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.