Effectiveness of individualized inhaler technique training on low adherence (lowad) in ambulatory patients with copd and asthma

ABSTRACT To analyze whether there is improvement in adherence to inhaled treatment in patients with COPD and asthma after an educational intervention based on the teach-to-goal method. This

is a prospective, non-randomized, single-group study, with intervention and before-after evaluation. The study population included 120 patients (67 females and 53 males) diagnosed with

asthma (70.8%) and COPD (29.1%). The level of adherence (low and optimal) and the noncompliance behavior pattern (erratic, deliberate and unwitting) were determined by the Test of the

adherence to Inhalers (TAI). This questionnaire allows you to determine the level of adherence and the types of noncompliance. Low Adherence (LowAd) was defined as a score less than 49

points. All patients received individualized educational inhaler technique intervention (IEITI). Before the IEITI, 67.5% of the patients had LowAd. Following IEITI, on week 24, LowAd was 55%

(_p_ = 0.024). Each patient can present one or more types of noncompliance. The most frequent type was forgetting to use the inhaler (erratic), 65.8%. The other types were deliberate:

43.3%, and unwitting: 57.5%. All of them had decreased on the final visit: 51.7% (_p_ = 0.009), 25.8% (_p_ = 0.002), 39.2% (_p_ = 0.002). There were no significant differences in adherence

between asthma and COPD patients at the start of the study. The only predicting factor of LowAd was the female gender. An individualized educational intervention, in ambulatory patients with

COPD and asthma, in real-world clinical practice conditions, improves adherence to the inhaled treatment. SIMILAR CONTENT BEING VIEWED BY OTHERS THE EFFECTS OF REPEATED INHALER DEVICE

HANDLING EDUCATION IN COPD PATIENTS: A PROSPECTIVE COHORT STUDY Article Open access 12 November 2020 INHALATION TECHNIQUE-RELATED ERRORS AFTER EDUCATION AMONG ASTHMA AND COPD PATIENTS USING

DIFFERENT TYPES OF INHALERS – SYSTEMATIC REVIEW AND META-ANALYSIS Article Open access 18 March 2025 FACTORS ASSOCIATED WITH HEALTH STATUS AND EXACERBATIONS IN COPD MAINTENANCE THERAPY WITH

DRY POWDER INHALERS Article Open access 26 May 2022 INTRODUCTION Chronic obstructive pulmonary disease (COPD) and asthma are conditions particularly prone to adherence issues due to their

chronic nature and to their periods of symptom remission1. Incorrect adherence and inhaler technique reduces the treatment benefits and leads to concerns in the healthcare management and

health-related consequences2. Adherence to oral or inhaler medication ranges between 41 to 57% in COPD3,4 and, in asthma, it is 50% in children5 and 30% in adults6. Adherence is associated

with numerous factors such as the disease, the route of administration, access to the treatment and specific characteristics of the patient7. Some systematic reviews have evaluated the

effectiveness of interventions to improve medication adherence, from self-management training to eHealth tools, with heterogeneous results8,9. Similarly, assessing medication adherence has

been done using a variety of methods and has rendered heterogeneous results. There is no standard prospective methodology in COPD or asthma10. The stated objectives include biochemical or

electronic monitoring of medication administration11. An example of these is the audio recording devices which simultaneously report on inhaler technique and adherence12. Self-reporting

questionnaires overestimate adherence. Also, most of these instruments have been designed to monitor oral medication13,14. Recently, the Test of adherence to inhalers (TAI)15 has been

validated for asthma and COPD. It comprises two complementary 12-item questionnaires with domains for patients and for professionals. It gathers information on the degree of adherence and

patterns of noncompliance. This test correlated better with adhesion measures made with electronic devices than the Morisky-Green test15. The inappropriate use of an inhaler is one of the

most commonly associated barriers with LowAd. Even easy application devices require training16. The ability to successfully administer medication through an inhaler has a direct effect, not

just on their deposition but also in the perception of benefits by the patient and in their willingness to maintain adherence. The training of the inhaler technique is the main factor that

health professionals can modify, although the real benefits are controversial17. The most effective training method to teach the inhaler technique is verbal instruction combined with a

physical demonstration18,19. The objective of the present study is to evaluate adherence to inhaled treatment using TAI15, in real clinical practice conditions, with a cohort of ambulatory

patients diagnosed with asthma and COPD; before and after an individualized educational inhaler technique intervention (IEITI). METHODS STUDY DESIGN AND PARTICIPANTS The prospective,

non-randomized, single-group study, with intervention and before-after evaluation, carried out between January 11, 2017 and December 21, 2018. Were included 160 ambulatory patients from a

