Hands-on Education to Increase Comfort and Knowledge Utilizing In-Check TM Inhaler Training Device in Medical Trainees

Abstract

Introduction

Correct inhaler technique is of utmost importance in the optimal delivery of therapeutics utilized for respiratory illnesses. Previous research suggests that the ability of both patients and providers to correctly use these inhalers is sub-optimal and is associated with poorer patient outcomes. Further education about inhaler types and technique as part of residency education could serve to correct these trends.

Methods

Family medicine residents were taught correct inhaler technique with an inhaler training device (In-Check^TM DIAL G16) using a didactic lecture with hands-on teaching exercise utilizing pharmacy interprofessional teaching. We assessed pre- and post-intervention comfort and knowledge of correct inhaler technique.

Results

Twenty of twenty-seven eligible family medicine residents attended an interdisciplinary workshop with clinical pharmacists with the purpose of improving inhaler technique comfort level and knowledge. A pre- and post-knowledge test and comfort questionnaire were provided to those participating. Comfort levels with prescribing different inhaler types increased after the intervention and knowledge of different inhalers improved.

Conclusion

Use of an inhaler training device coupled with an interdisciplinary lecture format improved provider knowledge of correct inhaler technique and comfort with prescribing inhalers.

Keywords

inhaler technique interprofessional education trainee hand-on didactics

Introduction

Correct inhaler technique is crucial in the management of respiratory diseases. Incorrect technique is common (70-80% of patients) and is associated with increased Emergency Department visits, hospitalizations, and poorer outcomes.^1,2 Global Initiative for Asthma (GINA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines note that patients should be instructed on correct inhaler technique when inhalers are prescribed and should be periodically checked.^3,4 Despite this recommendation, this is often not performed with one study in a pediatric population indicating that only 10% of providers have patients demonstrate correct technique for pressurized metered-dose inhalers (pMDIs) on prescribing.⁵ Moreover, many health care providers lack the knowledge and skill on how to model proper use with a meta-analysis finding only 15.5% of health care providers correctly exhibited inhaler techniques to patients.⁶ Various methods have been shown to improve inhalation techniques in patients including face-to-face provider-patient training sessions, video based inhaler technique interventions, and interventions utilizing both clinical pharmacists and well-trained nurses.^7-11 Furthermore, training sessions for primary care providers have been shown to improve their knowledge and ability to demonstrate correct inhaler techniques as well as improve patient outcomes.^7,12

Prior studies of inhaler technique knowledge among medical trainees has demonstrated association between postgraduate year of training and knowledge of correct inhaler technique, however correct response rates were low across the postgraduate years.¹³ Prior investigation has demonstrated that teaching interventions aimed at bolstering medical trainees knowledge of proper inhaler technique in internal medicine residents led to improvement in inhaler knowledge^14,15 A prior study demonstrated similar findings in family medicine residents that utilized instruction manuals and devices for home study with a follow-up tutorial session and post-test knowledge assessment.¹⁶

There are various inhalers on the market with pressurized metered-dose inhalers (pMDIs), dry powdered inhalers (DPIs), and soft mist inhalers (SMI) commonly prescribed. These device types differ in regard to patient’s pulmonary effort and inspiration for adequate medication delivery. Use of multiple inhaler types has been predictive of increased errors with use. This suggests that patients are likely not recognizing the need for different administration techniques between inhaler types.¹⁷ Different training tools have been developed to address this. The In-Check^TM DIAL G16 is an adjustable inspiratory flow meter that is able to simulate resistant patterns of different inhaler types. It has been shown to improve patient inhaler technique by informing patient of correct effort needed for different types of inhalers.¹⁸ However, there are limited studies investigating its use as an educational tool. The purpose of this study is to evaluate the change in baseline knowledge of inhaler technique and comfort level among family medicine trainees after a pharmacist-led workshop utilizing a didactic lecture and hands-on teaching session using the inhaler training device, In-Check^TM DIAL G16.

