Interventions to improve inhaler technique for people with asthma

Rebecca Fortescue; Kayleigh M Kew; Alexander G Mathioudakis

doi:10.1002/14651858.CD012286.pub2

. 2017 Mar 13;2017(3):CD012286. doi: 10.1002/14651858.CD012286.pub2

Interventions to improve inhaler technique for people with asthma

Rebecca Fortescue ^1,^✉, Kayleigh M Kew ^1,², Alexander G Mathioudakis ³

Editor: Cochrane Airways Group

PMCID: PMC6473469 PMID: 28288272

Abstract

Background

Asthma is a common chronic disease worldwide. Inhalers are often prescribed to help control asthma symptoms, improve quality of life and reduce the risk of exacerbations or flare‐ups. However, evidence suggests that many people with asthma do not use their inhaler correctly. It is therefore important to evaluate whether interventions aimed specifically at improving technique are effective and safe, and whether use of these interventions translates into improved clinical outcomes.

Objectives

To assess the impact of interventions to improve inhaler technique on clinical outcomes and safety in adults and children with asthma.

Search methods

We searched the Cochrane Airways Trials Register, which contains records compiled from multiple electronic and handsearched resources. We also searched trial registries and reference lists of primary studies. We conducted the most recent search on 23 November 2016.

Selection criteria

We included studies comparing a group of adults or children with asthma receiving an inhaler technique intervention versus a group receiving a control or alternative intervention. We included parallel and cluster‐randomised trials of any duration conducted in any setting, and planned to include only the first phase of any cross‐over trials identified. We included studies reported as full‐text articles, those published as abstracts only and unpublished data.

Data collection and analysis

Two review authors screened the search results for eligible studies. We extracted outcome data, assessed risk of bias in duplicate and resolved discrepancies by involving another review author. We grouped studies making similar comparisons by consensus (e.g. all those comparing enhanced inhaler technique education vs usual care) and conducted meta‐analyses only if treatments, participants and the underlying clinical question were similar enough for pooling to make sense. We analysed dichotomous data as odds ratios, and continuous data as mean differences or standardised mean differences, all with random‐effects models. We described skewed data narratively. We graded the results and presented evidence in 'Summary of findings' tables for each comparison. Primary outcomes were inhaler technique, asthma control and exacerbations requiring at least oral corticosteroids (OCS).

Main results

This review includes 29 parallel randomised controlled trials (RCTs) (n = 2210), although not all reported relevant or useable data. All participants had asthma, and follow‐up ranged from 2 to 26 weeks. Most studies were at low or unclear risk of selection and attrition biases and at high risk for biases associated with blinding. We considered most of the evidence to be of low quality owing to these biases and to imprecision in the estimates of effect.

We classified studies into three comparisons: enhanced face‐to‐face training session(s), multi‐media‐delivered inhaler training (e.g. DVD, computer app or game) and technique feedback devices. Differences between interventions, populations and outcome measures limited quantitative analyses, particularly for exacerbations, adverse events, unscheduled visits to a healthcare provider and absenteeism from work or school.

Enhanced inhaler technique education and multi‐media training improved technique in most studies immediately after the intervention and at follow‐up, although the variety of checklists used meant that this was difficult to assess reliably. For both adults and children, how and when inhaler technique was assessed appeared to affect whether inhaler technique improved and by how much.

Analyses of the numbers of people who demonstrated correct or 'good enough' technique were generally more useful than checklist scores. Adult studies of enhanced education showed benefit when this metric was used at 2 to 26 weeks' follow‐up (odds ratio (OR) 5.00, 95% confidence interval (CI) 1.83 to 13.65; 258 participants; three studies; 31 per 100 with correct technique in the control group compared with 69 (95% CI 45 to 86) in the education group; moderate‐quality evidence). A similar result was seen in studies looking at feedback devices at four weeks' follow‐up (OR 4.80, 95% CI 1.87 to 12.33; 97 participants; one study; 51 per 100 with correct technique in the control group compared with 83 (95% CI 66 to 93) in the feedback group; low‐quality evidence). However, the benefit of multi‐media training for adults even immediately after the intervention was uncertain (OR 2.15, 95% CI 0.84 to 5.50; 164 participants; two studies; I² = 49%; 30 per 100 in the control group with correct technique compared with 47 (95% CI 26 to 70) in the multi‐media group; moderate‐quality evidence). Evidence tended to be less clear for children, usually because results were based on fewer and smaller studies.

Some studies did not report exacerbations in a way that allowed meta‐analysis; others provided inconclusive results. Inhaler technique interventions provided some benefit for asthma control and quality of life but generally did not lead to consistent or important clinical benefits for adults or children. Confidence intervals included no difference or did not reach a threshold that could be considered clinically important. Responder analyses sometimes showed improvement among more people in the intervention groups, even though the mean difference between groups was small. We found no evidence about harms.

Authors' conclusions

Although interventions to improve inhaler technique may work in some circumstances, the variety of interventions and measurement methods used hampered our ability to perform meta‐analyses and led to low to moderate confidence in our findings. Most included studies did not report important improvement in clinical outcomes. Guidelines consistently recommend that clinicians check regularly the inhaler technique of their patients; what is not clear is how clinicians can most effectively intervene if they find a patient's technique to be inadequate, and whether such interventions will have a discernible impact on clinical outcomes.

Plain language summary

Strategies to help people with asthma use their inhaler correctly

Background to the question

Many asthma drugs are taken by an inhaler, which deposits the drug directly into the lungs. It is important that the inhaler is taken properly, so the patient gets the most benefit. Taken properly, asthma drugs can improve symptoms and reduce attacks.

Lots of people do not use their devices correctly. This means that the drug is not delivered properly to the lungs, and as a result, asthma may not be as well controlled as it should be. People also tell us that they can have more than one type of inhaler, so it is confusing to know what to do.

We wanted to find out whether teaching people with asthma how to use their inhalers works, and whether this leads to better control of symptoms and fewer attacks. It may seem obvious, but it is important that doctors and nurses know how best to help people with asthma.

Study characteristics

We found 29 studies involving 2210 people with asthma. Studies lasted between 2 and 26 weeks. Studies reported inhaler technique on a range of different checklists.

We grouped studies into three types: studies testing enhanced face‐to‐face training session(s), studies using multi‐media to deliver inhaler training (e.g. a video, computer app or game) and studies testing devices that give people visual or audio feedback about technique.

Studies tested different types of training and used different measures to gauge success, meaning that we could not bring data together. This was particularly true when we tried to assess effects on asthma attacks, adverse events, visits to a healthcare provider and absences from work or school.

Key results

Both face‐to‐face and multi‐media inhaler training improved inhaler technique in most studies, although results varied depending on how and when each technique was assessed.

Some studies reported the number of people who had correct or 'good enough' technique. More people had correct or 'good enough' technique after face‐to‐face training and with feedback devices. But the benefit of multi‐media training for adults was uncertain.

Interventions that provide inhaler training may bring some benefit for quality of life and asthma control among adults and children, but results were varied and studies were small.

Children may receive some benefit but results tended to be less clear for children because fewer and smaller studies have included children as participants.

Quality of the evidence

For studies like these, it is not possible to blind people to their assigned group. This may bias how people behave or respond to questionnaires, which reduced our confidence in the findings. We were uncertain about other results because studies did not provide enough data to show clear benefit.

Conclusions

We cannot say for sure what is the best way to help people learn how to use their inhaler properly. It is important that patients understand how their inhaler works, so they should ask their doctor or nurse for help.

We also use Cochrane Reviews to make suggestions for future research. We suggest that trials should last longer than six months and should report adherence information. The most useful information reported was the number of people who had 'good enough' inhaler technique, so we urge future trials to report this as well.

Summary of findings

Background

Description of the condition

Asthma is one of the most common chronic diseases in the world. It affects more than 300 million adults and children, and its prevalence is rising. By 2025, it is estimated that a further 100 million people may be affected by asthma. Asthma is thought to be responsible for approximately 1% of the disability‐adjusted life‐years lost globally, and for one in 250 deaths, which makes effective treatment an international priority (Masoli 2004). Although previously asthma was thought to be a disease primarily of high‐income countries, it is now recognised that much of the global asthma burden affects low‐ and middle‐income countries (Asher 2006). Asthma is estimated to be the 14th most important disease in the world in terms of extent and duration of disability (Global Asthma Network 2014). Asthma is characterised by chronic inflammation of the airways, leading to symptoms that include cough, wheeze, chest tightness and shortness of breath, which typically vary over time. People with asthma may experience a short‐term worsening of symptoms, known as a ‘flare‐up’, an ‘attack’ or an ‘exacerbation’, which may be life‐threatening (GINA 2016).

Inhalation therapy is the most effective treatment for almost all people with asthma (Dekhuijzen 2007). More than 50 years has passed since the first inhalers for asthma were introduced for routine clinical use (Crompton 2006a). The major advantage of the inhaled route is that the drug is delivered directly to the airways, where it has a rapid onset of action with a minimal dose, thus limiting systemic side effects. Inhalers are also portable and compact, which makes them suitable for ambulatory therapy (McFadden 1995).

