Prescribing information


Practice makes perfect: self-reported adherence a positive marker of inhaler technique maintenance1

  • A significant relationship exists between inhaler technique maintenance and adherence1


What was already known?

  • Poor inhaler technique and non-adherence to treatment are major problems in the management of asthma2–4
  • 72–83% of people with asthma are not using their inhalers correctly5
  • 50% of patients who are taught how to use their inhalers correctly subsequently experience difficulty in maintaining correct technique6
  • Incorrect technique is associated with sub-optimal dosing of prescribed medication, resulting in reduced response to treatment, poor asthma control6,7 and non-adherence to medication,8 which can lead to unstable asthma symptoms, significant morbidity, and premature death9,10


Why was this study conducted?1

  • To gain a deeper understanding of the way in which asthma management practices, health behaviors and psychosocial factors relate to inhaler technique maintenance
  • To identify key disease-related, patient-related or behavior-related factors that predict inhaler technique maintenance


Study design1


  • Analysis of data from a quality-controlled longitudinal community pharmacy dataset (collected by community pharmacists over a 12-month period)
  • 96 pharmacies across Australia collected data from 570 patients who fulfilled the inclusion criteria at Visit 1
  • Of these, 348 patients were taking preventer/combination medication on a regular basis
  • All patients who demonstrated incorrect technique at Visit 1 were trained to mastery
  • Visit 2 data (1-month follow-up) were available for 238 patients
  • Data were collected on clinical and patient-related measures at Visits 1 and 2 (see Table 1)

Table 1:  

Data measures and collection points

Data measures Visit 1 Visit 2
Asthma control
Medication profile
Future risk of medication non-adherence  
Inhaler technique
Asthma knowledge  
Hospital emergency department visits and admissions  
Asthma quality of life  
Asthma perceived control  



  • Identify predictors of inhaler technique maintenance by exploring a wide range of clinical and patient-related factors
  • Independent variables assessed included: asthma control, perceived control of asthma, asthma quality of life, inhaler device type, correct or incorrect inhaler technique at Visit 1, future risk of medication non-adherence


Included patients1

  • Patients ≥18 years, fulfilling ≥1 criterion from the Modified Jones Morbidity Index11
  • At Visit 2, data was available for 238 patients:
    • Pressurised metered-dose inhaler (pMDI) (n=71)
    • Turbuhaler® (TH) (n=90)
    • Accuhaler® (ACC) (n=77)


What are the results of the study and why are they relevant?1

  • The proportion of patients demonstrating correct technique throughout the study according to inhaler device type is summarised in Table 2
  • There were no statistically significant differences between the patients who maintained correct technique vs. those who did not maintain correct technique with respect to the use of different types of dry powder inhalers (DPI), the TH or ACC (p>0.05)
  • 68% scored ≥1 in the Brief Medication Questionnaire Regimen Screen indicating a future risk of medication non-adherence

Table 2:  

Proportion of patients with correct inhaler technique per device

  Visit 1* Visit 2
Correct technique (n=238) 24% (56/238) 50% (118/238)
Correct technique per device    
pMDI technique (n=71/238) 25% (18/71) 40% (28/71)
DPI technique (n=167/238) 23% (38/167) 54% (90/167)
TH technique (n=90/167) 17% (15/90) 52% (47/90)
ACC technique (n=77/167) 30% (23/77) 56% (43/77)

*All patients who demonstrated incorrect technique at Visit 1 were trained to mastery.


  • The strongest predictor of correct inhaler technique maintenance was correct inhaler technique at Visit 1 (p<0.001, correct vs. incorrect technique)
  • Self-reported adherent behaviour in the 7 days prior to initial inhaler technique assessment, as evaluated with the Regimen Screen subscale of the Brief Medication Questionnaire,12 was a significant predictor of correct inhaler technique maintenance (p=0.028)
  • Individuals who had correct inhaler technique at the initial assessment, used a DPI (TH or ACC) and had self-reported adherent behavior in the 7 days prior were more likely to maintain correct inhaler technique over time
  • Age, asthma control, perceived asthma control, asthma quality of life and asthma knowledge were not associated with inhaler technique maintenance

Implications for clinical practice1

Around 20% of patients who were assessed as having device mastery initially were not able to demonstrate maintenance of that mastery at Visit 2, raising questions about the stability of ‘correct’ inhaler technique, and highlighting the need for continued evaluation of inhaler technique over time. It is possible to identify patients at risk of poor inhaler technique through an evaluation of recent adherence and the device that they are using. By identifying these patients, healthcare professionals can make better decisions about the need for follow-up appointments with regards to inhaler use.


Indication: ENERZAIR BREEZHALER is indicated as a maintenance treatment for asthma in adult patients not adequately controlled with a maintenance combination of a long-acting beta2-agonist and a high dose of an inhaled corticosteroid, who experienced one or more asthma exacerbations in the previous year.13

ACC, Accuhaler®; DPI, dry powder inhaler; pMDI, pressurised metered-dose inhaler; TH, Turbuhaler®.


  1. Azzi E et al. NPJ Prim Care Respir Med 2017;27:29.
  2. Reddel H et al. Med J Aust 2015;202:492–497.
  3. Nathan R et al. J Allergy Clin Immunol Pract 2015;3:734–742.
  4. Price D Fletcher M & van der Molen T. NPJ Prim Care Respir Med 2014;24:14009.
  5. Armour C et al. J Asthma 2011;48:914–922.
  6. Basheti I et al. J Allergy Clin Immunol 2007;119:1537–1538.
  7. Giraud V & Roche N. Eur Respir J 2002;19:246–251.
  8. Rand C. Eur Respir Rev 2015;14:97–101.
  9. NAC (National Asthma Council) Asthma Adherence. 2005. Available at: Date accessed: December 2020.
  10. Everard M. Respir Drug Deliv 2012;1:251–260.
  11. Unwin D et al. Respir Med 2001;95:1006–1011.
  12. Svarstad B et al. Patient Educ Couns 1999;37:113–124.
  13. ENERZAIR BREEZHALER Summary of Product Characteristics.
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UK | February 2021 | 103407

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