Knowledge of Nurses and Primary Care Physicians on Inhaled Therapy Devices and Techniques

Abstract

Background:

We aimed to assess the knowledge of health care professionals regarding inhaled therapy devices and techniques and to evaluate the effectiveness of a targeted educational intervention.

Methods:

An educational program designed to update the knowledge and improve the technical skills of these professionals in the use of different types of inhalers was developed. Before and after each training session, we applied an ad hoc questionnaire that consisted of 15 multiple-choice questions on inhaled therapy grouped into three sections, including knowledge about devices used for inhaled therapy, knowledge about inhaler techniques, and knowledge about adherence to inhaled therapy, as well as the Test of the Adherence to Inhalers. The questionnaire also included a summary question. We calculated the mean score and the standard deviation for the pre- and postevaluations, compared the mean scores using Student’s t-test, and evaluated the relevance of the changes using Cohen’s d.

Results:

During the 23 meetings held throughout Spain, 267 participants completed the pretraining questionnaire, including 105 primary care physicians, 90 nurses of specialized care, 41 nurses working in primary care, and 31 health care professionals of various origins. Overall, the mean (SD) total score (i.e., number of correct answers out of a maximum of 15; range 0–15) significantly increased from 8.99 (2.26) to 11.46 (2.50) points, for a mean pre–post difference of 2.5 (p < 0.001). Notable issues included the misidentification of device types and confusion between inhalation techniques for pressurized metered-dose inhalers and dry powder inhalers. The mean total scores significantly increased across the three main specialties, with large effect sizes in all cases.

Conclusion:

Our study suggests that both primary care physicians and nurses have relevant gaps in knowledge- and technique-related issues regarding the use of inhalation devices that could be improved using a brief educational intervention.

Keywords

critical inhaler errors health care professionals’ knowledge inhaled therapy inhaler technique

Introduction

Inhaled therapy is an essential component of the treatment of asthma and chronic obstructive pulmonary disease (COPD). Frequent errors in the administration of inhaled therapy by patients have been reported from the incorporation of these devices into therapeutic resources without improvement over time.¹ In a systematic review of studies conducted in adults with asthma or COPD published up to 2014, Chrystyn et al.² reported pooled frequencies of overall errors and critical errors (i.e., those that may impact the effectiveness of the delivered drug) of 87% and 46%, respectively, among users of pressurized metered-dose inhalers (pMDIs) and 61% and 28%, respectively, among users of dry powder inhalers (DPIs), although variation across studies was high in all cases. Importantly, although the evidence is of limited quality, errors with inhaled therapy are associated with poor disease outcomes, such as a greater frequency of exacerbations and greater health-economic burden.^3–5 Patients who experienced a reduction in errors over time presented improved outcomes.⁴ Critical errors associated with inhaled therapy are reduced after patient training.⁶

Clinical practice guidelines for the management of asthma and COPD recommend regularly assessing the correct administration of inhaled therapy by patients and stress the importance of education and training in the inhaler technique.^7,8 Unfortunately, health care professionals who should provide education and training also have poor knowledge of inhaler techniques. Thus, in a systematic review of 55 studies that evaluated inhaler use by health care professionals by direct observation of the subject’s technique, Plaza et al.⁹ reported that the inhaler technique was considered correct in only 16% of the cases. In addition, errors were frequently noted regardless of the type of device (pMDI or DPI) or the health care professional involved (i.e., pulmonologists, primary care physicians, respiratory therapists, nurses, or pharmacists).⁹ Educational interventions with health care professionals addressing the inhaler technique could be easily implemented and subsequently provide an improvement in clinical outcomes and patients’ quality of life through simple interventions with patients.¹⁰ The situation described above for health care professionals has also been described in Spain among physicians and nurses.^11,12 Therefore, we designed and performed an educational intervention for the management of inhalation devices among primary care physicians, nurses, and other health care professionals interested in this topic. As part of the educational intervention, an ad hoc and brief questionnaire on their knowledge of the management of inhalation devices was administered before and after the intervention. The specific objectives of the questionnaire were to assess the baseline knowledge of health care professionals regarding inhaled therapy devices and techniques, identify common knowledge gaps and misconceptions on the proper use of various inhalation devices, and evaluate the effectiveness of a targeted educational intervention in improving health care professionals’ understanding and management of inhaled therapy devices.

