Abstract
Purpose
This study was designed to evaluate errors in inhaler technique in COPD vs asthma patients and to investigate the association of poor inhaler technique with patient demographics and clinical variables.
Patients and methods
A total of 509 adult patients with COPD (n=328) or asthma (n=181) who were currently using an inhaler device were included in this study. Data on patient demographics, duration of disease, type and duration of inhaler therapy, and assessment of inhaler technique were recorded.
Results
Metered dose inhaler (MDI) was the most common type of inhaler used by a similarly high percentage of patients in both COPD (83.2%) and asthma (77.3%) groups. Failure to exhale before inhaling through device (75.8% and 68.5% for MDIs; 73.2% and 71.8% for Aerolizer®/Handihaler®; 53.1% and 66.7% for Turbuhaler®) was the most common error in inhaler technique, in both COPD and asthma groups. Device-specific errors in inhaler techniques were more common in asthma patients as compared with COPD patients, particularly for MDIs (P-values ranged from 0.046 to 0.0005), as associated with female gender (failure to press the buttons on both sides of Aerolizer®/Handihaler®, P=0.006), shorter duration of disease (failure to hold MDI or head in a vertical position, P<0.001, and to keep Turbuhaler® upright, P=0.005), and shorter duration of inhaler usage (failure to hold head in a vertical position during MDI usage, P=0.006, and to keep Turbuhaler® upright, P=0.012).
Conclusion
In conclusion, our findings revealed that errors in inhaler technique in terms of inhalation maneuvers and device handling were similarly common in COPD and asthma patients. Errors in certain device handling maneuvers, particularly with MDIs, were more common among asthma patients than among COPD patients and associated with female gender and shorter durations of disease and inhaler therapy.
Introduction
Inhaled therapy is a mainstay in the management of asthma and COPD.Citation1–Citation3 Metered dose inhalers (MDIs), dry powder inhalers (DPIs), and nebulizers are the most common inhaler devices used to administer aerosolized medication in routine respiratory practice.Citation1–Citation5
Optimal inhaler technique depends on correct preparation and handling of the device before inhalation and an optimal inhalation technique.Citation3 Although MDIs are considered to be more difficult to use than DPIs,Citation3,Citation6–Citation9 errors in inhaler technique are very common among COPD and asthma patients in daily real-life practice.Citation3,Citation5,Citation10–Citation16 Poor inhaler technique has been associated with inadequate drug delivery to the lungs and thus with poor disease control and worse disease outcomes.Citation1–Citation3,Citation9,Citation14,Citation17–Citation19
Recent global position documents from the Global Initiative for Asthma (GINA) and GOLD both highlight the critical importance of assessing inhaler technique to guide appropriate inhaler prescribing and correcting poor inhalation technique before escalating drug therapy.Citation20,Citation21
However, published data on the interaction between patient, device, and inhaler technique are considered to be insufficient and inconsistent.Citation19 Moreover, comparison of inhaler techniques in COPD vs asthma patients also revealed inconsistent findings with similar rate of errorsCitation14,Citation17,Citation19 or higher odds of incorrect inhaler technique in COPD patients than in asthma patients,Citation8 after adjusting for age, gender, and level of education. Indeed, older age and higher prevalence of comorbidities in COPD patients have been associated with a higher likelihood of poor inhaler technique as compared with asthma patients.Citation3,Citation8 In addition, discordance between self-assessment and medical supervision in terms of rates of correct inhaler technique has been noted in COPD and asthma patients, while COPD patients were reported to be more uncertain with MDI technique on self-assessment and to make more errors during direct observation when compared to asthmatics.Citation22
Being addressed in a limited number of studies to date, the differences between asthma and COPD in terms of etiology, symptoms, pathophysiology, consequences of inflammation, response to therapy, and clinical course may affect the inhaler performance of patients. Thus, comparison of inhaler technique among COPD and asthma patients may help to better understand how to improve the use of inhalers. This study was therefore designed to comparatively evaluate errors in inhaler technique in COPD vs asthma patients and to investigate the association of poor inhaler technique with patient demographics and clinical variables.
