Inhaler misuse is common among patients with chronic obstructive pulmonary disease and associated with poor disease control. Many patient characteristics are reported to impact inhaler use, but there are no studies in the literature on the best way to evaluate them. This narrative review aims to identify patient characteristics that influence the correct use of an inhaler and describe the tools available for their assessment. First, we searched four different databases to identify reviews describing patient characteristics reported to impact inhaler use. In a second step, ways to characterize these aspects were searched using the same databases. Fifteen patient characteristics impacting on the use of inhalers were identified. Peak inspiratory flow, dexterity, and cognitive impairment were the most studied characteristics and appeared to have the highest impact on the correct use of inhalers. Notably, peak inspiratory flow can be reliably assessed in clinical practice using the In-Check Dial®. Triggering coordination, breath retention, collaboration/consciousness, and muscle strength in the fingers were important characteristics, but insufficient data exist to recommend the use of a specific tool for their assessment in daily practice. Other identified characteristics have a more uncertain impact. A demonstration of inhalation technique by the patient, combined with the measurement of peak inspiratory flow using the In-Check Dial®, appears to be an effective strategy to assess the characteristics with the highest impact on the correct use of an inhaler. In the future, “smart” inhalers could also play a decisive role in this area.

1.
Global Initiative for Chronic Obstructive Lung Disease
Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary Disease (2023 Report)
.
2022
. Available from: www.goldcopd.org.
2.
Voshaar
T
,
App
EM
,
Berdel
D
,
Buhl
R
,
Fischer
J
,
Gessler
T
.
Recommendations for the choice of inhalatory systems for drug prescription
.
Pneumologie
.
2001
;
55
(
12
):
579
86
.
3.
Anzueto
A
,
Miravitlles
M
.
The role of fixed-dose dual bronchodilator therapy in treating COPD
.
Am J Med
.
2018
;
131
(
6
):
608
22
.
4.
Lavorini
F
,
Fontana
GA
,
Usmani
OS
.
New inhaler devices: the good, the bad and the ugly
.
Respiration
.
2014
;
88
(
1
):
3
15
.
5.
Laube
BL
,
Janssens
HM
,
de Jongh
FHC
,
Devadason
SG
,
Dhand
R
,
Diot
P
.
What the pulmonary specialist should know about the new inhalation therapies
.
Eur Respir J
.
2011
;
37
(
6
):
1308
31
.
6.
Cataldo
D
,
Hanon
S
,
Peché
RV
,
Schuermans
DJ
,
Degryse
JM
,
De Wulf
IA
.
How to choose the right inhaler using a patient-centric approach
.
Adv Ther
.
2022
;
39
(
3
):
1149
63
.
7.
Rogliani
P
,
Calzetta
L
,
Coppola
A
,
Cavalli
F
,
Ora
J
,
Puxeddu
E
.
Optimizing drug delivery in COPD: the role of inhaler devices
.
Respir Med
.
2017
;
124
:
6
14
.
8.
Baumberger
M
,
Suter
P
,
Grobéty
T
,
Dumont
P
,
Grandmaison
G
.
Aérosolthérapie: aide à la sélection d’un inhalateur adapté chez les patients souffrant de BPCO
.
Rev Med Suisse
.
2021
;
17
(
749
):
1515
9
.
9.
Fink
JB
,
Colice
GL
,
Hodder
R
.
Inhaler devices for patients with COPD
.
COPD
.
2013
;
10
(
4
):
523
35
.
10.
Chrystyn
H
,
van der Palen
J
,
Sharma
R
,
Barnes
N
,
Delafont
B
,
Mahajan
A
.
Device errors in asthma and COPD: systematic literature review and meta-analysis
.
NPJ Prim Care Respir Med
.
2017
;
27
(
1
):
22
.
11.
Gregoriano
C
,
Dieterle
T
,
Breitenstein
AL
,
Dürr
S
,
Baum
A
,
Maier
S
.