Methods

Family Medicine residents from a single site in postgraduate years (PGY) 1-3 were invited to attend a one hour in-person inhaler training workshop as part of their regular didactic education. Participants were informed that their participation was voluntary and verbal consent was obtained. Pre- and post-surveys were marked with a unique identifier so as to blind investigators from the identity of participants. Education strategies utilized during the workshop included a lecture, which reviewed the characteristics of various inhaler types, followed by demonstration of correct inhalation technique using placebo inhaler devices and the In-Check^TM DIAL G16 inhaler training tool. Participants were then invited to demonstrate correct inhalation technique using the placebo inhaler devices and the In-Check^TM DIAL G16 tool for pMDI, DPI, and SMI and were given verbal feedback from the instructing pharmacist. The In-Check^TM DIAL G16 inhaler training tool is an inspiratory flow meter that is calibrated to mimic the airflow resistance pattern of various types of inhaler devices including pMDI and DPI inhaler devices.¹⁸

Participants were given identical pre- and post-workshop questionnaires and knowledge assessments regarding their comfort level of inhaler device prescribing and knowledge about each type of inhaler: pMDI, DPI, and SMI respectively. The comfort level questionnaire and knowledge-based assessment used were from a manuscript by Karle et al to assess the knowledge gap among health care providers in inhaler education (Table 1). Karle et al had developed this knowledge-based assessment to assess understanding of dose preparation/priming, inhalation maneuvers, generic inhaler handling, and device specific handling across pMDI, DPI, and SMI inhalers. They were reported to be validated by respiratory medicine physicians.¹³ Five comfort-level questions were measured on a Likert scale, and fifteen knowledge questions were assessed by a multiple-choice questionnaire. The participant’s year in training was collected, and participants were assigned a blinded unique identifier to compare pre- and post-workshop answers.

Table 1.

Pre- and Post- Workshop Questionnaire

Comfort level questions
Question number	How would you rate your comfort level in…	Likert scale
1	Prescribing inhaled medications?	Very Low – Low – Neutral – High – Very High
2	Teaching patients how to use inhaled medications?	Very Low – Low – Neutral – High – Very High
3	Understanding the limitations and differences between the various inhaler devices?	Very Low – Low – Neutral – High – Very High
4	Using the inhaler device?	Very Low – Low – Neutral – High – Very High
5	Recommending the most appropriate inhaler device for various patient populations?	Very Low – Low – Neutral – High – Very High

Knowledge-based questions
Question number	Inhaler device	Question (answer options)
1	Metered Dose Inhaler (MDI)	After removal of the cap, should the inhaler be shaken thoroughly prior to each use? (yes/no/unsure)
2	MDI	Does a new device require priming before the first use? (yes/no/unsure)
3	MDI	When using the device, should the inspiration be forceful and deep? (yes/no/unsure)
4	MDI	(True/False) When using MDI with a spacer, whistling by the spacer indicates poor inhaler technique.
5	MDI	How long do you instruct patient to hold their breath after each inhalation? (2-5 seconds/6-10 seconds/15-20 seconds/unsure)
6	Dry Powder Inhaler (DPI)	After removal of the cap, should the inhaler be shaken thoroughly prior to each use? (yes/no/unsure)
7	DPI	Does a new device require priming before the first use? (yes/no/unsure)
8	DPI	When using the device, should the inspiration be forceful and deep? (yes/no/unsure)
9	DPI	What is the inspiratory force required for adequate use of DPI? (<20 L per min / 30-50 L per min / >60 L per min / Unsure)
10	DPI	Which of the following impairs delivery / mobilization of medication with DPI? (Forgetting to shake device prior to use / Breathing into the device prior to use / Unsure)
11	Soft Mist Inhaler (SMI)	After removal of the cap, should the inhaler be shaken thoroughly prior to each use? (yes/no/unsure)
12	SMI	Does a new device require priming before the first use? (yes/no/unsure)
13	SMI	When using the device, should the inspiration be forceful and deep? (yes/no/unsure)
14	SMI	How does actuation of the SMI occur? (Pushing a button / Inhalation / Unsure)
15	SMI	With SMI, should the cap be removed before twisting the device in preparation of actuation? (yes/no/unsure)

Comfort questionnaire and knowledge-based questions were used as described in study performed by Karle et al.

