A study comparing first-time users of several different inhalers has highlighted the importance of training patients to avoid errors.
For some inhaler types, between 40–60% of patients with chronic obstructive pulmonary disease (COPD) made at least one critical error, despite reading the patient information leaflet on how to use the device.
The study, which was sponsored by GSK and published in Primary Care Respiratory Medicine
(online, 24 November 2016), was set up to compare COPD and asthma patients’ first use of a placebo ‘Ellipta’ dry powder inhalation device with the placebo version of a range of other commonly used inhaler devices, including the DISKUS/Accuhaler, metered dose inhaler (MDI), Turbuhaler, Handihaler and Breezhaler.
In general, the researchers found that fewer patients in the study made mistakes with the Ellipta inhaler than with other devices. They say this is likely because it was the device with the fewest steps required.
The results also showed that up to a third of patients with asthma who made critical mistakes when using their device relied solely on the information leaflet before being trained by a nurse.
Commenting on the study, Toby Capstick, lead respiratory pharmacist at Leeds Teaching Hospitals NHS Trust and chair of the UK Clinical Pharmacy Association respiratory group, says he is not surprised that patients in the study found the Ellipta device easier to use, but adds that relying on an information leaflet is never OK.
“Just reading the patient information leaflet is not enough to perfect inhaler technique. You need to explain to patients why you take different steps, otherwise they don’t take it on board,” he says.
In the COPD arm of the study, which involved 567 patients, 5–14% of patients made critical errors, such as not forming a seal with their lips around the inhaler when first using an Ellipta device after reading the information leaflet. This compares with 44–60% of those using one of the other devices for the first time – a significant difference in all cases.
For all errors, including less serious mistakes, between 30–43% of patients did something wrong using Ellipta compared with 56–85% for other inhaler devices.
Patients in the asthma arm of the study (162) tended to make fewer errors when using a new inhaler type for the first time, the researchers discovered; only 2–3% made a critical mistake with Ellipta compared with 13–33% for DISKUS, a MDI or Turbuhaler (which was the only significant difference).
However, the difference in overall errors in asthma patients was non-significant, with 21–28% for Ellipta compared with 31–47% for DISKUS, MDI or Turbohaler.
The researchers note that the most common mistake made with Ellipta was exhaling into the mouthpiece.
Study leader Raj Sharma, director of respiratory science and delivery systems at GSK, says all patients were recruited from routine clinical practice and their inhaler technique was independently assessed against an error checklist that was developed based on the respective patient information leaflet, existing literature and with the input from external experts.
“Part of good asthma and COPD management is having a device that is easier to use but there is no question that healthcare professional engagement on inhaler technique is a great advantage,” he adds.
Sandeep Sarkar, respiratory medical director at GSK UK, adds: “This study reinforces that patients do make mistakes and need to be properly shown how to use it and that inhaler technique is subsequently reassessed.”
Anna Murphy, consultant respiratory pharmacist at University Hospitals of Leicester NHS Trust, says that study should be taken with a pinch of salt because it was sponsored and funded by GSK, but admits that incorrect inhaler use is extremely high.
“It could [be worth] evaluating how good the patient information leaflet is,” she says. “But any study that highlights that inhaler technique is poor [means that we] need to do more to optimise inhaler technique. No device ticks every box and ultimately it is about individual choice,” she adds.
 van der Palen J, Thomas M, Chrystyn H et al. An open-label cross-over study of inhaler errors, preference and time to achieve correct inhaler use in patients with COPD or asthma: comparison of ELLIPTA with other inhaler device. Primary Care Respiratory Medicine 2016;26:16079. doi: 10.1038/npjpcrm.2016.79