Use and inhalation technique of inhaled medication in patients with asthma and COPD: data from a randomized controlled trial
.
Respir Res
.
2018
;
19
(
1
):
237
.
12.
Molimard
M
,
Raherison
C
,
Lignot
S
,
Balestra
A
,
Lamarque
S
,
Chartier
A
.
Chronic obstructive pulmonary disease exacerbation and inhaler device handling: real-life assessment of 2,935 patients
.
Eur Respir J
.
2017
;
49
(
2
):
1601794
.
13.
Baethge
C
,
Goldbeck-Wood
S
,
Mertens
S
.
SANRA—a scale for the quality assessment of narrative review articles
.
Res Integr Peer Rev
.
2019
;
4
(
1
):
5
.
14.
Dekhuijzen
PNR
,
Lavorini
F
,
Usmani
OS
.
Patients’ perspectives and preferences in the choice of inhalers: the case for Respimat or HandiHaler
.
PPA
.
2016
;
10
:
1561
72
.
15.
Frasnelli
M
,
Schnyder
B
,
Brutsche
M
.
Choix rationnel d’un système d’inhalation pour le traitement des pneumopathies obstructives
.
Forum Med Suisse
.
2016
16
14
).
16.
Usmani
OS
.
Choosing the right inhaler for your asthma or COPD patient
.
TCRM
.
2019
;
15
:
461
72
.
17.
Dekhuijzen
PNR
,
Bjermer
L
,
Lavorini
F
,
Ninane
V
,
Molimard
M
,
Haughney
J
.
Guidance on handheld inhalers in asthma and COPD guidelines
.
Respir Med
.
2014
;
108
(
5
):
694
700
.
18.
Barrons
R
,
Pegram
A
,
Borries
A
.
Inhaler device selection: special considerations in elderly patients with chronic obstructive pulmonary disease
.
Am J Health Syst Pharm
.
2011
;
68
(
13
):
1221
32
.
19.
Armitage
JM
,
Williams
SJ
.
Inhaler technique in the elderly
.
Age Ageing
.
1988
;
17
(
4
):
275
8
.
20.
Allen
SC
.
Competence thresholds for the use of inhalers in people with dementia
.
Age Ageing
.
1997
;
26
(
2
):
83
6
.
21.
Allen
SC
,
Ragab
S
.
Ability to learn inhaler technique in relation to cognitive scores and tests of praxis in old age
.
Postgrad Med J
.
2002
;
78
(
915
):
37
9
.
22.
Quinet
P
,
Young
CA
,
Héritier
F
.
The use of dry powder inhaler devices by elderly patients suffering from chronic obstructive pulmonary disease
.
Ann Phys Rehabil Med
.
2010
;
53
(
2
):
69
76
.
23.
Gray
SL
,
Williams
DM
,
Pulliam
CC
,
Sirgo
MA
,
Bishop
AL
,
Donohue
JF
.
Characteristics predicting incorrect metered-dose inhaler technique in older subjects
.
Arch Int Med
.
1996
;
156
(
9
):
984
8
.
24.
Allen
SC
,
Jain
M
,
Ragab
S
,
Malik
N
.
Acquisition and short-term retention of inhaler techniques require intact executive function in elderly subjects
.
Age Ageing
.
2003
;
32
(
3
):
299
302
.
25.
Allen
SC
,
Prior
A
.
What determines whether an elderly patient can use a metered dose inhaler correctly
.
Br J Dis Chest
.
1986
;
80
(
1
):
45
9
.
26.
Board
M
,
Allen
SC
.
A simple drawing test to identify patients who are unlikely to be able to learn to use an inhaler: a test to identify patients with inability to learn to use an inhaler
.
Int J Clin Pract
.
2006
;
60
(
5
):
510
3
.
27.
Allen
SC
,
Warwick-Sanders
M
,
Baxter
M
.
A comparison of four tests of cognition as predictors of inability to learn to use a metered dose inhaler in old age
.
