https://helda.helsinki.fi

Effectiveness of inhalation technique assessment service for

patients with Respimat (R) inhaler

Rossi, Vilma

2021-12

Rossi , V , Salimäki , J , Sandler , C , Airaksinen , M & Kauppi , P 2021 , ' Effectiveness of

inhalation technique assessment service for patients with Respimat (R) inhaler ' , Pulmonary

Pharmacology & Therapeutics , vol. 71 , 102077 . https://doi.org/10.1016/j.pupt.2021.102077

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https://doi.org/10.1016/j.pupt.2021.102077

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Available online 15 September 20211094-5539/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Effectiveness of inhalation technique assessment service for patients with Respimat® inhaler

Vilma Rossi a,*, Johanna Salimaki b, Charlotta Sandler b, Marja Airaksinen a, Paula Kauppi c,d

a Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland b Association of Finnish Pharmacies, Helsinki, Finland c Department of Pulmonary Diseases, Helsinki University Hospital, Helsinki, Finland d Department of Allergy, Skin and Allergy Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland

A R T I C L E I N F O

Keywords: Inhalation technique Inhalation technique assessment service Respimat® inhaler

A B S T R A C T

Objectives: The objective of this study was to examine how Inhalation Technique Assessment Service (ITAS) by community pharmacies affect patients’ inhalation techniques when using the Respimat® soft mist inhaler. The inhaler was simultaneously updated into a reusable inhaler. The study focused on the Respimat® inhaler because its use is known to be challenging for patients. Methods: The study was performed as a pre-post design in 33 community pharmacies (CPs) in Finland. Patients’ inhalation technique was assessed before ITAS (baseline) and immediately after ITAS (follow-up 1). Follow-up 2 was performed when the patient came to the pharmacy for a refill (1–3 months after the baseline and the follow- up 1). A Respimat specific twenty item checklist was used to assess inhalation technique. The checklist included 1) preparation steps before the first use of the Respimat® inhaler (8 items) and 2) daily use steps of the Respimat® inhaler (12 items). After ITAS, the patients received a brief questionnaire to assess their asthma/ COPD history. Results: A total of 228 patients were enrolled at the first visit (mean age 67.8 years, 61.0% female, 85.5% had previous Respimat® use experience) and 42 of them attended the follow-up 2, 1–3 months later (mean age 70.1 years, 69.0% female, 92.9% had previous Respimat® use experience. The median number of the steps performed correctly increased from 17/20 at the baseline to all the 20 steps at the follow-up 1 (p < 0.001). At the baseline, 27.6% of the patients (n = 228) performed all preparation steps correctly, while 87.3% at the follow-up 1 and 71.4% at the follow-up 2. The percentage of the patients with acceptable inhalation technique (all critical daily use steps correct) increased from 69.7% at the baseline to 93.0% at the follow-up 1 (p < 0.001). The corre-sponding figure at the follow-up 2 was 69.0%. At the baseline, 30.3% of patients had optimal inhalation tech-nique (all daily use steps correct). At the follow-up 1 corresponding figure was 85.1%, and 54.8% at the follow- up 2. Conclusions: A pharmacist-led intervention significantly improved asthma and COPD patients’ inhalation tech-nique with the Respimat® inhaler. Significant improvements were found in the daily use steps and the prepa-ration steps before the first use.

1. Introduction

Asthma and COPD are serious public health concerns throughout the world [1,2]. Medication for asthma and COPD consists mainly of inhaled pharmaceuticals [1,2]. Metered-dose inhalers (MDIs), dry powder in-halers (DPIs), nebulisers and soft mist inhalers (SMIs) are currently commercially available devices for administering inhaled medicines [3]. The effectiveness of inhaled medication requires that patients adhere to

their medication and have the correct inhalation technique [4]. Previous studies show that device use errors are common in the patients using inhaled medications [3,5]. According to Chrystyn et al., 50–100% of the patients with DPIs or MDIs fail to use their inhaler correctly [5].

