Dry Powder Inhaler Technique Research Articles

Does mixing inhaler devices lead to unchecked inhaler technique errors in patients with COPD? Findings from the cross-sectional observational MISMATCH study

BackgroundPatients with chronic obstructive pulmonary disease (COPD) may be prescribed multiple inhalers that require different techniques for optimal performance. Mixing devices has been associated with poorer COPD outcomes suggesting that...

Impact of a Pharmacist-led Educational Intervention on Inhalation Technique among Sudanese Patients with Asthma

The proper use of inhaler devices can improve medication efficacy while decreasing dose and adverse effects. The main objective of this study was to investigate the effect of pharmacist-led asthma education interventions on inhaler techniques. This study was a controlled, randomized, prospective intervention, in Wad Medani Teaching Hospital outpatient clinic, between March and June 2021.Structured questionnaire with validated checklists of inhaler techniques were used to collect data, from patients at baseline and at three months of follow-up, for both intervention and control groups. Paired and independent t-tests were used to monitor the effectiveness of the interventions. A total of 130 asthmatic patients were enrolled in this study. The intervention group contains 70 patients (53.8%), while the control group contains 60 patients (46.2%). The mean score for the inhaler techniques of Pressurized metered-dose inhalers(PMDIs) was (3.50±1.43) for the intervention group at baseline and increased after the intervention to (6.78±0.515), this result was significant at the (P = 0.05) level, and the mean score of the dry powder inhaler technique at the initial of this study in the intervention group was (4.72 ±1.50) this means were improved after the intervention to (6.83± 0.44) this result was statistically significant. There was no significant difference between the control group before and after intervention (P=0.321).This study has shown that the pharmacist-led educational intervention improved the inhalation technique of asthmatic patients. It is important to consider these programs as routine health care to enhance inhaler techniques.

Pharmacist‐led inhaler training for nurses on an acute care pulmonary unit

AbstractIntroductionAppropriate inhaler technique is important for optimizing treatment of pulmonary conditions, including asthma and chronic obstructive pulmonary disease. Nurses often administer inhaled medications in the acute care setting, providing an opportunity to educate patients on appropriate inhaler technique. To date, no published study has evaluated the impact of pharmacist‐led training on skill improvement and retention among acute care pulmonary nursing staff regarding their ability to instruct a patient on inhaler technique.ObjectiveThe primary objective of this study was to evaluate both the immediate and sustained impact of pharmacist‐led inhaler technique for acute care pulmonary nurses using hands‐on training for instructing on appropriate inhaler use.MethodsThis prospective study used a one group pre‐test, posttest design for an educational intervention. Pharmacists conducted a brief in‐service followed by an individualized simulation where the nurse participant instructed a standardized patient on how to use a placebo metered dose inhaler (MDI) and dry powder inhaler (DPI) before and after receiving individual technique training by a pharmacist. Participant inhaler counseling technique was assessed via standardized checklist. Nurses then received individual coaching from a pharmacist regarding proper inhaler technique. After the pharmacist intervention, the nurse again counseled the standardized patient on how to use the devices. Measures included investigator rating on inhaler technique at baseline, after training, and 2 months later.ResultsAfter the interventions, participant performance significantly improved for MDI and DPI technique. At the 2‐month follow‐up, there was a statistically significant increase for MDI and DPI technique from baseline.ConclusionBrief, pharmacist‐led inhaler technique education results in sustained improvements in inhaler administration skills among pulmonary nursing staff.

Efficacy of a newly developed cartoon video on dry powder inhaler technique: a multicenter study.

One of the factors associated with uncontrolled pediatric asthma is inadequate delivery of inhaled medication to the lungs. Incorrect inhaler technique has been reported. We developed a 2-minute cartoon video instruction aiming to improve dry powder inhaler (DPI) technique. To assess the efficacy of video instruction in improvement of DPI technique in Thai children with asthma. The prospective multicenter cohort study was conducted during March 2018 - February 2019. Children with asthma aged 6-15 years were recruited from the outpatient departments. Five videotapes demonstrated how the patients use DPI devices were recorded as the followings: before and after watching video (V₁pre and V₁post), at one-month (V₂post), at three-month (V₃post) after watching the video and at 5-month follow-up without watching the video (V₄pre). Scoring of correct DPI steps were evaluated by two independent respiratory specialists. Of 57 patients recruited, 30 used Accuhaler™ while 27 used Easyhaler™. In Accuhaler™ group, the median age (range) of 10 (8, 11) year. The mean score of V₁pre, V₁post, V₂post and V₃post were 10.7, 12.3, 12.4, and 12.2 out of 14 respectively. In Easyhaler™ group, the median age (range) of 11 (9-12) year. The mean score of V₁pre, V₁post, V₂post and V₃post were 8.6, 10.4, 11.2 and 11.4 out of 12 respectively. At the five-month follow-up, without watching video, the V₄pre score was still as high as 12.9 ± 1.3 in Accuhaler™ and 11.8 ± 0.4 in Easyhaler™. Our video instruction could improve Accuhaler± and Easyhaler± technique among Thai children with asthma.

