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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