Int J Clin Pract
.
2009
;
63
(
8
):
1150
3
.
28.
Lavorini
F
,
Mannini
C
,
Chellini
E
,
Fontana
GA
.
Optimising inhaled pharmacotherapy for elderly patients with chronic obstructive pulmonary disease: the importance of delivery devices
.
Drugs Aging
.
2016
;
33
(
7
):
461
73
.
29.
Ruessel
K
,
Luecke
E
,
Schreiber
J
.
Inhaler devices in a geriatric patient population: a prospective cross-sectional study on patient preferences
.
PPA
.
2020
;
14
:
1811
22
.
30.
Ciciliani
AM
,
Langguth
P
,
Wachtel
H
.
Handling forces for the use of different inhaler devices
.
Int J Pharm
.
2019
;
560
:
315
21
.
31.
Barrons
R
,
Wheeler
J
,
Woods
A
.
Opportunities for inhaler device selection in elderly patients with asthma or COPD
.
Patient Intelligence
.
2015
;
2015
:
53
65
.
32.
Thwaites
JH
.
Practical aspects of drug treatment in elderly patients with mobility problems
.
Drugs Aging
.
1999
;
14
(
2
):
105
14
.
33.
Pauwels
R
,
Newman
S
,
Borgström
L
.
Airway deposition and airway effects of antiasthma drugs delivered from metered-dose inhalers
.
Eur Respir J
.
1997
;
10
(
9
):
2127
38
.
34.
Mahler
DA
.
The role of inspiratory flow in selection and use of inhaled therapy for patients with chronic obstructive pulmonary disease
.
Respir Med
.
2020
;
161
:
105857
.
35.
Lavorini
F
,
Janson
C
,
Braido
F
,
Stratelis
G
,
Løkke
A
.
What to consider before prescribing inhaled medications: a pragmatic approach for evaluating the current inhaler landscape
.
Ther Adv Respir Dis
.
2019
;
13
:
1753466619884532
.
36.
Peché
R
,
Attar-Zadeh
D
,
Scullion
J
,
Kocks
J
.
Matching the inhaler to the patient in COPD
.
JCM
.
2021
;
10
(
23
):
5683
.
37.
Scullion
J
,
Murphy
A
Inhaler standards and competency document
UK Inhaler Group
2018
. Available from: http://www.ukinhalergroup.co.uk.
38.
Mahler
DA
,
Waterman
LA
,
Ward
J
,
Gifford
AH
.
Comparison of dry powder versus nebulized beta-agonist in patients with COPD who have suboptimal peak inspiratory flow rate
.
J Aerosol Med Pulm Drug Deliv
.
2014
;
27
(
2
):
103
9
.
39.
Janssens
W
,
Vanden Brande
P
,
Hardeman
E
,
De Langhe
E
,
Philps
T
,
Troosters
T
.
Inspiratory flow rates at different levels of resistance in elderly COPD patients
.
Eur Respir J
.
2008
;
31
(
1
):
78
83
.
40.
Mahler
DA
,
Waterman
LA
,
Gifford
AH
.
Prevalence and COPD Phenotype for a suboptimal peak inspiratory flow rate against the simulated resistance of the Diskus® dry powder inhaler
.
J Aerosol Med Pulm Drug Deliv
.
2013
;
26
(
3
):
174
9
.
41.
Sharma
G
,
Mahler
DA
,
Mayorga
VM
,
Deering
KL
,
Harshaw
O
,
Ganapathy
V
.
Prevalence of low peak inspiratory flow rate at discharge in patients hospitalized for COPD exacerbation
.
Chronic Obstr Pulm Dis
.
2017
;
4
(
3
):
217
24
.
42.
Ghosh
S
,
Ohar
JA
,
Drummond
MB
.
Peak inspiratory flow rate in chronic obstructive pulmonary disease: implications for dry powder inhalers
.
J Aerosol Med Pulm Drug Deliv
.
