Inhaler Technique Errors Research Articles

Critical Errors in Inhaler Technique among Children Hospitalized with Asthma

Past studies have not evaluated inhaler use in hospitalized children with asthma. The objectives of this study were to evaluate inhaler technique in hospitalized pediatric patients with asthma and identify risk factors for improper use. We conducted a prospective cross-sectional study in a tertiary children's hospital for children 2-16 years of age admitted for an asthma exacerbation, and inhaler technique demonstrations were analyzed. Of 113 participants enrolled, 55% had uncontrolled asthma, and 42% missed a critical step in inhaler technique. More patients missed a critical step when they used a spacer with mouthpiece instead of a spacer with mask (75% [51%-90%] vs 36% [27%-46%]) and were older (7.8 [6.7-8.9] vs 5.8 [5.1-6.5] years). Patients using the spacer with mouthpiece remained significantly more likely to miss a critical step when adjusting for other clinical covariates (odds ratio 6.95 [1.71-28.23], P = .007). Hospital-based education may provide teachable moments to address poor proficiency, especially for older children using a mouthpiece.

Inhaler training and asthma knowledge are associated with a higher proportion of patients with correct inhaler technique in young but not in elderly asthmatic patients

Objective: Incorrect inhaler usage is frequent, particularly in elderly asthmatic patients. This study aimed at comparing inhaler technique errors and their determinants, as well inhaler technique self-perception versus real performance, between elderly and non-elderly asthmatics. Methods: Cross-sectional assessment of 92 elderly and 100 non-elderly asthmatics followed at specialty clinics. A standardized questionnaire was applied and inhaler technique demonstration was requested. Errors were assessed using checklists based on manufacturers’ instructions and inhaler technique was graded as correct, acceptable or incorrect. Chi-Square Test and Fischer’s Exact Test were used for comparative analysis of nominal variables. A p value equal to or less than 0.05 was considered statistically significant. Results: Inhaler technique was correct in a minority of elderly and young patients, without significant differences between study groups. Only 11.1% of the elderly who classified their inhaler as easy and 12.7% who stated their technique was correct had no errors. Previous regular inhaler training was associated with better actual performance in young but not in elderly patients. Conclusion: Our study showed that in spite of regular follow up at specialized outpatient clinics, inhaler devices are associated with a high frequency of errors in elderly and non-elderly asthmatics. In addition, most patients tend to overestimate their technique as correct. Finally, previous, frequent training was associated with a significantly higher percentage of patients showing correct or acceptable technique but only in non-elderly asthmatics, which suggests that elderly asthmatics may need specifically tailored inhaler education programs.

Screening for inhalation technique errors with electronic medication monitors

Screening for inhalation technique errors with electronic medication monitors

Inhalation Technique Errors with Metered-Dose Inhalers Among Patients with Obstructive Lung Diseases: A Systematic Review and Meta-Analysis of U.S. Studies.

Metered dose inhalers (MDIs) are commonly prescribed for inhalation therapy, but correct use is critical to promoting effective medication delivery. This systematic literature review and meta-analysis evaluates the overall and step-by-step prevalence of errors among adults with obstructive lung diseases in the United States who used MDIs. Electronic and manual searches conducted between 1979-2018 using PubMed, EMBASE, PsycINFO, Cochrane, and Google identified 10 articles that met the following inclusion criteria: (a) English language, (b) U.S. adults diagnosed with chronic obstructive pulmonary disease, and (c) MDI use error rates. Meta-analytic techniques using random-effects models were applied to calculate effect sizes, weighted proportions, and 95% confidence intervals (CIs). Heterogeneity was assessed by the I2 statistic. Aggregate findings revealed that 86.7% of patients (n=390, 95% CI 77.5-96.0) made at least 1 inhalation technique error, and 76.9% (n=885, 95% CI 65.8-87.9) incorrectly performed ≥ 20% of device use steps. The most prevalent step-by-step errors across the studies (n=1105) were failure to: (a) exhale fully and away from the inhaler before inhalation (65.5% [95% CI 52.0, 78.9]); (b) hold breath for 5-10 seconds (41.9% [95% CI 29.8, 53.9]); (c) inhale slowly and deeply (39.4% [95% CI 26.2, 52.5]); (d) exhale after inhalation (35.9% [95% CI 17.0, 54.8]); and (e) shake the inhaler before use (34.2% [95% CI 30.6, 37.7]). Across the studies used in this meta-analysis more than three-fourths of U.S. adults with obstructive lung diseases used MDIs incorrectly. Our findings suggest the need for ongoing patient education and consideration of alternative devices to mitigate errors.

