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NIHR Signal Reviewing inhaler technique for older people with COPD can improve disease control

Published on 22 January 2019

doi: 10.3310/signal-000712

Educating older adults with chronic obstructive pulmonary disease or asthma about the correct way to use their inhalers, as part of disease management, can reduce their risk of exacerbations. Either a demonstration using a placebo inhaler or written information appears effective for this.

This review pooled the results of four trials, with a total of 1,225 participants. It found that a pharmacist or nurse intervention to improve inhaler technique for older adults can reduce exacerbations. People with exacerbations reduced from 58% in the usual care group to 43% in the inhaler education group. However, there was no difference in quality of life or lung function.

Nevertheless, regularly ensuring good technique should prevent unnecessary increases in inhaler doses or additional treatments and is considered good practice. It may also be cost effective if it reduces exacerbations requiring hospital admission.

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Why was this study needed?

Approximately 1.2 million people have been diagnosed with chronic obstructive pulmonary disease (COPD) in the UK while eight million have asthma. Inhaled short and long-acting bronchodilators and corticosteroids are the mainstays of treatment. They improve symptoms and reduce the risk of exacerbations in people with asthma. They also provide symptom relief for people with COPD, but their effects on the underlying disease processes are unclear.

However, up to 90% of people aren’t using their inhalers properly, meaning the full dose of medicine isn’t being delivered to the lungs. Previous Cochrane systematic reviews have shown some benefit from education in younger adults though not how best to improve inhaler technique.

The current study aimed to address whether educational interventions that aim to improve inhaler technique for older adults can reduce exacerbations and improve quality of life.

What did this study do?

This review included eight studies overall and a meta-analysis of 1,225 adults from four randomised controlled trials. The studies compared an educational intervention with usual care for people mostly aged 65 and older with COPD, and a few with asthma. The studies took place in Canada, the Netherlands, Belgium and Northern Ireland.

The intervention included individualised inhaler training by pharmacists or nurses in pharmacies and hospitals. This involved physical demonstrations with placebo inhalers or written instructions. Most trials also included COPD education, exercise and a prescription for antibiotics and steroids for early use during an exacerbation. Participants were followed for between three months and two years.

There were some non-randomised studies which are not reported here. There was unclear risk of bias in the randomised trials which were rated as low to moderate quality evidence.

What did it find?

  • The inhaler education group had fewer exacerbations, occurring in 43% (268/618) of older adults compared with 58% (353/607) of the control group (pooled risk ratio 0.71, 95% confidence interval [CI] 0.59 to 0.86, four trials).
  • There was no clear difference in the quality of life between the two groups (standardised mean difference [SMD] ‑0.12, 95% CI ‑0.26 to 0.03).
  • There were no differences between the two groups in lung function tests (SMD 0.06, 95% CI ‑0.35 to 0.47). 

What does current guidance say on this issue?

The NICE guidelines for adults with COPD (2018) and asthma (2017) say patients should only be prescribed an inhaler after being shown how to use it, and if their clinician is confident that they can use it correctly. Inhaler technique should also be regularly assessed, particularly if their condition is not under control and whenever they change devices, medication or doses.  

The UK Inhaler Group – a coalition of not-for-profit organisations and professional societies, which promotes the correct use of inhaled therapies – stresses that both initial prescribers and those clinicians reviewing patients’ care should be able to demonstrate device techniques correctly and clearly to patients and those who care for them.

What are the implications?

The review provides moderate quality evidence that teaching and reviewing correct inhaler technique to older adults with COPD and asthma can reduce exacerbations.

The studies included people with mild to severe COPD, a range of inhaler medications and types of devices, and additional individualised education and strategies, which limits firm conclusions.

Nevertheless, the principles of regularly ensuring good inhaler technique are in line with national and international guidance and research in other age groups and are unlikely to cause harm.