Today, commonly used inhaled therapies include short‐acting beta‐agonists (SABAs, e.g. salbutamol); short‐acting muscarinic antagonists (SAMAs, e.g. ipratropium); long‐acting beta‐agonists (LABAs, e.g. salmeterol); long‐acting muscarinic antagonists (LAMAs, e.g. tiotropium); and inhaled corticosteroids (ICSs, e.g. beclomethasone) (BNF 2016). These medications can be used as required to relieve acute symptoms of asthma (e.g. SABAs, SAMAs) or for daily maintenance to prevent worsening of symptoms (i.e. ICS with LABA or LAMA as an add‐on) (BTS/SIGN 2014). Sustained use of ICSs reduces airway inflammation, improves symptoms and reduces asthma‐related morbidity and mortality (Barnes 2003; Bårnes 2015).

The first inhalation devices for asthma were pressurised metered dose inhalers (pMDIs), which were introduced in the 1950s; today, many devices are available and different techniques are required for their proper use (Crompton 2006a; GINA 2016). Inhaler devices can be divided into two main groups: pMDIs and dry powder inhalers (DPIs). pMDIs require the patient to co‐ordinate pressing down on the inhaler canister whilst initiating a slow and deep inhalation, and DPIs require a rapid and forcible inhalation. Both inhaler types require a full exhalation before use, and breath‐holding is recommended after use (Haughney 2010). For those who find the co‐ordination required to use a pMDI difficult, a modified 'breath‐actuated' pMDI can be prescribed or an add‐on device can be used with the inhaler, such as a ‘spacer’ or a ‘holding chamber’. Spacers provide the added advantage of improving delivery of the drug to the appropriate portion of the airway while preventing oropharyngeal deposition, which is particularly important for ICSs (GINA 2016). Some experts recommend that a spacer device should be used universally for children five years of age or younger (Sanchis 2013; GINA 2016). The best choice of inhaler depends on patient factors such as age, co‐ordination and lung function, as well as on patient preference and local availability and cost (Haughney 2010; GINA 2016).

Description of the intervention

An intervention to improve inhaler technique may take many forms, but these interventions broadly fall into three categories: technological adaptations or interventions; education of the healthcare provider; and education of the patient or caregiver (Inhaler Error Steering Committee 2013). However, in reality, any given intervention is unlikely to fall neatly into any single category; for example, a device that provides feedback on inhaler technique may have the dual effect of providing education to the patient and healthcare provider. Interventions may promote self‐management by the patient, monitoring by the healthcare provider or both. They may be delivered face‐to‐face, in writing or through the use of visual or technological aids.

Several currently available inhaler ‘training tools’ could fall under the ‘technological’ umbrella. These devices have various purposes, which include giving feedback to the patient or healthcare provider about inhaler technique and allowing the patient to ‘practise’ the correct technique; helping to identify the best type of inhaler for that patient; or testing the inhalation capacity and co‐ordination of the patient (Lavorini 2010).

In addition, inhalers themselves may be developed to be easier to use; of note, the newer DPIs may be associated with better adherence (Roy 2011), which may be a result of ease of use, and breath‐actuated pMDIs should be considered for those who struggle with co‐ordination (Levy 2013). Simple technological devices such as ‘spacers’ may also improve technique and drug delivery for some patients (McFadden 1995). However, the literature does not suggest that one type of inhaler is consistently associated with a better technique than any other (van Beerendonk 1998). A 2001 Health Technology Assessment report concluded that no consistent advantage is offered by one type of inhaler over another after proper training, and so the cheapest option should be selected in most cases (Brocklebank 2001). More recently, a 'real‐world' cost‐effectiveness analysis based on routine observational data compared outcomes for patients initiated on ICS via a pMDI, a breath‐actuated inhaler pMDI or a DPI. Findings suggest that the real‐world effectiveness of ICS inhalers varies (which may be attributed in part to technique) and that both subsequent healthcare usage costs and the cost of the inhaler should be taken into account when prescribing (Kemp 2010).

Education of both healthcare professionals and patients about correct technique may be delivered in several ways. Multi‐media training tools may comprise Internet‐based or DVD video clips that demonstrate correct inhaler use, as well as interactive components such as games or quizzes (Navarre 2007; Lavorini 2010; Poureslami 2012). Indeed, it has been demonstrated that education delivered via the Internet can be as effective, at least in the short term, as face‐to‐face training for healthcare professionals (Erikson 2003; Toumas 2009).

Face‐to‐face education or coaching is another commonly used strategy for improving inhaler technique. This may be done as part of a comprehensive asthma management package and can be delivered to, or by, a variety of healthcare professionals, including nurses, pharmacists and physicians (Verver 1996; Basheti 2005; Basheti 2008; Armour 2013). Studies have shown that even brief interventions can substantially improve medical professionals’ knowledge about correct technique (Basheti 2009; Kim 2009). Trials of telephone interventions aimed at patients have yielded mixed results (Bynum 2001; Nelson 2011).

How the intervention might work

The breadth of interventions available to improve inhaler technique means that no single mechanism has been identified by which clinical outcomes might benefit. Some technological interventions may allow optimisation of the choice of inhaler for a patient by characterising the patient's breathing pattern, thus improving technique, or by allowing a patient to hone his or her technique at home or with the assistance of a healthcare professional (Lavorini 2010). Attempts to minimise the number of different types of inhalers prescribed for one patient may also improve technique; studies suggest that both adults and children who are prescribed more than one type of inhaler, especially a mixture of pMDIs and DPIs, are more likely to make inhaler errors (van der Palen 1999; Alotabi 2011).

Other interventions may ensure that a patient is following the correct sequence of steps for proper use; physical demonstration appears superior to verbal or written instructions alone (Basheti 2005; Bosnic‐Anticevich 2010), and a multi‐media presentation may be superior to written information alone (Savage 2003). This suggests that being able to watch and copy as the correct technique is demonstrated in person or via a video clip or the Internet is an important requirement for the intervention in many cases.

Children present a unique challenge, and evidence suggests that even after training, their inhaler technique may remain inadequate for effective drug delivery (Kamps 2000). Some studies suggest that repeated training with reinforcement is important (Deerojanawong 2009), that audiovisual training alone is insufficient and that children show the greatest improvement when they receive individual training with follow‐up at home (Agertoft 1998).

Knowledge of how a technique is assessed and recorded is important for determining whether or not an intervention has worked. As anticipated, we found that not all studies used a validated measurement instrument (Rootmensen 2010). We considered how each trial that contributed to this Cochrane Review assessed technique and how this impacted our confidence in this outcome.

Why it is important to do this review

As many as 70% to 80% of people with asthma are unable to use their inhaler device correctly (GINA 2016); poor technique has been associated with age, sex, educational level and emotional problems (Rootmensen 2010). Studies suggest that up to 67% of clinicians cannot describe the steps involved or cannot demonstrate correct inhaler use. Furthermore, of the approximate USD 50 billion spent annually on inhalers (for all respiratory conditions) in the USA, USD 7 to 15 billion is wasted owing to improper use (Fink 2005). Mistakes in inhaler use have been associated with poor clinical outcomes in asthma, including more frequent emergency department (ED) visits; hospitalisations; prescriptions of oral steroids and antimicrobials; and poorer asthma control as assessed by the Asthma Control Questionnaire (ACQ), the Asthma Instability Score (AIS) and the Asthma Therapy Assessment Questionnaire (ATAQ) (Giraud 2001; Melani 2011; Al‐Jahdali 2013; Westerik 2016). A similar association is seen in children (Capanoglu 2015). Evidence suggests that even after a successful intervention, many patients revert to incorrect use within a short time (Price 2002; Crompton 2006b).

International and national guidelines highlight that assessment of inhaler technique is an essential component of asthma care, especially for patients with inadequate control (BTS/SIGN 2014; GINA 2016). Recently, the Aerosol Drug Management Improvement Team (ADMIT) published a series of papers that focus on the need to improve inhalation technique in Europe (ADMIT 2016). In summary, the ADMIT reports suggest that specific education for patients and clinicians on correct technique for inhaler use is needed and should be repeated frequently; devices that provide ‘feedback’ about appropriate technique are useful; information about the correct technique for each device should be easily accessible; and standardised prescribing throughout Europe is preferable (Crompton 2006b; Dekhuijzen 2007). The Global Allergy and Asthma European Network (GA²LEN) initiative, which focusses on problematic severe asthma in children, calls for repeated checking of an individual's inhaler technique (Hedlin 2010). This inevitably raises the question of what is the most effective way to correct and improve improper technique.

Lewis 2016 developed a model to estimate the impact of poor inhalation technique on the economic burden of asthma and chronic obstructive pulmonary disease (COPD) in three European countries (Spain, Sweden and the United Kingdom). Study authors attributed 2.2% to 2.7% of direct asthma and COPD costs to poor inhalation technique, totaling 105 million euros across the three countries. Inclusion of lost productivity costs in additional analyses revealed that the annual expenditure was increased to 3.3 billion euros in the UK and 6.4 billion euros across all three countries. These figures further highlight the need for effective interventions to improve inhaler technique.

