Scolaris Content Display Scolaris Content Display

Study flow diagram.

Figures and Tables -
Figure 1

Study flow diagram.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Figures and Tables -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

In the control group, 31 out of 100 people had correct inhaler technique after 2 to 26 weeks, compared with 69 (95% CI 45 to 86) out of 100 in the active treatment group.

Figures and Tables -
Figure 3

In the control group, 31 out of 100 people had correct inhaler technique after 2 to 26 weeks, compared with 69 (95% CI 45 to 86) out of 100 in the active treatment group.

In the control group, 49 out of 100 people had at least 0.5 unit increase in AQLQ after 6 weeks, compared with 83 (95% CI 42 to 94) out of 100 in the active treatment group.

Figures and Tables -
Figure 4

In the control group, 49 out of 100 people had at least 0.5 unit increase in AQLQ after 6 weeks, compared with 83 (95% CI 42 to 94) out of 100 in the active treatment group.

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 1: Correct inhaler technique (at follow‐up)

Figures and Tables -
Analysis 1.1

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 1: Correct inhaler technique (at follow‐up)

Inhaler technique score

Study

Time of rating

Intervention mean (SD)

Control mean (SD)

Total N

Scale

(higher score=

better technique)

Basheti 2008

Post‐intervention

Follow‐up (26 wks)

2.80 (1.60)

0.90 (1.40)

100

Max 9 (change)

Bynum 2001

Post‐intervention

7.33 (0.72)

5.14 (1.62)

36

Max 8

Follow‐up (2 to 4 wks)

6.73 (1.22)

4.86 (1.10)

36

Max 8

Mehuys 2008

Post‐intervention

Follow‐up (26 wks)

93.2 (10.7)

83.7 (22.5)

150

Max 100

Rahmati 2014

Post‐intervention

10.8 (0.48)

5.57 (1.20)

120

Max 11

Follow‐up (4 wks)

10.17 (0.91)

5.48 (1.27)

90

Max 11

Rydman 1999

Post‐intervention

0.68 (0.46)

0.60 (0.49)

120

Max 1

Follow‐up (8 to 20 wks)

0.72 (0.45)

0.75 (0.43)

120

Max 1

Self 1983

Post‐intervention

16.8 (4.1)

10.7 (5.4)

19

Max 20

Follow‐up

Figures and Tables -
Analysis 1.2

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 2: Inhaler technique score

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 3: Asthma control

Figures and Tables -
Analysis 1.3

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 3: Asthma control

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 4: Asthma control

Figures and Tables -
Analysis 1.4

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 4: Asthma control

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 5: Exacerbations requiring at least OCS

Figures and Tables -
Analysis 1.5

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 5: Exacerbations requiring at least OCS

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 6: Exacerbations requiring ED/hospitalisation

Figures and Tables -
Analysis 1.6

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 6: Exacerbations requiring ED/hospitalisation

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 7: Quality of life

Figures and Tables -
Analysis 1.7

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 7: Quality of life

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 8: Subgroup analysis: inhaler technique (at follow‐up): to whom intervention is delivered

Figures and Tables -
Analysis 1.8

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 8: Subgroup analysis: inhaler technique (at follow‐up): to whom intervention is delivered

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 9: Subgroup analysis: asthma control: to whom intervention is delivered

Figures and Tables -
Analysis 1.9

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 9: Subgroup analysis: asthma control: to whom intervention is delivered

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 10: Subgroup analysis: inhaler technique (at follow‐up): off‐off vs repeated sessions

Figures and Tables -
Analysis 1.10

Comparison 1: Adults: enhanced education versus control/usual care, Outcome 10: Subgroup analysis: inhaler technique (at follow‐up): off‐off vs repeated sessions

Comparison 2: Children: enhanced education versus control/usual care, Outcome 1: Correct inhaler technique (at follow‐up)

Figures and Tables -
Analysis 2.1

Comparison 2: Children: enhanced education versus control/usual care, Outcome 1: Correct inhaler technique (at follow‐up)

Comparison 2: Children: enhanced education versus control/usual care, Outcome 2: Inhaler technique (PIF immediately after intervention)

