Effectiveness of educational inhaler technique interventions

to improve the adherence of COPD management:

systematic review

H A Baridah1, Y Kurniawati1, M D Kusumawati1, I Wabula1

1
Master of Nursing Program, Faculty of Nursing Universitas Airlangga,Campus C
UNAIR, Jl. Mulyorejo, Surabaya, East Java, Indonesia

Email: hurinin.aisy.baridah-2018@fkp.unair.ac.id

Abstract. Inhaler therapy is the principal pharmacological management of chronic obstructive

pulmonary disease (COPD). Each inhaler has certain usage rules to be most effective, proper
education of inhaler technique is an important part to improve treatment adherence. This
systematic review is to conduct of various educational inhaler technique for COPD indexed in
Science direct, ProQuest, Scopus, Ebsco, Pubmed for original research study, then we
reviewed systematically. There were 15 journals with RCTs study designs limited to the last 5
years; from 2013 to 2019 that discussed about educational inhaler technique. This systematic
review found five programs, they are face-to-face trainings, pharmacist counseling, health
coaching, a model of self-management education, and virtual teach-to-goal. The results of
studies was collected mostly for 6 months. An appropriate education of inhaler technique to
improve adherence on COPD management which can be used as a monitor effort of COPD
management.

Keywords: COPD, Adherence, Educational Inhaler Technique , Inhaler Technique

1. Introduction
Chronic Obstructive Pulmonary Disease (COPD) has been considered a significant global
health problem which considered a significant global health problem which is a major cause of
morbidity and mortality in countries of high, middle, and low income [1]. COPD is a preventable and
treatable disease that is characterized by limited air flow not being completely irreversible.
Nevertheless, the burden of each disease among patients is high and patients may be frequently
hospitalized due to exacerbation [2]. Effective therapy options and evidence-based guidelines
developed in recent years, disease control continues to be suboptimal in patients with chronic
obstructive lung disease like asthma and COPD. There are numerous reasons for the lack of disease
control in asthma and COPD patients. One important reason is the incorrect application of inhaler
devices, which is associated with worsened health outcomes, such as increased risk of hospitalization
and an insufficient diseases control [3].
The prevalence and severity of COPD in Vietnam has been reported in recent literature with
the prevalence rate was found to be 6.7% in 12 Asian countries, while another study indicated that
over half of those infected experienced exacerbation episodes[4]. According to research seventy-seven
of 103 patients (74.8%) did at least one wrong step. Patients using Handihaler had the lowest
compliance failure (42.5%). Low education level is the single most important factor related to the
wrong technique [5].
Inhaler therapy is the principal pharmacological management of chronic obstructive
pulmonary disease (COPD). The choice of device must be based on the needs of the patient [6]. Many
inhaler devices have been developed, and each has specific instructions for use to ensure proper
delivery of drug doses to the airways. Although a number of different devices have enabled
technological improvements in airway drug delivery, they certainly still have disadvantages [7]. Most
patients in daily use still make inhalation errors. Incorrect inhaler techniques can cause poor control of
disease, such as poor adherence, and an increased risk of hospitalization.[8].
The availability of effective treatmens such as various educational inhaler technique is pivotal
to the implementation of succesful intervention strategies [9]. Some studies do this by way of a
systematic literature review, the search in 2000 to 2018 showed a significant influence on the research
conducted and there did not show the level of scientific evidence in conducting research in the form of
journals. There are some educations of inhaler technique that are used to study the development of
interventions. This paper offers a systematic review of studies that investigate of educational
interventions focusing on inhaler technique in COPD patients and assess their overall effectiveness.

2. Methods
3.1 Study Selection
We use four steps to identify and select journals that meet the criteria specified in this PRISMA
review (Figure 1). First, we conducted a major search on the database (Scopus, SAGEjournal, and
Proquest) to identify relevant English works published in 2013-2019. The keyword used was Chronis
Obstructive Pulmonary Disesase (COPD), Educational Inhaler Technique, Inhaler Technique, and
Adherence.

Records identified through

searching 4 database :
Scopus (n= 46)
Proquest (n= 587)
SAGEjournal (n=179)
Duplicates removed
(n=637)
Records screened by
tittle/abstract (n=175)
Records excluded (n=139)
Review full text articles (n=36)

Studies included in this

review (n= 13)
Figure 1. PRISMA flow diagram
3.2 Inclusion and exclusion criteria
The inclusion criteria for the article are articles use English and explain ecuational inhaler
technique for patients with COPD. Articles would be excluded if the review/sistematic review study.