Material and methods
Study population
A total of 509 adult patients with COPD (n=328) or asthma (n=181) who were currently using at least one inhaler device for at least 1 month were included in this cross-sectional, observational study conducted at a tertiary pneumology outpatient clinic from February to May 2018. MDI, Aerolizer®/Handihaler®, Diskus®, and Turbuhaler® were assessed in this study as the most commonly used devices of those available in Turkey. Patients aged >18 years and diagnosed with asthma according to the GINACitation20 or with COPD according to the GOLDCitation21 were included in the study. Use of inhaler therapy for less than a month, lack of attendance of regular control visits, confirmed or suspected pregnancy, breastfeeding, allergy, sensitivity or intolerance to asthma or COPD therapy, and being on nebulizer therapy per se were the exclusion criteria of the study.
Written informed consent was obtained from each subject following a detailed explanation of the objectives and protocol of the study, which was conducted in accordance with the ethical principles stated in the Declaration of Helsinki and approved by the University of Health Sciences, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital Ethics Committee (date of approval: February 5, 2018, protocol number: 018).
Data collection
Data on patient demographics (age, gender), duration of disease, type and duration of inhaler therapy, and assessment of inhaler technique (correct, incorrect) were recorded in COPD and asthma groups. The inhaler technique for each device was evaluated through direct observation of patient’s performance using checklists developed in-house specifically for each inhaler device based on the manufacturers’ instructions and recommendations for correct implementation of inhalers provided by Turkish Thoracic Society Patient Information Handbook on AsthmaCitation23 and Turkish Thoracic Society National Asthma Diagnosis and Management Guidelines.Citation24 The same interviewer, who was an experienced respiratory technician blinded to diagnosis group, registered whether each step was performed properly and in an adequate order, and errors in inhaler technique were compared between COPD and asthma groups. Errors in maneuvers that significantly differed between patients with COPD and asthma were further analyzed in relation to demographic and disease-related characteristics.
Statistical analysis
Statistical analysis was performed using IBM SPSS Statistics for Windows, version 21.0 (IBM Corporation, Armonk, NY, USA). Chi-squared test was used to analyze the comparison of categorical data between COPD and asthma groups and to analyze the influence of gender on errors in inhaler techniques that differed between COPD and asthma groups. Student’s t-test and Mann–Whitney U test were used for sub-analysis of errors in inhaler techniques that differed between COPD and asthma groups in terms of age and duration of disease and inhaler therapy. Data were expressed as mean SD, percent (%), and minimum-maximum where appropriate. P<0.05 was considered statistically significant.
Results
Demographic and clinical characteristics in COPD and asthma groups
The COPD group was associated with older patient age (mean SD 64.6 [10.3, 29–89] vs 56.0 [14.5, 17–90] years, P<0.001) and higher percentage of males (65.2% vs 22.7%, P<0.001) than the asthma group ().
Table 1 Baseline characteristics of patients in COPD and asthma groups
MDI was the most common type of inhaler used by a similarly high percentage of patients in both COPD (83.2%) and asthma (77.3%) groups, followed by Aerolizer®/Handihaler® (75.9%) type of inhalers in COPD group and by Diskus® (41.4%) in the asthma group ().
Errors in inhaler technique in COPD and asthma groups
In both COPD and asthma patients, errors in inhalation maneuvers were the most prevalent errors, including failure to exhale before inhaling through device (75.8% and 68.5% for MDIs; 73.2% and 71.8% for Aerolizer®/Handihaler®; 53.1% and 66.7% for Turbuhaler®) and failure to deeply inhale (75.0% and 80.0%) for Diskus® type inhalers ().
Table 2 Errors in inhaler technique in COPD and asthma groups
The most common errors were device-specific errors and were related to shaking the MDI device before use (51.1% and 57.3%), removing the Diskus® (50.0% and 49.2%), and pressing the buttons on both sides of Aerolizer®/Handihaler® (26.8% and 52.6%) ().
Poorer inhaler technique was noted in asthma patients as compared with COPD patients with higher rate of errors in steps including taking off the inhaler cap (8.1% vs 14.5%, P=0.046), holding the MDI in a vertical position (19.4% vs 9.9%, P=0.011), and holding the head in a vertical position (20.2% vs 9.9%, P=0.007) during MDI usage, in pressing the buttons on both sides of the device (52.6% vs 26.8%, P=0.0005) and holding breath for 10 seconds (33.3% vs 19.5%, P=0.012) during Aerolizer®/Handihaler® usage, and keeping the Turbuhaler® upright (25.6% vs 6.3%, P=0.029) ().
Sub-analysis of errors in inhaler techniques that differed between COPD and asthma groups
Shorter duration of disease (failure to hold MDI or head in a vertical position, P<0.001, and to keep Turbuhaler® upright, P=0.005) and shorter duration of inhaler therapy (failure to hold head in a vertical position during MDI usage, P=0.006, and to keep Turbuhaler® upright, P=0.012) were associated with increased likelihood of device-specific errors in inhaler techniques in patients with COPD or asthma ().
