always come first—but it illustrates why inhaler availability and training can affect both bedside care and system throughput.

How it functions (mechanism overview)

While designs vary, most Metered dose inhaler MDI systems include:

• A pressurized canister containing medication (often in solution or suspension) and a propellant
• A metering valve that measures a fixed volume for each actuation
• A plastic actuator with a mouthpiece/nozzle that shapes the spray plume

When the user presses the canister into the actuator, the valve releases the metered volume, producing an aerosol plume. The patient’s inhalation carries particles into the airways. Because timing matters, many institutions encourage the use of a spacer or valved holding chamber (an accessory that holds the aerosol briefly and can reduce coordination demands). Breath-actuated versions also exist; their operation differs and is manufacturer-specific.

A few additional, practical details help explain why technique and maintenance matter:

• Solutions vs suspensions: Some MDI formulations are true solutions; others are suspensions with drug particles dispersed in propellant. Suspensions often require shaking to reduce dose variability between early and later puffs.
• Nozzle geometry matters: The actuator’s nozzle shapes plume velocity, spray pattern, and particle size distribution. In many products, the canister and actuator are designed as a matched pair; swapping actuators between products can lead to unexpected performance differences.
• Plume velocity and oropharyngeal deposition: MDIs generate a fast-moving plume. If the patient inhales too late, too fast, or does not seal well, more medication may impact the mouth/throat rather than reaching lower airways. Spacers and careful coaching can mitigate this.
• Priming and re-priming: Some devices require priming sprays into the air before first use or after prolonged non-use. Priming improves dose consistency but “uses up” actuations, which has implications for dose counters and inventory planning.

How medical students encounter Metered dose inhaler MDI in training

Trainees commonly learn Metered dose inhaler MDI through multiple lenses:

• Preclinical pharmacology: inhaled bronchodilators and inhaled anti-inflammatory therapies (drug classes vary)
• Physiology and pathophysiology: airflow limitation, airway hyperresponsiveness, and deposition concepts
• Clinical skills and OSCEs: teaching inhaler technique with demonstration and “teach-back”
• Inpatient rotations: medication reconciliation, discharge planning, and device counseling
• Interprofessional practice: working with nursing, respiratory therapy, and pharmacy on standardized education and safe administration

In many hospitals, the difference between “the patient has an inhaler” and “the patient is receiving inhaled therapy effectively” is largely determined by training, observation, and process reliability.

In practice, students also see how inhaler technique becomes a systems problem: a patient may be switched to a hospital formulary product with a different feel, different counter behavior, or different priming steps; a caregiver may be the one administering at home; or a language barrier may make “quick teaching” ineffective. These experiences are often where trainees learn the value of structured checklists, standardized teaching scripts, and involving pharmacy/respiratory therapy early—especially before discharge.

H2: When should I use Metered dose inhaler MDI (and when should I not)?

Appropriate use cases (general)

Metered dose inhaler MDI is used when a clinician has ordered a medication that is formulated for delivery via an MDI device and when the patient and care environment can support correct operation. Common, broad scenarios include:

• Maintenance therapy for chronic respiratory conditions when prescribed
• Reliever/rescue therapy where an MDI formulation is ordered and appropriate under local protocols
• Transition of care (e.g., discharge) when continuing inhaled therapy outside the hospital is planned
• Supervised self-administration models in clinics or wards, when supported by competency checks

In selected settings, a facility may have protocols for Metered dose inhaler MDI use with specific accessories (e.g., spacers, masks, or circuit adapters). These workflows should be treated as protocolized procedures, not improvised.

Operationally, MDIs are also common when continuity matters: for example, a patient who already uses an MDI at home may benefit from maintaining a consistent device type (when clinically and formulary-appropriate) so that technique teaching in the hospital directly transfers to home use. Similarly, for patients who travel or work in environments where portability is essential, an MDI can be easier to carry than equipment-dependent options.

Situations where it may not be suitable

Metered dose inhaler MDI may be less suitable when:

• The patient cannot coordinate actuation and inhalation and no appropriate accessory (e.g., spacer) is available
• The patient cannot create an effective seal around the mouthpiece (or an appropriate mask is not available)
• The patient’s condition or environment requires an alternative delivery method per local clinical protocols
• The specific medication needed is not available in an MDI formulation on the local formulary
• There is device damage, contamination concern, or unclear labeling that could create a medication safety risk

This section is not a substitute for clinical decision-making; it is an operational framing of common constraints.

Additional, real-world constraints that can make MDI use challenging include severe fatigue or tachypnea (making breath coordination difficult), delirium or cognitive impairment, significant tremor or arthritis (limiting the ability to press the canister), and poor vision (difficulty reading labels or counters). These are not always absolute barriers, but they increase the need for accessories, caregiver involvement, and close observation.

Safety cautions and contraindications (general, non-drug-specific)

Contraindications are usually medication-specific, not device-specific, and depend on the active ingredient and patient factors. Device-related cautions commonly include:

• Pressurized container precautions: avoid puncturing, crushing, or exposing to excessive heat; warnings vary by manufacturer
• Wrong-device/wrong-drug risk: multiple inhalers can look similar; do not rely on color alone
• Technique-dependent delivery: incorrect technique can result in under-delivery or deposition in the mouth/throat rather than the lungs
• Cross-contamination risk: shared use can transmit microorganisms; policies often specify single-patient use

Some additional, operational cautions that frequently appear in manufacturer labeling and facility policies include: avoiding storage in vehicles or near heat sources that can exceed recommended temperature ranges; keeping the mouthpiece capped to reduce contamination and blockage; and avoiding unapproved modifications such as homemade spacers or adapters. For certain medication classes delivered by MDI, patient counseling may include hygiene steps such as mouth rinsing after dosing; this is medication- and product-dependent and should follow the prescriber’s direction and the IFU.

