The gold standard for teaching inhaler technique is an intervention called TTG, which combines assessment and education through rounds of demonstration and patient teach-back. Essentially, the patient first shows the clinician how they use the device.4 The clinician (educator) then provides demonstration and verbal instruction that acknowledges what the patient did correctly while correcting any missteps. Then the patient performs teach-back, in which they again show the clinician how they will now use the device.

If further education is needed to correct ongoing missteps, the cycles of demonstration and teach-back can be completed until the patient is at goal. This technique can be used for both children and adults, although with younger children, the parents or guardians who will be involved in giving the child the medication will be the ones taught and assessed.

Pulmonology Advisor: What are additional research needs pertaining to inhaler misuse?

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Dr Press: Solutions that can be feasibly implemented across healthcare and home settings to provide patients with the skills they need to use their respiratory inhaler effectively. Because it is infeasible for all clinicians to become experts in providing this education to patients for all inhaler types, and time is often limited, innovative solutions are needed that can provide direct-to-patient education.

Virtual education strategies have been developed,7,8 but need further testing to confirm that these interventions are as effective as in-person education, can be readily implemented across settings, and improve patient outcomes, and to identify when virtual vs in-person education should be provided. Without large-scale real-world studies of inhaler education programs, it is likely that inhaler misuse will remain rampant for decades to come.


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2. Sanchis J, Gich I, Pedersen S; for the Aerosol Drug Management Improvement Team (ADMIT). Systematic review of errors in inhaler use: Has patient technique improved over time? CHEST. 2016;150(2):394-406.

3. Griffith MF, Feemster LC, Donovan LM, et al. Poor metered-dose inhaler technique is associated with overuse of inhaled corticosteroids in chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2019;16(6):765-768.

4. Volerman A, Toups MM, Hull A, Press VG. A feasibility study of a patient-centered educational strategy for rampant inhaler misuse among minority children with asthma. J Allergy Clin Immunol Pract. 2019;7(6):2028-2030.

5. 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 [published online August 16, 2019]. Ann Am Thorac Soc. doi:10.1513/annalsats.201906-445le

6. van der Palen J, Klein JJ, van Herwaarden CL, Zielhuis GA, Seydel ER. Multiple inhalers confuse asthma patients. Eur Respir J. 1999;14(5):1034-1037.

7. 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.

8. Thomas RM, Locke ER, Woo DM, et al. Inhaler training delivered by internet-based home videoconferencing improves technique and quality of life. Respir Care. 2017;62(11):1412-1422.