Pulmonology Department of a Public General University Hospital. The patients included were adults >18 years of age, diagnosed of bronchial asthma or COPD, who were being treated with one

of the following devices: Pressurized metered-dose inhaler (pMDI)/Soft mist inhaler (SMI), Dry powder inhaler multidose (DPIm), Dry powder inhaler single dose (DPIs), and Pressurized

metered-dose inhaler (pMDI) with spacer holding chamber (pMDI + spacer). The diagnosis of asthma was based on GINA criteria20. The diagnosis of COPD was done using GOLD criteria of airflow

limitation (FEV1/FVC post-bronchodilator <0,70)21. In all cases, more than 6 months have passed since the initial diagnosis of COPD or asthma. Patients over 70 years old and/or with

psychiatric history were evaluated for cognitive function using the Pentagon Drawing Test22. The patients who did not pass this test were excluded from the study and the treatment with

nebulizers was recommended. Other criteria for exclusion were refusal to participate and the presence of a language barrier. The study protocol was approved by the institutional review board

of the hospital, called the “Ethical Committee of Clinical Research of the General University Hospital” on 09/28/2016 (approval number: EST-30/16). All study participants provided written

informed consent. Following the recruitment phase, they were scheduled for an initial visit (IV) with a physical therapist who was not involved in the recruitment. Two Pulmonology

investigators recruited patients in the consultation. The Physical therapists were trained during several sessions until they master the competence in inhalation technique training and using

the TAI test. During this visit, IEITI was done and a final visit (FV) was performed on week 24. The IEITI consisted of an educational intervention based on the teach-bak model23. The

patient received verbal instruction on the inhaler technique and then was asked to show their ability to do it. When the patient does not show an acceptable skill technique, further

instructions are given until he achieved that. The patient did not show an acceptable level of skill if, after explanations followed by physiotherapy and two consecutive patient

demonstrations, he could not perform the loading of the system and/or the inspiratory maneuver. The sequence of study visits is shown in Fig. 1 and the systematic training, divided into four

consecutive stages, is explained in Fig. 2. The IEITI also included informational material on dosage, scheduling, and characteristics of the inhalers (Supplementary Fig. 1). DATA COLLECTION

The degree of adherence to the inhaler treatment was evaluated using the ten-item TAI15 (https://www.taitest.com/). Each item scored from 1 to 5 (where 1 was the worst possible score and 5

was the best possible score), resulting in a minimum score of 10 points and a maximum of 50 points. Three levels of adherence were established along this continuum: poor (≤45), intermediate

(46–49), and good (50). For this study, we have used a composite variable that we have named Low Adherence (LowAd), which includes all patients with “intermediate” and “poor” adherence,

according to the cut-off points established by the authors, with the purpose to facilitate the interpretation of the results. Therefore, LowAd patients are those with a score ≤49.

Consequently, patients with Optimal Adherence (OptAd) are those with a score of 50 points. The “complete TAI” includes two additional questions (12-item TAI15), performed asked by the

professional in order to explore nonadherence or noncompliance patterns. In item 11, 1 point is given if patients do not remember the dosage or frequency, and 2 points are given if they

remember it. In item 12, 1 point indicates that the patient makes some critical error in inhaler technique whereas 2 points indicate that the patient does not make any errors when using the

inhaler. Three patterns of noncompliance have been identified by dividing up the scores into three groups of questions: “erratic” <25 points (items 1–5), “deliberate” <25 points (items

