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Effectiveness and success factors of educational inhaler

technique interventions in asthma & COPD patients: a
systematic review
1
Sven L. Klijn , Mickaël Hiligsmann1, Silvia M. A. A. Evers1, Miguel Román-Rodríguez2, Thys van der Molen3 and Job F. M. van Boven3

With the current wealth of new inhalers available and insurance policy driven inhaler switching, the need for insights in optimal
education on inhaler use is more evident than ever. We aimed to systematically review educational inhalation technique
interventions, to assess their overall effectiveness, and identify main drivers of success. Medline, Embase and CINAHL databases
were searched for randomised controlled trials on educational inhalation technique interventions. Inclusion eligibility, quality
appraisal (Cochrane’s risk of bias tool) and data extraction were performed by two independent reviewers. Regression analyses
were performed to identify characteristics contributing to inhaler technique improvement. Thirty-seven of the 39 interventions
included (95%) indicated statistically significant improvement of inhaler technique. However, average follow-up time was relatively
short (5 months), 28% lacked clinical relevant endpoints and all lacked cost-effectiveness estimates. Poor initial technique, number
of inhalation procedure steps, setting (outpatient clinics performing best), and time elapsed since intervention (all, p < 0.05), were
shown to have an impact on effectiveness of the intervention, explaining up to 91% of the effectiveness variation. Other factors,
such as disease (asthma vs. chronic obstructive pulmonary disease), education group size (individual vs. group training) and inhaler
type (dry powder inhalers vs. pressurised metered dose inhalers) did not play a significant role. Notably, there was a trend (p = 0.06)
towards interventions in adults being more effective than those in children and the intervention effect seemed to wane over time.
In conclusion, educational interventions to improve inhaler technique are effective on the short-term. Periodical intervention
reinforcement and longer follow-up studies, including clinical relevant endpoints and cost-effectiveness, are recommended.
npj Primary Care Respiratory Medicine (2017)27:24 ; doi:10.1038/s41533-017-0022-1

INTRODUCTION health insurance policy driven inhaler switches, the need for
Bronchodilators and corticosteroids play a key role in maintaining optimal education on inhaler use is more evident than ever.
disease control in asthma and chronic obstructive pulmonary This review aims to provide a systematic overview of educa-
disease (COPD) patients. Delivery of these drugs is mainly tional interventions focusing on inhaler technique in asthma and
achieved by inhalers, which can be categorised into three types: COPD patients, assess their overall effectiveness, and identify their
pressurised metered dose inhalers (pMDIs), dry powder inhalers main drivers of success.
(DPIs) and nebulisers. Previous studies, performed in controlled
settings, showed that all inhalers are equally capable of delivering
RESULTS
an appropriate medication dose.1, 2 In daily use however, a large
majority of patients make inhalation errors.3 Suboptimal inhaler Inclusion
technique is associated with worsened health outcomes, such as The literature search yielded a total of 1393 results. Of the 970
increased risk of hospitalisation and poor disease control.4–6 unique articles, 862 were excluded based on title and abstract,
Consequences can also be found in the financial context as while a further 69 articles were excluded during full-text screening
studies estimate that a considerable amount of resources spent on (Fig. 1). Initial agreement between reviewers on eligibility was 87%
inhalers are wasted.7 Important inter-patient differences have (Cohen’s κ = 0.72). After one consensus round, full agreement was
repeatedly been shown, with as few as 25% of the patients able to reached (e-Appendix 2) and 39 articles were eventually
demonstrate a correct technique.8–11 As such, it is of utmost included.15–53 Full manuscripts of four studies were unavailable,
importance to properly train patients on inhaler technique.4, 12, 13 all dating from 2001 or before.54–57 Three authors were contacted,
Various educational interventions to do so have been reported. but did not reply. The remaining author could not be traced.
However, so far there has been no systematic review of these
interventions, leaving the key characteristics of successful inter- Study quality
ventions to remain obscure. With little improvement shown over Inter-reviewer agreement on the study quality assessment was of
time,14 the current wealth of new inhalers available and frequent moderate strength (Cohen’s weighted κ = 0.51), but consensus