2017
;
30
(
6
):
381
7
.
43.
Duarte
AG
,
Tung
L
,
Zhang
W
,
Hsu
ES
,
Kuo
YF
,
Sharma
G
.
Spirometry measurement of peak inspiratory flow identifies suboptimal use of dry powder inhalers in ambulatory patients with COPD
.
Chronic Obstr Pulm Dis
.
2019
;
6
(
3
):
246
55
.
44.
Sanders
MJ
.
Guiding inspiratory flow: development of the In-Check DIAL G16, a tool for improving inhaler technique
.
Pulm Med
.
2017
;
2017
:
1495867
7
.
45.
Broeders
ME
,
Molema
J
,
Vermue
NA
,
Folgering
HT
.
In check dial: accuracy for Diskus and turbuhaler
.
Int J Pharm
.
2003
252
1–2
275
80
.
46.
Mahler
DA
.
Peak inspiratory flow rate as a criterion for dry powder inhaler use in chronic obstructive pulmonary disease
.
Ann Am Thorac Soc
.
2017
;
14
(
7
):
1103
7
.
47.
Zervas
E
,
Petrocheilou
K
,
Tsopa
P
,
Evangeliou
M
,
Athanassiou
A
.
Peak inspiratory flow evaluation in different stages COPD patients using in-check method (Inspire Study)
.
Europ Respir J
.
2016
48
Suppl 60
PA3962
.
48.
Represas-Represas
C
,
Aballe-Santos
L
,
Fernández-García
A
,
Priegue-Carrera
A
,
López-Campos
JL
,
González-Montaos
A
.
Evaluation of suboptimal peak inspiratory flow in patients with stable COPD
.
J Clin Med
.
2020
9
12
E3949
.
49.
Alsomali
HJ
,
Vines
DL
,
Stein
BD
,
Becker
EA
.
Evaluating the effectiveness of written dry powder inhaler instructions and health literacy in subjects diagnosed with COPD
.
Respir Care
.
2017
;
62
(
2
):
172
8
.
50.
Frohnhofen
H
,
Hagen
O
.
Handgrip strength measurement as a predictor for successful dry powder inhaler treatment: application in older individuals with COPD
.
Z Gerontol Geriat
.
2011
;
44
(
4
):
245
9
.
51.
Samarghandi
A
,
Ioachimescu
OC
,
Qayyum
R
.
Association between peak inspiratory flow rate and hand grip muscle strength in hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease
.
PLoS One
.
2020
;
15
(
1
):
e0227737
.
52.
Enright
PL
,
Kronmal
RA
,
Manolio
TA
,
Schenker
MB
,
Hyatt
RE
.
Respiratory muscle strength in the elderly. Correlates and reference values. Cardiovascular Health Study Research Group
.
Am J Respir Crit Care Med
.
1994
149
2 Pt 1
430
8
.
53.
Tsuburai
T
,
Komase
Y
,
Tsuruoka
H
,
Oyama
B
,
Muraoka
H
,
Hida
N
.
The relationship between peak inspiratory flow and hand grip strength measurement in men with mild chronic obstructive pulmonary disease
.
BMC Pulm Med
.
2022
;
22
(
1
):
65
.
54.
Janknegt
R
,
Kooistra
J
,
Metting
E
,
Dekhuijzen
R
.
Rational selection of inhalation devices in the treatment of chronic obstructive pulmonary disease by means of the System of Objectified Judgement Analysis (SOJA)
.
Eur J Hosp Pharm
.
2021
;
28
(
2
):
e4
.
55.
Scichilone
N
,
Benfante
A
,
Bocchino
M
,
Braido
F
,
Paggiaro
P
,
Papi
A
.
Which factors affect the choice of the inhaler in chronic obstructive respiratory diseases
.
Pulm Pharmacol Ther
.
2015
;
31
:
63
7
.
56.
Barbara
S
,
Kritikos
V
,
Bosnic-Anticevich
S
.