Figures and Tables -
Analysis 2.2

Comparison 2: Children: enhanced education versus control/usual care, Outcome 2: Inhaler technique (PIF immediately after intervention)

Comparison 2: Children: enhanced education versus control/usual care, Outcome 3: Inhaler technique (PIF at follow‐up)

Figures and Tables -
Analysis 2.3

Comparison 2: Children: enhanced education versus control/usual care, Outcome 3: Inhaler technique (PIF at follow‐up)

Comparison 2: Children: enhanced education versus control/usual care, Outcome 4: Subgroup analysis: inhaler technique (at follow‐up): one‐off vs repeated sessions

Figures and Tables -
Analysis 2.4

Comparison 2: Children: enhanced education versus control/usual care, Outcome 4: Subgroup analysis: inhaler technique (at follow‐up): one‐off vs repeated sessions

Comparison 3: Adults: multi‐media training versus control/usual care, Outcome 1: Correct inhaler technique (immediately after intervention)

Figures and Tables -
Analysis 3.1

Comparison 3: Adults: multi‐media training versus control/usual care, Outcome 1: Correct inhaler technique (immediately after intervention)

Comparison 3: Adults: multi‐media training versus control/usual care, Outcome 2: Correct inhaler technique (at follow‐up)

Figures and Tables -
Analysis 3.2

Comparison 3: Adults: multi‐media training versus control/usual care, Outcome 2: Correct inhaler technique (at follow‐up)

Inhaler technique score

Study

Time of rating

MD (SE)

Total N

Scale

(higher score=

better technique)

Acosta 2009

Post‐intervention

14.77 (2.23)

116

% correct use

Follow‐up (4 wks)

13.30 (2.33)

116

% correct use

Self 1983

Post‐intervention

6.2 (2.33)

20

Max 20

Follow‐up (4 wks)

Control not followed‐up

Max 20

Figures and Tables -
Analysis 3.3

Comparison 3: Adults: multi‐media training versus control/usual care, Outcome 3: Inhaler technique score

Change in inhaler technique score

Study

Time of rating

Intervention mean (SD)

Control mean (SD)

Total N

Scale

(higher score=

better technique)

Boone 2002

Post‐intervention

Follow‐up (4 wks)

2.60 (0.60)

0.50 (0.50)

36

Max 15

Carpenter 2015

Post‐intervention

1.12 (1.09)

0.03 (1.07)

91

Max 8

Follow‐up (4 wks)

0.87 (1.09)

0.32 (1.14)

91

Max 8

Figures and Tables -
Analysis 4.1

Comparison 4: Children: multi‐media training versus control/usual care, Outcome 1: Change in inhaler technique score

Comparison 4: Children: multi‐media training versus control/usual care, Outcome 2: Asthma control (change from baseline)

Figures and Tables -
Analysis 4.2

Comparison 4: Children: multi‐media training versus control/usual care, Outcome 2: Asthma control (change from baseline)

Comparison 4: Children: multi‐media training versus control/usual care, Outcome 3: Asthma control (endpoint)

Figures and Tables -
Analysis 4.3

Comparison 4: Children: multi‐media training versus control/usual care, Outcome 3: Asthma control (endpoint)

Comparison 5: Adults: feedback device versus control/usual care, Outcome 1: Inhaler technique (PIF)

Figures and Tables -
Analysis 5.1

Comparison 5: Adults: feedback device versus control/usual care, Outcome 1: Inhaler technique (PIF)

Comparison 5: Adults: feedback device versus control/usual care, Outcome 2: Correct inhaler technique (at follow‐up)

Figures and Tables -
Analysis 5.2

Comparison 5: Adults: feedback device versus control/usual care, Outcome 2: Correct inhaler technique (at follow‐up)

Inhaler technique score

Study

Time of rating

Intervention mean (SD)

Control mean (SD)

Total N

Scale

(higher score=

better technique)

Toumas‐Shehata 2014

Follow‐up (4 wks)

9.50 (1.00)

8.90 (1.00)