Wrong inhalation technique is associated to poor asthma clinical outcomes. Is there room for improvement?

The long-term goals of asthma management are to control symptoms and to reduce the risk of exacerbations. Inhaled medication is the cornerstone of pharmacological treatment for asthma; therefore, good inhalation technique is the key for asthma management. However, up to 70% of asthma patients do not use their inhalers correctly. There is evidence on how poor inhalation technique is associated to poor asthma control. The purpose of this review is to present the most recent research in this field to help clinicians understand the importance of proper inhalers use and the possible interventions to optimize patients' inhalation technique. New evidence on how poor inhaler technique and specific critical errors are significantly associated to poor asthma control and exacerbations and how this negative impact could be improved by optimizing device selection, enhancing shared decision-making and giving more importance to education, both for patients and healthcare professionals. New devices and additional tools might help patients to achieve the correct inhaler technique and could form the basis of simplified educational interventions. There is an urgent need for specific interventions including new educational strategies to minimize the negative effects of wrong inhalation technique in asthma clinical outcomes.

Identifying Critical Errors: Addressing Inhaler Technique in the Context of Asthma Management.

Medication use has always played a highly significant role in the overall management of asthma, with appropriate use being linked to good asthma control. However, while patients with asthma enjoy the ‘luxury’ of having medications delivered directly to the lungs via inhaler devices, with that comes the additional challenge of ensuring that inhaler devices are used correctly. Research and practice provides evidence to the challenges associated with inhaler use and the particular steps that patients perform incorrectly. While this problem is well documented, acknowledged and reported, little has changed in 40 years, and the proportion of patients using inhaler devices remains unacceptably high. This review focuses on aspects specific to the errors that patient’s make, the significance of these errors, and the important considerations for health care practitioners in supporting patients in correctly using their inhalers. This review highlights the complexities associated with patient’s making inhaler technique errors and highlights the opportunities that lie in future technological developments of inhaler devices. Now more than ever, in the era of precision medicine, it is important that we address inhaler technique use once and for all.

A novel statistical method for assessing effective adherence to medication and calculating optimal drug dosages.

ObjectiveWe derive a novel model-based metric for effective adherence to medication, and validate it using data from the INhaler Compliance Assessment device (INCATM). This technique employs dose timing data to estimate the threshold drug concentration needed to maintain optimal health.MethodsThe parameters of the model are optimised against patient outcome data using maximum likelihood methods. The model is fitted and validated by secondary analysis of two independent datasets from two remote-monitoring studies of adherence, conducted through clinical research centres of 5 Irish hospitals. Training data came from a cohort of asthma patients (~ 47,000 samples from 218 patients). Validation data is from a cohort of 204 patients with COPD recorded between 2014 and 2016.ResultsThe time above threshold measure is strongly predictive of adverse events (exacerbations) in COPD patients (Odds Ratio of exacerbation = 0.52 per SD increase in adherence, 95% Confidence Interval [0.34–0.79]). This compares well with the best known previous method, the Area Under the dose-time Curve (AUC) (Odds Ratio = 0.69, 95% Confidence Interval [0.48–0.99]). In addition, the fitted value of the dose threshold (0.56 of prescribed dosage) suggests that prescribed doses may be unnecessarily high given good adherence.ConclusionsThe resulting metric accounts for missed doses, dose-timing errors, and errors in inhaler technique, and provides enhanced predictive validity in comparison to previously used measures. In addition, the method allows us to estimate the correct dosage required to achieve the effect of the medication using the patients’ own adherence data and outcomes. The adherence score does depend not on sex or other demographic factors suggesting that effective adherence is driven by individual behavioural factors.

Identification of inhaler technique errors with a routine procedure in Portuguese community pharmacy.

