Characteristics of patients making serious inhaler errors with a dry powder inhaler and association with asthma-related events in a primary care setting

Abstract

Objective: Correct inhaler technique is central to effective delivery of asthma therapy. The study aim was to identify factors associated with serious inhaler technique errors and their prevalence among primary care patients with asthma using the Diskus dry powder inhaler (DPI). Methods: This was a historical, multinational, cross-sectional study (2011–2013) using the iHARP database, an international initiative that includes patient- and healthcare provider-reported questionnaires from eight countries. Patients with asthma were observed for serious inhaler errors by trained healthcare providers as predefined by the iHARP steering committee. Multivariable logistic regression, stepwise reduced, was used to identify clinical characteristics and asthma-related outcomes associated with ≥1 serious errors. Results: Of 3681 patients with asthma, 623 (17%) were using a Diskus (mean [SD] age, 51 [14]; 61% women). A total of 341 (55%) patients made ≥1 serious errors. The most common errors were the failure to exhale before inhalation, insufficient breath-hold at the end of inhalation, and inhalation that was not forceful from the start. Factors significantly associated with ≥1 serious errors included asthma-related hospitalization the previous year (odds ratio [OR] 2.07; 95% confidence interval [CI], 1.26–3.40); obesity (OR 1.75; 1.17–2.63); poor asthma control the previous 4 weeks (OR 1.57; 1.04–2.36); female sex (OR 1.51; 1.08–2.10); and no inhaler technique review during the previous year (OR 1.45; 1.04–2.02). Conclusions: Patients with evidence of poor asthma control should be targeted for a review of their inhaler technique even when using a device thought to have a low error rate.

Time Required to Rectify Inhaler Errors Among Experienced Subjects With Faulty Technique

“…Approximately half of patients have subsequent difficulty in maintaining inhaler mastery irrespective of the device used and the duration of follow-up. [4][5][6][7] As a consequence, the role of education from trained caregivers is important to reduce poor inhaler technique not only at the time of the first prescription but also at follow-up visits. 8,9 Many studies have evaluated the time required for educating naive adult users to inhaler mastery, [10][11][12][13][14][15][16][17] but, to our knowledge, no information is available to evaluate the re-education time required to achieve inhaler mastery in experienced users with faulty baseline technique.…”

Impact of Inhalation Flow, Inhalation Volume and Critical Handling Errors on Delivered Budesonide/Formoterol Dose in Different Inhalers: An In Vitro Study

“…In addition, studies have shown that one third of the patients fail to exhale and inhale deep before inhalation, leading to additional decrease of the actual inhalation volume [5]. In this context it should be noted that the delivered dose test volume described in the European Pharmacopeia, developed for quality control and registration purposes, is 4 L. Thus, a volume dependence of an inhaler would not be detected during routine quality testing [12].…”

“…Correct use of the inhaler is necessary to enable the medication to be effectively delivered to the lungs with maximized clinical efficacy and minimized systemic side effects [3]. Still, a significant proportion of patients makes inhaler technique errors [3][4][5]. Generic inhalation instructions apply to all inhalers; to exhale before the inhalation and to inhale as deeply as possible; slow through a pressurized metered dose inhaler (pMDI), and fast through a dry powder inhaler (DPI) [6].…”

Dry Powder Inhalers—Between the Doctor and the Patient

“…The DPI inhalation errors are mostly specific to a given type of inhaler but there are also some errors (non-specific), common to all DPI [25]. The most frequent non-specific errors include as follows: not taking a maximally deep expiration (to the level of the functional residual capacity [FRC]) before inhalation, incorrect body position during the inhalation, too slow or too shallow inspiration via the inhaler as well as not holding the breath after the inhalation [26]. The list of the specific errors is much more longer and depends on the type of DPI [25].…”

“…The following persons belong to a high risk group: patients over 60 years of age, with severe obstructive disturbances of the bronchi, with neurological disorders, lonely persons [26,30]. These people need an appropriate education and a DPI that requires as little as possible (which minimises the risk of committing an error).…”