The mock patient that is

The mock patient that is actually investigator has visited these community pharmacies with pressurized metered dose inhaler that is Ventolin®. The investigator asked the community pharmacist to demonstrate the inhaler technique for him. Investigator observed the technique carefully and completed the validated checklist (Bryant et al., 2013) of 8 steps after leaving the pharmacy. Another step has been added after the checklist which states that pharmacist can ask to repeat the steps from patient after demonstration (Giraud and Roche, 2002; Knudsen, 2014). It helps the pharmacist to discover the problems that patient will face while using the product. The Phos-tag Biotin management guidelines also recommend checking this step at each patient visit (EPR-3, 2007).
We did a comparative evaluation of metered-dose inhaler technique demonstration among community Pharmacists in Al Qassim and Al Ahsa regions. Al Ahsa is the major urban center in the eastern region of Saudi Arabia (Khan and Azhar, 2013).

Discussion
This study has found that majority (93.7%) of community pharmacists failed to demonstrate proper inhalation technique of pMDI inhaler. In this study only 7.3% of pharmacists have demonstrated the proper standardized technique of using pressurized metered dose inhaler whereas only 2.1% pharmacists correctly demonstrated the modified criteria (include step 9) of MDI. The criteria of grading system (Lenney et al., 2000) have been used to understand the knowledge of pharmacists to demonstrate the technique and its effect on aerosol drug delivery. The optimal delivery represents grade A (explained step 1–8), grade B (explained step 5–7) shows some delivery and Grade C is those pharmacists who are unable to explain most of the steps (step 2–7) indicating little or no delivery of the drug to the target point. In this study it was found that 7.3% of pharmacist’s fall in grade A category, 28.1% in grade B and grade C are15.2%. In grade C most of pharmacists were just told to press the canister and take two puffs. One of the most important steps is neglected by pharmacists while dispensing the inhalers. This study has added an additional step (step 9) according to the guidelines (EPR-3, 2007; GINA, 2009) recommending to ask this step to ensure patient understanding of the inhaler technique.
There are a number of studies that have been done to assess the demonstration of proper inhalation technique by pharmacists. In one study about 105 community pharmacists had been approached, out of which only 1 pharmacist (0.9%) was able to demonstrate the technique properly (Osman et al., 2012). Another study (Mickle et al., 1990) evaluated pharmacist practice in patient education when dispensing a metered-dose inhaler. The result shows that only 1 (1.9%) of the 52 pharmacists demonstrated MDI inhalation technique correctly. (Hounkpati et al., 2007) did an assessment of pharmacist’s understanding of the inhalation technique. It revealed that only 27.4% of pharmacists gave a correct answer for all the steps involved.
Community pharmacists are last health care provider to see the patients so it places them at an ideal position to teach inhaler technique to them. Various studies have been done on asthma education given by community pharmacists. In one study the community pharmacists were provided training and then evaluated the impact of pharmacist teaching on patients; it showed reduced hospitalization and improves inhaler technique (Cordina et al., 2001). Similar results have been found in another study that showed improved inhaler technique as a result of pharmacist counseling (Basheti et al., 2005). Another study has used interactive tele-pharmacy video counseling, using compressed video, connecting adolescents in schools with pharmacists; this study showed an improvement in inhaler technique (Bynum et al., 2001). Moreover, organizing asthma education session by pharmacists, physicians or nurses can serve as best adjunct to routine care of the asthmatic patients (Kohler et al., 1995).