Effects of health literacy and cognitive abilities on COPD self-management behaviors: A prospective cohort study.

Low rates of adherence to self-management behaviors are common among patients with COPD. Health literacy and cognitive abilities may influence engagement in self-management behaviors. We sought to assess the association between health literacy and cognitive abilities with self-management behaviors in patients with COPD. We conducted an observational cohort study among American adults with COPD in New York, New York, and Chicago, Illinois. Outcomes included adherence to COPD medication, metered dose inhaler (MDI) and dry powder inhaler (DPI) technique, receipt of vaccination, and routine healthcare appointments. Health literacy was measured with the Short Test of Functional Health Literacy in Adults. Cognitive function was assessed in terms of global, fluid (working memory, processing speed, executive function) and crystallized (verbal) ability. Adequate health literacy was associated with adequate adherence to COPD medications (OR 1.46; 95% CI, 1.02-2.08), correct MDI (OR 1.66; 95% CI, 1.13-2.44) and DPI (OR 2.17; 95% CI, 1.30-3.64) technique. Fluid abilities were also associated with medication behaviors and visiting a regular healthcare provider, while crystalized abilities were not. Global cognitive abilities were associated with correct inhaler technique. No other associations were found with non-medication self-management behaviors. COPD patients with limited health literacy and deficits in fluid cognitive abilities have lower rates of adherence and poorer inhaler technique than individuals with adequate health literacy and greater fluid cognitive abilities. These findings highlight the importance of considering the health literacy level and cognitive ability when caring for and educating patients with COPD.

Inhaler technique in patients attending an urban pulmonology practice

Objective . To evaluate the use of inhaler therapy, primarily focusing on the source of the initial inhaler training and the effects of regular monitoring of inhaler use. Methods . We conducted a prospective study of 200 adult patients using either a metered dose inhaler (MDI) or dry powder inhaler (DPI), attending a private pulmonology practice for the treatment of asthma, chronic obstructive pulmonary disease (COPD) or asthma-COPD overlap. Each patient was evaluated once, and assessed by the investigators irrespective of the patient’s background and inhaler technique training. Results. The MDI and DPI techniques were found to be 45% and 79% adequate, respectively ( p <0.001). Patients who had initial training in a specialist or pulmonology practice showed 100% adequacy. In stark contrast, inadequate technique was observed where initial MDI training was performed by family members, general practitioners, hospital staff, pharmacy staff and self ( p <0.05). Similarly, inadequate technique was seen in the DPI group when taught by family members, general practitioners, hospital staff and pharmacy staff ( p <0.001). The Accuhaler was used by 59% of the patients using a DPI; 41% used the Turbuhaler. The percentage of inadequate inhaler technique in the Accuhaler was 28%, while the percentage of inadequate inhaler use in the urbuhaler group was lower at 10% ( p <0.001). Conclusion . In an urban private practice environment, the adequacy of inhaler technique was shown to be suboptimal. DPI technique was found to be superior to MDI technique, and the Turbuhaler was employed more adequately than the Accuhaler. There was no correlation between the duration of inhaler use and technique, but patients initially taught by non-pulmonology specialists and pulmonologists showed superior technique to that of other groups, i.e. patients taught by family members, general practitioners and hospital staff.

Do Face-to-Face Training and Telephonic Reminder Improve Dry Powder Inhaler Technique in Patients with COPD?