Materials and Methods

The educational program

The project was initiated by a sponsor, Chiesi España S.A.U., who selected a scientific committee that was composed of six health care professionals, members of the main scientific Spanish societies related to inhaled therapy (Spanish Society of Pulmonology and Thoracic Surgery [SEPAR], Primary Care Respiratory Group [GRAP], Spanish Society of Allergology and Clinical Immunology [SEAIC], and Spanish Society of Clinical, Family and Community Pharmacy [SEFAC]), and with extensive experience in inhaled therapy. The committee comprised four nurses, one primary care physician, and one community pharmacist. This program was endorsed by GRAP and SEFAC.

The scientific committee developed an educational program that consisted of theoretical and practical training sessions designed to update knowledge and improve the technical skills of these professionals in the use of different types of inhalers. To do so, they developed a slide kit with information on the following topics: theoretical foundations of inhaled therapy, classification/types of inhalers, and device-specific tips for the inhaler technique, including the use of spacers, importance of evaluating and reevaluating adherence to inhaled therapy and tools for evaluating it (specifically, the unique validated tool for evaluating adherence to inhalers, Test of Adherence to Inhalers [TAI]¹³), choice of inhaler device and patient preferences, use of the rescue inhaler as an indicator of poor control, and a practical workshop using videos on the use of inhalers and common errors.

The theoretical presentation lasted approximately 45 minutes, followed by a 30-minute practical workshop. The posttraining questionnaire was administered immediately after the workshop, about 90 minutes after the pretraining assessment.

A training session was held in Madrid in October 2023 to prepare 24 trainers (nurses, primary care physicians, and community pharmacists). From November to December 2023, 23 meetings were held throughout Spain with the participation of health care professionals interested in inhaled therapy.

The questionnaire

We collected information on the specialties of the respondents, Spanish geographic region (i.e., autonomous community), and duration of professional experience (less than 5 years, 5–10 years, or more than 10 years).

The questionnaire consisted of 15 multiple-choice questions on inhaled therapy grouped into three blocks (14 questions), including knowledge about devices for inhaled therapy, knowledge about inhaler techniques, and knowledge about adherence to inhaled therapy, as well as the Test of the Adherence to Inhalers (TAI). Finally, the questionnaire included a summary question on the key issues related to the inhaler technique. A translation of the complete questionnaire is included in Supplementary Appendix A1.

The questionnaire was administered twice at each of the meetings, before initiating the training session and after finalizing the session. The questionnaires were anonymous and administered independently before and after the training; therefore, pre- and postintervention comparisons were performed at the group level rather than based on paired individual responses.

Statistical analysis

The characteristics of the respondents are presented with absolute and relative frequencies.

To evaluate the overall results, each correct answer was given a score of 1 point; thus, the total score ranged from 0 to 15. We calculated the mean score and the standard deviation for the pre- and postevaluations and compared the mean scores using the Student’s t test. To evaluate the relevance of the changes, Cohen’s d was calculated as the mean difference divided by the pooled standard deviation. Cohen’s d was interpreted as follows: d ≥0.2–<0.5, small effect size; d ≥0.5–<0.8, moderate effect size; and d ≥0.8, large effect size. These cutoffs are based on the conventional interpretation proposed by Cohen.¹⁴

The results for each individual question are presented with their relative frequencies, and the pre–post comparison of the proportion of correct answers was made using a chi-square test. Differences in proportions and the corresponding 95% confidence intervals are presented.

The results are presented for the overall sample of respondents and for specific subgroups: nurses attending specialized care, primary care nurses, and primary care physicians.

All the statistical comparisons were performed using the statistical software package MedCalc Software Ltd., version 22.030.^15,16 Cohen’s d was calculated using the online calculator provided by Social Science Statistics.¹⁷

Results

During the 23 meetings held throughout Spain, 267 participants completed the pretraining questionnaire. They included 105 primary care physicians, 90 nurses of specialized care, 41 nurses working in primary care, and 31 health care professionals of various origins (only three were community pharmacists). They performed their professional activities in 8 of the 17 Spanish autonomous communities, including the largest ones by population (i.e., Andalucia, Cataluña, Comunidad de Madrid, and Comunitat Valenciana, which corresponds to over half of the Spanish population). Professional experience was categorized as less than 5 years (n = 74, 28%), 5–10 years (n = 45, 17%), and more than 10 years (n = 146, 55%). Overall, 239 participants (90%) answered the posttraining questionnaire.