Citation and Funding

Maricoto T, Monteiro L, Gama JM et al. Inhaler technique education and exacerbation risk in older adults with asthma or chronic obstructive pulmonary disease: a meta-analysis. J Am Geriatr Soc. 2019;67(1):57-66.

No funding information was provided for this study.

Bibliography

Asthma UK. How to use your inhaler. London: Asthma UK; 2018.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115. London: National Institute for Health and Care Excellence; 2018.

NICE. Asthma: diagnosis, monitoring and chronic asthma management. NG80. London: National Institute for Health and Care Excellence; 2017.

Normansell R, Kew M and Mathioudakis AG. Interventions to improve inhaler technique for people with asthma. Cochrane Database Syst Rev. 2017;(3):CD012286.

Sliwka A, Jankowski M, Gross-Sondej I et al. Once‐daily long‐acting beta₂‐agonists/inhaled corticosteroids combined inhalers versus inhaled long‐acting muscarinic antagonists for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018;(8):CD012355.

Tan DJ, White CJ, Walters JAE et al. Inhaled corticosteroids with combination inhaled long‐acting beta2‐agonists and long‐acting muscarinic antagonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016;(11):CD011600.

Yang IA, Clarke MS, Sim EHA et al. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;(7):CD002991.

Why was this study needed?

Approximately 1.2 million people have been diagnosed with chronic obstructive pulmonary disease (COPD) in the UK while eight million have asthma. Inhaled short and long-acting bronchodilators and corticosteroids are the mainstays of treatment. They improve symptoms and reduce the risk of exacerbations in people with asthma. They also provide symptom relief for people with COPD, but their effects on the underlying disease processes are unclear.

However, up to 90% of people aren’t using their inhalers properly, meaning the full dose of medicine isn’t being delivered to the lungs. Previous Cochrane systematic reviews have shown some benefit from education in younger adults though not how best to improve inhaler technique.

The current study aimed to address whether educational interventions that aim to improve inhaler technique for older adults can reduce exacerbations and improve quality of life.

What did this study do?

This review included eight studies overall and a meta-analysis of 1,225 adults from four randomised controlled trials. The studies compared an educational intervention with usual care for people mostly aged 65 and older with COPD, and a few with asthma. The studies took place in Canada, the Netherlands, Belgium and Northern Ireland.

The intervention included individualised inhaler training by pharmacists or nurses in pharmacies and hospitals. This involved physical demonstrations with placebo inhalers or written instructions. Most trials also included COPD education, exercise and a prescription for antibiotics and steroids for early use during an exacerbation. Participants were followed for between three months and two years.

There were some non-randomised studies which are not reported here. There was unclear risk of bias in the randomised trials which were rated as low to moderate quality evidence.

What did it find?

  • The inhaler education group had fewer exacerbations, occurring in 43% (268/618) of older adults compared with 58% (353/607) of the control group (pooled risk ratio 0.71, 95% confidence interval [CI] 0.59 to 0.86, four trials).
  • There was no clear difference in the quality of life between the two groups (standardised mean difference [SMD] ‑0.12, 95% CI ‑0.26 to 0.03).
  • There were no differences between the two groups in lung function tests (SMD 0.06, 95% CI ‑0.35 to 0.47). 

What does current guidance say on this issue?

The NICE guidelines for adults with COPD (2018) and asthma (2017) say patients should only be prescribed an inhaler after being shown how to use it, and if their clinician is confident that they can use it correctly. Inhaler technique should also be regularly assessed, particularly if their condition is not under control and whenever they change devices, medication or doses.  

The UK Inhaler Group – a coalition of not-for-profit organisations and professional societies, which promotes the correct use of inhaled therapies – stresses that both initial prescribers and those clinicians reviewing patients’ care should be able to demonstrate device techniques correctly and clearly to patients and those who care for them.

What are the implications?

The review provides moderate quality evidence that teaching and reviewing correct inhaler technique to older adults with COPD and asthma can reduce exacerbations.

The studies included people with mild to severe COPD, a range of inhaler medications and types of devices, and additional individualised education and strategies, which limits firm conclusions.

