Do You Know How To Use Your Inhaler?

Jill Ohar, MD, loves to test her patients.

The immunology doctor at the Lexington Medical Center at Wake Forest Baptist said she likes to ask her patients using inhaler therapies to show her how to properly use the device.

It’s not just an opportunity to laugh at what Ohar calls the “smokestack method” — when a patient mistakenly exhales the therapy formulation — it’s a critical practice for doctors.

Ohar, in a lecture at the 2017 Annual CHEST Meeting in Toronto, ON, CA, explained that inhalation devices are “far and away” the most common therapies prescribed to chronic obstructive pulmonary disease (COPD). Ensuring that patients are using the right method for the right device is just a part of the job.

Ohar cited recent large, European-based study that showed less than 40% of patients were able to perform a perfect inhalation, regardless of the device. Previous studies have indicated a direct relationship between incorrect inhaler use and COPD patient symptom control.

About 85% of COPD patients are smokers, which Ohar said indicates particular characteristics. Statistically, smokers on average have lower levels of education and health literacy. This makes face-to-face, iterative treatment instructions imperative for immunologists.

That also means understanding the varying inhaler devices approved for COPD. Ohar listed 5 different inhaler delivery mechanisms: pressurized metered dose inhaler (pMDI); pMDI with space; dry powder inhaler (DPI); nebulizer; and the Soft Mist inhaler (SMI), a branded delivery from Boehringer Ingleheim products.

Variations to each device can include size, length of treatment administration, spacer optimization, and storage conditions dependent on temperature, among other elements.

“Some inhalers need priming, some need to be stored upside-down,” Ohar said. “There are very important, inherent issues with each inhaler in different environments.”

There’s also differentiation in administration. Metered dose inhalers require a slow, long inhalation, Ohar said, while the pressurized form of the device is a short, strong inhalation. It’s fairly common for patients to show they’ve been administering the medicine incorrectly when Ohar tests them at the end of a treatment duration.

“These are problems you have to be aware of,” Ohar said.

Though randomized, controlled trials have not identified one device or formulation as superior to another for COPD treatment, Ohar said there’s distinct advantages and disadvantages to each mechanism. While DPIs does not contain a propellant, many patients cannot use it correctly. Nebulizers do not require any specific technique for inhalation, but carry a risk for bacterial combination.

Adversely, improved training and technique can make all the difference. Observational studies have indicated that device consistency with both rescue and long-term inhaler therapies is beneficial for COPD and asthma patients.

Ohar advocated for primary care physicians and healthcare providers in general to improve their inhaler technique teaching abilities — as not all patients are being prescribed the therapy by specialists.

Treatment education for patients boils down to 3 steps: simplification, demonstration, and repetition. If patients are making mistakes, it’s only advantageous to have them learn from the mistakes.

“Keep those patient factors really at the top of your mind,” Ohar said. “It’s not just the drug. It’s the drug and the device.”

The presentation, "Right Patient, Right Device: The Importance of Device Choice in Personalizing COPD Treatment," was sponsored by AstraZeneca.