INHALATION ACADEMY

THE CRITICAL ROLE OF INHALER USE

Worldwide millions of people suffer from COPD and asthma. The number of patients is expected to increase even further over the coming decades due to changing environmental factors and an ageing population.^1-3 WHO predicts that COPD will be the third leading cause of death in 2030¹, and other sources expect it will even be the leading cause of death in 15 years' time.⁴

Inhalation therapy is the cornerstone of asthma and COPD treatment.³ Critical errors in the use of inhaler devices can significantly reduce drug delivery to the lungs and effectiveness of the treatment, and result in poor disease control and increased risk of exacerbations.⁵ Therefore, correct inhalation technique is essential and requires explicit attention.⁶

There is a plethora of inhaler devices, each type with different handling and inhalation maneuver requirements.⁷ Patient characteristics and their capabilities to inhale are also very variable.

Professor Richard Dekhuijzen* explains that for these reasons, there is no single inhaler device which fits each patient.

HISTORIC FACT

The delivery of therapeutic aerosols has a rich history dating back more than 3500 years to ancient Egypt. By that time, patients struggling to breath were advised to inhale vapor from black henbane burning on hot bricks. Later the therapeutic effects were explained by the anticholinergic properties of atropine, contained in the henbane plant.¹⁵

"It takes careful consideration and time to find the optimal match between patient and device. Differences between inhaler devices can in fact be larger than differences between the active ingredients of the same therapeutic class."

Prescribers are therefore suggested to apply the following order of therapeutic decision making: diagnosis - medication class - device type - specific ingredients.^8,9

COPD, Asthma and inhalation errors

Worldwide an estimated number of 235 million people suffered
from asthma, and 251 million people suffered from COPD in 2016.

prevalence Asthma

prevalence COPD

In 2015, 383 000 people died due to asthma related disease and
more than 3 million people died from COPD related disease.

mortality Asthma

mortality COPD

Figure based on data from www.who.int/respiratory/en and Quaderi and Hurst, 2018.^1,4
The worldwide prevalence and morbidity of COPD and Asthma

Depending on the type of device used, 70-87% of patients made at least one inhaler error,
44-51% of patients made 1-2 errors, 20-25% of patients made 3-4 errors, and 6-17% of patients made 5 or more different errors.

At least one error

1-2 errors

3-4 errors

5 or more errors

Most common inhaler errors^10-13

Preparation of the device
Failure to exhale before inhalation
Coordination (MDI)
Insufficient inspiratory effort
Breath holding

Figure adapted from Price et al, 2017.¹⁰
Percentage of patients making errors when using dry powder inhalers (DPIs)
or pressurized metered dose inhalers (pMDIs), by number of errors made per patient.
3660 patients with asthma were included.

Incorrect inhaler technique is unacceptably frequent both in asthma and COPD patients and has not improved over the past 40 years.^5,11,13 Suboptimal drug delivery results in reduced clinical outcomes, and if the patient does not experience strong benefits, adherence may decrease.¹⁴

Device selection deserves a prominent role in the establishment of a personalized treatment plan to achieve optimal drug delivery.^5,9,11 This optimal match of patient and device can be considered a true art, that requires an in-depth knowledge on the interaction of device and patient characteristics.

The Inhalation Academy aims to provide you with specifically this information in a series of short Scientific Communications. To strive together to optimize the treatment and care for the asthma and COPD patients.

Join the academy and learn how to do it!

*) Professor of Pulmonology, Radboud University Medical Center, Nijmegen, the Netherlands.