Optimising inhaler technique, why it matters.


Over the last 50 years since the first short acting beta2 agonist was developed in 1969 and the first inhaled corticosteroid in 1972, we have seen the development of many new inhaled molecules in a range of devices to treat patients with asthma and COPD. Despite developments, it is well known that there are still considerable challenges with the use of inhalers, and no one device suits every patient.

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

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One of the main benefits of inhaled medication is that it is delivered to the target organ (lungs), and therefore it allows lower doses, reducing the risk of systematic side-effects compared to oral therapy¹. 

An effective inhaler technique is likely to improve control of respiratory symptoms and reduce the risk of exacerbations. However, the medication will be of little benefit if the patient is unable to use it effectively and therefore unable to get the medication into the lungs.

There is still a high rate of poorly controlled and monitored asthma and continued unacceptable levels of morbidity and mortality2 and inhaler misuse is contributing to this.  In patients with asthma or COPD, incorrect inhaler technique is associated with an increased risk of hospitalisation, increased emergency department visits, and increased use of oral corticosteroids3, yet inhaler errors are common place4,5.  

A systematic review showed that incorrect inhaler technique is not only widespread, but sadly has not improved over the past 40 years6 suggesting that a new approach is needed to address the issues around inhaler technique.

While there are many reasons for inadequate inhaler technique, an interesting observation from personal experience is that often patients don’t perceive their inhalers as medication and refer to them as a separate entity from their tablets, perhaps underestimating their importance. It is essential that patients understand their disease, how their inhalers work and the importance of the medications that their inhalers contain. This is basic patient care, and should be common practice.


Inhaler technique in Healthcare Professionals

Healthcare professionals working in primary care have an essential role in helping patients to access a suitable device with the medication that they require and in a device that they can use. This involves being aware of the licensed indications of the inhaled medications available and the possible side effects as well as teaching and reviewing inhaler technique at every opportunity to maintain correct technique. However, the quality of inhaler technique training delivered to patients is variable with studies highlighting that errors are also very common in HCPs7. One study found that a staggering 93% of HCPs made at least one error using a pressurised metered dose inhaler (pMDI)8.

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Prescribing Information
1. Seretide (salmeterol xinafoate/fluticasone propionate) Prescribing information
2. Relvar Ellipta (fluticasone furoate/vilanterol) Prescribing information

With new inhalers coming onto the market all the time, it can be overwhelming and this has led to some HCPs giving up even trying to keep up to date because it is just too difficult in the time pressured, challenging environment we work in. It is important that that HCPs keep up to date with the options available and know how to use them as well as being aware of their own biases when it comes to selecting an inhaler with the patient. 

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 so
9. 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

A common issue with inhalers is the prescribing of multiple different types of device for individual patients (mixing dry powder inhaler devices with pMDI inhalers or soft mist inhaler (SMIs) which require different inhalation techniques. This is likely to lead to confusion and increase the chance of inhalers being used incorrectly. 

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.

Inhaler switches

When a company reduces the cost of their inhaler product or a new, more ‘cost effective’ option comes onto the market, practices may opt to switch patients from their current treatment to a cheaper option regardless of the patient’s current disease control. The methods used to switch patients vary between practices but it often leads to discontented patients. 

A study of 19 asthmatic patients showed that patients whose device was switched without consultation or their approval expressed dissatisfaction and many felt that it damaged their confidence not only in the clinician but in their medication16. As well as dissatisfaction, inhaler switches in asthma without consultation can reduce disease control due to increased levels of misuse17

The UK inhaler Group (UKIG) recommend that patients should not be switched to an alternative device without their inhaler technique being assessed for that device and only if they can use the device and consent to the switch should it go ahead9.  Sadly, this is not always reflected in practice and can lead to the patient not taking their treatment or taking it ineffectively.

Considerations when choosing a device

There is variation in prescribing formularies across Clinical Commissioning Groups (CCG’s), some of which aim to reduce and simplify the options available and consider cost.  While it is important to be aware of cost, it is equally important to recognise that the ‘cheapest’ inhaler is not always the most cost effective, particularly if the patient is unable to use it, suffers increased symptoms, exacerbations and hospital admissions.

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Choosing an inhaler device should be a shared decision between the patient and the clinician and consider factors such as: 18,19, 20, 21

  • Physical capabilities (the young and elderly are more likely to experience physical difficulties)
  • Health beliefs
  • Adherence
  • Patient preference (operational use, convenience, oral sensation)
  • Co-morbidities
  • Natural inspiratory flow rate

The ‘cheapest’ inhaler is not always the most cost effective

pMDIs require a slow and steady inspiration that needs to be coordinated with the activation of the inhaler.  Common errors with pMDIs include18:

  • 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
A spacer device should be advised for patients using a pMDI.  