97

Max 10 or 11

Figures and Tables -
Analysis 5.3

Comparison 5: Adults: feedback device versus control/usual care, Outcome 3: Inhaler technique score

Comparison 5: Adults: feedback device versus control/usual care, Outcome 4: Asthma control

Figures and Tables -
Analysis 5.4

Comparison 5: Adults: feedback device versus control/usual care, Outcome 4: Asthma control

Comparison 5: Adults: feedback device versus control/usual care, Outcome 5: Quality of life

Figures and Tables -
Analysis 5.5

Comparison 5: Adults: feedback device versus control/usual care, Outcome 5: Quality of life

Comparison 5: Adults: feedback device versus control/usual care, Outcome 6: Quality of life (responders)

Figures and Tables -
Analysis 5.6

Comparison 5: Adults: feedback device versus control/usual care, Outcome 6: Quality of life (responders)

Comparison 6: Children: feedback device versus control/usual care, Outcome 1: Inhaler technique (PIF)

Figures and Tables -
Analysis 6.1

Comparison 6: Children: feedback device versus control/usual care, Outcome 1: Inhaler technique (PIF)

Comparison 6: Children: feedback device versus control/usual care, Outcome 2: Asthma control

Figures and Tables -
Analysis 6.2

Comparison 6: Children: feedback device versus control/usual care, Outcome 2: Asthma control

Comparison 6: Children: feedback device versus control/usual care, Outcome 3: Quality of life (change from baseline)

Figures and Tables -
Analysis 6.3

Comparison 6: Children: feedback device versus control/usual care, Outcome 3: Quality of life (change from baseline)

Comparison 6: Children: feedback device versus control/usual care, Outcome 4: Quality of life (endpoint)

Figures and Tables -
Analysis 6.4

Comparison 6: Children: feedback device versus control/usual care, Outcome 4: Quality of life (endpoint)

Summary of findings 1. Enhanced education compared with control versus usual care for people with asthma

Enhanced education compared with control/usual care for people with asthma

Patient or population: adults and children with asthma
Setting: primary and secondary care
Intervention: enhanced education
Comparison: control/usual care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control/usual care

Risk with enhanced education

Correct inhaler technique

Follow‐up:

2 to 26 weeks (adults)

12 to 26 weeks (children)

Adults

31 per 100

69 per 100
(45 to 86)

OR 5.00 (1.83 to 13.65)

258
(3 RCTs)

⊕⊕⊕⊝

MODERATEa

Additional results from technique rating scales could not be combined (Analysis 1.2)

Children

49 per 100

55 per 1,00
(40 to 69)

OR 1.29
(0.70 to 2.36)

175
(2 RCTs)

⊕⊕⊝⊝

LOWa,b

One study measured PIF as a marker for inhaler technique and showed benefit (Analysis 2.2; Analysis 2.3)

Asthma control score

4 to 26 weeks

Adults

Score in the intervention group was 0.48 SDs higher than in the control group
(0.29 lower to 1.24 higher)

247
(2 RCTs)

⊕⊝⊝⊝

VERY LOWa,b,c

We were not able to calculate a control risk, as the outcome was measured on different scales

Asthma control responders

8 to 12 weeks

Adults

42 per 100

70 per 100
(52 to 84)

OR 3.18
(1.47 to 6.88)

134
(2 RCTs)

⊕⊕⊝⊝

LOWd

Exacerbations requiring at least OCS

26 weeks

Adults

10 per 100

13 per 100

(5 to 28)

OR 1.32

(0.49 to 3.55)

158

(1 RCT)

⊕⊕⊝⊝

LOWa,b

The same study also reported exacerbations requiring ED/hospitalisation. Events were rare and results imprecise

Quality of life

26 weeks

Adults

Score in the intervention group was 0.52 SDs higher than in the control group
(0.04 lower to 1.09 higher)

247
(2 RCTs)

⊕⊕⊝⊝

LOWa,c,e

We were not able to calculate a control risk as the outcome was measured on different scales

Other outcomes

No results could be analysed for adverse events, unscheduled visits to a healthcare provider or school/work absences