Inhaler technique: does age matter? A systematic review
.
Eur Respir Rev
.
2017
;
26
(
146
):
170055
.
57.
Levy
ML
,
Dekhuijzen
PNR
,
Barnes
PJ
,
Broeders
M
,
Corrigan
CJ
,
Chawes
BL
.
Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT)
.
NPJ Prim Care Respir Med
.
2016
;
26
:
16017
.
58.
Wieshammer
S
,
Dreyhaupt
J
.
Dry powder inhalers: which factors determine the frequency of handling errors
.
Respiration
.
2008
;
75
(
1
):
18
25
.
59.
Price
D
,
Keininger
DL
,
Viswanad
B
,
Gasser
M
,
Walda
S
,
Gutzwiller
FS
.
Factors associated with appropriate inhaler use in patients with COPD - lessons from the REAL survey
.
Int J Chron Obstruct Pulmon Dis
.
2018
;
13
:
695
702
.
60.
Harb
HS
,
Ibrahim Laz
N
,
Rabea
H
,
Abdelrahim
MEA
.
Determinants of incorrect inhaler technique in chronic obstructive pulmonary disease patients
.
J Clin Pract
.
2021
;
75
(
6
):
e14073
.
61.
Martínez-Gestoso
S
,
García-Sanz
MT
,
Carreira
JM
,
Salgado
FJ
,
Calvo-Álvarez
U
,
Doval-Oubiña
L
.
Impact of anxiety and depression on the prognosis of COPD exacerbations
.
BMC Pulm Med
.
2022
;
22
(
1
):
169
.
62.
Ouellette
DR
,
Lavoie
K
.
Recognition, diagnosis, and treatment of cognitive and psychiatric disorders in patients with COPD
.
COPD
.
2017
;
12
:
639
50
.
63.
Kaplan
A
,
Price
D
.
Matching Inhaler devices with patients: the role of the primary care physician
.
Can Respir J
.
2018
;
2018
:
1
9
.
64.
Bulut
S
,
Karamanli
H
,
Akın Kabalak
P
.
Association of depression with improper use of inhaler devices by patients with obstructive disease
.
Clin Respir J
.
2021
;
15
(
7
):
721
7
.
65.
Schnell
K
,
Weiss
CO
,
Lee
T
,
Krishnan
JA
,
Leff
B
,
Wolff
JL
.
The prevalence of clinically-relevant comorbid conditions in patients with physician-diagnosed COPD: a cross-sectional study using data from NHANES 1999–2008
.
BMC Pulm Med
.
2012
;
12
(
1
):
26
.
66.
Dekhuijzen
PNR
,
Vincken
W
,
Virchow
JC
,
Roche
N
,
Agusti
A
,
Lavorini
F
.
Prescription of inhalers in asthma and COPD: towards a rational, rapid and effective approach
.
Respir Med
.
2013
;
107
(
12
):
1817
21
.
67.
Camilleri
K
,
Balzan
M
,
Bardon
MP
,
Schembri
E
,
Sullivan
M
,
Mifsud
S
.
Predictors of good inhaler technique in asthma and COPD
.
Europ Respir J
.
2015
46
Suppl 59
).
68.
Bartolo
K
,
Balzan
M
,
Schembri
EL
,
Asciak
R
,
Mercieca Balbi
D
,
Pace Bardon
M
.
Predictors of correct technique in patients using pressurized metered dose inhalers
.
BMC Pulm Med
.
2017
;
17
(
1
):
47
.
69.
Press
VG
,
Arora
VM
,
Shah
LM
,
Lewis
SL
,
Ivy
K
,
Charbeneau
J
.
Misuse of respiratory inhalers in hospitalized patients with asthma or COPD
.
J Gen Intern Med
.
2011
;
26
(
6
):
635
42
.
70.
Press
VG
,
Arora
VM
,
Trela
KC
,
Adhikari
R
,
Zadravecz
FJ
,
Liao
C
.