Background:A correct selection of drugs prescribed, but also the choice of the appropriate inhaler device, is crucial for the control of respiratory diseases.Objective:To evaluate the inhaler technique and identify potential errors of patients when treated with inhalers by testing a routinary procedure to be implemented in any community pharmacy.Methods:Adults with asthma/COPD and under inhalation therapy were invited to demonstrate how they use their inhalers. After direct observation it was registered whether all the sequential steps included in the summary of product characteristics (SmPC) were performed.Results:The study involved 67 patients from 4 community pharmacies (Portugal central region): 34 (50.7%) males, 65.4 (SD=18.28) years old, 42 (62.7%) with COPD, and 23 (34.3%) using more than one inhaler. The 67 patients used 95 inhalers, comprising: 57 (60.0%) multiple dose DPI (dry powder inhalers), 18 (18.9%) single dose DPI, 16 (16.8%) pMDI (pressurized metered dose inhalers), 2 (2.1%) pMDI+spacer and 2 (2.1%) SMI (soft mist inhalers). No errors were made only by 9 (13.4%) patients. In the 75 DPIs techniques, the most frequent errors were ‘no previous forced expiration’ (46=61.3%) and ‘no 10s apnea after inhalation’ (51=68.0%); in the 16 pMDIs techniques common errors were ‘lack of hand-lung coordination’ (7=43.8 %), ‘no previous forced exhalation’ (8=50.0%) and ‘no apnea after inhalation’ (10=62.5%). After inhaling from 56 devices containing corticosteroids, 34 (60.7%) of the patients did not wash their mouth.Conclusion:The study demonstrated the possibility of performing this procedure routinely in Portuguese community pharmacies and also its utility, since 58 (87%) of patients had at least one error during the inhalers use.

Inhaler technique: does age matter? A systematic review.

Poor inhaler technique and inferior asthma outcomes are evident in older adults. Reviews comparing metered dose inhaler (MDI) and dry powder inhaler (DPI) techniques across older adults and younger cohorts are scarce. This systematic review aimed to determine whether differences exist between such cohorts with regards to the number and type of MDI and DPI errors made. A systematic literature search was conducted in Embase, Medline and PubMed from July 1 to December 31, 2016. Studies were selected in accordance with preset inclusion criteria, relevant data were extracted, and quality was assessed with validated checklists. 14 studies were identified. Evidence suggests a negative correlation between advancing age and correct technique across MDI and varying DPI devices when examined collectively. Differences appear to exist between older adult and younger cohorts prescribed MDIs in error types. There is evidence of age-associated differences in the number and type of inhaler technique errors. Further research is required to assess outcomes in individual DPIs, reproducibility and the effects of confounders.

Recent Inhaler Device Switch is Not Associated With Poor Inhaler Technique: Analysis of Inhaler Technique in the Adult Calgary COPD and Asthma Clinic

SESSION TITLE: Respiratory Care SESSION TYPE: Original Investigation Slide PRESENTED ON: Tuesday, October 31, 2017 at 08:45 AM - 10:00 AM PURPOSE: Inhaled medications are essential for the treatment of asthma and COPD. Poor inhaler technique is linked reduced asthma control, increased hospitalizations and exacerbation rates. Unfortunately, inhaler technique errors are common and rates of poor inhaler technique have not changed despite introduction of educational strategies. Previous research has identified risk factors associated with poor technique, such as, increased age, English as a second language (ESL), and multiple medical comorbidities. We hypothesized that with increasing types of devices available for use a recent device switch may be an emerging risk factor for persistently elevated inhaler error rates. METHODS: 95 adult newly referred patients to the COPD and Asthma Respiratory Education Program were assessed by a certified respiratory education. Baseline demographics and information on inhaler usage was obtained. Critical errors were defined a priori. A patient was categorized as having inadequate inhaler technique if a critical error was identified. RESULTS: The total rate of critical errors/inadequate inhaler technique amongst new referrals was 52.6% (95% CI 42.4%-62.9%). Lower MMRC score in patients with COPD (p=0.016) and ESL (p=0.031) were associated with inadequate inhaler technique. 39% of patients referred had a device switch in the last year. Patients with previously identified risk factors for poor inhaler technique such as increased age (p=0.064), vision impairment (0.027), no high school education (0.006), ESL (0.056), poor asthma control (0.041), and increased number of devices (0.005) were associated with a recent device switch. Overall, there was no evidence to suggest that recent device switch is associated with increased odds of inadequate technique (OR=0.92; 95% CI 0.37-2.28). Interestingly, patients with vision problems who had a recent device switch had lower odds of inadequate inhaler technique (OR = 0.06; 95% CI 0.001-0.74, p=0.007). CONCLUSIONS: This pilot study shows that rates of inhaler error remain unacceptably high. A recent device switch was associated with multiple previously identified risk factors for poor technique. However, a recent device switch itself does not seem to be a risk factor despite the fact that the patient is required to learn a new skill. In fact, in patients with specific risks (ex. visual impairment) a device switch may be protective. CLINICAL IMPLICATIONS: It is important to understand that inhaler error remains a critical issue in respiratory health. As there are increasing numbers of devices available patients are more likely to have a new inhaler device to learn. Further research to understand that role device selection to improve patient technique is needed. DISCLOSURE: The following authors have nothing to disclose: Julia Pritchard, Alex Scurfield, Brandie Walker No Product/Research Disclosure Information

