Maryam Navaie, DrPH, MBA, and Bartolome Celli, MD, on Inhaler Use Among Patients With Obstructive Lung Diseases

A new study¹ evaluated the overall and step-by-step prevalence of inhalation technique errors among adults with obstructive lung diseases in the United States who use metered-dose inhalers. Lead author Maryam Navaie, DrPH, MBA, and senior author Bartolome R. Celli, MD, FCCP, answered our questions about their research and its key findings.

Dr Navaie is the chief global strategy officer at Advance Health Solutions, LLC, and lecturer at Columbia University, both in New York, NY.

Dr Celli is professor of medicine at Harvard Medical School and director of the Chronic Obstructive Pulmonary Disease Center at Brigham and Women's Hospital in Boston, Massachusetts.

PULMONOLOGY CONSULTANT: Can you tell us about your findings?

Maryam Navaie: Metered dose inhalers (MDIs) are commonly prescribed for inhalation therapy among patients with obstructive lung diseases, but patients often have difficulty using them correctly. Correct inhaler use is critical for effective medication delivery in order to control symptoms effectively and manage the patient’s pulmonary condition. We undertook our study for two reasons. First, we wanted to quantify the prevalence of inhalation technique errors among US adults who used MDIs to better understand the magnitude of the problem. Second, we wanted to determine which steps in the inhalation process were causing the most difficulty for respiratory patients.

Based on the 10 studies included in our meta-analysis, our results showed that more than three-fourths of US adults with obstructive lung diseases used MDIs incorrectly. We also found that the most common inhalation technique errors were associated with coordination and breath-holding steps. Specifically, 2 out of 3 patients had difficulty exhaling fully and away from their MDIs before inhalation. About 2 out of 5 patients failed to hold their breath for the few seconds needed in order to ensure that the medication was successfully delivered to the lungs. More than 1 in 3 patients failed to inhale slowly and deeply. And other steps involved in dose preparation, such as failing to shake the inhaler before use, led to mistakes in 1 out of 3 MDI users.

PULM CON: How might these findings impact clinical practice for pulmonologists?

Bartolome Celli: Most pulmonologists prescribing an MDI to COPD patients should be made aware that incorrect use is a frequent reason for poor treatment response to appropriately indicated medication. Further, the number of different inhalers has proliferated, and this makes the need to learn their use well so as to help each patient get the correct dose at the right site. From my experience, many US physicians believe the problem is not one seen in the United States. Our study indicates this is, in fact, not the case and that we should humbly pay attention to inhaler selection and proper use among our patients.

MN: Our findings have two important implications for pulmonary clinical practice. First, our results clearly signal a need for ongoing patient education by pulmonologists during office visits with their patients. This recommendation is in fact supported by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines that emphasize instruction on proper use of inhaler devices and reassessment of the patients’ inhalation technique at each office visit. This implication is very important because we know from the literature that at least 1 in 4 patients never receive instructions on inhaler use. Moreover, past studies have shown that as many as 70% of pulmonary patients say that their health care providers have never observed them using their inhalers. Even more concerning are findings that fewer than half of health care providers assess inhaler device technique in newly diagnosed patients with obstructive lung disease. Given these observations, it is not surprising that many patients do not feel confident using their inhalers correctly.

A second important implication of our study is that pulmonologists should consider alternative devices to handheld inhalers, such as nebulizers, for certain groups of patients in order to mitigate common inhalation technique errors. MDIs require patients to have hand- breath coordination, intact cognitive abilities to operate, the ability to hold breath, and the need to generate adequate inspiratory force. These types of requirements can be complex, and some patients simply cannot perform the required steps due to cognitive and/or physical dexterity limitations. In the past, practitioners may have been hesitant to prescribe a nebulizer because they tended to be bulky, not portable, and slower to deliver medications compared with handheld inhalers. However, today, with advanced technology and innovations in inhalation device designs, there are small portable nebulizers that deliver bronchodilator medications rapidly so physicians have an array of options from which to choose in order to make sure that the right patient is matched to the right device to optimize treatment outcomes.

PULM CON: What is the proper inhalation technique pulmonologists should teach their patients?

MN: In today’s market, there are a variety of inhalation devices available for bronchodilator treatment, including MDIs, dry powder inhalers (DPIs), soft mist inhalers (SMIs), and nebulizers. Each of these devices has particular features designed to facilitate use by the patient and to make medication delivery to the lungs an efficient process. And of course, each inhalation device has its own set of steps that patients have to follow. In general, handheld inhalers (MDIs, DPIs, and SMIs) are more complicated for patients to manage than nebulizers because they require hand-breath coordination and breath-holding, whereas nebulizers do not.

For our meta-analysis study, we focused solely on MDIs, which require the following ordered steps:

1. Remove the cap;
2. Shake the inhaler before use;
3. Attach the inhaler to a spacer, as needed;
4. Hold the inhaler upright;
5. Exhale completely (and away from the inhaler) before inhalation;
6. Place the inhaler mouthpiece between teeth and sealed lips;
7. Actuate once during inhalation;
8. Inhale slowly and deeply;
9. Hold breath for 5 to 10 seconds;
10. Remove the inhaler or spacer from the mouth;
11. Exhale and breathe normally; and
12. Repeat steps for a second puff.

Each of these steps are necessary and patients need to be trained to follow them to ensure medication dose delivery for symptom control.

PULM CON: In your experience, how have you counseled your adult patients with obstructive lung disease who have trouble using their inhaler?

BC: I tell my adult patients to come in with all of the medications they are taking and/or bring any new ones they have been prescribed so I can specifically supervise the use of the inhalers using an A to D grading system. I do that during all office visits until I feel my patients have mastered the necessary technique to properly use their inhaler device.

PULM CON: What else should pulmonologists know about your study or about proper inhaler inhalation techniques in general?

BC: I would say that my fellow pulmonologists should be humble and never feel that it is below one’s education to learn how to operate any and all new devices for medications that we prescribe to our patients. After all, we as the treating doctors have to know how to use the devices properly first in order to be able to train our patients to correctly use them.

Reference:

1. Cho-Reyes S, Celli BR, Dembek C, Yeh K, Navaie M. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of U.S. studies. Chronic Obstr Pulm Dis. 2019;6(3):267-280. https://doi.org/10.15326/jcopdf.6.3.2018.0168.