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Ease of Delivery Is Not So EasyEase of Delivery Is Not So Easy FREE TO VIEW

Lisa Cicutto, PhD, RN, ACNP(Cert)
Author and Funding Information

From Community Outreach and Research, National Jewish Health and the Clinical Science Program, University of Colorado Denver.

CORRESPONDENCE TO: Lisa Cicutto, PhD, RN, ACNP(Cert), Community Outreach and Research, National Jewish Health, 1400 Jackson St, G08a, Denver, CO 80206; e-mail: cicuttol@njhealth.org


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(5):1204-1206. doi:10.1378/chest.14-2703
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Published online

Inhaled therapies are central to effectively treating pulmonary conditions, especially asthma and COPD. Inhaled therapy has a number of advantages over systemic therapy but requires patients to use, and to master the use of, an inhaler device. Unfortunately, 50% to 81% of patients do not use their inhalational devices accurately, with older patients more likely to have poor technique.1 Perhaps more concerning is that many health professionals do not use inhalers accurately and are, therefore, not in a position to assess and coach patients effectively.2 Educating patients in the correct use of their inhalers results in mastery of the skill and improved disease outcomes.1 However, retention of correct technique is challenging, with 50% of patients unable to retain accurate technique over time.3 Despite the development of several new and improved types of inhaler devices, available evidence suggests that little to no progress has been made regarding patients’ ability to accurately use their inhalers. Clearly, this is a complex and widespread problem that we all need to be concerned about and motivated to change. A study by O’Conor and colleagues4 in this issue of CHEST (see page 1307) highlights this complexity and the interplay among a variety of factors by exploring the effect of health literacy and cognitive function on the proper technique of and adherence to controller medications in older patients with asthma.

Health literacy is defined as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health care decisions.”4 In the United States, 44% of adults have a basic or below basic level of health literacy.5 Low health literacy is associated with poorer health outcomes and poorer use of health-care services and these observations hold for asthma.6 The work of O’Conor et al4 supports previous research in that the frequency of inaccurate inhaler technique ranged from 38% to 53% depending on the device (metered dose inhaler [MDI] or dry powder inhaler [DPI]), that only 35% were adherent with controller therapy, and that having limited health literacy was associated with poorer adherence to controller medication and poorer inhaler technique. Importantly, their work extends our understanding of the mechanisms by which health literacy affects asthma outcomes by clearly demonstrating the important role of cognitive abilities. Two areas of cognition explored in this study include fluid and crystallized abilities. Fluid cognitive abilities refer to traits associated with active information processing in which prior knowledge is of little help. In contrast, crystallized ability refers to stored information in long-term memory. In multivariable analyses, when fluid abilities were added to the model, health literacy associations were reduced, supporting and suggesting the important role of fluid cognitive function and that a simple test of health literacy may be insufficient. This work clearly demonstrates that fluid cognitive abilities affect a patient’s ability to learn new skills such as correct use of a DPI or MDI. This observation is especially important in the context of aging patients as fluid cognition abilities decrease with age thereby diminishing the ability for active new learning. O’Conor et al4 provide some useful approaches to providing effective education and coaching to older patients who use inhalers.

It is a challenge finding the right inhaler device to meet the patient’s needs, preferences, and abilities and to support its use by effectively delivering education to patients. Simplification of treatment strategies and minimization/streamlining of inhaler options improves adherence and disease control.7 Previous work demonstrates that patients satisfied with their inhaler device are more adherent and experience better disease outcomes than those who are dissatisfied.8 Given that patients have difficulty learning and retaining accurate inhaler technique, the decision to switch devices or to add a new device to therapeutic regimens should not be taken lightly, as it can affect disease control. Research reveals that patients who undergo a nonconsensual switch of devices are at greater risk of unsuccessful treatment, increased use of short-acting bronchodilators, and stoppage of therapy compared with those not switched.9 To be effective and support patients, clinicians need to ensure that they know how to correctly use inhaler devices, regularly assess, coach, and reinforce patients for accurate technique, ask about patients’ satisfaction with their device, and consider switching or adding a new inhaler only when the benefits outweigh the drawbacks and the patient agrees.

The responsibility of achieving accurate and optimal inhaler technique does not lie solely on the shoulders of health-care providers but is shared with industry who need to step up to the important role they play in streamlining and delivering their medications in easy-to-use devices. Required inhalational maneuvers for accurate technique differ substantially among devices. For instance, an MDI requires good inhalation-actuation coordination with a slow and deep inhalation while DPIs require a forceful turbulent inspiratory flow to transform the powder formulation into disaggregated particles. Adding further complexity is that not all DPIs require the same technique; drug delivery across some devices is relatively stable while for others, a high flow rate is associated with a large dose emission.10,11 In addition, a review of medication inserts reveals variances in recommendations for priming MDIs in terms of the number of doses needed to be blown off before initially using the device, the number of doses necessary to be blown off if the device has not been used recently, and the variation among devices for operationalizing “recently” in terms of the number of days passed before needing to blow off doses before use. A goal of industry and human factors research should be to design an easy-to-use inhaler that eliminates the potential for inaccurate technique and effectively delivers the medication by eliminating unnecessary steps. Additional goals should include identifying best practices and common streamlined technique steps to be followed across devices and the need to provide a dose counter to allow quick determination of the number of doses remaining, while being inexpensive, as high costs pose a barrier to health providers, patients, and systems.

