Pulmonology Advisor
September 30, 2019
Tori Rodriguez, MA, LPC, AHC

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.

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%).