Dr Toby Capstick
ONE of the key interventions that should be provided for all patients with asthma and COPD is to check and optimise inhaler technique, and this is recognised in all national guidelines, as well as the NICE asthma quality standards.
However, this simple intervention is often overlooked for a variety of reasons such as lack of time during a busy clinic or pharmacy, and I suspect many healthcare professionals assume, or hope, that someone else will have checked it previously.
At a recent training event for GPs, many reported that they assumed the pharmacist would teach the patient at the point of dispensing, but did not specifically request this service to be performed. Many of the same GPs were surprisingly not aware of medicines use reviews (MURs) or the new medicine service (NMS) service either. Would this not be the ideal opportunity for GPs to request this service for individual patients that they think may benefit? Maybe this is a failing of their local pharmacists to publicise their skills and to co-ordinate medicines optimisation as a joined up service?
In terms of patient education, in my own experience, almost all patients have received inhaler technique training at some point, but how recently is another issue. Real-life studies show that more than half of patients make errors using Accuhaler, pMDI and Turbohaler devices (Molimard et al. J Aerosol Med 2003;16:249-54), which may contribute to poor outcomes.
There has been some excellent work on how inhaler technique training should be performed by Iman Basheti and colleagues in Sydney (Resp Care 2005;50:617-23; Patient Educ Counsel 2008;72:26-33). These studies have clearly demonstrated the value of pharmacists demonstrating correct inhaler technique to patients rather than merely describing or reading the patient information leaflet.
Demonstration of inhaler technique is more likely to get patients using their inhaler devices correctly and can significantly improve asthma control. One word of warning, is that the data suggests that to achieve prolonged and sustained improvements in inhaler technique and asthma control, repeated education and inhaler technique assessment maybe required at regular (even monthly) intervals. This is not something that a busy GP or practice nurse may be able to perform, so why can we as pharmacists who see our patients on a regular basis provide this important duty?
I’ve incorporated the lessons from these and other studies, and try to take every opportunity to improve inhaler technique. In my own opinion, I find that patients are more likely to use their inhaler devices correctly if I explain why individual steps are performed, whilst also demonstrating correct inhaler technique. For example, I believe patients are more likely to prime Turbohalers if they are told that they should do this because it allows the device to load a dose by a vertical gravitational drop, and consequently won’t load if primed in a horizontal position.
Patient perspective
I recall one patient who attended our hospital difficult asthma clinic. He had been particularly poorly controlled over 18 months and on this particular day had an Asthma Control Test Score of 9 (range 5 [poorly controlled] to 25 [total control]), and his forced expiratory volume (FEV1) was 62% predicted. At his last appointment, the consultant had switched his Seretide pressurised metered dose inhaler (pMDI) to a Seretide Accuhaler due to poor inhaler technique. However, he had returned to the clinic and was back on his Seretide pMDI, as he found the Accuhaler less helpful and the device rather ‘clunky’.
I performed a review of his asthma, trigger factors, co-morbidities, adherence and lifestyle, but found no other problematic issues besides poor inhaler technique. I had assessed his inhaler technique using a number of devices including pMDI and Turbohalers, and checked his inspiratory flow through these devices by using an In Check DIAL Inspiratory Flow Meter. His inspiratory flow through a pMDI was 140 L/min, which is far too fast for this device (the target being 25-60 L/min) and liable to significantly reduce lung deposition and increase oropharyngeal deposition, leading to increased local side effects and reduced clinical efficacy. I spent some time trying to get him to inhale more slowly, and while he could achieve the optimal inspiratory flow rate, he could not do this repeatedly.
Using a concordant consultation style, we discussed the pros and cons about using his usual pMDI compared to switching to a Turbohaler device, which he was much better using. However he was adamant that he wanted to continue using his usual Seretide pMDI. This left me in a tricky position as he was clearly naturally a ‘fast inhaler’ using different inhaler devices and would be more likely to do better with a dry powder inhaler device.
As he insisted on using pMDIs, I gave him a 2Tone Trainer whistle, which is a pMDI shaped device that will whistle with a mono-tone when a person inhales through it at the optimal inspiratory flow, but will whistle with two-tones if a person inhales too fast through the device. I advised him to use if twice a day before using his Seretide pMDI for a couple of weeks to allow him to practice the correct speed of inhalation, then to use it now and again as a refresher. He was somewhat dubious, but said that he would give it a go.
When he returned for follow-up three months later, he reported that his asthma was much better; his FEV1 had improved to 71% predicted and Asthma Control Test score to 15 – a large improvement. He fed back that the 2Tone Trainer whistle had made a big difference despite his initial scepticism, and his asthma was better than it had been for many months, and no-longer restricted his daily lifestyle.
This case demonstrates that improving inhaler technique can produce significant and important benefits for patients, but requires dedication from patients to practice correct inhaler technique, and repeated reinforcement from healthcare professionals to ensure that patients do not slip in to bad habits. The usefulness of training aids should not be underestimated, and whistles can continue to remind patients on the correct inhalation methods long after the initial consultation. There are a variety available, including the Flo-Tone for pMDIs, Turbohaler whistles, Accuhaler and Ellipta whistles.
It is my firm belief that all pharmacists, as well as all healthcare professionals involved in the prescribing of inhaled medications should regularly and routinely check and optimise inhaler technique at every patient contact, and not just when convenient.
Toby Capstick is lead respiratory pharmacist at Leeds Teaching Hospitals NHS Trust and Joint Chair of the UKCPA Respiratory Group
Follow Toby @tcapper78