Emphasize clinical judgment, supervision, and local protocols

Metered dose inhaler MDI is deceptively simple. Safe use depends on:

• A valid clinical order and local guideline alignment
• Staff competency and observation of technique
• Pharmacy and procurement controls to ensure the correct product is supplied
• Following the manufacturer’s IFU (Instructions for Use) and facility policies

A helpful mental model for teams is to treat inhaler administration like any other bedside procedure: the device is small, but the task includes preparation, patient positioning, coaching, assessment of response, and documentation. When institutions embed that mindset into standard work (rather than leaving technique to chance), both safety and effectiveness tend to improve.

H2: What do I need before starting?

Required setup, environment, and accessories

Before using Metered dose inhaler MDI in a clinical environment, teams typically ensure:

• The correct medication product (right formulation and device type)
• A clean, intact inhaler actuator and cap
• Any required accessory, such as a spacer/valved holding chamber, mask, or adapter (varies by patient population and protocol)
• A setting where staff can observe technique and where the patient can sit upright if feasible (clinical circumstances vary)

For hospitals, “accessories” are often the hidden operational bottleneck: spacers, masks, or single-patient mouthpieces may be stocked by central supply, respiratory therapy, or unit-based inventory depending on the institution.

It can also be helpful to confirm a few practical readiness items before the first dose on a unit:

• Patient-specific storage plan: where the inhaler will be kept (e.g., patient bin, locked drawer, medication room) to prevent mix-ups.
• Ability to coach and observe: enough time and privacy to watch at least one supervised dose when the inhaler is first introduced.
• Appropriate spacer selection (if used): pediatric vs adult chamber size, mask size and fit, and whether the spacer is designed to reduce static charge (which can affect aerosol retention).

Training and competency expectations

For safe, consistent use, many organizations treat Metered dose inhaler MDI administration as a teachable competency:

• Staff should be trained to demonstrate correct technique and to coach patients using teach-back.
• New staff and rotating trainees benefit from standardized checklists and observation.
• Patient education should be documented in a way that supports continuity across shifts and across care settings.

Competency programs often involve nursing, respiratory therapy (where available), and pharmacy education teams.

In mature programs, organizations also build in refresh cycles: technique is assessed at admission, rechecked after device substitutions, and revalidated at discharge. Some teams use placebo inhalers and demonstration spacers to reduce waste and avoid accidental medication exposure during teaching.

Pre-use checks and documentation

Common pre-use checks (always follow the specific product IFU) include:

• Confirm the patient identity and the medication order (the “rights” of medication administration)
• Inspect for damage, missing parts, or visible debris in the mouthpiece
• Check expiration date and, if present, the dose counter status
• Verify the canister is properly seated and that the cap is removed
• If required, prime the inhaler (priming instructions vary by manufacturer and by time since last use)

A commonly missed pre-use check in inpatient settings is verifying that the inhaler is the correct patient’s inhaler when multiple patients on a unit have similar products. Clear labeling and a consistent storage location help prevent wrong-patient errors.

Documentation considerations in hospitals can include:

• Recording administration in the medication administration record (MAR/eMAR)
• Capturing patient education (and whether technique was observed)
• Tracking lot/serial information when required by local policy (varies by jurisdiction and product)

Some facilities also document the use of a spacer (and the type), because accessory use can change technique requirements and can be important context for troubleshooting “medication not working” reports. Where barcode medication administration exists, scanning the inhaler packaging (or a patient-specific label) can add an extra layer of selection safety.

Operational prerequisites (commissioning, maintenance readiness, consumables, policies)

Unlike capital hospital equipment, Metered dose inhaler MDI typically does not require biomedical “commissioning” in the traditional sense. Operational readiness still matters:

• Policies: single-patient use rules, labeling standards, storage location, and discharge handling
• Consumables: spacers, masks, one-way valves, and cleaning supplies (as applicable)
• Maintenance readiness: clear responsibility for cleaning reusable accessories and replacing damaged parts
• Medication governance: formulary alignment, therapeutic interchange procedures, and shortage plans

Additional operational prerequisites that frequently determine success include:

• Standard teaching materials (multilingual when possible) so patients receive consistent messages.
• Shortage playbooks that anticipate not only drug substitution, but also device substitution (and therefore retraining needs).
• Stock rotation and recall workflows suitable for pressurized products, including “first-expire/first-out” practices and clear quarantine processes for recalled lots.
• Disposal procedures for pressurized containers and partially used patient-specific inhalers, aligned with local environmental health and safety rules.

Roles and responsibilities (clinician vs. biomedical engineering vs. procurement)

Roles vary by institution, but a common division of labor is:

• Clinicians (physicians/APPs): prescribe, align with protocols, reassess response, and plan follow-up
• Nursing/respiratory therapy: administer and coach technique, document, monitor for issues
• Pharmacy: product selection on formulary, dispensing, storage standards, medication safety review, shortage management
• Biomedical engineering: limited direct role for the inhaler itself, but may support accessory evaluation (e.g., spacers used as hospital equipment), compatibility assessments, and incident investigations involving device design
• Procurement/supply chain: contracting, vendor management, stock continuity, packaging and labeling requirements, and coordination with pharmacy and clinical leadership

In many institutions, infection prevention and quality/safety teams also play a meaningful supporting role by defining whether an MDI is treated as single-patient only, clarifying how accessories are cleaned or replaced, and reviewing incident trends (e.g., recurring wrong-inhaler selection events). Clear ownership prevents gaps—especially for “in-between” items like spacers that can be viewed as either a consumable or reusable equipment depending on local policy.

H2: How do I use it correctly (basic operation)?

The exact workflow depends on the specific Metered dose inhaler MDI design (press-and-breathe vs breath-actuated; with or without dose counter) and the medication IFU. The steps below describe a common, broadly applicable approach that should be adapted to manufacturer instructions and facility protocols.

