Guidelines recommend that healthcare providers (HCPs) assess and teach inhaler technique during all encounters with patients who have obstructive lung diseases like asthma or COPD, but recent research has shown that many patients are still misusing their devices. “Effective medications for these lung diseases are frequently delivered via inhalers, but patients often have difficulty using these devices correctly,” explains Valerie G. Press, MD, MPH. “The medications won’t work if they fail to enter the lungs via an inhaler.”

Studies suggest that inhaler misuse is a persistent and costly problem that has also been linked to worse symptom control, poorer quality of life, and greater acute care use. “Research shows that in-person patient education using teach-to-goal (TTG) methods, in which educators demonstrate how to use inhalers and then implement the teach-back method, are more effective than brief verbal instructions for improving inhaler technique,” Dr. Press says. “However, the TTG method is expensive and difficult to implement, highlighting the need for low-cost, easy-to-implement solutions.”

A Comparison of Approaches

A patient-derived virtual technology intervention was recently developed by Dr. Press and colleagues at the University of Chicago as a potential low-cost solution to assist with educating patients on inhaler technique. The virtual TTG (V-TTG) intervention consists of a module that is delivered using a handheld tablet (or any device that can receive email) with self-assessment questions before an inhaler demonstration, a narrated video that demonstrates the correct technique, and series of self-assessment questions for patients to answer after they participate in an inhaler demonstration.

For a study published in JAMA Open Network, Dr. Press and colleagues explored if the V-TTG intervention was as effective as in-person TTG education for improving inhaler technique among patients hospitalized with COPD. Among 118 participants, 59 received the V-TTG intervention and 59 received in-person TTG education. Both the V-TTG and in-person TTG groups received up to 3 rounds of their intervention as needed.

Key Study Findings

According to the results, the most common missed steps before patients received the V-TTG or TTG interventions included education on emptying lungs, emptying lungs away from the device, and breathing normally between puffs. After receiving either the V-TTG or TTG intervention, improvements were seen in these domains and others (Figure). Correct techniques increased similarly before versus after education interventions in both the V-TTG group (67%) and in-person TTG group (66%).

“The virtual intervention increased inhaler technique proficiency similarly to that of the well-validated in-person education,” says Dr. Press. “Of note, performance in inhaler technique for the V-TTG group declined by the same amount as the in-person TTG group in the month after discharge. This implies that skills learned with V-TTG may be as durable as those learned with in-person TTG. Importantly, the virtual intervention likely has significantly lower costs and time constraints in real-world settings when compared with costs for training and delivering in-person education in hospital and at home.”

Important Implications

Dr. Press says that a benefit of using the V-TTG intervention is that it may be repeated at home. “This virtual approach has potentially important implications for increasing access to high-quality patient education,” she says. “The V-TTG intervention can be used multiple times to ensure patients use their inhalers correctly. It also allows for ongoing refresher or practice education because it can be done in homes or other non-healthcare settings.”

Real-world studies are needed to test the feasibility of implementing the V-TTG intervention on a larger scale and to see if repeated administration improves long-term outcomes. “Effective patient-driven interventions that can work in any setting may help us improve how we treat patients with asthma and COPD,” Dr. Press says. “If the V-TTG intervention is shown to be feasible across a variety of patient populations and settings, it could transform our ability to deliver guideline-recommended education for inhalers and perhaps improve health outcomes and avoid exacerbations.”


Press VG, Arora VM, Kelly CA, Carey KA, White SR, Wan W. Effectiveness of virtual vs in-person inhaler education for hospitalized patients with obstructive lung disease: a randomized clinical trial. JAMA Netw Open. 2020;3(1):e1918205. Adapted from:

Press VG, Hasegawa K, Heidt J, Bittner JC, Camargo CA Jr. Missed opportunities to transition from nebulizers to inhalers during hospitalization for acute asthma: a multicenter observational study. J Asthma. 2017;54(9):968-976.

Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. J Gen Intern Med. 2011;26(6):635-642.

Press VG, Volerman A, Carpenter DM. Changing the course of the next 40 years: time to address rampant inhaler misuse using system-level educational solutions. Ann Am Thorac Soc. 2019;16(11):1459.

Press VG, Kelly CA, Kim JJ, White SR, Meltzer DO, Arora VM. Virtual teach-to-goal adaptive learning of inhaler technique for inpatients with asthma or COPD. J Allergy Clin Immunol Pract. 2017;5(4):1032-1039.e1.

Press VG, Arora VM, Trela KC, et al. Effectiveness of interventions to teach metered-dose and diskus inhaler techniques. a randomized trial. Ann Am Thorac Soc. 2016;13(6):816-824.