Overall, the mean (SD) total score significantly increased from 8.99 (2.26) to 11.46 (2.50) points, for a mean pre–post difference of 2.5 (p < 0.001), which corresponds to a Cohen’s d of 1.04 (Fig. 1A). The mean total scores significantly increased across the three main specialties, with large effect sizes in all cases (Cohen’s d ranging from 0.91 for primary care physicians to 1.45 for nurses working in primary care facilities) (Fig. 1B).

FIG. 1.

Changes in the total score of the questionnaire before and after training. PC, primary care; SC, specialized care. Note: To improve the clarity of the figure, the y-axis ranges from a score of 7–15, instead of 0–15. (A) Overall results (B) Results by specialty.

More than two-thirds of the respondents correctly answered 6 of the 15 questions in the pretraining evaluation, and this figure increased to 11 questions in the posttraining evaluation (Table 1). For all but three questions, the proportion of correct answers significantly improved after the training (Table 1). Question #5 did not show a significant improvement. Thus, before training, 57% of the respondents considered that having a dose counter allows for better control over the prescribed dosage by having information on the remaining doses, and this proportion increased to 63% (p = 0.169) after the training. Importantly, 24% of the respondents considered that when a DPI device is used, shaking it before inhalation is not necessary. The two other questions that did not significantly improve were question #3 on the use of spacers and question #14 on adherence to inhaled therapy. In both cases, the proportion of correct answers before the training was over 90%, and the increase after the training was not statistically significant.

Table 1.

