1. The Aerosol Drug Management Improvement Team
ADMIT
Slide Deck 2018

2. Part 4 Inhaler technique in adults Errors and solutions Chris Corrigan
King’s College London School of Medicine, UK

3. Poor asthma control:
the size of the problem

4. Asthma insights and reality in Europe (AIRE)
Rabe KF et al. Eur Respir J 2000;16:

5. Asthma insights and reality in Europe (AIRE)
Rabe KF et al. Eur Respir J 2000;16:

6. Asthma insights and reality in Europe (AIRE)
Rabe KF et al. Eur Respir J 2000;16:

7. Misuse of pMDIs is common and impairs asthma control
Giraud V, Roche N. Eur Respir J 2002;19:

8. Poor inhaler technique causes asthma attacks
Hoskins G et al. Thorax 2000;55:19-24

9. Guidelines are meant
to serve everybody

10. But in fact serve nobody!

11. Before increasing therapy, ask yourself…
Is the patient using the treatment at all?
Is the patient using an inhaler device which he/she
is able to use and which suits him/her best?
Is the patient using the correct inhalation technique?
Has the patient stopped smoking?
Have other possible exacerbating factors for
asthma been identified and eliminated where possible?

12. Before increasing therapy, ask yourself…
Is the patient using the correct inhalation technique?
Is the patient using the treatment at all?
Is the patient using an inhaler device which he/she
is able to use and which suits him/her best?
Has the patient stopped smoking?
Have other possible exacerbating factors for
asthma been identified and eliminated where possible?

13. Compliance

14. Compliance with medication is poor
Milgrom H et al.
J Allergy Clin Immunol
1996;98:
Bender B et al.
J Asthma
1998;35:

15. Pressurised, metered-dose inhalers (pMDIs)
Inhaler technique
Pressurised, metered-dose inhalers (pMDIs)

16. Shake the device (becoming less important)
pMDIs: key techniques
Shake the device (becoming less important)
Exhale fully
Actuate the device after starting to inhale
Inhale slowly
Breath hold following inhalation

17. Co-ordination errors with pMDIs
% Patients
Triggered during exhalation
0.5
Triggered before exhalation
24.6
Triggered at end of exhalation
18.6
Concluded triggering while holding breath
24.2
Triggered in mouth but inhaled through nose
12.1
Several dosages dispensed during one inhalation
7.9
Other mistakes*
5.1
*Stopping inhalation at the moment of activation
Crompton GK et al. Respir Dis 1982;119:

18. Poor co-ordination reduces lung delivery
Good
coordinator
Bad
coordinator
Newman SP et al. Thorax 1991;46:

19. Perfect inhalation with pMDIs
Slow and deep inhalation is optimal
Inhale at 30 l/min then hold breath for 10 sec
Actuation time is not critical
(as long as it commences after the slow and deep inhalation)
Slow vital inspiratory capacity manoeuvre: 2.5 litres over 5 seconds = 30 l/min
Newman SP et al. Eur J Respir Dis Suppl 1982;119:57-65

20. Most patients inhale too rapidly with pMDIs
Good
Verbal
Verbal + 2T
The 2T device
Al Showair RAM et al. Chest 2007;131:

21. Slow inhalation is not so critical with fine particles
Fast inhalation
Usmani OS et al. Am J Respir Crit Care Med 2005;172:

22. Spacer devices Obviate coordination of actuation and inhalation
May be bulky and patients often dislike them
Slow aerosol transit time and particle size
May fit only a single pMDI device
Deliver more drug to the lung periphery
Do not obviate the necessity for patients to inhale slowly and breath hold
Trap larger particles and stop their deposition in the oropharynx
May cause excessive loss of the respirable dose if there is excessive delay after actuation, or multiple actuation
May be used to guide inspiratory flow rate (whistle devices)
May accumulate static electricity, reducing the delivery of particles especially with plastic spacers

23. Not all spacers are the same
Bisgaard H et al. Arch Dis child 1995;73:

24. Spacers: slow inhalation and breath holding still important
BDP HFA with spacer and tidal breathing
BDP HFA with deep inspiration and breath hold
Roller CM et al. Eur Respir J 2007;29:

25. Spacers: clinical efficacy
pMDI + Aerochamber
12/18 discontinued oral steroids
pMDI alone
6/18 discontinued oral steroids
Salzman GA & Pyszczynski DR. J Allergy Clin Immunol 1988;81:

26. Dry powder inhalers (DPIs)
Inhaler technique
Dry powder inhalers (DPIs)

27. Make sure the device is primed properly
DPIs: key techniques
Make sure the device is primed properly
Inhale with a fast suck that is as deep and hard as possible from the start

28. Budesonide Turbohaler® 400 µg
DPIs: fast, sharp inhalation is critical
Budesonide Turbohaler® 400 µg
BDP HFA Autohaler® 100 µg
Kamin WES et al. J Aerosol Med 2002;15:65-73

29. DPIs: successful delivery depends on a threshold inspiratory force
Accuhaler®/Diskus®
Turbohaler®
Broeders MEAC et al. Eur Respir J 2001;18:

30. Inhaler technique
How to improve it

31. Strategies to improve inhaler technique
Choose the right device for the right patient
Can they use it?
Do they like it?
Education, education, education
At clinical review
Pharmacist-led education of small groups J Asthma 2007;44:57-64
Specialist compliance and technique clinics Respir Care 2004;49;
Training aids
Access to information (ADMIT, etc)

32. Physicians do not know how to use inhalers
Hanania NA et al. Chest 1994;105:

33. Recent current ADMIT activities
Video with recommendations for patients “how to use most common devices“
Criteria based inhaler device search database
Service tools for medical Professionals
Slide kit for medical professionals
CD ROM “inhalation Therapy in Asthma” with interactive tools
Info flyer for patients
Video on “Step consultation of the asthma patient”
Disease and therapy based information for patients and Health Care Professionals considering inhalation and device issues available in various languages
ADMIT periodic Newsletter and ADMIT Annual Newsletter
Publications
Presentations at Congresses i.e. ERS