*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
CI: confidence interval; ED: emergency department; OCS: oral corticosteroids; OR: odds ratio; PIF: peak inspiratory flow; RCT: randomised controlled trial; RR: risk ratio; SDs: standard deviations

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to the estimate of effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

aStudies contributing to this outcome were at high risk of bias in several domains (including performance and detection bias). Downgraded once

bWide confidence intervals including possible harm and benefit of intervention. Downgraded once

cHigh level of statistical inconsistency detected. Downgraded once

dThe two small studies contributing to this outcome were identified as abstracts only; it is therefore difficult to assess methodological quality. Studies were considered at high or unclear risk of bias in multiple domains (including selection, performance, detection and reporting biases). Downgraded twice

eConfidence interval includes no difference with random‐effects model, driven by statistical heterogeneity. Fixed‐effect sensitivity analysis yields more precise result. Not downgraded

Figures and Tables -
Summary of findings 1. Enhanced education compared with control versus usual care for people with asthma
Summary of findings 2. Multimedia training compared with control versus usual care for people with asthma

Multimedia training compared with control/usual care for people with asthma

Patient or population: adults and children with asthma
Setting: primary and secondary care
Intervention: multi‐media training
Comparison: control/usual care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control/usual care

Risk with multi‐media training

Correct inhaler technique

Immediately after intervention

Adults

30 per 100

47 per 100
(26 to 70)

OR 2.15
(0.84 to 5.50)

164
(2 RCTs)

⊕⊕⊕⊝

MODERATEa,b

Correct inhaler technique

2‐Week follow‐up

Adults

43 per 100

57 per 100
(23 to 86)

OR 1.78
(0.40 to 7.94)

28
(1 RCT)

⊕⊕⊝⊝

LOWa,c

Inhaler technique score

Adults

Not pooled; narrative summary of evidence provided in data table (Analysis 3.3)

136

(2 RCTs)

Not graded

Suggests benefit of multi‐media training over control

Children

Not pooled; narrative summary of evidence provided in data table (Analysis 4.1)

127

(2 RCTs)

Not graded

Suggests benefit of multi‐media training over control

Asthma control (ACT)

4 weeks

Children

Mean change in control group was 1.2

Mean change was 0.73 better

(‐0.99 worse to 2.45 better)

91

(1 RCT)

⊕⊕⊝⊝

LOWa,c

Other outcomes

No results could be analysed for quality of life, exacerbations, adverse events, unscheduled visits to a healthcare provider or school/work absences

*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
ACT: Asthma Control Test (range 0 to 25; higher is better); CI: confidence interval; OR: odds ratio; RCT: randomised controlled trial; RR: risk ratio; SDs: standard deviations

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to the estimate of effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

aConfidence intervals include no difference. Downgraded once

bAlthough participants in both studies were unblinded, inhaler technique was rated by a blinded assessor, and both groups received an intervention. Not downgraded

cHigh risk of bias for performance and detection. Downgraded once

Figures and Tables -
Summary of findings 2. Multimedia training compared with control versus usual care for people with asthma
Summary of findings 3. Feedback device compared with control versus usual care for people with asthma

Feedback device compared with control/usual care for people with asthma

Patient or population: adults and children with asthma
Setting: primary and secondary care
Intervention: feedback device
Comparison: control/usual care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Risk with control/usual care

Risk with feedback device

Correct inhaler technique

4‐Week follow‐up

Adults

51 per 100

83 per 100

(66 to 93)

OR 4.80 (1.87 to 12.33)

97

(1 RCT)

⊕⊕⊝⊝

LOWa,b

Additional results from technique rating scales could not be combined (Analysis 5.3)

Inhaler technique (PIF)

Follow‐up:

6 weeks (adults)

6 to 12 weeks (children)

Adults

66 per 100

97 per 100
(81 to 100)

OR 18.26
(2.22 to 150.13)

71
(1 RCT)

⊕⊕⊝⊝

LOWa,b

Children

Mean PIF was 51.2 litres/min

Mean PIF was 9.22 litres/min better (33.71 better to 15.27 worse)

98
(2 RCTs)

