Interventions to improve inhaler technique for people with asthma

Rebecca Fortescue; Kayleigh M Kew; Alexander G Mathioudakis

doi:10.1002/14651858.CD012286.pub2

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Figure 1

Study flow diagram.

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Figure 2

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

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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.

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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.

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Analysis 1.1

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

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Study	Time of rating	Intervention mean (SD)	Control mean (SD)	Total N	Scale (higher score= better technique)
Inhaler technique score
Basheti 2008	Post‐intervention	‐	‐	‐	‐
Basheti 2008	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
Bynum 2001	Follow‐up (2 to 4 wks)	6.73 (1.22)	4.86 (1.10)	36	Max 8
Mehuys 2008	Post‐intervention	‐	‐	‐	‐
Mehuys 2008	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
Rahmati 2014	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
Rydman 1999	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
Self 1983	Follow‐up	‐	‐	‐	‐

Analysis 1.2

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

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Analysis 1.3

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

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Analysis 1.4

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

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Analysis 1.5

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

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Analysis 1.6

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

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Analysis 1.7

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

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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

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Analysis 1.9

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

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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

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Analysis 2.1

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

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Analysis 2.2

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

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Analysis 2.3

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

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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

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Analysis 3.1

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

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Analysis 3.2

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

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Study	Time of rating	MD (SE)	Total N	Scale (higher score= better technique)
Inhaler technique score
Acosta 2009	Post‐intervention	14.77 (2.23)	116	% correct use
Acosta 2009	Follow‐up (4 wks)	13.30 (2.33)	116	% correct use
Self 1983	Post‐intervention	6.2 (2.33)	20	Max 20
Self 1983	Follow‐up (4 wks)	Control not followed‐up	‐	Max 20

Analysis 3.3

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

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Study	Time of rating	Intervention mean (SD)	Control mean (SD)	Total N	Scale (higher score= better technique)
Change in inhaler technique score
Boone 2002	Post‐intervention	‐	‐	‐	‐
Boone 2002	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
Carpenter 2015	Follow‐up (4 wks)	0.87 (1.09)	0.32 (1.14)	91	Max 8

Analysis 4.1

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

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Analysis 4.2

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

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Analysis 4.3

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

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Analysis 5.1

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

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Analysis 5.2

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

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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)

Max 10 or 11

Analysis 5.3

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

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Analysis 5.4

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

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Analysis 5.5

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

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Analysis 5.6

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

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Analysis 6.1

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

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Analysis 6.2

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

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Analysis 6.3

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

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Analysis 6.4

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

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

Outcomes	*Anticipated absolute effects (95% CI)**			Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
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	Risk with control/usual care		Risk with enhanced education	Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
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)	⊕⊕⊕⊝ MODERATE^a	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)	⊕⊕⊝⊝ LOW^a,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 LOW^a,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)	⊕⊕⊝⊝ LOW^d
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)	⊕⊕⊝⊝ LOW^a,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)	⊕⊕⊝⊝ LOW^a,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

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

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Summary of findings 2. Multimedia training compared with control versus usual care for people with asthma

Outcomes		*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
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		Risk with control/usual care	Risk with multi‐media training	Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
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)	⊕⊕⊕⊝ MODERATE^a,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)	⊕⊕⊝⊝ LOW^a,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
Inhaler technique score	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)	⊕⊕⊝⊝ LOW^a,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

Summary of findings 2. Multimedia training compared with control versus usual care for people with asthma

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Summary of findings 3. Feedback device compared with control versus usual care for people with asthma

Outcomes		*Anticipated absolute effects (95% CI)**		Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
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		Risk with control/usual care	Risk with feedback device	Relative effect (95% CI)	Number of participants (studies)	Quality of the evidence (GRADE)	Comments
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)	⊕⊕⊝⊝ LOW^a,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)	⊕⊕⊝⊝ LOW^a,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)	⊕⊕⊝⊝ LOW^a,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)	⊕⊕⊝⊝ LOW^a,c
Asthma control (ACQ) 6 to 12 weeks	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)	⊕⊕⊕⊝ MODERATE^a
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)	⊕⊕⊝⊝ LOW^a,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)	⊕⊕⊝⊝ LOW^a,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)	⊕⊕⊕⊝ MODERATE^a
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

Summary of findings 3. Feedback device compared with control versus usual care for people with asthma

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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

Table 1. Summary of characteristics of studies in comparisons 1 and 2: inhaler technique education

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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

Table 2. Summary of characteristics of studies in comparisons 3 and 4: multi‐media training

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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

Table 3. Summary of characteristics of studies in comparisons 5 and 6: add‐on/feedback device

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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]

Comparison 1. Adults: enhanced education versus control/usual care

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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]

Comparison 2. Children: enhanced education versus control/usual care

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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

Comparison 3. Adults: multi‐media training versus control/usual care

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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

Comparison 4. Children: multi‐media training versus control/usual care

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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

Comparison 5. Adults: feedback device versus control/usual care

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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

Comparison 6. Children: feedback device versus control/usual care

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