Oh, the errors they make (with inhalers)!

What your patients can (unexpectedly) teach you about inhalers!

Inhalation devices used in asthma to deliver medication are designed to get the medication  directly into the lungs. Numerous medications and a variety of devices exist, and each requires a series of complicated preparatory steps before the medication is actually delivered. Failure to complete these steps results in inadequate dosages being administered, and this isn turn can result in acute episodes of asthma.

Many asthma educators spend a lot of time teaching patients how to use their inhalers. If asked, they will tell you that they are constantly being surprised by what patients do when using their inhalers. “Innovative”, “unexpected” and “unimaginable” are terms used to described patients’ interpretation of instructions. Some of the common errors that relate to all the devices1 include

•    improper patient posture
•    failure to hold breath long enough
•    failure to use the proper inhalation technique such as
    ▸    a slow inhalation required with soft mist inhalers (SMI)
    ▸    a short, sharp inhalation required with a dry powder inhaler (DPI)
    ▸    a slow, deep inhalation required with a metered dose inhaler (MDI)
•    failure to seal lips around the mouthpiece
•    failure to keep the device clean (especially the mouthpiece)

The asthma educator must be alert and watch for a number of critical errors that patients make with inhalers. Eliminating or reducing these can help patients improve their inhaler technique. However, despite numerous studies, no consensus has been reached as to which errors are critical to inhalation technique, but the conclusion reached by them is unambiguous – there is a clear association between inhaler errors and deteriorating health outcomes.2-5

Poor inhalation technique has been associated with increased risk of
•    hospitalisation (47%)
•    emergency room visits (62%)
•    course of oral steroids (54%)
•    lost productive days (47%)

There are also costs, both economic and social, associated with poor inhaler technique that should be recognized. When two combination medications – Symbicort and Accuhaler (Advair in North America) – were studied over one year in three European countries, the results showed that poor inhalation technique wasted almost 5% of direct costs and cost €782 million (almost $ 1 billion US) in lost productivity. This was over 12% of the €6.4 billion total cost of lost productivity.5

A detailed list of the more common inhaler errors is available at the end of this article. Despite this rather extensive list, asthma educators should not be surprised if patients continue to invent even more innovative approaches to using their inhalers, such as attempting to double-load doses. Lack of knowledge, inadequate technique and inhalation errors pertaining to usage and maintenance will decrease the delivery of sufficient medication to patients and negatively affect both their health and well-being.

Due to cognitive and physical changes, the elderly, in particular, are at greater risk of forgetting how to use an inhaler correctly. Physically, they may not no longer have the strength and dexterity to use an MDI. They may also not have the necessary inspiratory flow required to use a DPI. A recent systematic review of the literature noted that inhalation technique errors increases with age.6

Choosing an inhalation device

The specific type of inhalation device recommend for a patient should be based on the patient's age, dexterity, ability to manipulate the device, the patient's natural inhalation technique (a slow versus a fast breather), hand-lung coordination and the patient’s personal preferences. These factors, together with health and cultural beliefs, may play a role in the fact that between 40 and 60% of patients with asthma are non-concordant with respect to their asthma medications.7 Patient preference includes a number of factors such as 8,9

•    performance or usability – how easy it is to learn, use, operate and keep clean
•    convenience – durability, size, shape, colour, weight, etc.
•    oral sensation – speed of spray, taste, irritation, coldness

A study involving almost 20,000 patients in the U.S.10 determined that patients have more concerns about performance than convenience in their inhalers. They require four attributes from their inhalers:

1.    medication that goes into their lungs
2.    inhalers that work consistently and reliably
3.    inhalers that are easy to use
4.    an indicator on the device, showing how much medication remains

The authors suggested that “Satisfaction with an inhaler device may contribute to the effectiveness of the treatment and therefore increase patients' treatment outcomes, which may improve adherence and result in further benefit of therapy.”

To correctly teach the use of an inhaler requires (a) verbal instruction, (b) a demonstration by the educator, and ( c ) a demonstration or ‘teach-back’ by the patient.  