Although the literature provides compelling evidence of the need for good inhaler technique in maintaining asthma control, the most effective ways to improve inhaler technique and thus improve clinical outcomes remain unclear. This Cochrane Review examined the evidence for this question for both adults and children.

Objectives

To assess the impact of interventions to improve inhaler technique on clinical outcomes and safety in adults and children with asthma.

Methods

Criteria for considering studies for this review

Types of studies

We included parallel and cluster‐randomised controlled trials (RCTs) of any duration conducted in any setting. If we identified cross‐over trials, we included only data from the first part of the study because of the potential for carry‐over effects from the intervention.

We included studies reported as full‐text articles, published as abstracts only and described in unpublished data.

Types of participants

We included both adults and children with asthma, diagnosed according to national or international guidelines or by a healthcare professional. We excluded participants with other respiratory comorbidities, including COPD and bronchiectasis. If we identified a study in which only a subset of participants had asthma, we included these participants if we were able to obtain disaggregated data.

We intended to analyse studies aimed solely at children (younger than 12 years) separately from those aimed at adults and adolescents (12 years of age and older). If within each of these comparisons we found trials focused on a more narrow age range (e.g. children younger than five years), we explored this potential source of heterogeneity. If a study recruited both adults and children and did not provide disaggregated data, we were guided by the average age of participants to determine in which comparison we should include the study.

Types of interventions

We included studies that compared an intervention primarily aimed at improving inhaler technique versus any of the following.

Usual care/No additional intervention.
An alternative intervention that did not primarily aim to improve inhaler technique (e.g. asthma education only vs asthma education plus an inhaler technique demonstration).
An alternative intervention of a different type or intensity, also aimed at improving inhaler technique (e.g. written instructions only vs written instructions plus physical demonstration).

It is likely that the effect of the intervention will be systematically different depending on which of these three types of comparison groups each study used, so we meta‐analysed results separately unless we had a justification for pooling data (i.e. if treatments, participants and the underlying clinical question were similar enough for pooling to make sense).

Trial interventions may be delivered to healthcare professionals (e.g. pharmacists, healthcare assistants, nurses, physicians) or directly to patients or their parents/caregivers. Interventions may involve education delivered face‐to‐face or remotely, and may include written, verbal or multi‐media methods of delivery. Interventions may also involve a device or a piece of technology designed to improve inhaler technique.

'Usual care' comprises the treatment that a patient with asthma in this setting would normally receive according to local or national guidelines, or according to the judgement of their healthcare provider. This may include routine advice about inhaler technique but not about the specific intervention that is being studied.

Types of outcome measures

Primary outcomes

Inhaler technique (as assessed/rated by triallist; change from baseline scores preferred if available)
Asthma control (preferably measured on a validated scale, e.g. Asthma Control Questionnaire (ACQ))
Asthma exacerbations requiring at least oral corticosteroids (OCSs)

Secondary outcomes

Quality of life (preferably measured on a validated scale, e.g. Asthma Quality of Life Questionnaire (AQLQ))
Adverse events (including local drug side effects, which can be associated with improper inhaler technique)
Unscheduled visits to healthcare provider (e.g. emergency department (ED), primary care)
Absenteeism from work or school

Reporting of one or more of the outcomes listed here within a study was not an inclusion criterion for the review.

We chose these outcomes to reflect the main aim of the intervention (improved inhaler technique) but also patient‐important clinical outcomes, such as exacerbations and quality of life. Adverse events may be associated with improper inhaler use (e.g. oropharyngeal deposition of ICS) and may decrease post intervention. Alternatively, some participants may have noted an increase in medication side effects as they were not receiving a therapeutic dose of their inhaler previously. We did not anticipate many serious adverse events linked to the intervention and so chose to capture all adverse events.

Search methods for identification of studies

Electronic searches

We identified studies from the Cochrane Airways Trials Register, which is maintained by the Information Specialist for the Group. The Cochrane Airways Trials Register includes studies identified from several sources.

Monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL), through the Cochrane Register of Studies Online (crso.cochrane.org).
Weekly searches of MEDLINE Ovid SP 1946 to date.
Weekly searches of Embase Ovid SP 1974 to date.
Monthly searches of PsycINFO Ovid SP.
Monthly searches of the Cumulative Index to Nursing and Allied Health Literature (CINAHL) EBSCO.
Monthly searches of Allied and Complementary Medicine (AMED) EBSCO.
Handsearches of the proceedings of major respiratory conferences.

Studies included in the Trials Register are identified through search strategies based on the scope of Cochrane Airways. We have provided details of these strategies, as well as a list of handsearched conference proceedings, in Appendix 1. See Appendix 2 for search terms used to identify studies for this review.

We searched the following trials registries.

US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (www.clinicaltrials.gov).
World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch).

We searched the Cochrane Airways Trials Register and additional sources from inception to the present, with no restriction on language of publication. We conducted the most recent search on 23 November 2016.

Searching other resources

We checked the reference lists of all primary studies and review articles for additional references. We searched relevant manufacturers' websites for trial information.

On 24 November 2016, we searched for errata or retractions from included studies published in full text on PubMed (www.ncbi.nlm.nih.gov/pubmed).

Data collection and analysis

Selection of studies

Two review authors (KK and RN or AM) screened titles and abstracts independently of all studies identified for potential inclusion as a result of the search, and coded them as 'retrieve' (eligible or potentially eligible/unclear) or 'do not retrieve'. We retrieved full‐text study reports/publications; two review authors (RN and KK) independently screened the full‐text reports, identified studies for inclusion and identified and recorded reasons for exclusion of ineligible studies. We resolved disagreements through discussion, or, if required, we consulted a third review author. We identified and excluded duplicates and collated multiple reports of the same study, so that each study, rather than each report, was the unit of interest in the review. We recorded the selection process in sufficient detail to complete a Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow diagram and a Characteristics of excluded studies table (Moher 2009).

Data extraction and management

We piloted a data collection form on at least one study included in the review and used it to document study characteristics and outcome data. One review author (RN, KK or AM) extracted the following study characteristics from the included studies.

Methods: study design, total duration of study, details of any 'run‐in' period, number of study centres and locations, study settings, withdrawals, dates of study.
Participants: N, mean age, age range, gender, severity of condition, diagnostic criteria, baseline lung function, smoking history, inclusion criteria, exclusion criteria.
Interventions: intervention, comparison, allowed medications and concomitant interventions, excluded medications and interventions.
Outcomes: primary and secondary outcomes specified and collected, time points reported.
Notes: funding for trial, notable conflicts of interest of trial authors.

Two review authors (RN and KK or AM) independently extracted outcome data from the included studies. We noted in the Characteristics of included studies table if the included trials did not report outcome data in a useable way. We resolved disagreements by reaching consensus or by consulting a third review author. One review author (RN) transferred data into Review Manager (RevMan) (RevMan 2014). We double‐checked that the review author had entered data correctly by comparing data presented in the systematic review versus the study reports. A second review author (KK or RN) spot‐checked study characteristics for accuracy against the trial report.

Assessment of risk of bias in included studies

Two review authors (RN and KK or AM) independently assessed the risk of bias of each included study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We resolved disagreements by discussion or by consultation with a third review author. We assessed risk of bias according to the following domains.

Random sequence generation.
Allocation concealment.
Blinding of participants and personnel.
Blinding of outcome assessment.
Incomplete outcome data.
Selective outcome reporting.
Other bias.

We graded each potential source of bias as high, low or unclear and provided a quote from the study report and a justification for our judgement in the 'Risk of bias' table. We summarised 'Risk of bias' judgements across different studies for each of the domains listed. We considered blinding separately for different key outcomes when necessary (e.g. for unblinded outcome assessment, risk of bias for all‐cause mortality may be very different from that determined for a patient‐reported pain scale). When information on risk of bias was related to unpublished data or correspondence with a triallist, we noted this in the 'Risk of bias' table.

When we considered treatment effects, we took into account the risk of bias for studies that contributed to those outcomes.

Assessment of bias in conducting the systematic review

We conducted the review according to the published protocol and reported deviations from it in the Differences between protocol and review section of the systematic review.

Measures of treatment effect

We analysed dichotomous data using Mantel‐Haenzsel odds ratios (ORs) with a random‐effects model and 95% confidence intervals (CIs). If we had encountered outcomes with very rare events, we planned to use Peto ORs. If the included trials had reported data as rates or time‐to‐event (e.g. exacerbations), we planned to analyse these as time‐to‐event or rate ratios. We planned to transform reported rate ratios into log rate ratios and to analyse them using a random‐effects model and generic inverse variance (GIV) in RevMan (RevMan 2014). We entered data presented as a scale with a consistent direction of effect.

We analysed continuous outcomes (e.g. ACQ, AQLQ) as mean difference (MD) or standardised mean difference (SMD) values using a random‐effects model and 95% CIs. We used change from baseline scores when available.

We undertook meta‐analyses only where this was meaningful i.e. if the treatments, participants and the underlying clinical question were similar enough for pooling to make sense.

We narratively described skewed data reported as medians and interquartile ranges.