Although challenging, we need to find effective and feasible ways to improve the proportion of patients, and health-care providers, who can accurately use inhalational devices. This challenge needs to be embraced by multidisciplinary teams quickly as the costs are high for all of us.

References

Crane MA, Jenkins CR, Goeman DP, Douglass JA. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ Prim Care Respir Med. 2014;24:14034. [PubMed]
 
Hanania NA, Wittman R, Kesten S, Chapman KR. Medical personnel’s knowledge of and ability to use inhaling devices. Metered-dose inhalers, spacing chambers, and breath-actuated dry powder inhalers. Chest. 1994;105(1):111-116. [CrossRef] [PubMed]
 
Ovchinikova L, Smith L, Bosnic-Anticevich S. Inhaler technique maintenance: gaining an understanding from the patient’s perspective. J Asthma. 2011;48(6):616-624. [CrossRef] [PubMed]
 
O’Conor R, Wolf MS, Smith SG, et al. Health literacy, cognitive function, proper use, and adherence to inhaled asthma controller medications among older adults with asthma. Chest. 2015;147(5):1307-1315.
 
National Center for Educational Statistics. The Health Literacy for America’s Adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: National Center for Educational Statistics; 2006.
 
Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107. [CrossRef] [PubMed]
 
Yu AP, Guérin A, Ponce de Leon D, et al. Therapy persistence and adherence in patients with chronic obstructive pulmonary disease: multiple versus single long-acting maintenance inhalers. J Med Econ. 2011;14(4):486-496. [PubMed]
 
Small M, Anderson P, Vickers A, Kay S, Fermer S. Importance of inhaler-device satisfaction in asthma treatment: real-world observations of physician-observed compliance and clinical/patient-reported outcomes. Adv Ther. 2011;28(3):202-212. [CrossRef] [PubMed]
 
Thomas M, Price D, Chrystyn H, Lloyd A, Williams AE, von Ziegenweidt J. Inhaled corticosteroids for asthma: impact of practice level device switching on asthma control. BMC Pulm Med. 2009;9:1. [CrossRef] [PubMed]
 
Abdelrahim ME. Emitted dose and lung deposition of inhaled terbutaline from Turbuhaler at different conditions. Respir Med. 2010;104(5):682-689. [CrossRef] [PubMed]
 
Weuthen T, Roeder S, Brand P, Müllinger B, Scheuch G. In vitro testing of two formoterol dry powder inhalers at different flow rates. J Aerosol Med. 2002;15(3):297-303. [CrossRef] [PubMed]
 

Figures

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References

Crane MA, Jenkins CR, Goeman DP, Douglass JA. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ Prim Care Respir Med. 2014;24:14034. [PubMed]
 
Hanania NA, Wittman R, Kesten S, Chapman KR. Medical personnel’s knowledge of and ability to use inhaling devices. Metered-dose inhalers, spacing chambers, and breath-actuated dry powder inhalers. Chest. 1994;105(1):111-116. [CrossRef] [PubMed]
 
Ovchinikova L, Smith L, Bosnic-Anticevich S. Inhaler technique maintenance: gaining an understanding from the patient’s perspective. J Asthma. 2011;48(6):616-624. [CrossRef] [PubMed]
 
O’Conor R, Wolf MS, Smith SG, et al. Health literacy, cognitive function, proper use, and adherence to inhaled asthma controller medications among older adults with asthma. Chest. 2015;147(5):1307-1315.
 
National Center for Educational Statistics. The Health Literacy for America’s Adults: Results from the 2003 National Assessment of Adult Literacy. Washington, DC: National Center for Educational Statistics; 2006.
 
Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Crotty K. Low health literacy and health outcomes: an updated systematic review. Ann Intern Med. 2011;155(2):97-107. [CrossRef] [PubMed]
 
Yu AP, Guérin A, Ponce de Leon D, et al. Therapy persistence and adherence in patients with chronic obstructive pulmonary disease: multiple versus single long-acting maintenance inhalers. J Med Econ. 2011;14(4):486-496. [PubMed]
 
Small M, Anderson P, Vickers A, Kay S, Fermer S. Importance of inhaler-device satisfaction in asthma treatment: real-world observations of physician-observed compliance and clinical/patient-reported outcomes. Adv Ther. 2011;28(3):202-212. [CrossRef] [PubMed]
 
Thomas M, Price D, Chrystyn H, Lloyd A, Williams AE, von Ziegenweidt J. Inhaled corticosteroids for asthma: impact of practice level device switching on asthma control. BMC Pulm Med. 2009;9:1. [CrossRef] [PubMed]
 
Abdelrahim ME. Emitted dose and lung deposition of inhaled terbutaline from Turbuhaler at different conditions. Respir Med. 2010;104(5):682-689. [CrossRef] [PubMed]
 
Weuthen T, Roeder S, Brand P, Müllinger B, Scheuch G. In vitro testing of two formoterol dry powder inhalers at different flow rates. J Aerosol Med. 2002;15(3):297-303. [CrossRef] [PubMed]
 
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