Using an inhaler requires three steps:
1.    Preparation of the device – orientation, shaking (for MDIs) and loading (DPI)
2.    Preparation for inhalation – breathing out away from the device, sealing mouth around the mouthpiece with correct posture and head positioning
3.    Actual  inhalation – slow for MDI and forceful for DPI, with the breath being held for at least 5 seconds, followed by a slow exhalation away from the direction of the inhaler.

Once a patient has mastered a particular inhalation technique, it is advisable to stay with the same device when medications are added or changed. Since different devices require different techniques, prescribing different devices can only lead to confusion, irritation and non-concordance. Changing devices without a consultation has been linked to a decrease in asthma control.11,12

Lack of proper and appropriate education by a trained professional has been associated with improper use of inhaler devices.13,14 Even for those patients who have been trained, 50% will not maintain correct technique over time,15 though frequency of review significantly decreases the number of mistakes made.16,17 It has also been shown that appropriate education of patients by trained professionals in the use of their inhalers significantly improves clinical outcomes and quality of life for patients.18

Possible errors using inhaler devices

Consider the MDI. There are many possibilities for errors including
•    failure to remove the cap
•    failure to ensure the valve is not blocked
•    failure to shake device
•    not holding the inhaler upright
•    putting the wrong end of the device in the mouth
•    having the wrong canister in the wrong device boot
•    failure to prime initially or after a long period of non-use
•    failure to breathe out to functional residual capacity prior to actuation
•    failure to actuate
•    failure to inhale
•    failure to seal lips around mouthpiece
•    placing mouthpiece against teeth, lips or tongue
•    actuation on exhalation
•    actuation not coordinated with inhalation
•    actuation without inhalation
•    actuation after end of inhalation
•    too-rapid inhalation
•    forceful inhalation
•    inhalation through the nose
•    repeated actuations with the same inspiration
•    actuation with mouthpiece aimed at the chest
•    actuation with mouthpiece placed beside ear
•    multiple actuations prior to a single inhalation
•    delay in inhalation after actuation
•    failure to hold breath for 6 seconds
•    incorrect posture – tilting the head back or bending forward so that medication hits the back of the throat
•    discontinuing inhalation when medication hits the back of the throat
•    using an empty or expired device
•    failure to protect device from extreme heat or extreme cold
•    not waiting for sufficient time before taking the second dose
•    failure to discard the inhaler at the time limit after opening the package
•    continuing to use the inhaler past the recommended time limit after opening the package has passed

Additional errors can occur when using an MDI with a spacer:
•    failure to ensure a tight seal when mouthpiece is inserted into a space
•    failure to remove the cap
•    failure to hold the spacer so that the inhaler is upright
•    failure to ensure a tight seal when inhaler inserted into spacer
•    failure to actuate the inhaler
•    actuation of more than one dose into the spacer
•    failure to seal lips around mouthpiece of spacer
•    breathing into the spacer
•    delaying inhalation after actuation into spacer
•    failure to inhale through mouthpiece within 2 seconds of actuation
•    inhalation through the nose
•    not waiting the recommended time before taking the second dose
•    coughing during inhalation
•    not cleaning the spacer regularly
•    not washing the spacer in soapy water, and then wiping dry
•    not air-drying the spacer
•    using a cracked spacer, or one with a faulty valve or damaged parts

DPIs also give problems when used incorrectly. Patient errors may include:
•    failure to remove cover
•    shaking, tilting or tipping the device during or after preparation
•    not loading the dose
•    failure to slide cover as far as possible
•    failure to slide lever to fully open the mouthpiece
•    swallowing the capsule
•    holding the device upside down
•    breathing into the device before inhalation
•    not breathing out fully prior to inhalation
•    incorrect positioning of the DPI for inhalation
•    slow  inhalation
•    lack of a forceful inhalation
•    inhalation that is not forceful from the start
•    failure to inhale through the mouthpiece
•    failure to hold breath for at least 5 seconds
•    failure to breathe out slowly
•    failure to breathe out away from the mouthpiece
•    failure to seal lips around mouthpiece
•    sucking in without putting the device into the mouth
•    putting these devices into a spacer
•    pushing the trigger and assuming that the medication will spray out
•    multiple loading of medication with a single inhalation
•    storage in damp areas or in areas of excess humidity
•    failure to replace the cover or to close the device
•    failure to discard the device when empty
•    failure to prepare dose properly (the Turbohaler base has to be twisted till it clicks before returning it to the original position)

