Virtual instruction for inhaler technique nearly as effective as in-person instruction, study finds

In a small randomized trial of hospitalized patients with asthma or chronic obstructive pulmonary disease, virtual education delivered by tablet computer led to similar improvements in inhaler technique as in-person instruction by trained staff.


A virtual, patient-directed intervention for improving inhaler technique worked nearly as well as a time-intensive, in-person strategy in a recent study of adults hospitalized with asthma or chronic obstructive pulmonary disease (COPD).

Researchers randomized adults with asthma or COPD admitted to general inpatient wards to receive either virtual (n=59) or in-person (n=59) educational interventions for improving inhaler technique. Virtual education was a module delivered by handheld tablet with narrated video demonstration of the correct technique, as well as self-assessment questions before and after demonstration (up to three rounds were repeated as needed). Participants in the in-person education group received iterative rounds of inhaler technique assessment and education by trained staff. Investigators and research assistants were blinded to interventions.

Study enrollment, assessments, and delivery of the interventions occurred in the hospital, and participants returned at 30 days for a follow-up research visit. Researchers tested the virtual education for noninferiority, based on whether the groups achieved an equal percentage with correct inhaler technique after education (>9 of 12 steps correct), against an a priori noninferiority limit of −10%. They also adjusted for differences in baseline technique and health literacy. Results were published online on Jan. 3 by JAMA Network Open.

Of 118 participants, most were black (n=114 [97%]) and female (n=76 [64%]), with a mean age of 54.5 years. Compared to before education, correct technique increased when assessed at discharge in both the virtual group (from 2% to 69%; difference, 67%) and the in-person group (from 17% to 83%; difference, 66%). While the difference after intervention exceeded the noninferiority limit (−14%; 95% CI lower bound, −26%), the difference was equivalent to the noninferiority limit (−10%; 95% CI lower bound, −22%) after adjustment for baseline technique. Among 100 (85%) participants who completed the 30-day follow-up visit, inhaler performance declined by a similar amount in both groups, with 26 of 49 (53%) in the virtual group and 32 of 51 (63%) in the in-person group using correct technique. After adjustment, the difference in the rates was −4% (95% CI lower bound, −18%).

Limitations of the study include the fact that participants were primarily urban, underserved, and black patients, and that there was an imbalance in baseline inhaler misuse between the two groups, the authors noted. The findings should be validated in future studies across diverse settings and populations with similar baseline rates of misuse, they said.

While technological interventions are not suitable for all patients, a potential advantage of virtual inhaler instruction is the identification of patients who may benefit from additional in-person training, they said, adding that the virtual education may be repeated at home as necessary. Larger studies are needed to determine whether the intervention will improve long-term inhaler technique skills and/or patient outcomes, they added.

“This virtual approach has potentially important implications for increasing access to high-quality education because the virtual intervention likely has significantly lower costs and time constraints in real-world settings compared with the costs of training and delivering in-person education in hospital and at home,” the authors wrote.