6–10), and “unwitting” <4 points (items 11–12). INDIVIDUALIZED EDUCATIONAL INHALER TECHNIQUE INTERVENTION (IEITI) The stages of IEITI are shown in Fig. 2. An IEITI was carried out in an

individual session of 30–40 min, conducted by a physical therapist. The session included the demonstration and assessment of the inhaler technique. Errors were corrected until the patient

reached an acceptable technique. Prior to the intervention, the patient was asked to complete the TAI (10 items). At the beginning of the session, the therapist asks the patient to show how

he uses the inhaler prescribed, before receiving any instructions for correct use. For that purpose, the patient received an identical device with a placebo. It was considered that the

patient had a Deficient Inhaler Technique (DeIT) when the inspiratory flow maneuver was insufficient and/or a critical error was made. The results of the evaluation were entered on an

inhaler technique evaluation card (ITEC) (Fig. 3). Next, the patient was asked about the dosage and frequency of the inhaler (item 11). If they have not made any “critical error24” (item

12), a graphic material of the inhaled medication is given (Supplementary Fig. 1) and the session is concluded. “Critical error” were considered if the patient showed an action or inaction

that, in itself, which can lead to a detrimental impact on drug administration in the lung24. If the patient does not present an acceptable skill level, the physical therapist will proceed

to the correct inhaler use model, correct errors, and ask the patient to show what he learned through this process. When the patient continued displaying DeIT, the therapist contacted the

prescribing doctor to report that the inhaler needed to be changed. CLINICAL VARIABLES AND OUTCOME MEASURE Data was gathered on sociodemographic, clinical, and spirometric information, type

of inhaler evaluated, and the results of the inhaler technique skill level of the patient (optimal or poor inhaler technique). The primary and secondary variables were analysed at the

baseline and after the intervention (IEITI). The main variable was the decrease in the percentage of patients with LowAd in the final visit. Secondary variables were: types of noncompliance:

erratic unwitting and deliberate, and percentage of patients with poor Inhaler Technique and critical errors. The differences between patients diagnosed with asthma and COPD were also

analysed as part of the study variables. To minimize measurement bias, the evaluation of the last visit, in week 24, was performed by a nurse previously trained in conducting the

questionnaire TAI, blinded to the results of the initial questionnaire and who has not participated in the initial training. STATISTICAL ANALYSIS The sample size was calculated in bilateral

contrast factoring in a 5% alpha risk and 0.1 beta risk (90% statistical power). A sample of 130 participants is necessary assuming that the initial rate of LAd would be 45% and the final

rate 25%25,26,27. The rate of patient loss to follow-up was estimated at 8%. Quantitative variables are shown as averages ± standard deviation (interquartile range: first and third

quartile). Comparisons between groups were performed with the Fisher exact test. Categorical variables were expressed as absolute and relative frequencies, and comparisons between them were

made using the Pearson Chi2 test or Fisher’s test. Quantitative variables were expressed as mean ± standard deviation and the comparisons were made between independent groups using the

Student’s _t_-test or the Mann–Whitney test if the variable did not present a normal distribution. When the variables have been measured at different points, the McNemar test was used for

their comparison and the paired samples _t_-test or Wilcoxon test depending on whether or not the distribution of the quantitative variables. A multivariate logistic regression analysis was

performed to evaluate associated factors with LowAd, calculating the odds ratios (ORs) and 95% confidence intervals (CI). The independent variables considered were: age, sex, deficient

inhaler technique (initial visit), smokers status, previous training, the severity level of disease (COPD/Asthma), type of disease (COPD/asthma), and types of inhalers evaluated (initial

visit). First, a univariate analysis of each variable was performed, and then, the variables whose univariate test had a _p_ value <0.3 were included in the multivariate logistic

regression model. The goodness-of-fit of the multivariate model was evaluated with the Hosmer–Lemeshow test. Odds ratio (OR) values were calculated with 95% confidence intervals (CI 95% CI).