Basic step-by-step workflow (universal concepts)

1. Verify the medication order and confirm the correct patient (standard medication safety checks).
2. Inspect the device: ensure it is intact, clean, and labeled appropriately (especially in inpatient settings).
3. Remove the cap and check the mouthpiece for visible debris.
4. Prepare the canister as directed (often includes shaking; some formulations may have specific instructions—varies by manufacturer).
5. Prime if required (commonly needed for first use or after a period without use; follow the IFU).
6. Position the patient as appropriate (often upright if feasible) and explain what will happen.
7. Coordinate actuation with inhalation: – For many MDIs, the patient begins a slow inhalation, and the actuation occurs at the start of inhalation. – The patient then continues inhaling to carry aerosol into the airways.
8. Breath-hold or controlled breathing may be instructed to allow deposition; exact guidance varies by manufacturer and patient factors.
9. If more than one actuation is ordered, wait the recommended interval between actuations (per IFU and prescribing instructions).
10. Replace the cap, store as per policy, and document administration and any coaching provided.

Because the above list is intentionally high-level, many teaching checklists add a few technique cues that are broadly applicable to press-and-breathe MDIs (always adapt to the IFU):

• Encourage the patient to exhale gently first (without blowing into the device), so the next inhalation can be slow and deep.
• Emphasize a slow, steady inhalation rather than a rapid gasp; some spacers include an audible indicator if inhalation is too fast.
• If the patient cannot hold their breath, coach a brief pause and then slow exhalation—any controlled pause may help compared with immediate exhalation.
• For patients with limited hand strength, consider whether a spacer, assist device, or caregiver support is needed to achieve consistent actuation.

Using a spacer/valved holding chamber (common in hospitals)

A spacer (or valved holding chamber) can reduce coordination demands and is commonly used in pediatrics and in adults who struggle with timing. General concepts include:

• Attach Metered dose inhaler MDI to the spacer per IFU.
• Actuate into the chamber and have the patient inhale promptly.
• Avoid “stacking” multiple actuations into the chamber unless the IFU explicitly supports it.
• Observe for cues of inhalation (e.g., valve movement in some designs); features vary by manufacturer.

Hospitals should standardize spacer models where feasible to simplify training and stocking.

A few additional points often matter in day-to-day ward use:

• Mask fit (if used): For infants, young children, or patients unable to seal around a mouthpiece, a mask may be used with a spacer. A good seal is essential; leaks reduce delivered dose and can blow medication into the eyes/face.
• Tidal breathing vs single deep breath: Some spacer protocols allow several normal breaths after one actuation for patients who cannot perform a single slow deep inhalation. The exact approach and breath count are device- and protocol-dependent.
• Static charge: Some spacers accumulate static, which can attract particles to chamber walls. Washing and air-drying practices (per spacer IFU) may reduce static and improve consistency.
• One puff at a time: Even when time-pressured, stacking puffs can overload the chamber and increase loss; standard work should reinforce one actuation followed by inhalation.

Calibration and “settings” (what is and isn’t adjustable)

Most Metered dose inhaler MDI devices have no user-adjustable calibration and no “settings” comparable to monitors or ventilators. Operational variables are mainly:

• The number of actuations ordered (a medication instruction, not a device setting)
• Whether a spacer/mask/adapter is used
• The patient’s inhalation technique

Some devices include dose counters or feedback mechanisms; these are not typically calibrated by end users.

A practical corollary is that users should avoid “DIY adjustments,” such as changing mouthpieces, drilling holes, using non-approved adapters, or swapping canisters into different actuators, unless the manufacturer explicitly supports interchangeability. Small physical differences can change the plume and dose delivery, and improvised modifications can introduce safety and contamination risks.

Common workflow variations (expect local differences)

• Breath-actuated MDIs: reduce coordination requirements but still require correct inhalation technique.
• Shared-care models: in outpatient clinics, patients may self-administer under observation; in wards, nurse-administered workflows are more common.
• Ventilated or noninvasive ventilation contexts: if used, this requires protocolized adapters and staff trained for that circuit; not all products are compatible.

When in doubt, prioritize the manufacturer IFU and your facility’s respiratory therapy/pharmacy guidance.

In addition, some institutions incorporate inhaler technique into discharge bundles (e.g., “meds-to-beds” delivery plus bedside inhaler coaching). Others include inhaler use as part of respiratory therapy-driven pathways. The operational theme is the same: the device works best when technique training is not left to chance.

H2: How do I keep the patient safe?

Safety with Metered dose inhaler MDI is less about electronics and more about medication safety, technique reliability, and infection prevention.

Safety practices and monitoring (general)

Common safety practices include:

• Use standard medication administration checks (right patient, right product, right dose, right route, right time, right documentation).
• Confirm the inhaler is the intended one when patients have multiple inhalers; do not rely on device color or shape alone.
• Observe the patient’s technique, especially on first use in the facility or at discharge teaching.
• Monitor the patient according to the clinical context (symptoms, vital signs, and other measures as directed by local protocols).

Monitoring also includes watching for medication-specific expected effects and adverse effects (which vary by drug class). From an operational standpoint, the key is to connect any unexpected response back to a structured review: correct inhaler, correct technique, correct dosing schedule, and whether an alternative delivery route is needed under protocol.

Human factors: where errors happen

Metered dose inhaler MDI errors often arise from predictable human-factors issues:

• Look-alike/sound-alike products and similar packaging across different medications
• Patients bringing home inhalers that differ from the hospital formulary device
• Confusion between maintenance and reliever products (a counseling and labeling risk)
• Technique drift over time, especially when staff assume “the patient already knows”

Mitigations can include barcode scanning where available, standardized labeling, and structured inhaler-technique teaching.