⊕⊕⊝⊝

LOWa,c

Asthma control (ACQ)

6 to 12 weeks

Adults

Mean ACQ score was 1.4

Mean score in the intervention group was 0.1 better

(0.46 better to 0.26 worse)

97

(1 RCT)

⊕⊕⊝⊝

LOWa,c

Children

Mean ACQ score was 0.7

Mean score in the intervention group was 0.02 worse
(0.35 worse to 0.32 better)

98
(2 RCTs)

⊕⊕⊕⊝

MODERATEa

Quality of life

Follow‐up:

6 weeks (adults)

6 to 12 weeks (children)

Adults

Mean score on the mini‐AQLQ was 4.2

Mean score in the intervention group was 0.38 better
(0.01 worse to 0.77 better)

100
(2 RCTs)

⊕⊕⊝⊝

LOWa,d

Children

Mean change in quality of life was 0.07

Mean change was 0.25 better
(0.07 worse to 0.58 better)

91
(2 RCTs)

⊕⊕⊝⊝

LOWa,d

One study reported endpoint quality of life (Analysis 6.4)

Quality of life (responders)

6 weeks

Adults

49 per 100

83 per 100
(62 to 94)

OR 5.29
(1.76 to 15.89)

71
(1 RCT)

⊕⊕⊕⊝

MODERATEa

Other outcomes

No results could be analysed for exacerbations, adverse events, unscheduled visits to a healthcare provider or school/work absences

*The risk in the intervention group (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI)
ACQ: Asthma Control Questionnaire (range 0 to 6; lower is better); CI: confidence interval; OR: odds ratio; PIF: peak inspiratory flow; RCT: randomised controlled trial; RR: risk ratio; SDs: standard deviations

GRADE Working Group grades of evidence
High quality: We are very confident that the true effect lies close to the estimate of effect
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

aHigh risk of performance and detection bias. Downgraded once

bVery wide confidence intervals based on one study. Downgraded once

cConfidence intervals include possible harm and benefit of the intervention. Downgraded once

dConfidence interval does not exclude no difference, and upper limit exceeds the MCID of 0.5 units. Downgraded once

Figures and Tables -
Summary of findings 3. Feedback device compared with control versus usual care for people with asthma
Table 1. Summary of characteristics of studies in comparisons 1 and 2: inhaler technique education

Study ID

Total n

Study duration

(weeks)

Age

Country

Intervention

Control

Inhaler technique measure

Outcomes

Agertoft 1998

72

2

Children aged 3 to 5 years

Denmark

Instructional video + individual training; delivered to participant

Instructional video

PIF

PIF, IVC, PEFR, FEV1, FVC

Basheti 2005

26

2

Adults

Australia

Group B: verbal counselling

Group C: verbal counselling + physical demonstration; delivered to participant

Group A: printed materials

9‐Step Turbuhaler checklist

Inhaler technique

Basheti 2008

31 pharmacists, 97 participants

26

Adults

Australia

Pharmacist‐participant education + inhaler technique labels; delivered to pharmacist

Peak flow measurement training

9‐Step checklist

Inhaler technique, asthma severity, peak flow variability, AQOL, perceived control

Bynum 2001

49

4

Adolescents aged 12 to 19 years

USA

Telepharmacy counselling; delivered to participant

Written instructions only

8‐Step MDI checklist

Inhaler technique, participant satisfaction

Fernandes 2011

89

12

Adults

Not reported

Respiratory therapist education; delivered to participant

Rotuine physician education

Not reported

Inhaler technique, asthma control

Mehuys 2008

201

26

Adults

Belgium

Pharmacist education; delivered to pharmacist

Usual pharmacy care

10‐Step MDI + spacer checklist/8‐step DPI checklist

Inhaler technique, ACT, exacerbations, ED/hospital visits, adherence, AQLQ, asthma knowledge

Nahafizadeh 2010

46

8.7

Adults

Iran

Face‐to‐face education; delivered to participant

Usual care (no further details)