1
Department of Health Services Research, CAPHRI, Maastricht University, P.O. Box 616, 6200 Maastricht, The Netherlands; 2Son Pisa Primary Health Care Centre, Balearic Health
Service, Palma de Mallorca, Spain and 3Department of General Practice, Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Centre Groningen,
University of Groningen, Groningen, The Netherlands
Correspondence: Sven L. Klijn ([email protected])

Received: 5 October 2016 Revised: 2 February 2017 Accepted: 14 February 2017

Published in partnership with Primary Care Respiratory Society UK

 Effectiveness of education on inhalation technique
SL Klijn et al
2

Fig. 1 Flow diagram on article inclusion

Fig. 2 Quality assessment of included studies. Percentages represent the percentage of included articles having a high risk (black bar), unclear
risk (light grey bar) or low risk (medium-grey bar) of bias for each category in the Cochrane Collaboration’s risk of bias assessment tool

was reached after one consensus round. Twelve of the 39 studies common (33.3%). One study reported outcomes as improvements
scored a low risk of bias on four or more of the seven categories in inhalation flow rate.15 Improvements over baseline displayed a
(see e-Appendix 3). Random sequence generation and selective large difference between studies, with correct-patients studies
reporting were found to be best addressed by the studies (Fig. 2). reporting improvements of 3% to 167% and correct-steps studies
Allocation concealment was frequently not described, and it was 14 to 86 percentage points. Eleven studies (28%) did not report
therefore difficult to determine whether concealment was any relevant clinical outcomes besides inhalation scores.
sufficient but not reported, or insufficient and a potential source
of bias. As was already established beforehand, blinding of
participants was not possible, which is reflected in the quality Educational interventions
appraisal results. Blinding of outcome assessment was possible, Almost all interventions (89%) included a physical or video
but in almost half of the studies not implemented. Regression
demonstration of inhaler use. Physical demonstrations were most
analysis showed that quality of the study was not associated with
intervention outcome results (p > 0.05), irrespective of the type of common, whereas video demonstrations were used in six
outcome reported. studies.21, 25, 30, 31, 40, 51 The form of the demonstration did not
have a significant effect on improvement of inhaler technique
over baseline (p > 0.05). Whether or not patients were requested
Study characteristics
to demonstrate own inhaler use after demonstration was
An overview of the 39 studies and their 56 intervention groups is frequently not reported.
provided in Table 1. Full details of the studies can be found in e- Approximately half of the studies (n = 22) provided additional
Appendix 4. The majority covered patients with asthma (n = 35), of disease education or embedded the inhaler education in a more
which six also included COPD patients. Studies exclusively
complex intervention. Disease education usually addressed topics
performed in COPD-patients were rare (n = 4). The interventions
such as disease pathophysiology49 and disease triggers.16 Com-
mainly took place in outpatient clinics (n = 17) or community
pharmacy settings (n = 15). plex interventions also included counselling on self-management
Sample sizes ranged from 10 to 1316 participants with a median skills38 and health beliefs.29
of 60 participants. One fifth of the studies targeted children. Of the The mean number of sessions was 2.6. The mean duration of a
studies that reported the included inhaler types, 82.8% included session was 30 min, excluding an outlier.36 The interventions in
pMDIs, whereas DPIs were included in 58.6% of the studies. Ten outpatient clinics and pharmacy settings were similar in the sense
studies did not specify which inhaler types were included. The that they were mostly individual educational interventions.
average follow-up time was five months; six studies had ≥1 year Furthermore, the mean number of sessions (outpatient clinics:2.6;
follow-up. pharmacies:2.7) and total intervention time (both 1.5 h) did not
Outcomes were most frequently recorded as correct-steps statistically differ (p > 0.05). However, videos and internet-based
(64.1%), whereas correct-patients outcome reporting was less education were more common in outpatient settings.20–23, 31, 40

npj Primary Care Respiratory Medicine (2017) 24 Published in partnership with Primary Care Respiratory Society UK
 Table 1. Study and intervention characteristics