Other common human-factors challenges include time pressure during busy medication passes, poor lighting in patient rooms, communication barriers (language differences, hearing impairment), and physical limitations (reduced grip strength, tremor, facial weakness, or dental issues affecting seal). Designing for these realities—through standardized spacers, simple checklists, and accessible patient education—often prevents more errors than repeating “be careful.”

Risk controls: labeling checks, storage, and device integrity

Operational risk controls include:

• Clear patient-specific labeling in inpatient use when policy requires it.
• Storage away from excessive heat and physical damage; the canister is pressurized.
• Avoiding device modifications not supported by the manufacturer (e.g., improvised spacers).
• Checking that the mouthpiece is free of blockage and that the device is clean.

Warnings about heat sources, flames, or pressurized container handling can differ; follow the manufacturer’s labeling.

Many facilities also adopt storage controls to reduce selection errors, such as separating look-alike inhalers in automated dispensing cabinets, using auxiliary warning labels for high-risk confusions, and standardizing the location of patient-specific inhalers (so they are not carried in pockets or left in unlabeled bedside areas).

Incident reporting culture (general)

Encourage a safety culture where staff report:

• Wrong-inhaler selection near misses
• Device failures (no spray, broken actuator, counter anomalies)
• Suspected contamination or inappropriate sharing
• Stock-outs and substitutions that create training or usability risk

Facilities typically route these events through internal reporting systems and, when required, through external medical device vigilance or medication safety channels per local regulations.

To make reporting actionable, some organizations categorize inhaler-related incidents into a few improvement-friendly buckets: selection error, technique error, device/accessory failure, education gap, and supply/stock issue. This helps leadership distinguish “needs more training” from “needs better storage design” or “needs formulary standardization.”

H2: How do I interpret the output?

Unlike many pieces of hospital equipment, Metered dose inhaler MDI does not produce physiologic waveforms or numeric patient readings. “Output” here mainly refers to device indicators and observable cues that help the clinician judge whether a dose was likely delivered as intended.

Types of outputs/readings you may see

Depending on the product, outputs can include:

• A dose counter (numeric or window-based), showing remaining actuations
• Audible/physical cues during actuation (clicks, resistance, plume characteristics), which vary by manufacturer
• Spacer-related cues such as valve movement or sound indicators (feature-dependent)

Some products have a true counter that counts down from a labeled number of actuations, while others have an indicator (for example, a colored zone) that signals when the inhaler is nearing empty. Behavior at low remaining doses varies: some devices continue to spray propellant even when labeled doses are exhausted, while others may lock out or change resistance. For hospital workflows, the key is to treat the manufacturer’s labeling as the source of truth for replacement timing.

How clinicians typically interpret them

Clinicians often combine device indicators with observation:

• Did the dose counter decrement appropriately after actuation?
• Was there an obvious blockage or leakage around the mouthpiece?
• Did the patient coordinate inhalation, or did most of the plume escape?
• If a spacer is used, was the patient inhaling promptly after actuation?

These cues help identify technique problems, not confirm lung deposition.

In teaching contexts, observing the patient’s exhalation and inhalation pattern often reveals the issue quickly: many patients actuate and then inhale late, inhale too fast, or exhale immediately afterward. If a spacer is used, a lack of valve movement or a persistent “whistle” (in devices that have such a feature) can indicate that the patient is inhaling too forcefully.

Common pitfalls and limitations

• A “taste” or “feel” does not reliably prove correct delivery.
• The old “float test” (placing a canister in water to guess remaining dose) is generally unreliable and is not a standard hospital practice; follow IFU instead.
• Dose counters may not exist on all products, and counter behavior can differ by manufacturer.
• A normal-looking spray plume does not guarantee effective inhalation timing or adequate inspiratory flow.

Another common pitfall is assuming the counter reflects therapeutic doses delivered to the lungs. A counter generally reflects actuations, including priming sprays and any accidental test sprays. In inpatient settings, this matters for both continuity of therapy (ensuring the inhaler does not unexpectedly run out) and for traceability when investigating complaints.

Clinical correlation matters

A Metered dose inhaler MDI cannot tell you whether the patient’s physiology improved. Clinicians correlate use with clinical assessment and, where relevant, objective testing (e.g., peak expiratory flow or spirometry when appropriate and available). Device indicators support technique assessment; they do not replace clinical judgment.

In quality improvement work, teams sometimes link technique assessment to outcomes such as symptom control, ED revisits, or readmissions. While many factors contribute to those outcomes, consistent technique coaching and device access are often modifiable contributors.

H2: What if something goes wrong?

When Metered dose inhaler MDI use fails, the cause is often straightforward: technique, blockage, empty canister, incorrect assembly, or product-specific priming requirements. The response should be systematic and well-documented.

Troubleshooting checklist (practical)

• Re-check the right patient/right medication and confirm the product is what was ordered.
• Confirm the cap is removed and the mouthpiece is unobstructed.
• Inspect for visible dirt or dried residue on the actuator/nozzle.
• Ensure the canister is fully seated in the actuator.
• Follow the IFU regarding shaking (some suspensions require it; varies by manufacturer).
• Confirm priming status (new device or long interval since last use may require priming).
• Check the dose counter (if present) and the expiration date.
• If a spacer is used, check valve function, cracks, and correct assembly.
• If the patient coughs or cannot coordinate, pause and consider re-coaching technique per protocol.

Additional practical troubleshooting steps that are often helpful in clinical settings (while still deferring to IFU and policy) include:

• If actuation feels “sticky” or inconsistent, consider whether the actuator/nozzle needs cleaning and drying per IFU, and replace the actuator if damaged.
• If the inhaler was stored in a very cold environment, allow it to return to recommended temperature range per labeling; extreme temperatures can affect spray performance.
• If the dose counter is at/near zero (or the indicator is in the “replace” zone), do not rely on residual spray as proof of dose—replace the inhaler per labeling.
• If technique seems correct but response is unexpectedly poor, verify whether the patient is using the inhaler as prescribed (number of actuations, interval, and frequency) and escalate clinically as appropriate.