Nevertheless, the principles of regularly ensuring good inhaler technique are in line with national and international guidance and research in other age groups and are unlikely to cause harm.

Citation and Funding

Maricoto T, Monteiro L, Gama JM et al. Inhaler technique education and exacerbation risk in older adults with asthma or chronic obstructive pulmonary disease: a meta-analysis. J Am Geriatr Soc. 2019;67(1):57-66.

No funding information was provided for this study.

Bibliography

Asthma UK. How to use your inhaler. London: Asthma UK; 2018.

NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NG115. London: National Institute for Health and Care Excellence; 2018.

NICE. Asthma: diagnosis, monitoring and chronic asthma management. NG80. London: National Institute for Health and Care Excellence; 2017.

Normansell R, Kew M and Mathioudakis AG. Interventions to improve inhaler technique for people with asthma. Cochrane Database Syst Rev. 2017;(3):CD012286.

Sliwka A, Jankowski M, Gross-Sondej I et al. Once‐daily long‐acting beta₂‐agonists/inhaled corticosteroids combined inhalers versus inhaled long‐acting muscarinic antagonists for people with chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018;(8):CD012355.

Tan DJ, White CJ, Walters JAE et al. Inhaled corticosteroids with combination inhaled long‐acting beta2‐agonists and long‐acting muscarinic antagonists for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016;(11):CD011600.

Yang IA, Clarke MS, Sim EHA et al. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;(7):CD002991.

Inhaler Technique Education and Exacerbation Risk in Older Adults with Asthma or Chronic Obstructive Pulmonary Disease: A Meta-Analysis

Published on 7 October 2018

Maricoto, T.,Monteiro, L.,Gama, J. M. R.,Correia-de-Sousa, J.,Taborda-Barata, L.

J Am Geriatr Soc , 2018

OBJECTIVES: To evaluate the effect of inhaler education programs on clinical outcomes and exacerbation rates in older adults with asthma or chronic obstructive pulmonary disease (COPD). DESIGN: Systematic review and meta-analysis. SETTING AND PARTICIPANTS: Older adults with asthma or COPD, either in primary or secondary health care and pharmacy setting. MEASUREMENTS: We searched the Medline, Embase, and Central databases according to the main eligibility criteria for inclusion: systematic reviews, meta-analysis, clinical trials and quasi-experimental studies; participants aged 65 and older; education on inhaler technique and reporting of disease control and exacerbation rates. We used the Grading of Recommendations, Assessment, Development and Evaluations scale for quality assessment and used a random-effect model with Mantel-Haenszel adjustment to perform a meta-analysis. RESULTS: We included 8 studies (4 randomized, 4 quasi-experimental) with a total of 1,812 participants. The most frequent type of intervention was physical demonstration of inhaler technique, training with placebo devices. Five studies showed significant reduction in exacerbation rates (pooled risk ratio=0.71, 95% confidence interval=0.59-0.86; p < .001), although effect on disease control and quality of life showed high discrepancy in the reported results, and all randomized studies revealed uncertainty in their risk of bias assessment. CONCLUSION: All interventions seemed to improve inhaler performance and clinically relevant outcomes, but a placebo device could be the most effective. There is evidence that interventions reduce exacerbation risk in older adults, although to an overall moderate degree.

Expert commentary

It has been evidenced many times over that improved inhaler technique reduces exacerbation rates for both asthma and chronic obstructive pulmonary disease.

As nurses and health professionals working clinically with these cohorts of patients, we cannot underestimate the benefit of taking the time to provide good education on how to administer inhalers correctly.

As prescribers, it is indeed our responsibility to do so as per guidance both nationally within the United Kingdom and internationally. There are many resources available to us if we do not have these skills ourselves such as the video suite hosted by Asthma UK.

Natalie Harper, Respiratory Advanced Nurse Practitioner; Asthma Lead, Association of Respiratory Nurse Specialists

The commentator declares no conflicting interests