All analyses were performed “two tails”, and a _p_ value of less than 0.05 was considered significant. All analyses were performed with the SPSS statistical software program (SPSS version

25.0; IBM®, Armonk, NY) and Stata [StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP]. A blinded researcher carried out the data analysis. REPORTING

SUMMARY Further information on research design is available in the Nature Research Reporting Summary linked to this article. RESULTS PARTICIPANTS A group of 160 patients was recruited for

the study. Of these, 31 (19.1%) were excluded, a majority of which, 20 (64.5%), refused to attend the visits. Nine patients (5.6%) were lost to follow-up. Two patients have prescribed a home

nebulizer due to repeated critical errors in inhaler technique and120 finished the study. The inclusion criteria and follow-up algorithm are shown in Fig. 4. Most of the patients were

female (55.8%) with an average age of 60,8 (±16.6) years. Most of them had been diagnosed with asthma, 85 patients (70.8%) and the rest, 35 patients, were diagnosed with COPD. The average

FEV1 was 72.6 ± 20.4 (of the predicted value). 45% of the patients report having some previous training in the use of the inhaler that was prescribed. The remaining baseline characteristics

of the 120 patients that participated in the study are shown in Table 1. The average score in the ten-item TAI questionnaire was 43,1 (±8,8) points in the initial visit and 46.6 (±5.9) at

the end of the study (_p_ < 0.001). About 120 inhalers were evaluated in the initial and final visits. The most commonly used inhaler at study recruitment was multidose DPIm, in 52

patients (43.3%) followed by pMDI with spacer chamber, in 31 patients (25.8%). The numbers and types of inhalers evaluated in the visits are listed in Table 2. Based on the definition

established in this study to evaluate inhaler technique, during the IV it was determined that the technique was poor or deficient in 69 inhalers (72.8%) and a critical error was made in the

manipulation of 21 inhalers (16.3%). Regarding the level of adherence, during the IV, 81 patients (67.5%) had LowAd. The most frequent form of noncompliance was forgetting to use the inhaler

in 65.8% of the patients (Noncompliance erratic). Lack of knowledge of the dosage and/or inhaler technique (unwitting), was the second most common form of noncompliance, in 69 patients

(57.5%). Finally, nonadherence that is deliberate and largely associated with patient motivation to use the inhaler, was identified in 52 patients (43.3%). EFFECTS OF THE INTERVENTION ON THE

STUDY VARIABLES During the IV, 81 patients (67.5%) presented LowAd compared to 66 (55%) in the FV. In contrast, the number of patients that presented OptAd at the start, 39 (32.5%), had

increased to 54 (45%) at the end of the study. The intervention (IEITI) produced a significant change in the level of adherence (_p_ = 0.024) and a decrease in the rate of patients with

LowAd on week 24 of the study. There was a decrease in erratic, 79 patients (65.8%), in the IV vs 62 (51.7%) after the IEITI (_P_ = 0.009). The number of patients presenting noncompliance

deliberate went from 52 (43.3%) to 31 (25.8%) at the end (_p_ = 0.002). Lastly, out of 69 patients (57.5%) with unwitting noncompliance, 47 (39.2%) remained in this category at the end (_p_ 

= 0.002). The pattern and relative frequency of noncompliance did not change by the end of the study, being the erratic pattern the most common one. Regarding the secondary variables, a

significant change was found in the percentage of inhalers that were used with poor inhaler technique. Similarly, the percentage of critical errors found in the initial visit improved after

the IEITI. Table 3 shows the description of the level of adherence, noncompliance, technique, and critical errors in the initial and final visit. Figure 5 shows point averages ± standard

deviation of the patients in the initial and final visit according to the cut-off points established for the classification of noncompliance and level of adherence No significant differences

were identified between the group of patients with COPD and asthma. Patients with asthma presented a higher rate of LowAd than patients with COPD, 71.8 vs 57.1% (_p_ = 0.120). Deliberate

noncompliance was also most frequent in patients with asthma, 48 vs 31.4%. In contrast, asthma patients displayed a better skill level in the use of the inhalers. 52.9% asthma patients had

