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      Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes

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          Abstract

          Background

          Inhaled drug delivery is the cornerstone treatment for asthma and chronic obstructive pulmonary disease (COPD). However, use of inhaler devices can be challenging, potentially leading to critical errors in handling that can significantly reduce drug delivery to the lungs and effectiveness of treatment.

          Methods

          A systematic review was conducted to define ‘critical’ errors and their impact on health outcomes and resource use between 2004 and 2016, using key search terms for inhaler errors in asthma and COPD (Search-1) and associated health-economic and patient burden (Search-2).

          Results

          Search-1 identified 62 manuscripts, 47 abstracts, and 5 conference proceedings ( n = 114 total). Search-2 identified 9 studies. We observed 299 descriptions of critical error. Age, education status, previous inhaler instruction, comorbidities and socioeconomic status were associated with worse handling error frequency. A significant association was found between inhaler errors and poor disease outcomes (exacerbations), and greater health-economic burden.

          Conclusions

          We have shown wide variations in how critical errors are defined, and the evidence shows an important association between inhaler errors and worsened health outcomes. Given the negative impact diminished disease outcomes impose on resource use, our findings highlight the importance of achieving optimal inhaler technique, and a need for a consensus on defining critical and non-critical errors.

          Electronic supplementary material

          The online version of this article (10.1186/s12931-017-0710-y) contains supplementary material, which is available to authorized users.

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          Most cited references 130

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          Development and validation of a questionnaire to measure asthma control

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            Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD.

            Incorrect usage of inhaler devices might have a major influence on the clinical effectiveness of the delivered drug. This issue is poorly addressed in management guidelines. This article presents the results of a systematic literature review of studies evaluating incorrect use of established dry powder inhalers (DPIs) by patients with asthma or chronic obstructive pulmonary disease (COPD). Overall, we found that between 4% and 94% of patients, depending on the type of inhaler and method of assessment, do not use their inhalers correctly. The most common errors made included failure to exhale before actuation, failure to breath-hold after inhalation, incorrect positioning of the inhaler, incorrect rotation sequence, and failure to execute a forceful and deep inhalation. Inefficient DPI technique may lead to insufficient drug delivery and hence to insufficient lung deposition. As many as 25% of patients have never received verbal inhaler technique instruction, and for those that do, the quality and duration of instruction is not adequate and not reinforced by follow-up checks. This review demonstrates that incorrect DPI technique with established DPIs is common among patients with asthma and COPD, and suggests that poor inhalation technique has detrimental consequences for clinical efficacy. Regular assessment and reinforcement of correct inhalation technique are considered by health professionals and caregivers to be an essential component of successful asthma management. Improvement of asthma and COPD management could be achieved by new DPIs that are easy to use correctly and are forgiving of poor inhalation technique, thus ensuring more successful drug delivery.
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              Inhaler competence in asthma: common errors, barriers to use and recommended solutions.

              Whilst the inhaled route is the first line administration method in the management of asthma, it is well documented that patients can have problems adopting the correct inhaler technique and thus receiving adequate medication. This applies equally to metered dose inhalers and dry powder inhalers and leads to poor disease control and increased healthcare costs. Reviews have highlighted these problems and the recent European Consensus Statement developed a call to action to seek solutions. This review takes forward the challenge of inhaler competence by highlighting the issues and suggesting potential solutions to these problems. The opportunity for technological innovation and educational interventions to reduce errors is highlighted, as well as the specific challenges faced by children. This review is intended as a policy document, as most issues faced by patients have not changed for half a century, and this situation should not be allowed to continue any longer. Future direction with respect to research, policy needs and practice, together with education requirements in inhaler technique are described. Copyright © 2012 Elsevier Ltd. All rights reserved.
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                Author and article information

                Contributors
                +44 (0)20 7351 8051 , o.usmani@imperial.ac.uk
                federico.lavorini@unifi.it
                jonathan.marshall@mundipharma.com
                will.dunlop@mundipharma.com
                louise.heron@adelphivalues.com
                emily.farrington@adelphivalues.com
                richard.dekhuijzen@radboudumc.nl
                Journal
                Respir Res
                Respir. Res
                Respiratory Research
                BioMed Central (London )
                1465-9921
                1465-993X
                16 January 2018
                16 January 2018
                2018
                : 19
                Affiliations
                [1 ]ISNI 0000 0001 2113 8111, GRID grid.7445.2, Airway Disease, , NHLI, Imperial College London & Royal Brompton Hospital, ; Dovehouse Street, London, SW3 6LY UK
                [2 ]ISNI 0000 0004 1759 9494, GRID grid.24704.35, Department of Experimental and Clinical Medicine, , Careggi University Hospital, ; Florence, Italy
                [3 ]Mundipharma International Limited, Cambridge Science Park, Cambridge, CB4 0AB UK
                [4 ]Adelphi Values, Adelphi Mill, Macclesfield, Cheshire, SK10 5JB UK
                [5 ]ISNI 0000 0004 0444 9382, GRID grid.10417.33, Radboud University Medical Center, ; Nijmegen, Netherlands
                Article
                710
                10.1186/s12931-017-0710-y
                5771074
                29338792
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Funding
                Funded by: Mundipharma International Ltd
                Award ID: n/a
                Categories
                Review
                Custom metadata
                © The Author(s) 2018

                Respiratory medicine

                obstructive lung diseases, adherence, errors, aerosols, inhalers

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