The Respimat® soft mist inhaler is a propellant-free device which produces a slow-moving mist of drug for inhalation [6]. The targets of the Respimat® inhaler development were to replace MDIs’ propellants with more environmentally friendly energy source, ease of inhalation

* Corresponding author. E-mail address: vilmamaria.rossi@hotmail.com (V. Rossi).

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https://doi.org/10.1016/j.pupt.2021.102077 Received 4 February 2021; Received in revised form 26 August 2021; Accepted 12 September 2021

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and high lung deposition of the drug. The original Respimat® inhaler has been available since 2004, and the inhaler became reusable in 2019 [7]. The new Respimat® can be reused with six cartridges, which re-duces environmental burden and increases convenience for patients.

According to a recent meta-analysis of SMIs, about 6 of 10 patients with a Respimat® inhaler make errors in the device use [3]. Inhaler misuse can affect patient’s disease control, adherence to medication, and as a result, increase health care costs [4,8]. Therefore, regular inhalation technique assessment by a healthcare-provider and correc-tion of possible errors in the inhalation technique have been suggested in the recommendations for management of asthma and COPD [1,2]. Pharmacy-based interventions have also been shown to improve pa-tients’ inhalation technique and adherence to the treatment [9–15]. A meta-analysis of 10 studies concluded that improvements in inhalation technique are associated with improvements lung functions of asthmatic patients [17].

The inhalation technique assessment service (ITAS) is a service that community pharmacies can provide to the patients with asthma or COPD. The aim of the ITAS is to ensure that the patient knows how to use the inhaler correctly and to optimise the patient’s outcome of the inhaled therapy [13,16,18]. Effectiveness of ITAS on patients’ asthma control and inhalation techniques have been studied in Norway and Denmark [13,16]. In Finland, effectiveness of ITAS has not been

previously studied. The aim of this study was to investigate how ITAS affects patients’ ability to prepare the Respimat® inhaler before the first inhalation and how it affects their inhalation technique. The study was conducted with the Respimat® inhaler because its use is known to be challenging for patients [13,19,20].

2. Materials and methods

2.1. Study design and patients

This study was designed as a pre-post design conducted between September 2019 and March 2020 in 33 community pharmacies (CPs) in Finland (Fig. 1). The Association of Finnish Pharmacies sent an invita-tion to participate in the study to all member pharmacies (n = 621). All the pharmacies that responded to the invitation were accepted into the study. The study-pharmacies were provided with the written in-structions and a 1-h online course on the study description and how to assess patient’s inhalation technique with the study checklist.

Each study-pharmacy enrolled patients to the study. A patient should be at least 18 years old and have a prescription for the Respimat® inhaler. All patients accepted to participate in the study received verbal, and written information about the study and they signed a written consent form prior to participation. Participation in the study was free of

Fig. 1. Study design. Inhalation technique was assessed immediately before ITAS (baseline), immediately after ITAS (follow-up 1) and 1–3 months after ITAS (follow- up 2).

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charge for the patients.

2.2. Intervention

At the baseline, patients were interviewed to collect necessary data like sex, age, the name of prescribed inhalation medication and whether the patient was a new or experienced Respimat® inhaler user. Experi-enced users were defined as patients who have used the Respimat® inhaler previously. At the end of the interview, experienced users were asked to demonstrate their inhalation technique. For new Respimat® users, the pharmacist showed the correct inhalation technique before the patient demonstrated their own inhalation technique. A twenty item Respimat® specific checklist was used to assess the inhalation tech-nique. After the baseline assessment, patients were instructed in the proper use of the Respimat® device and the correct inhalation tech-nique. Next, the patients demonstrated their inhalation techniques once again (follow-up 1) (teach back, i.e., confirm whether the patient un-derstand the instructions giving to them). Finally, the pharmacist pro-vided practical information on the care of the Respimat® inhaler and its associated medication, e.g., how to clean the inhaler, when the inhaler is empty and how to take care of oral hygiene. Follow-up 2 was performed when the patient came to the pharmacy for a refill (1–3 months after the baseline and the follow-up 1). The study design is presented in Fig. 1. The study was approved by the Ethics Committee of the Hospital District of Helsinki and Uusimaa, Finland.

