Chronic obstructive pulmonary disease rates continue to rise despite unprecedented advances in therapies supported by evidence-based guidelines.1,2 Declining lung function, a COPD hallmark indicative of progressive airflow limitation, can exact a physical, emotional, and financial toll on patients. Total deaths from this preventable, treatable condition, which predominantly affects smokers, are projected to increase by more than 30 percent over the next decade without interventions to cut risks.1
Effective COPD care should involve implementing guideline recommendations and risk factor reduction, for example by helping smokers to quit and using beneficial treatments to manage the disease.3-5 Inhaled therapy provides COPD patients with symptom relief from dyspnea, chronic cough, and sputum production.6 Short and long-acting bronchodilators and corticosteroid therapies typically prescribed for COPD have been formulated for either one or more of the following devices available in the U.S.: pressurized metered dose inhalers (pMDIs), dry powder inhalers (DPIs), and nebulizers.
Traditional power-driven nebulizers are used to administer liquid medication in the form of a vapor to ambulatory patients who are unable to use pMDIs or DPIs.6,7 Although DPIs and pMDIs are convenient, portable devices, each has device-specific technical aspects that must be learned, which can be confusing for patients.
Multiple inhalers may be a fact of life for many COPD patients over the course of their illness, and stepping up treatment may require short-acting beta-agonists (available in pMDIs) on an as-needed basis for mild COPD; long-acting beta-agonists as add-on maintenance therapy for moderate to severe COPD (in pMDIs and DPIs), and possibly a combination of the latter with corticosteroids for patients with very severe COPD (pMDIs; DPIs, or nebulizers).2
Given the numerous mono- or combination treatments available in an array of inhaler devices, medical personnel must know how to find the best drug and inhaler device combinations that can be adapted to patients' capabilities and individual needs.7 Sub-optimal device selection and use are common, mainly because prescriber decisions are based on device availability or personal preferences, with limited knowledge of guidelines, device features and proper use.
Although knowledge of the guidelines can aid in optimizing COPD management, it cannot identify patients' needs, preferences, and abilities to use different devices.2,5,8,9 Time and other constraints also may prevent medical personnel from providing inhaler education.6,10 Respiratory therapists equipped with updated inhaler knowledge are logical candidates to fill this recognized void because they are familiar with respiratory drugs and participate in pulmonary interventions.4,11
Reasons for ineffective inhaler use
Misuse of inhaler devices has been well documented. One review has observed that 11 percent and 32 percent of pMDI and DPI users, respectively, made critical errors that resulted in little or no pulmonary drug deposition.7 In other observational studies, only 8 percent to 31 percent of COPD patients could demonstrate correct inhaler technique.12,13 Several patients in these studies raised the point that physicians had never taught or observed them using the prescribed inhalers.12,13
All inhaler types have been shown to be effective when used under the special circumstances of clinical trials; however, in real-life circumstances, successful inhaler use is dependent on many variables.14,15 Assessing the patient's ability to use a given device is crucial to success, and it involves consideration of factors such as age, impaired motor skills, tremors, eyesight, reading comprehension, memory, and psychosocial factors. Cost, polypharmacy, drug administration time, and patient access to care are also important.16
Older patients, who represent a significant percentage of hospitalized COPD patients and those with severe COPD may, on occasion, be unable to generate the inhalation effort (DPIs), or breath coordination (pMDIs) required for correct use of various inhalers due to physical and mental frailties.17-19 Poor inhaler use can be directly correlated with age and COPD-related psychosocial factors, whereas good technique correlates with high mental status questionnaire scores.20-22
Key questions may aid the health care provider in assessing the most suitable inhaler for each individual:7
- Which devices are available that deliver the desired drug?
- Can the same type of device be used for all inhaler drugs prescribed for the patients?
- Which device does the patient prefer to use?
- Is the patient capable of reproducing the correct handling and inhalation maneuver required?
- Which are the most convenient and portable inhalers for each clinical situation?
- With which device is the health care professional familiar?