Inhaler devices and their challenges - Helping patients use inhalers

Inhaler therapy is the safest and most effective treatment for obstructive airway diseases, such as asthma and chronic obstructive pulmonary disease (COPD). It allows the use of smaller doses, thereby reducing systemic side effects, and results in enhanced action at the site of need. However, its effectiveness is contingent on inhaler devices being used appropriately.

The delivery of inhaled medications needs proper technique on part of the user. There are critical steps and errors which could lead to sub-optimal drug delivery. Unfortunately, studies have documented such errors being present in up to 90% of instances during regular use.[1,2] A recent meta-analysis of 72 studies in patients with asthma and COPD reported the prevalence of critical errors to be 14%–92% across all devices. At least one critical error in pressurised metered dose inhaler (pMDIs) and dry powder inhaler (DPIs) was made in 45.6% and 28.4% of patients, respectively.[2] Another meta-analysis reported that 87% of patients using pMDIs in obstructive lung diseases made inhaler technique errors.[3] The CRITIKAL study analysed inhaler errors in 3,660 patients with asthma. Insufficient inspiratory effort was a common error made by 32%–38% of dry-powder inhaler users (Turbohaler and Diskus devices). In metered-dose inhaler users, actuation before inhalation (24.9%) was a common error. The generic errors, such as not exhaling prior to taking an inhaler, not holding the breath, insufficient speed of inhalation, dose preparation errors for DPIs and coordination problems with MDIs, were the most frequently reported errors. These errors were not innocuous, and they are found to be associated with uncontrolled asthma and an increased exacerbation rate.[4] Such data and evidence support the necessity for assisting patients with the means of improving their inhaler technique.

The training must be ‘device specific’. Studies have suggested that even a single education session can significantly improve inhaler technique. However, at least three iterations of education have been found to be necessary to eliminate most of the critical errors.[5] Similarly, compared to a solitary teaching intervention, a combination of multiple interventions (leaflet, video and face-to-face education) appears to result in fewer errors.[6] However, adopting multiple approaches is time-consuming and labour-intensive. This is especially challenging in busy clinics in low-resource settings in countries such as India. In spite of the increasing rural health facilities over the years, the manpower availability in such settings is notably sub-optimal, as per World Health Organization’s suggested levels.[7] The rural health statistics also stated that the number and post-wise shortage in rural health set up as 79.9% and 33.8% of doctors in Community health centres (CHCs) and public health centres (PHCs) with 68% and 18.6% vacant posts across the CHCs and PHCs, respectively. There is a shortfall of nursing staff by 27.1% and 15.5% in CHCs and PHCs.[8] However, Government of India’s National Telemedicine Service, eSanjeevani, has completed 3 million (30 lakhs) online consultations. Currently, the National Telemedicine Service is operational and daily over 35,000 patients across the country are using this innovative digital medium – eSanjeevani, to seek health services. So far, over 21,00,000 patients have been served through eSanjeevani OPD.[9] Hence it necessitates the adoption of newer, less time-consuming methods such as easily accessible online education to empower health care.

Smartphones make learning possible at anytime, anywhere, which makes them ideal for point-of-use settings. India has 606.57 million smartphone users and a penetration of 43.5%.[10] The rural smartphone penetration is 67.6% and it has doubled in rural households in the past three years according to the latest Annual Status of Education Report survey.[11] The universality of mobile technology in India needs to be leveraged for health. The Indian government has begun such initiatives. Nikshay mobile app to register cases, record treatment details and monitor adherence to treatment in patients with tuberculosis is an example.[12] Medication Event Reminder Monitor System is also used in national tuberculosis elimination programme to monitor treatment adherence in tuberculosis patients.[13] Similarly, the National AIDS Control Organisation has launched a mobile app called ‘HELP’ for AIDS awareness and prevention to enhance the information and treatment of the human immunodeficiency virus.[14]

We need to use available technology to improve inhaler techniques through education. Video education has shown better results, due to the slow and clear explanatory nature of the content, and reinforcement with repeated viewings of the educational video. In addition, it is particularly helpful for patients who have difficulty with regard to engaging in face-to-face education. Various studies have found that video education was not inferior to face-to-face education.[5,15,16] There are various inhaler devices available in India. Patient and physician preferences, underlying disease, and availability of formulations only with certain devices guide the choice of inhaler.

With the aim of providing clinicians and patients easy access to videos demonstrating inhaler techniques for devices available in India, we created a patient information sheet [Figure 1] containing scannable QR codes. Our model of care would include a conversation with the patient explaining the available inhaler options, assessing patient eligibility based on lung function and other clinical parameters, and then, in concordance with the patient’s choice, prescribing the right inhaler. Once this choice has been made, the patient is then handed the information sheet, with the prescribed device checked. This can be supplemented with an in-person education, when feasible. We are presently pilot testing the sheet at our institute, to receive feedback from patients, and the response received from doctors and patients is encouraging. In a post-COVID world in which tele-health is gaining importance, such video education would be a way to reduce health literacy inequalities and will hopefully be a good catalyst for inhaler technique education.

Figure 1.

Patient information leaflet for inhalation therapy

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Conflicts of interest

There are no conflicts of interest.