Changes in critical inhaler technique errors in inhaled COPD treatment – A one-year follow-up study in Sweden

Sulku, Johanna; Janson, Christer; Melhus, Håkan; Ställberg, Björn; Bröms, Kristina; Högman, Marieann; Lisspers, Karin; Malinovschi, Andreï; Nielsen, Elisabet I.

doi:10.1016/j.rmed.2022.106849

Cited by 10 publications

(16 citation statements)

References 37 publications

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“…A significant improvement in the mean modified Medical Research Council (mMRC) breathlessness scale scores after training in inhaler use with no change in the control group11 was reported by Göriş et al but this was not confirmed other studies 13 19. Cross-sectional studies have found no significant relationship between mMRC and making errors5 12 20 25 (table 1) (figure 2).…”

Section: Resultsmentioning

confidence: 86%

“…The PIFotal study found that the errors in ‘breathing in’, ‘holding breath’ and ‘breathing out calmly after inhalation’ using a DPI were significantly associated with poorer Clinical COPD Questionnaire (CCQ) and COPD Assessment Test (CAT) outcomes (respective estimate of the difference (β) in the absolute score and 95% CIs CCQ β 0.16 CI (0.05 to 0.27), CAT β 0.97 CI (0.18 to 1.77); CCQ β 0.14 CI (0.01 to 0.28), CAT β 1.01 CI (0.16 to 2.02); CCQ β 0.27 CI (0.02 to 0.52); CAT β 2.62 CI (0.73 to 4.50)) 28. Other cross-sectional studies show no relationship between errors and health status12 20 25 (table 1, figure 2).…”

Section: Resultsmentioning

confidence: 88%

“…However, a subsequent publication claimed that patients with errors in ‘preparation’, ‘hold inhaler in correct position during inhalation’ or ‘breathe in’ had on average significantly more severe exacerbations than patients without these errors (respective rate ratios and 95% CIs: 2.83, 1.30 to 6.16; 1.94, 1.05 to 3.55; 1.85, >1.00 to 3.42) 28. Other cross-sectional studies showed an inconsistent relationship between error rates and moderate or severe exacerbations or healthcare utilisation5 14 15 18 20 22 25 (table 1, figure 2).…”

Section: Resultsmentioning

confidence: 99%

“…1091 abstracts were eliminated, leaving 55 full-text articles for review in detail. Among these articles, 36 did not contain information about associations between errors and outcomes or were review articles, resulting in a total of 19 publications that were included in this review5 11–28 (table 1).…”

Section: Resultsmentioning

confidence: 99%

“…10 retrospective case–controlled studies, reported in 12 publications, compared the characteristics of patients who made and who did not make errors using their inhalers (table 1). 5 12 14 15 17 18 20 22 23 25 27 28 These included larger numbers of patients than the prospective studies. Three publications23 27 28 reported different outcomes from the same study (The PIFotal COPD study).…”

Section: Resultsmentioning

confidence: 99%

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Systematic review of the effects of patient errors using inhaled delivery systems on clinical outcomes in COPD

Halpin,

Mahler

2024

BMJ Open Resp Res

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BackgroundErrors using inhaled delivery systems for COPD are common and it is assumed that these lead to worse clinical outcomes. Previous systematic reviews have included patients with both asthma and COPD and much of the evidence related to asthma. More studies in COPD have now been published. Through systematic review, the relationship between errors using inhalers and clinical outcomes in COPD, including the importance of specific errors, was assessed.MethodsElectronic databases were searched on 27 October 2023 to identify cohort, case–control or randomised controlled studies, which included patients with COPD, an objective assessment of inhaler errors and data on at least one outcome of interest (forced expiratory volume in 1 s, (FEV1), dyspnoea, health status and exacerbations). Study quality was assessed using the Newcastle and Ottawa scales. A narrative synthesis of the results was performed as there was insufficient detail in the publications to allow quantitative synthesis. There was no funding for the review.Results19 publications were included (7 cohort and 12 case–control) reporting outcomes on 6487 patients. 15 were considered low quality, and most were confounded by the absence of adherence data. There was weak evidence that lower error rates are associated with better FEV1, symptoms and health status and fewer exacerbations. Only one considered the effects of individual errors and found that only some were related to worse outcomes.ConclusionEvidence about the importance of specific errors using inhalers and outcomes would optimise the education and training of patients with COPD. Prospective studies, including objective monitoring of inhalation technique and adherence, are needed.PROSPERO registration numberCRD42023393120.