When a single trial reported multiple trial arms, we included only the relevant trial arms. If we combined two comparisons (e.g. intervention A vs usual care and intervention B vs usual care) in one meta‐analysis, we halved the control group to avoid double‐counting.

Unit of analysis issues

We analysed dichotomous data by using participants (rather than events) as the unit of analysis. However, if the included trials had reported exacerbations as rate ratios, we planned to analyse them on this basis. We meta‐analysed data from cluster RCTs only if we could adjust available data to account for clustering.

Dealing with missing data

We contacted investigators or study sponsors to verify key study characteristics and to obtain missing numerical outcome data when possible (e.g. when we identified a study as an abstract only). When this was not possible, and we thought that the missing data introduced serious bias, we took this into consideration in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) rating for affected outcomes.

Assessment of heterogeneity

We used the I² statistic to measure heterogeneity amongst the trials in each analysis. If we identified substantial heterogeneity, we reported this and explored possible causes by performing prespecified subgroup analysis.

Assessment of reporting biases

When we were able to pool more than 10 trials, we created and examined a funnel plot to explore possible small study and publication biases.

Data synthesis

We used a random‐effects model and performed a sensitivity analysis with a fixed‐effect model.

Subgroup analysis and investigation of heterogeneity

We planned the following subgroup analyses.

To whom the intervention is delivered: healthcare provider versus patient/caregiver.
Duration of intervention: one‐off session versus repeated sessions.

We did not pool studies that included children with studies that included adults. If within each of these two populations we found trials that focused on a more narrow age range (e.g. children younger than five years of age), we planned to explore this potential source of heterogeneity.

We suspected that interventions would differ from one another in various ways (e.g. inhaler type, physical demonstration vs no demonstration, remote vs face‐to‐face), which may make exploration through multiple formal subgroup analyses misleading. Instead we summarised intervention characteristics in additional tables (Table 4; Table 5; Table 6).

1. Summary of characteristics of studies in comparisons 1 and 2: inhaler technique education.

Study ID	Total n	Study duration (weeks)	Age	Country	Intervention	Control	Inhaler technique measure	Outcomes
Agertoft 1998	72	2	Children aged 3 to 5 years	Denmark	Instructional video + individual training; delivered to participant	Instructional video	PIF	PIF, IVC, PEFR, FEV₁, FVC
Basheti 2005	26	2	Adults	Australia	Group B: verbal counselling Group C: verbal counselling + physical demonstration; delivered to participant	Group A: printed materials	9‐Step Turbuhaler checklist	Inhaler technique
Basheti 2008	31 pharmacists, 97 participants	26	Adults	Australia	Pharmacist‐participant education + inhaler technique labels; delivered to pharmacist	Peak flow measurement training	9‐Step checklist	Inhaler technique, asthma severity, peak flow variability, AQOL, perceived control
Bynum 2001	49	4	Adolescents aged 12 to 19 years	USA	Telepharmacy counselling; delivered to participant	Written instructions only	8‐Step MDI checklist	Inhaler technique, participant satisfaction
Fernandes 2011	89	12	Adults	Not reported	Respiratory therapist education; delivered to participant	Rotuine physician education	Not reported	Inhaler technique, asthma control
Mehuys 2008	201	26	Adults	Belgium	Pharmacist education; delivered to pharmacist	Usual pharmacy care	10‐Step MDI + spacer checklist/8‐step DPI checklist	Inhaler technique, ACT, exacerbations, ED/hospital visits, adherence, AQLQ, asthma knowledge
Nahafizadeh 2010	46	8.7	Adults	Iran	Face‐to‐face education; delivered to participant	Usual care (no further details)	Not reported	ACT, FEV₁
Ozkaya 2010	130	12	Children	Turkey	Face‐to‐face nurse training; delivered to participant	Inhaler package insert only	10‐Step MDI checklist	Inhaler technique, PAQLQ, spirometry
Rahmati 2014	90	4	Adults	Iran	Face‐to‐face training (no spacer device); delivered to participant	Usual care (no training)	11‐Step MDI checklist	Inhaler technique, PEFR
Rydman 1999	68	8 to 20	Adults	USA	Face‐to‐face training + demonstration; delivered to participant	Inhaler package insert only	Checklist, converted to score out of 1 (0 if any steps missed)	BAI and MDI competency
Self 1983	29	1 to 16 (mean 6)	Adults	USA	Face‐to‐face pharmacist training; delivered to participant	Inhaler package insert only	10‐Step checklist	Inhaler technique, "effectiveness of instruction"
Turgeon 1996	96	26	Children and adolescents (max 15 years)	Canada	Interactive nurse training with feedback; delivered to participant	Pictorial nurse training only	Checklist with scores converted to percentages	Inhaler technique, parental perceptions of treatment, asthma morbidity (e.g. no. of exacerbations, ED visits, hospitalisations, days of schools missed)

Study ID	Total n	Study duration (weeks)	Age	Country	Intervention	Control	Inhaler technique measure	Outcomes
Acosta 2009	133	4	Adults	USA	Inhaler technique training video; delivered to participant	Asthma education video	Not reported	"Correct usage" of inhaler
Arthurs 2014	21	13	Children	Ireland	Inhaler technique DVD; delivered to participant	Individual instruction	New inhaler technique measurement tool	Inhaler technique, self‐efficacy, knowledge acquisition
Boone 2002	36	4.3	Children	UK	Inhaler technique educational computer software ("Space Inhalers"); delivered to participant	Placebo software	15‐Step checklist	Inhaler technique, asthma knowledge
Carpenter 2015	91	4.3	Children and adolescents	USA	Inhaler technique video; delivered to participant	Attention control video (about nutrition)	8‐Step checklist	Inhaler technique, self‐efficacy, ACT
Goodyer 2006	69	Outcomes assessed immediately	Adults	UK (Turkish‐ speaking population)	Multi‐media touch screen training; delivered to participant	Patient information leaflet plus verbal training	Inhaler checklist	Inhaler technique
Lirsac 1991	45	2.1	Adults and children (10 to 71 years)	France	Inhaler technique video OR inhaler technique video + spacer; delivered to participant	Patient information sheet	4‐Step checklist	Inhaler technique, FEV₁
Savage 2003	110	Outcomes assessed immediately	Children and adults (12 to 87 years)	UK	Multi‐media touch screen training; delivered to participant	Patient information leaflet	Inhaler checklist, global assessment of technique	Inhaler technique, acceptability
Self 1983	29	1 to 16 (mean 6)	Adults	USA	Video training; delivered to participant	Inhaler package insert only	10‐Step checklist	Inhaler technique, "effectiveness of instruction"
Shah 2014	50	Not reported	Not reported	USA	Computer training; delivered to participant	Written training OR no training	"Fixed rubric" used to give a score	Inhaler technique

Enhanced education compared with control/usual care for people with asthma
Patient or population: adults and children with asthma Setting: primary and secondary care Intervention: enhanced education Comparison: control/usual care
Outcomes	*Anticipated absolute effects (95% CI)**			Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes	Risk with control/usual care		Risk with enhanced education	Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
Correct inhaler technique Follow‐up: 2 to 26 weeks (adults) 12 to 26 weeks (children)	Adults	31 per 100	69 per 100 (45 to 86)	OR 5.00 (1.83 to 13.65)	258 (3 RCTs)	⊕⊕⊕⊝ MODERATE^a	Additional results from technique rating scales could not be combined (Analysis 1.2)
	Children	49 per 100	55 per 1,00 (40 to 69)	OR 1.29 (0.70 to 2.36)	175 (2 RCTs)	⊕⊕⊝⊝ LOW^a,b	One study measured PIF as a marker for inhaler technique and showed benefit (Analysis 2.2; Analysis 2.3)
Asthma control score 4 to 26 weeks	Adults	‐	Score in the intervention group was 0.48 SDs higher than in the control group (0.29 lower to 1.24 higher)	‐	247 (2 RCTs)	⊕⊝⊝⊝ VERY LOW^a,b,c	We were not able to calculate a control risk, as the outcome was measured on different scales
Asthma control responders 8 to 12 weeks	Adults	42 per 100	70 per 100 (52 to 84)	OR 3.18 (1.47 to 6.88)	134 (2 RCTs)	⊕⊕⊝⊝ LOW^d
Exacerbations requiring at least OCS 26 weeks	Adults	10 per 100	13 per 100 (5 to 28)	OR 1.32 (0.49 to 3.55)	158 (1 RCT)	⊕⊕⊝⊝ LOW^a,b	The same study also reported exacerbations requiring ED/hospitalisation. Events were rare and results imprecise
Quality of life 26 weeks	Adults	‐	Score in the intervention group was 0.52 SDs higher than in the control group (0.04 lower to 1.09 higher)	‐	247 (2 RCTs)	⊕⊕⊝⊝ LOW^a,c,e	We were not able to calculate a control risk as the outcome was measured on different scales
Other outcomes	No results could be analysed for adverse events, unscheduled visits to a healthcare provider or school/work absences
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) CI: confidence interval; ED: emergency department; OCS: oral corticosteroids; OR: odds ratio; PIF: peak inspiratory flow; RCT: randomised controlled trial; RR: risk ratio; SDs: standard deviations
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to the estimate of effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