2.3. Development of the checklist

A Respimat® specific, twenty item checklist was used to assess the inhalation technique (Appendix 1). The checklist had two parts: prep-aration steps before the first use of the Respimat® inhaler (steps 1–8) and daily use steps (9–20). The drug delivery to the lungs and thus, the efficacy of drug therapy can be significantly reduced if the patient per-forms certain critical steps improperly. The methodology of Ruud et al. was used to define the following five critical steps [13]: turning the clear base until it clicks (Step 10 in our checklist), opening the cap (Step 11), taking a deep breath (Step 15), pressing the dose-release button (Step 16), and continuing to breathe in slowly for as long as possible (Step 17). The study-pharmacists did not know which steps had been identified as critical. Patients who performed all the 12 daily use steps correctly were classified as having optimal inhalation technique. If patient performed all 5 critical steps correctly, the inhalation technique was classified as acceptable.

2.4. Data collection

The pharmacists collected the data during routine consultation in the study-pharmacies. The consulting pharmacists evaluated each step to be performed correctly or incorrectly. The patients used the Respimat® demo inhaler to demonstrate their inhalation technique, and the phar-macists reported the results using the electronic form. After ITAS, pa-tients received a questionnaire that assessed their asthma/COPD history including diagnosis, how long the patient had used the Respimat® inhaler and severity of asthma/COPD. Asthma and COPD severity was estimated using a numerical rating score from 0 to 10: 0–1 no symptoms; 2–5 mild symptoms not disturbing everyday life or sleep; 6–8 moderate symptoms disturbing daily activities and causing sleep disturbances; and 9–10 severe symptoms and hospitalizations [21,22].

2.5. Statistical analysis

The following outcome measures were used: rate of the correct steps before and after ITAS and the proportion of patients performing all preparation steps correct, all daily use steps correct (optimal technique), and all critical steps correct (acceptable technique) before and after ITAS. The analysis of the study results was undertaken using SPSS

Statistics (IBM Statistics for Windows, version 25.0.). The limit for sig-nificance was set at 0.05. According to the Kolmogorov-Smirnov test, the data did not follow the normal distribution (p < 0.001); thus, non- parametric tests were used in the analyses. The Wilcoxon rank sum test was used to analyse the difference in the rate of correct steps be-tween the baseline and the follow-up. The McNemar test for consistency across two variables was used to assess difference in proportion of pa-tients performing all checklist steps correctly (i.e., having optimal technique or acceptable technique).

3. Results

3.1. Study sample

Forty (40) CPs participated in the study. Seven (7) CPs withdrew from the study because of change of the pharmacy owner, lack of time or difficulties in patient enrolment. In total, 33 CPs recruited 228 patients whose inhalation technique was assessed before ITAS (baseline) and after ITAS (follow-up 1) (Fig. 2). Of the patients, 42 (18.4%) returned for follow-up 2, within 1–3 months after the baseline assessment. The flow diagram about the number of patients assessed for their inhalation technique is presented in Fig. 2. The questionnaire, which was given after the follow-up 1 assessment, was returned by 179 patients (78.5% of the baseline/follow-up 1 participants). Table 1 presents the character-istics of the study participants.

