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Correct use of inhalers: Help patients breathe easier
July 14, 2016

Asthma and chronic obstructive pulmonary disease (COPD) are life-long, potentially life-threatening diseases that represent the leading chronic respiratory diseases in the world.1 Inhalation of medications is an effective method for rapidly delivering short- or long-acting bronchodilators and corticosteroids to prevent, control, and treat respiratory symptoms that accompany these diseases. Inhalation of medications may also reduce the risk of adverse drug effects because the medications can often be provided in lower doses than an oral form of the drug.  

Types of inhalers

Rescue inhalers that deliver short-acting bronchodilators to relieve sudden respiratory symptoms, and maintenance inhalers that deliver long-acting bronchodilators and corticosteroids to prevent and control respiratory symptoms, are the cornerstone of managing asthma and COPD. For a list of common rescue and maintenance inhalers used in the US, visit: www.ismp.org/sc?id=1764. Inhalation devices that deliver these medications are available in four basic types:

Pressurized metered-dose inhalers (MDIs), which have been around for decades, typically consist of a small canister of medication fitted into a plastic body with a mouthpiece. Each dose is delivered by pressing the canister into the plastic body while inhaling through the mouthpiece. Use of a spacer that connects to the MDI makes it easier to inhale the dose, which is first released into the spacer and then inhaled slowly.

Dry-powder, breath-activated inhalers are preloaded with the medication(s) inside the device. Prior to use, a single dose of the medication is loaded into the mouthpiece, often by turning or twisting the inhaler body until a “click” signals the dose is ready to be inhaled. Patients simply take a deep breath while their lips are sealed around the inhaler, and a single dose is delivered (breath-activated).

Dry-powder, capsule inhalers utilize capsules as the dose-holding system, which are inserted into the device by the manufacturer or by the patient prior to use, and punctured by the device before each dose is inhaled directly from the inhaler.

Soft mist inhalers are a propellant-free liquid inhaler that provides a slow-moving, soft aerosol cloud of medicine to help patients inhale the medication, even if they can’t take a very deep breath.  

Errors with inhalers

The correct use of an inhaler depends on its type; thus, each manufacturer provides detailed instructions for use, some with a Medication Guide for consumers and/or a short online video to help visualize the technique. Unfortunately, up to 94% of patients with asthma and COPD use their inhalers incorrectly.2-4 Problems are not limited to one type of device,3 nor are they limited to patients—even healthcare professionals have made errors.2 Misuse leads to reduced efficacy and poor outcomes. For example, in a study published in 2015, Bonds et al. found that only 7% of patients who used MDIs demonstrated proper technique; 93% made at least one mistake, and of those, 63% missed 3 or more steps in the 11-step process.2 While most of these errors typically result in diminished drug delivery rather than no delivery at all, other errors have resulted in omitted doses, overdoses, and exacerbation of the underlying disease and respiratory symptoms.

Common errors made by patients using any inhaler include:5,6

  • Not holding their breath long enough after inhaling a dose (hold for about 10 seconds or as long as comfortable)
  • Using an empty inhaler, often believing an inhaler still provides doses even after the dose counter is at zero because the patient can still see or feel a “spray”
  • Forgetting to exhale completely before each dose or exhaling into the inhaler
  • Not using maintenance inhalers when asymptomatic

Common errors made by patients using an MDI (with and without a spacer) include:5,6

  • Not shaking the canister or container before each dose
  • Inhaling at the wrong time (not in sync with pressing the inhaler)
  • Aiming the inhaler at the roof of the mouth or tongue, rather than the throat
  • Inhaling an unnoticed foreign body that has entered an uncapped inhaler
  • Damaged or sticky spacer valves that limit the delivery of the medicine

Common errors made by patients using a dry-powder, breath-activated inhaler include:5,6

  • Failing to load a dose before inhaling
  • Loss of some medication by holding the inhaler mouthpiece upside down during or after loading a dose
  • Failure to inhale strongly enough to draw the medication out of the device

Common errors made by patients using a dry-powder inhaler that requires loading and piercing of a capsule prior to each dose include:5,6

