Expert discussion:
Reaching proper utilization of devices
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) provides clear guidance for selecting medication for COPD; however, there is no clear guidance for device selection. These simple steps may help select the device that is best suited for the patient.
Share this story
Some alarming facts about device use in COPD
Device selection may be part of the problem
There are clear guidelines (GOLD) on which medication is appropriate for which patient depending on symptoms and risk for exacerbation.3 This helps make decision-making easier for clinicians and helps ensure optimal medication selection. In contrast, there are no official guidelines regarding device selection. The guidelines briefly mention the importance of measuring the patient’s physical and cognitive ability to use the selected device but do not provide specific guidance on how to perform these evaluations and what to assess in these specific areas.3 Is a nebulizer appropriate? Which type of inhaler is best? Physicians who treat COPD are left to solve this on their own. Literature exists that can be helpful, and device manufacturers can be a useful source of information, but this still leaves the prescribing physician to sift through this information on their own. This issue is compounded by the fact that device selection is not “owned” by a consistent stakeholder. Sometimes the primary care physician makes the decision, sometimes it is the pulmonologist. Device ownership can fall on practically any member of the extended COPD care team. Finally, not all members of the COPD care team are adequately trained on device use.4
Who ensures proper nebulizer use2
Pulmonologists report:
DME: 45% Pulmonologist: 33% Other respiratory care practitioner: 32% Nurse: 31% Pharmacist: 13% No one: 8% Not sure: 7%
Patients report:
Pulmonologist: 32% No one: 28% Nurse: 26% Respiratory therapist: 22% DME: 9% Pharmacist: 7% Not sure: 3%
This process is clearly not ideal, and it may help explain the high error rates among patients.
Basic principles of device selection
To provide guidance to COPD treaters on device selection, Joanne Allen and Cheryl Nickerson have provided some basic selection criteria. These principles are intended to inform decisions and hopefully better meet the needs of the patient.
Use GOLD’s ABCD grading system, which was first introduced in 2011 to assess severity of COPD. The ABCD system provides recommendations on what class of medications to use depending on where the patient falls in the system. Other factors that may determine which medication to use are access to the medication and cost.
Measure peak inspiratory flow rate. Certain devices, like dry-powder inhalers, require a minimal inspiratory flow rate to achieve clinical effectiveness and may not be appropriate for all patients.5 The ability to generate an adequate peak inspiratory flow also decreases as COPD severity increases.3 Peak inspiratory flow rate may need to be re-evaluated in the future as a patient’s disease progresses.3
Assessing the patient’s actual ability to use the device will be essential to success. Factors such as coordination, manual dexterity and cognitive ability can be barriers for certain devices. Devices that require multiple steps to prepare for drug delivery may also lead to confusion and possible errors in patients who have limited or no experience with medical devices. Keep in mind that patients often begin using their device days after training in the physician’s office. The key is to keep it simple.
Taking into consideration the factors from steps 1 to 3, keep in mind that all medication delivery devices have pros and cons, and all devices may be appropriate for drug delivery as long as the patient can use them correctly. Consider the following regarding each device type.
Dry-powder inhalers (DPI)
- Each device will have different priming, and preparation requirements – which may lead to health care practitioner and patient confusion
- Breath-actuated – which means a minimal inspiratory flow will be required with each device
- A breath hold is required to optimize medication delivery.
- May result in higher oropharyngeal drug deposition, which can lead to increased medication side effects and poor clinical effectiveness
- If exposed to moisture, some clumping of the powder may occur in the inhaler
Does the patient have the ability to generate the minimal inspiratory flow for adequate medication delivery?
Will the patient have any issues remembering the multiple steps required to use the device adequately?
How comfortable are they using this system to dispense their own medication?
