Correct Inhaler Use: Study Shows Poor Adherence in Many Patients with COPD

Correct Inhaler Use: Factors of Poor Adherence

Background: Many studies show that correct inhaler use is poor in those with COPD. The technique of using inhalers can be challenging because there are four different kinds of ways that inhaled medications can be delivered. These include metered-dose inhalers, dry-powder inhalers, soft mist inhalers, and by a nebulizer. In my practice, I always ask the patient, “Does the inhaler help your breathing?” If the person answers, “No,” or “I don’t know,” then I ask – “How are you using the inhaler?” Certainly, if the medication does not get deep into the lungs, it can not relax the muscle that wraps around the breathing tubes to open up the airways.
Advair was used in a study to assess correct inhaler use

Advair Diskus is a dry powder inhaler

Study: Dr. Sulaiman and colleagues at the Royal College of Surgeons in Dublin, Ireland, evaluated the correct use of the Advair Diskus in patients after discharge from the hospital for either a flare-up of COPD or for another reason. The reason for the study was to ask the question, “Why inhalers may not help?” for those with COPD. While in the hospital, patients were repeatedly shown how to use the inhaler each time the medication was taken, and a check list was used to make sure that the person was using the inhaler correctly. Patients were instructed to use the inhaler as they had been shown in the hospital twice per day, and that someone would collect the inhaler between 26 to 30 days later. An electronic recording device was
Device to check correct inhaler use

Example of electronic audio recording device compared with size of a paper clip

attached to the Diskus at discharge from the hospital.  Each time that the person opened the inhaler, electronic recordings were made to calculate the time of use, the time period between doses, and whether the person used it correctly. The study was published in the May 15, 2017, issue of the American Journal of Respiratory & Critical Care Medicine (volume 195; pages 1333-1343). Results: There were 244 patients in the study; their mean age was 71 years. The authors calculated adherence which means whether someone is using the inhaler exactly as instructed. Actual adherence was 23% of expected if the doses were taken correctly and on time. Analyses showed three different patterns among the subjects: 1. 34% had low inhaler use and high error rates; 2. 25% had high inhaler use and high error rates; and 3. 36% had overall good adherence. Older age, mental impairment, and poor lung function on breathing tests were common in those with poor adherence and frequent errors.  Conclusions: This study demonstrates that many patients with COPD fail to follow instructions for correct inhaler use despite repeated instructions. The results also help health care professionals understand why a inhaler may not be effective. My Comments: These results are disappointing. It appears that some or many patients have physical and/or mental limitations that prevent correct inhaler use. This emphasizes that a spouse, family member, or caregiver should supervise their loved one when he/she uses the inhaler. In some cases, it is reasonable to try a different delivery system for the bronchodilator medications.  

Donald A. Mahler, M.D. is Emeritus Professor of Medicine at Geisel School of Medicine at Dartmouth in Hanover, New Hampshire. He works as a pulmonary physician at Valley Regional Hospital in Claremont, NH, where he is Director of Respiratory Services.