DPIs require a quick and deep inspiration from the start.  Common errors include18:

  • 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

NICE recently published a Patient Decision Aid Inhalers for Asthma22. This 14-page document aims to help the HCP and patient to decide which inhaler may be suitable. While it has some very useful content and good links to the Asthma UK Inhaler Videos11, it focuses on asthma alone (not COPD) and the length of the document makes its use in the consultation in everyday practice unrealistic. It would be of great value if something similar but simplified could be developed into a web-based decision aid that HCPs could use in the consultation with the patient. 

Right Breathe10 (website and app) is a useful tool designed for clinicians and patients to inform the selection, prescribing and ongoing use of inhalers. It covers every inhaler and spacer device licensed in the UK for asthma and COPD and maps them against the guidelines. It facilitates easy searching and filtering of options narrowing it down to those suitable for that patient saving time and is accompanied by inhaler technique videos. 


Adherence

Adherence to treatment is a well-recognised issue in the management of asthma and COPD23.  Some patients may be more adherent than others, and non-adherence can be intentional or non-intentional and the reasons behind this can be complex.

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In an attempt to overcome this, we need to understand the patient’s lifestyle and what may affect their adherence to treatment so we can make personalised and shared decisions with the patient about their inhalers. For example, a patient that works night shifts and only remembers their inhaler when they get home in the morning and always misses their evening dose, may be more suited to a once daily treatment option whereas some patients already take medication twice a day and may prefer this option.

Some patient’s adherence may be improved by using a medication that can be used as a reliever as well as a preventer (license indications apply).  It is also essential to consider the likes and dislikes of the patient. If the patient does not like the look of the device, finds it difficult to use or clean, they are less likely to use it and this may be detrimental to their disease management24.

It is essential to consider the likes and dislikes of the patient


Improving inhaler technique

The impact of interventions to improve inhaler technique has been demonstrated by the Isle of Wight Respiratory Inhaler Project25. They found higher levels of emergency admissions than expected for asthma and a high spend on inhaled medication. They identified improving inhaler technique as a cost-effective way of improving patient outcomes encouraging collaboration between GP practices and pharmacists. 

Over 1 year, training in inhaler technique reduced spend on relievers by over 22%, emergency admissions dropped by 50% (n=20 v’s 41) and asthma deaths decreased by a staggering 75% (n=2 v’s 8). 

The UK Inhaler Group (UKIG) is a group of individuals and organisations who are passionate about improving the use of inhalers. In 2016 they published the Inhaler Standards and Competency Document which provides a framework to assess and support the standards of those initiating inhaler therapies and for checking inhaler technique9.  

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It sets out examples of how healthcare professionals can work with patients to optimise their technique and maximise the benefit of their medications. It also encourages us to think about our competency in prescribing and administering inhalers.  

HCPs have a responsibility to ensure that they are appropriately trained to deliver the care they are required to provide. The Primary Care Respiratory Society’s Fit to Care document provides guidance for commissioners and clinicians as to the skills, knowledge and training required by healthcare professionals working with patients with a respiratory condition in a primary or community care setting26. This can be used as a tool to identify gaps in training and to support a case for approaching the practice to support ongoing continuous professional development. 

To overcome the variation in inhaler technique delivered to patients, it may be appropriate to consider validated training and an assessment of competency for HCPs involved in teaching inhaler technique.

It’s time to take the misuse of inhalers seriously and make a change.

In summary, asthma control and COPD outcomes are still falling short despite the developments in inhalers and a major contributing factor appears to be poor inhaler technique and the consequences of this. Optimising inhaler technique is fundamental to the effective management of these conditions and should be taught and reviewed by a healthcare professional competent to do so.

