1. Devices, demonstration and discussion
The 3 D’s
Devices, demonstration and discussion

2. Inhalation Medication
Proven benefits
Adherence and correct inhaler technique crucial
Diversity in available inhaler devices -> confusion
Errors in inhaler handling are common (patients AND
healthcare providers)
Reduced medication reaching the lungs
Reduction in therapeutic benefit (disease outcomes like
disease control, symptoms, quality of life, exacerbations)

3. Reasons why it is important to revisit inhaler technique
The most expensive device is the one the patient cannot or will not use
Many patients cannot use their device(s) effectively
Many health care professionals cannot demonstrate them correctly
Poor inhaler technique is extremely common and substantially reduces the effectiveness of inhaled therapy
Cost savings cannot be made unless the patient is taking the right medicine at the right time

4. Mainstay of respiratory treatment

5. Factors influencing the choice of inhaler device
GP/Nurse/Practitioner
Appropriate treatment – symptomatic control & risk prevention
Cost
Consistency of delivery
Availability of various drugs in the same device
Compatibility with other devices
Easy to teach technique
Effectiveness of the device
Patient
Acceptance of the diagnosis
Age
Lifestyle
Ease of use
Inspiration flow rate
Dexterity
Taste
Appearance of device
Preferences
Facilitator to present this slide as some of the factors influencing GP/nurse and patient choices when it comes to prescribing
Ease of use, feeling that the drug is taken and knowing how many doses are left are some of the main points of consideration for an ideal patient inhaler device1
1. Vincken W., Dekhuijzen R., Barnes P. on behalf of the ADMIT Group, Primary Care Respiratory Journal (2010); 19(1): 10
Vincken W., et al. Prim Care Respir J 2010; 19(1): 10-20

6. What issues to consider?
The patient
Wants and needs
The drug
Preventer/reliever
The technique
Good, moderate, poor
Ability
Tools to help AMES/In-check

7. Inhaler technique
Up to 90% of patients show incorrect inhaler technique in clinical studies
Techniques are significantly improved by brief instruction by trained HCP
However, 25% of patients have never received verbal inhaler instruction
Only 11% of patients receive follow-up assessment and education

8. Poor inhaler technique
Ask “Can you show me how you use your inhaler?”
75% of patients using an inhaler for on average 2-3 years reported they were using their inhaler correctly but on checking only 10% demonstrated correct technique
Critical errors =
remove cap
fail to load
fail to prime
too fast
too slow
(Basheti A et al (2008)

9. Inhaler technique Check at each review
Check before increasing medication

10. Do the people teaching know what they are doing?
6 different inhalers, 2 spacers
42 physicians (16 respiratory)
Correct technique?
19 accuhaler
12 MDI
5 handihaler
4 turbuhaler
2 autohaler
Adeni A et al AJCCM 179; 2009 Knowledge of inhaler technique amongst physicians

11. Results
Only 24 knew when MDI was empty
14 knew when Easi-breathe was empty
12 knew when autohaler was empty
5 knew when Turbuhaler was empty
Respiratory physicians scored higher than non respiratory for handi-haler only (p<0.01)
In all other devices no difference in competence!

12. So what about other HCP’s?
Incorrect inhaler technique of between 31-85% in ALL HCP’s
Similar levels between Doctors, Nurses and Pharmacists!
Basheti et al, 2008 Evaluation of novel educational strategy

13. 75% regularly involved in teaching inhaler technique
Do healthcare professionals have sufficient knowledge of inhaler techniques in order to educate their patients effectively in their use?
75% regularly involved in teaching inhaler technique
Baverstock et al Thorax 2010;65:A117

14. Vital variants in treatment in respiratory disease
The drug
The device
The patient
Important to get them all right!

15. Types of Inhaler Device?
Think of inhalers in 2 categories:
Aerosol: Liquid medication or
Dry powder preparation
Effectiveness of the inhaler depends on:
Patient co-ordination
Particle size
Effect of resistance of inhaler device MDI < DPI
Inspiratory Flow 15

16. Pressurised MDIs
High levels of prescribing – dictated by perceived costs – despite patient difficulties
51% - co-ordination of actuation with inspiration
24% - stop inhalation after actuation
12% - aerosol released into mouth whilst inhaling through the nose
Reflex arrest of inspiration - cold freon effect – can further complicate the situation
Ability to use pMDIs is lost with time
The cochrane et al study looked at the percentage of patients not complying with individual tasks on the inhaler task list. Lack of coordination of inhaler activation and onset of inspiration ranges from 17 to 68% for the
MDIs. Other tasks are not performed correctly by a significant proportion of patients, including expiration
before inhaling, inhaling deeply, and holding breath at the end of the inspiration. A study by Bailey et al 32 showed that only 10% of patients did all 10 skills and 48% did eight or more skills on a checklist for MDI use correctly before a self-management education programme
Broeders et al state that aerosol inhalation is considered the optimal route for administering the majority of drugs for treating obstructive airways disease. A number of MDIs and DPIs are available however inhalation is not without difficulty as it requires precise instructions on the inhalation manoeuvre. Available data indicates a frequent lack of knowledge by HCPs & patients on this manoeuvre & handling of the inhaler resulting in a reduction in therapeutic benefit
Broeders et al looked at assessment of pMDI use in 1173 outpatients attending a respiratory clinic showed 51% of them had serious problems co-ordinating actuation with inspiration, 24% of these patients stopped
inhaling prematurely after actuation, and in 12% the aerosol was released into the mouth while inhaling through the nose. Between 8 and 59% of pMDI users have poor or nadequate inhalation technique, the main problem being
difficulty in co-ordinating pMDI actuation with inspiration. Inhaler technique in patients using the pMDI is further complicated by the exit velocity and evaporation temperature of aerosol propellants (freons). The sudden impact of cold freon onto the oropharynx can lead to a reflex arrest of inspiration (‘the cold freon effect') or continuation of inspiration through the nose instead of the mouth. This problem may be less marked with the new hydrofluoroalkane (HFA) propellant-driven pMDIs due to their slower speed of delivery
Cochrane et al Chest 2000; 117: ; Broeders et al PCRJ 2009; 18:

