Skip to main navigation menu Skip to main content Skip to site footer
##common.pageHeaderLogo.altText##

Original article

Vol. 154 No. 4 (2024)

An in-hospital intervention to reduce the proportion of misused inhalers at hospital discharge among patients with COPD: a non-randomised intervention study

DOI
https://doi.org/10.57187/s.3394
Cite this as:
Swiss Med Wkly. 2024;154:3394
Published
04.04.2024

Summary

AIMS OF THE STUDY: Misuse of inhalers during chronic obstructive pulmonary disease (COPD) treatment is common and may result from errors in inhalation technique or insufficient peak inspiratory flow (PIF). We aimed to evaluate the impact of an in-hospital intervention to reduce inhaler misuse at hospital discharge among patients with COPD.

METHODS: We conducted a monocentric, non-randomised intervention study to compare the proportion of misused inhalers at hospital discharge by patients with COPD between a group with standard care and a group receiving an in-hospital intervention. The control group successively included all patients hospitalised between March and June 2022, and the intervention group included patients hospitalised between August and December 2022. The intervention consisted of (a) an evaluation of inhalation technique and PIF at admission, (b) the provision of a written guide to assist in the selection of an inhaler, and (c) therapeutic education. The primary outcome was the proportion of misused inhalers, defined as an inhaler used with a critical error and/or insufficient PIF, at hospital discharge. The primary outcome was assessed by observing inhalation technique and measuring PIF using the In-Check DIAL G16® .

RESULTS: The study included 93 patients: 46 in the control group and 47 in the intervention group. Mean age was 70.5 years (SD 10.9 years), 56 patients (60.2%) were men, and 57 patients (62%) were hospitalised for a COPD exacerbation. Patients used an average of 1.9 inhalers at hospital discharge; 98 inhalers were assessed in the control group and 81 in the intervention group. The proportion of misused inhalers at discharge was 61.2% in the control group and 21.0% in the intervention group (absolute risk reduction 40.2% [95% CI 25.5–55.0]; p <0.01). In the intervention group, the proportion of inhalers used with at least one critical error was reduced by 38.6% (95% CI 24.3–52.3%) and that of inhalers used with insufficient PIF by 13.9% (95% CI 4.2–23.6%).

CONCLUSIONS: An in-hospital intervention was associated with a reduction in the proportion of misused inhalers at hospital discharge. This intervention should be considered for hospitalised patients with COPD.

The trial was registered with ClinicalTrials.gov (NCT05207631).