Because inspiratory muscle weakness may change overtime, inspiratory flow requirements should be re-evaluated at each patient health care practitioner interaction.3
Metered-dose inhalers (MDI) with or without a spacer
- Requires priming with first use and after several days of not being used
- MDI requires hand and breath coordination
- A breath hold is required to optimize medication delivery
- MDIs that are used without a spacer may result in high oropharyngeal deposition, which can lead to medication side effects and poor clinical effectiveness
- Often used with a spacer to improve drug delivery for patients with hand-breath coordination issues
- The spacer removes the larger particles that would be deposited in the mouth and throat
- The spacer may have an auditory cue to alert patients if their inspiratory flow is too high
- Actuator on inhaler and spacer require periodic cleaning
How comfortable are they dispensing their own medication?
How coordinated are they in taking their MDI? Is a spacer required?
Nebulizers
- Old-style nebulizers that are big and bulky have given way to portable, streamlined, battery-operated, portable devices such as mesh nebulizers
- Treatment times are shorter than in the past and require less preparation
- No special breathing maneuver or breath hold is required—tidal breathing is effective for medication delivery
- Choice of mask or mouthpiece
- Require cleaning and may require maintenance
- Tubing and nebulizer cups require replacement to optimize medication delivery
Does the patient prefer nebulized treatments?
Does their cognitive functioning limit the use of other medication devices?
Though treatment times have reduced with newer technology, are they willing to spend a minimum the 3-4 minutes required to deliver their therapy? *times may vary depending on nebulizer
How comfortable are they using a nebulizer?
If frequent treatments are required, the patient is mobile and nebulizer is preferred, consider a small portable mesh nebulizer for use when the patient is away from home.
Soft-mist inhalers
- Newer type of inhaler that uses mechanical features to actuate the medication
- Still requires some coordination (press and breathe)
- Requires priming for first use and after periods of not being used
- No studies have been completed to support use of a spacer with these devices
Does the patient have the dexterity to use the device correctly?
How comfortable are they using this system to dispense their medication?
Medication adherence is just as important as all the other factors discussed. If the physician selects a medication delivery device that the patient is unwilling to use, this may lead to nonadherence and poor outcomes. Including the patient in the device selection process may improve learning as well as use of the device and adherence to medication regimes.
During every follow-up visit, it is important to re-assess the patient and equipment. Re-evaluate device choice and probe carefully to see if the patient is using the device properly. Based on that assessment, adjust device selection accordingly.
A final consideration
Readmissions are a key concern when it comes to COPD management. Readmissions can be an important indicator of suboptimal disease management—and they place a heavy burden on healthcare institutions. Consider this finding from an article recently published in the Annals of the American Thoracic Society:
Incorrect inhaler use was ”a direct predictor of 30- and 90-day readmission following hospitalization due to acute COPD exacerbation (P=0.041)6
This may suggest that proper device use is of central importance in successful COPD management. Better device selection and continuous re-evaluation of device technique is an important part of overall COPD management.3
Further reading
References
1. Melani AS, Bonavia M, Cilenti V, et al; Gruppo Educazionale Associazione Italiana Pneumologi Ospedalieri. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011;105(6):930-938.
2. Braman S. COPD and inhalation devices: pulmonologists’ and patients’ knowledge, attitudes, beliefs and behaviors. American Thoracic Society webinar. May 2, 2017. Available at: http://news.thoracic.org/upcoming-webinar-on-copd-and-inhalation-devices/.
3. Global Initiative for Chronic Obstructive Lung Disease. Pocket Guide to COPD Diagnosis, Management, and Prevention: A Guide for Health Care Professionals. 2017 edition. Available at: goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf. Accessed October 19, 2017.
4. Plaza V, Sanchis J. Medical personnel and patient skill in the use of metered dose inhalers: a multicentric study. Respiration. 1998;65(3):195-198.
5. Gardenhire DS, Ari A, Hess D, Myers TR. A Guide to Aerosol Delivery Devices for Respiratory Therapists. 3rd edition. American Association for Respiratory Care. Irving, Texas; 2013.
6. Loh CH, Peters SP, Lovings TM, Ohar JA. Suboptimal inspiratory flow rates are associated with chronic obstructive pulmonary disease and all-cause readmissions. Ann Am Thorac Soc. 2017;14(8):1305-1311.
