Opportunistic optimization of inhaler technique in hospitalized adults with asthma: a two-phase educational study

Abstract

Objective

To investigate effectiveness of two different educational methods to improve inhaler techniques in patients with prior diagnosis of asthma, hospitalized with a non-asthma-related diagnosis.

Methods

We undertook a real-world, opportunistic quality-improvement project. Inhaler technique in hospitalized patients with prior diagnosis of asthma was assessed in two cohorts over two 12-week cycles using a standardized device-specific proforma of seven-step inhaler technique, classed: “good” if 6/7 steps achieved; “fair” if 5/7 compliant; “poor” for others. Baseline data was collected in both cycles. Cycle one involved face-to-face education by a healthcare professional; cycle two involved additional use of an electronic device to show device-specific videos (asthma.org.uk). In both cycles, patients were reassessed within two days for improvements and the two methods compared for effectiveness.

Results

During cycle one 32/40 patients were reassessed within 48 h; eight lost to follow-up. During cycle two 38/40 patients were reassessed within 48 h; two lost to follow-up During cycle one, two and 12 had good/fair baseline technique respectively, and 26 poor. Most commonly missed steps were no expiry check/not rinsing mouth after steroid use. On reassessment 17% patients improved from poor to fair/good. During cycle two, initial technique assessment identified: 23 poor; 12 fair; five good. Post-videos, 35% of patients improved from poor to fair/good. Proportion of patients improving from poor to fair, or poor/fair to good increased in cycle two vs one (52.5% vs 33%).

Conclusion

Visual instruction is associated with improved technique compared to verbal feedback. This is a user-friendly and cost-effective approach to patient education.

Keywords:

• Asthma
• inhaler technique
• patient education
• quality improvement

Introduction

Asthma is one of the most common chronic diseases and responsible for approximately 1 in 250 deaths worldwide (1). Inhaled medications remain the mainstay of chronic stage treatment. This is due to direct delivery to the airways with rapid onset time with minimal dosing, as well as practicality with the use of portable and compact inhaler devices (2,3). Poor inhaler technique has been recognized as a frequently encountered issue in treatment optimization, due to less medication being deposited in the airway (4,5).

Due to the significant morbidity and mortality caused by poorly controlled asthma, patient education and optimization of inhaler provision and technique remains a global priority (6). Good management with inhaled medications leads to greater disease control and quality of life. However, their use may be limited by, for example, poor coordination (exacerbated by comorbid conditions such as poorly controlled arthritis, disabling stroke or history of memory impairment) or poor understanding of how to use the device, especially if multiple types are prescribed to a single individual (7). A Cochrane Review of interventions to improve inhaler technique in asthma found there to be marked variation in how inhaler technique is addressed in clinical practice, with most interventions failing to yield consistent or important benefits (2). This review also highlighted that it is consistently recommended that clinicians check inhaler technique regularly, but there is no guidance on how this is best achieved, and how to effectively intervene in cases of inadequate technique. A recent study has examined the involvement of the multidisciplinary team (community pharmacists and pulmonologists) (8). However, few studies have comprehensively examined interventions to optimize inhaler use and reduce error (9).

In our district general hospital, Inhaler techniques have been regularly checked in patient with asthma admitted with an exacerbation of their disease, albeit not in those presenting with non-asthma related conditions to the acute unselected medical take. We undertook a two-stage quality improvement study to opportunistically assess inhaler technique in patients with asthma admitted acutely with non-asthma related conditions and assess two methods of educational intervention designed to improve technique.

Methods

This study was undertaken over two subsequent 12-week phases (i.e. 12 weeks per cycle) in two separate cohorts, with 40 patients recruited to each phase. A standardized device-specific proforma of seven-step technique was produced, based on guidance from British Thoracic Society and Asthma UK (10). This was used as the gold-standard against which patient inhaler technique was assessed throughout the study.

Baseline data was obtained from patients during both cycles. Patients with a prior diagnosis of asthma using inhaled medication were identified consecutively via electronic health records from all patients admitted via the acute unselected medical take. Inclusion criteria were: patients 18 years or older; with a clinician-confirmed diagnosis of asthma prescribed at least one inhaler; and the primary reason or diagnosis on acute admission to hospital was not an exacerbation of asthma. Patients were only recruited if deemed having mental capacity to engage with the assessment of inhaler technique. Exclusion criteria were children (under 18 years old) and/or admitted acutely due to their asthma.