FFirst author Disease Setting Sessions Session length Delivery Deliverer N Inhaler Maximum follow- Outcome Inhaler Clinical outcomes
(h:mm) type up (months) type technique
Improvement
(%) (p.p.)
15
Al-Showair 2007 Asthma Outpatient 1 – Individual – 107 MDI 1.5 IFR – Peak flow:↑, AQLQ: ↑
clinic
Armour 201316 Asthma Pharmacy 4 00:26 Individual Pharmacist 398 MDI 6 Patients 50 p.p. ACQ:≈
Basheti 200817 Asthma Pharmacy 4 00:03 Individual Pharmacist 97 DPI 6 Steps 49% Asthma severity: ↓
Basheti 200518 Asthma Pharmacy 1 00:08 Individual Researcher 17 DPI 0.5 Steps 75% None
Asthma Pharmacy 1 00:08 Individual Researcher 17 DPI 0.5 Steps 80%
Bosnic-Anticevich Both Pharmacy 3 – Individual Researcher 52 MDI 4 Steps 38% None
201019
Bynum 200120 Asthma* Outpatient 1 00:15 Individual Pharmacist 49 MDI 1 Steps 77% None
clinic
21
Carpenter 2015 Asthma* Outpatient 1 00:03 Individual Researcher 91 MDI 1 Steps 16% ACT: ≈
clinic
Chan 200722 Asthma* Outpatient 5 – Individual Other 60 MDI 12 Steps 8% QOL: ≈, hospitalisations: ≈
clinic
Asthma* Outpatient 5 – Individual Other 60 DPI 12 Steps 12%

Published in partnership with Primary Care Respiratory Society UK

clinic
Chan 200323 Asthma* Outpatient 4 – Individual Other 10 Both 6 Steps – Peak flow: ↑, QOL: ≈
clinic
Cicutto 201324 Asthma* School 6 00:53 Group – 1316 – 12 Steps 48% QOL:↑, Urgent care:↓
Cordina 200125 Asthma Pharmacy 1 – Individual – 152 – 12 Patients 36 p.p. QOL: ↑, peak flow: ↑,
hospitalisations: ↓
Crane 201426 Asthma – 1 – Individual – 123 Both 12 Patients 16 p.p. None
De Blaquiere 198927 Both Outpatient 1 00:17 Individual Researcher 100 MDI 2 Patients 81 p.p. Hospitalisations: ≈
clinic
SL Klijn et al

De Oliveira 199928 Asthma Outpatient 8 – – Researcher 42 MDI 6 Patients 73 p.p. ER visits:↓, symptoms:↓, QOL:↑
clinic
Garcia-Cardenas Asthma Pharmacy 3 – Individual Pharmacist 336 DPI 6 Patients 56 p.p. ACQ:↑
201329
Goodyer 200630 Asthma – 1 – Individual Pharmacist 35 MDI 0 Steps – None
Asthma – 1 – Individual Pharmacist 34 MDI 0 Steps –
Goris 201331 COPD Outpatient 1 – Individual – 24 MDI 3 Steps 100% QOL:↑, attacks:↓,
clinic hospitalisations:≈
COPD Outpatient 1 – Individual – 110 DPI 3 Steps 43%
clinic
Hesselink 200432 Both Other 2 00:30 Individual Nurse 276 – 24 Patients – QOL: ≈
Horner 200833 Asthma* School 16 00:15 Group Other 183 MDI 1.5 Steps 36% None
Kiser 201234 COPD Hospital 1 00:23 Individual Researcher 99 MDI 1.25 Steps 29% None
Effectiveness of education on inhalation technique

