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

2. Part 2 Performance of inhalers in real life
Clinical outcomes related to
inhalers and technique
Mark Levy

3. Misuse of corticosteroid pMDI is associated with decreased asthma stability
AIS = Asthma
Instability Score
Giraud, European respiratory Journal. 2002;19(2):246-51

4. Misuse of corticosteroid pMDI is associated with decreased asthma stability
AIS = Asthma
Instability Score
Giraud, European respiratory Journal. 2002;19(2):246-51

5. Inhaler mishandling associated with reduced disease control
Cross sectional observational study
N=1664; > 14yr, mean age 62 yr; July–Sep 2008
Outpatient Chest Clinic - Asthma (42%); COPD (52%)
Regular inhaler users (daily for > 1mth, last 3 mths)
843 pMDIs
1113 DPIs (Aerolizer, Diskus, Handihaler, Turbohaler)
2 consecutive eligible patients recruited / clinic
Outcomes:
Inhaler technique (single trained investigator / center)
Asthma control (ACT), COPD mMRC,
Unscheduled attendances & Admissions, A/biotics, systemic corticosteroids
Melani (GENEBI) Resp Med 2011;105:

6. Exhale before inhalation 50
Inhaler mishandling associated with reduced disease controlInhaler mishandling associated with reduced disease control – pMDI
Technique
pMDI
Remove cap
0.2
Shake inhaler 37
Exhale before inhalation 50
Not holding upright 9
Forceful inhalation 52
Actuate against teeth lips or tongue
0.7
Press only once per inhalation 19
Actuation in 2nd half inspiration 18
Activation after end of inhalation 5
Stopping inhalation immediately after actuation 10
Inhalation through nose while & after actuation 2
No or short breath hold (2-3 seconds) 53
Critical errors
Melani (GENEBI) Resp Med 2011;105:

7. Aerolizer/Handihaler
Inhaler mishandling associated with reduced disease control - DPI
Technique
Aerolizer/Handihaler
Diskus
Turbohaler
Failure of Priming
Remove cap/ turn cover
0.65
Insert Capsule /Pierce Capsule 12
Failure of loading
Load dose 7 14
Hold inhaler upright (< 450) 23
Exhaling into mouthpiece before actuation 19 22
Stopping inhaling prematurely 26 29
Inhaling through nose while using device 2 1
Not sealing lips round mouthpiece 5 4
Slow and not forceful inhalation 24 28
Exhale into Mouthpiece after inhalation 21 11
No Breath holding after inhalation 25 32
Doesn't check capsule empty after inhalation 30
Critical errors
Melani (GENEBI) Resp Med 2011;105:

8. Diskus and Handihaler performed better than Turbohaler
Inhaler mishandling associated with reduced disease control
Results:
2288 observations of inhaler technique
4% pMDI users had spacers
At least one critical error in:
MDI (12%), Diskus (35%),
Handihaler (35%), Turbohaler (44%)
OR increased risk of critical errors compared with pMDI:
Diskus (3.4), Handihaler (3.1), Turbohaler (6)
Diskus and Handihaler performed better than Turbohaler
Melani (GENEBI) Resp Med 2011;105:

9. Inhaler mishandling associated with reduced disease control
Results:
Risks of making errors:
Single inhaler (NS), Little perceived benefit (1.4)
Gender (NS)
Low ACT Score risk of critical error (1.53; p<0.0001)
Critical errors in inhaler technique:
Increased risk of Hospital admissions (1.47, p<0.001)
ER Visits (1.62, p<0.001)
Use of antibiotics (1.50, p<0.001)
Systemic steroids (1.54, p<0.001)
Those who had > 1 inhaler check had lower risk of critical errors
Melani (GENEBI) Resp Med 2011;105:

10. Fist Test (n=2483) Second Test (n=2458) Third Test (n=1129) criteria
Results of the first (before training), and second and third Vitalograph Aerosol Inhalation Monitor (AIM) tests after training
Fist Test
(n=2483)
Second Test (n=2458)
Third Test (n=1129)
Failed in at least one criterion (%)
1437 (58%)
1282 (52%)
421 (38%)
criteria
Flow
40%
34%
31%
Synchronisation
58%
53%
42%
Breath holding
22%
18%
Single inhaler (NS)
Little perceived benefit (1.4)
Gender (NS)
Levy et al, Prim Care Resp J. 2013;22(4):406-11