In both phases, patients were approached by a trained clinician and had inhaler technique assessed against the gold-standard. Technique was graded as follows: good if at least six steps achieved; fair if at least five steps achieved; poor if one to four steps achieved. Type of inhaler device and details of missed steps were recorded.

Following the first assessment, an intervention to improve technique was performed in each of the two cohorts. During phase one, the clinician provided verbal instructions on how to better use the inhaler device. During phase two, based on feedback and results from phase one, patients viewed device-specific videos on how to use their inhaler on the Asthma UK website (10). Technique was reassessed within 48 h and graded as above.

Summary of our methodology is available in Figure 1, which is a “Plan-Do-Study-Act” format as per the convention for quality improvement studies.

Figure 1. Schematic analysis of “Plan-Do-Study-Act” cycles for phases 1 and 2 of this quality improvement study, respectively.

Patient demographics and comorbidities were collated. Direct statements were also taken and recorded from patients on their experience of the interventions.

Subjects and data analysis

Patients with asthma were opportunistically recruited to the study using a consecutive sampling approach, on admission under the general medicine team. Recruitment took place for a period of two months in each cycle, or until a total of 40 patients had been reached in one cycle (if earlier than two months). This sample size was reflective of the number of patients with a diagnosis of asthma on at least one inhaler admitted to our local hospital for a non-asthma-related condition. No patients were missed in the consecutive sampling process, other than those both admitted and discharged out of hours.

Descriptive statistics were collated with regards to basic demographics and numbers of steps completed on assessment and re-assessment in each of the two cycles. The mean number of steps performed was compared before and after intervention in each of the two cycles, as well as assessing improvement from poor to fair, poor to good and fair to good, specifically. Chi-Square test was used to further compare the level of improvement following intervention between the two cycles.

Results

In each phase, 40 patients were recruited (Tables 1 and 2). The average age of patients recruited to phase one and two was 62.7 (SD 18.6) and 62.5 years (SD 19.5) respectively. The majority of patients in both cycles was female (70% in cycle 1;75% in cycle 2). With regards to smoking status, in cycle 1, 17.5% were current smokers, 40% ex-smokers and 42.5% never smokers. In cycle 2, 7.5% were current smokers, 35% were ex-smokers and 57.5 were never smokers. All patients across cycles 1 and 2 were of Caucasian ethnicity.

Table 1. Phase one: Patient demographics and outcomes from inhaler checks, before and after intervention.