Results of the Questionnaire on Inhaled Therapy Before and After the Training

Question	Answers					Absolut difference in correct responses (pre–post)(95% CI)	p value
1. What is the main problem that patients with respiratory pathology have with pMDI inhalation devices? (select the correct one)	Candidiasis problems with short-acting beta2 medication	Very high inspiratory flow is needed	Poor actuation and inhalation coordination	None of the options are correct	—
Pretraining	0	10	86	4	—	10%(5.1–15.0)	<0.001
Posttraining	0	2	96	2	—
2. With the Turbuhaler® inhalation system (select the correct one)	Only used with rescue medication	No post inhalation breath-hold is needed as it is a dry powder device	Very high inspiratory flow is needed to achieve maximum concentration of the active ingredient in the bronchial mucosa	The best complement to achieve the highest pulmonary deposition is to use it together with a spacer	—
Pretraining	2	12	64	22	—	19%(11.4–26.3)	<0.001
Posttraining	1	2	83	14	—
3. The spacers (select the correct one)	All the answers are correct	Masks can be adapted to some spacers, allowing their use by children and the elderly during periods of crisis or in those patients with cognitive impairment or conditions such as facial paralysis	They are devices that eliminate the difficulty of synchronization between actuation and inspiration	They reduce drug deposition in the oropharynx, minimizing local and systemic adverse effects due to absorption through the mucosa	—
Pretraining	93	2	5	0	—	2%(2.3–6.3)	0.346
Posttraining	95	1	3	1	—
4. The use of spacers is indicated (select the correct one)	For all patients using pMDI devices	For infants and children up to 8 years old and adults with cognitive problems	For infants and children up to 5 years of age and adult patients with cognitive problems	For infants and children up to 3 years old and adults with cognitive problems	—
Pretraining	59	22	17	1	—	19%(10.9–26.3)	<0.001
Posttraining	78	15	7	1	—
5. An issue to take into account in relation to inhaled therapy devices is (select the correct one)	Spacers are devices that achieve greater pulmonary deposits of medication, so it is recommended to always use them with any inhalation system	Dry powder devices are more effective for inhaled therapy than pMDIs	For dry powder devices, it is not necessary to shake them before inhalation	Having a dose counter allows for better control over the prescribed dosage by having information on the remaining doses	—
Pretraining	12	7	24	57	—	6%(2.5–14.3)	0.169
Posttraining	13	3	20	63	—
6. Spiromax® and Easyhaler® inhalation systems are (select the correct one)	Single-dose and dry powder	Multidose and dry powder	Multidose and pressurized	Single-dose and pressurized	—
Pretraining	18	52	20	10	—	19%(10.5–27.0)	<0.001
Posttraining	13	71	12	4	—
7. NEXThaler®, Spiromax® and Handihaler® inhalation devices (select the correct one)	They are devices that require good coordination between actuation and inhalation	They are dry powder devices	They are single-dose dry powder devices	They are multidose dry powder devices	—
Pretraining	14	21	16	50	—	13%(2.2–20.6)	0.001
Posttraining	6	34	9	51	—
8. How many times will we have to check in our consultations that the patient is able to correctly perform the technique of their inhalation device? (select the correct one)	Every time they attend the clinic	In the first and recheck in the second visit to be able to correct the different deviations that the patient introduces into their routine	Only in the first consultation	In the first consultation and recheck on the third visit to be able to correct the different deviations that the patient introduces into their routine	—
Pretraining	61	29	0	10	—	17%(9.1–24.6)	<0.001
Posttraining	79	15	1	5	—
9. Regarding the preparation of the pressurized inhalation device (select the correct one)	Do not shake the device before use; it should always be considered a critical error	Inhalation should be forceful and deep followed by a breath-hold for 10 seconds	Always shake before pressing	For pressurized devices with Modulite® system, it is not essential to shake before actuation	—
Pretraining	2	31	24	43	—	22%(13.4–30.2)	<0.001
Posttraining	5	10	20	65	—
10. Regarding the technique with inhaled therapy treatments (select the correct one)	In dry powder devices, inhalation should be fast and deep, followed by a postinhalation breath-hold of 10 seconds	All the answers are correct	Dry and pressurized powder devices are equally effective if performed with proper technique	In pMDI devices, inhalation must be forceful and deep, followed by a postinhalation breath-hold of 10 seconds	—
Pretraining	6	61	27	6	—	41%(32.3–48.4)	<0.001
Posttraining	4	24	68	4	—
11. The Test of Adherence to Inhalers (TAI) (select the correct one)	All the options are correct	It is a test, and the last two questions must be completed by the health professional	The patterns of nonadherence to inhaled treatment identified by TAI are erratic, deliberate and Unconscious	It is a validated tool that allows us to identify the patient’s pattern of nonadherence to their inhaled therapy	—
Pretraining	71	3	5	21	—	19%(12.2–25.5)	<0.001
Posttraining	90	3	4	4	—
12. In the Test of Adherence to Inhalers (TAI) (select the correct one)	The pattern of nonadherence to inhaled therapy “unconscious” is identified in questions 11 and 12	The TAI is a validated questionnaire that we can use as a tool to evaluate the level of asthma control	The pattern of “deliberate” nonadherence to inhaled therapy is identified in the first 5 questions	The pattern of nonadherence to inhaled therapy “erratic” is identified in questions 6 to 10	—
Pretraining	21	33	33	13	—	31%(22.8–38.7)	<0.001
Posttraining	52	20	18	10	—
13. Following the criteria of the Test of Adherence to Inhalers (TAI-10) (select the correct one)	A score of 50 is considered good adherence to inhaled therapy	A score equal to or less than 45 points is considered poor adherence to inhaled therapy	A score between 46 and 49 points is considered intermediate adherence to inhaled therapy	All answers are correct
Pretraining	10	11	10	69		14%(6.6–21.2)	0.002
Posttraining	11	5	2	83
14. Regarding adherence to inhaled therapy (select the correct one)	All the answers are correct	We must be aware that there is no single ideal device for all patients	Health professionals must have training in inhaled therapy to be able to teach it rigorously to patients	As a general rule, the number of different devices that the patient must use in their treatment should always be simplified	Patient preferences should always be taken into account when choosing a type of device
Pretraining	91	3	2	1	3	2%(2.9–6.8)	0.409
Posttraining	93	1	1	3	1
15. In relation to the technique of inhalation devices, as a summary (select the correct one)	It is recommended to use a spacer as an adjunct when using a pMDI device	Dry powder inhalation devices require more inhalation effort than pMDIs	Breath-hold for 10 seconds after inhalation is an indication common to all inhalation devices	All the answers are correct	The patient should always be instructed to completely exhale before inhaling, regardless of the inhalation device they are using
Pretraining	5	2	3	84	6	11%(5.7–16.3)	<0.001
Posttraining	2	1	1	95	1

Bold figures correspond to the results obtained in the right answer.

