PATIENT TECHNIQUE
ERRORS IN USE
INTRODUCTION

Adequate drug delivery to the lungs is essential in the treatment of COPD and asthma. To achieve optimal results, the choice of inhaler device is just as important as the choice of medication.1 Sanchis' systematic review showed that incorrect inhaler technique is unacceptably frequent. Only 1 in 3 patients demonstrated correct technique.2 Moreover, despite of the increasing offer and variety of inhaler devices, mastery has not improved over the last 40 years.2

Clearly, errors when using an inhaler may vary from minor to critical. In addition, the majority of patients make more than one mistake when using their inhaler(s).

Errors when using inhalers can potentially reduce the amount of drug that reaches the lungs and negatively impact the effectiveness of treatment.1 Many studies have shown that inhalation errors are linked to worse disease outcomes.3,4 Therefore, the time spent by healthcare professionals to instruct and repeat inhalation technique is crucial.3

Patient characteristics, such as older age, having multiple comorbidities, cognitive impairment, lower education and socioeconomic status have all been associated with higher error frequency.1 While the use of MDIs requires patients to coordinate breathing and actuation, DPIs need forceful and deep inhalation, which may be problematic for a number of patients.1,5 As such, making the right match between patient phenotype and inhaler device is very important.6

Several studies have shown that the number of errors is negatively associated with the level of adherence.7

FACT OR MYTH?

“MDI inhaler devices must be shaken before use”

This advice dates from the time of the chlorofluorocarbon (CFC) propellants, when the active drug was delivered as a micronized suspension. Currently, most MDI contain hydrofluoroalkane (HFA) propelled drugs in solution that makes shaking unnecessary. If in doubt, shaking of MDI can be advised.4

ERRORS IN INHALER TECHNIQUE
pMDI
Failure to remove mouthpiece cap or device cover Incorrect preparation/priming of device or loading of dose Failure to pierce capsule Inhaler upside down
Breathing out into device Firing device at or after end of inhalation Open-mouth inhalation technique Weak or very slow inhalation
Inhaling through nose Stopping inhalation as device is fired
DPI
SMI
 
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Adapted from Newman et al., 20058
pMDI: pressurized metered dose inhaler | DPI: dry powder inhaler | SMI: soft mist inhaler
CONCLUSION

Appropriate choice of inhaler type, matched to the patient phenotype, as well as correct inhaler technique are essential to achieve effective therapy. Critical inhalation errors are not only missed opportunities for patient health outcomes but also add to the total healthcare spending.1

Strategies to improve inhaler technique include careful instruction (checklists, video demonstration), repeated observation of inhalation technique, and matching the inhaler type to the individual patient.2,5

Look out for our next communication about training of inhaler technique to improve patient outcomes.