Patient number	Age (Yrs)	Type of inhaler	1st round comments	Rating	Number of steps done (/7)	2nd round comments	Rating	Number of steps done (/7)	2nd check status	Comorbidities	Smoking status
1	65	pMDI	Not checking expiration, not rinsing mouth post Fostair, not cleaning mouth piece prior to use	Poor	3	Complete recollection	Good	7	Completed earlier than 48hrs—early discharge	Splenectomy	Never
2	48	pMDI	Not checking expiration, not rinsing mouth post-steroid, not cleaning mouth piece prior to use, not holding breath for 10 seconds	Poor	2	No recollection of discussion	Poor	2	48hr check achieved	Previous stroke; OSA on CPAP	Current smoker
3	65	pMDI	Not checking expiration, not rinsing mouth post steroid, not cleaning mouth piece prior to use, not holding breath for 10 seconds	Poor	3	Complete recollection	Good	7	Completed earlier than 48hrs—early discharge	Nil recorded	Never
4	60	pMDI	Not checking expiration, not rinsing mouth post Fostair	Poor	3	NOT done as patient acutely deteriorated and transferred to another hospital. Diagnosed with ACS.	–	–	Not completed (self/OOH discharge)	Nil recorded	Never
5	54	pMDI	Not checking expiration, not rinsing mouth post Fostair	Fair	5	Not checking expiration	Good	7	48hr check achieved	Somatisation disorder	Never
6	47	pMDI	Nil comments	Fair	4	Complete recollection	Good	7	Completed earlier than 48hrs—early discharge	Nil recorded	Current smoker
7	55	pMDI	Not checking expiration, not rinsing mouth post steroid, not cleaning mouth piece prior to use, not holding breath for 10 seconds, not holding a breath in (breathes in and out instead)	Poor	3	Not done as patient self-discharged	–	–	Not completed (self/OOH discharge)	Nil recorded	Current smoker
8	76	pMDI	Not rinsing mouth post steroid, incorrect technique, breathing in too quickly, does not wait for 10 seconds between usage	Poor	3	No recollection of discussion	Fair	4	Completed earlier than 48hrs—early discharge	Severe rheumatoid arthritis	Never
9	58	pMDI	Not rinsing mouth post steroid, incorrect technique, breathing in too quickly, does not wait for 10 seconds between usage	Poor	3	Not checking expiration, complete recollection of the other discussed points	Good	6	Completed earlier than 48hrs—early discharge	Nil recorded	Never
10	47	pMDI	Not checking expiration, not rinsing mouth post steroid	Fair	5	Not checking expiration	Good	6	Completed earlier than 48hrs—early discharge	Nil recorded	Current
11	87	pMDI	Not checking expiration, not rinsing mouth post steroid	Poor	2	Not completed, early discharge	–	–	Not completed (self/OOH discharge)	Nil recorded	Ex-smoker
12	22	pMDI	Not checking expiration, does not wait for 10 seconds between usage	Fair	5	Not completed, early discharge	–	–	Not completed (self/OOH discharge)	Nil recorded	Never
13	77	pMDI	Not checking expiration, not rinsing mouth post steroid, does not wait for 10 seconds between usage	Fair	4	Not checking expiration, complete recollection of the other discussed points	Good	6	Completed earlier than 48hrs—early discharge	Nil recorded	Never
14	71	pMDI	Does not wait for 10 seconds between usage	Poor	3	Does not wait for 10 seconds in between usage	Good	6	48hr check achieved	Nil recorded	Ex-smoker
15	62	pMDI	Not checking expiration, not rinsing mouth post steroid, does not wait for 10 seconds between usage	Poor	3	Not rinsing mouth post steroid, not checking expiration	Fair	5	48hr check achieved	Previous ischemic stroke; mild memory impairment	Never
16	33	pMDI	Not checking expiration, not rinsing mouth post steroid, does not wait for 10 seconds between usage	Poor	3	Does not wait for 10 seconds between usage	Good	6	48hr check achieved	Nil recorded	Current smoker
17	74	pMDI	Not checking expiration, not rinsing mouth post steroid, does not wait for 10 seconds between usage, not holding a breath in	Poor	2	No recollection of the points	Poor	2	48hr check achieved	Mild learning difficulties	Ex-smoker
18	34	pMDI	Not checking expiration, not rinsing mouth post steroid, does not wait for 10 seconds between usage	Fair	4	Not checking expiration	Good	7	48hr check achieved	Nil recorded	Current
19	62	pMDI	Not checking expiration, not holding a breath in, not cleaning spacer prior to use	Fair	5	Complete recollection	Good	7	Completed earlier than 48hrs—early discharge	Nil recorded	Ex-smoker