COPD Hospital 1 00:23 Individual Researcher 41 DPI 1.25 Steps 22%

COPD Hospital 1 00:23 Individual Researcher 27 DPI 1.25 Steps 20%
Kools 200635 Asthma – 1 00:01 Individual Researcher 50 MDI 0 Steps – None
Kritikos 200736 Asthma Pharmacy 1 02:30 Group Pharmacist 22 MDI 3 Patients 73 p.p. Poor control: ↓, AQOL: ↑
Asthma Pharmacy 1 02:30 Group Pharmacist 25 DPI 3 Patients 79 p.p.

npj Primary Care Respiratory Medicine (2017) 24

Asthma Pharmacy 1 02:30 Group Researcher 20 MDI 3 Patients 86 p.p.
3
 Table 1 continued 4

FFirst author Disease Setting Sessions Session length Delivery Deliverer N Inhaler Maximum follow- Outcome Inhaler Clinical outcomes
(h:mm) type up (months) type technique
Improvement
(%) (p.p.)

Asthma Pharmacy 1 02:30 Group Researcher 26 DPI 3 Patients 84 p.p.

Kumar 200937 Both Hospital 4 – Individual Pharmacist 98 MDI 2 Steps 115% FEV1:↑
Both Hospital 4 – Individual Pharmacist 18 DPI 2 Steps 100%
Martin 201538 Asthma* Other 4 – Individual Nurse 51 – 12 Steps 50% Control: ≈
Asthma* Other 4 – Individual Nurse 50 – 12 Steps 29%
Mehuys 200839 Asthma Pharmacy 3 – Individual Pharmacist 201 Both 6 Steps 25% Nighttime symptoms:↓, ACT:↑
Mulloy 199640 Asthma Outpatient 1 – Individual Nurse 60 – 12 Steps 20% Symptoms: ↓, peak flow: ≈
clinic
Patterson 200541 Asthma* School 8 – Group Nurse 173 – 4 Patients 38 p.p. QOL: ≈

npj Primary Care Respiratory Medicine (2017) 24

Perneger 200242 Asthma Hospital 3 01:15 Group Other 131 – 6 Patients 28 p.p. QOL: ≈, healthcare utilisation: ≈
Petkova 200843 Asthma Pharmacy 5 – – Researcher 50 – 4 Patients 14 p.p. Hospitalisation: ↓, QOL:↑
Press 201244 Both Hospital 1 00:06 Individual Researcher 50 MDI 0 Patients 52 p.p. Health-related events:↓
Both Hospital 1 00:06 Individual Researcher 18 DPI 0 Patients 50 p.p.
Rahmati 201445 Asthma – 3 – Group – 60 MDI 1 Steps 60% Peak flow: ↑
Asthma – 3 – Group – 60 MDI 1 Steps 90%
Rootmensen 200846 Both Outpatient 1 00:45 Individual Nurse 191 – 6 Steps 3% QOL: ≈, Exacerbations: ↓
clinic
SL Klijn et al
Effectiveness of education on inhalation technique

