Skip to main content
SpringerLink
Log in

Assessment of Poor Inhaler Technique in Older Patients with Asthma or COPD: A Predictive Tool for Clinical Risk and Inhaler Performance

  • Original Research Article
  • Published:
Drugs & Aging Aims and scope Submit manuscript

Abstract

Background/Objectives

Older patients with asthma or chronic obstructive pulmonary disease (COPD) are particularly susceptible to inhaler technique errors and poor clinical outcomes. Several factors may influence their risk, but most studies are inconsistent and contradictory. We developed a tool for the major predictors of individual risk in these patients.

Design, Setting and Participants

In this multicentre, cross-sectional study, several demographic, socioeconomic and clinical characteristics were collected as potential predictors. Clinical features and inhaler technique performance were the main outcomes. Linear and logistic regression models were set up to identify significant variables. Subgroup analysis was performed according to age, cognitive performance and different types of inhalers.

Results

We included 130 participants, mean age of 74.4 (± 6.4) years. Mean years of device use were 5.8 (± 7.3). Inhaler errors affected 71.6% (95% CI 64–78.5) and critical mistakes 31.1% (95% CI 24–38.8). There were respiratory comorbidities in 82.3% of participants, and 56.2% had moderate to severe disease. A predictive score of misuse probability was developed for clinical practice, including points attributable to cognitive score, adherence and having received previous education on a placebo device. Other significant variables of individual risk were having respiratory allergies or comorbidities, smoking status, depression and educational level. Worse performance was detected in cognitively impaired patients older than 75 years who were using dry powder inhalers (DPI). Lung function was associated with smoking load, incorrect dose activation and absent end pause after inhalation.

Conclusions

Individual risk assessment in older individuals should focus on inhaler technique performance (mainly on dose activation and end pause) and adherence, smoking, respiratory comorbidities and cognitive impairment. Placebo device training provided by doctors seems to best suit these patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Sa-Sousa A, Morais-Almeida M, Azevedo LF, et al. Prevalence of asthma in Portugal—The Portuguese National Asthma survey. Clin Transl Allergy. 2012;2(1):15. https://doi.org/10.1186/2045-7022-2-15.

    Article  PubMed  PubMed Central  Google Scholar 

  2. IfHMa E. Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Respir Med. 2017;5(9):691–706. https://doi.org/10.1016/s2213-2600(17)30293-x.

    Article  Google Scholar 

  3. Reddel H, Bacharier L, Bateman E, et al. Global Strategy for Asthma Management and Prevention. https://www.ginasthma.org: Global initiative for asthma; 2019. p. 201.

  4. Vestbo J, Anderson JA, Calverley PM, et al. Adherence to inhaled therapy, mortality and hospital admission in COPD. Thorax. 2009;64(11):939–43. https://doi.org/10.1136/thx.2009.113662.

    Article  CAS  PubMed  Google Scholar 

  5. Enright PL, McClelland RL, Newman AB, et al. Underdiagnosis and undertreatment of asthma in the elderly. Cardiovascular Health Study Research Group. Chest. 1999;116(3):603–13.

    Article  CAS  Google Scholar 

  6. Smith AM, Villareal M, Bernstein DI, et al. Asthma in the elderly: risk factors and impact on physical function. Ann Allergy Asthma Immunol Off Publ Am Coll Allergy Asthma Immunol. 2012;108(5):305–10. https://doi.org/10.1016/j.anai.2012.02.022.

    Article  Google Scholar 

  7. Crompton GK, Barnes PJ, Broeders M, et al. The need to improve inhalation technique in Europe: a report from the Aerosol Drug Management Improvement Team. Respir Med. 2006;100(9):1479–94. https://doi.org/10.1016/j.rmed.2006.01.008.

    Article  CAS  PubMed  Google Scholar 

  8. Price DB, Román-Rodríguez M, McQueen RB, et al. Inhaler errors in the CRITIKAL study: type, frequency, and association with asthma outcomes. J Allergy Clin Immunol. 2017. https://doi.org/10.1016/j.jaip.2017.01.004.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Al-Jahdali H, Ahmed A, Al-Harbi A, et al. Improper inhaler technique is associated with poor asthma control and frequent emergency department visits. Allergy Asthma Clin Immunol Off J Can Soc Allergy Clin Immunol. 2013;9(1):8–8. https://doi.org/10.1186/1710-1492-9-8.