Statistical analysis was performed on non-parametric data using the Wilcoxon Paired Test to evaluate pre- and post-test comfort scores both cumulatively (PGY1-PGY3) and within each postgraduate year group. Wilcoxon Paired Test was also used to evaluate pre- and post-test change in knowledge-based assessment among individual PGY groups given small sample sizes. Kruskal-Wallis test was utilized to evaluate changes across PGY groups in both pre-intervention and post-intervention comfort scores. The sum of participants knowledge-based questions corresponding with each type of inhaler type (pMDI, DPI, SMI) was obtained and paired t-tests were performed for cumulative knowledge-based pre-tests and post-tests. Statistical analysis with one-way ANOVA was performed to compare pre- and post-test scores across training level. This research project was granted exemption status from our institutional review board.

Results

In the Fall 2022, twenty-seven residents were invited to the described inhaler workshop as part of their regular didactic teaching of which twenty residents attended (74%). Those absent were primarily due to other clinical responsibilities. A total of 17 individuals completed the pre- and post-intervention comfort questionnaires whereas all twenty completed the knowledge-based assessment. The reasoning why 3 individuals did not complete the survey is unknown but all 3 were in post graduate year one (PGY-1). A plurality of participants that completed the knowledge-based assessment (9/20) were PGY-1 of training, six were PGY-2, and 5 PGY-3.

Comfort level questionnaires were completed both pre- and post- educational intervention. Pre-test scores demonstrated increased comfort scores that correlated with postgraduate year (Table 2) with a statistically significant difference in pre-test mean (out of total score of 25) between PGY-1 (mean of 10.5) and PGY-3 years (mean of 15.4, p value < 0.05). Cumulative comfort scores across all post graduate levels increased post-intervention from their pre-test scores (pre-test mean of 12.5, post-test mean of 16.2, p value < 0.001). When further divided into postgraduate year there was no statistical difference between pre- and post-test comfort level scores, however statistical analysis was limited in PGY subgroups given small sample size.

Table 2.

Pre- and Post-Intervention Comfort Questionnaire

PGY year	1	2	3
Participants (n)	6	6	5
Pre-Intervention Mean	10.5^a	12	15.4^a
Pre-Intervention Median	11	11	15
Pre-Intervention SE	0.92	1.21	0.68
Post-Intervention Mean	14.17	16.17	18.6
Post-Intervention Median	15	17	20
Post-Intervention SE	1.08	1.72	0.87

a denotes p value <0.05 between PGY-1 and PGY3 groups. Total score is out of 25.

Pre-intervention knowledge-based assessment of principles of pMDI inhalers (scored out of 5) showed similar results across years in training with no significant differences in pre-test mean scores across PGY cohorts. Cumulative knowledge-based assessment of pMDI inhaler principles showed improvement post intervention (pre-test mean of 3.3, post-test mean of 4.65, p value <0.001). First year postgraduate levels demonstrated significant improvements in knowledge-based scores of the pMDI inhaler after the educational intervention (pre-test median of 4,post-test median of 5, p value < 0.05). There was no significant difference in pre- and post-intervention knowledge of pMDI inhalers in the PGY-2 and PGY-3 cohort (Table 3). There was no significant difference in post-intervention knowledge-based test scores of pMDI inhalers across postgraduate level. Knowledge based assessment of principles of DPI and soft mist inhalers showed similarities to the findings for MDI inhalers. Pre-intervention scores (out of 5) did not show significant differences in knowledge scores between postgraduate level of training in both the DPI and soft mist inhaler evaluations. Cumulative post-intervention knowledge assessment indicated significant improvement as compared to pre-intervention means scores for both DPI (pre-test mean of 2.05, post-test mean of 4.45, p value <0.001) and soft mist inhalers (pre-test mean of 1.7, post-test mean of 3.65, p value <0.001). Improvements in knowledge-based post-test scores for DPI inhalers was noted in PGY-1 group, but no statistically significant change was noted from pre-to post-test scores among PGY-2 and PGY-3 groups individually and no change among individual PGY groups for SMI (Table 3). There was no significant difference among post-intervention scores across training level for DPI and soft mist inhalers.