Not reported

ACT, FEV1

Ozkaya 2010

130

12

Children

Turkey

Face‐to‐face nurse training; delivered to participant

Inhaler package insert only

10‐Step MDI checklist

Inhaler technique, PAQLQ, spirometry

Rahmati 2014

90

4

Adults

Iran

Face‐to‐face training (no spacer device); delivered to participant

Usual care (no training)

11‐Step MDI checklist

Inhaler technique, PEFR

Rydman 1999

68

8 to 20

Adults

USA

Face‐to‐face training + demonstration; delivered to participant

Inhaler package insert only

Checklist, converted to score out of 1 (0 if any steps missed)

BAI and MDI competency

Self 1983

29

1 to 16 (mean 6)

Adults

USA

Face‐to‐face pharmacist training; delivered to participant

Inhaler package insert only

10‐Step checklist

Inhaler technique, "effectiveness of instruction"

Turgeon 1996

96

26

Children and adolescents (max 15 years)

Canada

Interactive nurse training with feedback; delivered to participant

Pictorial nurse training only

Checklist with scores converted to percentages

Inhaler technique, parental perceptions of treatment, asthma morbidity (e.g. no. of exacerbations, ED visits, hospitalisations, days of schools missed)

ACT: Asthma Control Test; AQLQ: Asthma Quality of Life Questionnaire; AQOL: asthma quality of life; BAI: breath‐activated inhaler; DPI: dry powder inhaler; ED: emergency department; FEV1: forced expiratory volume in one second; FVC: forced vital capacity; IVC: inspiratory vital capacity; MDI: metered dose inhaler; PAQLQ: paediatric AQLQ; PEFR: peak expiratory flow rate; PIF: peak inspiratory flow

Figures and Tables -
Table 1. Summary of characteristics of studies in comparisons 1 and 2: inhaler technique education
Table 2. Summary of characteristics of studies in comparisons 3 and 4: multi‐media training

Study ID

Total n

Study duration (weeks)

Age

Country

Intervention

Control

Inhaler technique measure

Outcomes

Acosta 2009

133

4

Adults

USA

Inhaler technique training video; delivered to participant

Asthma education video

Not reported

"Correct usage" of inhaler

Arthurs 2014

21

13

Children

Ireland

Inhaler technique DVD; delivered to participant

Individual instruction

New inhaler technique measurement tool

Inhaler technique, self‐efficacy, knowledge acquisition

Boone 2002

36

4.3

Children

UK

Inhaler technique educational computer software ("Space Inhalers"); delivered to participant

Placebo software

15‐Step checklist

Inhaler technique, asthma knowledge

Carpenter 2015

91

4.3

Children and adolescents

USA

Inhaler technique video; delivered to participant

Attention control video (about nutrition)

8‐Step checklist

Inhaler technique, self‐efficacy, ACT

Goodyer 2006

69

Outcomes assessed immediately

Adults

UK (Turkish‐

speaking population)

Multi‐media touch screen training; delivered to participant

Patient information leaflet plus verbal training

Inhaler checklist

Inhaler technique

Lirsac 1991

45

2.1

Adults and children (10 to 71 years)

France

Inhaler technique video OR inhaler technique video + spacer; delivered to participant

Patient information sheet

4‐Step checklist

Inhaler technique, FEV1

Savage 2003

110

Outcomes assessed immediately

Children and adults (12 to 87 years)

UK

Multi‐media touch screen training; delivered to participant

Patient information leaflet

Inhaler checklist, global assessment of technique

Inhaler technique, acceptability

Self 1983

29

1 to 16 (mean 6)

Adults

USA

Video training; delivered to participant

Inhaler package insert only

10‐Step checklist

Inhaler technique, "effectiveness of instruction"

Shah 2014

50

Not reported

Not reported

USA

Computer training; delivered to participant

Written training OR no training

"Fixed rubric" used to give a score

Inhaler technique

ACT: Asthma Control Test; DVD: digital versatile disc; FEV1: forced expiratory volume in one second

Figures and Tables -
Table 2. Summary of characteristics of studies in comparisons 3 and 4: multi‐media training
Table 3. Summary of characteristics of studies in comparisons 5 and 6: add‐on/feedback device