3.3 Participants, Interventions, Comparators, Outcomes and Study design (PICOS)

The feasibility of the study was assessed using the PICOT approach : participants are patients
with COPD, interventions are types of educational inhaler technique, no comparison, outcomes are
improve inhaler adherence, HRQoL, self efficacy, self management, the correct technique for using
inhalers, and reduce the incidence of exacerbation. Study design is randomized controlled trial study
(RCTs) and cross sectional.

3. Results
4.1 Description of the Study
There were 13 randomized control trial design and cross sectional study on this journals
reviewed. All participants were aged +>45 years with COPD. There was one study with criteria for
acute exacerbatios participants, and one study with patients experiencing chronic bronchitis with
COPD.
Almost all interventions included a physical or video demonstration of inhaler use.
Interventions used face-to-face trainings, pharmacist counseling, health coaching, a model of self-
management education and Virtual Teach-to-goalTM. Six studies used face-to-face trainings. Two
studies used pharmacist counseling. Two studies used health coaching. one study used a model of self-
management education. Two studies used Virtual Teach-to-goalTM.

4.2 Face-to-face Trainings

The research conducted by Aydemir (2015) used face-to-face trainings by cross sectional
study for 3 min. The study was designed as a real life and no intervention was done except for the
standard face-to-face training sessions conducted by the same trainer[10]. The patients were asked to
administer medication using their own inhaler device and the inhala- tion procedure was observed.
The main treatment devices were evaluated (quick-relief inhalers not included). Inha- lation ability
was assessed based on the Turkish version of the “A Guide to Aerosol Delivery Devices for
Respiratory Therapists” published by the American Association of Respiratory Care (AARC) and the
inhalation ability chart prepared by the inhalation therapies workgroup of Turkish Respiratory
Society. Since the number of inhalation procedure steps was different for each device, three common
statuses were defined to facilitate statistical an- alyses: correct use (CU), incorrect use (IU) and
inadequate (false) use (FU). Inhaler device setup and inhalation technique were described using
demonstration devices. The inhalation technique was observed immediately after the training [10].
The results of this research show that the physicians should pay attention, in particular, while
prescribing pMDIs to elderly patients. Such patients’ ability to use the device should be observed after
the training, and the physicians should consider DPIs or home-nebulizer devices if inhalation cannot
be achieved with the correct technique.
The research conducted by Yoo et al. (2017) used face-to-face trainings by Randomised
Controlled Trials for one month. At first visit, we obtained the informed consent from each patient and
conducted a knowledge assessment about their chronic airway disease, and tested the inhaler
technique before the patients received the educational program. At the second and third visits, this
education program were repeated. Questionnaires were completed by patients and physicians at the
first visit and third visit to evaluate the following items; the knowledge about COPD, COPD
assessment test (CAT), inhaler use technique, and measurement items of each topic were composed of
six (knowledge), eight (CAT), seven (inhaler use), three (satisfaction of the patients), and five items
(satisfaction of the physicians)[11]. This study showed that in the primary care setting, a
comprehensive education program including inhaler training and COPD management resulted in
correct inhaler usage and improvement of CAT score, suggesting that such programs should be
extended further in the primary care of COPD.
Research Ngo, Phan, Vu, Dao, & Phan (2019) used a cross sectional design with face-to-face
interviews which conducted after patients stabilized the acute condition. This study asked patients to
demonstrate how they used their inhalers at home and to answer the 12-item Test of Adherence to
Inhaler (TAI) [12]. The result of study showed that worse dyspnea, greater health condition
impairment, and an increased frequency of exacerbations and hospitalizations were found to be
associated negatively with correct inhaler use and treatment adherence. Instructions to COPD patients
about using inhalers should focus on correct inhaler technique and adherence even when feeling
healthy.
Research conducted by Takaku et al., (2017) which focused on evaluate the number of
instructions that are necessary to minimize errors in using pressurized metered-dose inhaler (pMDI),
soft mist inhaler (SMI), and dry powder inhaler (DPI). The intervention program consisted of face-to-
face training Inhalation guidance/evaluation was performed successively from 2 times up to 5 times at
intervals of 2 weeks to 1 month until no futher improvement was observed [13]. This study concluded
that it is necessary to repeat at least three times of instructions to achieve effective inhalation skills in
both asthma and COPD patients.
Face-to-face training in study from Goris, Tasci, & Elmali, (2013) conducted on intervention
group and control group. The intervention group was educated on using an inhaler by verbal training,
demonstration movie, and leaflet. A follow-up after 3 months was carried out in both groups. Patients
in the control group were not educated but have been checked with the same indicators. Quality of life,
condition of dyspnea, and attack improved 3 months later in the intervention group compared with the
controls. Data were collected by a face-to-face interview for 15 months by the researcher. Three
months after the interview, patients were invited for the second one (follow-up). Training took 15–
20min on average and was held in a separate room apart from the outpatient clinic in order not to
interrupt the conversation[14]. The result of study showed that a planned inhaler training given to the
patients with COPD was found to decrease attack frequency and dyspnea, and improve quality of life.
Research conducted by Pothirat et al., (2015) assessed for inhalation technique compliance at
their routine medical (pre-training) visits by a qualified respiratory nurse without prior notification.
The respiratory nurse observed each step of the inhalation technique and recorded each incorrect step.
After the assessment, patients were given instructions, face-to-face demonstrations regarding the
correct use of the controller devices, and training until they could use the devices correctly. One month
later (post-training visit), all patients were requested to demonstrate their inhalation techniques and
were reevaluated by the same nurse [8]. The result of study showed that formal training resulted in a
statistically significant decrease in percentage of incorrect techniques for all devices and for the pMDI.

