1. bookVolume 9 (2022): Issue 4 (December 2022)
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Frontiers of Nursing
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2544-8994
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Inhaler use in chronic obstructive pulmonary disease patients: a meta-analysis†

Li-Juan Zhou,
Li-Juan Zhou,
Xian-Xiu Wen,
Xian-Xiu Wen,
Rong Jiang,
Rong Jiang,
Huang-Yuan Zhou,
Huang-Yuan Zhou,
Yan Li,
Yan Li,
Xiao-Rang Mao and
Xiao-Rang Mao and
Mei Lan
Mei Lan
Published Online: 31 Dec 2022
Volume & Issue: Volume 9 (2022) - Issue 4 (December 2022)
Page range: 343 - 352
Received: 03 Apr 2022
Accepted: 31 Aug 2022
Frontiers of Nursing's Cover Image
Frontiers of Nursing
Journal Details
License
Format
Journal
eISSN
2544-8994
First Published
30 Mar 2018
Publication timeframe
4 times per year
Languages
English
Introduction

Chronic obstructive pulmonary disease (COPD) is a common clinical chronic disease that affects approximately 251 million people worldwide.1,2 To effectively manage acute exacerbations of COPD and slow down disease progression, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 guidelines recommended the use of long-acting toxic alkaloid antagonists (LAMA) and/or long-acting β2-agonists (LABA) as the primary maintenance therapy for COPD.3 LAMA and LABA drugs are delivered in high concentrations directly to the respiratory tract via inhalation therapy, which rapidly achieves pharmacological effects and reduces systemic side effects.3 Inhalation therapy, therefore, plays a vital role in the treatment of COPD.4–6 The main inhalation devices used in inhalation therapy include metered-dose inhalers (MDI), dry powder inhalers (DPI), and soft mist inhalers (SMI).7–12 Inhalation therapy plays a particularly vital role in treatment and each inhaler requires a correct inhalation technique to effectively deliver the drug to the lungs. Failure to operate the device correctly can increase the risk of disease progression, hospitalization frequency, and utilization of health resources, potentially leading to premature death. For inhaler handling technique evaluations, clinical staff assess the patient’s inhaler technique against an inhaler handling checklist. Previous authors have systematically evaluated DPIs.13 In addition, Navaie et al.14 conducted an error rate analysis of SMIs and Cho-Reyes et al.15 studied the incidence of inhaler use errors in the US population. Another study found that the type and number of common inhalant errors had not changed over the past 40 years.11

The rate of inhaler error remains an unresolved issue, as it is determined by several factors, including patient country, region, literacy, age, and training instructions. This paper examines the incidence of inhalation errors in COPD patients from 2011 to 2020 and explores the incidence of user errors for three types of inhalation devices. The objectives of this study are to conduct a meta-analysis to (1) understand the current incidence of inhaler errors, (2) provide an accurate assessment of patients, (3) identify effective interventions for improving drug efficacy and reducing the incidence of adverse inhalation techniques, and (4) utilize the published literature to provide research-based evidence for future instruction of patients’ use of inhalers.
Methods

For the meta-analysis, studies were included if they met the following criteria: (1) Study type published: domestic and international studies on the error rate of inhaler handling in patients with COPD, including cross-sectional studies, observational studies, and randomized controlled studies; (2) Study population: adults >18 years of age diagnosed with COPD; (3) Observation indicator: use of at least one or more inhalation agents; (4) Outcome indicator: incidence of inhaler handling errors; (5) Study publication period: January 2011 to October 2020; and (6) Language: English or Chinese.

Studies were excluded using the following criteria: (1) COPD inhaler use without separate listings of outcome measurements; (2) incorrect, incomplete, or unavailable raw data; and (3) abstracts, reviews, and case reports.

Literature search strategy

Computer searches were conducted at PubMed, Embase, Web of Science, Cochrane Library, CINAHL, CNKI, WanFang, VIP, and SionMed databases using a combination of subject terms and free words. English search terms included chronic obstructive pulmonary disease, acute exacerbation of chronic obstructive pulmonary disease, COPD, inhalant, and inhaler. Chinese search terms included Chronic Obstructive Lung Disease, Chronic Obstructive Pulmonary Diseases, COAD, COPD, Chronic Obstructive Airway Disease, Chronic Obstructive Pulmonary Disease, Airflow Obstruction, Chronic, Airflow Obstructions, Chronic, Chronic Airflow Obstructions, Chronic Airflow Obstruction, Vaporizers and Nebulizers, Inhaler, Metered Dose, Metered Dose Inhaler, MDI (Inhalers), Inhalers, Metered Dose, Spacer Inhalers, Spacer Inhaler, Spacer-Inhalers, Spacer-Inhaler, Spinhalers, Spinhaler, cVaporizer, Inhalers, Inhaler, Inhalators, Inhalator, Nebulizers, Nebulizer, Atomizers, Atomizer, Inhalation Devices, Device, Inhalation, Devices, Inhalation, Inhalation Device, Relative risk, Error, Inaccuracy, Mistake, Misconfiguration, Improper, serious error, incorrect; error rate; failure rate; operation error; influencing factor; associated factor; risk factor. As an example, the search strategy used in PubMed is provided in Box 1.
Literature screening and data extraction

