Pharmacist-led education on inhaler technique improved the percentage of correct steps performed by patients with asthma or COPD treated in an outpatient clinic, but did not lead to any changes in inhaler adherence, according to Bianca Mayzel, PharmD.

For a study published in Hospital Pharmacy, Dr. Mayzel and colleagues conducted a small, prospective, non randomized, pre-test/post-test study to evaluate the effect that pharmacist education has on proper inhaler use and adherence in a teaching clinic setting. “The clinic provides multiple pharmacist-managed services, including medication therapy management,” Dr. Mayzel says. “The pharmacist within the clinic felt that chronic respiratory disease states and inhaler education was an area that could be improved. This pilot project was implemented to show the benefit pharmacists have on inhaler technique education.”

Pharmacists Corrected Any Mistakes and Gave Education on Proper Inhaler Use

More than half of participants were women (61%; mean age, 58) and African American (55%), and a little over half had asthma. The average number of inhalers per patient was 2.1. During the initial visit, patients underwent a baseline asthma control test (ACT) or COPD assessment test (CAT), Test of Adherence to Inhalers (TAI), and a baseline inhaler technique evaluation (performed for each inhaler used).

After the technique evaluation, the pharmacist corrected any mistakes and provided education on proper use of the inhaler and the patient repeated the steps (post-education technique evaluation #1). Patients who indicated adherence issues on the TAI were also assisted by the pharmacist in overcoming issues with inhaler access and cost until these issues were resolved. A follow-up visit took place 4-8 weeks after the initial visit, during which the baseline steps were repeated, including the technique evaluation (post-education technique evaluation #2).

Most Common Error During Evaluation Was Exhalation Before Inhalation

A statistically significant difference was observed when the percentage of correct steps before the education were compared with those after the education, both in the immediate period (evaluation #1) and during follow-up (evaluation #2). Before education was provided during the baseline evaluation, the median number of correct steps was 83% (interquartile range [IQR], 50% to 100%), which increased to a median of 100% during post-education evaluation #1 (IQR, 0; P<.00001) and remained a median of 100% during post-education evaluation #2 (IQR 83% to 100%; P=0.0022).

The most common inhaler technique error during baseline evaluation was exhalation before inhalation (21 occurrences), followed by the patient not holding their breath after inhalation (9 occurrences) and not rinsing out their mouth after using an inhaled corticosteroid (ICS) inhaler (4 occurrences).

Pharmacist-led education was found to increase the number of correct steps between baseline and post-education evaluation #1 across all inhaler types assessed, which predominantly included breath-activated, dry powder, metered dose, and soft mist inhalers. Only patients with breath-activated inhalers showed an improvement in inhaler technique between post-education evaluation #1 and #2, whereas patients using the other types of inhalers showed sustained inhaler technique from baseline to post-education evaluation #2 (Table).

Correct Inhaler Technique Can Be Challenging to Learn

When examining patients’ TAI scores, no significant difference was observed between their responses to individual questions or their overall scores between baseline and follow-up evaluations. The median TAI score was 44 at baseline (IQR, 34-47) and 43 at follow-up (IQR, 41-48).

“Correct inhaler technique is difficult for patients to achieve,” Dr. Mayzel notes. “Pharmacists embedded within primary care or specialty clinics can assist patients and their caregivers in teaching proper inhaler use and ensuring continued proper use.” She adds that larger studies are needed to determine whether any pharmacist-led educational efforts might also help improve inhaler adherence.