4.3 Pharmacist Counseling

There are two articles that used pharmacist counseling. Article from Axtell, Haines, &
Fairclough, (2017) used the pharmacist counseling to compare the effectiveness of 4 different
instructional interventions in training proper inhaler technique. These inhaler-naive subjects were
randomly assigned to 1 of the 4 interventions using a dice randomization process: (1) reading a
manufacturer-published MDI package insert pamph- let, (2) watching a CDC video demonstrating
MDI technique, (3) watching a general popular YouTube video demonstrating MDI technique, or (4)
receiving direct instruction ofMDI tech- nique from a pharmacist or fourth-year pharmacy student.
Utilizing a timer, all interventions were limited to 2 min- utes. Although previous studies suggest that
successful health care counseling sessions may require approximately 6 to 20 minutes, the allocation
of 2 minutes was considered to be more in line with the amount of time that a community phar- macist
may routinely be able to devote to inhaler instruction [15]. The result showed that a 2-minute
pharmacist counseling session is more effective than other interventions in successfully educating
patients on proper inhaler technique. Pharmacists can play a pivotal role in reducing the implications
of improper inhaler use.
Research conducted by Tommelein et al., (2013) used randomised controlled trials to knowing the
impact of community pharmacist interventions on pharmacotheraputic monitoring of patients with
chronic obstructive pulmonary disease (COPD). This study devided to two group. Control group
patients were given usual nonprotocol-based pharmacist care. Patients in the intervention group
received a protocol-defined two-session intervention; one session at the start of the study and one
session at the 1month follow-up visit. All interventions were given during one-to-one counselling
sessions. The duration of interventions was not predetermined; however, we estimated the duration to
be between 15 and 25min. To support interventions,pharmacistswereprovidedwithinformationleaflets
on COPD, demostration inhaler units and a list of practical solutions to specific nonadherent behaviour
[16]. The results this study showed that inhalation score and medication adherence were significantly
higher in the intervention group compared with control group.