Reviewing the literature to screen articles for inclusion in the study began with two researchers conducting a pre-review of 3 articles to ensure consistency in the literature screening and quality assessment. After both researchers determined the article selection process was consistent, all references were imported into Endnote software to eliminate duplicates, screen articles to assess their quality and relevance, extract data, and cross-check the results of the researchers. Any inconsistencies that arose were resolved through discussion. The researchers extracted the following information: (1) citation data (e.g., basic information: title, first author, date, country of publication); (2) type of study design; (3) study population (e.g., gender, age, number of cases included, type of inhaler); and (4) study outcomes, particularly the incidence of errors.

PubMed search strategy.

#1 Chronic Obstructive Pulmonary Diseases OR COPD OR Chronic Obstructive Airway Disease OR Chronic Obstructive Airway Disease OR Airflow Obstruction, Chronic OR Airflow Obstructions, Chronic OR Chronic Airflow Obstructions AND Chronic Airflow Obstruction OR Pulmonary Disease, Chronic Obstructive

#2 Vaporizer OR Inhalers OR Inhaler OR Inhalators OR Inhalator OR Nebulizers OR Nebulizer OR Atomizers OR Atomizer OR Inhalation Devices OR Device, Inhalation OR Devices, Inhalation OR Inhalation Device OR Nebulizers and Vaporizers

#3 Risk factor OR Relevant factor OR Relate* factor* OR Influenc* factor*OR Error OR Inaccuracy OR Mistake OR Misconfiguration OR Improper OR serious error OR incorrect OR error rate OR failure rate

#1AND #2 AND#3
Evaluation of risk of bias in included studies

The researchers evaluated the risk of bias using appropriate methods based on study type. Randomized controlled studies were evaluated using the Cochrane Collaboration Risk of Bias Tool, cross-sectional studies were evaluated using the Joanna Briggs Institute (JBI)-developed risk of bias criteria for cross-sectional studies, and cohort studies were evaluated using the Newcastle–Ottawa quality scale (NOS).
Statistical analysis

Clinical symptoms and laboratory results were compiled using Microsoft Excel 2016 version software and a single-arm meta-analysis of the included literature was performed via Stata 15.1. Study heterogeneity was determined using Cochran’s chi-square test and I2-test. When I2 <50%, it indicates a small heterogeneity among the studies, and a fixed-effects model was used for analysis. When I2 >50%, it indicates a large heterogeneity among the studies, and a random-effects model was selected for analysis, and further subgroup and sensitivity analyses were used to determine the source of heterogeneity. If the number of meta-analysis studies was ≥10, funnel plots and Egger’s test were used to detect the presence of publication bias.
Results
Literature search and study selection

A preliminary literature search involved screening 1024 published articles for inclusion in the current study: 821 were in English and 203 in Chinese. After stratification screening, 13 studies were selected, including 5 cohort studies,16–20 7 cross-sectional studies,8,21–26 and 1 randomized controlled study,27 with a total of 2499 study subjects. The literature screening process is shown in Figure 1.

Figure 1.

Literature search and selection.
Basic characteristics of studies included

Table 1 provides the basic characteristics of the selected studies, including the type of study, country, percentage of females, age, number of cases, and inhaler type. The present study included 2527 cases, with females representing 42.1% of the study population.

Clinical characteristics of included trials.

Inclusion of studiesType of studyCountryPercentage of women (%)Age (years) mean (+SD/range)Total number of people (n)Type of inhaler used
Loukil et al16CohortSpanish48.247.4 ± 16.354DPI
Gillissen et al.17CohortGermany44.665.6 ± 11.61236DPI
Lin et al18CohortChina36.867 ± 15136DPI, MDI
Li et al.19CohortChina33.164 (47–81)384DPI
Takaku et al.20CohortJapan9.072 ± 781MDI, DPI
Ngo et al21Cross-sectionalVietnam7.068.6 ± 8.770MDI, DPI, SMI
Bournival et al.22Cross-sectionalCanada49.069.8 ± 8.398DPI, SMI
Al Ammari et al.23Cross-sectionalSaudi Arabia48.958.4 ± 17.940MDI
Castel-Branco et al.24Cross-SectionalPortugal49.365.4 ± 18.3895DPI, MDI, SMI
Pothirat et al.8Cross-sectionalThailand35.971.2 ± 9.2103DPI, MDI, SMI
Ding et al.25Cross-sectionalAmerica48.0Men: 59.8 ± 10.2; Women: 60.7 ± 7.861MDI, SMI
Press et al.26Cross-SectionalAmerica58.659.229MDI
Oliveira et al.27RCTBrazil44.063.5 ± 8.2140DPI, SMI

Note: DPI, dry powder inhaler; MDI, metered dose inhaler; SMI, soft mist inhaler; ROC, randomised clinical trail.