3.2. Inhalation technique

The patients’ ability to the correct preparation of the Respimat® inhaler significantly improved during the study from the median value of six correct steps to the median value of maximum eight correct steps at the follow-up 1 (p < 0.001) (Fig. 3 a). Also, the inhalation technique significantly improved from the median 11 correct steps at the baseline to the median 12 correct steps at the follow-up 1 (p < 0.001) (Fig. 3 b). For 195 (86%) patients, the number of steps performed correctly increased between the baseline and the follow-up 1. The number of correct steps increased from the median value of 17 correct steps to the median value of 20 correct steps. Of those 33 patients whose inhalation technique did not change between the baseline and the follow-up 1, 30 (91%) were already performing all the steps correctly at the baseline. Fourteen (14.0) per cent of the patients performed all the checklist’s steps (n = 20) correct at the baseline and 77.2% at the follow-up 1 (p <0.001). ITAS did not worsen any patients’ inhalation techniques.

The number of patients with the correct Respimat® inhaler prepa-ration, optimal inhalation technique and acceptable inhalation tech-nique significantly increased between the baseline and the follow-up 1 (Fig. 4). At the baseline, only 27.6% of the patients performed all the preparation steps correctly, 69.7% had acceptable and 30.3% optimal inhalation technique. At the follow-up 1, the corresponding figures were 87.3%, 93.0% and 85.1% respectively. At the follow-up 2, the number of patients with the correct Respimat® inhaler preparation and optimal inhalation technique was higher than at the baseline. The number of patients with acceptable technique was almost equal at the baseline (69.7%) and the follow-up 2 (69.0%). When comparing the baseline and the follow-up 1 results, with the follow-up 2 results, it should be noted that the number of patients was remarkably lower at the follow-up 2 (N = 42) than at the baseline and the follow-up 1 (N = 228).

3.3. Effects of patients’ characteristics on the inhalation technique

A negative correlation was found between the patient’s age and the number of correct checklist steps (n = 20) both at the baseline and the follow-up 1 (Spearman’s rho − 0.245 at the baseline and − 0.219 at the follow-up 1, p < 0.001). There was a trend for better inhalation tech-nique among the experienced users compared to the new Respimat® users at the baseline (Fig. 5). After ITAS, no difference was observed

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between the new and the experienced users. Gender, current medication (Spiriva®/Inspiolto®), patient’s diagnosis (asthma, COPD or both), severity of the disease, or the number of years the patient had used the Respimat® inhaler did not affect patient’s inhalation technique (p >0.05).

4. Discussion

This study shows that only a minority (27.6%) of the Respimat® inhaler users can prepare their inhaler correctly before the first inhala-tion, and less than one-third (30.3%) have optimal inhalation technique without inhalation training such as ITAS. A structured intervention by pharmacists improved patients’ inhalation technique with the Respi-mat® inhaler. This outcome is consistent with previous studies that showed physical demonstration alone or combined with written and verbal instructions is more effective than written and verbal information alone in asthma and COPD patients counselling [23–25]. Previous studies showed that adding a training device to verbal counselling improved inhalation technique with pMDI and DPI [26,27]. In addition, use of the training device along with verbal counselling was more effective at improving more difficult steps with pMDIs than verbal counselling alone [26]. These difficult steps were ‘press the inhaler to emit the dose while starting inhalation’ and ‘inhale slowly until the lungs are full’ which are also important steps when using the Respimat® inhaler.

Poor inhalation technique in asthma and COPD patients is common [3,5,8–10,12,13,28]. Much research has been done on factors and in-terventions affecting the inhalation technique [9–15]. Checklists and study designs may vary, making it difficult to compare the results of the different studies. Most previous studies evaluating inhalation technique of the Respimat® inhaler consider only daily steps of inhalation. The preparation steps before the first use are often overlooked. The prepa-ration steps include inserting the cartridge into inhaler and steps of

activation that expel air from the drug solution flow path [6]. After these activation steps, the inhaler is ready for routine use and the volume of each dose delivered by the device is consistent [6]. In the present study, 14.0% of the patients performed both all the preparation and all daily use steps (n = 20) correctly. In the other studies that have included preparation steps and daily use steps, the rate of correct Respimat® inhaler use was 36.3% [29] and 23.0% [30]. Now that the Respimat® soft mist inhaler has become reusable, patients’ ability to prepare the inhaler before the first use is emphasised. In our study, correct prepa-ration steps for the first use of the Respimat® inhaler were frequent problems in inhaler use, which highlights the importance of counselling with the inhaler device that is used by the patient.