4.4 Health Coaching Programme

Research conducted by Derya Tuluce (2018) used health coaching on respiratory functions,
treatment adherence, self-efficacy, and quality of life in chronic obstructive pulmonary disease
patients. The implementation of “the education of COPD patient” initially on topics such as disease
physiopathology, diagnosis of signs and symptoms, regular use of medications, exercises, nutrition,
and control of exacerbations was performed by power point took about 40 to 50 minutes. After the
education implementation, printed educational booklets were given as written materials, which were
developed for the patients. The coaching agenda included treatment adherence in 4 coaching
interventions for the first 4 weeks, self-efficacy in the next 4 interventions for the next 4 weeks, and
the quality of life in the next 4 interventions for the last 2 months. The interventions were held in a
room with a quite and calm atmosphere where there was no interaction with other patients in the
outpatient clinic. It took about 30 to 45 minutes [17]. After health coaching intervention, self-efficacy
scale general score, and St.George Respiratory Questionnaire, total scores were found statistically
significant different between 2 groups in interaction values. There was a significant difference in the
8-item Morisky Adherence Scale scores for degree of treatment adherence between the groups.
Another research conducted by Crane, Jenkins, Goeman, & Douglass (2014) used health coaching
to improving inhaler techniques on patients with asthma and COPD. The comprehensive education
intervention group received one-on-one technique coaching, which included critical observation of
their device technique, verbal instruction regarding ways to improve their technique, physical
demonstration of correct technique and encouragement. The device information pamphlets were
standard educational pamphlets supplied by Astra-Zeneca (North Ryde, NSW, Australia) and
GlaxoSmithKline (Ermington, NSW, Australia) to healthcare practitioners. Device technique was
reviewed in both groups, at baseline and at 3 and 12 months. In the active group, this was done prior to
education. Device technique was assessed discretely according to current National Asthma Council
(NAC) guidelines and critical inhaler technique steps were scored using the NAC checklist for each
device. The checklists can be downloaded from the NAC website http://www.nationalasthma.org.au/
publication/inhaler-technique-in-adults-with-asthma-or-copd. Lung function, asthma control and
medication adherence were also measured as part of the wider intervention[18]. Post education there
was a statistically significant improvement in the proportion of participants with correct technique in
the active group at 3-month follow-up. The results of this study indicate that provision of passive
written information alone, even in pictorial form, is not adequate as a form of inhaler education for
older people with COPD.

4.5 A model of self-management education

Research conducted by Bourbeau (2017) used self-management education program with coaching
of a case managers who focused on treatment adherence, inhaler techniques, smoking cessation, and
the use of an action plan for exacerbations for 1 year in six family medicine clinics (FMCs).
Throughout the intervention, respiratory thera- pists acted as both educators and case managers. The
initial visit lasted around 90 minutes and consisted ofan assessment ofeducational needs, a spirometry,
and a 1-hour encounter with the educator (respiratory therapist). During this encounter, the following
topics were covered: COPD etiology and pathophysiology, COPD control, smoking cessation, use of a
written action plans for acute exacerbations, adequate inhaler technique, and medication
adherence[19]. The result this study showed that The COPD self-management educational intervention
reduced unscheduled visits to the clinic and improved patients’ quality of life, self- management skills,
and knowledge.
4.6 Virtual Teach-to-goalTM
There are two articles that used Virtual Teach-to-goalTM adaptive learning. Article by Press,
Kelly, Kim, White, & Meltzer (2016) used randomised controlled trials to develop and pilot a virtual
teach-to-goalTM (V-TTGTM) inhaler skill training module, using innovative adaptive learning
technology. This study is the first to demonstrate the efficacy of a self-directed adaptive V-TTGTM
learning tool to teach the inhaler technique. Among hospitalized patients with asthma or COPD. Then
answer adaptive self-assessment through short-answer questions[20]. This study found that the
innovative V-TTGTM adaptive learning strategy is an effective tool to teach the MDI technique to
hospitalized patients with asthma or COPD. After inhaler teaching with V-TTGÔ, almost all
participants demonstrated the improved inhaler technique with reduced rates of inhaler misuse, and
nearly half had complete mastery, demonstrating the potential efficacy of this learning tool.
Research conducted by Thomas et al.(2017) used videoconferencing inhaler education program
delivered at the patient’s home and whether the training improved inhaler. The participant download
the videoconferencing software (Cisco Jabber Video for TelePresence 4.5 software) and to complete
atest videoconferencing visit.Training was given for prescribed inhalers. After the initial visit, most
participants were offered a spacer. Participants were to complete 3 monthly videoconferencing visits
with a study pharmacist trained in TTG methodology. The TTG method breaks down the technique for
each inhaler into a standardized checklist of 12–17 steps, depending on the inhaler. With pharmacist
input, the checklists were adapted. Each TTG training visit began with the pharmacist assessing the
participant’s baseline inhaler technique and assigning a pre-training score. The pharmacist then
demonstrated correct technique and gave verbal instruction. After that educational intervention, the
participant re-demonstrated inhaler technique,and each round was assigned a score of post-training 1,
post-training 2, etc. The training was repeated until the participant demonstrated mastery (missed < 2
steps) or after 3 cycles. TTG scores were used both as an educational tool to assist with inhaler
training and as an objective measure of inhaler technique[21]. The results of this study showed that
Inhaler training provided by a pharmacist using home videoconference technology in this pilot study
improved inhaler technique during each participant visit, and improvements were sustained at the 1-
and 2-month video- conference visits. In addition, participants reported im- provements in COPD self-
efficacy, COPD health-related quality of life, and inhaler adherence following the inhaler training.