Table 3 Sub-analysis of errors in inhaler techniques that differed between COPD and asthma groups
Failure to press the buttons on both sides of the Aerolizer®/Handihaler® was more common among females than among males (42.0% vs 27%, P=0.006) with COPD or asthma ().
Discussion
Our findings revealed that errors in inhalator technique were very frequent in both COPD and asthma patients. The inhaler techniques of COPD vs asthma patients differed mostly in certain device-specific errors rather than the inhalation maneuvers. Poor inhaler technique in device handling was associated with shorter duration of disease and inhaler therapy.
MDI-type inhalers were the most commonly used inhalers in both COPD and asthma patients in our cohort. However, past studies in patients with COPD and asthma revealed more prevalent usage of DPIs (77.0%–78.9%) than MDI-(12.0%–16.8%) type inhalers.Citation13,Citation17,Citation19 This seems notable given that MDIs require a good ability of hand–lung coordination and is therefore considered to be inherently more difficult to use than DPIs.Citation13,Citation25,Citation26 In fact, while considered to be more likely with MDI-type inhalers,Citation9,Citation15,Citation27–Citation29 suboptimal inhaler technique is very common in real life with both MDIs and DPIs, and in the majority of asthma and COPD patients, despite advances in inhaler device technology.Citation3,Citation5,Citation10–Citation16
Overall, with no significant difference between COPD and asthma groups, the most common errors in inhaler technique for MDIs and DPIs in our cohort were failure to exhale before use of inhaler, followed by device-specific errors and failure to deeply inhale and to hold breath. In addition, errors related to device handling were common among MDI users than among DPI users. Likewise, failure to exhale before inhaling through device, inability to coordinate activation with inhalation, and failure to hold breath have also been reported to be errors in inhalation maneuvers that are common in all types of inhalers among COPD and asthma patients.Citation13,Citation17,Citation30,Citation31 In accordance with our findings, a high frequency of poor and/or suboptimal inhaler use has consistently been reported in past studies alongside a higher likelihood of errors related to device handling with use of MDIs compared with DPIs among COPD and asthma patients.Citation9,Citation15,Citation29
Past studies indicated either no difference between COPD and asthma patients in terms of inhaler techniqueCitation17,Citation19,Citation32 or higher odds of incorrect inhaler technique in COPD patients attributed to older age and higher prevalence of comorbidities.Citation8,Citation28,Citation33 Although the COPD patients were older than the asthma patients in our cohort, our findings revealed no significant difference between asthma and COPD patients in terms of basic inhalation maneuvers, whereas there was poorer inhaler technique in asthma than COPD patients, particularly in certain device-specific steps. Regarding the steps that significantly differed between asthma and COPD patients, a higher likelihood of incorrect technique was associated with shorter duration of disease and therapy for MDI and Turbuhaler® users, and with female gender for Aerolizer®/Handihaler® users. This seems to support the reported association of longer duration of therapy (repeated instructions over a period of time and regular follow-ups)Citation14,Citation34–Citation36 with a proper inhaler techniqueCitation37 as well as higher odds ratio of poor inhaler technique reported in females as compared to males.Citation19
Indeed, with overconfidence of patients toward use of the device, a steep rise in number of errors with a longer duration of therapy has also been noted, emphasizing a need for regular instructions and intermittent checkups of inhalation techniques, given the increased number of errors.Citation14 In addition, the preponderance of female patients in the asthma group compared to the COPD group in our cohort seemed to also be associated with the poorer inhaler technique noted among asthma patients with regard to certain device-specific maneuvers.
Hence, our findings support that structured and detailed education of patients on inhaler techniques should be an essential part of the pulmonary clinic practice.Citation8 Past studies revealed a likelihood of incorrect use of inhaler devices even by medical personnel.Citation38–Citation41 In this regard, the sufficient ability of health care professionals themselves to use the inhaler devices and their awareness of all the correct steps and possible mistakes is considered to be of critical importance regarding the close follow-up of patients with repeated checking of inhaler techniques and correction of suboptimal techniques with tailored, in-depth support.Citation3,Citation14,Citation34
The major strength of this study seems to be the comparative assessment of inhaler technique in a large-scale cohort of COPD vs asthma patients through direct observation of patients’ performance in real-life clinical practice and by using checklists based on the manufacturers’ instructions and national guidelines. However, certain limitations to this study should be considered. First, the cross-sectional design limits the interpretation of the findings and establishment of any cause and effect relationships. Second, inhaler technique was assessed based on frequently used type of inhalers, and several types of infrequently used inhalers could not be included in the analysis. Third, lack of data on past history of patient training in inhaler technique is another limitation which otherwise would have extended the knowledge gained in the current study.