In this study, 30.3% of patients had optimal inhalation technique at the baseline, 85.1% at the follow-up 1 and 54.8% at the follow-up 2. In a recent study, Ruud et al. evaluated a pharmacist-led ITAS with a similar intervention, checklist, and critical steps [13]. In their study, the pro-portion of patients with optimal technique increased from 11% at the baseline to 68% at the follow-up 1 and 47% at the follow-up 2 for the Respimat® inhaler. Optimal inhalation technique significantly improved with other inhaler devices from 8% at the baseline to 72% at the follow-up 1 and 52% at the follow-up 2. Acceptable inhalation technique was defined as patient performing all the critical steps of the inhalation correctly, and the same criterion was required for the efficacy of the inhaled therapy. In the present study, 69.7% of the patients per-formed acceptable technique at the baseline, 93.0% at the follow-up 1 and 69.0% of those attending the latter follow-up. This outcome com-pares with the finding of Ruud et al. where patients with acceptable technique increased from 37% at the baseline to 84% at the follow-up 1 and 79% at the follow-up 2 for the Respimat® inhaler [13]. In their investigation of other inhaler devices, the values were 31% at the baseline, 86% at the follow-up 1 and 75% at the follow-up 2.

Several other studies also show that pharmacist-led intervention improves the inhalation technique in asthma and COPD patients [9–12,

Fig. 2. Flow diagram of the number of ITAS included in the study and drop-outs in the 33 study pharmacies.

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14,15]. In Australia, pharmacy asthma care program increased the number of patients with the correct inhalation technique from baseline (24%) to follow-up (71%) six months later [9]. In Germany, 21.1% of the patients had optimal inhalation technique at baseline [10]. At follow-up, 46 weeks after the baseline assessment and the pharmacists’ intervention, 71.7% of the patients performed optimal inhalation tech-nique. In Spain, the pharmacist intervention improved patients’ inha-lation technique from 19.5% at baseline to 75.7% at follow-up six months later [11]. In Belgium, 22.4% of COPD patients in the control group had optimal inhalation technique at the beginning of the study, and at the end of 3 months, the corresponding figure was 68.5% [12]. In addition, asthma patients’ knowledge about asthma as a disease and asthma medication can be improved by pharmacy-based intervention and counselling [31]. Repeated counselling of inhalation technique was found to improve both the inhalation technique but also lung function [17,32–35]. In addition, personalized reminder labels of inhaling techinique on inhalers may even decrease the need of releaver [36]. Further, especially children and older patients seem to benefit of repeated counselling of inhaling technique [32,33,35]. The studies have also demonstrated that the pharmacist interventions improved patients’ asthma control [11] and medication adherence [11,12,14,15].

Assessment and advice on inhalation technique are a routine in pharmacies for those purchasing medication for the first time. However, assessment of inhalation technique at the follow-up depends on the patient and on the pharmacist. In addition, structured documentation if this has been done are missing. This study showed that both new and experienced users of the Respimat® inhaler improved their inhalation technique after ITAS. Previous studies show that long-term use of inhaled medicine is not a guarantee of the correct inhalation technique [10,13,37,38]. Our study, together with other previous studies, shows that even after education and correct inhalation technique

demonstration, there are patients with sub-optimal inhalation technique at the follow-up [9–13]. At the follow-up 1, immediately after the baseline assessment and correct inhalation technique education, pa-tients’ inhalation technique was significantly better than at the baseline in both the present and Ruud et al., studies [13]. However, there were significant reductions in correct Respimat® inhaler use from follow-up 1 to follow-up 2 in both studies. Because inhalation technique deteriorates over time, there is a need to reinforce inhaler education and have regular reassessments for both new and experienced users to maintain the cor-rect inhalation technique [28].