DeIT vs 68.6% in COPD patients (_p_ = 0.039). The differences between patients with COPD and asthma are shown in Table 4. The baseline characteristics of the patients, such as having

received previous training or their level of studies, showed no relationship with low adherence. Only gender was related to low adherence (Table 5). Finally, age, gender, and asthma

diagnosis were chosen for the multivariate adjustment. The analysis did not show any relation between the level of adherence and baseline characteristics of the patients except in the case

of being a female patient (OR = 2.384, IC: 1.039–5.5518; _p_ = 0.040). (Table 6). DISCUSSION The problem of low adherence to inhaled treatment of chronic respiratory disease includes

numerous factors of different nature and complexity. The perception of a therapeutic benefit by the patient and the effective use of the inhaler are the key to achieve adherence to the

treatment. Insufficient instructions on the use of the inhaler and poor inhaler technique are common and have negative repercussions on adherence in the case of asthma and COPD8,9. Several

studies have evaluated the implementation of interventions to improve inhaled treatment adherence. Interventions vary from providing only information in different formats to complex

self-management programs and have had uneven results8. Nine authors used “teach-back_”_ interventions similar to those used in the present study and evaluated their impact on the proportion

of patients with the correct use of the inhaler but did not look at the changes in the adherence23. Other reviews have evaluated multi-component strategies to improve adherence but it is

hard to determine the contribution of each component to the outcomes. It is also difficult to compare the results due to the diversity of methods employed to evaluate adherence8. An

observational study with 88 patients with COPD that evaluated adherence by means of a four-question _self-administered questionnaire_ found that the only factor significantly related to

adherence was having received instructions of inhaler technique previously28. We did not find any studies on the impact of adherence of an inhaler technique education intervention, using the

IAT, on a population with asthma and COPD. After the IEITI intervention, patients with LowAd decreased significantly and at the same time, patients with optimal adherence increased. The

types of noncompliance, the percentage of patients with poor inhaler technique, and the percentage of critical errors also improved. A recent metanalysis addressed the impact of these

interventions on asthma and COPD exacerbations29. Only three studies evaluated the impact on adherence to the inhaled medication although, according to the authors, the benefit could be

explained, in part, through the so-called Hawthorne effect: the awareness of being observed or of having a behavior that is being evaluated, generates beliefs about the researcher’s

expectations and considerations of social acceptance that lead to a change in behavior30. Also, different measures of adherence were used and, finally, these were not included in the

quantitative analysis. The percentage of LowAd in the COPD and asthma population in the study is similar to those reported by other authors who used different measurement instruments7. About

67.5% of the patients in our study presented a low level of adherence, with an average score of 43.1 ± 8.8 (10-item TAI). The TAI15 and other recent observational studies report similar

results31,32,33. The first, which was carried out among Asian patients with exacerbated COPD, reported low adherence in 70% of the cases (low + intermediate adherence)32. Another study which

was carried in Spain with 122 COPD and asthma patients found low adherence in 71.3% of the patients studied32. However, a multinational study conducted in Latin America with 795 patients

found surprisingly good adherence results. The average score was 47.4 ± 4.9 and the percentage of LowAd in this population was 45.9%33. When we analyze separately the levels of adherence in

patients with asthma and COPD, we found a LowAd level in asthma patients (57.1%) compared with COPD patients (71.8%), although without any significant differences. A multicentric study that

analysed these differences using the same TAI instrument, found significant differences in levels of adherence in both groups of patients, with a higher rate of LowAd in asthma patients

(72%) and lower in COPD patients (51%)34. The noncompliance patterns between COPD and asthma are also different in this study, being the most frequent pattern in asthmatics the erratic

(66.8%). These differences are more likely to be related to sociodemographic characteristics34. In our study, the erratic pattern was also higher in patients with asthma with very similar

values (69%). In this group of patients, at baseline, the frequency of the erratic pattern was 65% compared to 57.9% that was obtained in the validation work of the TAI15. These studies15,34

did not include educational interventions nor a longitudinal evolution analysis of patient adherence. In relation to the evaluation of the inhalation technique, there is high variability in

the comparison of results due to the heterogeneity of the methods used. In general, the ability of patients in the inhalation technique seems not to have improved in the last 40 years35.

