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      Misuse of inhalers among COPD patients in a community hospital in Taiwan

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          Respiratory inhalers, which directly deliver medication to the airway, are important for controlling symptoms and preventing exacerbations of chronic obstructive pulmonary disease (COPD). The inhaler misuse rate of patients with COPD in Taiwan is unclear. In this study, the inhaler techniques and patient characteristics associated with incorrect inhaler techniques among patients with COPD were evaluated.

          Patients and methods

          This cross-sectional study enrolled 298 patients with COPD (mean age 72.10 years) who used at least one inhaler device. The following five types of inhalers were included: metered-dose inhaler (MDI) with spacer, Diskus ®, Turbuhaler ®, Respimat ®, and Breezhaler ®. The inhaler technique was evaluated step by step. Misuse of an individual inhaler was defined as an error in at least one step. The sociodemographic characteristics, vision, hearing ability, type and number of inhalers, and inhaler-related knowledge of these patients were recorded.


          The misuse rates of the five types of inhalers ranged from 65.00% to 87.89%. The Respimat inhaler was the most likely to be assembled incorrectly. The steps that were most commonly performed incorrectly were “breathing out fully” and “holding breath”. In the logistic regression analysis, poor hearing was related to misuse of the MDI with spacer (adjusted odds ratio [aOR] 9.85; 95% CI 1.40–69.30); the number of acute exacerbations was related to misuse of Breezhaler (aOR 4.07; 95% CI 1.50–11.08). Incorrect inhaler-related knowledge was significantly associated with misuse in handling the MDI with spacer (aOR 9.58; 95% CI 2.14–42.80), Respimat (aOR 5.14; 95% CI 2.07–12.76), and Breezhaler (aOR 6.98; 95% CI 1.95–25.08).


          The misuse rates were high for all five types of inhaler. Poor hearing and the number of acute exacerbations were device-specific factors related to the misuse of inhalers. Inhaler-related knowledge was significantly associated with misuse, emphasizing the importance of inhaler education.

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          Most cited references 22

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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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            Epidemiology and costs of chronic obstructive pulmonary disease.

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              Inadequate literacy is a barrier to asthma knowledge and self-care.

              To determine the relationship of literacy to asthma knowledge and ability to use a metered-dose inhaler (MDI) among patients with asthma. Cross-sectional survey. Emergency department and asthma clinic at an urban public hospital. Convenience sample of 273 patients presenting to the emergency department for an asthma exacerbation and 210 patients presenting to a specialized asthma clinic for routine care. Measurement of literacy with the Rapid Estimate of Adult Literacy in Medicine, asthma knowledge (20 question oral test), and demonstration of MDI technique (six-item assessment). Only 27% of patients read at the high-school level, although two thirds reported being high-school graduates; 33% read at the seventh- to eighth-grade level, 27% at the fourth- to sixth-grade level, and 13% at or below the third-grade level. Mean asthma knowledge scores (+/-SD) were directly related to reading levels: 15.1+/-2.5, 13.9+/-2.5, 13.4+/-2.8, 11.9+/-2.5, respectively (p < 0.01). Patient reading level was the strongest predictor of asthma knowledge score in multivariate analysis. Poor MDI technique (< or =3 correct steps) was found in 89% of patients reading at less than the third-grade level compared with 48% of patients reading at the high-school level. In multivariate regression analyses, reading level was the strongest predictor of MDI technique. Inadequate literacy was common and strongly correlated with poorer knowledge of asthma and improper MDI use.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                23 April 2018
                : 13
                : 1309-1316
                [1 ]Division of Pulmonary and Critical Care Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan
                [2 ]Department of Medical Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi City, Taiwan
                Author notes
                Correspondence: Wei Chen, Division of Pulmonary and Critical Care Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Number 539, Zhongxiao Road, East District, Chia-Yi City, 60002, Taiwan, Tel +886 5 276 5041, Fax +886 5 277 4511, Email peteralfa2004@
                © 2018 Liang et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research

                Respiratory medicine

                misuse, inhaler, chronic obstructive pulmonary disease


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