  • Not piercing the capsule
  • Forgetting to remove the spent capsule and not using a new capsule for each dose
  • Failing to take a second breath (if indicated) to receive the full dose
  • Swallowing the capsule instead of inhaling its contents
  • Placing the capsule into the inhaler mouthpiece instead of the chamber designed to hold the capsule, which can result in swallowing or choking on the capsule during inhalation

Errors with newer inhalers

Over the past few years, several new devices for the administration of inhaled medications have been introduced. Some of the devices are used to administer newly marketed medications, while others contain previously available drugs in a different administration format. They were designed to address some of the problems with older inhalers and to improve the ability to use the inhalers correctly. Specifically, the newer inhalers include:

  • A dose counter, which allows patients to see when the supply of medication is low. This was previously available on some dry-powder inhalers but not on MDIs.
  • A longer duration of spray at a lower speed to help patients receive the full dose despite problems with coordinating the spray with the breath and the depth of the breath (e.g., Respimat soft mist inhalers).
  • The inability to activate a dose when all of the medication has been used. Once the last dose has been taken and the inhaler is empty, the mechanism to prepare another dose is locked, preventing the use of an empty inhaler.

Despite these new design enhancements to improve correct use, unfamiliarity with the newer inhalers on the market has been the source of several recently reported errors. 

Case #1

A patient discharged from the hospital with new prescriptions for ADVAIR HFA (fluticasone and salmeterol), PROVENTIL HFA (albuterol), SPIRIVA HANDIHALER (tiotropium), and predniSONE was readmitted to the emergency department (ED) 3 days later with complaints of feeling “jittery,” increasing shortness of breath, and wheezing. When the patient was asked about taking his newly prescribed medications, the ED nurse learned that the patient had been taking 3 Spiriva capsules by mouth each day since discharge, unaware that the drug in the capsule was intended to be inhaled. The patient was treated and given both verbal and written instructions for use of his inhaled medications. The patient was also asked to return to a hospital clinic the following day with all of his medications to meet with a pharmacist, who provided hands-on education. Prior to leaving the clinic, the patient was able to demonstrate proper technique and verbalize when to use each inhaler. But keep in mind, education and repeat demonstration to verify understanding of inhaled medications should have occurred prior to the patient’s initial discharge from the hospital, perhaps preventing a visit to the ED. 

Case #2

A community pharmacist misread a prescription for INCRUSE ELLIPTA (umeclidinium), which was a new prescription for a patient upon discharge from a hospital, as “Increase Ellipta.” The pharmacist was only familiar with BREO ELLIPTA (fluticasone and vilanterol) and had never filled a prescription for Incruse Ellipta prior to this incident. Because the patient was not taking an “Ellipta” inhaler previously, the pharmacist called the prescriber’s office to clarify the dose of what he thought was an order for Breo Ellipta. The prescriber confirmed the dose for Breo Ellipta as 100/25 mcg per inhalation, evidently overlooking the fact that he had prescribed Incruse Ellipta for this patient. When the patient was readmitted to the hospital several weeks later for an unrelated diagnosis, a pharmacist discovered the error while collecting a medication history from the patient and investigating why he was taking both Advair and Breo Ellipta.   

Case #3

A color-blind patient was unable to tell if the indicator window on a TUDORZA PRESSAIR (aclidinium) inhaler was red or green. The window turns green when the inhaler is loaded with a dose and is ready to use, and red when the dose has been completely inhaled. The patient mentioned this to his pharmacist when refilling his prescription. The pharmacist suggested that the patient use a pen to place a mark or dot on the green indicator to differentiate it from the red indicator. 

Optimal use of inhalation devices

Because many practitioners and patients may not be familiar with the newer inhalers, we have compiled a list of proactive risk-reduction strategies to support the proper use of these and other inhalers by patients and practitioners. Consider the following:

Prescribers

  • Ensure that prescriptions for inhaled medications include the medication name and strength, the device name, and the desired dose and frequency, particularly if the medication is available in more than one device format.
  • When prescribing any inhalation device, consider pertinent patient characteristics, such as inspiratory flow, cognition, and manual dexterity, before prescribing the medication.
  • Provide opportunities for patients to access videos on proper inhalation device technique while in the prescriber’s office.
  • If patients are not responding to treatment as expected, observe their technique using inhalation devices to ensure proper delivery of the prescribed medications.