11. pMDI Techique AIM 1st Test
pMDI technique using the Vitalograph Aerosol Inhalation Monitor (AIM) and GINA Control
pMDI Techique AIM 1st Test
Gina Control
Fail
Pass
Total
Controlled
476 (41%)
697 (59%)
1173
Partly Controlled
634 (71%)
263 (29%)
897
Uncontrolled
325 (79%)
85 (21%)
410
1435
1045
2480
Single inhaler (NS)
Little perceived benefit (1.4)
Gender (NS)
Levy et al, Prim Care Resp J. 2013;22(4):406-11

12. Patient preference and ability?
Role of clinician in selecting teaching and monitoring patients technique
Patient preference and ability?
N=50 (29 asthma, 21 COPD)
Diskus (Accuhaler) and Turbohaler handling
Mean age 49
40 previous instruction (1-7yrs ago)
Rotahaler, Diskhaler, pMDI, Inhaler Ingelheim
Shown inhaler & read leaflet → tested
Van der Palen, Journ Asthma 1998;35(2):

13. Patient preference and ability?
Diskus/Accuhaler Checklist (essential)
Turbohaler Checklist (essential)
Open inhaler (100%)
Remove cap from Inhaler (100%)
Push lever back completely (92%)
Keep inhaler upright (88%)
Exhale to residual volume
Rotate grip until click (86%)
Exhale away from mouthpiece
Mouthpiece between teeth and lips
Inhale forcefully and deeply (100%)
Hold breath for 5 sec
Close Inhaler
Replace cap
Single inhaler (NS)
Little perceived benefit (1.4)
Gender (NS)
Van der Palen, Journ Asthma 1998;35(2):

14. Patient preference and ability?
Loading
DA 97.3%; TH 93.5% (p<0.05; )
Patients performing all items correctly
DA 50% ; TH 46% (NS)
Patients performing all essential items correctly
DA 92%; TH 74% (p=0.023)
Patient preference
DA 34% ; TH 50% ; None 16%
Van der Palen, Journ Asthma 1998;35(2):

15. 35 controls; 34 inhaler technique – verbal, leaflet & movie
The Effects of Training on Inhaler Technique and Quality Of Life in Patients with COPD
Randomised OPD, COPD
35 controls; 34 inhaler technique – verbal, leaflet & movie
Patients performing all items correctly
3 mth follow up
Intervention
Control
Used correctly
82% 0%
Attacks, emergency attendances
and hospitalisations
6%, 3%, 3%
46% , 20%, 11%
Quality of Life
Improved SGRQ effect, symptoms & activity
Fewest mistakes were made with Diskus/Accuhaler followed by Aerolizer and Turbohaler
Goris, J Aer Med &Pulm Drug Del: DOI: /jamp

16. RCT - two strategies hospitalized patients with asthma or COPD (n=50)
Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD:
a randomized trial
RCT - two strategies hospitalized patients with asthma or COPD (n=50)
Brief intervention [BI]: single-set of verbal and written step-by-step instructions, or
Teach-to-goal [TTG]: BI + repeated demonstrations of inhaler use and participant comprehension assessments (teach-back)
Outcomes:
Primary: pMDI misuse post-intervention
(<75% steps correct).
Secondary: Diskus/Accuhaler misuse, self-reported inhaler technique confidence and prevalence of 30-day
health-related events.
Press, Jnl of Gen Int Med 2012;27(10):

17. Teach to Goal (TTG) educational strategy
Repeated rounds of assessment and education
12/12 steps correct for pMDI
10/10 steps correct for Diskus/Accuhaler
TTG (repeated up to 2X)
Trained blinded Research Assistants to evaluate participants’ baseline inhaler technique.
Trained research educator - Demonstration & reassessment of participants’ technique (i.e. “teach-back”)
Written instructions and a pamphlet about asthma/COPD)
RA performed a final assessment of participants’ technique
Press, Jnl of Gen Int Med 2012;27(10):

