Critical inhalation technique errors that occur with the use of dry powder inhalers (DPIs) are associated with worse outcomes in patients with chronic obstructive pulmonary disease (COPD), according to study findings published in BMC Pulmonary Medicine.

Researchers evaluated how individual inhalation errors were associated with poor health status or more frequent exacerbations (moderate or severe) among patients with COPD who use DPIs. The findings were derived from a post hoc analysis of the cross-sectional, observational PIFOTAL study ( Identifier: NCT04532853), which used video of patients with COPD using DPIs for maintenance therapy to assess inhaler technique.

PIFOTAL participants were enrolled from October 2020 to May 2021; all had a clinical diagnosis of COPD, were at least 40 years of age, and were treated with a DPI as maintenance therapy in the previous 3 months or longer.

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Inhalation technique was observed with use of video recording and was rated by 2 independent observers. Errors were grouped into 12 distinct error categories. The researchers analyzed the associations between individual inhalation errors and use of the Clinical COPD Questionnaire (CCQ), COPD Assessment Test (CAT), and the number of moderate or severe exacerbations within the previous 12 months.

The cohort included 1434 patients with COPD from Greece, the Netherlands, Poland, Portugal, Spain, and Australia. Their mean (SD) age was 69.2 (9.3) years, and 50.1% were female. Their average CCQ score was 1.7 (± 1.1), and their average CAT score was 13.6 (± 7.8).

The most common errors committed by more than 70% of patients related to the directives: “sit up/stand straight and tilt head”; “breathe out completely before inhalation”; and “hold breath (for at least 6 seconds).”

CCQ and CAT scores were significantly associated with the inhalation errors “breathe in” (CCQ β, 0.16; 95% CI, 0.05-0.27), (CAT β, 0.97; 95% CI, 0.18-1.77); “hold breath” (CCQ β, 0.14; 95% CI, 0.01-0.28), (CAT β, 1.01; 95% CI, 0.16-2.02); and “breathe out calmly after inhalation” (CCQ β, 0.27; 95% CI, 0.02-0.52), (CAT β, 2.62; 95% CI, 0.73-4.50) in the adjusted analysis. No inhalation errors were associated with the frequency of moderate exacerbations.

Patients who had errors related to “preparation” (rate ratio [RR], 2.83; 95% CI, 1.30-6.16), “hold inhaler in correct position during inhalation” (RR, 1.94; 95% CI, 1.05-3.55), or “breathe in” (RR, 1.85; 95% CI, >1.00 to 3.42) had significantly more severe exacerbations on average compared with patients who did not have these errors.

Participants who had a pattern of errors related to “preparation,” “breathing out completely before inhalation,” “breathing in,” and “holding breath” (6.4%) had a significantly greater number of severe exacerbations vs those without these errors (RR, 5.70; 95% CI, 1.00-32.24; P =.05).

A trend was observed for CCQ or CAT scores worsening with an increasing number of inhalation technique errors.

Study limitations include the researchers’ inability to exclude residual confounding, although the analyses were adjusted for potential confounders based on the literature and clinical expertise.

“Over 80% of the patient population revealed at least 1 critical inhalation technique error when handling their DPI, further stressing the importance of monitoring and tackling inhalation technique errors in daily clinical practice,” stated the investigators.

Disclosure: Boehringer Ingelheim was the funding and scientific partner. Some of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.


Kocks J, Bosnic‑Anticevich S, van Cooten J, et al. Identifying critical inhalation technique errors in Dry Powder Inhaler use in patients with COPD based on the association with health status and exacerbations: findings from the multi-country cross-sectional observational PIFotal study. BMC Pulm Med. 2023;23(1):302. doi: 10.1186/s12890-023-02566-6

This article originally appeared on Pulmonology Advisor