Multimedia training compared with control/usual care for people with asthma
Patient or population: adults and children with asthma Setting: primary and secondary care Intervention: multi‐media training Comparison: control/usual care
Outcomes		*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes		Risk with control/usual care	Risk with multi‐media training	Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
Correct inhaler technique Immediately after intervention	Adults	30 per 100	47 per 100 (26 to 70)	OR 2.15 (0.84 to 5.50)	164 (2 RCTs)	⊕⊕⊕⊝ MODERATE^a,b
Correct inhaler technique 2‐Week follow‐up	Adults	43 per 100	57 per 100 (23 to 86)	OR 1.78 (0.40 to 7.94)	28 (1 RCT)	⊕⊕⊝⊝ LOW^a,c
Inhaler technique score	Adults	Not pooled; narrative summary of evidence provided in data table (Analysis 3.3)		‐	136 (2 RCTs)	Not graded	Suggests benefit of multi‐media training over control
Inhaler technique score	Children	Not pooled; narrative summary of evidence provided in data table (Analysis 4.1)		‐	127 (2 RCTs)	Not graded	Suggests benefit of multi‐media training over control
Asthma control (ACT) 4 weeks	Children	Mean change in control group was 1.2	Mean change was 0.73 better (‐0.99 worse to 2.45 better)	‐	91 (1 RCT)	⊕⊕⊝⊝ LOW^a,c
Other outcomes	No results could be analysed for quality of life, exacerbations, adverse events, unscheduled visits to a healthcare provider or school/work absences
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) ACT: Asthma Control Test (range 0 to 25; higher is better); CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial; RR: risk ratio; SDs: standard deviations
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to the estimate of effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

Feedback device compared with control/usual care for people with asthma
Patient or population: adults and children with asthma Setting: primary and secondary care Intervention: feedback device Comparison: control/usual care
Outcomes		*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
Outcomes		Risk with control/usual care	Risk with feedback device	Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
Correct inhaler technique 4‐Week follow‐up	Adults	51 per 100	83 per 100 (66 to 93)	OR 4.80 (1.87 to 12.33)	97 (1 RCT)	⊕⊕⊝⊝ LOW^a,b	Additional results from technique rating scales could not be combined (Analysis 5.3)
Inhaler technique (PIF) Follow‐up: 6 weeks (adults) 6 to 12 weeks (children)	Adults	66 per 100	97 per 100 (81 to 100)	OR 18.26 (2.22 to 150.13)	71 (1 RCT)	⊕⊕⊝⊝ LOW^a,b
	Children	Mean PIF was 51.2 litres/min	Mean PIF was 9.22 litres/min better (33.71 better to 15.27 worse)	‐	98 (2 RCTs)	⊕⊕⊝⊝ LOW^a,c
Asthma control (ACQ) 6 to 12 weeks	Adults	Mean ACQ score was 1.4	Mean score in the intervention group was 0.1 better (0.46 better to 0.26 worse)	‐	97 (1 RCT)	⊕⊕⊝⊝ LOW^a,c
Asthma control (ACQ) 6 to 12 weeks	Children	Mean ACQ score was 0.7	Mean score in the intervention group was 0.02 worse (0.35 worse to 0.32 better)	‐	98 (2 RCTs)	⊕⊕⊕⊝ MODERATE^a
Quality of life Follow‐up: 6 weeks (adults) 6 to 12 weeks (children)	Adults	Mean score on the mini‐AQLQ was 4.2	Mean score in the intervention group was 0.38 better (0.01 worse to 0.77 better)	‐	100 (2 RCTs)	⊕⊕⊝⊝ LOW^a,d
	Children	Mean change in quality of life was 0.07	Mean change was 0.25 better (0.07 worse to 0.58 better)	‐	91 (2 RCTs)	⊕⊕⊝⊝ LOW^a,d	One study reported endpoint quality of life (Analysis 6.4)
Quality of life (responders) 6 weeks	Adults	49 per 100	83 per 100 (62 to 94)	OR 5.29 (1.76 to 15.89)	71 (1 RCT)	⊕⊕⊕⊝ MODERATE^a
Other outcomes	No results could be analysed for exacerbations, adverse events, unscheduled visits to a healthcare provider or school/work absences
*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI) ACQ: Asthma Control Questionnaire (range 0 to 6; lower is better); CI: confidence interval; OR: odds ratio; PIF: peak inspiratory flow; RCT: randomised controlled trial; RR: risk ratio; SDs: standard deviations
GRADE Working Group grades of evidence High quality: We are very confident that the true effect lies close to the estimate of effect Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

Inhaler technique score
Study	Time of rating	Intervention mean (SD)	Control mean (SD)	Total N	Scale (higher score= better technique)
Basheti 2008	Post‐intervention	‐	‐	‐	‐
Basheti 2008	Follow‐up (26 wks)	2.80 (1.60)	0.90 (1.40)	100	Max 9 (change)
Bynum 2001	Post‐intervention	7.33 (0.72)	5.14 (1.62)	36	Max 8
Bynum 2001	Follow‐up (2 to 4 wks)	6.73 (1.22)	4.86 (1.10)	36	Max 8
Mehuys 2008	Post‐intervention	‐	‐	‐	‐
Mehuys 2008	Follow‐up (26 wks)	93.2 (10.7)	83.7 (22.5)	150	Max 100
Rahmati 2014	Post‐intervention	10.8 (0.48)	5.57 (1.20)	120	Max 11
Rahmati 2014	Follow‐up (4 wks)	10.17 (0.91)	5.48 (1.27)	90	Max 11
Rydman 1999	Post‐intervention	0.68 (0.46)	0.60 (0.49)	120	Max 1
Rydman 1999	Follow‐up (8 to 20 wks)	0.72 (0.45)	0.75 (0.43)	120	Max 1
Self 1983	Post‐intervention	16.8 (4.1)	10.7 (5.4)	19	Max 20
Self 1983	Follow‐up	‐	‐	‐	‐

Change in inhaler technique score
Study	Time of rating	Intervention mean (SD)	Control mean (SD)	Total N	Scale (higher score= better technique)
Boone 2002	Post‐intervention	‐	‐	‐	‐
Boone 2002	Follow‐up (4 wks)	2.60 (0.60)	0.50 (0.50)	36	Max 15
Carpenter 2015	Post‐intervention	1.12 (1.09)	0.03 (1.07)	91	Max 8
Carpenter 2015	Follow‐up (4 wks)	0.87 (1.09)	0.32 (1.14)	91	Max 8

Database	Search frequency
MEDLINE (Ovid)	Weekly
EMBASE (Ovid)	Weekly
CENTRAL (The Cochrane Library)	Monthly
PsycINFO (Ovid)	Monthly
CINAHL (EBSCO)	Monthly
AMED (EBSCO)	Monthly

Conference	Years searched
American Academy of Allergy, Asthma and Immunology (AAAAI)	2001 onwards
American Thoracic Society (ATS)	2001 onwards
Asia Pacific Society of Respirology (APSR)	2004 onwards
British Thoracic Society Winter Meeting (BTS)	2000 onwards
Chest Meeting	2003 onwards
European Respiratory Society (ERS)	1992, 1994, 2000 onwards
International Primary Care Respiratory Group Congress (IPCRG)	2002 onwards
Thoracic Society of Australia and New Zealand (TSANZ)	1999 onwards

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Correct inhaler technique (at follow‐up)	3	258	Odds Ratio (M‐H, Random, 95% CI)	5.00 [1.83, 13.65]
1.2 Inhaler technique score	6		Other data	No numeric data
1.3 Asthma control	2	247	Std. Mean Difference (IV, Random, 95% CI)	0.48 [‐0.29, 1.24]
1.4 Asthma control	2	134	Odds Ratio (M‐H, Random, 95% CI)	3.18 [1.47, 6.88]
1.5 Exacerbations requiring at least OCS	1		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only
1.6 Exacerbations requiring ED/hospitalisation	1		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only
1.7 Quality of life	2	247	Std. Mean Difference (IV, Random, 95% CI)	0.52 [‐0.04, 1.09]
1.8 Subgroup analysis: inhaler technique (at follow‐up): to whom intervention is delivered	3	258	Odds Ratio (M‐H, Random, 95% CI)	5.00 [1.83, 13.65]
1.8.1 Delivered to participants	2	174	Odds Ratio (M‐H, Random, 95% CI)	3.03 [1.61, 5.68]
1.8.2 Delivered to pharmacists	1	84	Odds Ratio (M‐H, Random, 95% CI)	12.38 [4.04, 37.90]
1.9 Subgroup analysis: asthma control: to whom intervention is delivered	2	247	Std. Mean Difference (IV, Random, 95% CI)	0.48 [‐0.29, 1.24]
1.9.1 Delivered to participants	1	150	Std. Mean Difference (IV, Random, 95% CI)	0.10 [‐0.22, 0.42]
1.9.2 Delivered to pharmacists	1	97	Std. Mean Difference (IV, Random, 95% CI)	0.88 [0.46, 1.30]
1.10 Subgroup analysis: inhaler technique (at follow‐up): off‐off vs repeated sessions	3	258	Odds Ratio (M‐H, Random, 95% CI)	5.00 [1.83, 13.65]
1.10.1 One‐off	1	24	Odds Ratio (M‐H, Random, 95% CI)	3.50 [0.50, 24.56]
1.10.2 Repeated	2	234	Odds Ratio (M‐H, Random, 95% CI)	5.64 [1.40, 22.66]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Correct inhaler technique (at follow‐up)	2	175	Odds Ratio (M‐H, Random, 95% CI)	1.29 [0.70, 2.36]
2.2 Inhaler technique (PIF immediately after intervention)	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
2.3 Inhaler technique (PIF at follow‐up)	1		Mean Difference (IV, Random, 95% CI)	Totals not selected
2.4 Subgroup analysis: inhaler technique (at follow‐up): one‐off vs repeated sessions	2	175	Odds Ratio (M‐H, Random, 95% CI)	1.29 [0.70, 2.36]
2.4.1 One‐off	1	120	Odds Ratio (M‐H, Random, 95% CI)	1.37 [0.66, 2.83]
2.4.2 Repeated	1	55	Odds Ratio (M‐H, Random, 95% CI)	1.11 [0.37, 3.38]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Correct inhaler technique (immediately after intervention)	2	164	Odds Ratio (M‐H, Random, 95% CI)	2.15 [0.84, 5.50]
3.2 Correct inhaler technique (at follow‐up)	1		Odds Ratio (M‐H, Random, 95% CI)	Totals not selected
3.3 Inhaler technique score	2		Other data	No numeric data

