Original Article
Errors in the Use of Inhalers by Health Care Professionals: A Systematic Review

https://doi.org/10.1016/j.jaip.2017.12.032Get rights and content

Background

Inefficient inhaler technique (IT) compromises the optimal delivery of medication. However, the IT knowledge of health care professionals (HCPs) has received scant attention.

Objective

The objective of this study was to perform a systematic review of published reports assessing the IT proficiency of HCPs in using pressurized metered dose (pMDI) and dry powder (DPI) inhalers.

Methods

Studies published between 1975 and 2014 that directly assessed the IT skills of HCPs were selected according to predefined selection criteria.

Results

Data were extracted from 55 studies involving 6,304 HCPs who performed 9,996 tests to demonstrate their IT proficiency. Overall, the IT was considered correct in 15.5% of cases (95% confidence interval [CI], 12-19.3), decreasing over time from 20.5% (95% CI, 14.9-26.8) from the early period (defined as 1975-1995) to 10.8% (95% CI, 7.3-14.8) during the late period (1996-2014). The most common errors in the use of pMDIs were as follows: not breathing out completely before inhalation (75%; 95% CI, 56-90), lack of coordination (64%; 95% CI, 29-92), and postinhalation breath-hold (63%; 95% CI, 52-72). The most common errors using DPI were deficient preparation (89%; 95% CI, 82-95), not breathing out completely before inhalation (79%; 95% CI, 68-87), and no breath-hold (76%; 95% CI, 67-84).

Conclusions

HCPs demonstrated inadequate knowledge of the proper use of inhalers. The poor understanding of the correct use of these devices may prevent these professionals from being able to adequately assess and teach proper inhalation techniques to their patients.

Section snippets

Methods

The selection criteria and methods used in this review were similar to those of a recent systematic review conducted by members of our group.5 See https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=9347 for full details of the protocol.

Results

The electronic database searches yielded 404 articles on IT by HCPs. After removing duplicates and unrelated articles, articles not contributing new data or that did not evaluate overall technique were also excluded (Figure 1). After the full screening process was completed, a total of 55 articles met all inclusion criteria.18, 19, 20, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70

Discussion

This systematic review shows that a majority of HCPs involved in caring for patients with respiratory diseases exhibited poor knowledge of the inhalation technique for the main inhalers they prescribe, administer, or supervise. This is a clinically relevant deficiency. Moreover, the rate at which IT was correctly performed decreased considerably in the later years of the study period. Two of the most common IT errors observed in pMDI and DPI, respectively, were lack of coordination (step 3) and

Acknowledgements

We would like to thank Marta Pulido, MD, PhD, and Bradley Londres for their editorial assistance with this manuscript. V. Plaza was responsible for the conception and design of the study, coordination and supervision of all tasks, and writing of the manuscript; J. Giner was responsible for the search of databases, selection of studies and data extraction, development of the study database, and critical review of the manuscript for intellectual content; G. J. Rodrigo was responsible for the

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      In a study of patients with asthma under specialist care, inhaler technique was not checked in 80%.19 In a recent meta-analysis, only 15.5% of HCPs demonstrated proficiency in the use of metered dose inhalers and dry powder inhalers.20 Although most specialty and primary care HCPs agree that inhaler technique teaching is important, they may not be playing an active role to execute this at each visit due to lack of knowledge and training themselves and time constraints.19,20

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    No funding was received for this work.

    Conflicts of interest: The authors declare that they have no relevant conflicts of interest.

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