4. Discussion
Various effective treatments are available for COPD, but patients still do not achieve treatment
goals, partly because of low adherence to therapy. Non-compliance with treatment is associated with
ineffective monitoring of symptoms, errors in inhaler techniques, and decreased quality of life related
to health. There are many types of education on inhaler techniques that have been applied to COPD
patients. This review showed that educational inhaler technique are effective, at least on the short
term. Most of the results of the study show that the impact of educational programs on inhaler
techniques to increase the use of appropriate inhalers, quality of life, self-efficacy, self-management,
and treatment adherence. Retrieved from seven articles related to improving of inhaler technique
[10,11,13,8,15,18,20]. There is one article that has an impact on quality of life [14]. Two articles
related to improving treatment adherence [12,22]. There is one article that discusses quality of life and
self-management [19]. Retrieved from two articles to improving quality of life, self-efficacy, and
treatment adherence[17,21]. This systematic review showed that face-to-face trainings are more
widely used with six journals. Face-to-face trainings increase the use of the correct inhaler technique
[10,11,13,8], impact on quality of life of COPD patients [14], improve treatment adherence even when
feeling healthy [12].

5. Conclusion
This systematic review has several limitations is some subjects may not be motivated to learn the
right inhaler techniques as well as patients who are aware of the fact that inhalers are an important
element in treating their COPD so that this can lead to bias. A list of standard assessments is used for
 all participants to minimize bias, and ratings for each step in the inhaler technique only give 2 choices
: competent or incompetent. The educational inhaler technique what extended further in the primary
care of COPD are effective to improve the correct inhaler technique, quality of life, and treatment
adherence.

6. Appendices
Tabel 1. Summary of studies included in review
Author Method Population Intervention Comparison Outcomes Time
[10] Cross- There were 342 face-to-face - The physicians should pay 3 min
sectional respondents who training sessions attention, in particular, while
had been referred conducted by the prescribing pMDIs to elderly
to the chest same trainer. patients. Such patients’ ability to
diseases Inhaler device use the device should be
polyclinics of a setup and observed after the training, and
state hospital in the inhalation the physicians should consider
center of a technique were DPIs or home-nebulizer devices
metropolis (Konya, described using if inhalation cannot be achieved
TURKEY) demonstration with the correct technique.
devices.
[15] Randomised A total of 72 Subjects were - A 2-minute pharmacist -
Controlled subjects who assigned to counseling session is more
Trials patients clinic in complete the effective than other
following: interventions in successfully
West Palm Beach,
(1) read a metered educating patients on proper
Florida. dose inhaler inhaler technique. Pharmacists
(MDI) package can play a pivotal role in
insert pamphlet reducing the implications of
(2) watch a improper inhaler use.
Centers for
Disease Control
and Prevention
(CDC) video
demonstrating
MDI technique
(3) watch a
YouTube video
demonstrating
MDI technique
(4) receive direct
instruction of
MDI technique
from a
pharmacist.
[20] Randomised Among 90 enrolled Participants - Participants demonstrated the 1 year
Controlled participants, the completed the improved inhaler technique with
Trials majority were interactive V- reduced rates of inhaler misuse,
TTGTM session and nearly half had complete
African American
comprising cycles mastery, demonstrating the
(94%) of demonstration potential efficacy of this
and adaptive self- learning tool.
assessment
through short-
answer questions.
[11] Randomised 127 with COPD Education - Patients with improved CAT 1
Controlled and 158 with program scores of 4 points or more had a month
Trials asthma. including inhaler better understanding of COPD
training and management and the correct
COPD technique for using inhalers than
management those who did not have
improved CAT scores.
[12] Cross- 70 COPD patients Face-to-face - 1. Worse dyspnea, greater + 12
sectional interviews were health condition impairment, months
conducted after and an increased frequency
patients stabilized
of exacerbations and
the acute
condition. Then, hospitalizations were found
asked patients to to be associated negatively
demonstrate how with correct inhaler use and
they used their treatment adherence.
inhalers at home 2. Instructions to COPD
and answer the patients about using inhalers
12-item Test of
should focus on correct
Adherence to
Inhaler (TAI). inhaler technique and
adherence even when feeling
healthy.

