Inhaler Choice: Are You Using the Right One?
Inhaler Choice Using Shared Decision-Making
Background
Current recommendations are for the health care professional to select an inhaler based on “access, cost, prescriber, and most importantly, patient’s ability and preference.” For various reasons, inhaler choice is typically a decision by the health care professional. Unfortunately, studies show that individuals with COPD have frequent errors using whatever inhaler device has been prescribed.
Another approach to inhaler selection is “shared decision-making” which enables patients to participate in the process of deciding on which inhaler device “is best for me.”
Study
Dr. Yi-Han Hsiao and colleagues in Taiwan conducted a study involving shared decision-making for inhaler selection in four hospitals in Taiwan. All subjects were newly diagnosed COPD who were able to use three different inhalers with similar bronhodilator medications. Patients had no previous experience with any of the study inhalers.
At visit 1 a COPD educator showed each patient three different inhalers in random order and demonstrated the steps for using each one. The three medication-inhaler combinations were: 1. Anoro Ellipta® dry powder inhaler; 2. Stiolto Respimat® Soft Mist Inhaler; and 3. Ultibro Breezhaler® dry powder inhaler. Each inhaler had two similar bronchodilator medications. After understanding the different inhalers, each patient chose one inhaler and recorded the reasons for the selection.
From left to right: Ellipta dry powder inhaler, Respimat soft mist inhaler, Breezhaler dry powder inhaler (not available in US)
The study results were published on September 2, 2022, in the International Journal of Chronic Obstructive Pulmonary Disease (volume 17; pages 2067-2078).
Results
109 treatment-naive patients with newly diagnosed COPD were enrolled. As shown in the Figure below, 41% chose Ellipta®, 39% chose Respimat®, and 19% chose Breezhaler®.
A. Flow diagram of study.
B. Bullseye plot showing the number of patients choosing different inhalers on first visit (inner circle) and the decision of keeping or changing on the second visit (outer circle).
In general, the reasons why patients selected a particular inhaler were: Ellipta® – considered simple to use; Respimat® – concern of cough with dry powder and feeling of easy to inhale while the others required more force; and Breezhaler® – visibility of the inhaled medication and the device appeared delicate.
There were no differences among groups for patients with critical errors, either in preparation of the inhaler or for inhaling.
At a follow-up appointment one month later:
patient errors in inhaler use were significantly decreased compared with Visit 1
there was a strong willingness to keep the initial inhaler
Conclusions
Inhaler choice can use a shared decision-making approach for each person. This may reduce technique errors.
My Comments
This unique study used shared decision-making approach to select an inhaler – a COPD educator showed each patient three different inhaler devices and then asked the patient to pick the one preferred. Although this takes time at the initial visit, it will likely lead to better outcomes and also reduce errors in inhaler use.
In my practice, many patients with COPD have difficulty understanding that there are different instructions for inhaling depending on the device. For example, with a pressurized metered-dose inhaler and with the Respimat® soft mist inhaler, a “slow and steady”inhalation is recommended followed by a breath hold. With a dry powder inhaler, a “hard and fast” inhalation is recommended to break up the powder inside the device into small particles followed by a breath hold.
If you are not sure that you are using your inhaler correctly, make sure to take your inhaler to your next appointment and ask a health care professional to watch you use it. You can also look up correct technique on-line for each inhaler as many are available on YouTube.