Study ID

Total n

Study duration (weeks)

Age

Country

Intervention

Control

Inhaler technique measure

Outcomes

Al‐Showair 2007

108

6

Adults

UK

Verbal training + 2Tone trainer; delivered to participant

Verbal training alone

PIF

PIF, FEV1, AQLQ

Ammari 2013

56

6

Adults and children

(4 to 55 years)

UK

Verbal training + 2Tone trainer; delivered to participant

Verbal training alone

PIF

PIF, FEV1, AQLQ/PAQLQ

Ammari 2015

80

12

Children

UK

AeroChamber Plus with Flo‐Vu; delivered to participant

AeroChamber Plus alone

PIF

PIF, PAQLQ, ACQ, parent spacer preference

Ammari 2015a

30

6 to 8

Children

Not reported

Verbal training and use of Trainhaler; delivered to participant

Verbal training alone

PIF

PIF, ACQ

Rahmati 2014

90

4

Adults

Iran

Face‐to‐face training (with spacer device); delivered to participant

Usual care (no training)

11‐Step MDI checklist

Inhaler technique, PEFR

Schultz 2012

132

52

Children

Australia

Funhaler incentive device; delivered to participant

AeroChamber device

Filter used to measure salbutamol deposition

Inhaler technique, asthma control, quality of life

Tarsin 2008

76

4

Not reported

Libya

Verbal training + 2Tone trainer; delivered to participant

Verbal training alone

PIF

PIF, FEV1, AQLQ, Jones Morbidity Index (JMI)

Toumas‐Shehata 2014

19 pharmacists (101 participants)

4

Adults

Australia

Verbal training + quantitative inhaler feedback; delivered to pharmacist

Verbal training alone

Inhaler checklist/proportion with correct technique

Inhaler technique, ACQ

Vitari 2013

43

4

Not reported

USA

Face‐to‐face demonstration + In‐Check simulator; delivered to participant

Face‐to‐face demonstration

PIF, inhaler checklist

PIF, inhaler technique

ACQ: Asthma Control Questionnaire; AQLQ: Asthma Quality of Life Questionnaire; FEV1: forced expiratory volume in one second; MDI: metered dose inhaler; PAQLQ: paediatric AQLQ; PEFR: peak expiratory flow rate; PIF: peak inspiratory flow

Figures and Tables -
Table 3. Summary of characteristics of studies in comparisons 5 and 6: add‐on/feedback device
Comparison 1. Adults: enhanced education versus control/usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 Correct inhaler technique (at follow‐up) Show forest plot

3

258

Odds Ratio (M‐H, Random, 95% CI)

5.00 [1.83, 13.65]

1.2 Inhaler technique score Show forest plot

6

Other data

No numeric data

1.3 Asthma control Show forest plot

2

247

Std. Mean Difference (IV, Random, 95% CI)

0.48 [‐0.29, 1.24]

1.4 Asthma control Show forest plot

2

134

Odds Ratio (M‐H, Random, 95% CI)

3.18 [1.47, 6.88]

1.5 Exacerbations requiring at least OCS Show forest plot

1

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

1.6 Exacerbations requiring ED/hospitalisation Show forest plot

1

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

1.7 Quality of life Show forest plot

2

247

Std. Mean Difference (IV, Random, 95% CI)

0.52 [‐0.04, 1.09]

1.8 Subgroup analysis: inhaler technique (at follow‐up): to whom intervention is delivered Show forest plot

3

258

Odds Ratio (M‐H, Random, 95% CI)

5.00 [1.83, 13.65]

1.8.1 Delivered to participants

2

174

Odds Ratio (M‐H, Random, 95% CI)

3.03 [1.61, 5.68]

1.8.2 Delivered to pharmacists

1

84

Odds Ratio (M‐H, Random, 95% CI)

12.38 [4.04, 37.90]

1.9 Subgroup analysis: asthma control: to whom intervention is delivered Show forest plot

2

247

Std. Mean Difference (IV, Random, 95% CI)

0.48 [‐0.29, 1.24]