Rydman 199947 Asthma Outpatient 1 – Individual Researcher 68 MDI 3 Patients 36 p.p. None
clinic
Santos 201048 Asthma Outpatient 2 01:00 Individual Pharmacist 28 MDI 2 Steps 167% None
clinic
Asthma Outpatient 2 01:00 Individual Pharmacist 28 DPI 2 Steps 33%
clinic
Tommelein 201449 COPD Pharmacy 2 00:20 Individual Pharmacist 734 Both 3 Steps 38% Hospitalisations↓
Toumas-Shehata Asthma Pharmacy 1 – Individual Pharmacist 101 DPI 1 Steps 40% ACQ:↑
201450
Van der Palen COPD Outpatient 1 00:45 Group Nurse 70 Both 9 Steps 26% None
199751 clinic
COPD Outpatient 1 00:45 Individual Other 73 Both 9 Steps 18%
clinic
COPD Other 1 00:45 Individual Other 71 Both 9 Steps 26%
Verver 199652 Asthma Other 1 – Individual Nurse 48 DPI 0.5 Steps 9% Dyspnoea: ↓
Wilson 199353 Asthma Hospital 4 00:45 Individual Nurse 227 MDI 12 Steps – Asthma status: ↑, physical
activity: ↑, Acute visits:↓
Asthma Hospital 4 01:30 Group Nurse 229 MDI 12 Steps –
*: children, ↑: increase/improvement, ↓: decrease/worsening, ≈: no difference, Outcome type: mean number or percentage of correct steps (in the table: “Steps”), the percentage of patients who showed a correct
technique (in the table: “Patients”), or inhalation flow rate (IFR). Improvement over baseline is either reported as percentage (%) or as percentage points (p.p.)

Published in partnership with Primary Care Respiratory Society UK

 Effectiveness of education on inhalation technique
SL Klijn et al
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Inhaler technique improvement delivered to a group (n = 11), whereas the majority was delivered
Over 90% of studies reported a significant improvement in inhaler to individuals (n = 35). Differences between diseases were difficult
technique after intervention. Two studies reported no effect over to determine, as there were no correct-patients studies in COPD-
usual care.27, 46 These studies were both single-session interven- patients and confidence intervals were large (Fig. 3e, f).
tions in outpatient clinics. Martin et al.38 reported a significant
improvement only in a subgroup. Younger children did not have Clinical outcomes
significant changes, whereas inhaler technique in older children Twenty-eight studies (72%) reported additional clinical outcomes
significantly improved. Several studies reported a (partial) loss of
(Table 1). Those outcomes included a measure of control or quality
effect of the intervention over time.17, 19, 24, 47 This waning effect
of life (44%), lung function (FEV1, peak flow) (15%), symptoms (e.g.
did not seem to be related to the intervention’s characteristics, the
setting in which it was performed, or any patient characteristics. night-time symptoms/dyspnoea) (10%), healthcare utilisation (e.g.
The study with the longest follow-up time showed in a subgroup ER visits, hospitalisations) (28%). Cost-effectiveness was never
analysis that patients who attended multiple sessions had an reported. The majority indicated favourable results for the
increased inhaler technique over patients who only attended one intervention group, with highest discrepancy regarding effects
session.32 on quality of life.
Regression models (Table 2) showed that several intervention
characteristics influenced the intervention’s effectiveness. For
correct-step studies (n = 21), using a forward selection procedure, DISCUSSION
these were the total number of steps evaluated, setting (out- Main findings
patient clinics performing best, community pharmacies and non- This review showed that educational interventions on inhaler
categorised settings performing worst), adults improved more technique are effective, at least on the short term. All studies
than children, and baseline performance. The model had an showed improvements and 95% indicated statistical significance
excellent fit (adjusted R2: 0.906). Using a backward selection with a mean intervention time of 30 min and an average follow-up
procedure, the total number of steps evaluated and the baseline of five months. Regression analysis revealed several key char-
performance were the only study characteristics that showed a acteristics that influenced intervention’s effectiveness. Major
significant influence on the intervention’s effectiveness. For predictors for success were low baseline performance, outpatient
correct-patients studies (n = 12, with 16 intervention groups), the setting and short follow-up time, with setting only being
percentage of patients with baseline correct technique, and significant when outcomes were assessed in terms of correct
follow-up time were significant. Both selection procedures, number of inhalation steps. Other factors that predicted
forward selection and backward elimination, led to the same
effectiveness were higher number of steps evaluated, and higher
result and the model had a good fit (adjusted R2: 0.862). In both
age group. Duration of the intervention, scale (group or
models, publication year, general disease education, number of
sessions, session length, total length of intervention, delivery form, individual), executor (pharmacist, nurse or other), inhaler (pMDI
sample size, disease, inhaler and gender did not significantly or DPI) and disease (asthma or COPD) were not associated with
influence improvement inhaler technique improvement. intervention effectiveness. Of note, a trend (p = 0.06) was
Baseline performance explained a large percentage of inter- observed in interventions being more effective in adults than in
vention’s effectiveness, independent of outcome measurement children, however relatively few studies targeted children
used (Fig. 3a, b). Patients with good baseline technique showed specifically. The studies that included clinical relevant endpoints
little improvement after intervention. Delivery form (group or mostly indicated favourable clinical effects with highest discre-
individual) was not significantly correlated to inhaler technique pancy regarding effects on quality of life. Cost-effectiveness was
improvement (Fig. 3c, d). However, only few interventions were never reported.

