Improving inhaler technique – who needs teaching?

In 2011, over 45 million prescriptions for inhalers containing a bronchodilator, a corticosteroid or both were dispensed in primary care in England with a total cost of over £900 million.¹ Four out of the top 10 drugs with the highest total expenditure in 2011 were inhalers (fluticasone, budesonide, tiotropium and beclometasone). A fundamental requirement that underlies all inhaled drugs is the need to use the device correctly in order to achieve the optimal therapeutic response from the drug. Even with correct technique, at best 20–35% of the drug reaches the lungs, at worst 0%.² How confident are we that patients and clinicians are getting best value from inhaled therapy?

Numerous studies over the past 30 years have shown that many patients cannot use inhalers correctly and over 50% of patients struggle to use a metered dose inhaler (MDI) properly.³ Of perhaps more concern is the fact that many health professionals also do not know how to use inhalers correctly and are therefore not in a position to coach patients effectively. One study showed that 91% of healthcare professionals who teach patients how to use inhalers could not demonstrate all the recognised steps involved in administering an MDI.⁴ There is a widespread lack of attention with regard to teaching, checking and re-checking inhaler technique and this applies to prescribers, healthcare professionals who review patients and those involved in the dispensing and supply of such medication. The National Institute for Health and Clinical Excellence Clinical Guideline for COPD states “it is surprising that assessment of inhaler technique is so often neglected, but that …most patients whatever their age are able to acquire and maintain adequate inhaler technique given adequate instruction”.⁵ The guidance also urges that “retention of inhaler technique is as important as its acquisition” and that …