• Stress the importance of exhaling gently for a few seconds before inhaling (deeply and slowly for a metered dose inhaler, and deeply and rapidly for most dry powder inhalers). C
• Observe the inhaler technique of every patient receiving inhalation therapy on more than one occasion. C
• Don’t rely on self-reports regarding inhaler technique; despite claims of proficiency, most patients make at least one mistake. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
For patients with asthma or chronic obstructive pulmonary disease (COPD), inhalation therapy is the foundation of treatment. Yet all too often, patients don’t get the full value of their inhaled medications because they use their inhaler incorrectly. When technique is markedly flawed, suboptimal outcomes typically result.
Given the number of Americans with asthma (at least 22 million)1 and COPD (more than 13 million adults),2 faulty inhaler technique is a major public health problem. In fact, the number of people suffering from COPD may be even larger: Close to 24 million US adults are believed to have impaired lung function.3,4 For patients with asthma or COPD—many of whom are treated by family physicians—comprehensive education with a focus on correct use of an inhaler is essential.
In this review, we present evidence of frequent inhaler errors (from clinical studies) and highlight some of the more common mistakes (based on our clinical experience [TABLE]5). Finally, we offer ‘‘time-efficient’’ solutions to inhaler problems—steps that physicians in busy primary care practices can take to ensure that patients with asthma or COPD get the maximum benefit from inhalation therapy.
Caution patients about these device-specific mistakes*
|Metered dose inhaler|
|Metered dose inhaler plus spacer/VHC|
|Dry powder inhaler|
|*These are examples based on the experience of the authors; other errors are possible.|
†Timing is not as crucial as it is for an MDI without a spacer, but the drug is still lost if inhalation is delayed.
‡Correct use varies by type of product (see product literature for specifics).
DPI, dry powder inhaler; MDI, metered dose inhaler; VHC, valved holding chamber.
Source: Adapted with permission from Self TH, et al. Consultant. 2003.5
Inhaler error is well documented
Since 1965, when it was first reported that many patients used metered dose inhalers (MDIs) incorrectly,6 evidence has accumulated supporting the magnitude of the problem.7-12 (Studies conducted in family practice settings are described in “Researchers look at inhaler problems in primary care” and in TABLE W1.13-20)
A number of studies of various sizes (from 41 to 3955 patients) have assessed inhaler technique in patients being treated by clinicians in primary care. The researchers used a variety of scoring methods, as well. Among them were a simple 4-step (0-4) rating system, a 9-step system, a standardized inhaler-specific checklist, and a system that tracked the number of omissions patients made.13-20 All found significant problems with inhaler technique. (You’ll find a detailed look at the studies in TABLE W1 at jfponline.com.)
In one study of 422 patients,13 including young children, adolescents, and adults, participants received one point for correctly performing each of the following steps:
- Adequate preparation (shaking well for those using a metered dose inhaler [MDI]; loading correctly for patients using a dry powder inhaler [DPI])
- Adequate expiration, correct head position
- Adequate inspiratory technique
- Holding breath afterwards.
The researchers found that 25% of the patients had inadequate technique (≤2 on a 0-4 point scale). In this study, as in others that included patients using various types of devices, use of an MDI was associated with a higher rate of incorrect technique.
Another much-smaller study14 used the same 4-step system to assess the technique of 50 patients, all of whom had the same type of DPI and had received extensive training in the correct use of the device. Despite the training, 27% of the patients received scores of ≤2 (inadequate technique). Sixty-eight percent received a score of 3 (adequate); only 5% received a score of 4 (good).
The 2 largest studies—one including 3955 patients using MDIs20 and the other looking at 3811 patients using various kinds of devices18—found high levels of errors, as well. In the latter study, 76% of patients with MDIs made at least one error vs 49% to 55% of patients using DPIs.18 The results convinced a large majority of the physicians caring for these patients of the need to check inhaler technique more frequently. In the study of MDI users alone, 71% of the patients made at least one mistake.20 inhaler misuse was associated with higher asthma instability scores, this study showed.
More recently, a researcher assessed the effects of an integrated primary care model on the management of asthma and/or COPD in middle-aged and elderly patients, in a study of 260 patients in 44 family practices.19 The study included an evaluation of inhaler technique.
Participants were divided into an intervention group—137 patients who received education regarding inhaler use from a nurse—and a usual care group (123 patients). After 2 years, correct inhaler technique among those in the intervention group went from 41% at baseline to 54%. At the same time, the proportion of those in the usual care group with correct technique fell from 47% to 29%.19