O5.1 Inhaler technique

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. 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]. 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). 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 fact-sheets for patients which provide step-by-step instructions on correct inhaler technique.  These are available at https://lungfoundation.com.au/patient-support/copd/inhaler-technique-fact-sheets/.

Lung Foundation Australia’s Stepwise Management of Stable COPD available at http://lungfoundation.com.au/health-professionals/guidelines/copd/stepwise-management-of-stable-copd/ 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 Blippar 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 Australia has produced a number of “how-to” video clips which are available on their 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/2014/02/08-Using-your-inhaler-devices.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 programs may improve inhaler technique and refill adherence in patients with COPD (Tommelein 2014) [evidence level II].