The variety of devices available should increase the likelihood of finding a suitable option for every patient that they can use effectively. However, is this the case or has the ever-increasing number of drugs and devices on the market led to a growing confusion?
Inhaler technique in patients
Inhaler technique in Healthcare Professionals
When a new inhaler is prescribed, be it by a nurse, GP, pharmacist or other HCP, the patient should not leave the room without knowing how to use it and demonstrating that they can do so9. There are some really useful resources available such as Right Breathe10 and Asthma UK Inhaler Videos11, these are discussed in more detail later.
93% of HCPs made at least one error using a pressurised metered dose inhaler (pMDI)
Prescribing of multiple types of inhaler device
Studies have shown that the use of multiple inhaler devices rather than one can have an adverse effect on outcomes, even without consideration of inhalation technique12,13,14. More recent studies in COPD mirror this adding that it may negatively affect exacerbation frequency and SABA use, compared with the use of multiple inhalers of a similar type15.
All healthcare professionals involved in respiratory care should be aware of the fundamental difference between pMDIs and DPIs in terms of inspiratory flow rate and aim for consistency where the patient requires more than one device:
- pMDI – Slow and steady inspiration.
- DPI – Quick and deep inspiration.
Considerations when choosing a device
- Physical capabilities (the young and elderly are more likely to experience physical difficulties)
- Health beliefs
- Patient preference (operational use, convenience, oral sensation)
- Natural inspiratory flow rate
The ‘cheapest’ inhaler is not always the most cost effective
- Not shaking the device
- Failing to achieve a good mouth seal around the mouthpiece
- Inhaling too quickly or forcefully
- Not coordinating actuation with inhalation
- Actuating more than one dose at a time
- Failing to recognise when the device is empty
- Failing to get a good seal around the mouthpiece
- Not loading the device/not preparing the dose correctly
- Not holding the device upright
- Not inhaling rapidly enough from the beginning
Tools to aid choosing a device
It is essential to consider the likes and dislikes of the patient
Improving inhaler technique
It’s time to take the misuse of inhalers seriously and make a change.
Patient’s ideas, concerns and expectations about treatment and their understanding of their disease should be explored to enable them to make informed shared decisions about their inhalers to improve adherence. Suboptimal use of inhalers and the consequences of this cannot be ignored. Further training for healthcare professionals and patients has been shown to improve outcomes and reduce costs. It’s time to take the misuse of inhalers seriously and make a change.
Recommendations going forward
- Reflect on your current practice
- Consider an assessment of staff teaching inhaler technique
- Regular education sessions on inhaler technique and new devices
- Utilise the multidisciplinary team, work together to implement change
- Ensure you have inhaler placebos to show patients the available options and to teach technique
- Utilise the resources discussed in this blog to build your own skills and support colleagues