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

Purpose Of the Study: The authors aimed to systematically review studies of health care provider (HCP) inhaler technique proficiency. Study Population: The study included all original research articles published from 1975 to 2014 in which researchers evaluate HCP inhaler technique. Methods: Articles were selected by a systematic search of PubMed Medline. Analyses were conducted following published guidelines. They evaluated proficiency and compared differences in proficiency by type of HCP and by time (divided as 1975–1995 and 1996–2014). The types of errors were classified by inhaler type and HCP type (subspecialist and primary care physician or medical student, respiratory therapist, nurses or nursing students, and pharmacists or pharmacist students or technicians). They categorized inhalers into 3 categories: (1) pressurized metered-dose inhalers (pMDIs), (2) pMDI with inhalation chamber, and (3) dry powder inhalers (DPIs). Results: The final study included 55 studies of 6304 HCPs who underwent a total of 9996 tests of inhaler technique. Overall, 15.5% (95% confidence interval [CI]: 12.0%–19.3%) of HCPs demonstrated correct technique. The proportion with correct technique decreased over time, with 20.5% in the earlier group (1975–1995; 95% CI: 14.9%–26.8%) and a decrease to 10.8% (1996–2014; 95% CI: 7.3%–14.8%) in the latter group. Overall, there was a pooled average of >50% error by HCPs in all inhalation technique steps, and DPIs had the highest rate of error. The most common mistakes were as follows: for pMDI, not first breathing out completely and coordination; for pMDI with inhalation chamber, improper placement; and for DPI, preparation and forceful rapid inhalation. Specific errors varied by HCP type. Conclusions: Researchers in this study synthesize data from a large and representative set of studies and report that the majority of HCPs have suboptimal technique in use of inhalers commonly used for asthma.