Table 2. Linear regression models with improvement over baseline as dependent variable

Correct-steps interventions (n = 32) Correct-patients interventions (n = 16)

β 95% CI p-value β 95% CI p-value
min max min max

Total number of steps evaluated 0.065 0.027 0.104 0.002

Intervention setting
Community pharmacy [ref ]
Hospital 0.089 −0.051 0.228 0.200
Outpatient clinic 0.149 0.024 0.274 0.022
School 0.025 −0.224 0.275 0.835
Other −0.004 −0.172 0.164 0.958
Age group (adults vs. children) 0.153 −0.003 0.310 0.055
Baseline performance −2.720 −3.101 −2.338 <0.001 −1.498 −1.921 −1.075 <0.001
Intervention provider
Pharmacist [ref]
Researcher −0.052 −0.190 0.087 0.414
Nurse −0.224 −0.450 0.001 0.051
Other −0.226 −0.458 0.007 0.056
Follow-up time −0.034 −0.068 −0.001 0.046

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 Effectiveness of education on inhalation technique
SL Klijn et al
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Fig. 3 Improvement in inhaler technique plotted against baseline performance (a, b), type of intervention (c, d), and patients’ disease
background (e, f) with 95% confidence intervals. The left column (a, c, and e) displays results for correct-steps studies, the right column shows
results for correct-patients studies

Interpretation of findings in relation to previously published work embedding the intervention in a multi-component intervention
There are several factors which were found to explain the variation did not provide a benefit for improving inhaler technique either.
in improvement of inhaler technique. Of these factors, baseline Contrary to reports of multi-component interventions on adher-
performance was found to be associated with positive outcomes ence which showed mixed results,58 inhaler technique did not
in both correct-steps and correct-patients studies. Intervention suffer negative effects. Intervention effectiveness was shown to be
setting and intervention provider showed a relative strong independent of disease, but note that COPD-specific studies were
dependency (Fisher exact test: 0.00296). This might explain why scarce and patient populations were heterogeneous, warranting
inclusion of one of the two factors may have led to exclusion of further investigation of specific subgroups (such as children and
the other. The higher number of technique steps evaluated being patients with low literacy). Patients benefited from interventions,
positively correlated to the effectiveness of the intervention might irrespective of the type of inhaler they used. This is in line with
point to a methodological issue. A potential explanation for this previous studies, which report improvements made with multiple
correlation could be that interventions are improving parts types of inhalers.59 It also confirms a previous recommendation to
of the patient’s technique which are not measured by educate patients on their inhaler instead of switching inhalers.60
all studies. Considering the large variability of outcome measures
in use, ranging from five to eleven different steps in inhaler Strength and limitations
technique,24, 45, 48 this seems plausible. Equally important are the To our knowledge, this is the first systematic review on
factors which were found to not be associated with improvements educational inhaler technique interventions in asthma and COPD
in inhaler technique. Duration and type of intervention, individual patients and it provides definitive evidence on their effectiveness
or group based, did not have a significant impact on outcomes. and success factors. Especially given the current wealth of new
This bears important consequences for health-economic decisions inhalers available and insurer-driven inhaler switches, we feel this
in clinical practice, as less time-consuming and group interven- study is very relevant and timely. This systematic review was
tions can be selected without sacrificing effectiveness. The however limited to RCTs and did therefore exclude useful
addition of general disease education, or in more general terms, observational studies. A limiting factor was the wide variety of