Effectiveness of interventions to teach metered-dose and Diskus inhaler techniques. A randomized trial
.
Ann Am Thorac Soc
.
2016
;
13
(
6
):
816
24
.
71.
Incalzi
RA
,
Gemma
A
,
Marra
C
,
Capparella
O
,
Fuso
L
,
Carbonin
P
.
Verbal memory impairment in COPD: its mechanisms and clinical relevance
.
Chest
.
1997
;
112
(
6
):
1506
13
.
72.
Melani
AS
,
Bonavia
M
,
Cilenti
V
,
Cinti
C
,
Lodi
M
,
Martucci
P
.
Inhaler mishandling remains common in real life and is associated with reduced disease control
.
Respir Med
.
2011
;
105
(
6
):
930
8
.
73.
Aydemir
Y
.
Assessment of the factors affecting the failure to use inhaler devices before and after training
.
Respir Med
.
2015
;
109
(
4
):
451
8
.
74.
Melzer
AC
,
Ghassemieh
BJ
,
Gillespie
SE
,
Lindenauer
PK
,
McBurnie
MA
,
Mularski
RA
.
Patient characteristics associated with poor inhaler technique among a cohort of patients with COPD
.
Respir Med
.
2017
;
123
:
124
30
.
75.
Chorão
P
,
Pereira
AM
,
Fonseca
JA
.
Inhaler devices in asthma and COPD: an assessment of inhaler technique and patient preferences
.
Respir Med
.
2014
;
108
(
7
):
968
75
.
76.
Zhang
W
,
Xu
L
,
Gao
S
,
Ding
N
,
Shu
P
,
Wang
Z
.
Technical evaluation of soft mist inhaler use in patients with chronic obstructive pulmonary disease: a cross-sectional study
.
Int J Chron Obstruct Pulmon Dis
.
2020
;
15
:
1471
9
.
77.
Rootmensen
GN
,
van Keimpema
ARJ
,
Jansen
HM
,
de Haan
RJ
.
Predictors of incorrect inhalation technique in patients with asthma or COPD: a study using a validated videotaped scoring method
.
J Aerosol Med Pulm Drug Deliv
.
2010
;
23
(
5
):
323
8
.
78.
Sriram
KB
,
Percival
M
.
Suboptimal inhaler medication adherence and incorrect technique are common among chronic obstructive pulmonary disease patients
.
Chron Respir Dis
.
2016
;
13
(
1
):
13
22
.
79.
Öztürk
C
,
Kaya
A
,
Bilgin
C
,
Yücesoy
L
,
İkidağ
B
,
Demirel
M
.
Evaluation of inhaler technique and patient satisfaction with fixed-combination budesonide/formoterol dry-powder inhaler in Chronic Obstructive Pulmonary Disease (COPD): data on real-life clinical practice in Turkey
.
Tuberk Toraks
.
2012
;
60
(
4
):
301
13
.
80.
Lee
H
,
Boo
S
,
Lim
Y
,
Kim
S
,
Kim
IA
.
Accuracy of inhaler use in patients with chronic obstructive pulmonary disease
.
Clin Nurs Res
.
2014
;
23
(
5
):
560
74
.
81.
Pun
S
,
Prasad
GK
,
Bharati
L
.
Assessment of inhalation techniques in COPD patients using metered-dose inhaler and Rotahaler at a tertiary care hospital in Nepal
.
Int Res J Pharm
.
2015
;
6
(
5
):
288
93
.
82.
Pothirat
C
,
Chaiwong
W
,
Phetsuk
N
,
Pisalthanapuna
S
,
Chetsadaphan
N
,
Choomuang
W
.
Evaluating inhaler use technique in COPD patients
.
Int J Chron Obstruct Pulmon Dis
.
2015
;
10
:
1291
8
.
83.
Duarte-de-Araújo
A
,
Teixeira
P
,
Hespanhol
V
,
Correia-de-Sousa
J
.