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Section: Resultsmentioning

confidence: 86%

Section: Resultsmentioning

confidence: 88%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

See 3 more Smart Citations

Systematic review of the effects of patient errors using inhaled delivery systems on clinical outcomes in COPD

Halpin,

Mahler

2024

BMJ Open Resp Res

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

Dijk,

Kerkhof,

Driessen

et al. 2023

BMJ Open Resp Res

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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 it leads to inappropriate inhaler technique. However, empirical evidence is lacking.AimsCompare the nature and frequency of dry powder inhaler (DPI) technique errors in patients with COPD using (1) a single DPI or (2) mixed-devices (a DPI and pressurised metered dose inhaler (pMDI)).MethodsData from the PIFotal study—a cross-sectional study on Peak Inspiratory Flow in patients with COPD using a DPI as maintenance therapy, capturing data from 1434 patients on demographic characteristics, COPD health status and inhaler technique—were used to select 291 patients using mixed-devices. Frequency matching based on country of residence and DPI device type was used to select 291 patients using a DPI-only for comparison. Predetermined checklists were used for the evaluation of DPI video recordings and complemented with additional errors that were observed in ≥10%. Error proportions were calculated for the (1) individual and total number of errors, (2) number of critical errors and (3) number of pMDI-related errors.ResultsThe study sample contained 582 patients (mean (SD) age 69.6 (9.4) years, 47.1% female). DPI technique errors were common, but not significantly different between the groups. The majority of patients made at least one critical error (DPI-only: 90.7% vs mixed-devices: 92.8%). Proportions of total, ‘pMDI-related’ and critical errors did not significantly differ between the groups.ConclusionThe nature and frequency of inhaler technique errors did not substantially differ between patients prescribed with a single DPI and mixed-devices. Currently, ‘pMDI-related errors’ in DPI use are not accounted for in existing checklists.Trial registration numberENCEPP/EUPAS48776.

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Personalizing Selection of Inhaled Delivery Systems in Chronic Obstructive Pulmonary Disease

Mahler

Halpin

2023

Annals ATS

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It can be challenging for healthcare professionals (HCPs) to prescribe inhaled therapy for patients with chronic obstructive pulmonary disease (COPD) because of the multiple individual and combinations of inhaled medications available in numerous delivery systems. Guidance on the selection of an inhaled delivery system has received limited attention compared with the emphasis on prescribing the class of the inhaled molecule(s). Although numerous recommendations and algorithms have been proposed to guide the selection of an inhaled delivery system for patients with COPD, no specific approach has been endorsed in COPD guidelines/strategies or by professional organizations. To provide recommendations for an inhaler selection strategy at initial and follow-up appointments, we examined the impact of patient errors using handheld inhalers on clinical outcomes and performed a focused narrative review to consider patient factors (continuity of the inhaled delivery system, cognitive function, manual function/dexterity, and peak inspiratory flow) when selecting an inhaled delivery system. On the basis of these findings, five questions are proposed for HCPs to consider in the initial selection of an inhaler delivery system and three questions to consider at follow-up. We propose that HCPs consider the inhaled medication delivery system as a unit and to match appropriate medication(s) with the unique features of the delivery system to individual patient factors. Assessment of inhaler technique and adherence together with patient outcomes/satisfaction at each visit is essential to determine whether the inhaled medication delivery system is providing benefits. Continued and repeated education on device features and correct technique is warranted to optimize efficacy.

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Changes in critical inhaler technique errors in inhaled COPD treatment – A one-year follow-up study in Sweden

Cited by 10 publications

References 37 publications

Systematic review of the effects of patient errors using inhaled delivery systems on clinical outcomes in COPD

Systematic review of the effects of patient errors using inhaled delivery systems on clinical outcomes in COPD

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

Personalizing Selection of Inhaled Delivery Systems in Chronic Obstructive Pulmonary Disease

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