Good asthma management is said to be 10% medication and 90% education.1
Inhaled therapies are the backbone of management for asthma and COPD (chronic obstructive pulmonary disease) – adherence and inhaler technique are essential for optimal dose delivery. But, up to 90% of patients don’t use their devices correctly and therefore aren’t receiving the dose they should.2 By some estimates, between 28% and 68% of patients do not use their metered-dose inhalers (MDIs) or dry powder inhalers (DPIs) well enough to benefit from the prescribed medication.3
Barriers to checking inhaler technique
Some GPs may not regularly check adherence and demonstrate or check inhaler technique due to time pressures.4 In other cases GPs might not be familiar with the correct technique to demonstrate inhaler device use4 or do not have a particular inhaler on hand. This highlights the need for healthcare professionals to be up to date with inhaler devices and to have placebo inhalers handy for providing advice on correct use.
For patients, there can be substantial stigma around the use of medication inhalers, particularly in certain age and cultural groups.5-8 Such stigma can deter initiation of inhaler use in some patients and persistence of use in others.6 A recent large Asian study found that approximately half of all patients surveyed agreed with statements that having an inhaler was ‘embarrassing’ or ‘a nuisance’. Patients with uncontrolled asthma, in particular, felt that it was an embarrassment (62.0%) or a nuisance (52.2%) to use or even carry (56.7%) an inhaler in public, representing real psychosocial barriers to inhaler therapy.6 Inhalers are something ‘to hide in a bag’.8
Stigma is an important barrier to effective self-management practices, but there are a range of other issues including forgetfulness, confusion and the burden of having a range of medicines to take if patients have comorbid illnesses. Health professionals are encouraged to raise these issues with patients and explore the reasons for non-adherence. Patients should understand the importance of taking medicines as prescribed, including correct techniques of inhaler use.
Checking inhaler technique: whose job?
Depending on the setting, patient training in inhaler use may be the responsibility of the GP, pharmacist, practice/asthma nurse or respiratory therapist. Checking inhaler technique is not solely the domain of the GP – a practice nurse or pharmacist can also help.2
It takes time to check inhaler technique, but if you don't, patients may be getting suboptimal medicine delivery and may experience subsequent lack of symptom control.2,9
Patient technique, compliance and confidence levels have all been shown to improve with nurse-led education.10,11 If you have a practice nurse, make sure that they are appropriately trained in the use of inhalers, and encourage them to provide regular checks and instructions to patients taking these medicines.
A community-based pharmacist can play a significant role in training by demonstrating technique using placebo inhalers, before dispensing the real thing to patients. Pharmacists are ideally positioned to teach inhaler technique as they are the last healthcare providers to see patients before medication is dispensed and are often in frequent contact with patients.12,13 Pharmacists can also help identify poorly controlled asthma by scanning the use and refill patterns of bronchodilators and inhaled steroids.1
Do it normal
The National Asthma Council Australia has written instructions for teaching inhaler technique. The verse, ‘Do it normal, do it slow, do it with me, then off you go’ was devised to help health professionals remember the process.
Evidence supports the National Asthma Council Australia ‘Watch, don’t just ask’, ‘Show, don’t just tell’ and ‘Repeat, don’t just prescribe or dispense’ messages. Repeated studies have shown that even after personalised instruction in correct use of inhalers, patients still struggle to retain modest improvements in technique.14-16 Including a physical demonstration is more effective in improving technique than providing written and verbal instructions alone.12,17
The National Asthma Council Australia recommends checking inhaler technique at each patient encounter, through the process listed below.18
- Have the patient demonstrate their inhaler technique, while checking against a checklist of steps for the specific device.
- Demonstrate correct technique using a placebo device and correct any specific errors identified.
- Have the patient repeat the demonstration to check they can now use the device correctly. If necessary, repeat instruction until the patient has all steps correct.