18. Patient confidence in their technique:
Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: a randomized trial
Patient confidence in their technique:
Of the 72% who were confident in their MDI technique, more than two-thirds (69%) used their MDIs incorrectly.
Almost all participants (94%) were confident in their Diskus/Accuhaler technique.
Among these participants, three-quarters (76%) used their device incorrectly.
Press, Jnl of Gen Int Med 2012;27(10):

19. pMDI Diskus/Accuhaler
Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: a randomized trial
Percentage of patients demonstrating incorrect use of inhaler (MDI) before and after either a brief intervention (BI) or TTG intervention
pMDI
Diskus/Accuhaler
Press, Jnl of Gen Int Med 2012;27(10):

20. It is worth teaching inhaler technique while in hospital?
Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: a randomized trial
TTG took 3X longer than BI
Secondary Outcomes:
Participants with 30-day acute health-related events were less common in the group receiving TTG vs. BI
(1 vs. 8, p=0.02)
There were 6 participants with ED visits and/or hospitalizations (BI n=5, TTG n=1)
3 separate participants who died (BI n=3, TTG =0) prior to 30 days post-discharge
It is worth teaching inhaler technique while in hospital?
Press, Jnl of Gen Int Med 2012;27(10):

21. Repeated instruction: inhaler technique in asthma
Cross-sectional questionnaire study
Understanding factors - patient-related
aspects of adherence to inhalation therapy
176 (146) consecutive adults (>16 yr) - Physician diagnosed asthma (GINA)
Regular clinic attendees (every 3 mo)
Inhaled treatment >12 months
No change in medication 3 months
Journal of Asthma, 47:202–208, 2010

22. No change in medication 3 months
Modified Adherence Questionnaire
In the last 3 months have you:
Been careless about using your inhaler?
Ever forgotten to use your inhaler?
Ever stopped using your inhaler because you felt better?
Used your inhaler less than your doctor prescribed because you felt better?
Most of the time
Some of the time
None of the time 1 2 3 4 5
No change in medication 3 months
Journal of Asthma, 47:202–208, 2010

23. Repeated instruction: inhaler technique in asthma
Journal of Asthma, 47:202–208, 2010

24. Repeated instruction: inhaler technique in asthma
Journal of Asthma, 47:202–208, 2010

25. Repeated instruction: inhaler technique in asthma
Journal of Asthma, 47:202–208, 2010

26. Repeated instruction: inhaler technique in COPD
Cross-sectional questionnaire study
Understanding factors – patient -related
aspects of adherence to inhalation therapy
88 (55) consecutive adults; >10 pack yr;
respiratory physician diagnosed COPD (confirmed – GOLD)
Regular clinic attenders (every 3 months)
Inhaled treatment >12 months
No change in medication 3 months
International Journal of COPD 2011:6 97–104

27. Good adherence: mean score was ≥4.0; non-adherence <4
Modified Adherence Questionnaire
In the last 3 months have you:
Been careless about using your inhaler?
Ever forgotten to use your inhaler?
Ever stopped using your inhaler because you felt better?
Used your inhaler less than your doctor prescribed because you felt better?
Most of the time
Some of the time
None of the time 1 2 3 4 5
Good adherence: mean score was ≥4.0; non-adherence <4
Journal of Asthma, 47:202–208, 2010

28. Repeated instruction: inhaler technique in COPD
International Journal of COPD 2011:6 97–104

29. Repeated instruction: inhaler technique (Takemura et al)
Asthma
COPD
25/146 (17% ) had repeated instruction
21/55 had repeated instruction
(specific devices, verbal and demonstration)
Better adherence scores
(4.4 vs 3.9 p = .0016)
(4.4 vs 3.9; p=0.032)
Less exacerbations
(r = −0.19, p =0.021)
Better SGRQ Scores
(33.7 vs 44.9 p=0.03)
Fewer ER visits
(r=−0.19, p =0.042)
Better SGRQ scores
(Total: r = −0.22, p =0.024)
Takemura, International Journal of COPD 2011:6 97–104
Takemura, Journal of Asthma, 47:202–208, 2010