Don’t Forget to Check the Technique!

This post was written by Michael W. Hess, MPH, RRT, RPFT.

Inhaled medications have been with us for a very long time; longer, perhaps, than we usually recognize. The first known description of a medicinal inhaler device (outside of pipes and such used for smoking and similar activities) was actually created in 1654 by an English physician by the name of Christopher Bennet.​¹​ Just over three hundred years later, an American scientist named George Maison invented a dose-metering valve at the behest of his daughter, who sought a more convenient way to take her asthma medication. That invention, and the subsequent development of the metered-dose inhaler (MDI), set the stage for decades of convenient, portable, and effective inhaled therapy for a variety of respiratory conditions.^​2​

At least, it was supposed to.

Unfortunately, the reality has not quite kept up with the promise. Without question, MDIs and their cousins the dry powder inhaler (DPI) and soft mist inhaler (SMI) are portable, fitting into pockets far more easily than most nebulizers. Many find them to be quite convenient due to that portability. However, their efficacy is often limited by their relative complexity. The steps involved in preparing and using an inhaler vary from device to device, but are certainly more complicated than what is usually portrayed in popular media. The fact that patients cannot simply “puff and go” has led to roughly two-thirds of inhaler users not using their inhaler correctly, an error rate that has stayed largely unchanged since it was first studied in the 1970s.​³​ Frequent misuse has been demonstrated to lead to worse outcomes and more healthcare-related expenditures.^​4​ This is particularly true in cases where people are prescribed multiple inhalers, often having different inhalation demands.​⁵​

The problem is not limited to patients, either. A meta-analysis of 55 studies again beginning in 1975 found that a mere 15.5% of health care professionals overall demonstrated proper inhaler technique.^​6​ The study also suggests that the problem is getting worse. The group found that during the first 20 years of studies, just over 20% of clinicians showed proper technique, but that rate had fallen to 11% during the second 20 years. This could be attributable to the increasing variety of inhaler devices on the market, but suffice it to say, if people are not instructed correctly, they will not be able to use their devices correctly, and their health will unfortunately suffer.

Organizations like the Global Initiative for Chronic Obstructive Lung Disease (GOLD) have long recognized the importance of proper inhaler technique, recommending assessment of technique and adherence in COPD management algorithms.^​7​ The most recent GOLD report goes a step further, including for the first time a dedicated table on principles for choosing the appropriate drug/device combination. These principles are largely based on the evidence-based guidelines published nearly 20 years ago (yet sadly still under-utilized) by the American College of Chest Physicians and the American College of Asthma, Allergy, and Immunology.^​8​ One critical addition recognizes that many clinicians are not well versed in many devices, recommending that prescribers should only order medications that come in devices they are familiar with, ensuring they are able to appropriately match the device’s characteristics with the patient’s preferences and abilities, as well as enabling them to teach its operation.

Fortunately, various resources are available to help clinicians improve their inhaler knowledge base. The COPD Foundation maintains an entire series of instructional videos covering the myriad inhalers and nebulizers on the market today. These videos, produced by respiratory therapists intimately familiar with each device, walk viewers through each step of priming and actuating these devices. The nebulizer section also includes how to clean each device, an often-overlooked component of education. Because these videos are free, they can also serve as an ongoing reference for people prescribed inhaled medications. This is critical; I have personally seen cases where without ongoing assessment and re-instruction inhaler technique competence can drop rapidly. Even with physical demonstration, inhaler technique can be noticeably worse within 4 months.^​9​

With the increasing demands placed on health care professionals at all levels, it is easy to see why many do not feel they have the time to teach good technique. Unfortunately, this is really one of those corners that cannot be cut. When someone has poor technique and does not know it, they run the risk of worsening outcomes, not to mention feeling like additional treatment may be futile. I encourage everyone out there who touches the COPD community to take advantage of resources like our video library, become more knowledgeable about inhalers, and help your patients breathe easier!