    Article  Google Scholar 

  10. Baddar S, Jayakrishnan B, Al-Rawas OA. Asthma control: importance of compliance and inhaler technique assessments. J Asthma Off J Assoc Care Asthma. 2014;51(4):429–34. https://doi.org/10.3109/02770903.2013.871558.

    Article  Google Scholar 

  11. Engelkes M, Janssens HM, de Jongste JC, et al. Medication adherence and the risk of severe asthma exacerbations: a systematic review. Eur Respir J. 2015;45(2):396–407. https://doi.org/10.1183/09031936.00075614.

    Article  PubMed  Google Scholar 

  12. Lurslurchachai L, Krauskopf K, Roy A, et al. Metered dose inhaler technique among inner-city asthmatics and its association with asthma medication adherence. Clin Respir J. 2014;8(4):397–403. https://doi.org/10.1111/crj.12084.

    Article  PubMed  Google Scholar 

  13. Maricoto T, Rodrigues LV, Teixeira G, et al. Assessment of inhalation technique in clinical and functional control of asthma and chronic obstructive pulmonary disease. Acta Med Port. 2015;28(6):702–7.

    Article  Google Scholar 

  14. Molimard M, Raherison C, Lignot S, et al. Chronic obstructive pulmonary disease exacerbation and inhaler device handling: real-life assessment of 2935 patients. Eur Respir J. 2017. https://doi.org/10.1183/13993003.01794-2016.

    Article  PubMed  Google Scholar 

  15. Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy: evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest. 2005;127(1):335–71. https://doi.org/10.1378/chest.127.1.335.

    Article  PubMed  Google Scholar 

  16. Wieshammer S, Dreyhaupt J. Dry powder inhalers: which factors determine the frequency of handling errors? Respir Int Rev Thorac Dis. 2008;75(1):18–25. https://doi.org/10.1159/000109374.

    Article  Google Scholar 

  17. Allen SC, Warwick-Sanders M, Baxter M. A comparison of four tests of cognition as predictors of inability to learn to use a metered dose inhaler in old age. Int J Clin Pract. 2009;63(8):1150–3. https://doi.org/10.1111/j.1742-1241.2009.02060.x.

    Article  CAS  PubMed  Google Scholar 

  18. Board M, Allen SC. A simple drawing test to identify patients who are unlikely to be able to learn to use an inhaler. Int J Clin Pract. 2006;60(5):510–3. https://doi.org/10.1111/j.1368-5031.2006.00933.x.

    Article  CAS  PubMed  Google Scholar 

  19. Aydemir Y. Assessment of the factors affecting the failure to use inhaler devices before and after training. Respir Med. 2015;109(4):451–8. https://doi.org/10.1016/j.rmed.2015.02.011.

    Article  PubMed  Google Scholar 

  20. Bartolo K, Balzan M, Schembri EL, et al. Predictors of correct technique in patients using pressurized metered dose inhalers. BMC Pulm Med. 2017;17(1):47. https://doi.org/10.1186/s12890-017-0386-6.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Quinet P, Young CA, Heritier F. The use of dry powder inhaler devices by elderly patients suffering from chronic obstructive pulmonary disease. Ann Phys Rehabil Med. 2010;53(2):69–766. https://doi.org/10.1016/j.rehab.2009.11.001.

    Article  CAS  PubMed  Google Scholar 

  22. Gray SL, Williams DM, Pulliam CC, et al. Characteristics predicting incorrect metered-dose inhaler technique in older subjects. Arch Intern Med. 1996;156(9):984–8.

    Article  CAS  Google Scholar 

  23. Blasi F, Canonica GW, Centanni S, et al. Genuair(R) usability test: results of a national public survey of the elderly. COPD. 2016;13(3):367–71. https://doi.org/10.3109/15412555.2015.1067675.