When to stop use

Stop and escalate per facility policy if:

• The inhaler is damaged, leaking, or visibly contaminated.
• The device repeatedly fails to actuate correctly despite basic troubleshooting.
• There is concern that the wrong product is being used or labeling is unclear.
• The patient’s condition worsens or the situation becomes clinically unstable (activate the appropriate clinical escalation pathway).

This is informational; actual decisions should follow local protocols and clinical supervision.

In addition, if a canister shows signs of deformation, puncture, or exposure to excessive heat, it should be removed from service due to pressurization risk and handled according to local safety guidance.

When to escalate to biomedical engineering, pharmacy, or the manufacturer

• Pharmacy: suspected medication product issue, lot concerns, shortage-driven substitution, labeling/dispensing questions.
• Biomedical engineering: recurring failures linked to accessories used as hospital equipment (spacers, masks, adapters), compatibility concerns, or incident investigation support.
• Manufacturer/vendor: suspected device defect, counter malfunction patterns, or IFU clarification requests.

In practice, escalation is most efficient when the initial report includes concrete observations: “counter did not decrement,” “no plume despite full depression,” “valve in spacer does not move,” or “actuator visibly cracked.” This helps the receiving team (pharmacy, biomed, or vendor) quickly separate technique issues from device quality issues.

Documentation and safety reporting expectations (general)

Document:

• What happened, including device type, dose counter status, and visible condition.
• Actions taken (cleaning, replacement, re-teaching).
• Product identifiers available on packaging (e.g., lot number), as required by local policy.

Report through the facility’s incident system and follow any local requirements for external reporting.

Where possible, documenting whether a spacer was used (and which type) can be valuable, because spacer malfunction or improper assembly is a common root cause of “no medication delivered” complaints.

H2: Infection control and cleaning of Metered dose inhaler MDI

Infection prevention for Metered dose inhaler MDI focuses on reducing cross-contamination risk while maintaining device function. Because design and materials vary, always prioritize the manufacturer IFU and your facility infection prevention policy.

Cleaning principles (what to aim for)

• Treat the mouthpiece and actuator as patient-contact surfaces.
• Prefer single-patient use where required by policy and product labeling.
• Keep the device visibly clean and dry; moisture and residue can interfere with aerosol delivery.

In acute care settings, the most impactful infection-control step is often preventing sharing—both the MDI itself and any spacer/mask accessories—unless a device is explicitly designed, validated, and reprocessed for multi-patient use under a defined protocol.

Disinfection vs. sterilization (general)

• Sterilization (killing all microorganisms including spores) is typically not applicable to standard MDI actuators and canisters.
• Disinfection level depends on risk classification and local policy; for shared accessories, facilities may require higher-level processes or single-patient disposables.

Many hospitals avoid sharing Metered dose inhaler MDI devices between patients because it increases infection control complexity.

Where MDIs are used in teaching (for example, staff training with placebo devices), facilities sometimes use disposable mouthpiece covers or patient-specific teaching devices to avoid repeated direct contact with a shared mouthpiece.

High-touch points to consider

• Mouthpiece and nozzle area
• Cap and exterior actuator surfaces
• Spacer/valved holding chamber (including mask if used)
• Storage containers used on the unit (bins, patient drawers)

Also consider the hands that handle the inhaler: consistent hand hygiene before and after assisting a patient with inhaler use reduces contamination of both the device and the surrounding environment.

Example cleaning workflow (non-brand-specific)

• Perform hand hygiene and don gloves per policy.
• If permitted by IFU, remove the metal canister from the plastic actuator (do not wash the metal canister unless the IFU explicitly states it is acceptable).
• Clean the actuator/mouthpiece as described in the IFU (often involves rinsing or washing and then thorough air drying; details vary by manufacturer).
• Clean or replace spacers/masks per their IFU; some are intended for single-patient use.
• Reassemble only when fully dry, then recap and store appropriately.

From a function perspective, drying is not cosmetic—residual moisture inside the actuator can contribute to nozzle blockage or inconsistent plume. From an infection prevention perspective, a dry device also discourages microbial growth.

Key reminder

Cleaning agents, soak times, and drying steps can affect plastic components and dose delivery. Follow the manufacturer IFU and your facility’s infection prevention guidance, especially when developing unit-based standard work.

In addition, confirm your facility’s policy for disposal of pressurized containers and partially used patient-specific inhalers at discharge or transfer. Disposal requirements can differ from routine pharmaceutical waste because the canister remains pressurized even when “empty.”

H2: Medical Device Companies & OEMs

Manufacturer vs. OEM (Original Equipment Manufacturer)

A manufacturer is the entity that markets the finished product and is typically responsible for regulatory compliance, labeling, complaint handling, and post-market surveillance. An OEM (Original Equipment Manufacturer) produces components or subsystems that may be integrated into a finished product sold under another company’s name.

For Metered dose inhaler MDI, OEM relationships can be particularly relevant because different parties may supply:

• Canisters and metering valves
• Plastic actuators and mouthpieces
• Dose counters or indicator components
• Contract manufacturing and packaging services

Because MDIs are often regulated as combination products (drug + device), quality oversight typically spans both pharmaceutical manufacturing controls and device design controls. Hospitals don’t need to manage those regulations directly, but they do feel downstream effects: changes in suppliers can lead to changes in device feel, counter behavior, packaging, or IFUs, all of which influence training.

Why OEM relationships matter for hospitals

OEM and contract manufacturing structures can affect:

• Supply continuity (single-source components can be a vulnerability)
• Change control (small design changes can alter technique, training needs, or accessory compatibility)
• Service and support (who provides training materials, IFUs, or defect response)
• Quality transparency (what is publicly stated vs. what is proprietary)

For procurement and biomedical engineering teams, practical questions include IFU availability in local languages, traceability (lot information), and how product complaints are managed.