CI, confidence interval; pMDI, pressurized metered-dose inhalers; TAI, Test of Adherence to Inhalers.

The following questions in the pretraining evaluation obtained fewer than 50% correct answers: #7 on the NEXThaler®, Spiromax®, and Handihaler® devices; #9 regarding the preparation of pMDI devices; #10 on the inhaled technique; and #12 on the Test of the Adherence to Inhalers (TAI). In Question #7, more than 50% of the respondents incorrectly identified these devices as multidose DPIs (note: Handihaler® is a single-dose DPI), both in the pre- and posttraining evaluations, and 16% and 9% identified them as single-dose devices in the pre- and posttraining evaluations, respectively (Table 1). Although the proportion of correct responses was slightly greater than that in question #7, in question #6, the proportion of respondents who correctly identified Spiromax® and Easyhaler® as multidose DPI devices was 52%; 30% of the respondents identified these devices as pMDIs (Table 1). In question #9 concerning pMDI, 31% incorrectly considered that inhalation should be forceful and deep, followed by a 10-second breath-hold, and 24% considered that it is always necessary to shake before actuating. Only 43% were aware that for devices with a Modulite® system, shaking before actuating is not mandatory (Table 1). For question #10, 61% of the respondents incorrectly considered that pMDI inhalation should be forceful and deep, followed by 10 seconds of breath-hold, and that for DPI inhalers, inhalation should be fast and deep, followed by a postinhalation breath-hold of 10 seconds (61% considered all answers correct and 6% considered that in pMDI devices, inhalation must be forceful and deep). In addition, 27% correctly considered that the pMDI and DPI devices showed similar efficacy. For question #12, 21% were aware of the correct answer regarding the content of the TAI. For all four questions, the results were similar across the three main types of health care professionals (data not shown). Regarding the use of spacers, in question #2 concerning the use of Turbuhaler®, 22% considered that the use of a spacer is the best complement to achieve the highest pulmonary deposition.

In question #8, 62% of the respondents considered that they had to check that the patient was able to correctly perform the technique of their inhalation device every time they attended the clinic, and the proportion increased to 79% after the training.

A summary of the pre–post results for each question, stratified by professional group, is presented in Table 2.

Table 2.

Results of the Questionnaire on Inhaled Therapy Before and After Training (Absolut Difference in Correct Responses [Pre–Post]) for the Whole Sample and by Subgroup

Question	GroupNo before/No after
Question	All267/240	NSC90/79	NPC41/44	PCP105/86
1. What is the main problem that patients with respiratory pathology have with pMDI inhalation devices?	10%^**	18%^**	2%^*	7%^*
2. With the Turbuhaler® inhalation system	19%^**	8%^*	13%^**	32%^*
3. The spacers	2%^*	6%^*	3%^*	1%^*
4. The use of spacers is indicated	19%^**	19%^**	16%^**	13%^**
5. An issue to take into account in relation to inhaled therapy devices is	6%^*	5%^*	15%^**	7%^*
6. Spiromax® and Easyhaler® inhalation systems are	19%^**	20%^***	22%^***	11%^**
7. NEXThaler®, Spiromax® and Handihaler® inhalation devices	13%^**	15%^**	41%^***	4%^*
8. How many times will we have to check in our consultations that the patient is able to correctly perform the technique of their inhalation device?	17%^**	12%^**	21%^***	22%^***
9. Regarding the preparation of the pressurized inhalation device	22%^***	27%^***	18%^**	28%^***
10. Regarding the technique with inhaled therapy treatments	41%^***	40%^***	55%^***	47%^***
11. For the Test of Adherence to Inhalers (TAI)	19%^**	23%^***	35%^***	9%^*
12. For the Test of Adherence to Inhalers (TAI)	31%^***	41%^***	34%^***	16%^**
13. Following the criteria of the Test of Adherence to Inhalers (TAI-10)	14%^**	13%^**	30%^***	5%^*
14. Regarding adherence to inhaled therapy (check the correct one)	2%^*	0%^*	5%^*	3%^*
15. In relation to the technique of inhalation devices, as a summary	11%^**	7%^*	8%^*	17%^**

*: small effect size (Absolut difference in correct responses [pre–post] <10%); **: moderate effect size (Absolut difference in correct responses (pre–post) 10% to <20%; ***: large effect size (Absolut difference in correct responses (pre–post) ≥20%).