    Article  PubMed  Google Scholar 

  24. Dodd JW, Getov SV, Jones PW. Cognitive function in COPD. Eur Respir J. 2010;35(4):913–22. https://doi.org/10.1183/09031936.00125109.

    Article  CAS  PubMed  Google Scholar 

  25. Villeneuve S, Pepin V, Rahayel S, et al. Mild cognitive impairment in moderate to severe COPD: a preliminary study. Chest. 2012;142(6):1516–23. https://doi.org/10.1378/chest.11-3035.

    Article  PubMed  Google Scholar 

  26. Jarvis S, Ind PW, Shiner RJ. Inhaled therapy in elderly COPD patients; time for re-evaluation? Age Ageing. 2007;36(2):213–8. https://doi.org/10.1093/ageing/afl174.

    Article  PubMed  Google Scholar 

  27. Vogelmeier C, Agusti A, Anzueo A, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease; 2020. p. 141. https://www.goldcopd.org. Accessed Feb 2020.

  28. Amaro F. Escala de Graffar, 1990.

  29. Apóstolo JLA, Loureiro LMDJ, Reis IACD, et al. Contribuição para a adaptação da Geriatric Depression Scale-15 para a língua portuguesa. Revista de Enfermagem Referência. 2014;serIV:65–73.

    Article  Google Scholar 

  30. Nunes DP, Duarte YADO, Santos JLF, et al. Screening for frailty in older adults using a self-reported instrument. Rev Saude Publica. 2015;49:2. https://doi.org/10.1590/S0034-8910.2015049005516.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Freitas SSMR, Cristina M, Vilar M, Santana I. Estudos de adaptação do Montreal Cognitive Assessment (MoCA) para a população portuguesa. Aval Psicol [online]. 2010;9(3):345–57.

    Google Scholar 

  32. Ben AJ, Neumann CR, Mengue SS. The brief medication questionnaire and Morisky–Green test to evaluate medication adherence. Rev Saude Publica. 2012;46(2):279–89.

    Article  Google Scholar 

  33. Camelier A, Rosa FW, Salim C, et al. Using the Saint George's Respiratory Questionnaire to evaluate quality of life in patients with chronic obstructive pulmonary disease: validating a new version for use in Brazil. Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia. 2006;32(2):114–22.

    Article  Google Scholar 

  34. Ferreira J, Silveira P, Figueiredo MM, et al. Validation of the Portuguese version of the Asthma Quality of Life Questionnaire [AQLQ-M] by Marks. Revista portuguesa de pneumologia. 2005;11(4):351–66.

    Article  Google Scholar 

  35. Silva GP, Morano MT, Viana CM, et al. Portuguese-language version of the COPD Assessment Test: validation for use in Brazil. Jornal brasileiro de pneumologia: publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia. 2013;39(4):402–8. https://doi.org/10.1590/s1806-37132013000400002.

    Article  Google Scholar 

  36. Kovelis D, Segretti NO, Probst VS, et al. Validation of the Modified pulmonary functional status and dyspnea questionnaire and the medical research council scale for use in Brazilian patients with chronic obstructive pulmonary disease. Jornal brasileiro de pneumologia: publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia. 2008;34(12):1008–18.

    Article  Google Scholar 

  37. Fonseca JA, Nogueira-Silva L, Morais-Almeida M, et al. Validation of a questionnaire (CARAT10) to assess rhinitis and asthma in patients with asthma. Allergy. 2010;65(8):1042–8. https://doi.org/10.1111/j.1398-9995.2009.02310.x.

    Article  CAS  PubMed  Google Scholar 

  38. Roxo JP, Ponte EV, Ramos DC, et al. Portuguese-language version of the Asthma Control Test. Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia. 2010;36(2):159–66.

    Article  Google Scholar 

  39. Collins GS, Reitsma JB, Altman DG, et al. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (tripod): the tripod statement. Ann Intern Med. 2015;162(1):55–63. https://doi.org/10.7326/M14-0697.

