Inhaler technique is more important now than ever, but when good technique cannot be confirmed. Could more use of spacers improve outcomes?
Controlling chronic respiratory diseases has never been more important.
The COVID-19 pandemic and the winter cold and flu season is here. Therefore, it is even more vital that people with respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) control their conditions effectively. That means persistence in using inhaler-delivered medicines as often as prescribed and using the correct inhaler technique.
Sticking to the right routines and techniques can be challenging at the best of times – figures show that eight out of 10 people’s inhaler techniques are incorrect.1 The best way to learn the right techniques is face-to-face, from a healthcare practitioner skilled in their use. Digital services, such as video appointments or website self-assessments, have provided utility in helping enhance asthma care with guides and resources, but they do not replace face-to-face services. Due to the pandemic, many regular face-to-face consultations are not taking place, which means basic levels of asthma care are not provided and will result in declining asthma care. Lives could be at risk.
“A July 2020 survey of 8,268 asthma patients by Asthma UK2 showed that one in three asthma patients had delayed or avoided visiting their GP or hospital when unwell. This was because they didn’t feel safe or didn’t want to overburden the health service – even if it meant that their condition worsened. Around four out of 10 people with respiratory conditions had had an asthma attack or worsening of their lung disease since the start of the pandemic, but most did not seek help” says GP Dr Michael D Smith.
The importance of inhaler technique
“Inhaler technique is 50% of the prescription, alongside the right drugs,” says Dr Omar Usmani, consultant chest physician and Chair of the UK Inhaler Group. “But systematic reviews have shown that health care practitioners themselves are poor at understanding the devices and often relay poor techniques to patients.”
Many practitioners have turned to online or telephone consultations during the pandemic, but it is almost impossible to check inhaler technique over the phone. Even video consultations have limits, says respiratory nurse consultant Carol Stonham.
“Video consultations risk increasing health inequalities,” she says. “What if you cannot afford the necessary technology, cannot operate it or have a poor internet connection? Inability to access your GP face-to-face means missed opportunities to pick up problems with inhaler techniques.”
Due to the pandemic, many regular face-to-face consultations are not taking place, which means basic levels of asthma care are not provided and will result in declining asthma care
What could help with better inhaler use?
Better education in inhaler use for practitioners and patients is essential. But if an effective inhalation technique cannot be confirmed, the prescription of a spacer should be considered as a risk mitigation approach.
Spacers – valved holding chambers that attach to inhalers – have been typically prescribed for use by children, or adults who find it hard to co-ordinate their actions consistently. However, they could be used to help many more people.
Dr Richard Iles, a consultant in respiratory paediatrics, says: “To stand the best chance of using an inhaler with the kind of co-ordination that ensures the majority of the drug gets into your airway, you need to be fit and healthy (i.e. not having an acute exacerbation) and ideally aged 14 to 35 (without any co-morbidities). If you are not in that group, a spacer will help. It holds the gaseous drug so you can breathe it into your lower airways and removes the need for masterful coordination between actuation and inhalation.”
Recommended in guidelines for general use
GINA Report, Global Strategy for Asthma Management and Prevention (2020) and the UK BTS/SIGN Asthma Guidelines recommend the use of valved holding chambers to improve drug delivery.
Despite this, prescriptions for spacers have dropped dramatically during the pandemic, even though the guidelines recommend spacers. Doctors also say spacers should be used more widely as they can only help in monitoring disease control and avoiding exacerbations.
Smith says: “In the present circumstances in particular I am reconsidering which patients I prescribe a spacer device to and will have a low threshold for doing so, especially if it means reducing the risk of poor inhaler technique. To those asthma patients with a pMDI/puffer inhaler reading this, who think that a spacer may help them; please talk to a qualified HCP for appropriate advice.”
For more information visit www.trudellmedical.co.uk/pmdi-and-spacer-inhaler-technique or contact [email protected]
UK AC 054 1120 | Date of preparation: November 2020
This article is sponsored by Trudell Medical UK Limited (TM-UK). All interviewees are members of TM-UK’s ActOnAsthma advisory board.
Members of the ActOnAsthma advisory board will receive an appropriate honorarium for their time dedicated to the project.
1 GINA Report, Global Strategy for Asthma Management and Prevention (2020)
2Asthma UK: Five Headlines from our summer COVID-19 survey. August 2020 https://www.asthma.org.uk/support-us/campaigns/campaigns-blog/five-survey-headlines/ Accessed Nov. 2020
3 Suggett J et al Am J Respir Crit Care Med 2020;201:A5689
4 Burudpakdee C et al. Pulmonary Therapy 2017; 3(2):283–296.