Another practical implication is interchangeability assumptions. Two products might contain similar medications but use different actuators, counters, or valve designs, which can change how they should be taught and how they fit with local accessories. A robust formulary review process considers not only active ingredient and dose, but also device usability and training impact.

Top 5 World Best Medical Device Companies / Manufacturers

Example industry leaders (not a ranking). Metered dose inhaler MDI products are often drug–device combinations, so “manufacturers” frequently include pharmaceutical companies with device engineering and/or OEM partners; portfolios vary by country and product line.

1. GlaxoSmithKline (GSK)
   GSK is widely recognized for a long-standing respiratory therapy portfolio that includes inhaled medicines delivered via multiple device types. The company operates globally, but availability of specific Metered dose inhaler MDI products varies by market and regulatory context. As with many large manufacturers, product support materials and training resources may be provided through local affiliates and are country-specific.

From a hospital perspective, large multinational manufacturers often support structured education resources, but the practicality depends on local distribution and the specific product: the same company may have both MDI and non-MDI platforms in the same therapeutic area, which can complicate standardization.

2. AstraZeneca
   AstraZeneca has a global presence and markets respiratory medicines that may be delivered via inhaler platforms depending on the product. For hospitals, the key operational issue is often standardizing education when multiple inhaler types exist within the same therapeutic area. Local distribution and tender participation can differ significantly by region.

In many systems, the decision to keep a narrow set of inhaler device types on formulary (where clinically appropriate) is driven as much by training reliability as by acquisition cost.

3. Boehringer Ingelheim
   Boehringer Ingelheim is an international healthcare company with products that include inhaled therapies across different device platforms. In many systems, procurement interactions occur through national affiliates and authorized distributors, with training and IFU materials localized. Device design, accessory compatibility, and patient teaching requirements vary by product.

For hospitals, compatibility questions often surface around spacers, masks, and—where used—protocolized circuit adapters. Even when the medication is familiar, the device platform may require updated education.

4. Teva Pharmaceuticals
   Teva is known for branded and generic medicines in multiple therapeutic areas, and in some markets it participates in inhaled therapy products. For hospital operations, generic availability can influence standardization, substitution policy, and staff training requirements. Product portfolios and device designs vary by manufacturer and country.

Generic substitution can be operationally beneficial, but it can also introduce device variability. Facilities that anticipate that variability and build retraining into substitution plans tend to have fewer downstream technique failures.

5. Cipla
   Cipla has a significant presence in many low- and middle-income countries and is often associated with expanding access to respiratory therapies. In some regions, local manufacturing capacity and pricing dynamics influence availability of Metered dose inhaler MDI products. As with any manufacturer, device-specific IFU and quality documentation should be reviewed for the exact product being procured.

In access-focused settings, the limiting factor is often not only procurement price but also the availability of spacers and the capacity to provide consistent patient education—especially when health systems are managing high patient volumes.

Additional ecosystem note (non-exhaustive)

Beyond the companies that market finished inhaler medicines, the MDI ecosystem includes specialized component suppliers (for valves, canisters, counters, and plastics), contract packagers, and design firms. While hospitals rarely contract with these parties directly, their role can be visible during shortages, recalls, or design updates that change how an inhaler is used.

H2: Vendors, Suppliers, and Distributors

Role differences (vendor vs. supplier vs. distributor)

In hospital purchasing language, terms are sometimes used interchangeably, but they can imply different functions:

• A vendor is the party selling to the hospital (often the contracted entity on the purchase order).
• A supplier provides the product or components; this may be the manufacturer or an intermediary.
• A distributor focuses on warehousing, order fulfillment, transportation, and sometimes inventory management and returns.

For Metered dose inhaler MDI, distribution commonly flows through pharmaceutical wholesalers and hospital pharmacy supply chains, with additional oversight for controlled storage, recall management, and traceability.

Because MDIs are pressurized, shipping and storage can have additional handling considerations compared with many oral solid medications (for example, protection from extreme heat). Hospitals generally rely on distributors to maintain appropriate logistics and to communicate backorder or allocation issues early enough to activate substitution plans.

What hospital buyers typically evaluate

• Reliable availability and backorder communication
• Cold-chain needs (often not required for MDIs, but verify per product)
• Lot traceability and recall handling processes
• Support for formulary conversions and device training materials
• Return policies and handling of damaged pressurized canisters

Some buyers also evaluate packaging formats (unit dose vs multi-pack), labeling clarity for bedside scanning, and whether distributors support “delivered to ward” or “meds-to-beds” workflows that affect how quickly patients can receive and learn their inhalers.

Top 5 World Best Vendors / Suppliers / Distributors

Example global distributors (not a ranking). Capabilities and geographic reach vary by country and subsidiary.

1. McKesson
   McKesson is a major healthcare distribution and services organization with strong presence in the United States. For hospitals, such distributors may support pharmacy distribution, inventory programs, and systems integration depending on contract structure. Specific Metered dose inhaler MDI availability depends on the local market and formulary agreements.

2. Cardinal Health
   Cardinal Health operates in healthcare distribution and services, including pharmaceutical and medical products in certain regions. Hospital buyers may interact with Cardinal Health for centralized purchasing, logistics, and supply continuity support. Service offerings differ by business unit and country.

3. Cencora (formerly AmerisourceBergen)
   Cencora is known for pharmaceutical distribution and related services in multiple markets. Distributors in this category often provide logistics, demand planning support, and recall execution in coordination with manufacturers and pharmacies. Contract terms and local regulatory responsibilities vary by jurisdiction.

4. Sinopharm (China National Pharmaceutical Group-related distribution businesses)
   Sinopharm is associated with large-scale pharmaceutical distribution activities within China. For multinational manufacturers, local distribution networks can be critical for hospital access, tender participation, and last-mile logistics. Operational processes depend on the specific Sinopharm entity and regional structure.