Outcome or subgroup title	No. of studies	Statistical method	Effect size
4.1 Change in inhaler technique score	2	Other data	No numeric data
4.2 Asthma control (change from baseline)	1	Mean Difference (IV, Random, 95% CI)	Subtotals only
4.3 Asthma control (endpoint)	1	Mean Difference (IV, Random, 95% CI)	Subtotals only

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 Inhaler technique (PIF)	1		Odds Ratio (M‐H, Random, 95% CI)	Totals not selected
5.2 Correct inhaler technique (at follow‐up)	1		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only
5.3 Inhaler technique score	1		Other data	No numeric data
5.4 Asthma control	1		Mean Difference (IV, Random, 95% CI)	Subtotals only
5.5 Quality of life	2	100	Mean Difference (IV, Random, 95% CI)	0.38 [‐0.01, 0.77]
5.6 Quality of life (responders)	1		Odds Ratio (M‐H, Random, 95% CI)	Subtotals only

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
6.1 Inhaler technique (PIF)	2	98	Mean Difference (IV, Random, 95% CI)	‐9.22 [‐33.71, 15.27]
6.2 Asthma control	2	98	Mean Difference (IV, Random, 95% CI)	‐0.02 [‐0.35, 0.32]
6.3 Quality of life (change from baseline)	2	91	Mean Difference (IV, Random, 95% CI)	0.25 [‐0.07, 0.58]
6.4 Quality of life (endpoint)	1		Mean Difference (IV, Random, 95% CI)	Subtotals only

*Study characteristics*
Methods	Design: single‐blind parallel‐group randomised controlled trial Duration: 4 weeks Setting: USA Trial registration: not reported
Participants	Population: 133 people with asthma randomised to an MDI inhaler technique training video or an asthma education video (n per group not reported) Age: "adults" Baseline asthma severity: not reported Inclusion criteria: "asthma patients" Exclusion criteria: not reported Percentage withdrawn: not reported per group; 17/133 (13%) did not complete trial Other allowed medication: not reported
Interventions	Intervention summary: MDI training video shown at index visit with pre and post assessment of inhaler technique, with follow‐up at 1 month Control summary: asthma education video shown at index visit with pre and post assessment of inhaler technique, with follow‐up at 1 month
Outcomes	Outcomes measured: "correct usage" Technique assessment method used: not reported
Notes	Type of publication: conference abstract Funding: not reported
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"Patients were randomized" ‐ no further details of sequence generation
Allocation concealment (selection bias)	Unclear risk	No details
Blinding of participants and personnel (performance bias) All outcomes	High risk	No description of procedures intended to blind participants or personnel to group assignment
Blinding of outcome assessment (detection bias) All outcomes	Low risk	"The examiner (who assessed inhaler technique) was blinded to the intervention"
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Although 116/133 (87%) participants completed the trial, the drop‐out for each arm is not reported
Selective reporting (reporting bias)	High risk	No prospective trial registration identified. Minimal details as reported, as conference abstract only. Unclear how "correct technique" was assessed
Other bias	Low risk	None noted

*Study characteristics*
Methods	Design: parallel‐group randomised controlled trial; blinding not stated Duration: 6 weeks Setting: 1 outpatient clinic, UK Trial registration: not reported
Participants	Population: 108 people with asthma randomised to verbal training plus 2Tone Trainer (n = 36) or verbal training alone (n = 36) Age: mean age (SD) in the intervention group 58.3 (13.7) years, and in the control group 52.6 (16.7) years Baseline asthma severity: intervention group: FEV₁ % predicted (SD) 71.4 (22.0); mini‐AQLQ (SD) 3.8 (1.1). Control group: FEV₁ % predicted (SD) 76.9 (24.1); mini‐AQLQ (SD) 3.9 (1.0) Inclusion criteria: Patients with asthma who were attending an outpatient clinic were invited to take part in this study. Each patient had to be receiving an inhaled corticosteroid from an MDI without a spacer device. Patients with adequate co‐ordination but too rapid inspiratory flow were randomised to 1 of the 2 intervention groups Exclusion criteria: patients who had experienced an acute exacerbation in the past 4 weeks; patients who were deaf or unable to distinguish between 1 and 2 tones with the 2T; patients with poor inhaler co‐ordination who were ineligible for the study and were referred to the asthma nurse for inhaler technique training Percentage withdrawn: 0% of participants withdrew from the intervention group, and 3% from the control group Other allowed medication: "There were no changes to patients' prescriptions"
Interventions	Intervention summary: The 2Tone Trainer looks like an MDI but does not have a canister, so that when it is used, the patient does not receive a dose. During use, this training aid provides users with audible feedback according to the patient’s inhalation rate. It makes a 2‐tone sound when the patient is inhaling at 60 L/min, 1 tone when inhaling between 30 and 60 L/min and no sound when inhaling at 30 L/min. Patients are advised to obtain the 1‐tone noise and thus become accustomed to the degree of inspiratory effort they need to make to achieve this rate through an MDI. Participants were given a 2Tone Trainer to use at home and received the same verbal training as the verbal training alone group Control summary: Verbal training participants were trained on the most desirable inhalation technique with emphasis on breathing out slowly as far as comfortable and actuating a dose at or soon after the start of a slow inhalation. A slow inhalation was defined as an inhalation that filled the lungs with air that lasted 5 seconds
Outcomes	Outcomes measured: peak inspiratory flow (PIF), FEV₁ and quality of life (AQLQ) Technique assessment method used: PIF was used as a measure of inhaler technique
Notes	Type of publication: single peer‐reviewed journal article plus 2 conference abstracts Funding: 2Tone Trainers were donated by Canday Medical Ltd. Dr Al‐Showair was financially supported by a scholarship from the Saudi Arabian Government, and the study was part of his PhD thesis
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"Subjects in the intervention group were randomly allocated into the verbal training (VT) group or the 2T group" ‐ no further details of sequence generation
Allocation concealment (selection bias)	Unclear risk	No details
Blinding of participants and personnel (performance bias) All outcomes	High risk	No description of procedures intended to blind participants or personnel to group assignment
Blinding of outcome assessment (detection bias) All outcomes	High risk	No description of procedures intended to blind outcome assessors to group assignment; for outcomes such as AQLQ, the participant/caregiver is the outcome assessor; therefore these outcomes may be at risk of detection bias
Incomplete outcome data (attrition bias) All outcomes	Low risk	Only 1 participant withdrew from the study
Selective reporting (reporting bias)	Unclear risk	No prospective trial registration identified. However, all outcomes listed in Methods clearly reported in paper
Other bias	Low risk	None noted