NSC, nurses (specialized care); NPC, nurses (primary care); PCP, primary care physicians; pMDI, pressurized metered-dose inhalers; TAI, Test of Adherence to Inhalers.

When stratified by years of professional experience, the three subgroups showed a statistically significant increase in the total score. Thus, in health care professionals with less than 5 years of experience total score increased from 8.5 (2.2) to 10.6 (2.7) points (mean pre–post difference of 2.1, p < 0.001), in those with 5–10 years of experience total score increased from 8.7 (1.7) to 10.8 (2.6) points (mean pre–post difference of 2.0, p < 0.001), and those with more than 10 years of experience total score increased from 9.2 (2.4) to 12.0 (2.3) points (mean pre–post difference of 2.8, p < 0.001).

Discussion

Our survey revealed that in this sample of Spanish health care professionals (mainly nurses and primary care physicians), knowledge of inhaled therapy devices and techniques has relevant gaps. Importantly, it seems that a high proportion of them do not pay the required attention in their clinics because they do not consider it necessary to assess the inhalation technique of patients during every consultation. A brief educational intervention with these health care professionals improved their knowledge of these issues to a significant and relevant extent.

With respect to inhaled therapy devices, a relevant proportion of respondents were unable to identify all multidose and single-dose DPI devices. When asked about three specific DPI devices (two multidose devices and one single-dose device), 50% identified all of them as multidose devices, and 16% identified all of them as single-dose devices. After training, these mistakes persisted in a high proportion of the respondents. Importantly, 30% of the respondents erroneously identified two DPI devices as pMDI devices. There is a large variety of inhaled therapy devices,¹⁸ and the increased number of devices may contribute to the frequency of errors.¹⁹ However, because the inhaler technique varies significantly depending on the type of device, it is important that health care professionals correctly identify these devices.

It is worth noting that although most DPIs do not require shaking before use, there are exceptions such as Easyhaler®, which must be shaken prior to inhalation as per the manufacturer’s instructions. This may have contributed to confusion among respondents when answering question 5.

Errors were also common with inhaled therapy techniques. For example, when asked about inhaled therapy techniques, two-thirds of the respondents considered that pMDI device inhalation should be forceful and deep instead of slow and deep. This is a common mistake made with pMDI devices among patients^20,21 and health care professionals.⁹ A systematic review of the literature identified the most common errors among health care professionals regarding the use of pMDI, including not performing slow deep inspiration (pooled mean 59%) and failing to hold the breath after inhalation (pooled mean 63%).⁹ Although the questionnaire considered the use of spacers in all patients using pMDIs as a correct answer, we acknowledge that this may be surprising at first glance. However, the Global Initiative for Asthma (GINA 2023)⁷ strongly supports the use of spacers in all patients prescribed pMDIs due to multiple clinical benefits. These include improved drug deposition in the lungs, reduced oropharyngeal deposition and side effects—particularly with inhaled corticosteroids—and simplified inhaler technique, which mitigates errors in coordination between actuation and inhalation. Spacers are especially essential in children under 5 years of age, but their use is also recommended in adults to optimize therapeutic efficacy and safety. Therefore, while not mandatory in all clinical scenarios, the routine use of spacers with pMDIs is broadly endorsed by current guidelines. Similarly, two-thirds of the respondents considered that for DPI inhalers, inhalation should be fast and deep instead of forceful and deep. With these devices, forceful and deep inhalation is needed to transform the powder formulation into particles that can be deposited in the lung.²² In a large cohort of patients with asthma, 32%–38% showed insufficient inspiratory effort, which was associated with an increased likelihood of uncontrolled asthma and an increased exacerbation rate.²³