The international study “_International Helping Asthma in Real-life Patients_” (iHARP), the largest asthma study on patient inhaler technique with 5000 structured evaluations, showed an

error rate for inhalers (pMDI and DPIm) higher than 90% 36. At this point, we must comment on our results. Unlike other studies35, our definition of poor inhalation technique was not based

on a strict recording of an error checklist. Only the presence of an insufficient or uncoordinated inspiratory step and/or the existence of a critical error led us to consider an inhalation

technique as deficient. Following the opinion of some authors37, some steps such as exhaling before inhaling and/or the absence of apnea were not considered sufficient to consider the

inhalation technique as deficient. These considerations may represent a lower percentage of DeIT than reported in other studies36. Something similar happens with the disparity of assessments

of inhaler technique critical errors24. Our results suggest that educational interventions on inhaler techniques improve patients’ ability and, at the same time, can also improve the

perception of therapeutic benefit and adherence to inhaled medication. Although, these results should be interpreted with caution. First, the efficacy of a healthcare intervention is ideally

demonstrated under the conditions of double-blind randomized controlled trials with highly selected populations and operating under highly monitored and controlled conditions38. However,

logistical limitations conditioned the design to a pre-post intervention study, thus incorporating possible biases to the results obtained. Occasionally, studies with minimal exclusion

criteria may be more representative of the patients seen in daily clinical practice and provide complementary data to those obtained in traditional efficacy studies39. Second, it is possible

that the modifications in the patients’ behavior could have influenced the results of the IAT in the final visit since the patients knew that they were being evaluated and not as an effect

of the intervention itself (Hawthorne effect)30. Having a wide age range in the study may have introduced a bias, mainly due to endotypic and phenotypic differences. This could have led to

different clinical and questionnaire responses to the educational intervention27. Another aspect that should be considered when interpreting the results is the measure of adherence to the

inhaled medication by means of a self-administered questionnaire due to the biases inherent to this type of qualitative instrument14. Recent studies show evidence of an overstatement of

adherence in patients evaluated using the TAI compared to medication administration records40,41. The TAI seems to be more reliable when assessing patients with low adherence. But, with

higher scores, it should be modulated with more objective methods, particularly in the context of studies of intervention effectiveness40. In our study, the TAI was evaluated longitudinally

in two visits. This bias could have been present in both measurements, but it did not condition the favorable evolution of adherence in a significant way. Another limitation of the study is

the sample size, which was slightly lower than the calculated sample size, and the possible impact of other unmeasured confounding or covariates not included in the variable selection in the

logistic regression model, such as the educational or socioeconomic level of the patients. Finally, the possibility of a regression problem of the mean, although this phenomenon is frequent

when there is a change between two measurements, where the first shows a value and the second is closer to the mean. Despite the overall improvement of patients in the score of the TAI

questionnaire is slight, it rises three points on average in the second measurement, we believe that this is not the main finding of the study, but rather a 12% improvement in optimal

adherence. Given the substantial cost of asthma and COPD management, it is necessary to continue developing strategies to optimize the benefits of inhaled medication. There are still many

aspects that need to be researched in relation to adherence and inhaler technique skill, particularly in “real-life” studies. Among the future needs pointed out by authors like Price et

al.42, is needed a more holistic healthcare system, with an integrated approach to optimize the inhaled treatment and adherence. To achieve this objective, it is necessary to better

understand the conceptual connection between adherence and technique (whether they are different aspects, or they must be combined into one integrated quality approach to the administration

of inhaled medication). Understanding behavioral patterns of adherence in a subpopulation of patients (e.g., children, adults) and at different stages of the disease, will help to develop

more specific and effective interventions. This study can contribute to the understanding of how adherence and inhaler technique interact by evaluating them longitudinally following a

structured educational intervention in real-world clinical practice conditions. We demonstrated that, among patients with COPD and asthma, an individualized educational inhaler technique

intervention, carried out in real-world clinical practice conditions, improves adherence to the inhaled treatment, as evaluated by means of TAI. However, the small sample size limits the

external validity of these results and suggests the need for further studies. DATA AVAILABILITY The data that support the findings of this study are available from the corresponding author

upon reasonable request. The original contributions presented in the study are included in the article/supplementary material (Supplementary Fig. 1). Correspondence and requests for

