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Inhalation devices: Could we grade individual technique?

SUMMARY: A systematic review took a look at how inhalation technique has been assessed in research, finding no standardized method to assess, and thereby, compare or rate the quality of inhalation technique.

For many decades, inhalers have been used to treat respiratory diseases. However, a recent study has shown that correct inhaler technique (IT) is becoming poorer and contributes to reduction in disease control¹. 

A team of researchers from the UK came to realize that, to date, there were no known scoring systems to assess and quantify inhaler technique. In medicine, scoring systems are widely used and scoring IT has been observed as an outcome measure within research studies. Hence, the investigators conducted a systematic review to collate and evaluate methods of scoring IT in research literature.

The literature search was conducted through EMBASE, MEDLINE, CINAHL, PubMed, BNI google scholar and citation searching.

  • Asthma and COPD was the terms that the search was centred around.
  • Use of score as an outcome to measure of inhaler technique was the eligible criteria for the publications included in the search.
  • 77 articled was included in the systematic review

Articles were categorized and grouped according to the method of scoring IT and 6 themes identified;

  • awarding 1-point per step
  • grading final score 
  • points deducted from final scoring method
  • expressing total score as a percentage
  • weighting steps within the checklist
  • “validated” scoring methods

All of the above mentioned methods brought challenges and uncertainties such as no consensus on score interpretation, complex and time consuming etc. For the investigators, this confirmed an unmet need for a validated scoring system to assess IT in clinical practice. 

Investigator’s wish list for a scoring tool: 

  1. A standardized and content valid IT checklist
  2. Robust validation processes to ensure the tool measures IT and highlights poor technique
  3. A score yielding a meaningful outcome that can facilitate IT optimization

A validated measurement tool, applicable to all inhaler device types, would, if available, be useful in clinical practice to better assess, measure, and optimize patient’s inhaler technique. 

Maria Messerer, PhD
Medical Director, Chiesi Nordic


1J. Sanchis. Chest 2016. 150 (2).394-406

ID 410-2023-MARK (sept 2023)