1.9.1 Delivered to participants

1

150

Std. Mean Difference (IV, Random, 95% CI)

0.10 [‐0.22, 0.42]

1.9.2 Delivered to pharmacists

1

97

Std. Mean Difference (IV, Random, 95% CI)

0.88 [0.46, 1.30]

1.10 Subgroup analysis: inhaler technique (at follow‐up): off‐off vs repeated sessions Show forest plot

3

258

Odds Ratio (M‐H, Random, 95% CI)

5.00 [1.83, 13.65]

1.10.1 One‐off

1

24

Odds Ratio (M‐H, Random, 95% CI)

3.50 [0.50, 24.56]

1.10.2 Repeated

2

234

Odds Ratio (M‐H, Random, 95% CI)

5.64 [1.40, 22.66]

Figures and Tables -
Comparison 1. Adults: enhanced education versus control/usual care
Comparison 2. Children: enhanced education versus control/usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

2.1 Correct inhaler technique (at follow‐up) Show forest plot

2

175

Odds Ratio (M‐H, Random, 95% CI)

1.29 [0.70, 2.36]

2.2 Inhaler technique (PIF immediately after intervention) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

2.3 Inhaler technique (PIF at follow‐up) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Totals not selected

2.4 Subgroup analysis: inhaler technique (at follow‐up): one‐off vs repeated sessions Show forest plot

2

175

Odds Ratio (M‐H, Random, 95% CI)

1.29 [0.70, 2.36]

2.4.1 One‐off

1

120

Odds Ratio (M‐H, Random, 95% CI)

1.37 [0.66, 2.83]

2.4.2 Repeated

1

55

Odds Ratio (M‐H, Random, 95% CI)

1.11 [0.37, 3.38]

Figures and Tables -
Comparison 2. Children: enhanced education versus control/usual care
Comparison 3. Adults: multi‐media training versus control/usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

3.1 Correct inhaler technique (immediately after intervention) Show forest plot

2

164

Odds Ratio (M‐H, Random, 95% CI)

2.15 [0.84, 5.50]

3.2 Correct inhaler technique (at follow‐up) Show forest plot

1

Odds Ratio (M‐H, Random, 95% CI)

Totals not selected

3.3 Inhaler technique score Show forest plot

2

Other data

No numeric data

Figures and Tables -
Comparison 3. Adults: multi‐media training versus control/usual care
Comparison 4. Children: multi‐media training versus control/usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

4.1 Change in inhaler technique score Show forest plot

2

Other data

No numeric data

4.2 Asthma control (change from baseline) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Subtotals only

4.3 Asthma control (endpoint) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Subtotals only

Figures and Tables -
Comparison 4. Children: multi‐media training versus control/usual care
Comparison 5. Adults: feedback device versus control/usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

5.1 Inhaler technique (PIF) Show forest plot

1

Odds Ratio (M‐H, Random, 95% CI)

Totals not selected

5.2 Correct inhaler technique (at follow‐up) Show forest plot

1

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

5.3 Inhaler technique score Show forest plot

1

Other data

No numeric data

5.4 Asthma control Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Subtotals only

5.5 Quality of life Show forest plot

2

100

Mean Difference (IV, Random, 95% CI)

0.38 [‐0.01, 0.77]

5.6 Quality of life (responders) Show forest plot

1

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

Figures and Tables -
Comparison 5. Adults: feedback device versus control/usual care
Comparison 6. Children: feedback device versus control/usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

6.1 Inhaler technique (PIF) Show forest plot

2

98

Mean Difference (IV, Random, 95% CI)

‐9.22 [‐33.71, 15.27]

6.2 Asthma control Show forest plot

2

98

Mean Difference (IV, Random, 95% CI)

‐0.02 [‐0.35, 0.32]

6.3 Quality of life (change from baseline) Show forest plot

2

91

Mean Difference (IV, Random, 95% CI)

0.25 [‐0.07, 0.58]

6.4 Quality of life (endpoint) Show forest plot

1

Mean Difference (IV, Random, 95% CI)

Subtotals only

Figures and Tables -
Comparison 6. Children: feedback device versus control/usual care