Picking the right device is so important

The Brussels Declaration, published in the European Respiratory Journal in 2008 recognises the high prevalence of patients with poorly controlled asthma and calls for changes in asthma management across Europe. Prescribing an appropriate inhaler device for asthma, a device that the patient accepts and can handle correctly, is one key element in this process. Inhaler mishandling is very common in real-world clinical practice and can contribute to poor asthma control The International Primary Care Respiratory Group (IPCRG) is committed to identifying reasons for poor asthma control and to promoting interventions to help patients achieve asthma control. An international panel of healthcare providers (HCPs), academics and a patient representative was convened under the auspices of IPCRG to discuss and challenge the science behind inhaler therapy, and to propose practical solutions to real-life problems related to inhaler choice and mishandling. The focus was on the problems confronting clinicians in prescribing a suitable inhaler for each individual and those confronting patients in using their inhalers.

Editorial in the EUROPEAN RESPIRATORY JOURNAL by A. Papi et al discussed these problems and the choice of appropriate devices for patients. The authors stated that:

‘Drug choice is usually the first step in prescribing inhaled therapy for asthma and, together with availability and reimbursement criteria, dictates the inhaler device options. The next two steps, choice of inhaler device type and patient training in use of the inhaler, are hampered by the lack of robust evidence or effective tools to aid HCPs . Patients with severe airway obstruction, as well as young children and the elderly, may be unable to inhale with sufficiently fast acceleration for DPIs for which inspiratory flow is the only driving force. Conversely, a common problem with the use of MDIs is too fast an inhalation which results in difficulty coordinating actuation with inhalation, and increased oropharyngeal impaction.’

Inhalation technique is something that is seen as a regular problem in practice but maybe not in RCTs, this point was taken up by the authors:

‘Some patients have coordination problems with MDIs but otherwise have anappropriate speed of inhalation may benefit from being prescribed a breath-actuated MDI (BAI) , but the use ofBAIs can be limited by the available range of drug content. Moreover, although MDIs were the first devices to be studied, poor technique is also a concern with BAIs and DPIs.

The authors acknowledged that maintaining good technique may be difficult:

‘Other clinical challenges include helping patients to maintain inhaler technique once learned and stay motivated to continue regular therapy for asthma when recommended. Written or online supporting information is useful. Moreover, practical technology for patients to self-assess technique would be of value (e.g. a feedback mechanism built into the inhaler device to confirm correct inhalation).’

The authors concluded:

‘Our knowledge of pharmacological interventions in well-defined patient populations is substantial. The need to translate this knowledge into improved care of individual patients in real-life settings by individual clinicians is rightly attracting greater academic attention. Knowledge gaps in the design and performance of inhalers, the practice of prescribing inhalers, patient preferences, and issues around inhaler technique, all of which are fundamental and critical aspects of asthma management, remain substantial and must be addressed.’

Reference:

A. Papi, J. Haughney, J.C. Virchow, N. Roche, S. Palkonen and D. Price. Eur Respir J 2011; 37: 982–985