20	76	pMDI	Does not wait for 10 seconds between usage, not holding a breath in	Fair	4	Not completed, early discharge	–	–	Not completed (self/OOH discharge)	Nil recorded	Never
21	82	pMDI	Not checking expiration, not rinsing mouth post steroid, does not wait for 10 seconds between usage, not holding a breath in	Poor	1	Not checking expiration	Fair	5	48hr check achieved	AF; osteoarthritis; HTN	Ex-smoker
22	70	pMDI	Not checking expiration, not rinsing mouth post steroid, does not wait for 10 seconds between usage	Poor	1	Not breathing out fully and gently, does not wait for 10 seconds between usage	Fair	4	48hr check achieved	Nil recorded	Ex-smoker
23	48	pMDI	Not checking expiration, not breathing out fully and gently, not taking deep breath in, not waiting for a few seconds before repeating	Poor	3	Not breathing out fully and gently	Good	6	48hr check achieved	Spina bifida; T2DM; HTN	Never
24	74	pMDI	Nil comments	Good	7	Complete recollection	–	–	Completed earlier than 48hrs—early discharge	Nil recorded	Never
25	65	pMDI	Not checking expiration, not breathing out fully and gently	Fair	4	Not breathing out fully and gently	Good	7	48hr check achieved	CHD; HTN; anxiety; T2DM	Ex-smoker
26	54	pMDI	Not breathing out fully and gently, does not wait for 10 seconds between usage	Fair	5	Not completed, early discharge	–	–	Not completed (self/OOH discharge)	Nil recorded	Current
27	89	pMDI	Not checking expiration, not rinsing mouth post steroid, not holding breath in	Poor	3	Not checking expiration	Good	6	Completed earlier than 48hrs—early discharge	PVD	Ex-smoker
28	56	pMDI	Not checking expiration, not rinsing mouth post steroid, not holding breath in	Poor	3	Not breathing out fully and gently, not holding breath in	Fair	5	Completed earlier than 48hrs—early discharge	OSA	Ex-smoker
29	24	pMDI	Not rinsing mouth post steroid	Good	7	Not completed, early discharge	–	–	Not completed (self/OOH discharge)	PCOS; IHD	Never
30	83	pMDI	Does not wait for 10 seconds between usage, not rinsing mouth post steroid, not holding breath in	Poor	3	Not completed, early discharge	–	–	Not completed (self/OOH discharge)	Nil recorded	Ex-smoker
31	65	pMDI	Not checking expiration, not rinsing mouth post steroid, does not wait for 10 seconds between usage, not breathing out fully and gently	Poor	3	Not checking expiration, not rinsing mouth post steroid, does not wait for 10 seconds between usage, not breathing out fully and gently	Poor	3	48hr check achieved	T1DM; previous myocardial infarction	Ex-smoker
32	38	pMDI	Not breathing out fully and gently	Poor	3	Complete recollection	Good	6	48hr check achieved	Ulcerative colitis; psoriasis	Never
33	82	pMDI	Not breathing out fully and gently	Fair	4	Not breathing out fully and gently	Fair	4	48hr check achieved	T2DM; HTN; AVR	Ex-smoker
34	85	pMDI	Not checking expiration, not breathing out fully and gently, does not wait for 10 seconds between usage	Poor	2	Not breathing out fully and gently	Good	6	48hr check achieved	Hypercholesterolaemia	Ex-smoker
35	82	pMDI	Not checking expiration, not breathing out fully and gently, not rinsing mouth post steroid	Fair	4	Not checking expiration, not rinsing mouth post steroid	Fair	5	48hr check achieved	Nil recorded	Ex-smoker
36	91	pMDI	Not checking expiration, not breathing out fully and gently, not rinsing mouth post steroid, does not wait for 10 seconds between usage	Poor	1	Not checking expiration, not breathing out fully and gently, not rinsing mouth post steroid, does not wait for 10 seconds between usage	Poor	3	48hr check achieved	Mild dementia	Ex-smoker
37	49	pMDI	Not checking expiration, not rinsing mouth post steroid	Poor	3	Complete recollection	Poor	3	48hr check achieved	Anxiety and depression	Never
38	41	pMDI	Not checking expiration, not rinsing mouth post steroid, does not wait for 10 seconds between usage	Poor	2	Not checking expiration, not rinsing mouth post steroid	Fair	4	48hr check achieved	Epilepsy; alcohol excess	Never
39	68	pMDI	Not checking expiration, does not wait for 10 seconds between usage	Poor	2	Not checking expiration	Fair	5	48hr check achieved	AF	Never
40	89	pMDI	Not checking expiration, not rinsing mouth post steroid, does not wait for 10 seconds between usage	Poor	3	Not checking expiration, does not wait for 10 seconds between usage	Fair	5	48hr check achieved	Nil recorded	Ex-smoker