Table 3.

Pre- and Post-Intervention Knowledge Based Assessment

PGY year	1	2	3	Cumulative
Participants (n)	9	6	5	20
MDI Inhaler Pre-Test Mean	3.33	3	3.2	3.3
MDI Inhaler Pre-Test Std Dev	0.87	1.10	0.54	0.92
MDI Inhaler Pre-Test Median	4	3	4	3.5
MDI Inhaler Pre-Test SE	0.29	0.45	0.2	0.21
MDI Inhaler Post-Test Mean	4.67	4.83	4.4	4.65^c
MDI Inhaler Post-Test Std Dev	0.5	0.41	0.55	0.49
MDI Inhaler Post Test Median	5^a	5	4	5
MDI Inhaler Post-Test SE	0.17	0.17	0.24	0.11
DPI Inhaler Pre-Test Mean	1.44	2.5	2.6	2.05
DPI Inhaler Pre-Test Std Dev	1.13	1.22	1.34	1.28
DPI Inhaler Pre-Test Median	1	2	2	2
DPI Inhaler Pre-Test SE	0.38	0.5	0.6	0.29
DPI Inhaler Post-Test Mean	4.67	4.33	4.20	4.45^c
DPI Inhaler Post-Test Std Dev	0.5	0.52	1.10	0.69
DPI Inhaler Post Test Median	5^b	4	5	5
DPI Inhaler Post-Test SE	0.17	0.21	0.49	0.15
Soft Mist Inhaler Pre-Test Mean	1.22	2.67	1.4	1.7
Soft Mist Inhaler Pre-Test Std Dev	0.67	1.51	1.14	1.22
Soft Mist Inhaler Pre-Test Median	1	3	1	1.5
Soft Mist Pre-Test SE	0.22	0.61	0.51	0.27
Soft Mist Post-Test Mean	3.67	3.83	3.6	3.65^c
Soft Mist Post-Test Std Dev	1.66	0.98	1.34	1.31
Soft Mist Post-Test Median	4	3.5	3	3.5
Soft Mist Post-Test SE	0.55	0.40	0.6	0.29

Pre- and Post- Intervention data grouped by inhaler type and postgraduate year. Cumulative data for all trainee levels is included. Statistical significance between pre-test and post-test labeled with superscript values as follows: a denotes p value <0.05; b denotes <0.01, c denotes p value <0.001.

As described above, the In-Check^TM DIAL G16 inhaler training tool is an inspiratory flow meter calibrated to mimic the airflow resistance pattern of various types of inhaler devices including pMDI and DPI. The efficacy of this device as a teaching tool was indirectly evaluated in the comfort level questionnaire (Questions 3 and 5) and in question number 3,5,8, and 13 of the knowledge-based assessment (Table 1). As noted above, comfort level was significantly increased across postgraduate levels after this intervention. The number of learners answering question 3 pertaining to force required for inspiration on pMDI inhalers correctly improved from 6 out of 20 on pre-test to 15 out of 20 on post-test. Most learners were aware of the need for deep inspiration while utilizing DPI (Question 8). Post-intervention, there was improvement in learners correctly identifying the inspiratory force required for DPI inhalers (Question 9) with only one learner identifying the correct response on pre-intervention assessment as compared to 18 out of 20 learners on post-intervention assessment.

