Identification of inhaler technique errors with a routine procedure in Portuguese community pharmacy

Abstract

Background:A correct selection of drugs prescribed, but also the choice of the appropriate inhaler device, is crucial for the control of respiratory diseases.Objective:To evaluate the inhaler technique and identify potential errors of patients when treated with inhalers by testing a routinary procedure to be implemented in any community pharmacy.Methods:Adults with asthma/COPD and under inhalation therapy were invited to demonstrate how they use their inhalers. After direct observation it was registered whether all the sequential steps included in the summary of product characteristics (SmPC) were performed.Results:The study involved 67 patients from 4 community pharmacies (Portugal central region): 34 (50.7%) males, 65.4 (SD=18.28) years old, 42 (62.7%) with COPD, and 23 (34.3%) using more than one inhaler. The 67 patients used 95 inhalers, comprising: 57 (60.0%) multiple dose DPI (dry powder inhalers), 18 (18.9%) single dose DPI, 16 (16.8%) pMDI (pressurized metered dose inhalers), 2 (2.1%) pMDI+spacer and 2 (2.1%) SMI (soft mist inhalers). No errors were made only by 9 (13.4%) patients. In the 75 DPIs techniques, the most frequent errors were ‘no previous forced expiration’ (46=61.3%) and ‘no 10s apnea after inhalation’ (51=68.0%); in the 16 pMDIs techniques common errors were ‘lack of hand-lung coordination’ (7=43.8 %), ‘no previous forced exhalation’ (8=50.0%) and ‘no apnea after inhalation’ (10=62.5%). After inhaling from 56 devices containing corticosteroids, 34 (60.7%) of the patients did not wash their mouth.Conclusion:The study demonstrated the possibility of performing this procedure routinely in Portuguese community pharmacies and also its utility, since 58 (87%) of patients had at least one error during the inhalers use.

A comparative analysis of errors in inhaler technique among COPD versus asthma patients

“…Likewise, failure to exhale before inhaling through device, inability to coordinate activation with inhalation, and failure to hold breath have also been reported to be errors in inhalation maneuvers that are common in all types of inhalers among COPD and asthma patients. 13 , 17 , 30 , 31 In accordance with our findings, a high frequency of poor and/or suboptimal inhaler use has consistently been reported in past studies alongside a higher likelihood of errors related to device handling with use of MDIs compared with DPIs among COPD and asthma patients. 9 , 15 , 29 …”

“… 13 , 17 , 19 This seems notable given that MDIs require a good ability of hand–lung coordination and is therefore considered to be inherently more difficult to use than DPIs. 13 , 25 , 26 In fact, while considered to be more likely with MDI-type inhalers, 9 , 15 , 27 – 29 suboptimal inhaler technique is very common in real life with both MDIs and DPIs, and in the majority of asthma and COPD patients, despite advances in inhaler device technology. 3 , 5 , 10 – 16 …”

<p>Promoting Community Pharmacy Practice for Chronic Obstructive Pulmonary Disease (COPD) Management: A Systematic Review and Logic Model</p>

“…41 Long-term follow-up for patients by pharmacists and monitoring of the risk of exacerbations were also expected to improve patient medication behaviours, thereby improving medication compliance and, finally, greatly reducing the further development of COPD. 50 Moreover, based on the current study, there was a general agreement on the practicality and feasibility of community pharmacists' interventions in improving early detection and diagnosis, 24,30,35,40,47 supporting smoking cessation, 27,30,36,38 ensuring that patients acquire the skills to use inhalator devices appropriately, 26,29,[31][32][33][34]37,42,44,45,47 and promoting influenza vaccination to population groups at risk of COPD or exacerbations. 25,46 However, areas such as collaborating with doctors and other healthcare providers to provide integrative care were under-researched.…”

“…35,38,39,43 At the same time, as the current mainstay of treatment for COPD, inhaled medication therapy needed more education from pharmacists, leading to improved inhalation techniques. 12,49 To achieve the goal of optimizing the inhalation technique, pharmacists' education for patients needs to include both shortterm instruction, in which pharmacists teach patients how to correctly use the inhalation device until the patients demonstrate understanding and proper handling techniques; 25,26,28,29,[31][32][33][34][36][37][38][39][42][43][44][45] and long-term using monitor levels, in which patients are required to demonstrate using the device while the pharmacist evaluates them and then, if necessary, corrects their use in the subsequent process. [31][32][33][43][44][45]…”

“…25,32,33,43,46,48 Outputs Among all of the outputs, the most popular output referred to in the studies was the patients' technique in using inhalation devices, and all studies showed positive intervention effects (n=11). 26,29,[31][32][33][34]37,42,44,45,47 This was followed by medication compliance; all studies involving compliance showed that patient compliance improved after intervention by apharmacist. [32][33][34]36,38,41 Of the studies involving interventions for patients to quit smoking, most (n=4) showed a positive effect; 27,30,36,38 however, Tommelein et al reported there was no help available for the intervention.…”