Background Inhaler technique is crucial to effective disease control. Amongst the most frequent mistakes made with all inhalers are the failure to exhale adequately, an insufficient breath-hold and, with pressurised metered-dose inhalers (pMDIs), the failure to inhale “slowly”. We present an easy to remember ‘2–3–4’ training paradigm, designed to address these errors, that was used in an open-label, cross-over study comparing patient handling of fluticasone propionate/formoterol (FP/FORM; flutiform®) breath-actuated inhaler (BAI) and pMDI devices. Here we present the pMDI data.

Methods The study was carried out in 311 patients (≥12 years) with persistent asthma (64%), COPD (28%), or both asthma and COPD (8% of patients). Patients were randomised to one of two sequences (BAI/pMDI or pMDI/BAI). Patients were trained to correctly use each device prior to an assessment of correct handling according to prespecified criteria. Eight steps were assessed including, but not limited to: exhale ≥2s; inhale ≥3s; hold breath ≥4s: the 2–3–4 technique. Patients were assessed on a single device (BAI or pMDI) at each visit, with 7–21 days between the two visits.

Results Overall, 77.2% of patients demonstrated correct performance of all steps of FP/FORM pMDI use at their first attempt post-training (N = 307); a further 14.0% required 2 attempts. 99.3% of patients were successfully trained within 15 min. Step 2 (Removes cap) and steps 4–6 (Places upright in mouth; starts inhaling and actuates; inhales for at least 3 s) were considered critical steps, and 82.4% of patients demonstrated correct performance of all 4 critical steps at their first attempt post-training. 96.1%, 87.6% and 95.8% of patients correctly followed each component of the ‘2–3–4’ training paradigm with the pMDI at the first attempt post-training (exhale ≥2s, inhale ≥3s; hold breath ≥4s, respectively).

Conclusions Almost all patients can be rapidly taught to use a pMDI (within 15 min) using a simple training method suitable for all clinical settings. An easy to remember, sequential “2–3–4” paradigm is effective in encouraging patients to exhale to residual volume, to inhale slowly, and to breath hold satisfactorily: manoeuvres that are frequently performed incorrectly without such instruction.

Sponsor Mundipharma Research Ltd.