30 Days to Forget - Time Limit for Inhaler Instruction Retention

When patients fail to adhere to prescribed medical regimens, the fault lies as much with them as with healthcare providers (HCP).1 This is an unfortunate fact worth investigating. A recent study showed that only 37% of HCP provided written action plans and only 15% employed technology. It concluded that despite awareness of the SMART (single maintenance and reliever therapy) approach, HCP “generally do not employ standardised tools to monitor asthma control or to manage its treatment”.2

The role of the HCP is to ensure that the patient:
•  has the correct prescription
•  knows the purpose of the medications and how to use them
•  has a written Asthma Action Plan
•  is taught and instructed in the proper use of the inhaler
•  is taught how to avoid personal asthma triggers.

Once the HCP has done this, focus can shift to the patient’s role, which is to follow the required medical regimen.  

Most often, patients receive instructions from an HCP. But studies have shown that these instructions are not effective, since 40% to 80% of the information is forgotten immediately.3 What, then, is the most effective way to teach a patient how to use an inhaler? Proper inhaler use is a requirement for asthma control,4 because incorrect use can lead to

•  reduced efficacy
•  increased dosages of medication being prescribed
•  increased side effects
•  reduced control of the asthma
•  increased asthma exacerbations
•  increased need for acute care
•  escalated health care costs.

A systematic review of children with asthma found that their inhaler technique was poor. The review suggested that “Physicians and other members of the health care team should instruct children and their caregivers on the proper use of their inhalation devices at every opportunity and correct mistakes when made to ensure effective medication delivery”.5

Consider the basic difficulties involved when a patient is prescribed two inhalers, one an MDI and the other a DPI. The first requires a slow inhalation while the latter requires a quick inhalation. One requires shaking, while the other does not. Such a situation almost guarantees problems, confusion and errors in inhalation technique.

Instruction in the proper use of an MDI requires between 10 and 29 minutes, and instruction must be repeated regularly for patients to maintain and improve their technique.6 A randomized trial involving patients found that the greatest benefit was obtained with repeated instruction. 120 patients hospitalized for asthma or COPD in two urban medical centers were divided into two groups. One group received teach-to-goal or teach-back instruction in three separate sessions. The second group merely received brief instructions. However, despite the use of an effective teaching strategy, patients in the first teach-to-goal group forgot the correct steps for inhaler usage just as quickly as the second group! At the end of 30 days, there was no difference between the two groups, and misuse of the inhalers – both MDI and Diskus – was noted in both groups. It became clear that inhaler technique requires consistent, ongoing instruction for both retention in inhaler usage skills as well as improved health outcomes.7

Is the teach-back approach effective? In teach-back, the educator first demonstrates the use of an inhaler; then, the patient demonstrates its usage back to the educator. The educator corrects any mistakes, and the teach-back process repeats. This sequence continues until the patient can show that he knows how to use the inhaler correctly. This teaching strategy – of repeated instruction and testing – is also known as the ‘show-me’ approach. The patient’s memory is reinforced when she has to retrieve the information and teach someone else how to use the device, an approach also known as the “testing effect”. A systematic literature review confirmed this belief – it found that use of the teach-back approach significantly increased the correct use of an inhaler.8

A study of 491 individuals with asthma found that the following sequence was beneficial for patients:
•  a first-visit check of MDI inhalation technique and correction of mistakes
•  two following monthly visits that included inhaler counseling

In each case, the number of inhalation technique mistakes decreased as the number of visits increased. There was an added benefit of a significant improvement in pulmonary function in all age groups but particularly in those over the age of 60.9

Education in the use of an MDI can also aid health literacy. Inadequate health literacy has been associated with reduced control of asthma. In a study, 73 patients, of whom 16 were identified as having low health literacy, were taught how to use an MDI. A follow-up survey found that low health literacy was not associated with either learning or retention of the correct inhaler technique. Thus appropriate teaching can surmount barriers to learning and remembering essential asthma self-management skills.10

Healthcare professionals may assume that using an MDI is more difficult than using a DPI. A systematic review of the literature with respect to device effectiveness by Brocklebank and colleagues found no difference in clinical effectiveness between inhaler devices after patients were taught the correct technique.11 It would seem that effective teaching negates any possible difficulties with different inhalers.

Reinforcement does not have to wait for the next visit. Teaching aids are available on a number of web sites. The CDC’s National Asthma Control Program provides instructional videos and printable instructions that are designed for all patients,  including those with impairments in literacy, hearing, vision, or who speak Spanish. The National Jewish Health website has free patient education materials that may be downloaded. It also provides excellent videos showing how to use different inhalers.

In short ... The role of the healthcare professional is twofold when it comes to inhalers – first, ensure that the patient learns the initial correct inhaler technique, and secondly, review regularly to maintain the correct technique. Continuing review and correction over time is critical to helping patients maintain control over their asthma. Thus it becomes imperative that the HCP, should know how to use the different inhalers correctly. Unfortunately, this is generally not the case: studies have shown that few HCP provide correct inhaler instruction.12-14 Yet, when education on inhaler technique is consistently repeated, the proportion of patients who maintain correct technique improves.15,16

This is where a trained Asthma Educator can play a powerful role by both freeing the HCP from the time (almost 30 minutes) needed to provide patient education, and by providing that education correctly. Education should hence ideally be done by professional Asthma Educators who know how to effectively teach the use of the different inhalers.17

DPI       dry powder inhaler
HCP      healthcare provider(s)
MDI       metered dose inhaler
pMDI     pressurized metered dose inhaler (also called MDI)


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