Remind patients to bring their inhalers along to their appointments, so that they can demonstrate their technique. This includes the once- or twice-daily inhalers that patients might not usually carry with them. Watch the person use their inhaler – don’t just ask whether they think they know how to use it properly.
Checklists of steps, and videos demonstrating correct technique, for various types of inhalers are available on the Lung Foundation Australia and the National Asthma Council Australia’s websites. Advise patients of available resources such as training videos and provide them with the URL so they can be easily accessed.
Placebo inhalers can be requested from pharmaceutical company representatives or healthcare product suppliers.
Resources for teaching inhaler technique
Videos showing inhaler technique for a range of devices
Online training for health professionals
- NPS MedicineWise online learning module for nurses and pharmacists: 'Unlocking asthma inhaler technique’
- Lung Foundation Australia online training for health professionals
- Fink JB. Inhalers in asthma management: is demonstration the key to compliance? Respiratory care 2005;50:598–600. [PubMed].
- Lung Foundation Australia. COPD-X concise guide for primary care, 2016. [Online] (accessed 18 August 2016).
- Fink JB, Rubin BK. Problems with inhaler use: a call for improved clinician and patient education. Respiratory care 2005;50:1360–75. [PubMed].
- Plaza V, Sanchis J, Roura P, et al. Physicians' knowledge of inhaler devices and inhalation techniques remains poor in Spain. J Aerosol Med Pulm Drug Deliv 2012;25:16–22. [PubMed].
- Partridge MR, Dal Negro RW, Olivieri D. Understanding patients with asthma and COPD: insights from a European study. Prim Care Respir J 2011;20:315–23, 17 p following 23. [PubMed].
- Price D, David-Wang A, Cho S-H, et al. Time for a new language for asthma control: results from REALISE Asia. J Asthma Allergy 2015;8:93. [PubMed].
- Andrews KL, Jones SC, Mullan J. Stigma still an important issue for adults with asthma. J Asthma & Allergy Educators 2013;4:165–71.
- Cole S, Seale C, Griffiths C. ‘The blue one takes a battering’: why do young adults with asthma overuse bronchodilator inhalers? A qualitative study. BMJ open 2013;3:e002247. [PubMed].
- Yang I, Dabscheck E, George J, et al. The COPD-X plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease. Milton, QLD: Lung Foundation Australia, 2016. [Online] (accessed June 2016).
- Mac Hale E, Costello RW, Cowman S. A nurse-led intervention study: promoting compliance with Diskus Inhaler use in asthma patients. Nursing Open 2014;1:42–52. [PubMed].
- Al-Kalaldeh M, El-Rahman MA, El-Ata A. Effectiveness of nurse-driven inhaler education on inhaler proficiency and compliance among obstructive lung disease patients: a quasi-experimental study. Can J Nurs Res 2016;48:48–55.
- Giraud V, Allaert F-A, Roche N. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respir Med 2011;105:1815–22. [PubMed].
- van der Molen T, van Boven JF, Maguire T, et al. Optimizing identification and management of COPD patients - reviewing the role of the community pharmacist. Br J Clin Pharmacol 2017;83:192-201. [PubMed].
- Johnson D, Robart P. Inhaler technique of outpatients in the home. Respir Care 2000;45:1182–7. [PubMed].
- Ovchinikova L, Smith L, Bosnic-Anticevich S. Inhaler technique maintenance: gaining an understanding from the patient's perspective. J Asthma 2011;48:616–24. [PubMed].
- Crompton G, Barnes P, Broeders M, et al. The need to improve inhalation technique in Europe: a report from the Aerosol Drug Management Improvement Team. Respir Med 2006;100:1479–94. [PubMed].
- Bosnic-Anticevich SZ, Sinha H, So S, et al. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. J Asthma 2010;47:251–6. [PubMed].
- National Asthma Council Australia. Australian Asthma Handbook, Version 1.1. Melbourne: National Asthma Council Australia, 2015. [Online].