Inhalation Errors: Rethinking Devices for Your COPD Patients

Chronic Obstructive Pulmonary Disease (COPD)

Many patients with chronic obstructive pulmonary disease (COPD) struggle to use their inhalers properly.¹ Though COPD is the fourth-leading cause of death in the United States, proper treatment can help many patients manage their condition.^1,2 Unfortunately, the challenges presented by inhalation devices can place an additional burden on an already vulnerable patient population.¹

It is critical that healthcare professionals work with patients to train them on inhalation techniques upon initiating treatment. In follow-up appointments, physicians and nurses should reassess and refresh patients on proper technique; and, when necessary, it may be important for healthcare professionals to consider and advocate for alternative device options for appropriate patients.¹

A meta-analysis published in Chronic Obstructive Pulmonary Diseases in 2019 was a strong reminder of that basic tenet of treating patients with COPD: a large fraction of patients may not be getting adequate treatment because they are making errors with their inhalers. Metered-dose inhalers (MDIs) are the most commonly prescribed handheld device for treating COPD patients, but MDIs require hand–breath coordination that can be a barrier to proper administration. Some delivery devices, such as nebulizers, may be preferred by some patients. COPD treatments and devices vary and should be individualized to a patient's needs and abilities. Matching the proper delivery device to the correct patient can make a significant difference for patients struggling with their MDIs.¹

How many patients are making errors with their MDIs?

Eight in 10 patients who used an MDI made at least 1 error in taking their medication, according to the meta-analysis, which aggregated data for 1360 individuals across 10 published studies. Furthermore, the study showed that 7 in 10 patients performed ≥20% of their devices’ steps incorrectly.¹

Though these numbers might seem high, the authors point out that they are in line with previous studies of MDI usage.¹ The problem has been well documented by others looking at adherence and device usage in COPD. In other select reports, researchers have shown that ~25% of patients never receive instructions on how to use their device, and 69% report that their healthcare providers have never watched them try to take their medication.¹

What kinds of errors are patients making?

Coordinating breath, generating an adequate inspiratory force, and engaging the device by hand can be challenging, especially for a patient population plagued by comorbidities that include dementia and arthritis in addition to their breathing difficulties.¹

The authors of the meta-analysis highlighted the following mistakes:

• 2 in 3 patients had trouble exhaling fully away from the MDI before inhalation (ie, failure to empty their lungs)¹
• 2 in 5 patients failed to hold their breath after inhaling. This type of error can negatively impact treatment because of poor medication deposition¹
• 1 in 3 patients failed to inhale slowly and deeply¹
• 1 in 3 patients failed to shake the MDI¹

What can be done?

Clearly, nurses treating patients with COPD have significant challenges to overcome. More patient education and assessing and reassessing their patients’ technique with MDIs are crucial steps.¹

Nurses should advocate for treatment options that suit their patients’ abilities and preferences, which may include nebulized therapies.¹

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