The NOS scale was divided into eight items in the areas of study population selection, comparability, and outcome evaluation to determine the risk of bias in cohort studies. The quality of the scale was considered to be of (1) good quality when the study population selection was 3 or 4 stars (*), comparability was 1 or 2 stars, outcome evaluation was 2 stars; (2) fair quality when the population selection was 2 stars, outcome evaluation was 2 stars, population selection was 2 stars, comparability was 1 or 2 stars, and outcome evaluation was 2 or 3 stars; and (3) poor quality when the population selection was 0 or 1 stars, comparability was 0 stars, and outcome evaluation was 0 or 1 stars (Table 2).

Results of risk of bias evaluation of the included literature by NOS score.

Inclusion of studiesStudy population selectionComparability of resultsEvaluation of outcomes
Loukil et al.16*******
Gillissen et al.17********
Lin et al.18******
Li et al.19*******
Takaku et al.20*******

Note: NOS, Newcastle–Ottawa quality scale.

Table 3 shows the results of the JBI cross-sectional study risk of bias evaluation. A risk of bias score >70% in the JBI cross-sectional survey is considered low. The results of the randomized controlled study risk of bias evaluation are shown in Figure 2.

Results of the JBI cross-sectional survey bias risk assessment.

Inclusion in the studyRationale for the titlePopulation selectionExclusion criteriaSample characteristicsInstrument reliability and validity testsVeracityEthical principlesStatistical methods StudyStudy resultsStudy valueTotal score
Ngo et al.21②①②①①②②②②②17
Bournival et al.22②①①①NA②①②②②14
Al Ammari et al.23②①①①NA②②②②②15
Castel-Branco et al.24②①①①NA②②②②②15
Pothirat et al.8②①①①NA②②②②②15
Ding et al.25②①①①NA②NA②②②13
Press et al.26②①①①①②②②②②16

Note: “②” is 2 marks for a detailed and comprehensive description; “①” is 1 mark for mentioning but not describing in detail; “NA” is 0 mark for not meeting the requirements.

Figure 2.

Results of risk bias evaluation of randomized controlled studies.

Good quality: 3 or 4 stars (*) selected in the study population, 1 or 2 stars for comparability and 2 stars for outcome assessment; fair quality: 2 stars selected in the study population, 1 or 2 stars for comparability and 2 or 3 stars for outcome assessment; poor quality: 0 or 1 star selected in the study population, 0 stars for comparability and 0 or 1 star for outcome assessment.
Inhalant use

Analysis of 13 studies reporting on inhaler use in COPD patients revealed that 76% (95% CI: 0.69–0.83) of patients made at least one handling error (Figure 3). Significant heterogeneity was observed in all included studies, with I2 = 93.6%, heterogeneity chi-square = 188.49, df = 12, and P = 0.000. Sensitivity analysis showed that with four studies17,19,20,22 sequentially excluded, the combined effect sizes decreased to 86.6% (95% CI: 0.85–0.88), 76.5% (95% CI: 0.75–0.78), 83.1% (95% CI: 0.82–0.85), 83.3% (95% CI: 0.82–0.85).

Figure 3.

Forest plots of error rates for at least 1 inhaler.
Subgroup and sensitivity analyses

The included studies were subjected to subgroup analysis according to different countries, study types, years of publication, and inhaler types. The greatest change in heterogeneity was when study types were subjected to subgroup analysis. Among them, forest plots of seven cross-sectional studies for inhalant use error rates showed I2 = 57.2%, heterogeneity chi-square = 14.01, df = 6, P = 0.030. Excluding each cross-sectional study in turn, only excluding Castel-Branco et al.24 resulted in no heterogeneity, with a combined effect size = 71%, 95% CI: 0.66–0.76, I2 = 0%; heterogeneity chi-square = 3.69, df = 5, P = 0.594, see (Figure 4). Therefore, it was determined that Castel-Branco et al.24 was the main source of heterogeneity in the cross-sectional studies.

Figure 4.

A cross-sectional forest map of the error rates of different inhalants.

