Continued Innovation in Respiratory Care: The Importance of Inhaler Devices

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Abstract

When it comes to the use in inhalers in the management of chronic obstructive pulmonary diseases, there are many options, considerations and challenges, which health care professionals need to address. Considerations for prescribing and dispensing, administering and following up, education, and adherence; all of these factors impact on treatment success and all are intrinsically linked to the device selected. This review brings together relevant evidence, real-life data and practice tools to assist health care professionals in making decisions about the use of inhalers in the management of chronic obstructive pulmonary diseases. It covers some of the key technical device issues to be considered, the evidence behind the role of inhalers in disease control, population studies which link behaviors and adherence to inhaler devices as well as practice advice on inhaler technique education and the advantages and disadvantages in selecting different inhaler devices. Finally, a list of key considerations to aid health care providers in successfully managing the use of inhaler devices are summarized.

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Most cited references 48

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Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology.

Trevor P. Anderson, R C Ahrens, Gordon Guyatt … (2004)

The proliferation of inhaler devices has resulted in a confusing number of choices for clinicians who are selecting a delivery device for aerosol therapy. There are advantages and disadvantages associated with each device category. Evidence-based guidelines for the selection of the appropriate aerosol delivery device in specific clinical settings are needed. (1) To compare the efficacy and adverse effects of treatment using nebulizers vs pressurized metered-dose inhalers (MDIs) with or without a spacer/holding chamber vs dry powder inhalers (DPIs) as delivery systems for beta-agonists, anticholinergic agents, and corticosteroids for several commonly encountered clinical settings and patient populations, and (2) to provide recommendations to clinicians to aid them in selecting a particular aerosol delivery device for their patients. A systematic review of pertinent randomized, controlled clinical trials (RCTs) was undertaken using MEDLINE, EmBase, and the Cochrane Library databases. A broad search strategy was chosen, combining terms related to aerosol devices or drugs with the diseases of interest in various patient groups and clinical settings. Only RCTs in which the same drug was administered with different devices were included. RCTs (394 trials) assessing inhaled corticosteroid, beta2-agonist, and anticholinergic agents delivered by an MDI, an MDI with a spacer/holding chamber, a nebulizer, or a DPI were identified for the years 1982 to 2001. A total of 254 outcomes were tabulated. Of the 131 studies that met the eligibility criteria, only 59 (primarily those that tested beta2-agonists) proved to have useable data. None of the pooled metaanalyses showed a significant difference between devices in any efficacy outcome in any patient group for each of the clinical settings that was investigated. The adverse effects that were reported were minimal and were related to the increased drug dose that was delivered. Each of the delivery devices provided similar outcomes in patients using the correct technique for inhalation. Devices used for the delivery of bronchodilators and steroids can be equally efficacious. When selecting an aerosol delivery device for patients with asthma and COPD, the following should be considered: device/drug availability; clinical setting; patient age and the ability to use the selected device correctly; device use with multiple medications; cost and reimbursement; drug administration time; convenience in both outpatient and inpatient settings; and physician and patient preference.

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Inhaler Errors in the CRITIKAL Study: Type, Frequency, and Association with Asthma Outcomes.

Federico Lavorini, Antonio Infantino, Catherine Hutton … (2017)

Poor inhaler technique has been linked to poor asthma outcomes. Training can reduce the number of inhaler errors, but it is unknown which errors have the greatest impact on asthma outcomes.

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Chronic obstructive pulmonary disease exacerbation and inhaler device handling: real-life assessment of 2935 patients.

Pierre-Olivier Girodet, Nicholas Moore, Anais Chartier … (2017)

Acute exacerbations of chronic obstructive pulmonary disease (COPD) can be prevented by inhaled treatment. Errors in inhaler handling, not taken into account in clinical trials, could impact drug delivery and minimise treatment benefit. We aimed to assess real-life inhaler device handling in COPD patients and its association with COPD exacerbations.To this end, 212 general practitioners and 50 pulmonologists assessed the handling of 3393 devices used for continuous treatment of COPD in 2935 patients. Handling errors were observed in over 50% of handlings, regardless of the device used. Critical errors compromising drug delivery were respectively made in 15.4%, 21.2%, 29.3%, 43.8%, 46.9% and 32.1% of inhalation assessment tests with Breezhaler® (n=876), Diskus® (n=452), Handihaler® (n=598), pressurised metered-dose inhaler (pMDI) (n=422), Respimat® (n=625) and Turbuhaler® (n=420).The proportion of patients requiring hospitalisation or emergency room visits in the past 3 months for severe COPD exacerbation was 3.3% (95% CI 2.0-4.5) in the absence of error and 6.9% (95% CI 5.3-8.5) in the presence of critical error (OR 1.86, 95% CI 1.14-3.04, p<0.05).Handling errors of inhaler devices are underestimated in real life and are associated with an increased rate of severe COPD exacerbation. Training in inhaler use is an integral part of COPD management.

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Author and article information

Journal

Journal ID (nlm-ta): Tuberc Respir Dis (Seoul)

Journal ID (iso-abbrev): Tuberc Respir Dis (Seoul)

Journal ID (publisher-id): TRD

Title: Tuberculosis and Respiratory Diseases

Publisher: The Korean Academy of Tuberculosis and Respiratory Diseases

ISSN (Print): 1738-3536

ISSN (Electronic): 2005-6184

Publication date (Print): April 2018

Publication date (Electronic): 22 March 2018

Volume: 81

Issue: 2

Pages: 91-98

Affiliations

Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.

Author notes

Address for correspondence: Sinthia Zrinka Bosnic-Anticevich, B.Pharm. (Hons.), Ph.D. Woolcock Institute of Medical Research, University of Sydney, 431 Glebe Point Road, Glebe, Sydney, NSW 2037, Australia. Phone: 61-2-9114-0145, Fax: 61-2-9114-0014, Sinthia.bosnic-anticevich@ 123456sydney.edu.au

Article

DOI: 10.4046/trd.2017.0119

PMC ID: 5874147

PubMed ID: 29589381

SO-VID: bddfe540-6993-4a7c-a126-b3ade4cd7137

License:

It is identical to the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/)

History

Date received : 31 October 2017

Date revision received : 03 November 2017

Date accepted : 06 November 2017

Funding

Funded by: Australian Research Council, CrossRef http://dx.doi.org/10.13039/501100000923;

Funded by: University of Sydney, CrossRef http://dx.doi.org/10.13039/501100001774;

Funded by: Commonwealth Govt of Australia;

Funded by: National Health and Medical Research Council, CrossRef http://dx.doi.org/10.13039/501100000925;

Funded by: TEVA Pharmaceuticals, CrossRef http://dx.doi.org/10.13039/100006259;

Funded by: AstraZeneca Australia, CrossRef http://dx.doi.org/10.13039/501100005205;

Funded by: Zentiva;

Funded by: Mundipharma International;

Funded by: MEDA Pharmaceuticals;

Funded by: Research in Real Life Pty;

Funded by: University of Michigan, CrossRef http://dx.doi.org/10.13039/100007270;

Continued Innovation in Respiratory Care: The Importance of Inhaler Devices

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Most cited references 48

Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology.

Inhaler Errors in the CRITIKAL Study: Type, Frequency, and Association with Asthma Outcomes.

Chronic obstructive pulmonary disease exacerbation and inhaler device handling: real-life assessment of 2935 patients.

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