Most health care professionals use incorrect asthma inhaler technique

Joshua Davidson, MD, MPH

The systematic review presented by Plaza and colleagues offers insight into a long-suspected problem: health care professionals are not teaching their patients proper inhaler technique.

Preparing the systemic review was an arduous task, as studies from 1975 to 2014 were evaluated. While several reviewed studies did not meet inclusion criteria, the 55 studies that remained clearly supported the notion that healthcare professionals across the spectrum, from medical students to primary care or specialist physicians, even respiratory therapists, often fail to properly teach inhaler technique to their patients.

The collected data were stratified based on device type, including pressurized metered-dose inhalers, with and without an inhalation chamber, and dry powder inhalers. The authors also compared data collected during an “early period,” 1975-1995, vs. a “late period,” 1996-2014. Efficacy was established by comparing study findings to commonly accepted steps for proper device use.

The findings were impressive. The extracted data in the 55 studies identified 6,304 healthcare professionals and 9,996 tests that were performed to prove appropriate inhaler technique. Overall, proper technique was demonstrated in only 15.5% of the tests — 20.5% in the early period and 10.8% in the late period. The most common mistakes included failure to exhale fully before inhalation, poor coordination between release of medication and inhalation, and failure to appropriately hold a breath after use. It is important to note that these poor results were noted to exist independent of training status, and the rates of errors rose, as the rate of correct inhaler technique fell. Apparently health care professionals’ inhaler technique is worsening over time.

While the data are impressive, there are some important limitations to consider, and the authors eloquently identify them in the study. As a systematic review, many different study types were considered, each with different methods and outcome measures. Two of the 55 accepted and reviewed studies were randomized controlled trials, which raises concerns about bias and confounding variables.

That said, the data presented here shine light on a very important aspect of treatment for chronic respiratory diseases. It is our responsibility as clinicians to not only prescribe appropriate inhalers for respiratory conditions, but to ensure that each patient fully understands how to use a given device. This simple act of prescribing an inhaler is not enough.

Compliance with treatment is a fundamental concern for treatment of any chronic condition. If we create additional technical obstacles by failing to teach our patients proper inhaler technique, then high compliance rates will be more difficult to achieve. Furthermore, there are documented clinical consequences of poor inhaler technique, including an association with poorly controlled asthma and increased exacerbation rates.

The consistently high error rates noted in this study suggest that educational efforts to improve inhaler technique are desperately needed. Whether health care professionals are receiving poor instruction or no instruction at all, this systematic review supports the development of improved and consistent teaching efforts, utilizing well-documented techniques that optimize medication deposition for patients with chronic respiratory diseases.