npj Primary Care Respiratory Medicine (2017) 24 Published in partnership with Primary Care Respiratory Society UK
 Effectiveness of education on inhalation technique
SL Klijn et al
7
interventions and outcome measures, hampering the perfor- important to match the inhaler device to the patient, ensuring a
mance of a meta-analysis. From a clinical perspective it is high baseline performance of inhaler technique.71 This could
unrealistic to combine the outcome effects of studies that focus potentially reduce the need for retraining of patients.
on different patient populations (e.g. school children vs. adults) Considering the important role of inhaler medication in asthma
and implement interventions with vastly different characteristics and COPD, future research should try to understand the type of
(e.g. short video vs. interactive disease management sessions). educational interventions that could be effective in different
Performing a meta-analysis would imply comparability of inter- patient groups, the optimal duration of the interventions, their
ventions and may lead to false interpretation of outcomes. maintenance and ways to improve their cost-effectiveness.
Assessment of relevant independent variables in the regression
analysis was based on forward selection and backward elimination
procedures. These procedures are sometimes referred to as data CONCLUSIONS
dredging methods and come with their own flaws, such as an Educational interventions on inhaler technique in asthma and
overestimation of the variance explained by the model.61 COPD patients are effective on the short-term. Key predictors for
Furthermore, the backward elimination models suffered from success are patient’s initial technique and time elapsed since
problems with multicollinearity resulting in the exclusion of intervention. Disease and inhaler do not play a significant role.
several potential predicting variables. Nonetheless, considering
Periodical intervention reinforcement and longer follow-up
the explorative nature of this study and the lack of clinical
studies, including clinical relevant endpoints and cost-effective-
guidance on relevant independent predictors of improvement of
inhaler technique over baseline, this methodology was assessed to ness, are recommended.
be a relevant option to use.
The vast majority of studies showed a positive effect of their METHODS
intervention on inhaler technique, a warning marker for potential
Study design
publication (or reporting) bias. An alternative explanation for the
positive results could be the relatively short follow-up time of The study design was a systematic review, performed as per PRISMA-
guideline.72
most studies. Lastly, it should be noted that studies were
conducted by well-trained healthcare professionals with plenty
of time available. In clinical practice however, available consulta- Inclusion and exclusion criteria
tion time, knowledge and skills regarding inhalers among All articles reporting randomised controlled trials (RCTs) on interventions
healthcare professionals are often limited, highlighting that well- aimed at improving inhaler technique in asthma or COPD patients (no age
trained intervention deliverers with sufficient time available are restriction) vs. usual care, published before 31 March 2015, were eligible for
essential.62, 63 inclusion. Exclusion criteria were non-English manuscripts, no asthma or
COPD, non-original research, qualitative studies, non-RCT design and
interventions not aimed at patients. In addition, articles that did not
Implications for future research, policy and practice operationalise their outcome measures or interventions without individual
Focusing efforts and resources on educational interventions could components description were excluded.
result in improved inhaler technique and clinical outcomes in
asthma and COPD patients.64 This is an important finding Search strategy
underlining the value of educational interventions. Switching of
Manuscripts were retrieved from the Medline, Embase and CINAHL-
inhaler devices is associated with several disadvantages to the
databases. It is advisable to use a combination of both Medline and
patient, such as an increase in the number of errors made and Embase as they return only partly overlapping results.73, 74 CINAHL was
reduced compliance.65 In this light, clinicians may prefer to opt for added as it provides additional coverage on the nursing subfield.
an educational intervention to improve inhaler technique of the Keywords in the search strategy (please refer to e-Appendix 1 for a full