Importantly, only two-thirds of the respondents considered that health care professionals have to assess the patient’s ability to correct the inhaled therapy technique of their device every time they visit the clinic; despite the educational intervention, the proportion increased only up to approximately 80%. Despite the inclusion of informative leaflets with all inhaled therapy devices and the fact that the type and frequency of errors may differ across types of devices, as international organizations state, “there is no device obviating the need to explain, demonstrate, and regularly check inhalation technique.”⁸ Although several other factors, such as age, education status, comorbidities, and socioeconomic status, are associated with a greater frequency of errors in the use of inhaled therapy, several studies have consistently reported that previous inhaler instructions are associated with fewer errors in the inhaled technique.³ Given that some errors associated with inhaled therapy are repetitive,²⁰ that the benefits of training on the use of inhalers seem to wane over time²⁴ and that repeated inhaled therapy education is associated with an improved inhaler technique,²⁵ it is important to check the inhaler technique and provide proper education every time we have the opportunity to do so. Consistently, some guidelines for the management of asthma recommend reviewing and reinforcing inhalation techniques at every follow-up visit.²⁶ Finally, assessment tools for evaluating adherence to inhaled therapy, such as the TAI, are also needed; this tool could help clinicians identify barriers related to inhaled therapy.¹³

The fact that our results are based on an ad hoc questionnaire for evaluating the impact of an educational activity on the use of inhaled therapy and not a study specifically designed to evaluate errors with inhaled therapy among health care professionals should be considered a limitation. As the information sessions were an educational activity, we can assume that attendees were interested in improving their knowledge of inhaled therapy. It is unclear whether this could have biased the results to a higher or lower frequency of errors. Importantly, a key stakeholder involved in the management and training of patients, namely, the community pharmacist, was almost not represented in our sample. Our evaluation of the educational intervention in improving healthcare professionals’ understanding and management of inhaled therapy devices was focused on the short term, and we lack information on the long-term uptake of this training. Despite these limitations, our study suggests that both primary care physicians and nurses face relevant gaps in knowledge- and technique-related issues regarding the use of inhalation devices, which could negatively impact the education provided to their patients. The brief educational intervention had a positive and significant effect on increasing knowledge about inhalation techniques across all groups of health care professionals. However, some errors tend to persist, suggesting that a single educational intervention is not sufficient to fully address these gaps in knowledge; thus, continuous training programs for health care professionals are recommended in the management of inhaled therapy devices. These continuous training programs, in addition to key content, such as that presented in our program, should be tailored to the knowledge gaps identified among attendees and ideally accompanied by a clinical audit to assess the impact of the program. Nevertheless, the importance of reviewing inhalation techniques with patients at every consultation should be stressed in all training sessions with health care professionals.

Authors’ Contributions

F.J.P.-Z.: Writing—original draft preparation. V.L.-C.: Designed the questionnaire. All the authors were involved in conceptualization, methodology, formal analysis, and writing—review and editing. All the authors gave final approval of the version to be published, have agreed on the journal to which the article has been submitted, and agreed to be accountable for all aspects of the work.

Footnotes

Acknowledgments

The authors thank Cata Ramis and Jordi Puig (Ampersand, Barcelona, Spain) for the implementation and analysis of this survey and Fernando Rico-Villademoros (COCIENTE S.L., Madrid, Spain) for his editorial assistance. This assistance was funded by Chiesi España S.A.U.

Author Disclosure Statement

F.J.P.-Z. has received fees and funding from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Menarini, MundiPharma, and Teva. V.L.-C. has received speaker honoraria from Chiesi and consulting honoraria from Chiesi. J.G.-R. has received speaker honoraria from ACIS-SERGAS, Adamed Pharma, AsacPharma, Astra-Zeneca, Bial, Chiesi, Cipla, GRAP, GSK, and MSD; travel grants from Cipla, GRAP, MSD, and Viatris; and advisory honorarium from Boehringer Ingelheim. M.d.C.M.-H. has received fees and funding from Chiesi. M.V.P. has received fees and funding from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Menarini, and Teva. J.G.-D. reports no conflicts of interest.

Funding Information

This study was funded by Chiesi España SA.

Data Sharing Statement

Data are available from the corresponding author upon reasonable request.

Supplemental Material

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