    Article  PubMed  Google Scholar 

  40. Hosmer D, Lemeshow S. Applied logistic regression. 2nd ed. New York: Wiley; 2000.

    Book  Google Scholar 

  41. Suissa S. Statistical treatment of exacerbations in therapeutic trials of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2006;173(8):842–6. https://doi.org/10.1164/rccm.200508-1338PP.

    Article  PubMed  Google Scholar 

  42. McDonald VM, Gibson PG. Inhalation-device polypharmacy in asthma. The Med J Aust. 2005;182(5):250–1.

    Article  Google Scholar 

  43. Sadowski CA, Cor K, Cave A, et al. Administration technique and acceptance of inhaler devices in patients with asthma or COPD. Ann Pharmacother. 2015;49(6):639–48. https://doi.org/10.1177/1060028015579097.

    Article  PubMed  Google Scholar 

  44. Galffy G, Mezei G, Nemeth G, et al. Inhaler competence and patient satisfaction with Easyhaler(R): results of two real-life multicentre studies in asthma and COPD. Drugs R&D. 2013;13(3):215–22. https://doi.org/10.1007/s40268-013-0027-3.

    Article  CAS  Google Scholar 

  45. Pinnock H, Ostrem A, Rodriguez MR, et al. Prioritising the respiratory research needs of primary care: the International Primary Care Respiratory Group (IPCRG) e-Delphi exercise. Primary Care Respir J Gen Pract Airways Group. 2012;21(1):19–27. https://doi.org/10.4104/pcrj.2012.00006.

    Article  Google Scholar 

  46. Takemura M, Kobayashi M, Kimura K, et al. Repeated instruction on inhalation technique improves adherence to the therapeutic regimen in asthma. J Asthma Off J Assoc Care Asthma. 2010;47(2):202–8. https://doi.org/10.3109/02770900903581692.

    Article  Google Scholar 

  47. Freitas Ferreira E, Pascoal A, Silva P, et al. Inhaler training and asthma knowledge are associated with a higher proportion of patients with correct inhaler technique in young but not in elderly asthmatic patients. J Asthma. 2019. https://doi.org/10.1080/02770903.2019.1582063.

    Article  PubMed  Google Scholar 

  48. Maricoto T, Monteiro L, Gama JMR, 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. 2018. https://doi.org/10.1111/jgs.15602.

    Article  PubMed  Google Scholar 

  49. Pothirat C, Chaiwong W, Phetsuk N, et al. Evaluating inhaler use technique in COPD patients. Int J Chronic Obstr Pulm Dis. 2015;10:1291–8. https://doi.org/10.2147/copd.s85681.

    Article  CAS  Google Scholar 

  50. Dalcin Pde T, Grutcki DM, Laporte PP, et al. Factors related to the incorrect use of inhalers by asthma patients. Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia. 2014;40(1):13–20. https://doi.org/10.1590/s1806-37132014000100003.

    Article  Google Scholar 

  51. Beatty CR, Flynn LA, Costello TJ. The impact of health literacy level on inhaler technique in patients with chronic obstructive pulmonary disease. J Pharm Pract. 2017;30(1):25–30. https://doi.org/10.1177/0897190015585759.

    Article  PubMed  Google Scholar 

  52. Alismail A, Song CA, Terry MH, et al. Diverse inhaler devices: a big challenge for health-care professionals. Respir Care. 2016;61(5):593–9. https://doi.org/10.4187/respcare.04293.

    Article  PubMed  Google Scholar 

  53. Muchao FP, Perin SL, Rodrigues JC, et al. Evaluation of the knowledge of health professionals at a pediatric hospital regarding the use of metered-dose inhalers. Jornal brasileiro de pneumologia : publicacao oficial da Sociedade Brasileira de Pneumologia e Tisilogia. 2008;34(1):4–12.

    Article  Google Scholar 

  54. Gemicioglu B, Borekci S, Can G. Investigation of knowledge of asthma and inhaler devices in pharmacy workers. J Asthma Off J Assoc Care Asthma. 2014;51(9):982–8. https://doi.org/10.3109/02770903.2014.928310.

    Article  Google Scholar 

  55. Ovchinikova L, Smith L, Bosnic-Anticevich S. Inhaler technique maintenance: gaining an understanding from the patient's perspective. J Asthma Off J Assoc Care Asthma. 2011;48(6):616–24. https://doi.org/10.3109/02770903.2011.580032.

