<p>Critical Error Frequency and the Impact of Training with Inhalers Commonly used for Maintenance Treatment in Chronic Obstructive Pulmonary Disease</p>

Abstract

Introduction: Training in correct inhaler use, ideally in person or by video demonstration, can minimize errors but is rarely provided in clinics. This open-label, low-intervention study evaluated critical error rates with dry-powder inhalers (DPIs), before and after training, in patients with chronic obstructive pulmonary disease. Methods: Patients prescribed an inhaled corticosteroid (ICS)/long-acting β 2-agonist (LABA) (ELLIPTA, Turbuhaler, or DISKUS), long-acting muscarinic antagonist (LAMA)/ LABA (ELLIPTA or Breezhaler), or LAMA-only DPI (ELLIPTA, HandiHaler, or Breezhaler) were enrolled. Critical errors were assessed before training (Visit 1 [V1]; primary endpoint) and 6 weeks thereafter (Visit 2 [V2]; secondary endpoint). Logistic regression models were used to calculate odds ratios (ORs) for between-group comparisons. Results: The intent-to-treat population comprised 450 patients. At V1, fewer patients made ≥1 critical error with ELLIPTA (10%) versus other ICS/LABA DPIs (Turbuhaler: 40%, OR 4.66, P=0.005; DISKUS: 26%, OR 2.48, P=0.114) and other LAMA or LAMA/LABA DPIs (HandiHaler: 34%, OR 3.50, P=0.026; Breezhaler: 33%, OR 3.94, P=0.012). Critical error rates with the primary ICS/LABA DPI were not significantly different between ELLIPTA ICS/LABA (10%) and ICS/LABA plus LAMA groups (12-25%). Critical errors with the primary ICS/LABA DPI occurred less frequently with ELLIPTA ICS/LABA with or without LAMA (11%) versus Turbuhaler ICS/LABA with or without LAMA (39%, OR 3.99, P<0.001) and DISKUS ICS/LABA with or without LAMA (26%, OR 2.18, P=0.069). Simulating singleinhaler versus multiple-inhaler triple therapy, critical error rates were lower with ELLIPTA fluticasone furoate/vilanterol (FF/VI; 10%) versus ELLIPTA FF/VI plus LAMA (22%), considering errors with either DPI (OR 2.50, P=0.108). At V2, critical error rates decreased for all DPIs/groups, reaching zero only for ELLIPTA. Between-group comparisons were similar to V1. Conclusion: Fewer patients made critical errors with ELLIPTA versus other ICS/LABA, and LAMA or LAMA/LABA DPIs. The effect of "verbal" training highlights its importance for reducing critical errors with common DPIs.

Critical inhaler technique errors in Swedish patients with COPD: a cross-sectional study analysing video-recorded demonstrations

“…Errors related to the inhalation manoeuvre were defined as critical for all device models included in this study. The identified error rates were somewhat lower compared with previous studies in patients with COPD, 1–16 vs. 0-29% 15 , 16 , 18 , 19 , depending on the device model. The wording for the definitions for incorrect inhalation manoeuvre varied in the previous studies 15 , 16 , 18 , but the message being the same, that is, the inhalation manoeuvre should be as fast and as long as possible for the DPIs, and slow and steady for the SMI.…”

“…The identified error rates were somewhat lower compared with previous studies in patients with COPD, 1–16 vs. 0-29% 15 , 16 , 18 , 19 , depending on the device model. The wording for the definitions for incorrect inhalation manoeuvre varied in the previous studies 15 , 16 , 18 , but the message being the same, that is, the inhalation manoeuvre should be as fast and as long as possible for the DPIs, and slow and steady for the SMI. Noteworthy is that two previous studies 14 , 15 categorised inhalation manoeuvre errors as non-critical, while another study 19 defined incorrect inhalation manoeuvre as “incorrect inhalation were considered critical errors” with no further explanation.…”

“…van der Palen et al 14 showed in a randomised study with a cross-over design, including COPD patients naive to the device models studied, that patients treated with a single fixed-dose Ellipta DPI made fewer critical errors compared with patients using a combination of Diskus and Handihaler or Turbuhaler and Handihaler. Collier et al 15 compared single device model treatment with Ellipta against different dual DPI model treatment combinations, and found that the odds of making ≥1 critical error were up to seven times higher in patients using a combination of two inhaler device models, compared with patients using a single Ellipta inhaler. Khassawneh et al 16 showed, also in a cross-sectional study including patients using device models Diskus, Turbuhaler and pMDI, that those who were using more than one device model more often made critical errors in inhaler technique.…”

“…However, detailed guidance is lacking regarding how to combine the different inhaler device models when more than one inhaler device is needed in a treatment regimen. Currently, there are limited data about critical inhaler technique errors in patients with COPD using multiple inhaler device models [14][15][16] , and previous studies have typically been restricted to studying a specific type and/or number of device models [14][15][16][17][18] . The aim of this study was to determine the prevalence and types of critical errors in inhaler technique among patients with COPD, and to investigate factors associated with critical errors.…”

Inhaler Use Technique in Chronic Obstructive Pulmonary Disease Patients: Errors, Practices and Barriers

“…A high proportion of patients inaccurately believe that their technique is adequate [ 14 ], and as in this study, 83% of participants believed their technique is almost correct. This kind of attitude appears to create a disconnect between inhaler technique theory and practice, as mastery at the time of teaching does not translate into the maintenance of correct inhaler technique over time [ 15 ]. We recognize that, for the patient, there is a range of competing factors that impact their willingness, ability, and preference to using their inhalers [ 16 - 17 ], but we believe they can be trained successfully to use their inhalers with effective and repeated instruction [ 9 - 18 ].…”