For patients who are given peak flow meters to monitor their asthma, peak flow meters can also pose a challenge. Some errors include:
•    failure to reset the pointer
•    sucking in
•    breathing out slowly
•    breathing in instead of out
•    not standing
•    using with chewing gum or other food in the mouth
•    incorrectly holding the device so that the pointer cannot move
•    moving pointer with the little finger
•    poor posture
•    having food in the mouthpiece or even in the device
•    placing mouthpiece in front of teeth and closing the teeth
•    not sealing lips around the mouthpiece
•    rocking the head in an attempt to improve effort
•    bending the knees in an attempt to improve effort

The possibilities for error persist and it is only through frequent assessment of technique and repeated instructions that patients will learn and maintain a proper technique in the use of asthma-related devices.

References

  1. Inhaler Error Steering Committee, Price D, Bosnic-Anticevich S et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013 Jan;107(1):37-46. doi: 10.1016/j.rmed.2012.09.017.
  2. Usmani OS, Lavorini F, et al. Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes. Respiratory Research 2018; 19:10. https://doi.org/10.1186/s12931-017-0710-y
  3. Melani AS, Bonavia M, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011;105:930–8.
  4. Price D, Bosnic-Anticevich S, et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med. 2013;107:37–46
  5. Lewis A, Torvinen S, et al. The economic burden of asthma and chronic obstructive pulmonary disease and the impact of poor inhalation technique with commonly prescribed dry powder inhalers in three European countries. BMC Health Serv Res. 2016;16:251
  6. Barbara S, Kritikos V, Bosnic-Anticevich A.  Inhaler technique: does age matter? A systematic review. European Respiratory Review 2017; 26: 170055; DOI: 10.1183/16000617.0055-2017
  7. Cochrane MG, Bala MV et al. Inhaled corticosteroids for asthma therapy: patient compliance, devices, and inhalation technique. Chest. 2000; 117: 542–550
  8. Welch MJ, Nelson HS, et al. Comparison of patient preference and ease of teaching inhaler technique for Pulmicort Turbuhaler versus pressurized metered-dose inhalers. J Aerosol Med. 2004; 17: 129–139
  9. Lenney J, Innes JA, and Crompton GK. Inappropriate inhaler use: assessment of use and patient preference of seven inhalation devices. EDICI. Respir Med. 2000; 94: 496–500
  10. Davis KH, Su J et al. Quantifying the importance of inhaler attributes corresponding to items in the patient satisfaction and preference questionnaire in patients using Combivent Respimat. Health and Quality of Life Outcomes 2017; 15:201  https://doi.org/10.1186/s12955-017-0780-z
  11. Thomas M, Price D et al. Inhaled corticosteroids for asthma: impact of practice level device switching on asthma control. BMC Pulm Med. 2009 Jan 2;9:1. doi: 10.1186/1471-2466-9-1.
  12. Bjermer L. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration. 2014;88(4):346-52. doi: 10.1159/000363771.
  13. Al-Jahdali H, Ahmed A, Al-Harbi A, et al. Improper inhaler technique is associated with poor asthma control and frequent emergency department visits. Allergy Asthma Clin Immunol. 2013;9:8.
  14. Scarfone RJ, Capraro GA, Zorc JJ, Zhao H. Demonstrated use of metered-dose inhalers and peak flow meters by children and adolescents with acute asthma exacerbations. Arch Pediatr Adolesc Med. 2002;156:378-383.
  15. Bosnic-Anticevich SZ, Sinha H et al. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. J Asthma. 2010; 47: 251–256
  16. Elgendy MO, Abdelrahim ME, Eldin RS. Potential benefit of repeated MDI inhalation technique counselling for patients with asthma. European J Hospital Pharmacy: Science and Practice, 2015 (22): 318-322
  17. Boise E and Rotella M. ABCs of asthma inhaler and device training. Int Forum Allergy Rhinol. 2015 Sep; 5 Suppl 1:S71-5. doi: 10.1002/alr.21605.
  18. Basheti IA, Reddel HK et al. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol. 2007; 119: 1537–1538