    Article  Google Scholar 

  56. Self TH, Hoth LM, Bolin JM, et al. Metered-dose inhaler technique per the global initiative for asthma and expert panel report 3. Ann Allergy Asthma Immunol. 2016;117(1):101–2. https://doi.org/10.1016/j.anai.2016.05.002.

    Article  PubMed  Google Scholar 

  57. Aguiar R, Lopes A, Ornelas C, et al. Terapêutica inalatória: Técnicas de inalação e dispositivos inalatórios. Revista Portuguesa de Imunoalergologia. 2017;25:9–26.

    Google Scholar 

  58. Puente-Maestu L, Calle M, Rodriguez-Hermosa JL, et al. Health literacy and health outcomes in chronic obstructive pulmonary disease. Respir Med. 2016;115:78–82. https://doi.org/10.1016/j.rmed.2016.04.016.

    Article  PubMed  Google Scholar 

  59. Crane MA, Jenkins CR, Goeman DP, et al. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ Prim Care Respir Med. 2014;24:14034. https://doi.org/10.1038/npjpcrm.2014.34.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Bouwmeester C, Kraft J, Bungay KM. Optimizing inhaler use by pharmacist-provided education to community-dwelling elderly. Respir Med. 2015;109(10):1363–8. https://doi.org/10.1016/j.rmed.2015.07.013.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Luís Teixeira, Family Doctor at Senhora de Vagos Family Health Unit and Tiago Lopes, Family Doctor at Baía Family Health Unit, for their collaboration as investigators during the conduct of the study. These colleagues were involved in the recruitment of participants and data collection only, but had no involvement in study design, data analysis or writing of this manuscript.

Author information

Authors and Affiliations

  1. Aveiro-Aradas Family Health Unit, Aveiro Healthcare Centre, Aveiro, Portugal

    Tiago Maricoto & Duarte Santos

  2. Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal

    Tiago Maricoto

  3. Flor de Sal Family Health Unit, Aveiro Healthcare Centre, Aveiro, Portugal

    Catarina Carvalho & Inês Teles

  4. Life and Health Sciences Research Institute (ICVS)/3B’s-PT Government Associate Laboratory, University of Minho, Braga, Portugal

    Jaime Correia-de-Sousa

  5. Horizonte Family Health Unit, ULS Matosinhos, Matosinhos, Portugal

    Jaime Correia-de-Sousa

  6. CICS-Health Sciences Research Centre, University of Beira Interior, Covilhã, Portugal

    Luís Taborda-Barata

  7. CACB-Clinical Academic Center of Beiras, Covilhã, Portugal

    Luís Taborda-Barata

  8. Department of Allergy and Clinical Immunology, Cova da Beira University Hospital Centre, Covilhã, Portugal

    Luís Taborda-Barata

  9. USF Aveiro-Aradas, Praceta Rainha D. Leonor, 3800, Aveiro, Portugal

    Tiago Maricoto

Authors
  1. Tiago Maricoto
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Duarte Santos
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Catarina Carvalho
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Inês Teles
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jaime Correia-de-Sousa
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Luís Taborda-Barata
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

TM, LT-B and JC-S contributed on the study design, conduction and monitoring, on data analysis and manuscript review. TM contributed on patient recruitment and writing of the first draft of the manuscript. DS, CC and IT contributed on study conduction, participant recruitment, data analysis and manuscript review. LT-B and JC-S had full access to all of the data in the study and are the guarantors for the integrity of the data and the accuracy of the data analysis.

Corresponding author

Correspondence to Tiago Maricoto.

Ethics declarations

Conflict of interest

There is no conflict of interests to declare.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 343 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Maricoto, T., Santos, D., Carvalho, C. et al. Assessment of Poor Inhaler Technique in Older Patients with Asthma or COPD: A Predictive Tool for Clinical Risk and Inhaler Performance. Drugs Aging 37, 605–616 (2020). https://doi.org/10.1007/s40266-020-00779-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40266-020-00779-6

Search

Navigation