The introduction of pressurized meter-dose inhalers (MDI) in the 1950s transformed treatment for patients with respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD).1 However, challenges pertaining to the correct use of these devices have limited their overall effectiveness. Across numerous populations, settings, and inhaler types, patients have demonstrated high rates of misuse, leading to unintentional nonadherence and, therefore, poor symptom control and greater morbidity.

In a systematic review published in 2016 in CHEST, researchers examined inhaler use errors based on data spanning between 1975 and 2014, including a total of 144 articles and 54,354 patients.2 The results revealed that the overall prevalence rates of correct, acceptable, and poor technique were 31% (95% CI, 28%-35%), 41% (95% CI, 36%-47%), and 31% (95% CI, 27%-36%), respectively, with no significant differences noted between the first and second 20-year periods reviewed. The authors concluded: “Incorrect inhaler technique is unacceptably frequent and has not improved over the past 40 years, pointing to an urgent need for new approaches to education and drug delivery.”

For MDI users, the most common errors involved coordination (45%; 95% CI, 41%-49%), speed and/or depth of inspiration (44%; 95% CI, 40%-47%), and no postinhalation breath-hold (46%; 95% CI, 42%-49%). The most common errors among dry-powder inhaler users were incorrect preparation (29%; 95% CI, 26%-33%), no full expiration before inhalation (46%; 95% CI, 42%-50%), and no postinhalation breath-hold (37%; 95% CI, 33%-40%).

Among the range of problems that can result from misuse, “[u]nintentional nonadherence to first-line rescue inhalers may…lead to escalation of long-acting inhaled medications that might not otherwise be needed,” wrote Griffith et al in a cross-sectional study published in the Annals of the American Thoracic Society.3 On the basis of analyses of data from 95 patients with mild to moderate COPD using albuterol MDIs, the findings showed that 33% of patients reported inhaled corticosteroid (ICS) use, with more frequent use among those with poor vs adequate albuterol MDI technique (41% vs 25%).

After adjustment for potentially confounding variables, including patient demographics, disease severity, and comorbidities associated with dyspnea, the results further linked poor MDI technique with a significantly higher risk for ICS overuse (adjusted prevalence ratio, 2.4; 95% CI, 1.8-3.2). These observations raise “concern that clinicians are providing ICS to patients who may not require such escalation,” the authors stated. “Given the potential direct harms associated with ICS use and the indirect harms financially to patients and health systems, our results highlight the need for inhaler technique training.”

Effective Intervention

Although research has shown that technique training interventions combining demonstration and verbal instruction are more effective than instruction-only approaches, because as few as 5% of interventions include a demonstration component.4 Study findings support the effectiveness of a patient-centered approach called Teach-to-Goal (TTG) in improving technique and health outcomes in adult patients.4 Expanding on these results, researchers at the University of Chicago tested the feasibility of this approach in a sample of predominantly African American children (n=64; aged 8-14 years; roughly half female), a population with significantly higher asthma prevalence (13% vs 7%) and morbidity (24% vs 8%) compared with white children.4

After assessing each child’s baseline inhaler technique, using a 12-step checklist, an asthma “educator taught and assessed the inhaler technique using TTG, using iterative rounds of demonstration and instruction followed by child redemonstration as teach-back (maximum 3 rounds).” TTG was associated with a statistically significant improvement from baseline in the number of children who performed each step correctly (P <.002). From baseline to post-TTG, rates of inhaler misuse decreased significantly from 97% to 17% of children, and rates of mastery increased from 2% to 75% of children (both P <.001).

Although such interventions can lead to immediate improvements in patients’ inhaler technique, these skills may diminish after a single session, pointing to the need for multisession interventions to ensure skills retention. “Unfortunately, patient education as an intervention is consistently down-graded by funders as lacking innovation and potential for impact,” Valerie Press, MD, MPH, associate director of med-peds research and assistant professor of medicine at the University of Chicago, Illinois, and colleagues, stated in a recent article.5 “We hope that studies such as this one by Griffith et al will pique funders’ interest in supporting multi-center comparative effectiveness and implementation research that evaluates the long-term impact of high-quality, evidence-based inhaler skill training interventions. Without this support, we fear another systematic review in 40 years will again state that patient inhaler technique has remained unchanged.”

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Pulmonology Advisor interviewed Dr Press to learn more about inhaler misuse, which has been her main area of study for the past decade.

Pulmonology Advisor: What are some of the current problems with inhaler misuse among patients with asthma and COPD?

Dr Press: The majority of patients across all ages, children through adults, have difficulty using their respiratory inhaler correctly. A systematic review published in 2016 noted that these high rates of misuse had not changed in 40 years of research on the subject.2 This inhaler technique misuse means that the medication in the devices may not be adequately making it into the lungs to control or prevent symptoms. This inhaler misuse leads to poor disease control, worse symptoms, lower quality of life, and increased use of acute care such as emergency department visits and hospitalizations, and it is quite costly. Some devices are trickier than others to use, although all of them can be difficult to use correctly. Patients who use multiple devices are more likely to have difficulty with at least 1 of their devices.6

Pulmonology Advisor: How should clinicians address this issue in practice, and how do interventions differ for children vs adults?

Dr Press: One of the most important things to consider as a clinician is that poor disease control may be due to inadequate inhaler technique. Oftentimes, clinicians note that their patients’ disease is uncontrolled due to excessive symptoms, rescue medication use, or acute care use, and then simply add medications to their treatment regimen. However, a critical first step is to determine whether patients are attempting to take their medications correctly (ie, they have filled their prescriptions and report use of the devices as directed) and whether they are using the correct inhaler technique.