Analysis of DPI, MDI, and SMI revealed incorrect use of rates of >50% for all inhaler types. DPI use was reported in 9 of the 13 included studies, and meta-analysis using a random effects model showed that 66% (95% CI: 0.57, 0.74) of patients used it incorrectly (Figure 5). Seven studies reported on MDI use, and meta-analysis using a random-effects model showed that 67% (95% CI: 0.57, 0.77) of patients used it incorrectly (Figure 6). Six of the included studies reported on SMI use and the results of meta-analysis using a random effects model showed that 51% (95% CI: 0.38, 0.64) of patients used it incorrectly (Figure 7).

Figure 5.

Forest plot of error rates for use. Abbreviation: DPI, dry powder inhaler.

Figure 6.

Forest plot of error rates for quantified inhaler use.

Figure 7.

Forest plot of errors in SMI use. Abbreviation: SMI, soft mist inhalers.
Publication bias

To check for potential publication bias, Begg’s and Egger’s tests were performed to quantitatively assess the symmetry of the funnel plots (Figure 8). The Begg’s rank correlation test (P = 0.304) and Egger’s test (P = 0.223) showed that differences were not statistically significant and no publication bias was present.

Figure 8.

Funnel plot of at least 1 inhaler error made.
Discussion

This study found that 76% of patients made at least one inhaler error and that the rate of MDI handling errors was greater than the rate of DPI and SMI handling errors. MDIs have a high rate of oropharyngeal hyper-deposition and require coordination between drive and inspiration.11 DPIs require high inspiratory flow rates and the effects of humidity, which have an impact on dose accuracy.13 Overall, the operational steps of “hand-lung coordination”, “exhaling all the air,” “holding the breath,” and “slow and deep inhalation” were the most common errors. Approximately 60% of patients failed to hold their breath as required or had difficulty in hand-to-mouth coordination, and approximately 50% of patients fail to exhale and inhale slowly and deeply. Analysis of SMI errors showed that the step to “inhale slowly and deeply and press the dose release button while inhaling” resulted in the highest number of errors, which is consistent with reports of simultaneous inhalation and dose release of MDIs.11,28,29 SMIs have been shown to emit medication more slowly and the aerosols produced last 4–10 times longer than aerosols in pressurized dose inhalers, releasing a higher proportion of the dose into the lungs.30–32 Also, SMI lung deposition is greater than with DPIs.33

The three inhalers evaluated differ in their technical operation and how they function. As a result, patient preferences for inhaler type vary. More importantly, the patient’s preference for the device is closely related to his or her compliance with the inhaler.22,27 Therefore, the clinician’s choice of inhalation device should be based on the characteristics of the inhalation device, the patient’s ability to use the device, and the patient’s preference. COPD disease control, disease progression, and health care costs are influenced by patients’ inhalation techniques.11,23,33 Therefore, appropriate inhaler equipment, ongoing educational interventions, and regular supervision are essential to reduce disease exacerbation and improve quality of life. In-person demonstration and training will improve the accuracy of patient inhaler use,25 permitting medical staff to observe patient inhalation technique handling and enhancing patient education on inhaler technique. By increasing patient knowledge related to inhalation techniques, incorrect inhalation techniques of patients can be corrected. This will reduce the incidence of errors and increase the effectiveness of inhalation medication, reducing the hospitalization rates of COPD patients. At present, there are a large number of COPD patients and very few of them are educated adequately about the disease or properly trained in inhalation techniques. In the future, electronically monitored inhalation devices may provide an effective solution to the challenges of educating patients with chronic disease due to limited health care resources. Regardless, there remains a pressing need for research that improves our understanding of the risk factors that affect correct inhalation by patients, identifies high-risk groups, and objectively determines the risk of inhalation errors in patients, which is essential in terms of optimizing device selection and disease control.
Conclusions

Although this meta-analysis provides important data for addressing inhalation errors in COPD, there are limitations to this study which should be noted: (1) subjectivity in the assessment of patients inhalation technique and patient-reported bias may have influenced the results; (2) reasons for device use errors were only analyzed for patients, as clinicians, nurses, and pharmacists were not included in the analysis; (3) the sample size was relatively small and only literature published in English and Chinese was considered; (4) inclusion of different countries, study types, literacy levels, inhaler types, and COPD patient disease classifications may have influenced the inhaler technique error rate results. Therefore, researchers in all countries are encouraged to conduct additional studies with larger sample size and more detailed analyses to improve the efficacy of inhaler use and inform the development of electronically monitored inhalation devices.

Figure 1.

Literature search and selection.
Literature search and selection.

Figure 2.

Results of risk bias evaluation of randomized controlled studies.
Results of risk bias evaluation of randomized controlled studies.

Figure 3.