Discussion

Management of chronic respiratory illness is an important aspect of primary care practice. Excellence in managing this chronic condition depends on selecting the most appropriate drug and a delivery system best suited for the ability and needs of the patient. While GOLD and GINA guidelines recommend instruction to patients on inhaler technique, many healthcare providers do not practice this and/or lack the skills to complete this important task.^3-6 Therefore, education about inhaler delivery systems and technique as part of residency education is of vital importance.

In this pilot study, an interprofessional educational intervention utilizing didactic learning and a novel approach for hands-on learning of inhaler technique using the In-Check^TM DIAL G16 inhaler training tool was demonstrated. The data from this pilot study shows the potential efficacy of this approach with improvement in knowledge base across inhaler types and increased comfort in inhaler prescribing present across postgraduate year of training. These results are consistent with other prior studies that have demonstrated improvement in knowledge of correct inhaler technique.^7-12,14,15 Our results suggest that an inhaler training tool could provide learners with increased comfort and knowledge with various inhaler delivery systems.

While the described pilot study demonstrated improvement with this learning intervention, further studies with greater sample sizes and more longitudinal follow-up are clearly warranted. Learning cohorts were admittedly small and homogenous. Including larger sample sizes as well as learners from different institutions could further assess the validity of this intervention. Results from statistical analysis must also be tempered by the small sample sizes (especially with subgroup analysis) and lack of multiple comparison correction. The results of the comfort survey data could also be impacted by the absence of 3 individuals (all in PGY-1 class) that did not complete this survey. While knowledge of correct inhaler technique was tested, individuals were not assessed on their ability to demonstrate correct inhaler technique and inspiratory flow measurements were not objectively captured. The importance of the inclusion of this skill-based assessment cannot be understated as providers may ultimately have to demonstrate technique to patients. In addition, long-term retention of material was not captured in this study and is important for assessing the durability of the learning intervention. Future investigations into the retention of this information, and ability to demonstrate correct technique as individuals progress through their postgraduate years, could be future direction of investigation into this question.

Finally, the impact of this learning on provider inhaler prescribing or patient outcomes was not assessed. However, the impact of improving patient education on correct inhaler technique has been shown in several studies with positive outcomes including improved medication adherence and reduced acute care events 30 days after discharge from the hospital for asthma or COPD.^19,20 It would be reasonable to hypothesize that improved health care provider knowledge and comfort level with correct inhaler techniques could translate into better patient education and ultimately to better patient outcomes. This could certainly be an area of worthwhile future study.

Conclusion

An interprofessional workshop with clinical pharmacists and family medicine residents that utilized hands-on teaching devices including placebo inhalers and the novel inhaler training device (In-Check^TM DIAL G16) was effective in improving the knowledge of inhaler technique and comfort level in prescribing inhalers among family medicine residents across postgraduate year. Given the importance of proper inhaler technique, further studies are warranted. Proposed areas of further studies include investigation into durability of inhaler knowledge, demonstration of correct inhaler technique across inhaler types, and whether this improved knowledge base leads to better patient education and outcomes.

Footnotes

ORCID iDs

Robert Strother

Nathaniel E. Miller

Audrey Umbreit

Ethical Considerations

Ethics approval was not required for the study described in this manuscript.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Melani

Bonavia

Cilenti

, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respiratory medicine. 2011;105(6):930-938.

Asthma GIf . Gobal Strategy for Asthma Management and Prevention; 2023. Updated July. ginaasthma.org.

Asthma GIf . Asthma management and prevention for adults, adolescents and children 6-11 years (2025). A summary guide for healthcare providers; 2025. Updated June.

Disease GIfCOL . Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease; 2025.

