O5. Inhaler technique and adherence

Adherence and inhaler technique need to be checked on a regular basis [evidence level I, strong recommendation]

O5.1 Inhaler technique

Incorrect inhaler technique is common and is associated with worse outcomes.  A systematic review of articles reporting direct observation of inhaler technique in COPD and asthma reported that the overall prevalence of optimal inhaler technique was only 31% (95% CI 28 to 35%), and that this pattern had not improved over 40 years.  Common errors were identified, for the MDI these were poor coordination (45%; 95% CI 41 to 49%), inadequate speed and/or depth of inspiration (44%; 95% CI 40 to 47%), and the absence of post inhalation breath-hold (46%; 95% CI 42 to 49%).  For the DPI, common errors included incorrect preparation in 29% (95% CI 26 to 33%), inadequate expiration before inhalation in 46% (95% CI 42 to 50%), and the absence of a post inhalation breath-hold in 37% (95% CI 33 to 40%) (Sanchis 2016).  These data highlight the importance of inhalation technique education.

Inhaler devices must be explained and demonstrated for patients to achieve optimal benefit. It is necessary to check regularly that the patient has the correct inhaler technique as proficiency will wane with time. Ensuing that patients are shown the correct inhaler technique requires the health professional to have an understanding of the devices.  Unfortunately, large gaps remain in health professionals’ knowledge and skill in this area.  A systematic review that included 55 studies and evaluated health professionals performing 9,996 tests demonstrating their inhaler technique confirmed this (Plaza 2018) [evidence level I].  Inhaler technique was only considered correct in 15.5% of health professionals (95% CI 12 to 19.3) overall.  Another finding of the review was that inhaler technique proficiency of health professionals has decreased over time. In studies between 1975 and 1995, overall proficiency was 20.5% (95% CI 14.9 to 26.8) compared to only 10.8% (95% CI 7.3 to 14.8) in the period between 1996 and 2014.  These data highlight the necessity of health professionals to develop their knowledge and proficiency of inhaler device use.

Elderly and frail patients, especially those with cognitive deficits, may have difficulty with some devices. Correct inhaler technique is essential for the optimal use of all inhaled medications (Melani 2011) [evidence level I] and is associated with fewer severe exacerbations. An observational study involving 2,935 patients with COPD, reported that in individuals who were treated for at least three months (n=2,760), the occurrence of prior (past three months) severe exacerbation was significantly associated with at least one observed critical error using prescribed inhalers (OR 1.86, 95% CI 1.14-3.04; p=0.0053) (Molimard 2017).  Ease of operating and dose preparation were rated as being the most important inhaler features leading to higher patient satisfaction and fewer critical errors in a randomised, open-label, multicentre, cross-over study of two inhaler devices (van der Palen 2013) [evidence level II]. An Australian cross-sectional study found that the proportion of patients with COPD who made at least one error in inhaler technique ranged from 50 to 83%, depending on the device used (Sriram 2016). Similarly, a systematic review and meta-analysis of 72 studies involving asthma and COPD patients, reported that 50-100% of patients performed at least one handling error.  The pooled summary results for pMDI estimated an overall error rate of 86.6% (95% CI 79.4-91.9) and for DPIs it was 60.9% (95% CI 39.3-79.0) (Chrystyn 2017) [evidence level I].

Consideration of cognitive impairment is important for the learning and retaining of inhaler technique (Baird 2017, Iamthanaporn 2023) [evidence level I]. Ongoing training for re-enforcement, or alternative inhaler device substitution, may be beneficial.

With the proliferation of new inhaler devices, inhaler device poly-pharmacy is becoming an increasing problem amongst COPD patients and has a negative impact on outcomes (Bosnic-Anticevich 2017).  A study of 16,450 COPD patients compared exacerbation frequency and SABA use of patients who were using similar style inhalers e.g. all MDI to those that were prescribed devices that required a different technique.  Those in the similar device cohort experienced fewer exacerbations (adjusted IRR 0.82, 95% CI 0.80 to 0.84; and used less SABA (adjusted OR 0.54, 95% CI 0.51-0.57), compared to the mixed device cohort.  These data support the recommendation to minimise the number of different devices prescribed in COPD patients.

Lung Foundation Australia has developed a series of inhaler device technique videos and factsheets for patients which provide step-by-step instructions on correct inhaler technique.  These are available at: https://lungfoundation.com.au/resources/?user_category=32&search=inhaler%20device.

Lung Foundation Australia’s Stepwise Management of Stable COPD available at: https://lungfoundation.com.au/resources/?search=stepwise has images of asthma and COPD medicines on page 2.  These are linked directly to the video and factsheets page on the Lung Foundation website via the Zappar app.  The app allows the user to scan the images on either the hard copy or on-screen using their mobile device and the videos will automatically open on their device.

The National Asthma Council has produced a number of “how-to” video clips instructing patients how to use their inhalers, which are available on its website at https://www.nationalasthma.org.au/living-with-asthma/how-to-videos. The Lung Foundation Australia resource, Better Living With COPD: A Patient Guide contains an inhalation devices chapter which can be accessed at https://lungfoundation.com.au/wp-content/uploads/2018/09/Book-Better-Living-with-COPD-Dec2016.pdf.

The cost of inhaler devices varies between products. As there are no differences in patient outcomes for the different devices, the cheapest device the patient can use adequately should be prescribed as first line treatment (NHS Centre for Reviews and Dissemination 2003). The range of devices currently available, the products and dosage, as well as their advantages or disadvantages, are listed in Appendix 2. Brief counselling; monitoring and feedback about inhaler use through electronic medication delivery devices; and multi-component interventions consisting of self-management and care co-ordination delivered by pharmacists and primary care teams have been shown to improve medication adherence (Bryant 2013) [evidence level I].

Pragmatic pharmacist care programmes may improve inhaler technique and refill adherence in patients with COPD (Tommelein 2014) [evidence level II].