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Educating older adults with chronic obstructive pulmonary disease or asthma about the correct way to use their inhalers, as part of disease management, can reduce their risk of exacerbations. Either a demonstration using a placebo inhaler or written information appears effective for this.

This review pooled the results of four trials, with a total of 1,225 participants. It found that a pharmacist or nurse intervention to improve inhaler technique for older adults can reduce exacerbations. People with exacerbations reduced from 58% in the usual care group to 43% in the inhaler education group. However, there was no difference in quality of life or lung function.

Nevertheless, regularly ensuring good technique should prevent unnecessary increases in inhaler doses or additional treatments and is considered good practice. It may also be cost effective if it reduces exacerbations requiring hospital admission.

Why was this study needed?

Approximately 1.2 million people have been diagnosed with chronic obstructive pulmonary disease (COPD) in the UK while eight million have asthma. Inhaled short and long-acting bronchodilators and corticosteroids are the mainstays of treatment. They improve symptoms and reduce the risk of exacerbations in people with asthma. They also provide symptom relief for people with COPD, but their effects on the underlying disease processes are unclear.

However, up to 90% of people aren’t using their inhalers properly, meaning the full dose of medicine isn’t being delivered to the lungs. Previous Cochrane systematic reviews have shown some benefit from education in younger adults though not how best to improve inhaler technique.

The current study aimed to address whether educational interventions that aim to improve inhaler technique for older adults can reduce exacerbations and improve quality of life.

What did this study do?

This review included eight studies overall and a meta-analysis of 1,225 adults from four randomised controlled trials. The studies compared an educational intervention with usual care for people mostly aged 65 and older with COPD, and a few with asthma. The studies took place in Canada, the Netherlands, Belgium and Northern Ireland.

The intervention included individualised inhaler training by pharmacists or nurses in pharmacies and hospitals. This involved physical demonstrations with placebo inhalers or written instructions. Most trials also included COPD education, exercise and a prescription for antibiotics and steroids for early use during an exacerbation. Participants were followed for between three months and two years.

There were some non-randomised studies which are not reported here. There was unclear risk of bias in the randomised trials which were rated as low to moderate quality evidence.

What did it find?

  • The inhaler education group had fewer exacerbations, occurring in 43% (268/618) of older adults compared with 58% (353/607) of the control group (pooled risk ratio 0.71, 95% confidence interval [CI] 0.59 to 0.86, four trials).
  • There was no clear difference in the quality of life between the two groups (standardised mean difference [SMD] ‑0.12, 95% CI ‑0.26 to 0.03).
  • There were no differences between the two groups in lung function tests (SMD 0.06, 95% CI ‑0.35 to 0.47).

What does current guidance say on this issue?

The NICE guidelines for adults with COPD (2018) and asthma (2017) say patients should only be prescribed an inhaler after being shown how to use it, and if their clinician is confident that they can use it correctly. Inhaler technique should also be regularly assessed, particularly if their condition is not under control and whenever they change devices, medication or doses.

The UK Inhaler Group – a coalition of not-for-profit organisations and professional societies, which promotes the correct use of inhaled therapies – stresses that both initial prescribers and those clinicians reviewing patients’ care should be able to demonstrate device techniques correctly and clearly to patients and those who care for them.

What are the implications?

The review provides moderate quality evidence that teaching and reviewing correct inhaler technique to older adults with COPD and asthma can reduce exacerbations.

The studies included people with mild to severe COPD, a range of inhaler medications and types of devices, and additional individualised education and strategies, which limits firm conclusions.

Nevertheless, the principles of regularly ensuring good inhaler technique are in line with national and international guidance and research in other age groups and are unlikely to cause harm.

Citation and Funding

Maricoto T, Monteiro L, Gama JM et al. Inhaler technique education and exacerbation risk in older adults with asthma or chronic obstructive pulmonary disease: a meta-analysis. J Am Geriatr Soc. 2019;67(1):57-66.

No funding information was provided for this study.


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Normansell R, Kew M and Mathioudakis AG. Interventions to improve inhaler technique for people with asthma. Cochrane Database Syst Rev. 2017;(3):CD012286.

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Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre


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Expert commentary

It has been evidenced many times over that improved inhaler technique reduces exacerbation rates for both asthma and chronic obstructive pulmonary disease.As nurses and health professionals working clinically with these cohorts of patients, we cannot underestimate the benefit of taking the time to provide good education on how to administer inhalers correctly.As prescribers, it is indeed our responsibility to do so as per guidance both nationally within the United Kingdom and internationally. There are many resources available to us if we do not have these skills ourselves such as the video suite hosted by Asthma UK.Natalie Harper, Respiratory Advanced Nurse Practitioner; Asthma Lead, Association of Respiratory Nurse SpecialistsThe commentator declares no conflicting interests 
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