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00106 (2016). Article  Google Scholar  Download references ACKNOWLEDGEMENTS The authors wish to thank the patients and personnel of the hospital unit for their cooperation during the course

of this study. AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Division of Pneumology, Morales Meseguer General University Hospital, 30008, Murcia, Spain Juan Miguel Sánchez-Nieto, Roberto

Bernabeu-Mora, Irene Fernández-Muñoz, Juan Alcántara-Fructuoso, Javier Fernández-Alvarez, Juan Carlos Vera-Olmos, María José Martínez-Ferre, Mercedes Garci-Varela Olea & Maria José

Córcoles Valenciano * Institute for Bio-health Research of Murcia (IMIB-Arrixaca), El Palmar, 30120, Murcia, Spain Juan Miguel Sánchez-Nieto, Roberto Bernabeu-Mora & Diego Salmerón

Martínez * Department of Internal Medicine, University of Murcia, El Palmar, 30120, Murcia, Spain Juan Miguel Sánchez-Nieto & Roberto Bernabeu-Mora * Division of Intensive Care Unit,

Morales Meseguer General University Hospital, 30008, Murcia, Spain Andrés Carrillo-Alcaraz * Department of Health and Social Sciences, Murcia University, Murcia, Spain Diego Salmerón

Martínez * CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain Diego Salmerón Martínez Authors * Juan Miguel Sánchez-Nieto View author publications You can also search for this

author inPubMed Google Scholar * Roberto Bernabeu-Mora View author publications You can also search for this author inPubMed Google Scholar * Irene Fernández-Muñoz View author publications

You can also search for this author inPubMed Google Scholar * Andrés Carrillo-Alcaraz View author publications You can also search for this author inPubMed Google Scholar * Juan

Alcántara-Fructuoso View author publications You can also search for this author inPubMed Google Scholar * Javier Fernández-Alvarez View author publications You can also search for this

author inPubMed Google Scholar * Juan Carlos Vera-Olmos View author publications You can also search for this author inPubMed Google Scholar * María José Martínez-Ferre View author

publications You can also search for this author inPubMed Google Scholar * Mercedes Garci-Varela Olea View author publications You can also search for this author inPubMed Google Scholar *

Maria José Córcoles Valenciano View author publications You can also search for this author inPubMed Google Scholar * Diego Salmerón Martínez View author publications You can also search for

this author inPubMed Google Scholar CONTRIBUTIONS Conceptualization, J.M.S.-N. and I.F.-M.; methodology, J.M.S.-N., I.F.-M., and A.C.-A.; software, J.M.S.-N. and I.F.-M.; formal analysis,

J.M.S.-N., I.F.-M., A.C.-A. and D.S.M.; writing—original draft preparation, R.B.-M. and J.M.S.-N.; writing—review and editing, R.B.-M.; J.A-F.; J.F-A.; J.C.V.-O.; M.J.M.-F.; M.G.-V.O.;

M.J.C.V. and J.M.S.-N.; project administration, J.M.S.-N.; funding acquisition, J.M.S.-N. CORRESPONDING AUTHOR Correspondence to Roberto Bernabeu-Mora. ETHICS DECLARATIONS COMPETING

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http://creativecommons.org/licenses/by/4.0/. Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE Sánchez-Nieto, J.M., Bernabeu-Mora, R., Fernández-Muñoz, I. _et al._ Effectiveness

of individualized inhaler technique training on low adherence (LowAd) in ambulatory patients with COPD and asthma. _npj Prim. Care Respir. Med._ 32, 1 (2022).

https://doi.org/10.1038/s41533-021-00262-8 Download citation * Received: 17 February 2021 * Accepted: 12 November 2021 * Published: 10 January 2022 * DOI:

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