Introduction. Current modes of instruction on inhaler technique are inadequate. We aimed to evaluate the value of face-to-face training and telephonic reminder (FFTTR) for improving Rotahaler technique in experienced patients with COPD. Materials and Methods. A single group pre-/postinterventional study was conducted at Chitwan Medical College Teaching Hospital, Nepal. We assessed the Rotahaler technique of thirty consecutive patients using Rotahaler device for more than one year. Patients with incorrect technique (n = 20) were instructed and trained by a pharmacist. Telephonic reminder was used to reinstruct patients on the correct technique on weekly basis for two weeks and technique was reassessed after 4 weeks of their first training. Descriptive statistics including Wilcoxon Signed Rank test were applied. Results. The mean age was 66.06 ± 10.6. Of 30 patients, 10 (33.3%) performed Rotahaler technique correctly at baseline and were excluded from FFTTR intervention. FFTTR corrected the technique in 18 (90%) patients and the median (IQR) score increased from 6 (5-6) to 8 (8-8) (p < 0.001). The most incorrect steps were “breathe out gently but not towards the inhaler mouthpiece” (16, 80%) and “hold breath for about 10 seconds” (18, 90%) at baseline which improved after intervention. Conclusion. FFTTR approach markedly improved Rotahaler technique in patients with COPD.

Benefit of hospital pharmacy intervention on the current status of dry powder inhaler technique in patients with asthma and COPD: a study from the Central Development Region, Nepal.

BackgroundThe majority of patients with asthma and chronic obstructive pulmonary disease (COPD) have been known to perform inhaler technique inadequately. We aimed to evaluate the benefit of hospital pharmacy intervention on the current status of dry powder inhaler (Rotahaler®) technique in such patients and the factors associated with the correct use.MethodsA pre–post interventional study was conducted at the outpatient pharmacy in a teaching hospital of the Central Development Region, Nepal, in patients with asthma and COPD currently using a Rotahaler device. Patients’ demographics and Rotahaler technique were assessed before intervention. Those who failed to demonstrate the correct technique were educated and trained by the pharmacist, and their technique was reassessed after 2 weeks of intervention. Descriptive statistics, including Wilcoxon signed rank test, Mann–Whitney U test, Spearman’s correlations and Kruskal–Wallis test, were performed for statistical analysis.ResultsBefore intervention, only 5.7% (10 of 174) of the patients demonstrated the correct Rotahaler technique and the most common errors observed were failure to breathe out gently before inhalation (98.8%) and failure to hold breath for about 10 seconds after inhalation (84.8%). After the intervention (n=164), 67.1% of the patients showed their technique correctly (p≤0.001) and failure to breathe out gently before inhalation was the most common error (27.44%). Age (p=0.003), previous instruction (p=0.007), patient’s education level (p=0.013) and source of instruction (p<0.001) were associated with an appropriate technique before intervention, while age (p=0.024), duration of therapy (p=0.010) and gender (p=0.008) were the factors correlated with correct usage after intervention.ConclusionThe current status of Rotahaler technique is inadequate in patients with asthma and COPD attending the Chitwan Medical College Teaching Hospital in the Central Development Region, Nepal. However, a single hospital pharmacy intervention can significantly improve the correct use of the technique, highlighting the role of hospital pharmacies in the improvement of inhaler technique.

Potential Benefit of Repeated Dry Powder Inhaler’s Inhalation Technique Counseling on Asthmatic Patients

The aim of the work presented here was to determine the role of dry powder inhaler (DPI) counselling on inhalation technique and lung function test scores of the asthmatic patients. To decrease variability, asthmatic patients using an Aerolizer were enrolled in the study, as this was the most commonly prescribed DPI in outpatient clinics of Beni Suef University hospital. Each patient was subjected to three visits separated by 1 month each. In each visit, patient inhalation technique from the DPI was checked, and the number of mistakes was identified and corrected. Also, patients’ peak expiratory flow (PEF) and forced expiratory volume in one second (FEV1) presented as a percentage of the forced vital capacity (FVC) were checked. As the number of visits increased, the mean number of observed mistakes was significantly decreased (p < 0.001). The most common repeated mistakes were “To inhale fast” and “To maintain a fast inhalation rate until the lungs are full”. In all age groups, there was a significant increase (p < 0.001) in the pulmonary function test after the period of counselling. To improve and maintain the recommended inhalation technique of DPI and possibly improve patients’ lung function test scores, counselling on proper DPI technique should be repeated at every possible opportunity.