Erratum to: Impact of Inhalation Flow, Inhalation Volume and Critical Handling Errors on Delivered Budesonide/Formoterol Dose in Different Inhalers: An In Vitro Study

Inhaled drugs are essential for treatment of asthma and chronic obstructive pulmonary disease, but drug delivery via the respiratory tract is complex. Correct inhaler use is challenging as inhalers differ and inhaler technique errors are common. This in vitro study examined impact of inhalation flow, volume, and shaking of commonly used budesonide/formoterol (BUD/FORM) dry powder inhalers (DPIs). Two strengths of each included BUD/FORM DPI, Turbuhaler, Easyhaler and Spiromax, were examined. Fine particle dose (FPD) was measured using the Next Generation Impactor, at fixed pressure drops of 2, 4 and 6 kPa. Delivered dose (DD) for inhalation volume and shaking tests was performed at an airflow rate equivalent to a 4-kPa pressure drop, collected on Respirgard II, 303EU filters. FPD flow rate dependence was similar for all inhalers and strengths. BUD/FORM Turbuhaler and Easyhaler were unaffected by inhalation volume, whereas Spiromax showed significant inhalation volume dependence with about 50% decrease for both inhaler strengths. For a BUD/FORM Turbuhaler 160/4.5-µg/dose, there were no differences in the DD between shaking and no shaking, whereas the higher strength showed a 10% decrease after shaking. BUD/FORM Easyhaler DD decreased with about 50% for both strengths when the device was not shaken, while Spiromax decreased with 20% for the lower strength and 80% for the higher strength when shaken. This study revealed significant differences in inhaler performance after testing at different inhalation flow and volume and following exposure to potential pre-inhalation handling errors, which may lead to decreased drug delivery to the lungs. AstraZeneca

Impact of Inhalation Flow, Inhalation Volume and Critical Handling Errors on Delivered Budesonide/Formoterol Dose in Different Inhalers: An In Vitro Study

Inhaled drugs are essential for treatment of asthma and chronic obstructive pulmonary disease, but drug delivery via the respiratory tract is complex. Correct inhaler use is challenging as inhalers differ and inhaler technique errors are common. This in vitro study examined impact of inhalation flow, volume, and shaking of commonly used budesonide/formoterol (BUD/FORM) dry powder inhalers (DPIs). Two strengths of each included BUD/FORM DPI, Turbuhaler, Easyhaler and Spiromax, were examined. Fine particle dose (FPD) was measured using the Next Generation Impactor, at fixed pressure drops of 2, 4 and 6 kPa. Delivered dose (DD) for inhalation volume and shaking tests was performed at an airflow rate equivalent to a 4-kPa pressure drop, collected on Respirgard II, 303EU filters. FPD flow rate dependence was similar for all inhalers and strengths. BUD/FORM Turbuhaler and Easyhaler were unaffected by inhalation volume, whereas Spiromax showed significant inhalation volume dependence with about 50% decrease for both inhaler strengths. For a BUD/FORM Turbuhaler 160/4.5-µg/dose, there were no differences in the DD between shaking and no shaking, whereas the higher strength showed a 10% decrease after shaking. BUD/FORM Easyhaler DD decreased with about 50% for both strengths when the device was not shaken, while Spiromax decreased with 20% for the lower strength and 80% for the higher strength when shaken. This study revealed significant differences in inhaler performance after testing at different inhalation flow and volume and following exposure to potential pre-inhalation handling errors, which may lead to decreased drug delivery to the lungs. AstraZeneca

The Impact of Common Inhaler Errors on Drug Delivery: Investigating Critical Errors with a Dry Powder Inhaler.