17. …….add a spacer?
Reduce problems of co-ordinating actuation and inhalation
Particle size optimised by larger particle impaction on walls of device and droplet evaporation
Side effects related to oropharyngeal deposition and gut absorption reduced
Optimal technique variable – e.g. multiple actuation, delay in inhalation, disuse
Inspiratory flow ≤ 30 l/min needed
Care/cleaning issues
Does adding a spacer help? It can reduce the problems of co-ordination etc however there remains some issues which need to be addressed
Broeders et al PCRJ 2009; 18: 76-82

18. Breath Actuated Devices
Flow triggered system
No difference between “good” and “bad” users
Co-ordination of inspiration and puff release needed
≥ l/min inspiratory flow needed to trigger drug release
Fewer critical errors than pMDI
According to Broeders et al there are fewer critical errors when using this system however there are still problems encountered with this delivery system. Only available for use with salbutamol in patients with COPD
Broeders et al PCRJ 2009; 18: 76-82

19. Dry Powder Devices Multi-dose devices and single dose capsules
All DPIs require the patient to prepare the dose prior to inhalation
Failure to do this correctly results in no dose irrespective of inhalation technique
More critical errors with single dose than multi dose devices
Failure to exhale to FRC and exhaling into the device are the most common critical errors
Abstract of the Azouz & Chrystyn paper explains why inhalation manoeuvres through a DPI should start with gentle expiration away from the device. Place the inhaler in the mouth ensuring there is a tight seal. This should be followed by an immediate forceful inhalation as fast as possible and continuing as long as the patient can comfortably achieve. There is a wrong assumption that inhalation flows through each DPI is the same and that low flows through some DPIs suggest that dose delivery is impaired eg. A low flow through a DPI with high resistance generates the same turbulent energy as a fast flow with low resistance. Therefore depending in the device different inhalation flows are compatible with potentially effective use, Flow measurements should be a guide to train patients to inhale faster
Azouz and Chrystyn PCRJ 2011; 21:

20. Misconception
True or false
using a DPI always require a forceful inhalation 
some inhalers require forceful and deep inhalation while others require slow and deep inhalation
depending on the internal inhaler resistance

21. So how would YOU inhale?
Quick test of how you would inhale through commonly-used devices
1. MDI
2. Dry Powder Inhaler (DPI)
Need to:
1. Simulate resistance of device
2. Measure speed of inhalation 21

22. How would you breathe in for these?
Slow and Steady 22

23. How about these?
Deep and fast 23

24. How about these? ? 24

25. Examples of poor technique 25

26. 7 Steps to Success ....... Prepare inhaler device
Prepare (or load) dose
Stand up or sit up straight
Breathe out (not into inhaler!)
Put lips around mouthpiece
Breathe in
- MDI: Slow and Steady
- DPI: Deep and fast or Deep and slow
Remove inhaler from mouth and hold breath for up to 10 seconds
Repeat as directed
Its easy isn’t it?
Murphy and Scullion 2012

27. Inhaler technique education
Written instruction alone is not enough!
Inform patients (knowledge)
Practice (skills)
Use uniform inhaler-specific protocols
Regular monitoring of inhaler technique (using standardised checklists) and repeat instruction
Provide (visual) instruction material
Skilled trainers (knowledge and skills up to date!)

28. Take home message Adequate inhaler technique remains a real challenge
Be aware of the possibility of inhaler handling mistakes (even when patients tell you they are familiar with the use of inhalers)
Choose the right inhaler (involve patient preferences)
Learn patients the device specific inhaler technique (using uniform protocols), inform patients, and monitor inhaler technique frequently

29. Take home message
Proper (uniform and consistent) inhaler technique education has to be emphasised
Training of health care providers highly recommended (knowledge, skills and fine- tuning of cooperation)

30. Take home message
Proper (uniform and consistent) inhaler technique education has to be emphasised
Training of health care providers highly recommended (knowledge, skills and fine- tuning of cooperation between HCPs)

31. Real life demonstration
Inhaler technique
Questions
&
Real life demonstration