Conclusion
In conclusion, our findings revealed that errors in inhaler technique in terms of inhalation maneuvers and device handling were similarly common in COPD and asthma patients. Errors in certain device handling maneuvers, particularly with MDIs, were more common among asthma patients than among COPD patients, and associated with female gender and shorter durations of disease and inhaler therapy. Our findings emphasize that suboptimal inhaler technique is common in real life for both MDIs and DPIs, emphasizing the potential role of regular assessment and reinforcement of correct inhalation technique in achieving treatment efficacy and improved disease outcomes.
Disclosure
The authors report no conflicts of interest in this work.
References
- CochraneMGBalaMVDownsKEMauskopfJBen-JosephRHInhaled corticosteroids for asthma therapy: patient compliance, devices, and inhalation techniqueChest2000117254255010669701
- VirchowJCCromptonGKdal NegroRImportance of inhaler devices in the management of airway diseaseRespir Med20081021101917923402
- UsmaniOSLavoriniFMarshallJCritical inhaler errors in asthma and COPD: a systematic review of impact on health outcomesRespir Res20181911029338792
- PritchardJNIndustry guidance for the selection of a delivery system for the development of novel respiratory productsExpert Opin Drug Deliv201512111755176526067581
- KlijnSLHiligsmannMEversSRomán-RodríguezMvan der MolenTvan BovenJFMEffectiveness and success factors of educational inhaler technique interventions in asthma & COPD patients: a systematic reviewNPJ Prim Care Respir Med20172712428408742
- LavoriniFUsmaniOSCorrect inhalation technique is critical in achieving good asthma controlPrim Care Respir J201322438538624270367
- PriceDRocheNChristian VirchowJDevice type and real-world effectiveness of asthma combination therapy: an observational studyRespir Med2011105101457146621612903
- KhassawnehBYAl-AliMKAlzoubiKHHandling of inhaler devices in actual pulmonary practice: metered-dose inhaler versus dry powder inhalersRespir Care200853332432818291048
- MolimardMRaherisonCLignotSDepontFAbouelfathAMooreNAssessment of handling of inhaler devices in real life: an observational study in 3811 patients in primary careJ Aerosol Med200316324925414572322
- BrocklebankDRamFWrightJComparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literatureHealth Technol Assess20015261149
- Leiva-FernándezFLeiva-FernándezJZubeldia-SantoyoFGarcía-RuizAPrados-TorresDBarnestein-FonsecaPEfficacy of two educational interventions about inhalation techniques in patients with chronic obstructive pulmonary disease (COPD). TECEPOC: study protocol for a partially randomized controlled trial (preference trial)Trials2012136422613015
- PurohitANPatelPPGandhiAMDesaiMKAn evaluation of impact of educational interventions on the technique of use of metered-dose inhaler by patientsIndian J Pharmacol201749219420028706334
- Castel-BrancoMMFontesAFigueiredoIVIdentification of inhaler technique errors with a routine procedure in Portuguese community pharmacyPharm Pract20171541072
- AroraPKumarLVohraVEvaluating the technique of using inhalation device in COPD and bronchial asthma patientsRespir Med2014108799299824873874
- SanchisJGichIPedersenSAerosol Drug Management Improvement Team (ADMIT). Systematic review of errors in inhaler use: has patient technique improved over time?Chest201615039440627060726
- GangulyAdasAKRoyAAdhikariABanerjeeJSenSStudy of Proper use of Inhalational Devices by Bronchial Asthma or COPD Patients Attending a Tertiary Care HospitalJ Clin Diagn Res2014810HC04
- MelaniASBonaviaMCilentiVGruppo Educazionale Associazione Italiana Pneumologi Ospedalieri. Inhaler mishandling remains common in real life and is associated with reduced disease controlRespir Med201110593093821367593
- SanchisJCorriganCLevyMLViejoJLADMIT GroupInhaler devices – from theory to practiceRespir Med2013107449550223290591
- ChorãoPPereiraAMFonsecaJAInhaler devices in asthma and COPD – an assessment of inhaler technique and patient preferencesRespir Med2014108796897524873873