Note. OSA = obstructive sleep apnea; CPAP = continuous positive airway pressure; HTN = hypertension; AF = atrial fibrillation; T2DM = type 2 diabetes mellitus; CHD = coronary heart disease; PVD = peripheral vascular disease; PCOS = polycystic ovary syndrome; IHD = ischemic heart disease; T1DM = type 1 diabetes mellitus; AVR = aortic valve replacement.

Table 2. Phase two: Patient demographics, outcomes and comments from inhaler checks, before and after intervention.

Patient number	Age (yrs)	Type of inhaler	1st round comments	Rating	Number of steps done (/7)	2nd round comments	Rating	Number of steps done (/7)	2nd check status	Comorbidities	Smoking status	Patient comments/quotes
1	44	pMDI	No date check, no test spray, didn’t hold breath, didn’t rinse mouth	Poor	2	Held breath appropriately this time	Poor	3	Completed earlier than 48hrs—early discharge	Right lower lobe lobectomy for lung cancer with metastatic spinal disease + moderate stenosis L5/S1; diverticular disease; B12 deficiency; T2DM; hypothyroidism; hearing impairment; osteoarthritis	Never
2	81	pMDI	No date check, did not rinse mouth	Poor	3	Held breath for appropriate time, waited before second dose	Fair	5	Completed earlier than 48hrs—early discharge	Fibromyalgia; restless legs	Never	Patient was keen to learn from the video, repeated steps back as they were being played
3	73	pMDI		Fair	4				Not completed (self/OOH discharge)	COPD; HTN; cholecystectomy; hysterectomy	Current smoker
4	56	pMDI	No expiry date check, didn’t shake inhaler, didn’t wait between puffs	Poor	3	Did not check expiry date, didn’t rinse mouth	Fair	5	Completed earlier than 48hrs—early discharge	Liver failure	Never	Good, helped to see things she was doing right
5	52	pMDI	No expiry date check, shook inhaler for 10 seconds, inhaled quickly, didn’t rinse mouth	Fair	4	Didn’t check expiry date, knows to rinse mouth but doesn’t	Fair	5	48hr check achieved	OSA; T2DM; HTN; oesophagitis; liver steatosis; GORD; bipolar disorder	Never
6	73	pMDI	No dose counter check, no time between puffs, did not rinse mouth	Fair	4	Didn’t check expiry date	Good	6	48hr check achieved	HTN; pre-diabetes; COPD; chronic back pain; glaucoma	Ex-smoker
7	69	pMDI	No expiry date check	Good	6				Not completed (self/OOH discharge)		Ex-smoker
8	65	pMDI	Didn’t check expiry date, no time between puffs	Fair	5	Didn’t check expiry date but knows to do so every now & then	Good	7	48hr check achieved	Nasal polyps; conductive hearing loss; depression; previous bowel perforation	Ex-smoker
9	22	pMDI	Didn’t check expiry date, didn’t breathe out before, didn’t breathe in slowly	Poor	4	Knows to check expiry date, to breathe out before and hold breath after	Good	7	Completed earlier than 48hrs—early discharge		Never	With time it’s easy to forget instructions given regarding inhalers so the video was good for a reminder
10	92	pMDI	Didn’t check expiry date, didn’t rinse mouth after	Fair	5	Didn’t check expiry date, didn’t rinse mouth after	Fair	5	Completed earlier than 48hrs—early discharge	COPD; CCF; AF; colitis	Ex-smoker
11	35	pMDI	Didn’t check expiry date, only few seconds between puffs, only didn’t rinse mouth	Poor	4	Didn’t check expiry date, didn’t rinse mouth after	Fair	5	Completed earlier than 48hrs—early discharge	Anxiety; depression; lumbar radiculopathy	Ex-smoker	Video content was easy to understand
12	70	pMDI	Didn’t check expiry date, didn’t breathe out before, 5–10 minute between puffs, knows to rinse mouth after steroid inhaler	Poor	4	Didn’t check expiry, 30 seconds between puff	Good	6	Completed earlier than 48hrs—early discharge	AF; HTN; IBS; recurrent falls; recurrent UTIs	Never	Video was excellent
13	81	pMDI	Didn’t check expiry, knows to rinse mouth after	Good	6	Didn’t check expiry	Good	6	Completed earlier than 48hrs-early discharge	Cognitive decline; compression fractures of spine; osteoporosis; IHD; HTN; anxiety	Ex-smoker	It was a helpful exercise
14	70	pMDI	Didn’t check expiry, didn’t shake inhaler, didn’t breathe out before, didn’t wait between puffs, didn’t rinse mouth after	Poor	2	Didn’t breathe out before, didn’t rinse mouth after	Fair	5	Completed earlier than 48hrs—early discharge	T2DM; HTN; osteoarthritis; diverticular disease; depression; high cholesterol	Ex-smoker	"Taught me some things, quite useful"
15	69	pMDI	Sprayed puff into air then inhaled, didn’t hold breath, didn’t rinse mouth after, no time between puffs	Poor	1	Shook inhaler, sealed lips around mouthpiece, held breath, 10 seconds between puffs, didn’t rinse mouth after	Poor	4	Completed earlier than 48hrs—early discharge	Hypertrophic non-obstructive cardiomyopathy; alcohol excess	Ex-smoker	Video was "informative and straightforward"
16	29	pMDI	Didn’t shake inhaler or check expiry, no time between puffs, doesn’t rinse mouth after	Poor	4	Didn’t check expiry, shook inhaler, waited 30 seconds between puffs, knows to rinse mouth after	Good	6	Completed earlier than 48hrs—early discharge	No comorbidities	Ex-smoker	Video was "helpful"; "Good to see someone do it"
17	75	pMDI	Didn’t check expiry, didn’t breathe out before taking dose, knows to rinse mouth if steroid inhaler	Good	5	Breathed out, checked expiry and for dust inside mouthpiece	Good	7	Completed earlier than 48hrs—early discharge	Hiatus hernia; duodenitis; gastric ulcer; diverticulosis; rectal polyps; right total hip replacement; osteoporosis	Never	Video is useful and clear for new asthma patients
18	62	pMDI	Only took inhaler, no other steps performed	Poor	2	Shook inhaler, breathed out beforehand on second attempt	Poor	4	Completed earlier than 48hrs—early discharge	Lung fibrosis; pulmonary cystic fibrosis; ulcerative colitis	Never
19	83	Accuhaler	Only didn’t rinse mouth	Good	6	Same as before—didn’t rinse mouth	Good	6	Completed earlier than 48hrs—early discharge	Previous hemicolectomy; B12 deficiency; CCF; gout	Never