Previous studies also show that patients tend to overestimate their own inhalation technique [24,39]. Thus, patients may not recognise the mistakes they have made and the need for ITAS. In our study, we found negative correlation between age and the number of correct steps which is consistent with the previous study [20]. Other patient characteristics did not have strong impact on the inhalation technique in agreement with the previous study [19,38]. These findings demonstrate that reg-ular evaluation of the inhalation technique is essential with every pa-tient using inhaled medication.

Educational interventions aimed to improve patients’ inhalation technique seem useful, but research on the cost-effectiveness of ITAS or other educational inhaler technique interventions is limited [40]. However, the suboptimal inhalation technique is associated with disease exacerbation, poorer symptom control, increased hospitalisation or emergency room visits, and increased healthcare costs [8,24,41,42]. In Finland, more than 610 000 patients bought drugs for obstructive airway diseases in 2016 [43]. The reimbursement cost was over 76 million euros [43]. To maximise the benefit of the inhaled medicine therapy and reimbursements for medical expenses, inhalation technique needs to be assessed regularly. Pharmacists in the community pharma-cies have the required skills to educate patients on correct inhalation

Table 1 Characteristics of the study participants at the baseline and the follow-up 1 (n = 228) and the follow-up 2 (n = 42).

The Baseline and Follow-up 1 (n = 228) Follow-up 2 (n = 42)

n (%) mean (SD) n (%) mean (SD)

Age, years Not applicable 67.8 (12.0) Not applicable 70.1 (10.1) Range 27–91 Range 44–91

Gender Female 139 (61.0) Not applicable 29 (69.0) Not applicable Male 89 (39.0) 13 (31.0) Has the patient used Respimat inhaler before? Yes 195 (85.5) Not applicable 39 (92.9) Not applicable No 33 (14.5) 3 (7.1) Medication Spiriva Respimat 202 (88.6) Not applicable 39 (92.9) Not applicable Inspiolto Respimat 25 (11.0) 3 (7.1) Missing data 1 (0.4) 0 How many years the patient had used Respimat® inhaler?a 4.1 (3.4) 3.2 (2.7)

Range Range 1 month–19 years 1 month–10 years

Diagnosisa

Asthma 54 (23.7) Not applicable 14 (33.3) Not applicable COPD 43 (18.9) 5 (11.9) Both 51 (22.4) 11 (26.2) The patient did not 8 (3.5) 2 (4.8) know his/her diagnosis Missing data 72 (31.6) 10 (23.8) Severity of asthmaa 5.1 (2.2) 5.4 (2.3) No symptoms (0–1) 5 (4.5) Range 0–10 1 (3.7) Range 0–9 Mild symptoms (2–5) 60 (54.5) 12 (44.4) Moderate symptoms (6–8) 40 (36.4) 13 (48.1) Severe symptoms (9–10) 5 (4.5) 1 (3.7) Severity of COPDa 5.0 (2.2) 4.6 (2.5) No symptoms (0–1) 4 (4.0) Range 1–10 2 (11.1) Range 1–9 Mild symptoms (2–5) 48 (48.5) 10 (55.6) Moderate symptoms (6–8) 42 (42.4) 5 (27.8) Severe symptoms (9–10) 5 (5.1) 1 (5.6)

a This Information was obtained from those patients who answered the questionnaire (n = 179). The questionnaire was given to every patient in the study. SD=Standard deviation.