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




References

1. Brocklebank D, Ram F, Wright J, Barry P, Cates C, Davies L, Douglas G, Muers M, Smith D, White J. Comparison of effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a review of the literature. Health Technology Assessment. 2001; 5(26):1-149.
2. Royal College of Physicians. National Review of Asthma Deaths: why asthma still kills. 2014. Available at: https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
3. Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, Serra M, Scichilone N, Sestini P, Aliani M, Neri M; Gruppo Educazionale Associazione Italiana Pneumologi Ospedalieri. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011;105(6):930–938.
4. Chrystyn H, van der Palen J, Sharma R, Barnes N, Delafont B, Mahajan A, Thomas M. Device errors in asthma and COPD: systematic literature review and meta-analysis. npj Prim Care Respir Med. 2017;27:22.
5. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK.  Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Education and Counselling. 208; 72:26-33.
6. Sanchis J, Gich I, Pedersen S. Aerosol Drug Management Improvement Team (ADMIT). Systematic review of errors in inhaler use: Has patient technique improved over time? Chest. 2016; 150(2): 394-406.
7. Lavorini F,  Mannini C, Chellini E, Fontana GA. Optimising Inhaled Pharmacotherapy for Elderly Patients with COPD: the importance of delivery devices. Drugs and Aging. 2016; 33(7): 451-473.
8. Baverstock M, Woodhall N, and Maarman V. Do healthcare professionals have sufficient knowledge of inhaler techniques in order to educate their patients effectively in their use? Thorax. 2010;65(4): A117-A118.
9. UK Inhaler Group. Inhaler Standards and Competency Document. Respiratory Futures Respiratory Futures. 2016.
10. RightBreathe 2017 Available at: https://www.rightbreathe.com
11. Asthma UK. How to use your inhaler. Available at:    https://www.asthma.org.uk/advice/inhaler-videos/
12. Chrischilles E, Gilden D, Kubisiak J, Rubenstein L, Shah H. Delivery of ipratropium and albuterol combination therapy for chronic obstructive pulmonary disease: effectiveness of a two-in-one inhaler versus separate inhalers. Am J Manag Care. 2002;8(10):902–911.
13. Yu AP, Guerin A, de Leon DP, et al. Clinical and economic outcomes of multiple versus single long-acting inhalers in COPD. Respir Med. 2011;105(12):1861–1871.
14. Price et al (2016). Add-on LABA in a separate inhaler as asthma step-up therapy versus increased dose of ICS or ICS/LABA combination inhaler. ERJ Open Research 2: 00106-2015; DOI: 10.1183/23120541.00106-2015. https://openres.ersjournals.com/content/2/2/00106-2015
15. Bosnic-Anticevich S, Chrystyn H, Costello RW, et al. The use of multiple respiratory inhalers requiring different inhalation techniques has an adverse effect on COPD outcomes. Int J Chron Obstruct Pulmon Dis. 2016;12:59–71.
16. Doyle S, Lloyd A, Williams A, Chrystyn H, Moffat M, Thomas M and Price D. What happens when patients who have their asthma device switched without their consent? Primary Care Respiratory Journal. 2010: 19(2):131–139
17. Thomas M, Price D, Chrystyn H, Lloyd A, Williams A.E, von Ziegenweidt, J. Inhaled corticosteroids for asthma: impact of practice level device switching on asthma control. BMC Pulm Med 2009: 9(1).
18. Inhaler Error Steering Committee, Price D, Bosnic-Anticevich S, Briggs A, Chrystyn H, Rand C, Scheuch G, Bousquet J. Inhaler competence in asthma: common errors, barriers to use and solutions. Respiratory Medicine. 2013; 107:37-46.
19. Usmani O. Choosing the right inhaler for your asthma or COPD patient Therapeutics and Clinical Risk Management. 2019; 15: 461–472. 
20. Haughney J, Price D, Barnes NC, Christian Virchow J, Roche N, Chrystyn H.  Choosing inhaler devices for people with asthma: Current knowledge and outstanding research needs. Respiratory Medicine CME. 2010; 3(2):125–31.
21.Kaplan and Price (2018). Matching Inhaler Devices with Patients: The Role of the Primary Care Physician. Canadian Respiratory Journal. https://doi.org/10.1155/2018/9473051. https://www.hindawi.com/journals/crj/2018/9473051/
22. NICE. Patient decision aid: inhalers for asthma. 2019. Available at: https://www.nice.org.uk/guidance/ng80/resources/inhalers-for-asthma-patient-decision-aid-pdf-6727144573
23. Brandstetter, S. et al. (2017). Diferences in medication adherence are associated with beliefs about medicines in asthma and COPD. Clin Transl Allergy 7:39 DOI 10.1186/s13601-017-0175-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5680826/
24. Chrystyn H, Small M, Milligan G, Higgins V, Gill E.G, and Estruch J. Impact of Patients’ Satisfaction with their Inhalers on treatment compliance and health status in COPD. Respiratory Medicine. 2014; 108(2): 358-65.
25. National Institute of Health and Care -Excellence. Isle of Wight Inhaler Project. TA138: Inhaled corticosteroids for the treatment of chronic asthma in adults and in children aged 12 years and over. 2011. https://www.nice.org.uk/sharedlearning/isle-of-wight-respiratory-inhaler-project
26. Lawlor R. Fit to care: key knowledge skills and training for clinicians providing respiratory care. PCRS, 2017. Available at: www.pcrs-uk.org/sites/pcrs-uk.org/files/FitToCare_FINAL.pdf

Laura Rush has received an honorarium from GSK for developing this article/content.

PM-GB-CPU-WCNT-190014 - August 2019

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PM-GB-CAU-WCNT-190006
March 2019