- Global initiative for chronic obstructive lung diseasePocket guide to COPD diagnosis, management and prevention Available from: http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdfAccessed December 12, 2017
- Global initiative for asthmaPocket guide for asthma management and prevention Available from: http://ginasthma.org/2017-pocket-guide-for-asthmamanagement-and-prevention/Accessed October 8, 2017
- Josef MicallefJMicallefLAGouderCComparison of asthma and COPD patients’ perception of appropriate metered-dose inhaler technique with a questionnaire and supervision based reference standardEur Resp J201444401
- Turkish Thoracic SocietyLiving with AsthmaPatient Information HandbookErdincMGulmezIIstanbul, TurkeyAves Publications2009 Available from: http://toraks.org.tr/userfiles/file/02_Astimla_yasam.pdf
- Turkish Thoracic Society Asthma Diagnosis and Management Guidelines 2016 updateTurkish Thoracic J201617Suppl 11108 Available from: http://www.toraks.org.tr/uploadFiles/book/file/1082017TTD-Astim-Tani-ve-Tedavi-Rehberi-2016.pdfAccessed January 25, 2018
- RootmensenGNvan KeimpemaARJansenHMde HaanRJPredictors of incorrect inhalation technique in patients with asthma or COPD: a study using a validated videotaped scoring methodJ Aerosol Med Pulm Drug Deliv201023532332820804428
- PothiratCChaiwongWPhetsukNPisalthanapunaSChetsadaphanNChoomuangWEvaluating inhaler use technique in COPD patientsInt J Chron Obstruct Pulmon Dis2015101291129826185435
- Al AmmariMSultanaKYunusFAl GhobainMAl HalwanSMA cross-sectional observational study to assess inhaler technique in Saudi hospitalized patients with asthma and chronic obstructive pulmonary diseaseSaudi Med J201637557057427146622
- SouzaMLMeneghiniACFerrazEViannaEOBorgesMCKnowledge of and technique for using inhalation devices among asthma patients and COPD patientsJ Bras Pneumol200935982483119820807
- TakakuYKurashimaKOhtaCHow many instructions are required to correct inhalation errors in patients with asthma and chronic obstructive pulmonary disease?Respir Med201712311011528137486
- LavoriniFMagnanADubusJCEffect of incorrect use of dry powder inhalers on management of patients with asthma and COPDRespir Med2008102459360418083019
- García-CárdenasVSabater-HernándezDGarcía-CorpasJPFausMJMartínez-MartínezFBenrimojSIErrors in Turbuhaler technique in a Spanish population of asthmatic patientsRespir Care201257581781822546303
- PressVGAroraVMShahLMMisuse of respiratory inhalers in hospitalized patients with asthma or COPDJ Gen Intern Med201126663564221249463
- LavoriniFManniniCChelliniEFontanaGAOptimising inhaled pharmacotherapy for elderly patients with chronic obstructive pulmonary disease: the importance of delivery devicesDrugs Aging201633746147327216613
- YıldızFGroupASASIT Study GroupFactors influencing asthma control: results of a real-life prospective observational asthma inhaler treatment (ASIT) studyJ Asthma Allergy201369310123843695
- Gracia-AntequeraMMorales Suárez-VarelaMAn intervention to improve the inhalatory technique of children and adolescents with asthmaAllergol Immunopathol1999275255260
- Al-JahdaliHAhmedAAl-HarbiAImproper inhaler technique is associated with poor asthma control and frequent emergency department visitsAllergy Asthma Clin Immunol201391823510684
- SenEGonulluUEkiciZKursunNAssessment of inhaler technique and treatment compliance of hospitalized patients and outpatients in a university hospitalJ Ankara Univ Fac Med20065916
- PlazaVSanchisJMedical personnel and patient skill in the use of metered dose inhalers: a multicentric study. CESEA GroupRespiration19986531951989670301
- HananiaNAWittmanRKestenSChapmanKRMedical personnel’s knowledge of and ability to use inhaling devices. Metered-dose inhalers, spacing chambers, and breath-actuated dry powder inhalersChest199410511111168275720
- GuidryGGBrownWDStognerSWGeorgeRBIncorrect use of metered dose inhalers by medical personnelChest1992101131331729104
- Lee-WongMMayoPHResults of a programme to improve house staff use of metered dose inhalers and spacersPostgrad Med J20037993022122512743342