The Aerosol Drug Management Improvement Team ADMIT Slide Deck 2018

Part 4 Inhaler technique in adults Errors and solutions Chris Corrigan King’s College London School of Medicine, UK

Poor asthma control: the size of the problem

Asthma insights and reality in Europe (AIRE) Rabe KF et al. Eur Respir J 2000;16:802-807

Asthma insights and reality in Europe (AIRE) Rabe KF et al. Eur Respir J 2000;16:802-807

Asthma insights and reality in Europe (AIRE) Rabe KF et al. Eur Respir J 2000;16:802-807

Misuse of pMDIs is common and impairs asthma control Giraud V, Roche N. Eur Respir J 2002;19:246-251

Poor inhaler technique causes asthma attacks Hoskins G et al. Thorax 2000;55:19-24

Guidelines are meant to serve everybody

But in fact serve nobody!

Before increasing therapy, ask yourself… Is the patient using the treatment at all? Is the patient using an inhaler device which he/she is able to use and which suits him/her best? Is the patient using the correct inhalation technique? Has the patient stopped smoking? Have other possible exacerbating factors for asthma been identified and eliminated where possible?

Before increasing therapy, ask yourself… Is the patient using the correct inhalation technique? Is the patient using the treatment at all? Is the patient using an inhaler device which he/she is able to use and which suits him/her best? Has the patient stopped smoking? Have other possible exacerbating factors for asthma been identified and eliminated where possible?

Compliance

Compliance with medication is poor Milgrom H et al. J Allergy Clin Immunol 1996;98:1051-1057 Bender B et al. J Asthma 1998;35:347-350

Pressurised, metered-dose inhalers (pMDIs) Inhaler technique Pressurised, metered-dose inhalers (pMDIs)

Shake the device (becoming less important) pMDIs: key techniques Shake the device (becoming less important) Exhale fully Actuate the device after starting to inhale Inhale slowly Breath hold following inhalation

Co-ordination errors with pMDIs % Patients Triggered during exhalation 0.5 Triggered before exhalation 24.6 Triggered at end of exhalation 18.6 Concluded triggering while holding breath 24.2 Triggered in mouth but inhaled through nose 12.1 Several dosages dispensed during one inhalation 7.9 Other mistakes* 5.1 *Stopping inhalation at the moment of activation Crompton GK et al. Respir Dis 1982;119:101-104

Poor co-ordination reduces lung delivery Good coordinator Bad coordinator Newman SP et al. Thorax 1991;46:712-716

Perfect inhalation with pMDIs Slow and deep inhalation is optimal Inhale at 30 l/min then hold breath for 10 sec Actuation time is not critical (as long as it commences after the slow and deep inhalation) Slow vital inspiratory capacity manoeuvre: 2.5 litres over 5 seconds = 30 l/min Newman SP et al. Eur J Respir Dis Suppl 1982;119:57-65

Most patients inhale too rapidly with pMDIs Good Verbal Verbal + 2T The 2T device Al Showair RAM et al. Chest 2007;131:1776-1782

Slow inhalation is not so critical with fine particles Fast inhalation Usmani OS et al. Am J Respir Crit Care Med 2005;172:1497-1504

Spacer devices Obviate coordination of actuation and inhalation May be bulky and patients often dislike them Slow aerosol transit time and particle size May fit only a single pMDI device Deliver more drug to the lung periphery Do not obviate the necessity for patients to inhale slowly and breath hold Trap larger particles and stop their deposition in the oropharynx May cause excessive loss of the respirable dose if there is excessive delay after actuation, or multiple actuation May be used to guide inspiratory flow rate (whistle devices) May accumulate static electricity, reducing the delivery of particles especially with plastic spacers

Not all spacers are the same Bisgaard H et al. Arch Dis child 1995;73:226-230

Spacers: slow inhalation and breath holding still important BDP HFA with spacer and tidal breathing BDP HFA with deep inspiration and breath hold Roller CM et al. Eur Respir J 2007;29:299-306

Spacers: clinical efficacy pMDI + Aerochamber 12/18 discontinued oral steroids pMDI alone 6/18 discontinued oral steroids Salzman GA & Pyszczynski DR. J Allergy Clin Immunol 1988;81:424-428

Dry powder inhalers (DPIs) Inhaler technique Dry powder inhalers (DPIs)

Make sure the device is primed properly DPIs: key techniques Make sure the device is primed properly Inhale with a fast suck that is as deep and hard as possible from the start

Budesonide Turbohaler® 400 µg DPIs: fast, sharp inhalation is critical Budesonide Turbohaler® 400 µg BDP HFA Autohaler® 100 µg Kamin WES et al. J Aerosol Med 2002;15:65-73

DPIs: successful delivery depends on a threshold inspiratory force Accuhaler®/Diskus® Turbohaler® Broeders MEAC et al. Eur Respir J 2001;18:780-783

Inhaler technique How to improve it

Strategies to improve inhaler technique Choose the right device for the right patient Can they use it? Do they like it? Education, education, education At clinical review Pharmacist-led education of small groups J Asthma 2007;44:57-64 Specialist compliance and technique clinics Respir Care 2004;49;600-605 Training aids Access to information (ADMIT, etc)

Physicians do not know how to use inhalers Hanania NA et al. Chest 1994;105:111-116

Recent current ADMIT activities Video with recommendations for patients “how to use most common devices“ Criteria based inhaler device search database Service tools for medical Professionals Slide kit for medical professionals CD ROM “inhalation Therapy in Asthma” with interactive tools Info flyer for patients Video on “Step consultation of the asthma patient” Disease and therapy based information for patients and Health Care Professionals considering inhalation and device issues available in various languages ADMIT periodic E-Mail Newsletter and ADMIT Annual Newsletter Publications Presentations at Congresses i.e. ERS