COPD: misuse of inhaler devices in clinical practice
.
Int J Chron Obstruct Pulmon Dis
.
2019
;
14
:
1209
17
.
84.
Usmani
OS
,
Lavorini
F
,
Marshall
J
,
Dunlop
WCN
,
Heron
L
,
Farrington
E
.
Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes
.
Respir Res
.
2018
;
19
(
1
):
10
.
85.
Sadeghi
S
,
Brooks
D
,
Stagg-Peterson
S
,
Goldstein
R
.
Growing awareness of the importance of health literacy in individuals with COPD
.
COPD
.
2013
;
10
(
1
):
72
8
.
86.
O’Conor
R
,
Muellers
K
,
Arvanitis
M
,
Vicencio
DP
,
Wolf
MS
,
Wisnivesky
JP
.
Effects of health literacy and cognitive abilities on COPD self-management behaviors: a prospective cohort study
.
Respir Med
.
2019
;
160
:
105630
.
87.
Kiser
K
,
Jonas
D
,
Warner
Z
,
Scanlon
K
,
Shilliday
BB
,
DeWalt
DA
.
A randomized controlled trial of a literacy-sensitive self-management intervention for chronic obstructive pulmonary disease patients
.
J Gen Intern Med
.
2012
;
27
(
2
):
190
5
.
88.
Shum
J
,
Poureslami
I
,
Wiebe
D
,
Doyle-Waters
MM
,
Nimmon
L
,
FitzGerald
JM
.
Airway diseases and Health Literacy (HL) measurement tools: a systematic review to inform respiratory research and practice
.
Patient Educ Couns
.
2018
;
101
(
4
):
596
618
.
89.
Lee
HY
,
Song
JH
,
Won
HK
,
Park
Y
,
Chung
KB
,
Lim
HJ
.
Comparing inhaler use technique based on inhaler type in elderly patients with respiratory disease
.
Tuberc Respir Dis
.
2021
;
84
(
1
):
46
54
.
90.
Dekhuijzen
R
,
Lavorini
F
,
Usmani
OS
,
van Boven
JFM
.
Addressing the impact and unmet needs of nonadherence in asthma and chronic obstructive pulmonary disease: where do we go from here
.
J Allergy Clin Immunol Pract
.
2018
;
6
(
3
):
785
93
.
91.
Calzetta
L
,
Aiello
M
,
Frizzelli
A
,
Ritondo
BL
,
Pistocchini
E
,
Rogliani
P
.
Impact of sex on proper use of inhaler devices in asthma and COPD: a systematic review and meta-analysis
.
Pharmaceutics
.
2022
;
14
(
8
):
1565
.
92.
Ocakli
B
,
Ozmen
I
,
Tuncay
EA
,
Gungor
S
,
Ozalp
A
,
Yasin
Y
.
Influence of gender on inhaler technique
.
Respir Care
.
2020
;
65
(
10
):
1470
7
.
93.
Chen
SY
,
Huang
CK
,
Peng
HC
,
Tsai
HC
,
Huang
SY
,
Yu
CJ
.
Peak-inspiratory-flow-rate guided inhalation therapy reduce severe exacerbation of COPD
.
Front Pharmacol
.
2021
;
12
:
704316
.
94.
Halpin
DMG
,
Mahler
DA
.
A Systematic review of published algorithms for selecting an inhaled delivery system in chronic obstructive pulmonary disease
.
Ann Am Thorac Soc
.
2022
;
19
(
7
):
1213
20
.
95.
Plaza
V
,
Sanchis
J
,
Roura
P
,
Molina
J
,
Calle
M
,
Quirce
S
.
Physicians’ knowledge of inhaler devices and inhalation techniques remains poor in Spain
.
J Aerosol Med Pulm Drug Deliv
.
2012
;
25
(
1
):
16
22
.
96.
Ali
HD
,
Worku
GS
,
Alemayehu
AA
,
Gebrehiwot
WH
.