Health Literacy, Cognitive Function, Proper Use, and Adherence to Inhaled Asthma Controller Medications Among Older Adults With Asthma

We sought to investigate the degree to which cognitive skills explain associations between health literacy and asthma-related medication use among older adults with asthma. Patients aged ≥ 60 years receiving care at eight outpatient clinics (primary care, geriatrics, pulmonology, allergy, and immunology) in New York, New York, and Chicago, Illinois, were recruited to participate in structured, in-person interviews as part of the Asthma Beliefs and Literacy in the Elderly (ABLE) study (n = 425). Behaviors related to medication use were investigated, including adherence to prescribed regimens, metered-dose inhaler (MDI) technique, and dry powder inhaler (DPI) technique. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Cognitive function was assessed in terms of fluid (working memory, processing speed, executive function) and crystallized (verbal) ability. The mean age of participants was 68 years; 40% were Hispanic and 30% non-Hispanic black. More than one-third (38%) were adherent to their controller medication, 53% demonstrated proper DPI technique, and 38% demonstrated correct MDI technique. In multivariable analyses, limited literacy was associated with poorer adherence to controller medication (OR, 2.3; 95% CI, 1.29-4.08) and incorrect DPI (OR, 3.51; 95% CI, 1.81-6.83) and MDI (OR, 1.64; 95% CI, 1.01-2.65) techniques. Fluid and crystallized abilities were independently associated with medication behaviors. However, when fluid abilities were added to the model, literacy associations were reduced. Among older patients with asthma, interventions to promote proper medication use should simplify tasks and patient roles to overcome cognitive load and suboptimal performance in self-care.

Self-management behaviors in older adults with asthma: associations with health literacy.

To examine self-management behaviors, including medication adherence and inhaler technique, in older adults with asthma and their association with health literacy. Observational cohort study. Primary care and pulmonary specialty practices in two tertiary academic medical centers and three federally qualified health centers in New York, New York, and Chicago, Illinois. Adults with moderate or severe persistent asthma aged 60 and older (N = 433). Outcomes were adherence to asthma controller medications, metered dose inhaler (MDI) and dry powder inhaler (DPI) techniques, having a usual asthma physician, and avoidance of four common triggers. Health literacy was assessed using the Short Test of Functional Health Literacy in Adults. The mean age was 67, and 36% of participants had marginal or low health literacy. Adherence was low (38%) overall and worse in individuals with low health literacy (22%) than in those with adequate literacy (47%, P < .001) and after adjusting for demographic factors and health status (odds ratio (OR) = 0.48, 95% confidence interval (CI) = 0.31-0.73). Similarly, inhaler technique was poor; only 38% and 54% had good MDI and DPI technique, respectively. Technique was worse in those with low health literacy (MDI technique: OR = 0.57, 95% CI = 0.38-0.85; DPI technique: OR = 0.42, 95% CI = 0.25-0.71). Asthma self-monitoring and avoidance of triggers occurred infrequently but were less consistently associated with low health literacy. Adherence to medications and inhaler technique are poor in older adults with asthma and worse in those with low health literacy. Clinicians should routinely assess controller medication adherence and inhaler technique and use low-literacy communication strategies to support self-management in older adults with asthma.

From the authors

H.K. Reddel and co-workers refer to a paper by Basheti et al. 1, describing a pharmacist intervention targeting only dry powder inhaler technique and taking ∼2.5 min per visit. First, we agree that ideally this …

Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique

Objective To evaluate the feasibility, acceptability and effectiveness of a brief intervention about inhaler technique, delivered by community pharmacists to asthma patients. Methods Thirty-one pharmacists received brief workshop education (Active: n = 16, Control: n = 15). Active Group pharmacists were trained to assess and teach dry powder inhaler technique, using patient-centered educational tools including novel Inhaler Technique Labels. Interventions were delivered to patients at four visits over 6 months. Results At baseline, patients (Active: 53, Control: 44) demonstrated poor inhaler technique (mean ± S.D. score out of 9, 5.7 ± 1.6). At 6 months, improvement in inhaler technique score was significantly greater in Active cf. Control patients (2.8 ± 1.6 cf. 0.9 ± 1.4, p < 0.001), and asthma severity was significantly improved ( p = 0.015). Qualitative responses from patients and pharmacists indicated a high level of satisfaction with the intervention and educational tools, both for their effectiveness and for their impact on the patient–pharmacist relationship. Conclusion A simple feasible intervention in community pharmacies, incorporating daily reminders via Inhaler Technique Labels on inhalers, can lead to improvement in inhaler technique and asthma outcomes. Practice implications Brief training modules and simple educational tools, such as Inhaler Technique Labels, can provide a low-cost and sustainable way of changing patient behavior in asthma, using community pharmacists as educators.