20	85	pMDI	Didn’t shake inhaler, didn’t breathe out, didn’t rinse	Poor	2	Didn’t check expiration or rinse mouth	Fair	5	Completed earlier than 48hrs—early discharge	Rheumatoid arthritis; T2DM	Never
21	72	pMDI	No expiry check, shakes before use, doesn’t breathe out first, doesn’t hold breath, few minutes between puffs, rinses mouth after	Poor	3	Did test spray, breathes out before, 30 seconds between puff, rinses mouth after	Good	7	Completed earlier than 48hrs—early discharge	HTN; CCF; cataracts	Never	"Was helpful"
22	25	pMDI	No expiry check, shakes inhaler, 5–10 minutes between puffs, doesn’t hold breath, rinses mouth after	Poor	4	No expiry check, shakes inhaler, holds breath, 30 seconds between puffs, rinses mouth after	Good	6	Completed earlier than 48hrs—early discharge		Never	"Helpful video"
23	73	pMDI	No expiry check, shakes inhaler, 30 mins between puffs, doesn’t rinse mouth after	Fair	5	Checks expiry and does test spray, shakes inhaler, 30 mins between puffs, doesn’t rinse mouth after	Good	6	Completed earlier than 48hrs—early discharge	T2DM; GORD	Never	"Didn’t know about test spray so video was quite useful"
24	20	pMDI	No expiry check, shakes inhaler, doesn’t hold breath, 30 seconds between puffs, rinses mouth after steroid inhaler	Fair	5	No expiry check, shakes inhaler, holds breath, 30 seconds between puffs, rinses mouth after steroid inhaler	Good	6	Completed earlier than 48hrs—early discharge	Fibromyalgia; chronic fatigue syndrome; depression	Never	"Informative"
25	80	pMDI	No expiry check, shakes inhaler, few seconds between puffs, rinses mouth after steroid inhaler	Fair	5	Knows to check expiry, shakes inhaler, 30 seconds between puffs, rinses mouth after steroid inhaler	Good	7	Completed earlier than 48hrs—early discharge	Chronic pulmonary aspergillosis; bronchiectasis	Ex-smoker	"Very good, very informative"
26	71	Handihaler	Didn’t breathe out fully and away, didn’t hold breath after taking dose	Fair	5	All done perfectly	Good	7	Completed earlier than 48hrs—early discharge	Right hip severe osteoarthritis; psoriatic arthritis; aspergillosis; previous right upper lobectomy	Ex-smoker	Patient engaged very well, keen to improve her technique
27	50	pMDI	No expiry check, did not breathe away before taking inhaler, did not hold breath after	Poor	2	Much better but did not wash mouth	Good	6	Completed earlier than 48hrs—early discharge	Back pain; depression; AF	Current smoker	"I sometimes wonder if the medicine is going in, but I will remember to tilt my head back and hold breath after taking inhaler"
28	74	Turbohaler	No expiry check, did not rinse	Fair	5	Same as previously	Fair	5	Completed earlier than 48hrs—early discharge	Previous PE; PPM; OSA; aortic stenosis; T2DM; mastectomy for breast cancer; GORD	Never	Felt it was a good video despite no change in technique
29	71	pMDI	No expiry check, did not wait between puffs	Fair	5	Waited between puffs but still no expiry check	Good	6	Completed earlier than 48hrs—early discharge	End stage peritoneal serous adenocarcinoma with large bowel involvement	Never
30	64	pMDI	No expiry check, didn’t shake inhaler, did not rinse mouth	Poor	4	Checked expiry and shook inhaler, didn’t rinse mouth	Good	6	Completed earlier than 48hrs—early discharge	IHD; HTN; myocardial infarction	Ex-smoker	Relatively recent asthma diagnosis, had not had any training on inhaler use so found very helpful
31	89	pMDI	No expiry check, didn’t shake inhaler, did not wait before repeating, did not rinse mouth	Poor	3	Shook inhaler and waited before repeat dose	Fair	5	Completed earlier than 48hrs—early discharge	Osteomyelitis; thrombocytopenia	Never
32	31	Ellipta	Good technique, has been using inhalers since childhood	Good	7	No issues first time, good technique second time	Good	7	Completed earlier than 48hrs—early discharge	Crohn’s colitis; ME	Never
33	58	pMDI	Missed most steps—no expiry check, doesn’t breathe out beforehand, no wait between doses, no rinsing	Poor	2	Stated he would probably take it the same way, despite the video	Poor	2	Completed earlier than 48hrs—early discharge	HTN; recurrent UTIs; T2DM; alcohol-related fatty liver disease; previous COVID-19 requiring ITU support	Ex-smoker
34	72	pMDI	No expiry check, doesn’t wait between doses	Poor	3	Same as previously	Poor	3	Completed earlier than 48hrs—early discharge	Osteoarthritis; HTN; BPH; TIA	Never	Patient stated she was grateful for asthma nurse at GP who checks on inhaler technique yearly
35	52	pMDI	No expiry check, doesn’t wait between doses	Poor	3	Would now wait between doses	Poor	4	Completed earlier than 48hrs—early discharge	Anxiety disorder; endometriosis; gastritis; hiatus hernia; IBS; interstitial cystitis; unstable angina	Never
36	78	pMDI	No expiry check, didn’t hold breath	Poor	4	Waiting between doses, and counting to hold medication	Fair	5	Completed earlier than 48hrs—early discharge	Mild aortic stenosis; moderate aortic regurgitation	Never	Found video useful
37	58	pMDI	No expiry check, didn’t hold breath, didn’t wash mouth	Poor	3	Would now hold breath	Poor	4	Completed earlier than 48hrs—early discharge	Otitis externa	Ex-smoker
38	81	pMDI	No expiry check, not waiting between doses, not drinking water at end	Poor	3	Same as before except would now rinse mouth	Poor	4	Completed earlier than 48hrs—early discharge	JAK2 negative polycythemia; iron deficiency anemia; emphysema; depression	Current smoker
39	30	pMDI	No expiry check, not shaking inhaler, not waiting between doses, not drinking water at end	Poor	2	Would now wait between doses	Poor	3	Completed earlier than 48hrs—early discharge	Nil comorbidities	Never
40	66	pMDI	No expiry check, does not breathe in deeply for 10s (much shorter length of time)	Fair	5	States she would not do anything differently as a result of the video	Fair	5	Completed earlier than 48hrs—early discharge	Diverticular disease	Never	Patient mentioned that her daughter has Accuhaler and she feels this would be easier to use

