Retraining may prevent asthma, COPD patients’ inhaler technique from getting worse
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Key takeaways:
- One-time training sessions only provide temporary improvements in technique.
- Digital technologies may help patients maintain their technique.
- Training should address social determinants of health.
Inhaler technique deteriorates within 12 months of clinical instruction among patients with asthma and COPD, according to a review published in The Journal of Allergy and Clinical Immunology: In Practice.
However, repeat instruction using various methodologies may preserve inhaler technique as well as beneficial outcomes, Sinthia Bosnic-Anticevich, BPharm, PhD, FPSA, respiratory pharmacist at Woolcock Institute of Medical Research, University of Sydney, and colleagues wrote.
“While we have known that inhaler technique is generally poor amongst people with asthma and COPD, and management guidelines promote that inhaler technique be checked regularly, in real-life practice, there still remains a high proportion of patients who have poor inhaler technique and suboptimal outcomes,” Bosnic-Anticevich told Healio.
“We felt it was important to draw attention to the fact that inhaler technique, even after training, can decline over time, and this may be part of the reason that inhaler technique remains an issue, despite all the evidence,” she continued.
Review findings
The review of 14 articles found that short-term improvements in inhaler technique after training are rarely maintained, with substantial decay within 12 months of single-session or multiple-session interventions.
Specifically, technique decay occurs 2 or 3 months after monthly one-to-one retraining sessions without further assessment or instruction. Technique also declines within 1 to 6 months of face-to-face training interventions despite reminder labels.
Long-term inhaler technique improvement may require regular, active and repeated intervention, including regular interactions with health care professionals, in turn leading to improvements in clinical and quality-of-life outcomes, the researchers wrote.
Although they differ based on the device, the researchers wrote, failure points include exhalation pre-actuation, slow deep inhalation, forceful deep inhalation, steady deep inhalation and breath holding after use but before exhaling away from the device.
Individualized training based on the inhaler or inhalers, if multiple devices are required, may improve inhaler maintenance and use, the researchers added. On-device features such as audible signals and audio data collection can improve technique and reduce inhalation, priming and actuation errors as well.
Further, the researchers wrote, written materials and verbal instruction represent standard modes of inhaler technique education. But single-session verbal instruction had a transient effect on improving technique, they continued. And although physical demonstrations were more effective than written instruction, technique still decayed 1 to 3 months later.
Video instruction may provide convenience, the researchers added, but decay again occurred 1 to 3 months later. Home monitoring did not prevent errors within the following month either, although live-remote assessment and instruction via video telemedicine can improve technique and serve as an alternative to in-person training.
Technique decay occurred regardless of the location of the training, including hospitals, clinics, pharmacies and homes, and regardless of the professional providing the training, including pharmacists, respiratory therapists, pulmonologists, specialist nurses and researchers.
Conclusions, next steps
Based on their findings, the researchers determined that there was a clear need for repeated training including ongoing technique reminders, feedback and coaching. Also, they said, a wide range of health care professionals can successfully provide this retraining.
“Overall, the most significant finding is the complexity of inhaler use and the multifactorial influences that are associated with inhaler technique maintenance over time, from timing of inhaler education to the personnel and venue for education delivery and the type of inhaler,” Bosnic-Anticevich said, adding that it was particularly significant that technique can decline or decay within just 24 hours of successful education.
Practical demonstrations are effective for initial retraining, the researchers wrote, although on-demand video and telehealth counseling may be effective in the long term. Patient motivation is key to good technique and adherence as well, they continued.
Additionally, the researchers wrote, clinicians should allow for social determinants of health and tailor educational interventions to different cultures and levels of health literacy. Novel technological solutions may play a role here as well.
Currently, the researchers noted, guidance in optimizing patient education and accounting for socioeconomic and psychosocial factors is lacking, making standardized and actionable guidelines urgently needed.
Interventions using in-person instruction and digital health platforms including telehealth and on-device features alike must be individualized to maximize the odds for effective inhaler technique, the researchers wrote.
Individual factors may include disparities in opportunities to receive training and retraining, with poor technique associated with lower socioeconomic class and educational level, joblessness, age and age-related comorbidities.
Inadequate communication between patients and clinicians also may impact technique, the researchers continued, with the strength of this relationship essential in improving adherence, self-efficacy and satisfaction among other outcomes.
Educational materials should use language and illustrations appropriate for low literacy and low health literacy, the researchers suggested, with cultural relevance and without prohibitive complications or expense.
Downstream negative impacts on treatment outcomes, clinical decision-making and health care costs follow when physicians neglect their patients’ inhaler use, the researchers concluded, but re-training with a stepwise clinical framework and new technologies may prevent technique decay.
“Please continue to review and discuss inhaler technique and device use over time,” Bosnic-Anticevich said.
Changes at the policy level may help as well, she continued.
“It is very difficult to introduce new things into practice unless there is a sustainable way in which to do so. Health care professionals need to have the resources/remuneration to support these fundamental clinical issues, such as inhaler technique,” she said.
“This is up to the policymakers. It should be in their interest to support this clinical activity, as it is linked to respiratory outcomes.”
Next, Bosnic-Anticevich said that she and her colleagues will continue to explore how modern health technologies such as digital inhalers can help address deficiencies in inhaler technique over time.
For more information:
Sinthia Bosnic-Anticevich, BPharm, PhD, FPSA, can be reached at sinthia.bosnic-anticevich@mq.edu.au.
Perspective
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MeiLan Han, MD
The findings of the study are significant but not surprising. Our practice environment has evolved significantly over the past 10 years. It is getting harder and harder to find time to do appropriate inhaler training with patients. Visits are increasingly done virtually. And even if education is delivered, due to insurance coverage, medications may be changed without notice.
When patients are failing their medications, we need to first revisit whether they are using their inhalers correctly. In my practice, many of my patients have incorrect technique when checked, even if they have been previously educated.
The study highlights the need to figure out better ways to not just deliver inhaler training but to continue to retrain patients. This is getting more and more challenging when insurance changes medications frequently and visits are conducted remotely.
As the paper suggests, more research is needed on how to best do retraining and whether this can be delivered without the patient having to come into the doctor’s office. Pharmacies may be a key intermediary in this regard.
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Bosnic-Anticevich S, et al. J Allergy Clin Immunol Pract. 2023;doi:10.1016/j.jaip.2023.04.031.
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