Nurse, Pharmacist, Respiratory Therapist

  • Obtain demonstration inhalers from the manufacturer or local lung association to provide hands-on education (it is best if the prescription is filled and the actual device is used). Maintain these demonstration devices in a segregated area away from actual medications so they don’t find their way into the supply for patients.
  • Ensure that patient education and counseling includes a demonstration of how the inhalation device is to be used. Helpful how-to videos are available from the Centers for Disease Control and Prevention (www.ismp.org/sc?id=1759), the use-inhalers.com website (http://use-inhalers.com), product-specific websites, and other websites. The use-inhalers.com website also offers free handouts for patients that provide step-by-step instructions for most inhalers in both English and Spanish.
  • Focus education on essential aspects of proper inhaler use and the importance of taking all doses, and place less emphasis on aspects of treatment that allow some flexibility, such as timing between BID or q12h doses.
  • Remind patients to discard an inhaler when the dose counter is at zero, even if the device continues to spray what seems to be a dose.
  • Ask the patient to demonstrate inhaler technique (using a demonstration inhaler or preferably their own). Such demonstrations can create opportunities to correct improper technique, which may be a contributing factor for patients who continue to experience difficulty with symptoms of asthma or COPD. For devices using capsules, emphasize the need to place the capsule in the piercing chamber and not in the mouthpiece, and that the capsules should never be swallowed.
  • Provide opportunities for patients to access videos on the proper use of inhalation devices prior to discharge.

Outpatient Pharmacists

  • In addition to providing written instructions, reinforce proper and safe use of the inhalation devices during patient counseling.
  •  Ask the patient to demonstrate inhaler technique (using a demonstration inhaler) both when filling new prescriptions and periodically when refilling prescriptions.
  • Ask patients if they discussed use of a spacer with their provider. Consider contacting the prescriber if the use of a spacer would be beneficial for the patient.
  • Maintain all demonstration inhalers in a segregated area to ensure they cannot be inadvertently dispensed to patients as actual medications.

Healthcare Organizations

  • Distribute this newsletter to healthcare providers to support awareness of patient errors with inhalation devices, particularly with the new inhalation devices with which they may be unfamiliar.
  • Post the summary chart included in the PDF of the newsletter on pages 5 and 6 for reference and to help staff and prescribers when they are providing instructions to patients. The chart provides an overview of the newer inhalation devices, the medications they deliver, and selected safety considerations to be shared with patients. It supplements, but does not replace, the information provided by the inhaler manufacturers.

ISMP gratefully acknowledges ISMP Canada for providing most of the content for this article.5

References

1. Ambrosino N, Paggiaro P. The management of asthma and chronic obstructive pulmonary disease. Expert Rev Respir Med. 2012;6(1):117-27.

2. Bonds RS, Asawa A, Ghazi AI. Misuse of medical devices: a persistent problem in self management of asthma and allergic disease. Ann Allergy Asthma Immunol. 2015;114(1):74-6.

3. Rootmensen GN, van Keimpema AR, Jansen HM, de Haan RJ. Predictors of incorrect inhalation technique in patients with asthma or COPD: a study using a validated videotaped scoring method. J Aerosol Med Pulm Drug Deliv. 2010;23(5):323-8.

4. Lavorini F, Magnan A, Dubus JC, et al. Effect of incorrect use of drug powder inhalers on management of patients with asthma and COPD. Respir Med. 2008;102(4):593-604.

5. ISMP Canada. Safety considerations with newer inhalation devices. ISMP Canada Safety Bulletin. 2016;16(3):1-5.

6. National Asthma Council Australia. Inhaler technique in adults with asthma or COPD. 2008. 

 

 

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