*Study characteristics*
Methods	Design: open‐label parallel‐group randomised controlled trial Duration: 1 month Setting: 2 paediatric practices in a medium‐sized metropolitan county in North Carolina, USA Trial registration: NCT01641211
Participants	Population: 91 children and adolescents with asthma randomised to inhaler technique video (n = 46) or an attention control video (n = 45) Age: mean age (SD) in the intervention group was 10.9 (2.6) years, and in the control group 10.8 (2.9) years Baseline asthma severity: intervention group: mild persistent asthma = 52% moderate/severe asthma = 44%; control group: mild persistent asthma = 49% moderate/severe asthma = 51% Inclusion criteria: 7 to 17 years old, could speak English or Spanish, could read the assent form, were present at the visit with an adult (> 18 years old) caregiver (parent or legal guardian) who could speak English or Spanish, used an MDI, missed or incorrectly performed at least 1 step on an inhaler technique assessment, had mild, moderate or severe persistent asthma Exclusion criteria: not reported Percentage withdrawn: 7% of children withdrew from the intervention arm, and 13% from the control arm Other allowed medication: not reported
Interventions	Intervention summary: 3‐minute video in English or Spanish. Separate videos were available for an MDI with or without a spacer; children who indicated that they had used an MDI with a spacer and without a spacer watched both MDI videos. Each inhaler video provided an overview of the device and specific instructions for how to use the device correctly. Children watched the videos on a laptop computer and were given a wallet card with a web address and login information, so they could watch the video again after leaving the clinic Control summary: control group: children allocated to an attention control group in which they watched a 3‐minute video about nutrition in English or Spanish. The nutrition video discussed the importance of balancing protein, carbohydrates and lipids in one’s diet
Outcomes	Outcomes measured: inhaler technique, child inhaler self‐efficacy, asthma control (ACT) Technique assessment method used: MDI technique was measured as the number of steps (out of 8 possible steps) that the child performed correctly. The RA used an inhaler technique checklist to document whether each step was performed correctly
Notes	Type of publication: single peer‐reviewed journal article Funding: This pilot project was supported by Award Number ULTR000083 from the National Center for Advancing Translational Sciences. Dr Carpenter’s salary was supported in part by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant KL2TR000084
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	The randomisation sequence was prepared ahead of time by a statistician who used computer‐generated random numbers. Randomisation was stratified by clinic
Allocation concealment (selection bias)	Low risk	Immediately after the child’s medical visit, the RA opened a sequentially numbered, sealed envelope to determine whether the child had been allocated to the experimental or control group
Blinding of participants and personnel (performance bias) All outcomes	High risk	The study RA was not blinded to children’s experimental group assignment. All children and caregivers were informed that the study was about how children use their asthma devices
Blinding of outcome assessment (detection bias) All outcomes	High risk	The study RA was not blinded to children’s experimental group assignment. All children and caregivers were informed that the study was about how children use their asthma devices
Incomplete outcome data (attrition bias) All outcomes	Low risk	Less than 15% of participants were lost to follow‐up. All randomised participants were included in the adjusted intention‐to‐treat primary analysis
Selective reporting (reporting bias)	Low risk	The study was prospectively registered as NCT01641211; outcomes were reported as planned at all time points
Other bias	Low risk	None noted

*Study characteristics*
Methods	Design: open‐label randomised trial; design not clearly reported Duration: not reported Setting: 1 hospital, Evanston, Illinois, USA Trial registration: not reported
Participants	Population: 50 people with asthma randomised to computer training, written training or no training (n in each group not reported) Age: not reported Baseline asthma severity: not reported Inclusion criteria: not reported Exclusion criteria: not reported Percentage withdrawn: not reported Other allowed medication: not reported
Interventions	Computer training: Participants completed a "computer based training solution" such as those at www.use‐inhalers.com Written training: "traditional written instruction on inhaler technique" No training: "our controls were patients without any training and patients given written training"
Outcomes	Outcomes measured: inhaler technique Technique assessment method used: "videotapes of patients using their inhalers before and after training were created and analysed by a fixed rubric and given a score"
Notes	Type of publication: conference abstract Funding: not reported
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"patients were recruited in a randomized, unblinded enrolment process." ‐ no further details
Allocation concealment (selection bias)	High risk	"randomized, unblinded enrolment process" ‐ implies that allocation was not concealed
Blinding of participants and personnel (performance bias) All outcomes	High risk	Described as 'unblinded'
Blinding of outcome assessment (detection bias) All outcomes	Unclear risk	Described as 'unblinded', although 'Inhaler technique was assessed by "fixed rubric", which may have controlled for some bias, depending on who was making the assessment and whether they knew what sort of training the participant had received
Incomplete outcome data (attrition bias) All outcomes	Unclear risk	Drop‐out not reported
Selective reporting (reporting bias)	High risk	No prospective trial registration identified. Minimal details reported as conference abstract only
Other bias	Low risk	None noted

*Study characteristics*
Methods	Design: parallel‐cluster repeated‐measures randomised controlled trial; blinding not stated Duration: 4 weeks Setting: 1 community pharmacy, Australia Trial registration: not reported
Participants	Population: 19 pharmacists (101 adult patients) randomised to pharmacist training + quantitative inhaler feedback (51 patient participants) or to pharmacist training no quantitative feedback (50 patient participants) (control) Age: mean age not reported; age categories given (18 to > 60 years) Baseline asthma severity: mean (SD) ACQ score in intervention group: 1.6 (0.96), and in control group 1.7 (1.01) Inclusion criteria: diagnosis of asthma and aged 18 years or over; currently using a Turbuhaler (TH) or Accuhaler (ACC) for delivery of preventer asthma medication; having been on the same asthma medication and dose regimen for a minimum of 1 month Exclusion criteria: medication not self‐administered; inability to speak or understand English; inability to return for follow‐up visit; and/or involved in another clinical trial/study Percentage withdrawn: 6% of patient participants withdrew from the intervention group, and 2% from the control group Other allowed medication: not reported
Interventions	Intervention summary: combination of qualitative and quantitative visual feedback for DPI inhalers. Training of community pharmacists occurred on an individual basis with the researcher delivering a 2‐hour 1‐on‐1 training session to each pharmacist in their own community pharmacy. Intervention group pharmacists were also trained as per a train‐the‐trainer approach and an established pharmacist‐training programme with an additional quantitative feedback process. Quantitative feedback involved the use of a portable hand‐held spirometer, which has been developed with the ability to assess breathing manoeuvres associated with the use of different inhaler devices. It is a preprogrammed device that can measure breathing manoeuvres and provides feedback in both numerical and visual/graphic forms. Actual breathing manoeuvres are then compared with optimal manoeuvres for a particular inhaler. This allows patients to see exactly where they are making errors and to what extent. A DVD showing HCPs delivering inhaler technique education to people with asthma was used to consolidate the training of pharmacists. Pharmacists also received an update on basic asthma management and inhaled medications Control summary: current best practice DPI inhaler technique education utilising qualitative visual feedback. Training of community pharmacists occurred on an individual basis, with the researcher delivering a 2‐hour 1‐on‐1 training session to each pharmacist in their own community pharmacy. Control group pharmacists were trained as per a train‐the‐trainer approach and an established pharmacist‐training programme. A DVD showing HCPs delivering inhaler technique education to people with asthma was used to consolidate the training of pharmacists. Pharmacists also received an update on basic asthma management and inhaled medications
Outcomes	Outcomes measured: asthma control (ACQ), inhaler technique Technique assessment method used: The inhaler technique was assessed according to manufacturer‐approved checklists. Individuals were considered to use the correct technique if they were able to perform all steps in the checklist correctly. Inhaler technique data were represented in 2 ways: proportion of participants with correct technique and mean number of steps performed correctly for each device
Notes	Type of publication: peer‐reviewed journal article Funding: This study was funded by the Australian Postgraduate Award. The DVD was funded through Australian Research Council Linkage Project LP LP0882737. Checklists were developed in collaboration with the National Prescribing Service, Sydney, Australia, through funding from the Australian Research Council Linkage Project LP LP0882737
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	"19 community pharmacists were recruited and randomised" ‐ no further details
Allocation concealment (selection bias)	Unclear risk	No details
Blinding of participants and personnel (performance bias) All outcomes	High risk	No description of procedures intended to blind participants or personnel to group assignment
Blinding of outcome assessment (detection bias) All outcomes	High risk	'No description of procedures intended to blind outcome assessors to group allocation; therefore assessment of inhaler technique and asthma control may be at risk of detection bias
Incomplete outcome data (attrition bias) All outcomes	Low risk	Less than 10% drop‐out in both groups
Selective reporting (reporting bias)	Unclear risk	No prospective trial registration identified; all outcomes listed in methods reported
Other bias	Low risk	None noted

Study	Reason for exclusion
Andres Jacome 2003	Not an RCT
Azouz 2015	Cross‐over study performed during 1 clinic visit. Participants used 2 different inhaler types in a randomised order before and after normal, and then enhanced training with the IN‐CHECK device. Before‐and‐after data presented only
Basheti 2005a	Intervention delivered to pharmacists; focus was pharmacists' knowledge rather than participant outcomes
Bosnic‐Anticevich 2010	Mixed population with asthma and COPD; no disaggregated data presented
Compton 2000	Healthy participants
Eakin 2015	Preliminary observational findings from a complex educational intervention. Primary focus of intervention not inhaler technique
Epstein 2001	Not an RCT
Eriksson 1980	Trial of impact of spacer delivery on bronchodilatation outcomes
Fornell 2014	Primary focus of intervention not inhaler technique
Garcia‐Cardenas 2013	Primary focus of intervention not inhaler technique
Grover 2016	Primary focus of intervention not inhaler technique
Hesselink 2004	Mixed population with asthma and COPD; no disaggregated data presented
Hodges 1981	Trial of impact of spacer delivery on bronchodilatation outcomes
Horner 2008	Primary focus of intervention not inhaler technique
Jolly 2012	Not stated that participants had asthma; likely mixed population with asthma and COPD judging by age and sex of participants
Jolly 2015	Mixed population with asthma and COPD; no disaggregated data
Kritikos 2007	Primary focus of intervention not inhaler technique
Lee 2010	Not an RCT
McElnay 1989	Randomised portion of trial involved healthy volunteers
Mulloy 1996	Primary focus of intervention not inhaler technique
NCT01426581	Mixed population with asthma and COPD; no disaggregated data
NCT01456494	Mixed population with asthma and COPD; no disaggregated data
NCT01641211	Subanalysis of a larger trial investigating a multi‐faceted intervention to improve asthma management in older adults. Primary focus of intervention not inhaler technique
NCT02046759	Primary focus of intervention not inhaler technique
NCT02307669	Primary focus of intervention not inhaler technique
NCT02363192	Primary focus of intervention not inhaler technique
NCT02715219	Primary focus of intervention not inhaler technique
Pedersen 1983	Primary focus of intervention not inhaler technique
Poureslami 2016	Primary focus of intervention not inhaler technique
Rachelefsky 1986	Cross‐over study of spacer drug delivery
Reiser 1986	Cross‐over study primarily assessing impact of spacer delivery on lung function
Sandos Dde 2010	Not an RCT
Schacer 2005	Control group but no mention of random allocation
Tuazon 2002	Primary focus of intervention not inhaler technique
Verver 1996	Mixed population with asthma and COPD; no disaggregated data
WIlliams 1983	Not an RCT ‐ children used as their own controls
Wong 1995	Trial of impact of spacer delivery on bronchodilatation outcomes
Yoon 1993	Primary focus of intervention not inhaler technique