Forest plots of error rates for at least 1 inhaler.
Forest plots of error rates for at least 1 inhaler.

Figure 4.

A cross-sectional forest map of the error rates of different inhalants.
A cross-sectional forest map of the error rates of different inhalants.

Figure 5.

Forest plot of error rates for use. Abbreviation: DPI, dry powder inhaler.
Forest plot of error rates for use. Abbreviation: DPI, dry powder inhaler.

Figure 6.

Forest plot of error rates for quantified inhaler use.
Forest plot of error rates for quantified inhaler use.

Figure 7.

Forest plot of errors in SMI use. Abbreviation: SMI, soft mist inhalers.
Forest plot of errors in SMI use. Abbreviation: SMI, soft mist inhalers.

Figure 8.

Funnel plot of at least 1 inhaler error made.
Funnel plot of at least 1 inhaler error made.

Results of the JBI cross-sectional survey bias risk assessment.

Inclusion in the study Rationale for the title Population selection Exclusion criteria Sample characteristics Instrument reliability and validity tests Veracity Ethical principles Statistical methods Study Study results Study value Total score
Ngo et al.21 ② ① ② ① ① ② ② ② ② ② 17
Bournival et al.22 ② ① ① ① NA ② ① ② ② ② 14
Al Ammari et al.23 ② ① ① ① NA ② ② ② ② ② 15
Castel-Branco et al.24 ② ① ① ① NA ② ② ② ② ② 15
Pothirat et al.8 ② ① ① ① NA ② ② ② ② ② 15
Ding et al.25 ② ① ① ① NA ② NA ② ② ② 13
Press et al.26 ② ① ① ① ① ② ② ② ② ② 16

Results of risk of bias evaluation of the included literature by NOS score.

Inclusion of studies Study population selection Comparability of results Evaluation of outcomes
Loukil et al.16 *** ** **
Gillissen et al.17 **** ** **
Lin et al.18 ** ** **
Li et al.19 ** ** ***
Takaku et al.20 *** ** **

Clinical characteristics of included trials.

Inclusion of studies Type of study Country Percentage of women (%) Age (years) mean (+SD/range) Total number of people (n) Type of inhaler used
Loukil et al16 Cohort Spanish 48.2 47.4 ± 16.3 54 DPI
Gillissen et al.17 Cohort Germany 44.6 65.6 ± 11.6 1236 DPI
Lin et al18 Cohort China 36.8 67 ± 15 136 DPI, MDI
Li et al.19 Cohort China 33.1 64 (47–81) 384 DPI
Takaku et al.20 Cohort Japan 9.0 72 ± 7 81 MDI, DPI
Ngo et al21 Cross-sectional Vietnam 7.0 68.6 ± 8.7 70 MDI, DPI, SMI
Bournival et al.22 Cross-sectional Canada 49.0 69.8 ± 8.3 98 DPI, SMI
Al Ammari et al.23 Cross-sectional Saudi Arabia 48.9 58.4 ± 17.9 40 MDI
Castel-Branco et al.24 Cross-Sectional Portugal 49.3 65.4 ± 18.38 95 DPI, MDI, SMI
Pothirat et al.8 Cross-sectional Thailand 35.9 71.2 ± 9.2 103 DPI, MDI, SMI
Ding et al.25 Cross-sectional America 48.0 Men: 59.8 ± 10.2; Women: 60.7 ± 7.8 61 MDI, SMI
Press et al.26 Cross-Sectional America 58.6 59.2 29 MDI
Oliveira et al.27 RCT Brazil 44.0 63.5 ± 8.2 140 DPI, SMI

World Health Organization. Chronic obstructive pulmonary disease (COPD). 2018. http://www.who.int/mediacentre/factsheets/fs315/en/. Accessed April 20, 2021. World Health Organization . Chronic obstructive pulmonary disease (COPD) . 2018 . http://www.who.int/mediacentre/factsheets/fs315/en/. Accessed April 20, 2021. Search in Google Scholar

Rabe KF, Watz H. Chronic obstructive pulmonary disease. Lancet. 2017;389:1931–1940. Rabe KF Watz H. Chronic obstructive pulmonary disease . Lancet. 2017 ; 389 : 1931 – 1940 . 10.1016/S0140-6736(17)31222-928513453 Search in Google Scholar

2020 Global Strategy for Prevention, Diagnosis and Management of COPD. http://gold-copd.org/gold-reports/. Accessed April 20, 2021. 2020 Global Strategy for Prevention, Diagnosis and Management of COPD . http://gold-copd.org/gold-reports/. Accessed April 20, 2021. Search in Google Scholar