References

  1. GOLD. Global strategy for the diagnosis, management, and prevention of chronic lung obstructive disease. 2021.
  2. Sanchis J, Gich I, Pedersen S; Aerosol Drug Management Improvement Team (ADMIT). Systematic Review of Errors in Inhaler Use: Has Patient Technique Improved Over Time? Chest. 2016 Aug;150(2):394–406. 10.1016/j.chest.2016.03.041
  3. Chrystyn H, van der Palen J, Sharma R, Barnes N, Delafont B, Mahajan A, et al. Device errors in asthma and COPD: systematic literature review and meta-analysis. NPJ Prim Care Respir Med. 2017 Apr;27(1):22. 10.1038/s41533-017-0016-z
  4. Usmani OS, Lavorini F, Marshall J, Dunlop WC, Heron L, Farrington E, et al. Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes. Respir Res. 2018 Jan;19(1):10. 10.1186/s12931-017-0710-y
  5. Kocks JW, Chrystyn H, van der Palen J, Thomas M, Yates L, Landis SH, et al. Systematic review of association between critical errors in inhalation and health outcomes in asthma and COPD. NPJ Prim Care Respir Med. 2018 Nov;28(1):43. 10.1038/s41533-018-0110-x
  6. Molimard M, Raherison C, Lignot S, Balestra A, Lamarque S, Chartier A, et al. Chronic obstructive pulmonary disease exacerbation and inhaler device handling: real-life assessment of 2935 patients. Eur Respir J. 2017 Feb;49(2):1601794. 10.1183/13993003.01794-2016
  7. Ghosh S, Ohar JA, Drummond MB. Peak Inspiratory Flow Rate in Chronic Obstructive Pulmonary Disease: Implications for Dry Powder Inhalers. J Aerosol Med Pulm Drug Deliv. 2017 Dec;30(6):381–7. 10.1089/jamp.2017.1416
  8. Mahler DA. The role of inspiratory flow in selection and use of inhaled therapy for patients with chronic obstructive pulmonary disease. Respir Med. 2020 Jan;161:105857. 10.1016/j.rmed.2019.105857
  9. Harb HS, Laz NI, Rabea H, Abdelrahim ME. Prevalence and predictors of suboptimal peak inspiratory flow rate in COPD patients. Eur J Pharm Sci. 2020 Apr;147:105298. 10.1016/j.ejps.2020.105298
  10. Sharma G, Mahler DA, Mayorga VM, Deering KL, Harshaw O, Ganapathy V. Prevalence of Low Peak Inspiratory Flow Rate at Discharge in Patients Hospitalized for COPD Exacerbation. Chronic Obstr Pulm Dis (Miami). 2017 Jul;4(3):217–24. 10.15326/jcopdf.4.3.2017.0183
  11. Loh CH, Peters SP, Lovings TM, Ohar JA. Suboptimal Inspiratory Flow Rates Are Associated with Chronic Obstructive Pulmonary Disease and All-Cause Readmissions. Ann Am Thorac Soc. 2017 Aug;14(8):1305–11. 10.1513/AnnalsATS.201611-903OC
  12. Chen SY, Huang CK, Peng HC, Tsai HC, Huang SY, Yu CJ, et al. Peak-Inspiratory-Flow-Rate Guided Inhalation Therapy Reduce Severe Exacerbation of COPD. Front Pharmacol. 2021 Jun;12:704316. 10.3389/fphar.2021.704316
  13. Mahler DA, Halpin DM. Peak Inspiratory Flow as a Predictive Therapeutic Biomarker in COPD. Chest. 2021 Aug;160(2):491–8. 10.1016/j.chest.2021.03.049
  14. Renaud Y, Suter P, Grandmaison G. Patient Characteristics to Consider When Selecting an Inhaler for the Treatment of Chronic Obstructive Pulmonary Disease and Available Assessment Methods: A Narrative Review. Respiration. 2023;102(6):416–25. 10.1159/000530277
  15. Braman SS, Carlin BW, Hanania NA, Mahler DA, Ohar JA, Pinto-Plata V, et al. Results of a Pulmonologist Survey Regarding Knowledge and Practices With Inhalation Devices for COPD. Respir Care. 2018 Jul;63(7):840–8. 10.4187/respcare.05717
  16. Plaza V, Giner J, Rodrigo GJ, Dolovich MB, Sanchis J. Errors in the Use of Inhalers by Health Care Professionals: A Systematic Review. J Allergy Clin Immunol Pract. 2018;6(3):987–95. 10.1016/j.jaip.2017.12.032
  17. Halpin DM, Mahler DA. A Systematic Review of Published Algorithms for Selecting an Inhaled Delivery System in Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc. 2022 Jul;19(7):1213–20. 10.1513/AnnalsATS.202108-930OC
  18. Press VG, Arora VM, Shah LM, Lewis SL, Ivy K, Charbeneau J, et al. Misuse of respiratory inhalers in hospitalized patients with asthma or COPD. J Gen Intern Med. 2011 Jun;26(6):635–42. 10.1007/s11606-010-1624-2