Researchers, using checklists, have identified that 30%-90% of patients make errors in inhaler use. It is not certain whether these errors affect the delivery of medication. We have developed an electronic monitor (INCA™) that records audio each time an inhaler is used, providing objective information on inhaler technique. The aim of this study was to assess the effect that correctly identified inhaler errors, with the INCA device, have on drug delivery. This was a prospective study of healthy volunteers using a salbutamol Diskus™. The inclusion criteria allowed for the recruitment of healthy participants who were nonfrequent users of Salbutamol. Each participant was assigned to one control "phase" first and two/three subsequent error "phases." Each phase consisted of six doses of the drug taken 6 hours apart, and the participants' blood was drawn before and 25 minutes after doses one and six. This allowed us to sample their trough and peak serum salbutamol levels. Fourteen healthy volunteers were studied. The inhaler technique errors simulated in this study included exhaling into the device after drug priming but before inhalation, low inspiratory flow, multiple inhalations, low breath hold, missed doses, and wrong inhaler position. Only the exhalation error, low inspiratory flow, and missed doses led to a significant reduction in serum salbutamol levels. After six doses of the exhalation error, there was a 62% reduction in peak salbutamol levels. Low inspiratory flow led to a 52% reduction in peak salbutamol levels and a 78% reduction in trough levels. Missed doses led to a 37% reduction in trough salbutamol levels. These findings confirm that technique errors affect drug delivery. Furthermore, we were able to identify that the most critical technique errors with the Diskus inhaler are exhalation into the device before inhalation, poor inspiratory flow, and missing doses.

Predictors of correct technique in patients using pressurized metered dose inhalers

BackgroundCorrect inhaler technique is recommended by guidelines for optimum asthma care. The objective of the study is to determine real life predictors of correct pressurized metered dose inhaler (pMDI) technique in Asthma and COPD patients.MethodsTwo hundred eight adult patients aged 18+ from respiratory outpatients (69.2%) and the community on regular pMDI for a diagnosis of Asthma (78.9%) or COPD, were recruited. A questionnaire containing 31 possible predictors was administered and pMDI technique with or without spacer was observed by trained researchers on 12 point steps, of which 4 were considered critical.Results23.1% of patients had no errors in inhaler technique and 32.2% had no critical errors. Patients had a median of 10 correct steps (IQR9-11), and 3(IQR2-4) correct critical steps. Using binary logistic regression the predictors of 10 correct steps were, other healthcare professional (pharmacist, nurse, physiotherapist) explained OR 3.73(1.63–8.54, p = 0.001), male gender 2.70(1.35–5.39, p = 0.004), self-score 1–10 1.21(1.05–1.39, p = 0.007), spacer use 0.38(0.19–0.79, p = 0.007), inhaled steroid 3.71(1.34–10.25, p = 0.01), heart disease 0.31(0.13–0.77, p = 0.01), pneumococcal vaccine 2.48(1.0–6.15, p = 0.043), education level 1–4 1.44(1.00–2.06, p = 0.05) and respiratory physician explained 0–7 times, 1.11(0.99–1.26, p = 0.08). Using ordinal logistic regression, predictors for correct critical steps 0–4, were: technique self-score 1–10 1.2(1.05–1.42, p = 0.006), inhaled corticosteroid use 2.78(1.1–7.31, p = 0.03) and education level 1–4 1.41(1.02–1.95, p = 0.03 Times respiratory physician explained inhaler technique 0–7 1.1(0.98–1.24, p = 0.1), married status 1.55(0.85–2.82, p = 0.15), hypercholesterolaemia 0.52(0.25–1.01, p = 0.054) and male gender 1.76(0.97–3.18, p = 0.06).ConclusionsKnown predictors of correct pMDI use, such as gender and education level were confirmed, while age and concomitant use of dry powder inhaler were not. Pneumococcal vaccination and awareness of steroid side effects were possible novel positive predictors, while the use of a spacer and co-morbidity with heart disease were found to be negative predictors. Patients’ self-assessment correlated well with actual performance. This information may be useful in defining approaches to optimize inhaler techniques which are so susceptible to human error.