Note. T2DM = type 2 diabetes mellitus; COPD = chronic obstructive pulmonary disease; HTN = hypertension; OSA = obstructive sleep apnea; CCF = congestive cardiac failure; AF = atrial fibrillation; IBS = irritable bowel syndrome; UTI = urinary tract infection; GORD = gastro-oesophageal reflux disease; PE = pulmonary embolism; PPM = permanent pacemaker; IHD = ischemic heart disease; UTI = urinary tract infection; ME = myalgic encephalomyelitis; ITU = intensive treatment unit; BPH = benign prostatic hypertrophy.

During phase one, 80% of patients were reassessed within 48 h, with eight lost to follow-up due to early discharge (n = 7) or transfer to another hospital (n = 1). During phase two 95% of patients were reassessed within 48 h, with two lost to follow-up. Across both phases, 12 patients had comorbidities which could adversely affect their technique e.g. dementia, disabling stroke, poorly-controlled inflammatory arthritis. Summary of all results are available in Tables 1 and 2.

During phase one, 65% of patients had poor inhaler technique at baseline check, 30% fair, and 5% good. On average, each patient was on two different inhalers with Salbutamol and Beclomethasone being the most frequently prescribed. The most commonly missed steps were not checking device expiry date and not rinsing mouth after steroid use. Two patients completed all steps with no errors, which was in contrast to only two self-identifying their techniques as being “suboptimal” prior to our intervention. On reassessment, 17% of patients improved from poor to fair or good, or fair to good. Seven patients achieved all seven steps on reassessment and three had no recollection of the consultations. The average number of steps performed increased 2.9 to 5.1 (Chi-Square test p < 0.05).

During phase two, 57% of patients had poor inhaler technique at baseline check, 30% fair, and 12% good. After viewing a device-specific video on use of their inhaler on the Asthma UK website, 35% of patients improved from poor to fair or good, or fair to good. The average number of steps performed increased from 3.9 to 5.2 (Chi-Square test p < 0.05). As for phase one, seven patients achieved all seven steps on reassessment. However, the proportion of patients improving from poor to fair, or poor/fair to good, increased in phase two (verbal instructions with videos) compared to phase one (verbal instructions alone) (52.5% vs 33%).