Newman SP. Inhaler treatment options in COPD. Eur Respir Rev. 2005;14:102–108. Newman SP . Inhaler treatment options in COPD . Eur Respir Rev. 2005 ; 14 : 102 – 108 . 10.1183/09059180.05.00009605 Search in Google Scholar

Capstick TG, Clifton IJ. Inhaler technique and training in people with chronic obstructive pulmonary disease and asthma. Expert Rev Respir Med. 2012;6:91–101. Capstick TG Clifton IJ . Inhaler technique and training in people with chronic obstructive pulmonary disease and asthma . Expert Rev Respir Med. 2012 ; 6 : 91 – 101 . 10.1586/ers.11.8922283582 Search in Google Scholar

Sheikh K, Coxson HO, Parraga G. This is what COPD looks like. Respirology. 2016;21:224–236. Sheikh K Coxson HO Parraga G . This is what COPD looks like . Respirology. 2016 ; 21 : 224 – 236 . 10.1111/resp.1261126333307 Search in Google Scholar

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;13:816–824. 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 : 816 – 824 . 10.1513/AnnalsATS.201509-603OC501892326998961 Search in Google Scholar

Pothirat C, Chaiwong W, Phetsuk N, Pisalthanapuna S, ChetsadaphanN, Choomuang W. Evaluating inhaler use technique in COPD patients. Int J Chron Obstruct Pulmon Dis. 2015;10:1291–1298. Pothirat C Chaiwong W Phetsuk N Pisalthanapuna S Chetsadaphan N Choomuang W . Evaluating inhaler use technique in COPD patients . Int J Chron Obstruct Pulmon Dis. 2015 ; 10 : 1291 – 1298 . 10.2147/COPD.S85681450144626185435 Search in Google Scholar

Press VG, Arora VM, Shah LM, et al. Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: a randomized trial. J Gen Intern Med. 2012;27:1317–1325. Press VG Arora VM Shah LM et al. Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: a randomized trial . J Gen Intern Med. 2012 ; 27 : 1317 – 1325 . 10.1007/s11606-012-2090-9344567922592354 Search in Google Scholar

Press VG, Arora VM, Shah LM, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. J Gen Intern Med. 2011;26:635–642. 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 : 635 – 642 . 10.1007/s11606-010-1624-2310198221249463 Search in Google Scholar

Sanchis J, Gich I, Pedersen S. Aerosol drug management improvement team (ADMIT). systematic review of errors in inhaler use: has patient technique improved over time? Chest. 2016;150:394–406. Sanchis J Gich I Pedersen S . Aerosol drug management improvement team (ADMIT). systematic review of errors in inhaler use: has patient technique improved over time? Chest. 2016 ; 150 : 394 – 406 . 10.1016/j.chest.2016.03.041 Search in Google Scholar

Thomas RM, Locke ER, Woo DM, et al. Inhaler training delivered by internet-based home video-conferencing improves technique and quality of life. Respir Care. 2017;62:1412–1422. Thomas RM Locke ER Woo DM et al. Inhaler training delivered by internet-based home video-conferencing improves technique and quality of life . Respir Care. 2017 ; 62 : 1412 – 1422 . 10.4187/respcare.05445637385028720676 Search in Google Scholar

Lavorini F, Magnan A, Dubus JC, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med. 2008;102:593–604. Lavorini F Magnan A Dubus JC et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD . Respir Med. 2008 ; 102 : 593 – 604 . 10.1016/j.rmed.2007.11.00318083019 Search in Google Scholar

Navaie M, Dembek C, Cho-Reyes S, Yeh K, Celli BR. Device use errors with soft mist inhalers: a global systematic literature review and meta-analysis. Chron Respir Dis. 2020;17:1479973119901234. Navaie M Dembek C Cho-Reyes S Yeh K Celli BR . Device use errors with soft mist inhalers: a global systematic literature review and meta-analysis . Chron Respir Dis. 2020 ; 17 : 1479973119901234 . 10.1177/1479973119901234698597731984767 Search in Google Scholar

Cho-Reyes S, Celli BR, Dembek C, Yeh K, Navaie M. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of U.S. studies. Chronic Obstr Pulm Dis. 2019;6:267–280. Cho-Reyes S Celli BR Dembek C Yeh K Navaie M . Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of U.S. studies . Chronic Obstr Pulm Dis. 2019 ; 6 : 267 – 280 . 10.15326/jcopdf.6.3.2018.0168 Search in Google Scholar

Loukil M, Mejri I, Khalfallah I, Ghrairi H. Evaluation of inhaler techniques in patients with asthma and chronic obstructive disease. Rev Pneumol Clin. 2018;74:226–234 (in French). Loukil M Mejri I Khalfallah I Ghrairi H . Evaluation of inhaler techniques in patients with asthma and chronic obstructive disease . Rev Pneumol Clin. 2018 ; 74 : 226 – 234 (in French). 10.1016/j.pneumo.2018.04.00130031594 Search in Google Scholar