device currently in use by the patient. overview) related to both intervention and disease. Intervention keywords
The effectiveness of interventions holds true for patients with included a combination of variations on ‘inhaler’ and ‘technique’ or
an insufficient initial technique, whereas interventions may be less ‘instructions’, whereas disease keywords included variations on ‘asthma’
valuable for patients with an already moderate to good technique. and ‘COPD’. Disease specific keywords were based on previous publica-
Therefore, the patient population targeted by an intervention tions.58 A high sensitivity therapy filter based on the work of the Hedges
could affect its cost-effectiveness. Unfortunately, only few cost- Project was selected to limit search results to clinical trials, while reducing
effectiveness studies have been conducted on improving inhaler the probability of excluding relevant studies.75, 76 The filter was extensively
technique in COPD 66 and asthma.67, 68 Considering constraints on validated for all three databases included within this review and was
budgets and time available, clinicians may wish to provide shown to have a sensitivity of 94.6% to 99.4%.77–79
intervention on inhaler technique to patients who have been Initial screening based on title and abstract was conducted by one
identified to suffer from a poor inhaler technique, instead of reviewer (S.K.). Afterwards, each potentially eligible full-text manuscript
indiscriminately providing these interventions to a more general was independently reviewed by at least two reviewers (S.K., J.B., and M.H.).
Disagreements were resolved in consensus round(s).
patient population. Regular reviewing of inhaler technique is a
recommendation that has been voiced previously 65 and enables a
more appropriate application of interventions. Quality assessment
Evidence on effectiveness of educational inhaler technique All included articles were independently assessed by two different
interventions in COPD patients is scarce and the rate of inhaler reviewers (S.K., J.B., M.H., M.R.) using the Cochrane Collaboration’s tool
errors has not decreased over time.14 To ease comparability, we for assessing risk of bias in randomised trials.80 Scoring was carried out as
recommend that studies use a uniform method to assess inhaler described in the tool’s guidelines,74 even though risk of performance bias
technique. Unfortunately, no golden standard exists yet, but was not fully applicable, due to lack of feasible blinding options of
technological developments, including acoustic sound based participants. This is characteristic of educational interventions. Inter-
technology and eHealth applications are promising.69, 70 reviewer discrepancies in scoring were resolved in a consensus procedure.
Lastly, the positive effect of interventions seems to wane over
time, stressing the need for continuous monitoring and periodi- Data extraction
cally reinforcement of inhalation instructions. In conjunction with Study characteristics, study population, and outcomes were systematically
continuous monitoring and periodical retraining it may be recorded for all included articles using a pre-structured spreadsheet.

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 Effectiveness of education on inhalation technique
SL Klijn et al
8
Study characteristics. If multiple intervention groups were included within support from Teva, personal fees from Mundifarma, personal fees from Boehringer
a single study, or outcomes were separately reported for pMDI and DPI Ingelheim, outside the submitted work. Dr. J.F.M.v.B. reports grants (GSK, Boehringer
users, each group was recorded separately. Data were extracted by a single Ingelheim), consultancy fees (AstraZeneca) and travel fees (European COPD Coalition,
researcher (S.K.) in order to maintain consistency throughout coding. Respiratory Effectiveness Group) outside the submitted work. Other authors report no
Extracted data of 10% of the included studies was validated by a second disclosures.
reviewer (M.H. or J.B.), based on a random sample. Extracted study
characteristics included country, intervention, comparator, setting, execu-
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Mr. S.K. reports current employment (Pharmerit International), during the study he 21. Carpenter, D. M. et al. Using videos to teach children inhaler technique: a pilot
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personal fees from Mundipharma, personal fees from Novartis, personal fees from 22. Chan, D. S. et al. Internet-based home monitoring and education of children with
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