With regards to comments taken directly from patients, there was a demonstrable preference for the videos used during phase two, with patents describing them as “helpful,” “easy to understand,” “informative.” Patients also reported that they were able to learn specific steps of taking their inhaler that they had previously missed or had not realized their importance, e.g. “I sometimes wonder if the medicine is going in, but I will remember to tilt my head back and hold my breath after taking my inhaler.” Most patients felt that an acute admission is a good time to check inhaler technique as it is a quick and easy exercise provided the patient is not too unwell and has capacity to do so: “With time it is easy to forget instructions given regarding inhalers so the video was good for a reminder for me.”

Discussion

In this opportunistic educational study we have demonstrated that visual instruction (via videos) is associated with improved inhaler technique compared to verbal feedback when assessing and optimizing the use of inhalers in adults with asthma. This is novel study comparing interventions for an area of need which previous studies and reviews have highlighted as a cause of suboptimal asthma control leading to poor clinical outcomes.

Poor inhaler technique has been demonstrated as one of the most common reasons for suboptimal disease management in adults with asthma. Poor technique has a direct correlation with patients’ co-morbidities with higher chance of poorer technique in multi-morbid individuals (4,5). It is unclear whether there is an association between the place where the patient was initially taught their techniques (inpatient vs outpatient vs community) and the professional who delivered the teachings (physician, nurse or pharmacist) make any difference in achieving optimal technique. Nonetheless, a recent study comprising 140 patients with diagnosis of asthma or COPD demonstrated that increasing partnership between the pharmacists and chest physicians improve outcomes with inhaler techniques (8). We have demonstrated improvements in inhaler technique, optimized through the use of freely available videos, in patients acutely admitted for non-asthmatic conditions. This is an opportunistic way by which to check inhaler technique in patients with asthma, harnessing a user-friendly, quick and cost-effective method.

Interventions to enhance inhaler technique fall broadly into three categories: technological interventions; educating the clinician; educating the patient (9). Within these, the breadth of interventions available is so great that no individual method has been proven to improve technique and long-term outcomes. In our study, we were able to show the utility of opportunistic assessment of patients’ inhaler techniques during admission for a non-asthmatic problem. Generally, these patients are multimorbid and potentially at increased risk of asthma exacerbations. Furthermore, the reduction in face-to-face outpatient assessments in light of the COVID-19 pandemic makes it more imperative to address comorbidities such as asthma whilst in hospital for another reason.

We demonstrated some improvement in technique with verbal instruction, but an even greater improvement with the use of freely available online videos. Each video was approximately four minutes in length, leading to a total assessment time of under ten minutes. This is therefore a cost-effective and time-sensitive resource, which can be utilized globally and non-dependent on socioeconomic factors or language. Patient anecdotes demonstrate satisfaction with the intervention and overall interaction with the healthcare professional during the study.

Strengths of this study are a large sample size comprising patients of a broad age range and comorbidities, allowing assessment of these factors. Two separate interventions were trialed and allowing comparison between the two. The population surrounding our local hospital is homogenous with regards to ethnicity and socioeconomic status, allowing for reliable comparison of results. Our study was limited in that we were unable to test these interventions in those with conditions such as severe dementia or the acutely unwell due to lack of capacity. However, it would be expected, in the case of dementia patients, caregivers would undergo the training instead, potentially with the use of a delivery system, e.g. spacer. In the case of acutely unwell patients, interventions may be given later in the admission once the patient’s clinical condition improves. Patients who have had a cerebrovascular accident, leading to physical disability limiting their inhaler technique, would likely benefit from multidisciplinary input from specialist pharmacists, occupational therapists and stroke physicians for technique optimization. Additionally, patients who are not comfortable using the Internet may not be able to easily access the videos on discharge, should they wish to do so. However, to overcome this, printed screen-captures of key steps from the video were offered to these patients to take home.

Conclusion

In conclusion, we have shown, in an opportunistically-recruited cohort of patients admitted to hospital with non-asthma-related conditions, that there are deficiencies in inhaler technique amongst patients with asthma. We have demonstrated that visual instruction (with the use of specialized videos) is associated with improved inhaler technique compared to verbal instruction alone. Consideration of comorbidities and involvement of the multidisciplinary team, including carers and family members, is vital in ensuring optimized use of inhalers and subsequent good asthma control. The use of online videos for optimization of inhaler technique is a user-friendly and cost-effective approach to patient education.

Declaration of interest

All authors mentioned do not have any declarations of interest to disclose.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.