Study identifies most important inhaler technique errors that are linked to poor asthma outcomes

Study identifies most important inhaler technique errors that are linked to poor asthma outcomes

Characteristics of patients making serious inhaler errors with a dry powder inhaler and association with asthma-related events in a primary care setting

Objective: Correct inhaler technique is central to effective delivery of asthma therapy. The study aim was to identify factors associated with serious inhaler technique errors and their prevalence among primary care patients with asthma using the Diskus dry powder inhaler (DPI). Methods: This was a historical, multinational, cross-sectional study (2011–2013) using the iHARP database, an international initiative that includes patient- and healthcare provider-reported questionnaires from eight countries. Patients with asthma were observed for serious inhaler errors by trained healthcare providers as predefined by the iHARP steering committee. Multivariable logistic regression, stepwise reduced, was used to identify clinical characteristics and asthma-related outcomes associated with ≥1 serious errors. Results: Of 3681 patients with asthma, 623 (17%) were using a Diskus (mean [SD] age, 51 [14]; 61% women). A total of 341 (55%) patients made ≥1 serious errors. The most common errors were the failure to exhale before inhalation, insufficient breath-hold at the end of inhalation, and inhalation that was not forceful from the start. Factors significantly associated with ≥1 serious errors included asthma-related hospitalization the previous year (odds ratio [OR] 2.07; 95% confidence interval [CI], 1.26–3.40); obesity (OR 1.75; 1.17–2.63); poor asthma control the previous 4 weeks (OR 1.57; 1.04–2.36); female sex (OR 1.51; 1.08–2.10); and no inhaler technique review during the previous year (OR 1.45; 1.04–2.02). Conclusions: Patients with evidence of poor asthma control should be targeted for a review of their inhaler technique even when using a device thought to have a low error rate.

Suboptimal inhaler medication adherence and incorrect technique are common among chronic obstructive pulmonary disease patients.

Patients with chronic obstructive pulmonary disease (COPD) are routinely prescribed one or more inhaled medications. Adherence to inhaler medications and correct inhaler device technique are crucial to successful COPD management. The goals of this study were to estimate adherence and inhaler technique in a cohort of COPD patients. This was an observational study conducted on a sample of 150 COPD patients. Medication adherence was assessed using the Medication Adherence Report Scale (MARS). Inhaler technique was assessed using standardized checklists. Clinical data were collected using a proforma. Of the 150 patients (mean age 70.3 years, 52% male), 58% reported suboptimal adherence (MARS ≤ 24). High adherence to therapy (MARS = 25) was associated with older age (p = 0.001), but not any of the other studied variables. Medication non-adherence was not associated with COPD exacerbations. Errors (≥ 1) in inhaler technique were common across all of the types of inhaler devices reportedly used by patients, with the highest proportion of errors among Turbuhaler users (83%) and the least proportion of errors among Handihaler users (50%). No clinical variables were associated with errors in inhaler technique. Suboptimal adherence and errors in inhaler technique are common among COPD patients. No clinical variables to assist in the prediction of medication non-adherence and poor inhaler technique were identifiable. Consequently, regular assessment of medication adherence and inhaler technique should be incorporated into routine clinical practice to facilitate improved health outcomes among patients with COPD.

Validation of scores of use of inhalation devices: valoration of errors.