[13] Randomised 216 patients Inhalation - Repeat at least three times of 2

Controlled guidance/evaluati instructions to achieve effective weeks
Trials on was performed inhalation skills in both asthma to 1
successively from and COPD patients. month
2 times up to 5
times at intervals
of 2 weeks to 1
month until no
futher
improvement was
observed.
[21] Randomised 41 participants Giving the - Inhaler training provided by a 8
Controlled videoconferencin pharmacist using home months
Trials g software (Cisco videoconference technology in
Jabber Video for this pilot study improved inhaler
TelePresence 4.5 technique during each
software) and to participant visit, and
completea test improvements were sustained at
videoconferencin the 1- and 2-month video-
g visit.Training conference visits
was given for
prescribed
inhalers.
[14] Randomised A total of 69 with Educated on Checked A planned inhaler training given 18
Controlled COPD; 34 subjects using an inhaler with the to the patients with COPD was months
Trials were put in the by verbal same found to decrease attack
intervention group training, indicators frequency and dyspnea, and
and 35 in the demonstration improve quality of life.
control group movie, and
leaflet.
[17] Non- A total of 54 The education of The patients After health coaching 1 year
Randomised chronic obstructive COPD patient receiving intervention, self-efficacy scale
Controlled pulmonary disease initially on topics standard care general score, and St.George
Trials patients (27 such as disease and Respiratory Questionnaire, total
patients both health physiopathology, treatment scores were found statistically
coaching and diagnosis of signs significant different between 2
control groups) and symptoms, groups in interaction values.
regular use of There was a significant
medications, difference in the 8-item Morisky
exercises, Adherence Scale scores for
nutrition, and degree of treatment adherence
control of between the groups.
exacerbations was
performed by
power point took
about 40 to 50
minutes. derya
[8] cross- A total of 103 face-to-face - Formal training resulted in a 1 year
sectional COPD patients demonstrations statistically significant decrease
regarding the in percentage of incorrect
correct use of the techniques for all devices and
controller for the pMDI.
devices, and
training until they
could use the
devices correctly.
[18] Randomised There were 123 in Education - By 3 months 26 of the active 12
Controlled New South Wales intervention group achieved adequate months
Trials and Victoria, group received technique and remained
Australia. one-on-one significant at 12 months
technique
coaching, which
included critical
observation of
their device
technique, verbal
instruction
regarding ways to
improve their
technique,
physical
demonstration of
correct technique
and
encouragement.

[16] Randomised 734 Patients Received a Given usual inhalation score and medication 3
Controlled protocol-defined nonprotocol- adherence were significantly months
Trials two-session based higher in the intervention group
intervention; one pharmacist compared with control group.
session at the start care.
of the study and
one session at the
1month follow-up
visit. All
interventions
 were given during
one-to-one
counselling
sessions.
[19] Randomised 54 patients were Respiratory - The COPD self-management 1 year
Controlled diagnosed with therapists acted as educational reduced
Trials COPD both educators unscheduled visits to the clinic
and case and improved patients’ quality
managers. of life, self- management skills,
and knowledge. unscheduled
visits to the clinic and improved
patients’ quality of life,
selfmanagement skills, and
knowledge. reduced
unscheduled visits to the

