High rates of incorrect technique (28%Â to 68%) with pressurized metered-dose inhalers and dry-powder inhalers have been reported,1 and poor technique with corticosteroid inhalers has been associated ...with poor asthma control and increased emergency department visits.2 We have previously shown that a physical demonstration is a necessary component of device counselling to achieve optimal Turbuhaler (AstraZeneca, New South Wales, Australia) technique.3 Pharmacists are in an excellent position to educate patients about inhaler technique because they are the last health care professionals seen by patients before an inhaled medication is used. ...international asthma guidelines recommend that pharmacists should form part of a team approach to patient education about the use of inhalers.4 Hence the objective of this randomized controlled study was to investigate the effect on clinical and humanistic outcomes of a simple educational intervention concerning dry-powder inhaler technique delivered by community pharmacists to patients with asthma.
Poor inhaler technique has been linked to poor asthma outcomes. Training can reduce the number of inhaler errors, but it is unknown which errors have the greatest impact on asthma outcomes.
The ...CRITical Inhaler mistaKes and Asthma controL study investigated the association between specific inhaler errors and asthma outcomes.
This analysis used data from the iHARP asthma review service-a multicenter cross-sectional study of adults with asthma. The review took place between 2011 and 2014 and captured data from more than 5000 patients on demographic characteristics, asthma symptoms, and inhaler errors observed by purposefully trained health care professionals. People with asthma receiving a fixed-dose combination treatment with inhaled corticosteroids and long-acting beta agonist were categorized by the controller inhaler device they used-dry-powder inhalers or metered-dose inhalers: inhaler errors were analyzed within device cohorts. Error frequency, asthma symptom control, and exacerbation rate were analyzed to identify critical errors.
This report contains data from 3660 patients. Insufficient inspiratory effort was common (made by 32%-38% of dry-powder inhaler users) and was associated with uncontrolled asthma (adjusted odds ratios 95% CI, 1.30 1.08-1.57 and 1.56 1.17-2.07 in those using Turbohaler and Diskus devices, respectively) and increased exacerbation rate. In metered-dose inhaler users, actuation before inhalation (24.9% of patients) was associated with uncontrolled asthma (1.55 1.11-2.16). Several more generic and device-specific errors were also identified as critical.
Specific inhaler errors have been identified as critical errors, evidenced by frequency and association with asthma outcomes. Asthma management should target inhaler training to reduce key critical errors.
Inhaled therapies are the backbone of asthma and chronic obstructive pulmonary disease management, helping to target therapy at the airways. Adherence to prescribed treatment is necessary to ensure ...achievement of the clinician's desired therapeutic effect. In the case of inhaled therapies, this requires patients' acceptance of their need for inhaled therapy together with successful mastery of the inhaler technique specific to their device(s). This article reviews a number of challenges and barriers that inhaled mode of delivery can pose to optimum adherence—to therapy initiation and, thereafter, to successful implementation and persistence. The potential effects on adherence of different categories of devices, their use in multiplicity, and the mixing of device categories are discussed. Common inhaler errors identified by the international Implementing Helping Asthma in Real People (iHARP) study are summarized, and adherence intervention opportunities for health care professionals are offered. Better knowledge of common errors can help practicing clinicians identify their occurrence among patients and prompt remedial actions, such as tailored education, inhaler technique retraining, and/or shared decision making with patients regarding suitable alternatives. Optimizing existing therapy delivery, or switching to a suitable alternative, can help avoid unnecessary escalation of treatment and health care resources.
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