5. Zuellig Pharma
   Zuellig Pharma is recognized in parts of Asia for pharmaceutical distribution and commercial services. In geographically complex regions, distributor capability can influence stock reliability for Metered dose inhaler MDI and related accessories. Hospitals often evaluate service level agreements, temperature-control capabilities when relevant, and returns/recall workflows.

H2: Global Market Snapshot by Country

Global demand for Metered dose inhaler MDI is shaped by respiratory disease burden, air quality, smoking prevalence, healthcare access, reimbursement, and the strength of pharmaceutical distribution networks. The notes below are intentionally high-level and operational; within any country, access and device types can vary significantly between urban and rural regions and between public and private systems.

India

Demand for Metered dose inhaler MDI is influenced by a large population, urban air quality challenges, and expanding diagnosis and treatment of chronic respiratory disease. India also has substantial domestic pharmaceutical manufacturing and a strong generic market, which can improve availability, though rural access and inhaler-technique training capacity can be uneven.

In many Indian settings, affordability and continuity of supply are central procurement concerns, and large-scale public programs may prioritize products that are widely teachable with limited specialist time. Spacer access and consistent counseling can be variable, making simple, repeatable teaching methods particularly valuable.

China

China’s market is shaped by a large hospital system, regional variation in access, and active domestic manufacturing alongside imported products. Procurement often occurs through hospital formularies and tender mechanisms, and service ecosystems in major cities may support more structured inhaler education than in remote areas.

Device adoption can also be influenced by national and provincial policies that shape tender outcomes and by the growth of community health services that manage chronic disease follow-up. Standardizing inhaler education across tiers of care is an ongoing operational challenge.

United States

In the United States, Metered dose inhaler MDI use is widespread across outpatient and inpatient care, with purchasing influenced by insurance coverage, pharmacy benefit design, and hospital formulary management. There is significant focus on medication safety processes (labeling, barcode scanning) and increasing attention to sustainability and propellant-related environmental considerations, which may affect future product choices.

Hospitals also face frequent device switching due to payer-driven formulary changes in the outpatient setting, which can undermine technique continuity unless discharge teaching explicitly addresses the exact device the patient will use at home.

Indonesia

Indonesia’s archipelago geography can complicate distribution and consistent access to inhaled therapies, particularly outside major urban centers. The market often depends on import channels and national coverage policies, with variability in respiratory specialist availability and inhaler technique education resources.

Operationally, maintaining reliable stock across islands may require careful buffer inventory planning and strong distributor performance. Training tools that work in primary care settings (not only tertiary hospitals) can have outsized impact.

Pakistan

Pakistan’s demand is driven by respiratory disease burden and cost sensitivity in both public and private sectors. Access can depend on import availability and local manufacturing capacity, while consistent patient education and follow-up may be constrained in under-resourced settings.

Where continuity of care is fragmented, practical counseling—how to use, how to store, and when to replace—can be as important as the prescription itself. Hospitals may also need clear substitution policies during shortages.

Nigeria

Nigeria’s market reflects a mix of public and private purchasing, with significant reliance on imports and variable availability across regions. Urban centers may have better access to Metered dose inhaler MDI and trained staff, while rural access can be limited by supply chain constraints and out-of-pocket costs.

In many settings, ensuring availability of spacers (including affordable pediatric options) and improving technique teaching through community health workers can influence real-world effectiveness more than device availability alone.

Brazil

Brazil combines a large public health system with private-sector care, and procurement decisions can be influenced by national and regional formularies. Distribution tends to be stronger in urban areas, and local production in parts of the healthcare supply chain may support availability, though access gaps still exist across regions.

Hospital systems may balance national purchasing frameworks with local device preferences, particularly when staff training resources vary by region. Standard work for patient education is often a key quality lever.

Bangladesh

Bangladesh’s market is influenced by a growing urban population, air quality issues, and a strong domestic pharmaceutical sector that can support generic availability. Challenges often include ensuring consistent technique education and maintaining reliable supply for public facilities outside major cities.

In high-volume clinics, short, standardized technique messages and caregiver training can help address limited time for counseling, especially for pediatric patients who need spacer/mask workflows.

Russia

Russia’s market is shaped by a large geographic footprint, regional variation in healthcare infrastructure, and a mix of domestic production and imported products. Supply chain resilience can be an operational concern, and hospitals may prioritize secure sourcing and substitution policies when brand availability changes.

Long travel distances and seasonal logistics constraints can amplify the impact of stock-outs, making inventory forecasting and contingency planning important for continuity of chronic therapy.

Mexico

Mexico has a mixed public–private healthcare landscape, and access to Metered dose inhaler MDI can differ by insurance coverage and region. Large urban areas generally have stronger distribution and specialist availability, while rural access may rely more heavily on primary care supply chains and local procurement.

In many systems, hospital discharge planning must account for what patients can realistically obtain afterward, which may influence whether the same inhaler device can be continued in the community.

Ethiopia

Ethiopia’s demand is influenced by increasing recognition of chronic respiratory disease and expanding healthcare coverage, but access can be constrained by limited specialist services and supply chain capacity. Imports and donor-supported channels may play a role, and facilities often prioritize standardized education to maximize benefit from available devices.

Where access is limited, minimizing wasted doses (for example, through careful priming practices and reliable storage) and maximizing technique effectiveness become particularly important operational goals.

Japan

Japan’s market is shaped by a mature healthcare system, strong regulatory oversight, and an emphasis on quality and standardization. Device training and patient education are often integrated into routine care, though product availability and device types depend on local approvals and manufacturer portfolios.

High expectations for documentation and patient understanding can support consistent inhaler technique, but an aging population may require additional support for dexterity and vision limitations.