PERMALINK

Interventions to improve inhaler technique for people with asthma

Rebecca Fortescue

Kayleigh M Kew

Alexander G Mathioudakis

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Types of outcome measures

Primary outcomes

Secondary outcomes

Search methods for identification of studies

Electronic searches

Searching other resources

Data collection and analysis

Selection of studies

Data extraction and management

Assessment of risk of bias in included studies

Assessment of bias in conducting the systematic review

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

1. Summary of characteristics of studies in comparisons 1 and 2: inhaler technique education.

2. Summary of characteristics of studies in comparisons 3 and 4: multi‐media training.

3. Summary of characteristics of studies in comparisons 5 and 6: add‐on/feedback device.

Sensitivity analysis

Summary of findings and assessment of the certainty of the evidence

Results

Description of studies

Results of the search

1.

Included studies

Population characteristics and inclusion criteria

Interventions and comparisons

Excluded studies

Risk of bias in included studies

2.

Allocation

Blinding

Incomplete outcome data

Selective reporting

Other potential sources of bias

Effects of interventions

Summary of findings 1. Enhanced education compared with control versus usual care for people with asthma.

Summary of findings 2. Multimedia training compared with control versus usual care for people with asthma.

Summary of findings 3. Feedback device compared with control versus usual care for people with asthma.

Structure of the analysis

Comparisons 1 and 2: enhanced inhaler technique education versus control or usual care

Inhaler technique

1.1. Analysis.

3.

1.2. Analysis.

2.1. Analysis.

2.2. Analysis.

2.3. Analysis.

Asthma control

1.3. Analysis.

1.4. Analysis.

Methods	Open‐label parallel‐group randomised controlled trial
Participants	Adults with asthma aged 18 to 75 years receiving step 3 or 4 therapy for asthma as defined by British Thoracic Society (BTS) guidelines (daily doses of BDP‐equivalent ICS ≥ 800 mcg to 2000 mcg as part of fixed or free combinations with long‐acting beta‐agonists (LABAs))
Interventions	Comparison of inhaler technique mastery of Spiromax vs Symbicort Turbohaler
Outcomes	Critical and number of errors, adherence, patient satisfaction, exacerbations, change in asthma treatment, adverse events
Notes	Study reported as completed in March 2015, but no study results posted on clinicaltrial.gov; we are unable to link record to a full‐text publication

Methods	Quasi‐experimental study; a convenience sample of children were "randomly assigned to one of two equal groups"
Participants	Children (7 to 12 years of age) with asthma; sample included 154 children (African American and Caucasian)
Interventions	Mnemonic device to assist in learning to use the MDI (3 colourful cards with keywords and animated pictures representing MDI use)
Outcomes	At 2 points in time, participants answered demographic and medical history questions, had their inhaler technique evaluated, received mnemonic or standard instructions and performed pulmonary function tests. An inhaler checklist measured skill in MDI use
Notes	Not clear from the abstract whether this is a truly randomised study. Attempted to contact NK Westhus (lead author) via the University of St Louis; email sent on 26 August 2016; no response received at the time of publication

Study name	Assessing the effectiveness of Inhaler Technique Labels on asthma patients' inhaler technique
Methods	Parallel‐group randomised controlled trial
Participants	People aged 14 to 85 years with a doctor diagnosis of asthma, currently using inhaled corticosteroids with or without long‐acting beta‐agonists via Turbuhaler or Diskus, who have been on the same asthma medication and dose for a minimum of 1 month before study enrolment. Planned recruitment 214 participants
Interventions	Inhaler technique labels used as part of inhaler technique education (verbal plus physical demonstration) compared with inhaler technique education alone
Outcomes	Inhaler technique, asthma control (using Asthma Control Test)
Starting date	01/08/2009
Contact information	Dr Iman Amin Basheti 940344 Amman 11194 Jordan Email: ibasheti@usyd.edu.au
Notes	Listed as 'active but not recruiting'. Unable to link to a full‐text publication

Study name	The relationship between asthma management and inhaler technique training
Methods	Parallel‐group randomised controlled trial
Participants	Adults with asthma aged 20 years and older with an ACT score under 24. Planned recruitment 90 participants
Interventions	No inhaler technique training vs inhaler technique training vs inhaler technique training and education
Outcomes	Adherence, ACT, FEV₁, FeNO
Starting date	01/11/2011
Contact information	Kumiya Sugiyama 880 Kita‐kobayashi Mibu Tochigi 321‐0293 Japan Email: sugiyama@dokkyomed.ac.jp
Notes	Status listed as 'enrolling by invitation'. Unable to link to a full‐text publication

Study name	A protocol for a randomised clinical trial of the effect of providing feedback on inhaler technique and adherence from an electronic device in patients with poorly controlled severe asthma
Methods	Single‐blind prospective parallel‐group randomised clinical trial
Participants	Patients with partially controlled or uncontrolled severe asthma who have also had at least 1 severe asthma exacerbation in the prior year are eligible to participate. Planned recruitment 220 participants
Interventions	Active group will receive feedback on their inhaler technique and adherence with the new device over a 3‐month period. Control group will also receive training in inhaler technique and strategies to promote adherence, but no feedback from the device
Outcomes	Adherence, inhaler technique, number who remain poorly controlled despite appropriate technique
Starting date	2011
Contact information	Imran Sulaiman Email: imransulaiman@rcsi.ie
Notes

Study name	A randomised, parallel‐group, multi‐centre trial using a novel 'INCA' Tracker Device to measure and monitor compliance and technique of Seretide Diskus inhaler in a community pharmacy setting
Methods	Open‐label parallel‐group randomised controlled trial
Participants	Adults with asthma or COPD aged 18 years or older with a valid prescription for Seretide Diskus inhaler or currently using a Seretide Diskus inhaler. Planned recruitment 200 participants
Interventions	Feedback on the participant's own inhaler use, with personalised information on participant technique and timing of use of the Diskus inhaler as recorded on the INCA device, will be provided to participants in the feedback group after 1, 2 and 6 months vs current best practice inhaler technique education
Outcomes	Adherence, inhaler technique, rescue inhaled medication use, rescue antibiotic/steroid use, quality of life
Starting date	February 2014
Contact information	Richard Costello Royal College of Surgeons Clinical Research Centre Beuamont Hospital Email: rcostello@rcsi.ie
Notes

Study name	Evaluating the efficacy of 2 different educational strategies for improving and maintaining inhaler technique
Methods	Open‐label parallel‐group randomised controlled trial
Participants	Adults aged 35 to 90 years whose regular treatment requires inhaled medication. They will be included regardless of age, disease, inhaler device used or cognition
Interventions	Structured education on the use of inhalers vs usual standard informal education
Outcomes	Inhaler technique
Starting date	December 2014
Contact information	Steven Hickey, Respiratory Nurse Specialist Northampton General Hospital NHS Trust
Notes

Study name	Video vs Teach‐To‐Goal Respiratory Inhaler Technique Assessment and InstructioN (V‐TRaIN)
Methods	Single‐blind (outcomes assessor) parallel‐group randomised controlled trial
Participants	Adults aged 18 years and older, admitted to the inpatient medical service and surgical service with physician‐diagnosed COPD or asthma. We will enrol patients even if the primary reason for admission is not COPD or asthma (e.g. patients admitted for heart failure but with a physician diagnosis of COPD are eligible)
Interventions	Those in the TTG condition will be provided with an intensive, iterative education and evaluation strategy. Those in the video module education condition will be provided with a tablet device and instructions on how to complete video training and self‐assessment
Outcomes	Inhaler technique, symptoms, quality of life, self‐efficacy, healthcare utilisation, lung function
Starting date	November 2015
Contact information	Susannah Butters Email: sbutters@medicine.bsd.uchicago.edu
Notes