Previous research conducted by Valerie G. Press, MD, MPH, indicates that about 86% of hospitalized patients with asthma or COPD misuse their rescue inhaler device and more than 70% misuse a common controller device. Dr. Press and colleagues have found that the in-person “teach to goal” (TTG) process can help provide patients with training for proper use of inhalers through rounds of demonstration and “teach back” until the skills have been attained. However, these skills appear to have waned within a month. A virtual TTG intervention (V-TTG) developed by Dr. Press for use in the home may allow re-training and practice without requiring patients to visit their clinician.


Introducing the Virtual TTG

“The V-TTG mimics the in-person TTG by having rounds of demonstration and assessment,” says Dr. Press. “Patients complete a brief pre-demonstration assessment by answering questions in the module, then they watch a brief, narrated demonstration of how to use the inhaler, followed by post-demonstration assessment questions. If any of the questions are answered incorrectly, they simply re-watch the demonstration and repeat the questions to firm up their knowledge and skills.”

For a study published in The Journal of Allergy and Clinical Immunology: In Practice, Dr. Press and colleagues sought to determine if the questions asked in a pilot version of the V-TTG effectively identify whether hospitalized patients with asthma or COPD would benefit from additional rounds of demonstration and whether the intervention effectively reduces inhaler misuse. An edited and revised version of questions was then assessed. Results of this round were used to test the efficacy of a final version. Early versions had up to 11 questions, while the final module contained seven questions, all falling into three domains: knowledge, skills, and attitude (Table). Pre-assessment questions covered knowledge and attitude, while post-assessment questions covered all three domains. Five of six questions in the final module showed significant improvements in their respective domains when comparing answers prior to versus after watching the demonstration. “This finding highlights that these questions were a useful assessment of knowledge or attitude,” adds Dr. Press.


Reducing Misuse

The researchers found that the proportion of study participants who misused their inhalers after using V-TTG was significantly lower than what was observed before using the intervention (24% vs 83%), based on a misuse cutoff of three questions answered incorrectly. The finding remained even after adjusting the cutoff from more than two to more than four incorrect answers. “Although perfect inhaler technique is not the goal—the goal is simply to get enough medication into the lungs, hence the misuse cutoff—the proportion of participants with perfect technique after using V-TTG was significantly higher when compared with the pre-V-TTG period (7%), with nearly half (46%) of patients achieving mastery,” says Dr. Press. Rates of confidence also increased with use of V-TTG, from 67% to 83%. Additionally, there was greater congruence between perceived versus actual inhaler skills following V-TTG use.

“The V-TTG may be a useful option for hospitals without the resources to train providers and deliver in-person inhaler teaching,” Dr. Press says. “The rigorous testing of the questions contained in the module should support that this is a well-developed tool tailored for patients across health literacy levels, such that those requiring more than one round of teaching have that opportunity in this self-delivered educational session.”


What’s Next?

Dr. Press and colleagues hope to test the V-TTG for home use in recently hospitalized patients to determine if repeating V-TTG sessions helps patients maintain inhaler technique skills that were learned while hospitalized. “Ultimately, we’d like to study if patients with long-term inhaler skill retention have better outcomes, including fewer symptoms and exacerbations, less acute health care utilization, etc.,” adds Dr. Press. “Future work is also needed to compare the V-TTG with in-person TTG.”


Press V, Kelly C, Kim J, et al. Virtual Teach-To-Goal™ adaptive learning of inhaler technique for inpatients with asthma or COPD. J Allergy Clin Immunol Pract. 2017;5:1032-1039. Available at