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technique, and ITAS can be provided as a part of daily routine. This study provided information about how ITAS affects patients’

ability to prepare the inhaler before the first use and inhale the medi-cine. The limitation of this study is using the baseline information as the control and the comparison instead of using a placebo group. It was important for the ethics of the study that all the participants in the study were advised on the correct use of the inhaler because the Respimat® inhaler had changed reusable at the beginning of the study. A further major limitation of this study was that there were only 42 inhalation technique assessments at the follow-up 2 (18.4% of the number of the assessments at baseline and follow-up 1). The number of participants at the follow-up 1 was estimated to be large enough (n = 228) for the power of the study but the study was terminated earlier than planned because of the beginning of the COVID-19-pandemic in Finland in March 2020. Large drop-out numbers limit the generalizability of the results. In

addition, large drop-out numbers must be considered when comparing the baseline and follow-up 1 results with the follow-up 2 results. Further, this study did not include any lung function measurements and thus we cannot estimate if improvement in the inhalation technique resulted in better lung function.

More research is needed on the long-term effectiveness of ITAS to determine how often asthma and COPD patients’ inhalation techniques should be reviewed. In previous studies, follow-up time has varied be-tween four weeks [10] and six months [9,11]. Based on the results of this and previous studies, it is not known whether the effect of ITAS will sustain longer, for example, 12 months. This should be investigated in future studies, as well as how to maintain optimal or at least acceptable inhalation technique for long-lasting asthma/COPD therapies.

Fig. 3. (a) The Boxplot illustrates the number of correct preparation steps for the first use of the Respimat® inhaler at the baseline and the follow-up 1 (N = 228) and the follow-up 2 (N = 42). The maximum number of correct preparation steps is 8. (b) Boxplot illustrating number of correct steps for daily use of the Respimat® inhaler at the baseline and the follow-up 1 (N = 228) and the follow-up 2 (N = 42). The maximum number of daily use steps is 12. o: Outliers (cases with values between 1.5 and 3 times the IQ range). *: Extreme values (cases with values more than 3 times the IQ range). IQ = interquartile range. Box represents 25–75 percentiles and dark line the median.

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5. Conclusion

The study shows that pharmacist-led intervention significantly im-proves asthma and COPD patients’ inhalation technique with the Respimat® inhaler. Both new and experienced users’ inhalation tech-nique improved after ITAS. Inhalation technique should be reviewed regularly to prevent relapses and ensure the effectiveness of the

medication. Pharmacists in community pharmacies have the required skills to educate patients on correct inhalation technique, and ITAS can be provided as a part of daily routine. More studies on the effectiveness of ITAS with other inhalers are needed.

Fig. 4. The proportion of patients with all preparation steps done correctly, optimal inhalation technique, acceptable inhalation technique at the baseline and the follow-up 1 (N = 228) and the follow-up 2 (N = 42).

Fig. 5. The boxplot illustrates the number of correct checklist steps and the distribution of correct steps for new and experienced users at baseline and follow-up 1 (N = 228). The maximum number of correct steps is 20◦: Outliers (cases with values between 1.5 and 3 times the IQ range). *: Extreme values (cases with values more than 3 times the IQ range). IQ = interquartile range. Box represents 25–75 percentiles and dark line the median.

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Author statement

Vilma Rossi. The corresponding author. Division of Pharmacology and Pharmacotherapy, Faculty of Phar-macy, University of Helsinki, Helsinki, Finland. Writing - Original Draft, Formal analysis. Johanna Salimaki. Association of Finnish Pharmacies, Helsinki, Finland. Conceptualization, Methodology, Writing - Original Draft. Charlotta Sandler. Association of Finnish Pharmacies, Helsinki, Finland. Methodology, Writing - Original Draft. Marja Airaksinen. Clinical Pharmacy Group, Division of Pharmacology and Pharma-cotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland. Writing - Original Draft, Supervision. Paula Kauppi. 1 Department of Pulmonary Diseases, Helsinki University Hospital, Helsinki, Finland. 2 Department of Allergy, Skin and Allergy Hospital, Helsinki Uni-versity Hospital and University of Helsinki, Helsinki, Finland. Writing - Original Draft, Supervision.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.pupt.2021.102077.

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