Objective: To validate two scores quantifying the ability of patients to use metered dose inhalers (MDIs) or dry powder inhalers (DPIs); to identify the most common errors made during their use; and to identify the patients in need of an educational program for the use of these devices. Methods: This study was conducted in three phases: validation of the reliability of the inhaler technique scores; validation of the contents of the two scores using a convenience sample; and testing for criterion validation and discriminant validation of these instruments in patients who met the inclusion criteria. Results: The convenience sample comprised 16 patients. Interobserver disagreement was found in 19% and 25% of the DPI and MDI scores, respectively. After expert analysis on the subject, the scores were modified and were applied in 72 patients. The most relevant difficulty encountered during the use of both types of devices was the maintenance of total lung capacity after a deep inhalation. The degree of correlation of the scores by observer was 0.97 (p < 0.0001). There was good interobserver agreement in the classification of patients as able/not able to use a DPI (50%/50% and 52%/58%; p < 0.01) and an MDI (49%/51% and 54%/46%; p < 0.05). Conclusions: The validated scores allow the identification and correction of inhaler technique errors during consultations and, as a result, improvement in the management of inhalation devices.

Patients' reasons for accepting a free community pharmacy asthma service.

Challenges in recruiting patients at the pharmacy counter for cognitive services have been observed, hampering development in this area. To overcome this barrier, insight into the patient perspective is crucial to understanding their lack of appreciation of the services. However, very few studies have been conducted so far to explore why patients accept or decline offers of cognitive services at the pharmacy counter. To explore patients' reasons for accepting a particular cognitive service (the Inhaler Technique Assessment Service) a service intended to detect inhalation technique errors. The service is reimbursed by the Danish state and takes approximately 10 min. Setting Ten community pharmacies located in different regions of Denmark, including the center and suburbs of Copenhagen. Two types of interviews were conducted: long and short semi-structured interviews with 24 patients suffering mainly from asthma and COPD. Researchers from Copenhagen University conducted 11 long interviews and pharmacy internship students from Copenhagen University carried out 13 short interviews. The interviews were analyzed using descriptive analysis. Patients' perceived needs of an inhalation counseling service as well as their motivation for accepting the service, including their accounts of how the service was orally offered by staff. The majority of participants were used to using inhaler devices. The participants felt, for several reasons, little need of an inhaler service and seldom noticed the precise way the service was offered. Patients did not seem to accept the service expecting personal benefits. First timers appeared to accept the service to learn how to use the device correctly, whereas experienced users appeared to accept the ITAS to be helpful to staff or to learn more about health issues in general or were convinced by individual employees who showed a special interest in the participant receiving the service. Privacy problems were felt by several participants. The patients felt little need for the inhaler counseling service. Patients however accepted the service for various reasons of which the feeling how staff showing an interest in helping them seemed especially convincing.

Preference, satisfaction and critical errors with Genuair and Breezhaler inhalers in patients with COPD: a randomised, cross-over, multicentre study.

Background:The specific attributes of inhaler devices can influence patient use, satisfaction and treatment compliance, and may ultimately impact on clinical outcomes in patients with chronic obstructive pulmonary disease (COPD).Aims:To assess patient preference, satisfaction and critical inhaler technique errors with Genuair (a multidose inhaler) and Breezhaler (a single-dose inhaler) after 2 weeks of daily use.Methods:Patients with COPD and moderate to severe airflow obstruction were randomised in a cross-over, open-label, multicentre study to consecutive once-daily inhalations of placebo via Genuair and Breezhaler, in addition to current COPD medication. The primary end point was the proportion of patients who preferred Genuair versus Breezhaler after 2 weeks (Patient Satisfaction and Preference Questionnaire). Other end points included overall satisfaction and correct use of the inhalers after 2 weeks, and willingness to continue with each device.Results:Of the 128 patients enrolled, 127 were included in the safety population (male n=91; mean age 67.6 years). Of the 110 of the 123 patients in the intent-to-treat population who indicated an inhaler preference, statistically significantly more patients preferred Genuair than Breezhaler (72.7 vs. 27.3%; P<0.001). Mean overall satisfaction scores were also greater for Genuair than for Breezhaler (5.9 vs. 5.3, respectively; P<0.001). After 2 weeks, there was no statistically significant difference in the number of patients who made ⩾1 critical inhaler technique error with Breezhaler than with Genuair (7.3 vs. 3.3%, respectively).Conclusions:Patient overall preference and satisfaction was significantly higher with Genuair compared with Breezhaler. The proportion of patients making critical inhaler technique errors was low with Genuair and Breezhaler.