Gillissen A, Gessner C, Hechenbichler K, et al. Patient satisfaction and clinical outcomes with budesonide plus formoterol spiromax for asthma and chronic obstructive pulmonary disease: A real-world, observational trial. Respiration. 2019;97:292–301. Gillissen A Gessner C Hechenbichler K et al. Patient satisfaction and clinical outcomes with budesonide plus formoterol spiromax for asthma and chronic obstructive pulmonary disease: A real-world, observational trial . Respiration. 2019 ; 97 : 292 – 301 . 10.1159/00049386030391944 Search in Google Scholar

Lin Q, Dai WS, Zhang WY. Pharmacy education on the use of dry powder inhalers in outpatients with COPD. Strait Pharmacy. 2013;25:205–207. Lin Q Dai WS Zhang WY . Pharmacy education on the use of dry powder inhalers in outpatients with COPD . Strait Pharmacy. 2013 ; 25 : 205 – 207 . Search in Google Scholar

Li H, Chen Y, Zhang Z, Dong X, Zhang G, Zhang H. Handling of Diskus dry powder inhaler in Chinese chronic obstructive pulmonary disease patients. J Aerosol Med Pulm Drug Deliv. 2014;27: 219–227. Li H Chen Y Zhang Z Dong X Zhang G Zhang H . Handling of Diskus dry powder inhaler in Chinese chronic obstructive pulmonary disease patients . J Aerosol Med Pulm Drug Deliv. 2014 ; 27 : 219 – 227 . 10.1089/jamp.2012.103323905575 Search in Google Scholar

Takaku Y, Kurashima K, Ohta C, et al. How many instructions are required to correct inhalation errors in patients with asthma and chronic obstructive pulmonary disease? Respir Med. 2017;123:110–115. Takaku Y Kurashima K Ohta C et al. How many instructions are required to correct inhalation errors in patients with asthma and chronic obstructive pulmonary disease? Respir Med. 2017 ; 123 : 110 – 115 . 10.1016/j.rmed.2016.12.01228137486 Search in Google Scholar

Ngo CQ, Phan DM, Vu GV, et al. Inhaler technique and adherence to inhaled medications among patients with acute exacerbation of chronic obstructive pulmonary disease in Vietnam. Int J Environ Res Public Health. 2019;16:185. Ngo CQ Phan DM Vu GV et al. Inhaler technique and adherence to inhaled medications among patients with acute exacerbation of chronic obstructive pulmonary disease in Vietnam . Int J Environ Res Public Health. 2019 ; 16 : 185 . 10.3390/ijerph16020185635193230634631 Search in Google Scholar

Bournival R, Coutu R, Goettel N, et al. Preferences and inhalation techniques for inhaler devices used by patients with chronic obstructive pulmonary disease. J Aerosol Med Pulm Drug Deliv. 2018;31: 237–247. Bournival R Coutu R Goettel N et al. Preferences and inhalation techniques for inhaler devices used by patients with chronic obstructive pulmonary disease . J Aerosol Med Pulm Drug Deliv. 2018 ; 31 : 237 – 247 . 10.1089/jamp.2017.140929206566 Search in Google Scholar

Al Ammari M, Sultana K, Yunus F, Al Ghobain M, Al Halwan SM. A cross-sectional observational study to assess inhaler technique in Saudi hospitalized patients with asthma and chronic obstructive pulmonary disease. Saudi Med J. 2016; 37: 570–574. Al Ammari M Sultana K Yunus F Al Ghobain M Al Halwan SM . A cross-sectional observational study to assess inhaler technique in Saudi hospitalized patients with asthma and chronic obstructive pulmonary disease . Saudi Med J. 2016 ; 37 : 570 – 574 . 10.15537/smj.2016.5.14369488065927146622 Search in Google Scholar

Castel-Branco MM, Fontes A, Figueiredo IV. Identification of inhaler technique errors with a routine procedure in Portuguese community pharmacy. Pharm Pract (Granada). 2017;15:1072. Castel-Branco MM Fontes A Figueiredo IV . Identification of inhaler technique errors with a routine procedure in Portuguese community pharmacy . Pharm Pract (Granada). 2017 ; 15 : 1072 . 10.18549/PharmPract.2017.04.1072574200029317923 Search in Google Scholar