Competence in metered dose inhaler technique among dispensers in Mekelle
.
Allergy Asthma Clin Immunol
.
2014
;
10
(
1
):
18
.
97.
Crane
MA
,
Jenkins
CR
,
Goeman
DP
,
Douglass
JA
.
Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial
.
NPJ Prim Care Resp Med
.
2014
;
24
(
1
):
14034
.
98.
Alwashmi
MF
,
Mugford
G
,
Vokey
B
,
Abu-Ashour
W
,
Hawboldt
J
.
Effectiveness of the BreatheSuite device in assessing the technique of metered-dose inhalers: validation study
.
JMIR Biomed Eng
.
2021
;
6
(
4
):
e26556
.
99.
Chrystyn
H
,
Audibert
R
,
Keller
M
,
Quaglia
B
,
Vecellio
L
,
Roche
N
.
Real-life inhaler adherence and technique: time to get smarter
.
Respir Med
.
2019
;
158
:
24
32
.
100.
Jansen
EM
,
van de Hei
SJ
,
Dierick
BJH
,
Kerstjens
HAM
,
Kocks
JWH
,
van Boven
JFM
.
Global burden of medication non-adherence in Chronic Obstructive Pulmonary Disease (COPD) and asthma: a narrative review of the clinical and economic case for smart inhalers
.
J Thorac Dis
.
2021
;
13
(
6
):
3846
64
.
101.
Chrystyn
H
,
Saralaya
D
,
Shenoy
A
,
Toor
S
,
Kastango
K
,
Calderon
E
.
Investigating the accuracy of the digihaler, a new electronic multidose dry-powder inhaler, in measuring inhalation parameters
.
J Aerosol Med Pulm Drug Deliv
.
2022
;
35
(
3
):
166
77
.
102.
Taylor
TE
,
Lacalle Muls
H
,
Costello
RW
,
Reilly
RB
.
Estimation of inhalation flow profile using audio-based methods to assess inhaler medication adherence
.
PLoS One
.
2018
;
13
(
1
):
e0191330
.
103.
D’Arcy
S
,
MacHale
E
,
Seheult
J
,
Holmes
MS
,
Hughes
C
,
Sulaiman
I
.
A method to assess adherence in inhaler use through analysis of acoustic recordings of inhaler events
.
PLoS One
.
2014
;
9
(
6
):
e98701
.
104.
Sulaiman
I
,
Cushen
B
,
Greene
G
,
Seheult
J
,
Seow
D
,
Rawat
F
.
Objective assessment of adherence to inhalers by patients with chronic obstructive pulmonary disease
.
Am J Respir Crit Care Med
.
2017
;
195
(
10
):
1333
43
.
105.
Häußermann
S
,
Arendsen
LJ
,
Pritchard
JN
.
Smart dry powder inhalers and intelligent adherence management
.
Adv Drug Deliv Rev
.
2022
;
191
:
114580
.
106.
Levy
ML
,
Hardwell
A
,
McKnight
E
,
Holmes
J
.
Asthma patients’ inability to use a pressurised Metered-Dose Inhaler (pMDI) correctly correlates with poor asthma control as defined by the Global Initiative for Asthma (GINA) strategy: a retrospective analysis
.
Prim Care Respir J
.
2013
;
22
(
4
):
406
11
.
107.
Sorino
C
,
Negri
S
,
Spanevello
A
,
Visca
D
,
Scichilone
N
.
Inhalation therapy devices for the treatment of obstructive lung diseases: the history of inhalers towards the ideal inhaler
.
Europ J Int Med
.
2020
;
75
:
15
8
.
108.
Blum
E
,
Thavarajah
K
,
Martirosov
AL
.
Optimization of patient-specific inhaler regimens with the use of the aerosol inhalation monitor
.
J Am Pharm Assoc
.
2019
;
59
(
2
):
252
7
.
You do not currently have access to this content.