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The Impact of Adding a Training Device to Familiar Counselling on Inhalation Technique and Pulmonary Function of Asthmatics

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We have investigated the effect of adding a pressurized metered dose inhaler (pMDI) training device to verbal counselling on pulmonary function and inhalation technique.


A total of 304 adult asthmatic subjects (> 18 years old) were enrolled in a 3-month study of assessment and education. They were divided into an investigation group (Trainhaler plus Flo-Tone and verbal counselling, n = 261, mean age 49.2 years) and a control group (verbal counselling only, n = 43, mean age 48.7 years). Pulmonary function and inhalation technique were evaluated, mistakes noted, and the correct technique advised at three consecutive monthly visits. Visits also included verbal pMDI counselling (both groups) and training device coaching (investigation group).


By visit 2, the mean number of technique errors decreased significantly (p < 0.05) in both groups (investigation group p < 0.001). The investigation group demonstrated a marked decrease in the frequency of the critical error of maintaining a slow inhalation rate until the lungs are full—a technique difficult to learn via verbal counselling alone. The improvement in pulmonary function was significant from the second clinic visit in the investigation group (p < 0.05) and from the third visit in both groups (p < 0.001).


Use of a training device combined with verbal counselling improved inhalation technique. An earlier, significant improvement was also noted in pulmonary function.

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  1. Laube BL, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir Soc. 2011;37(6):1308–31.

    Article  CAS  Google Scholar 

  2. Sanchis J, et al. Inhaler devices—from theory to practice. Respir Med. 2013;107(4):495–502.

    Article  PubMed  Google Scholar 

  3. Dolovich MB, Dhand R. Aerosol drug delivery: developments in device design and clinical use. Lancet. 2011;377(9770):1032–45.

    Article  PubMed  CAS  Google Scholar 

  4. Abdelrahim M, Assi K, Chrystyn H. Dose emission and aerodynamic characterization of the terbutaline sulphate dose emitted from a turbuhaler at low inhalation flow. Pharm Dev Technol. 2013;18(4):944–9.

    Article  PubMed  CAS  Google Scholar 

  5. Abdelrahim ME. Emitted dose and lung deposition of inhaled terbutaline from turbuhaler at different conditions. Respir Med. 2010;104(5):682–9.

    Article  PubMed  Google Scholar 

  6. Elgendy MO, Abdelrahim ME, Eldin RS. Potential benefit of repeated dry powder inhaler’s inhalation technique counseling on asthmatic patients. Pulm Ther. 2015;1(1):91–101.

    Article  Google Scholar 

  7. Ali A, Abdelrahim M. Modeling and optimization of terbutaline emitted from a dry powder inhaler and influence on systemic bioavailability using data mining technology. J Pharm Innovation. 2014;9(1):38–47.

    Article  Google Scholar 

  8. Sarhan RM, et al. Effect of a nebulizer holding chamber on aerosol delivery. Respir Care. 2018.

    Article  PubMed  Google Scholar 

  9. Stein SW, et al. Advances in metered dose inhaler technology: hardware development. AAPS Pharm Sci Tech. 2014;15(2):326–38.

    Article  CAS  Google Scholar 

  10. Bosnic-Anticevich SZ. Inhaler device handling: have we really started to address the problem? Eur Respir Soc. 2017;49(2):1700120.

    Article  Google Scholar 

  11. Fink JB, Rubin BK. Problems with inhaler use: a call for improved clinician and patient education. Respir Care. 2005;50(10):1360–75.

    PubMed  Google Scholar 

  12. George CM, Schrock M. Inhalation therapy: help patients avoid these mistakes. J Fam Pract. 2011;60(12):714a–20a.

    Google Scholar 

  13. Papi A, et al. Inhaler devices for asthma: a call for action in a neglected field. Eur Respir Soc. 2011;37(5):982–5.

    Article  CAS  Google Scholar 

  14. Saji M, Alhas J, Siraj S. Study on the impact of patient counseling on the quality of life and pulmonary function of asthmatic patient. Int J Pharm Pharm Sci. 2012;4(Suppl 5):300–4.

    Google Scholar 

  15. Shareef J, Sajitha M, Shastry C. Impact of pharmacist provided patient counseling on quality of life inpatients with asthma in a tertiary care teaching hospital. Int J Pharma Res Rev. 2014;3(2):1–10.

    Google Scholar 

  16. Small M, et al. Importance of inhaler-device satisfaction in asthma treatment: real-world observations of physician-observed compliance and clinical/patient-reported outcomes. Adv Ther. 2011;28(3):202–12.

    Article  PubMed  CAS  Google Scholar 

  17. Gamble J, Stevenson M, Heaney LG. A study of a multi-level intervention to improve non-adherence in difficult to control asthma. Respir Med. 2011;105(9):1308–15.

