Chronic obstructive pulmonary disease (COPD) is an irreversible disease characterized by progressive airflow limitation associated with an abnormal inflammatory response to noxious particles or gases, primarily cigarette smoke. Approximately 15 million Americans, or 6.3% of adults, are diagnosed with COPD, which includes chronic bronchitis and emphysema.1 According to the Centers for Disease Control and Prevention, the prevalence of COPD rises sharply in persons older than 40 years.2

COPD has been recognized as a significant cause of disability, morbidity, and mortality. In 2014, 6.9 million visits to emergency departments were associated with complications from COPD.2 COPD is the third leading cause of death in the United States, killing >135,000 Americans each year.3

Maintenance pharmacotherapy with long-acting bronchodilators effectively improves pulmonary symptoms and reduces risk for exacerbations. However, the effectiveness of medical therapy requires the correct use of inhaler devices. Practitioners can play a vital role in providing education and training on correct inhalation techniques to enhance therapeutic benefit and optimal medication delivery.

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Treatment of COPD

Maintenance pharmacotherapy with long-acting bronchodilators is the cornerstone of COPD management. Bronchodilators can be short-acting or long-acting. Long-acting bronchodilators include long-acting beta2 agonists (LABAs) and long-acting muscarinic antagonists (LAMAs). When used together, the 2 medications have improved lung function and reduced symptoms more effectively than monotherapy.4

Patients with severe COPD can be treated with a LAMA or a combination of an inhaled corticosteroid and LABA. Those with severe disease and poorly controlled symptoms can be prescribed triple therapy: inhaled corticosteroid, LAMAs, and LABAs.

Suboptimal inhaler use can limit the clinical effectiveness of inhaled therapies in the real-world setting.5 Inhaler efficiency is maximized by selecting a patient-preferred inhaler. The key characteristics of an ideal inhaler device are minimal steps to operate, breath-actuated mechanism, and confirmation of dose delivery.5

Types of Inhalers

The most common types of inhalers include pressurized metered dose inhalers (MDIs), single-dose and multidose dry powder inhalers (DPIs), nebulizers, and soft mist inhalers. Within these categories, the inhalers differ in drug delivery characteristics and ease of use. The most common errors occurring with most inhalers include preparation, preinhalation expiration, speed and/or depth of inhalation, and postinhalation breath hold.6

The pressurized MDIs consist of a pressurized canister that, once pressed, becomes activated, releasing a short burst or puff of aerosolized medicine. A propellant is used to drive medication out of the inhaler and into the lungs. Hydrofluoroalkane is the most commonly used propellant spray in MDIs. The proper use of MDIs requires a high level of coordination; the user must take a slow and deep inhalation while simultaneously activating the device.7 To help overcome the hand-inhalation coordination and improve drug delivery, a spacer device can be attached to the inhaler. The use of a spacer allows the user to take a breath at a normal rate because the medication will be suspended in the spacer for a short time.

DPIs are breath-actuated, meaning they only release the dry powdered medication when the patient inhales through the device. They do not require coordination of breathing and activation maneuvers to inhale the medicine, but inspiration must produce an appropriate inspiratory flow rate to be effective.7 With the DPIs, the drug is contained in a capsule or reservoir, and on deep inhalation, the powder breaks into particles small enough to be distributed to the lower airways. A factor to consider before prescribing a DPI is that some patients lack the inspiratory ability to inhale deeply and forcibly, which is a fundamental requirement that affects the dispersion of the dry powder particles, affecting pulmonary deposition.8

Soft mist inhalers are a new technology that provides a propellant-free inhaler. Using a handheld device, a liquid form of the medication is converted to a fine mist to be inhaled.8 A premeasured dosage is delivered in a slow-moving mist, regardless of the patient’s inspiratory flow rate.

Proper Inhalation Technique Key

Proper inhaler technique has been identified as a vital element in COPD management by the Global Initiative for Chronic Obstructive Lung Disease (GOLD).4 Poor inhaler technique is associated with decreased medication delivery, contributing to insufficient long-term COPD management. Assessment of correct inhaler technique is a crucial aspect in evaluating the progress of disease treatment.4 It is imperative that those educating patients are themselves competent in device handling and techniques.