Philippines

The Philippines faces a mix of public-sector provisioning and out-of-pocket purchasing, with access varying across islands and rural areas. Distribution reliability and patient education capacity can differ substantially by region, making standardized training materials and clear labeling important operational supports.

Local procurement practices and variable availability can result in device switching; teaching patients to recognize their inhaler by name and purpose (not color) can reduce misuse when substitutions occur.

Egypt

Egypt’s market includes domestic pharmaceutical manufacturing and significant public-sector healthcare delivery, with procurement influenced by government purchasing and local availability. Urban centers typically have stronger service ecosystems for respiratory care, while rural access may be affected by distribution and staffing limitations.

Operational focus often includes balancing broad access with consistent training, particularly when multiple device types coexist across public and private channels.

Democratic Republic of the Congo

In the Democratic Republic of the Congo, access to Metered dose inhaler MDI may be limited by infrastructure constraints, supply chain challenges, and variability in healthcare funding. Urban areas are more likely to have consistent availability and trained staff, while remote regions may depend on intermittent supply and limited follow-up.

In such settings, simple, durable accessories and clear, low-literacy education approaches can be important to preserve effectiveness when follow-up opportunities are scarce.

Vietnam

Vietnam’s market is influenced by expanding health insurance coverage, increasing chronic disease management, and growing capacity in hospital systems. Distribution and training resources are stronger in major cities, and procurement decisions often balance imported brands with locally available alternatives.

As chronic disease programs mature, consistent inhaler technique assessment in outpatient follow-up becomes a practical lever for improving control and reducing acute visits.

Iran

Iran has domestic pharmaceutical production capacity, but availability of specific inhaler products can be affected by import limitations and supply chain complexity. Hospitals may prioritize locally available Metered dose inhaler MDI options and develop strong substitution and patient education practices to manage portfolio changes.

When product portfolios shift, facilities that standardize teaching around inhaler “families” (press-and-breathe with spacer, breath-actuated, etc.) can reduce confusion and maintain safer transitions.

Turkey

Turkey’s market benefits from a large healthcare system and a growing medical manufacturing ecosystem, with a mix of public procurement and private-sector provision. Urban hospitals often have structured respiratory services, while regional differences in access and training resources can influence outcomes from inhaler-based therapy.

Tender outcomes and reimbursement can influence which devices are most common in practice; hospitals often address this by aligning nursing and pharmacy teaching to a limited number of device workflows.

Germany

Germany’s market is characterized by strong reimbursement structures, high standards for quality and documentation, and well-developed pharmacy and outpatient support systems. Hospitals and payers may pay attention to device usability, patient training pathways, and broader sustainability initiatives that influence inhaler selection over time.

Because outpatient support is robust, coordination between hospital discharge instructions and community pharmacy counseling can support continuity—especially when patients have multiple inhalers.

Thailand

Thailand’s demand is supported by a large public coverage system and growing chronic disease management capacity. Access is generally better in urban areas, while rural regions may face limitations in specialist availability and patient education bandwidth, making standardized Metered dose inhaler MDI teaching tools operationally valuable.

Facilities may also focus on integrating inhaler technique into routine chronic care visits so that patients receive repeated reinforcement rather than one-time instruction.

H2: Key Takeaways and Practical Checklist for Metered dose inhaler MDI

• Treat Metered dose inhaler MDI as a drug–device combination product.
• Always follow the specific product IFU (Instructions for Use).
• Verify the right patient, right inhaler product, and right order.
• Do not rely on inhaler color to identify the medication.
• Check the expiration date before first use on the unit.
• Inspect the mouthpiece for blockage or visible debris.
• Confirm the canister is properly seated in the actuator.
• Prime only when the IFU indicates priming is required.
• Teach and reassess technique; do not assume prior mastery.
• Use teach-back: “show me how you use it.”
• Consider spacer availability as a core supply item.
• Standardize spacer models to simplify staff training.
• Avoid actuating multiple puffs into a spacer unless IFU allows.
• Do not share Metered dose inhaler MDI between patients.
• Label patient-specific inhalers clearly per facility policy.
• Store pressurized canisters away from heat and physical damage.
• Replace cracked, sticky, or visibly contaminated actuators promptly.
• Document both administration and technique coaching in the record.
• Treat dose counters as helpful cues, not proof of lung delivery.
• If the spray seems weak, re-check technique and device assembly.
• If the device repeatedly fails, remove it from use and escalate.
• Route suspected product defects to pharmacy and procurement teams.
• Capture lot information when required for traceability.
• Build shortage plans that include retraining for substituted devices.
• Use barcode scanning where available to prevent wrong-inhaler errors.
• Separate look-alike inhalers in storage to reduce selection errors.
• Include inhaler technique in discharge planning workflows.
• Ensure cleaning steps do not damage plastics or leave moisture.
• Do not wash metal canisters unless IFU explicitly permits it.
• Keep caps on when not in use to reduce contamination.
• Train staff on human-factors risks: timing, seal, and coordination.
• Align respiratory therapy, nursing, and pharmacy on standard work.
• Treat accessories (spacers/masks) as hospital equipment with owners.
• Encourage incident reporting for near misses and device failures.
• Review incidents for system fixes, not individual blame.
• Confirm local policies for disposal of pressurized containers.
• Consider sustainability goals alongside clinical and formulary needs.
• Audit inhaler technique periodically as a quality improvement activity.
• Maintain multilingual patient education materials when possible.
• Reassess training needs when switching vendors or formulations.

Additional practical reminders that often improve reliability in day-to-day care:

• Document whether a spacer or mask was used, since accessory use changes technique and troubleshooting.
• Avoid swapping canisters and actuators between different products unless the manufacturer explicitly states they are interchangeable.
• When patients bring home inhalers, reconcile them carefully and clarify whether the home device will be used or replaced by a hospital-supplied product.
• Reinforce the difference between “I saw a spray” and “the patient received an effective inhaled dose,” and use observation to close that gap.

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