  19. Capstick TG, Azeez NF, Deakin G, Goddard A, Goddard D, Clifton IJ. Ward based inhaler technique service reduces exacerbations of asthma and COPD. Respir Med. 2021 Oct;187:106583. 10.1016/j.rmed.2021.106583
  20. Des Jarlais DC, Lyles C, Crepaz N, Group T; TREND Group. Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement. Am J Public Health. 2004 Mar;94(3):361–6. 10.2105/AJPH.94.3.361
  21. Sanders MJ. Guiding Inspiratory Flow: Development of the In-Check DIAL G16, a Tool for Improving Inhaler Technique. Pulm Med. 2017;2017:1495867. 10.1155/2017/1495867
  22. Barnes CN, Mahler DA, Ohar JA, Lombardi DA, Crater GD. Peak Inspiratory Flows: Defining Repeatability Limits and a Predictive Equation for Different Inhalers. Chest. 2020 Oct;158(4):1413–9. 10.1016/j.chest.2020.03.072
  23. Batterink J, Dahri K, Aulakh A, Rempel C. Evaluation of the use of inhaled medications by hospital inpatients with chronic obstructive pulmonary disease. Can J Hosp Pharm. 2012 Mar;65(2):111–8. 10.4212/cjhp.v65i2.1118
  24. Norton EC, Miller MM, Kleinman LC. Computing adjusted risk ratios and risk differences in Stata. Stata J. 2013;13(3):492–509. 10.1177/1536867X1301300304
  25. Wang R, Ware JH. Detecting moderator effects using subgroup analyses. Prev Sci. 2013 Apr;14(2):111–20. 10.1007/s11121-011-0221-x
  26. Harris PA, Taylor R, Minor BL, Elliott V, Fernandez M, O’Neal L, et al.; REDCap Consortium. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019 Jul;95:103208. 10.1016/j.jbi.2019.103208
  27. Kebede AT, Trapnes E, Lea M, Abrahamsen B, Mathiesen L. Effect of pharmacist-led inhaler technique assessment service on readmissions in hospitalized COPD patients: a randomized, controlled pilot study. BMC Pulm Med. 2022 May;22(1):210. 10.1186/s12890-022-02004-z
  28. Hardwell A, Barber V, Hargadon T, McKnight E, Holmes J, Levy ML. Technique training does not improve the ability of most patients to use pressurised metered-dose inhalers (pMDIs). Prim Care Respir J. 2011 Mar;20(1):92–6. 10.4104/pcrj.2010.00088
  29. Sulku J, Bröms K, Högman M, Janson C, Lisspers K, Malinovschi A, et al. Critical inhaler technique errors in Swedish patients with COPD: a cross-sectional study analysing video-recorded demonstrations. NPJ Prim Care Respir Med. 2021 Feb;31(1):5. 10.1038/s41533-021-00218-y
  30. Takaku Y, Kurashima K, Ohta C, Ishiguro T, Kagiyama N, Yanagisawa T, et al. How many instructions are required to correct inhalation errors in patients with asthma and chronic obstructive pulmonary disease? Respir Med. 2017 Feb;123:110–5. 10.1016/j.rmed.2016.12.012
  31. Sulku J, Janson C, Melhus H, Ställberg B, Bröms K, Högman M, et al. Changes in critical inhaler technique errors in inhaled COPD treatment - A one-year follow-up study in Sweden. Respir Med. 2022 Jun;197:106849. 10.1016/j.rmed.2022.106849
  32. Klijn SL, Hiligsmann M, Evers SM, Román-Rodríguez M, van der Molen T, van Boven JF. Effectiveness and success factors of educational inhaler technique interventions in asthma & COPD patients: a systematic review. NPJ Prim Care Respir Med. 2017 Apr;27(1):24. 10.1038/s41533-017-0022-1
  33. Rogliani P, Ora J, Puxeddu E, Matera MG, Cazzola M. Adherence to COPD treatment: myth and reality. Respir Med. 2017 Aug;129:117–23. 10.1016/j.rmed.2017.06.007
  34. Levy ML, Dekhuijzen PN, Barnes PJ, Broeders M, Corrigan CJ, Chawes BL, et al. Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT). NPJ Prim Care Respir Med. 2016 Apr;26(1):16017. 10.1038/npjpcrm.2016.17
  35. Bosnic-Anticevich S, Bakerly ND, Chrystyn H, Hew M, van der Palen J. Advancing Digital Solutions to Overcome Longstanding Barriers in Asthma and COPD Management. Patient Prefer Adherence. 2023 Jan;17:259–72. 10.2147/PPA.S385857
  36. Tschopp J, Dumont P, Hayoz D. True prevalence of COPD and its association with peripheral arterial disease in the internal medicine ward of a tertiary care hospital. Swiss Med Wkly. 2017 Jul;147:w14460.

Most read articles by the same author(s)