Key learning points

  • The coronavirus pandemic led to an increase in virtual consultations
  • Poor inhaler technique has been shown to increase morbidity and mortality
  • Trying to teach correct inhaler technique through a telephone consultation is challenging
  • The use of video consultations and telemedicine can be effective for patient and clinician education
  • Need to offer an opportunity to improve the way we teach and review inhaler technique in order to optimise outcomes

The coronavirus pandemic led to an increase in virtual consultations, via both telephone and video calls. This move to remote consultations included annual reviews for people living with respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). Inhaled therapy is a key part of managing these conditions so correct inhaler technique is essential to ensure that medication is deposited in the lungs. Poor inhaler technique has been shown to increase morbidity and mortality, increase the use of healthcare resources and lead to greater overall costs to the NHS and the wider economy.1 Furthermore, the National Institute for Health and Care Excellence (NICE) has highlighted the environmental benefits of using green inhalers, such as dry powder inhalers (DPIs), and the Investment and Impact Fund rewards Primary Care Networks for making a switch from pressurised metered dose inhalers (pMDIs) to DPIs where clinically appropriate.2,3 People switching from a pMDI to a DPI will need to be reviewed and taught the technique required to optimise the deposition of a drug from a DPI, which is quite different from the technique used with a pMDI.4 The Global Initiative for Asthma (GINA) also recommends using a maintenance and reliever therapy (MART) approach to managing asthma where appropriate so again, correct inhaler technique will ensure that patients get the most from their inhaler when stable and when experiencing symptoms.5

So, can we really teach and observe inhaler technique effectively through a virtual consultation? It goes without saying that trying to teach correct inhaler technique through a telephone consultation is challenging. The steps for teaching and assessing technique, require the patient to see and be seen. The device needs to be primed, the patient needs to be seen to exhale before the device is actuated, they need to use the correct inspiratory flow and they need to be seen to hold their breath after inhaling. When assessing inhaler technique, the acronym PEACH – prime, exhale, actuate, correct flow rate, hold the breath, can be used as a reminder of the steps needed to fully assess each patient. For each of these steps, the clinician needs to see the patient and a telephone consultation does not allow for this.  Furthermore, an objective measurement of inspiratory flow rate can be useful in guiding the choice of inhaler.6 Smart peak flow meters and inhaler devices have also been produced which have built in sensors can be used to monitor medication adherence and inspiratory flow rates.7,8

Sometimes, the way a patient holds the device or the position in which the device is primed may need correcting and this will usually be easier to correct face to face.  However, research suggests that healthcare professionals teaching inhaler technique do not always know how to use devices correctly themselves.9

The use of video consultations and telemedicine can be effective for patient and clinician education. Reliable video-based training can help to teach inhaler technique in a standardised way.10 Using inhaler videos from established and credible sources, such as Asthma and Lung UK, Rightbreathe or pharmaceutical companies, ensures consistency. Patients may receive information and advice on how to use their inhalers from a range of sources, including primary, secondary and emergency care clinicians, family and friends, and online resources such as Asthma UK and YouTube, so having a properly informed source of information is essential.11

There is no doubt, though, that seeing people in person and repeatedly reviewing them, has been shown to have a positive impact on inhaler technique.12 People taught correct technique face-to-face demonstrated clear improvements in their technique, but the impact of this teaching waned within a few weeks, suggesting that an annual review of technique is inadequate.13,14 It is not always practical to offer multiple in-person appointments to review, reassess and correct inhaler technique, however, so a combination of an initial face-to-face approach with video-based follow up may be the most pragmatic and effective intervention. Alternatively, increasing the involvement of community and practice pharmacists to provide ongoing inhaler technique assessment and education may be effective.14 All of these options offer an opportunity to improve the way we teach and review inhaler technique in order to optimise outcomes. As we learn to live with coronavirus, and services adapt to include a mixture of remote and face-to-face consultations, each individual will have a preference for different types of consultation, and these preferences will also change from appointment to appointment. There are pros and cons to each approach, both for patients and clinicians but offering an annual face to face review with follow up video assessments or access to video-based training may result in an evidence-based yet pragmatic approach to optimising respiratory care.

Beverley Bostock, Advanced Nurse Practitioner, Moreton in Marsh, PCN Nurse Coordinator, Hereford, Asthma Lead for the Association of Respiratory Nurse Specialists, Policy Forum member for PCRS, council member on the Primary Care Cardiovascular Society and Editor in Chief for Practice Nurse Journal

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