Ding B, Siddiqui S, DePietro M, Petersson G, Martin UJ. Inhaler usability of a pressurized metered dose inhaler and a soft mist inhaler in patients with COPD: a simulated-use study. Chron Respir Dis. 2019;16:1479972318787914. Ding B Siddiqui S DePietro M Petersson G Martin UJ . Inhaler usability of a pressurized metered dose inhaler and a soft mist inhaler in patients with COPD: a simulated-use study . Chron Respir Dis. 2019 ; 16 : 1479972318787914 . 10.1177/1479972318787914630296930016880 Search in Google Scholar

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: 1032–1039. 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 : 1032 – 1039 . 10.1016/j.jaip.2016.11.018549827628065689 Search in Google Scholar

Oliveira MVC, Pizzichini E, da Costa CH, et al. Evaluation of the preference, satisfaction and correct use of Breezhaler® and Respimat® inhalers in patients with chronic obstructive pulmonary disease – INHALATOR study. Respir Med. 2018;144:61–67. Oliveira MVC Pizzichini E da Costa CH et al. Evaluation of the preference, satisfaction and correct use of Breezhaler® and Respimat® inhalers in patients with chronic obstructive pulmonary disease – INHALATOR study . Respir Med. 2018 ; 144 : 61 – 67 . 10.1016/j.rmed.2018.10.00630366585 Search in Google Scholar

Yawn BP, Colice GL, Hodder R. Practical aspects of inhaler use in the management of chronic obstructive pulmonary disease in the primary care setting. Int J Chron Obstruct Pulmon Dis. 2012;7:495–502. Yawn BP Colice GL Hodder R . Practical aspects of inhaler use in the management of chronic obstructive pulmonary disease in the primary care setting . Int J Chron Obstruct Pulmon Dis. 2012 ; 7 : 495 – 502 . 10.2147/COPD.S32674341317622888221 Search in Google Scholar

Vincken W, Dekhuijzen PR, Barnes P, Group A. The ADMIT series – Issues in inhalation therapy. 4) How to choose inhaler devices for the treatment of COPD. Prim Care Respir J. 2010;19:10–20. Vincken W Dekhuijzen PR Barnes P Group A . The ADMIT series – Issues in inhalation therapy. 4) How to choose inhaler devices for the treatment of COPD . Prim Care Respir J. 2010 ; 19 : 10 – 20 . 10.4104/pcrj.2009.00062682761419890594 Search in Google Scholar

Newman SP, Steed KP, Reader SJ, Hooper G, Zierenberg B. Efficient delivery to the lungs of flunisolide aerosol from a new portable handheld multidose nebulizer. J Pharm Sci. 1996;85:960–964. Newman SP Steed KP Reader SJ Hooper G Zierenberg B . Efficient delivery to the lungs of flunisolide aerosol from a new portable handheld multidose nebulizer . J Pharm Sci. 1996 ; 85 : 960 – 964 . 10.1021/js950522q8877887 Search in Google Scholar

Newman SP, Brown J, Steed KP, Reader SJ, Kladders H. Lung deposition of fenoterol and flunisolide delivered using a novel device for inhaled medicines: Comparison of Respimat with conventional metered-dose inhalers with and without spacer devices. Chest. 1998;113:957–963. Newman SP Brown J Steed KP Reader SJ Kladders H . Lung deposition of fenoterol and flunisolide delivered using a novel device for inhaled medicines: Comparison of Respimat with conventional metered-dose inhalers with and without spacer devices . Chest. 1998 ; 113 : 957 – 963 . 10.1378/chest.113.4.9579554631 Search in Google Scholar

Pitcairn G, Reader S, Pavia D, Newman S. Deposition of corticosteroid aerosol in the human lung by Respimat® Soft Mist™ Inhaler compared to deposition by metered dose inhaler or by Turbuhaler® dry powder inhaler. J Aerosol Med. 2005;18: 264–272. Pitcairn G Reader S Pavia D Newman S . Deposition of corticosteroid aerosol in the human lung by Respimat® Soft Mist™ Inhaler compared to deposition by metered dose inhaler or by Turbuhaler® dry powder inhaler . J Aerosol Med. 2005 ; 18 : 264 – 272 . 10.1089/jam.2005.18.26416181001 Search in Google Scholar

Rönmark P, Jagorstrand B, Safioti G, Menon S, Bjermer L. Comparison of correct technique and preference for Spiromax®, Easyhaler® and Turbuhaler®: A single-site, single-visit, crossover study in inhalernaïve adult volunteers. Eur Clin Respir J. 2018, 5:1529536. Rönmark P Jagorstrand B Safioti G Menon S Bjermer L . Comparison of correct technique and preference for Spiromax®, Easyhaler® and Turbuhaler®: A single-site, single-visit, crossover study in inhalernaïve adult volunteers . Eur Clin Respir J. 2018 , 5 : 1529536 . 10.1080/20018525.2018.1529536620181430370020 Search in Google Scholar

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