Key learning points

  • Poor inhaler technique increases the possibility that a patient will experience poor symptom control, which may result in a higher risk of exacerbations or even death
  • Being familiar with the different inhaler devices available will help healthcare professionals ensure that they can tailor treatment effectively
  • Incorrect inhaler use is strongly associated with a lack of instruction from the clinician so no inhaler should be prescribed without a healthcare professional teaching and assessing the patient’s inhaler technique

Introduction

There is a huge selection of inhaled therapies and devices used to treat people with asthma and COPD and it can feel as though matching the right device to the right patient can be a bit of a minefield. Whichever device a patient uses, good technique is essential to ensure that the drugs are delivered to the lungs, so time should be invested in getting this key principle right.  

Box 1: Key errors1

Common errors when using inhalers are:
  • Failure to exhale fully before inhalation
  • Failure to breath-hold after inhalation
  • Incorrect positioning of and/or priming of the inhaler
  • Poor co-ordination
  • Failure to use correct inspiratory rate for the device
  • Forgetting to remove the cap.
  • The impact of poor technique on the patient 

    If the patient has poor inhaler technique, the medication will not be deposited correctly and its effect will be limited. This increases the chance of the patient experiencing poor symptom control and has been linked to a higher risk of exacerbations or even death.2–4 

    In the National Review of Asthma Deaths, almost half of the people who died from an acute asthma attack had not had their inhaler technique checked in primary care in the year before they died.5 Of those who had been admitted to hospital, almost one in five people had no documented evidence that their inhaler technique had been checked during their admission.5 

    The economic burden of poor technique 

    A study of the economic impact of poor inhaler technique in asthma and COPD in UK, Sweden and Spain showed that poor inhalation technique comprises 2.2–7.7% of the direct costs of managing asthma.6 When lost productivity costs are included, €782 million was attributable to poor inhalation technique across the three countries.7 Poor inhaler technique and poor symptom control increases unplanned admissions for COPD, with significant associated costs.7 

    Choosing the right device

    The National Institute for Health and Care Excellence states that inhalers should be prescribed only after patients have received training in the use of the device and have demonstrated satisfactory technique. Patients should have their ability to use an inhaler device regularly assessed by a competent healthcare professional and, if necessary, should be re-taught the correct technique.8

    In general, inhaler devices can be categorised as metered dose inhalers (MDIs), which are often prescribed (but not always used) with a spacer device, breath-actuated inhalers and dry powder inhalers (DPIs). Key messages about inhaler technique stress the importance of a slow and steady inhalation for MDIs and a fast and deep inhalation for most (but not all) DPIs. Local formularies may suggest drug/device combinations for people with asthma and COPD but clinicians should not underestimate the importance of working with patients to identify the most suitable device for each individual. 

    Assessment of patient preference and factors that predict the ability to use a device should be considered to individualise therapy and these include the patient’s dexterity, age and lifestyle.9 The aim is to help people to choose the most appropriate device for them, to teach them the correct technique and to assess them as they actually use the device to ensure they are competent. Incorrect inhaler use is strongly associated with a lack of instruction from the clinician so no inhaler should be prescribed (or switched) without a healthcare professional teaching and assessing the patient’s inhaler technique.10 

    Assessing inhaler technique 

    Patients should have thorough training in the use of their inhalers when they are first prescribed and should continue to have their inhaler technique reviewed on a regular basis. According to De Blaquiere et al,11 79% of patients demonstrated correct technique after training but this figure dropped to 55% two months later. In a study by van der Palen et al,12 involving patients with COPD, training in inhaler technique improved the rate of correct technique from 72–76% at baseline to 90–93% after training, but this then fell back to around 75% four or five months later. Similarly, Pothirat et al13 studied inhaler technique in 103 older patients with COPD and found that 41% had correct technique at baseline, rising to 100% after training; however, at follow-up just one month later, this had dropped back to 51%. Correct inhaler technique may be affected by other issues aligned with COPD, as prevalence of the condition increases with age, so particular consideration should be given to cognitive function, manual dexterity and hand strength.14 

    Summary 

    Incorrect teaching and assessment of inhaler technique can result in poor disease management, increased use of healthcare resources and wasted medication. Correct inhaler technique depends on priming the device and using the appropriate technique for the device, which will include exhaling before inspiration, using an inspiratory flow rate appropriate for the device and holding the breath after inhalation to optimise drug deposition. The ideal device should be easy to demonstrate and easy to use, and should deliver medication to the lungs to optimise symptom control and reduce the risk of exacerbations, hospitalisation and death.

    Beverley Bostock, education lead and clinical specialist, Education for Health

    This project was initiated and funded by Teva Respiratory. Teva have had no influence over content. Topics and content have been selected and written by independent experts.

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