Physical and Mental Factors Promote Poor COPD Inhaler Technique

Cognitive impairment, manual dexterity, and suboptimal peak inspiratory flow are associated with inadequate inhaler technique and poor outcomes in patients with chronic obstructive pulmonary disease (COPD), based on new data from about 500 individuals.

Despite worldwide use of handheld delivery systems in the treatment of COPD, data on how patient factors affect inhaler technique with different device types are limited, said lead author Donald A. Mahler, MD, a pulmonologist and emeritus professor of medicine at the Geisel School of Medicine at Dartmouth in Hanover, New Hampshire.

Misuse of inhalers can lead to inadequate medication delivery and an increase in COPD symptoms, the researchers noted.

In a study known as INHALE published in the Annals of the American Thoracic Society, Mahler et al examined the impact of cognitive function, manual dexterity, and inhalational ability on inhaler technique. The multicenter study population included 503 outpatients aged ≥ 60 years with smoking history of at least 10 pack-years and a diagnosis of COPD. The median age was 70 years, 55% were men, 28% were current smokers, and the mean post-bronchodilator forced expiratory volume in 1 second (FEV₁) was 46% predicted.

Participants were assessed at baseline for demographics and type of inhalers, and their spirometry and peak inspiratory flow were measured on a subsequent visit 2-21 days later. Participants were instructed not to use their inhalers prior to the second visit. At the second visit, participants were asked to use their inhalers on-site, instructed to do “as you do at home,” during which time they were observed by the researchers and critiqued on their technique via a checklist. The items included preparing the device (opening the inhaler and cap), breathing out completely, positioning teeth and lips on the mouthpiece, breathing in slowly and deeply without stopping, and holding the breath for 5-10 seconds or as long as possible.

The types of handheld devices included pressurized metered dose inhalers (60%), dry powder inhalers (59%), and slow mist inhalers (18%). Cognitive function was assessed using the Mini-Mental State Exam (MMSE), and dexterity was measured using the Functional Dexterity Test (FDT). About 10% participants met criteria for cognitive impairment (MMSE score < 24), 34.8% demonstrated nonfunctional manual dexterity (FDT > 50 seconds), and 20.5% had a suboptimal peak inspiratory flow rate (PIFr < 60 L/min).

Overall, 71% of participants met criteria for acceptable inhaler technique (four or five items satisfactory) based on the checklist.

Among 103 participants who met criteria for unacceptable inhaler technique (≥ 2 items unsatisfactory), cognitive impairment, nonfunctional manual dexterity, and suboptimal PIFrs were significantly and independently associated with poor technique (P = .0001, P = .0152, P = .014, respectively).

The individuals with poor technique also experienced smaller improvements in lung function after using their prescribed bronchodilator medications, with an average improvement in FEV1 of 69 mL at 30 minutes after inhalation compared to 105 mL among patients with acceptable technique.

Notably, satisfactory performance on the “hold your breath” technique item was the only technique that improved acute bronchodilation compared to unsatisfactory performance, which was surprising, Mahler said. “This directive or instruction needs to be emphasized when educating patients on how to use their inhalers,” he noted.

The findings were limited by several factors including the lack of data on whether participants were instructed on proper inhaler use and possible inconsistency of assessment across the multiple study sites.

However, the results provide evidence of the importance of a patient’s cognitive function, manual dexterity, and inhalational ability on effective inhaler use and support the need for healthcare professionals to consider these factors when selecting an inhaler delivery system, said Mahler. “It is most important that patients hold their breath for as long as possible after inhaling their medication from a handheld device to optimally open their airways,” he said.

“Although algorithms are available to guide healthcare professionals for inhaler selection, one or more of these algorithms needs to be tested in clinical practice to assess whether such an approach provides additional benefit for patients with COPD,” Mahler added.

Check Technique in Advance of Inhaler Selection

Although inhalers are a cornerstone therapy for COPD, many patients’ poor technique reduces the efficacy of these devices, said Arianne K. Baldomero, MD, MS, ATSF, a pulmonologist, critical care physician, and assistant professor of medicine at the University of Minnesota in Minneapolis.

“It is crucial to determine which specific patient-related factors are independently linked to poor technique, as identifying these elements may allow targeted interventions and selection of optimal device delivery systems for high-risk patients,” said Baldomero, who was not involved in the study.

The association between cognitive impairment, nonfunctional manual dexterity, and suboptimal PIFr and unacceptable technique are not surprising, said Baldomero. “Handheld devices demand precise mental step sequence recall, coordinated hand-finger manipulation, and sufficient physical inhalation strength to separate and deliver the medication. These results validate that baseline physiological and cognitive limitations directly impair a patient’s mechanical ability to operate standard inhalers successfully,” she said.

Consequently, inhaler prescriptions must be tailored to a patient’s physical and cognitive abilities, rather than relying on a one-size-fits-all approach, Baldomero emphasized. “Clinicians should evaluate technique, prioritizing the ‘hold your breath’ step, which was uniquely tied to significant bronchodilation benefits,” she said. For patients identified with cognitive or dexterity limitations, consider alternative delivery systems, such as nebulized therapies, she added.

The real-world rates of cognitive and dexterity impairments in COPD inhaler users are likely higher than those seen in the current study, said Baldomero. In addition, the findings were limited by a lack of data on whether patients had received prior formal device training, and a lack of data on long-term clinical outcomes, she noted. “Future research should focus on validating standard screening tools for clinics and establishing clear, evidence-based guidelines for choosing alternative delivery systems,” Baldomero said.

The study was supported by the COPD Foundation, Theravance Biopharma LLC, and Viatris. Disclosure information for the authors is available in the original study publication. Baldomero had no financial conflicts to disclose.

A version of this article first appeared on Medscape.com.