Schmitz

Ivancie

Rhee

Pierce

Cantu

Fisher

. Imperative Instruction for Pressurized Metered-Dose Inhalers: Provider Perspectives. Respir Care. 2019;64(3):292-298. doi:10.4187/respcare.06302.

Plaza

Giner

Rodrigo

Dolovich

Sanchis

. Errors in the use of inhalers by health care professionals: a systematic review. The Journal of Allergy and Clinical Immunology: in Practice. 2018;6(3):987-995.

Vazquez-Gonzalez

Leiva-Fernandez

Cotta-Luque

, et al. Effectiveness of an educational intervention about inhalation technique in healthcare professionals in primary care: a cluster randomized trial. Front Pharmacol. 2023;14:1266095. doi:10.3389/fphar.2023.1266095.

Al-Kharouf

Abdeljalil

Obeidat

Oweidat

Awwad

. Video-based teach-to-goal intervention on inhaler technique on adults with asthma and COPD: A randomized controlled trial. PLoS One. 2023;18(6):e0286870. doi:10.1371/journal.pone.0286870.

Huang

Miao

Dai

Chang

Zhang

Dai

. Qualitative and quantitative evaluation of a standardized training model for improving patients' ability to use inhalers. Front Public Health. 2023;11:1065311. doi:10.3389/fpubh.2023.1065311.

10.

Marko

Klimczak

Sobczak

, et al. Effective inhaler technique education is achievable - assessment and comparison of five inhaler devices errors. Front Pharmacol. 2025;16:1538283. doi:10.3389/fphar.2025.1538283.

11.

Kim

Moon

Lee

Kim

. Effects of a tailored inhaler use education program for chronic obstructive pulmonary disease patients. Patient Educ Couns. 2020;103(4):717-723. doi:10.1016/j.pec.2020.02.005.

12.

Leung

Bhutani

Leigh

Pelletier

Good

Sin

. Empowering family physicians to impart proper inhaler teaching to patients with chronic obstructive pulmonary disease and asthma. Can Respir J. 2015;22(5):266-270. doi:10.1155/2015/731357.

13.

Karle

Patel

Zweig

Krvavac

. Understanding the Knowledge Gap and Assessing Comfort Level among Healthcare Professionals Who Provide Inhaler Education. COPD. 2020;17(2):197-204. doi:10.1080/15412555.2020.1746251.

14.

Kim

Kwak

Kim

, et al. Inappropriate techniques used by internal medicine residents with three kinds of inhalers (a metered dose inhaler, Diskus, and Turbuhaler): changes after a single teaching session. J Asthma. 2009;46(9):944-950. doi:10.3109/02770900903229701.

15.

Vesbianu

Quaye

Rodriguez

. Improving Knowledge of Inhaler Technique among Internal Medicine Residents. Chest. 2019;156(4):849a. doi:10.1016/j.chest.2019.08.808.

16.

Kelcher

Brownoff

. Teaching residents to use asthma devices. In: Assessing family residents' skills and a brief intervention. Canadian Family Physician; 1994, vol 40, p 2090.

17.

Chrystyn

van der Palen

Sharma

, et al. Device errors in asthma and COPD: systematic literature review and meta-analysis. NPJ Prim Care Respir Med. 2017;27(1):22. doi:10.1038/s41533-017-0016-z.

18.

Sanders

. Guiding inspiratory flow: development of the In-Check DIAL G16, a tool for improving inhaler technique. Pulmonary medicine. 2017;2017:1495867.

19.

Jia

Zhou

Luo

Zhao

Zhou

Cui

. Effect of pharmacist led interventions on medication adherence and inhalation technique in adult patients with asthma or COPD: a systematic review and meta analysis. Journal of clinical pharmacy and therapeutics. 2020;45(5):904-917.

20.

Press

Arora

Trela

, et al. Effectiveness of interventions to teach metered-dose and diskus inhaler techniques. A randomized trial. Annals of the american thoracic society. 2016;13(6):816-824.