Recognizing and Tackling Inhaler Technique Decay in Asthma and Chronic Obstructive Pulmonary Disesase (COPD) Clinical Practice

Abstract

A poor inhaler technique continues to represent a substantial barrier to effective asthma and chronic obstructive pulmonary disease management. It can result in perceived lack of treatment effectiveness even with apparent adherence to a prescribed regimen of inhaled maintenance therapies, potentially resulting in an unnecessary change or escalation of treatment. Many patients are not trained to inhaler mastery in real-world practice; furthermore, even where mastery is initially achieved, an ongoing assessment and education are seldom maintained. In this review, we present an overview of the evidence for deterioration of the inhaler technique over time after training, investigate the factors that contribute to this deterioration, and explore innovative approaches to addressing the problem. We also propose steps forward drawn from the literature and our clinical insights. A poor inhaler technique continues to represent a substantial barrier to effective asthma and chronic obstructive pulmonary disease management. It can result in perceived lack of treatment effectiveness even with apparent adherence to a prescribed regimen of inhaled maintenance therapies, potentially resulting in an unnecessary change or escalation of treatment. Many patients are not trained to inhaler mastery in real-world practice; furthermore, even where mastery is initially achieved, an ongoing assessment and education are seldom maintained. In this review, we present an overview of the evidence for deterioration of the inhaler technique over time after training, investigate the factors that contribute to this deterioration, and explore innovative approaches to addressing the problem. We also propose steps forward drawn from the literature and our clinical insights. Inhaled maintenance therapy remains fundamental to the management of asthma and chronic obstructive pulmonary disease (COPD). A good inhaler technique is essential to achieving disease control and improving health.1Dudvarski Ilic A. Zugic V. Zvezdin B. Kopitovic I. Cekerevac I. Cupurdija V. et al.Influence of inhaler technique on asthma and COPD control: a multicenter experience.Int J Chron Obstruct Pulmon Dis. 2016; 11: 2509-2517Crossref PubMed Scopus (51) Google Scholar,2Gregoriano C. Dieterle T. Breitenstein A.L. Dürr S. Baum A. Maier S. et al.Use and inhalation technique of inhaled medication in patients with asthma and COPD: data from a randomized controlled trial.Respir Res. 2018; 19: 237Crossref PubMed Scopus (55) Google Scholar However, individual studies on populations with obstructive lung diseases demonstrated that ≥80% of patients make ≥1 inhalation technique error.3Cho-Reyes S. Celli B.R. Dembek C. Yeh K. Navaie M. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of U.S. studies.Chronic Obstr Pulm Dis. 2019; 6: 267-280PubMed Google Scholar A poor inhaler technique prevents medication from reaching areas of the lung where it is most effective;4Levy M.L. Dekhuijzen P.N. Barnes P.J. Broeders M. Corrigan C.J. Chawes B.L. et al.Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT).NPJ Prim Care Respir Med. 2016; 2616017Google Scholar consequently, it has a substantial detrimental effect on clinical outcomes and economic impacts on health systems5Usmani O.S. Lavorini F. Marshall J. Dunlop W.C.N. Heron L. Farrington E. et al.Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes.Respir Res. 2018; 19: 10Crossref PubMed Scopus (173) Google Scholar and should be assessed before any adjustment to therapy is initiated.6Global Initiative for AsthmaGlobal strategy for asthma management and prevention.2021https://ginasthma.org/wp-content/uploads/2023/04/GINA-Main-Report-2021-V2-WMSA.pdfDate accessed: May 22, 2023Google Scholar,7Global Initiative for Chronic Obstructive Lung DiseaseGlobal strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease.2022https://goldcopd.org/wp-content/uploads/2021/12/GOLD-REPORT-2022-v1.1-22Nov2021_WMV.pdfDate accessed: May 22, 2023Google Scholar Despite long-standing and global recognition that the poor inhaler technique remains a major problem,2Gregoriano C. Dieterle T. Breitenstein A.L. Dürr S. Baum A. Maier S. et al.Use and inhalation technique of inhaled medication in patients with asthma and COPD: data from a randomized controlled trial.Respir Res. 2018; 19: 237Crossref PubMed Scopus (55) Google Scholar,8Sanchis J. Gich I. Pedersen S. Systematic review of errors in inhaler use: has patient technique improved over time?.Chest. 2016; 150: 394-406Abstract Full Text Full Text PDF PubMed Google Scholar, 9Li H. Chen Y. Zhang Z. Dong X. Zhang G. Zhang H. Handling of Diskus dry powder inhaler in Chinese chronic obstructive pulmonary disease patients.J Aerosol Med Pulm Drug Deliv. 2014; 27: 219-227Crossref PubMed Scopus (0) Google Scholar, 10Westerik J.A. Carter V. Chrystyn H. Burden A. Thompson S.L. Ryan D. et al.Characteristics of patients making serious inhaler errors with a dry powder inhaler and association with asthma-related events in a primary care setting.J Asthma. 2016; 53: 321-329Crossref PubMed Scopus (81) Google Scholar, 11Wrench W. Van Dyk L. Srinivas S. Dowse R. 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Farrington E. et al.Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes.Respir Res. 2018; 19: 10Crossref PubMed Scopus (173) Google Chrystyn H. J. M. L. et review of association errors in inhalation and health outcomes in asthma and Prim Care Respir Med. 2018; Scopus Google Scholar errors to be with poor disease outcomes of and health care in asthma and O.S. Lavorini F. Marshall J. Dunlop W.C.N. Heron L. Farrington E. et al.Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes.Respir Res. 2018; 19: 10Crossref PubMed Scopus (173) Google Chrystyn H. J. M. L. et review of association errors in inhalation and health outcomes in asthma and Prim Care Respir Med. 2018; Scopus Google M. S. Carter V. K. et al.Inhaler errors in the and association with asthma Full Text Full Text PDF PubMed Scopus Google Scholar errors be or among in this M. S. Carter V. 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