Comparative effectiveness of different inhaler technique education modalities on clinical outcomes in patients with asthma and chronic obstructive pulmonary disease: a protocol for a systematic review and network meta-analysis of randomised controlled trials.

introductionAsthma and chronic obstructive pulmonary disease (COPD) collectively affect an estimated 475 million individuals worldwide, yet only 31% of patients achieve correct inhaler technique, a proportion that has not meaningfully improved over four decades of clinical practice. Critical technique errors are independently associated with poor disease control, increased exacerbation risk and greater healthcare utilisation. Although multiple educational modalities exist, no systematic review has applied network meta-analysis (NMA) to simultaneously compare and rank all six principal training approaches. This protocol describes a systematic review and NMA to generate comparative effectiveness evidence for inhaler technique training modality selection in adults with asthma or COPD. METHODS AND ANALYSIS: A Bayesian random-effects NMA will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (PRISMA-P) 2015, PRISMA-NMA and PRISMA 2020, with prospective PROSPERO registration (systematic search: June 2026; completion anticipated: February 2027). Seven databases will be searched from inception to June 2026 without language restriction: PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science Core Collection, CINAHL, CNKI and Wanfang Data, supplemented by clinical trial registry searches. Eligible randomised controlled trials will enrol adults aged 18 years or older with confirmed asthma (Global Initiative for Asthma (GINA) criteria) or COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria). Six intervention nodes defined a priori using the Template for Intervention Description and Replication (TIDieR) framework will be compared against usual care and each other: face-to-face physical demonstration, video and digital training, teach-to-goal training, pharmacist-led training, nurse or clinician-led training and sensor-assisted technique feedback training. Primary analyses comprise two disease-specific NMAs (asthma: Asthma Control Test; COPD: COPD Assessment Test) with a pooled exploratory NMA as secondary analysis, a prespecified sparsity contingency and Bayesian meta-regression for transitivity (four covariates in disease-specific NMAs: device category, baseline severity, number of training sessions and participant age; disease type is added as a fifth in the pooled NMA). Risk of bias will be assessed using the Cochrane Risk of Bias 2; certainty of evidence will be evaluated using the Confidence in Network Meta-Analysis framework. ETHICS AND DISSEMINATION: Formal ethical approval is not required. Findings will be published in a peer-reviewed respiratory or evidence synthesis journal, presented at ERS and ATS annual congresses and communicated to GINA, GOLD and NICE guideline development groups. PROSPERO REGISTRATION NUMBER: CRD420261347918.