    Article  PubMed  Google Scholar 

  18. Joshi AV, et al. Association of medication adherence with workplace productivity and health-related quality of life in patients with asthma. J Asthma. 2006;43(7):521–6.

    Article  PubMed  Google Scholar 

  19. Elgendy MO, Abdelrahim ME, Salah Eldin R. Potential benefit of repeated MDI inhalation technique counselling for patients with asthma. Eur J Hosp Pharm. 2015;22(6):318–22.

    Article  Google Scholar 

  20. Welch MJ, et al. Evaluation of MDI inhaler technique using a new training device. J Allergy Clin Immunol. 2015;135(2):AB48.

    Article  Google Scholar 

  21. Roche N, et al. Effectiveness of inhaler devices in adult asthma and COPD. EMJ Respir. 2013;1:64–71.

    Google Scholar 

  22. To KW, et al. Educational and supportive interventions for improving adherence to inhalation therapy in people with chronic respiratory diseases: a systematic review protocol. JBI Database Syst Rev Implement Rep. 2013;11(1):329–45.

    Article  Google Scholar 

  23. Price D, et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013;107(1):37–46.

    Article  PubMed  CAS  Google Scholar 

  24. Sanchis J, Gich I, Pedersen S. Systematic review of errors in inhaler use: has patient technique improved over time? Chest. 2016;150(2):394–406.

    Article  PubMed  Google Scholar 

  25. Melani AS, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011;105(6):930–8.

    Article  PubMed  Google Scholar 

  26. Al-Showair RAM, Pearson SB, Chrystyn H. The potential of a 2 tone trainer to help patients use their metered dose inhalers. Chest. 2007;131(6):1776–82.

    Article  PubMed  Google Scholar 

  27. Voelcker-Rehage C. Motor-skill learning in older adults—a review of studies on age-related differences. Eur Rev Aging Phys Act. 2008;5(1):5–16.

    Article  Google Scholar 

  28. Saeed H, et al. Effect of nebulizer designs on aerosol delivery during non-invasive mechanical ventilation: a modeling study of in vitro data. Pulm Ther. 2017;3(1):233–41.

    Article  Google Scholar 

  29. Molimard M, et al. Assessment of handling of inhaler devices in real life: an observational study in 3811 patients in primary care. J Aerosol Med. 2003;16(3):249–54.

    Article  PubMed  CAS  Google Scholar 

  30. Rabea H, et al. Modelling of in vitro and in vivo performance of aerosol emitted from different vibrating mesh nebulisers in non-invasive ventilation circuit. Eur J Pharm Sci. 2017;97:182–91.

    Article  PubMed  CAS  Google Scholar 

  31. Hussein RRS, et al. In vitro/in vivo correlation and modeling of emitted dose and lung deposition of inhaled salbutamol from metered dose inhalers with different types of spacers in noninvasively ventilated patients. Pharm Dev Technol. 2017;22(7):871–80.

    Article  PubMed  CAS  Google Scholar 

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We thank the participants of the study.


There was no external funding for this study itself. Clement Clarke International Limited (CCIL) funded the article processing charges. CCIL is the manufacturer and distributor (direct in UK and through third parties in other countries) of the Trainhaler® and Flo-Tone® devices. All authors had full access to all of the data in this study and take complete responsibility for the integrity of the data and accuracy of the data analysis.

Medical Writing Assistance

Medical writing assistance came from Alexis Harper of Jalcyon Ltd. Clement Clarke International Limited (CCIL) funded the medical writer/editor fluent in English science writing to assist the authors in the presentation of the final text. The scientific authors were provided with successive versions and queries for resolution throughout the editing process.


All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Authorship Contributions

Mina Nicola: Experiment, data entry, writing. Ahmed A. Alberry: Concept, study design, and review. Ossama Mohamed Mahmoud Sayed: Concept, study design. Raghda R.S. Hussein: Concept, study design. Haitham Saeed: Modelling. Mohamed E. Abdelrahim: Concept, planning of study design, review, and writing. All authors have read and approved the manuscript.


Mina Nicola, Ahmed Elberry, Ossama Sayed, Raghda Hussein, Haitham Saeed, and Mohamed Abdelrahim have nothing to disclose.

Compliance with Ethics Guidelines

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Ethical approval was obtained from the hospital ethical committee and written consent was given by the patients.

Data Availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Correspondence to Mohamed Abdelrahim.

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Nicola, M., Elberry, A., Sayed, O. et al. The Impact of Adding a Training Device to Familiar Counselling on Inhalation Technique and Pulmonary Function of Asthmatics. Adv Ther 35, 1049–1058 (2018).

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