Many providers, however, have insufficient knowledge on administration techniques for different inhaler types, and often do not feel confident in their own technical skills of administration creating a barrier to patient education. A survey of 150 healthcare professionals reported that 75% provide inhaler training to patients, yet only 7% could demonstrate the correct usage of an inhaler and assessment of inspiratory flow.9

A key focus for providers is to consider patient preferences and provide patients with comprehensive instruction for correct use of the device and routine technique monitoring and review.10 To be able to provide a demonstration and use a “teach back” method to the patients, it is fundamental for providers to know the correct technique for the different inhalers they will be prescribing (Table 1).11,12 Creating an environment with sufficiently trained providers, who in turn can provide ongoing training to patients, is the first step to take in the path of improving patient medication adherence. Effective management in patients with COPD include device selection, technique monitoring, and inhaler maintenance, along with providing a reference guide on inhalation technique.

Table 1. Step-Wise Guide to Proper Inhalation Technique in the Clinical Setting11,12

The following are key components that providers should be performing to optimize correct use of inhalers amongst their patients:
• Explain the purpose of prescribed medication and how it improves lung capacity. Patients are more likely to adhere to a medication program if they understand how it will benefit them.
• Conduct individualized hands-on training demonstrating correct inhaler techniques when inhaler is initially prescribed and when devices change. Reassess patient technique and understanding on every follow-up visit.
• Educate patients on how to keep inhaler clean and functioning properly.
• Provide inhaler technique checklist that includes the following inhaler technique steps:

1) Prepare the device by removing the mouthpiece cover, open the device, and hold inhaler upright.
2) Prepare the dose by shaking aerosol and load dose.
3) Breathe out gently (not into inhaler).
4) Put mouthpiece in mouth and seal the lips around it.
5) Breathe in slowly and steadily for aerosol device (with or without spacer); breathe quickly and deeply for DPI.
6) Remove inhaler from mouth and hold breath for 10 seconds.
7) Slowly breathe out
8) Repeat dose if required, then replace mouthpiece or close device.

In a study by Pothirat et al, researchers found a 10% to 30% improvement in proper inhalation technique among 69 patients with COPD who received training on proper inhaler technique and device usage.13 Formal training on correct usage resulted in a significant decrease in the percentage of incorrect techniques for all devices, with the exception of the tiotropium bromide inhaler (Spiriva HandiHaler®), the researchers noted.

To ensure ongoing competency, it is recommended that a patient’s inhaler technique be reviewed and adjusted at every visit, so that implementation of intervention strategies to rectify errors can be initiated. Quality patient outcomes with inhaled therapy hinge on their appropriate use by patients.

Innovative Technology Improves Effectiveness of Inhalers

Emerging smart drug delivery systems have the potential to enhance the management of respiratory disease, as well as improve the effectiveness of medications.14 At this time, there are a few smart inhaler monitoring devices approved by the US Food and Drug Administration available to provide enhanced management of COPD. According to 3M, the makers of the 3MIntelligent Control Inhaler, the inhaler is “an intuitive, fully-integrated device that delivers accurate doses to patients, whilst providing on-screen instructions for use and feedback to the patient and health care provider via an app.”15 The downloaded recorded data can be used by the provider to view and assess patient technique and medication adherence. The use of the data would allow for more productive conversations with patients, as counseling can be targeted to the individual’s specific need, indicated by the collected data.

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Suboptimal inhaler technique and use can limit the effectiveness of inhaled therapies, leading to poor disease control among patients with COPD. It has been demonstrated that face-to-face demonstration and training by clinicians significantly improves inhalation technique. An important aspect of care by the practitioner is to engage in a holistic assessment of patients to explore all factors affecting the individual’s ability to use correct technique and improve medication adherence. Education and shared decision making between the practitioner and patient are the cornerstone for optimal medication adherence and symptom control in patients with COPD and improved patient outcomes.

Erin Keller, APRN, FNP-BC, CCRN is a family nurse practitioner at Specialists in Pain Care in Louisville, Kentucky. Christy Catlett, MSN, APRN, FNP-C is a family nurse practitioner at Baptist Health Louisville in Louisville, Kentucky. Katherine Medina, APRN, FNP-C, is a family nurse practitioner at Louiseville Hospitalist Associates and Baptist Health Louisville Hospital in Louiseville, Kentucky. Nancy Kern, EdD, MSN, APRN is the department chair and assistant professor at the School of Nursing at Spalding University in Louiseville, Kentucky. Ann Lyons, PhD, MSN, RN, CNE was an assistant professor in the department of Theory and Research at the School of Nursing at Spalding University in Louiseville, Kentucky.


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