7. References
[1] Celli BR, Macnee W 2004 Standards for the diagnosis and treatment of patients with COPD : a
summary of the ATS / ERS position paper 932–46.
[2] Gregoriano C, Dieterle T, Breitenstein A, Dürr S, Baum A, Maier S, Arnet I, Hersberger KE,
Leuppi JD 2018 Use and inhalation technique of inhaled medication in patients with asthma
and COPD : data from a randomized controlled trial 1–15.
[3] Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, Serra M, Scichilone N,
Respiratoria F, Elena IR 2011 Inhaler mishandling remains common in real life and is
associated with reduced disease control Respir Med. 105 930–8.
[4] 2003 ORIGINAL ARTICLE COPD prevalence in 12 Asia – Pacific countries and regions :
Projections based on the COPD prevalence estimation model
[5] Al-worafi YM 2018 Evaluation of inhaler technique among patients with asthma and COPD in
Yemen J Taibah Univ Med Sci. 13 488–90.
[6] GOLD 2018 The Global Strategy For Diagnosis, Management and Prevention of COPD
(updated 2016), the Pocket Guide (updated 2016)
[7] Luiza M, Souza DM, Meneghini AC 2009 Knowledge of and technique for using inhalation
devices among asthma patients and COPD patients 35 824–31.
[8] Pothirat C, Chaiwong W, Phetsuk N, Pisalthanapuna S, Chetsadaphan N, Choomuang W 2015
Evaluating inhaler use technique in COPD patients 1291–8.
[9] Backer V, Hedegaard M, Ma MJ 2013 Adherence to inhaled therapies , health outcomes and
costs in patients with asthma and COPD
[10] Aydemir Y 2015 Assessment of the factors affecting the failure to use inhaler devices before
and after training Respir Med. 109 451–8.
[11] Yoo KH, Chung WY, Park JH, Hwang SC, Kim T, Oh MJ, Sc B, Kang DR, Ph D, Rhee CK,
Yoon HK, Kim T, Kim DK, Park YB, Kim S, Yum H 2017 Short-term Evaluation of a
Comprehensive Education Program Including Inhaler Training and Disease Management on
Chronic Obstructive Pulmonary Disease 3536 377–84.
[12] Ngo CQ, Phan DM, Vu G Van, Dao PN, Phan PT 2019 Inhaler Technique and Adherence to
Inhaled Medications among Patients with Acute Exacerbation of Chronic Obstructive
Pulmonary Disease in Vietnam
[13] Takaku Y, Kurashima K, Ohta C, Ishiguro T, Kagiyama N, Yanagisawa T, Takayanagi N 2017
How many instructions are required to correct inhalation errors in patients with asthma and
chronic obstructive pulmonary disease ? Respir Med. 123 110–5.
[14] Goris S, Tasci S, Elmali F 2013 The Effects of Training on Inhaler Technique and Quality Of
Life in Patients with COPD 26 336–44.
[15] Axtell S, Haines S, Fairclough J 2017 Effectiveness of Various Methods of Teaching Proper
Inhaler Technique : The Importance of Pharmacist Counseling 30 195–201.
[16] Tommelein E, Mehuys E, Hees T Van, Adriaens E, Bortel L Van, Christiaens T, Tongelen I
Van, Remon J, Boussery K, Brusselle G 2013 Effectiveness of pharmaceutical care for patients
with chronic obstructive pulmonary disease ( PHARMACOP ): a randomized controlled trial
[17] Derya Tuluce SK 2018 The effect of health coaching on treatment adherence , self ‐ efficacy ,
and quality of life in patients with chronic obstructive pulmonary disease 1–11.
[18] Crane MA, Jenkins CR, Goeman DP, Douglass JA 2014 Inhaler device technique can be
improved in older adults through tailored education : fi ndings from a randomised controlled
trial Nat Publ Gr. 1–5.
[19] Bourbeau J, Farias R, Li PZ, Gauthier G, Battisti L, Beauchesne M, Villeneuve D 2017 The
Quebec Respiratory Health Education Network : Integrating a model of self-management
education in COPD primary care Chron Respir Dis. 1–11.
[20] Press VG, Kelly CA, Kim JJ, White SR, Meltzer DO 2016 Virtual Teach-To-Goal ä Adaptive
Learning of Inhaler Technique for Inpatients with Asthma or COPD J Allergy Clin Immunol
Pract. 1–9.
[21] Thomas RM, Locke ER, Woo DM, Nguyen EHK, Press VG, Layouni TA, Trittschuh EH,
Reiber GE, Fan VS 2017 Inhaler Training Delivered by Internet-Based Home
Videoconferencing Improves Technique and Quality of Life 1412–22.
[22] Boven JFM Van, Tommelein E, Boussery K, Mehuys E, Vegter S, Brusselle GGO, Mölken
MPMHR, Postma MJ 2014 Improving inhaler adherence in patients with Chronic Obstructive
Pulmonary Disease : a cost-effectiveness analysis 1–11.