Education of patients and healthcare providers is essential for effective management of COPD

Benefit from and adherence to inhalation therapy in asthma and COPD patients depend to an equal extent on the choice and the correct handling of the inhaler devices. This requires appropriate education of patients and healthcare providers, says Professor Walter G Vinken.

30 June 2010

Management of obstructive respiratory diseases including asthma and COPD can be successful only if devices used to deliver the appropriate medications are used properly, which requires appropriate education.

Failure to recognise this is likely a key factor contributing to unsatisfactory symptom control reported by a majority of patients despite the availability of effective drugs and numerous inhaler devices.

In his review[1] published in the Primary Care Respiratory Journal in March, Vincken describes the factors considered to be of key importance when choosing the most appropriate inhaler device for each individual COPD patient.

These include availability and affordability of the inhaled drugs and inhaler devices, the uniformity of inhaler devices when several drugs are inhaled, the ability of patients to handle the device correctly and, finally, patient preferences.

Vincken states that the prescribing clinician should not only take these factors into account when selecting the most appropriate drug/device combination but also provide comprehensive instructions for the correct handling of the device in addition to regularly reviewing the patient's inhalation technique.

Vincken is a member of the ADMIT Team[2], striving to improve asthma and COPD therapy by optimising the use of devices and ensuring the selection of the most suitable device for each patient. ADMIT has developed COPD-therapy adjustment and educational tools for patients and physicians which may help enhance treatment outcomes.

Choice of inhaler devices

The pharmacological treatment of COPD patients is based principally around inhalation therapy. Inhaler devices can be grouped into three categories according to the method used for drug dispersion:

  •  electrically-powered "wet" nebulisers;
  • standard (with or without spacers) and breath-actuated mechanically driven pocket-sized inhalers pMDIs; and
  • the dry powder inhaler DPIs.

The devices differ in terms of their drug delivery characteristics, reliability, consistency and ease of use and thus there is considerable scope for tailoring the devices to individuals.

While for the majority of patients the choice of drug used for treatment is reasonably straightforward, selecting the appropriate delivery device for an individual COPD patient is more complicated.

 The primary factors when determining the choice of an inhaler device should be the efficacy and safety of the device. However, according to Vincken other factors should be considered. Since different drugs are available in various types of inhaler, attention should be paid to consistency of inhaler choice.

The use of multiple inhaler types confuses the patient and increases the risk of handling errors. Taking several drugs with the same inhaler device is likely to enhance the patient's ability to use the device properly. In acute situations, the pMDI-spacer combination or nebuliser treatment is recommended, while hand-held, pocket sized pMDIs or DPIs may be preferred for chronic maintenance.

Ageing critically affects handling of inhaler devices

COPD is a disease which becomes apparent in middle-aged current and ex-smokers and predominantly affects elderly people. Ageing can affect the patient's cognitive and physical abilities which in turn influence their ability to handle inhaler devices correctly and to retain inhaler technique.

According to Vincken, incorrect use of inhalers is common for both pMDIs and DPIs, and is most clearly associated with increasing age, lower levels of education and less instruction by health care providers. Inhaler handling errors double in patients over 60 years of age, and quadruple in those over 80 years compared to younger patients.

 Training by the healthcare provider more than halves the overall error rate. COPD patients have more problems with effective co-ordination than do healthy people or younger patients. They appear to make fewer device-handling errors when using a DPI than with a pMDI, even when using the pMDI in combination with a large spacer.

One of the reasons for this is that patients have difficulties assembling the pMDI with the spacer. According to Vincken, ageing and reduced hand-inhaler coordination should therefore be taken into account when choosing the appropriate inhaler device.

Attention to patient preferences and education enhance treatment outcomes

Many patients derive incomplete benefit from their inhaled medication because they do not use their inhalers regularly or correctly. Technique may deteriorate with time without regular training.

 According to Vincken, patients are unlikely to use a device properly and regularly unless they feel comfortable with it, know how to use it properly and come to trust it even if their own respiratory capacity and handling skills are limited. Factors rated as particularly important by patients included speed and ease of use and the presence of a dosage counter.

In VinckenĀ“s opinion, efficacious and safe administration of drugs may enhance patient adherence. Providing patients with a device which they find easy to use properly is as important as the drug itself. Hence, according to Vincken, the patient should be involved in the choice of the inhaler device.

The physician's initial role in the management of COPD is to carefully select the most appropriate drug-device combination for the patient. It is a permanent role and commitment, however, that the physician ensures that the patient knows how to use the device to its most efficient extent and that this knowledge is reviewed regularly.

Many healthcare providers are not however themselves familiar with the correct usage of every device available, or know how to tailor a particular device to a particular patient's capability. Detailed instructions on the handling of devices are appropriate, therefore, not only for patients but for their carers as well.

ADMIT: New web based service and educational material

Despite the awareness of the importance of inhaler choice and patient education in COPD therapy, the published COPD management guidelines pay little attention to these criteria.

International experts of ADMIT, therefore, developed several tools and service materials in order to facilitate inhaler choice and patient education and to increase therapy success.

The three-part COPD therapy adjustment regimen is a summary of the key principles behind the evidence-based management of stable COPD. It offers physicians a rapid and user-friendly overview of the requirements for COPD therapy, starting with making a diagnosis to optimising therapy in follow-up appointments.

This comprises everything from providing check-lists for disease assessment and recommendations for reducing risk factors to selecting the proper inhalers and performing continuous checks on issues such as compliance and inhaler technique.

Information on COPD therapy adjustment can be found on the ADMIT web page:

Interactive online course

The interactive online course on the educational aspects of COPD, developed by ADMIT member Prof. Lorenzo Corbetta offers suggestions as to how to organise a complete doctor-patient consultation.

The web-based video is divided into several sections: differential diagnosis, classification of severity, elimination of risk factors, treatment based on severity, and key considerations for device selection. Physicians can test their knowledge by answering multiple choice questions and then receiving direct feedback and explanations regarding the proper procedure.

The video also compares the advantages and disadvantages of the most common inhaler devices and demonstrates the correct way of using these inhalers. The COPD flash is intended as a presentational point of reference during a consultation and can serve as a basis for the patient/doctor consultation.

Product search

With the help of an anchored databank (features-based product search) on the ADMIT internet platform, the physician can apply different search criteria to aid the selection of the most suitable inhaler device for specific patients.

Search criteria include important intrinsic characteristics of devices such as high deposition of the active ingredient in the lungs, precise and constant dosage regulation and lack of dependence on inspiratory flow rate, but also include patient oriented criteria such as user-friendliness or the provision of patient feedback to reassure that the correct dosage has been delivered.

Factors influencing the selection of the delivery device[3]

  • Efficacy and safety
  • Availability of device and drug
  • Clinical setting
  • Age of patient
  • Ability to use the selected device
  • Ability to use device with multiple medications
  • Cost and reimbursement
  • Drug administration time
  • Convenience in both outpatient and inpatient settings
  • Patient preference

Professor Walter G. Vincken
Walter G. Vincken is a Professor of Respiratory Physiology, Respiratory Pathophysiology and Pulmonary Medicine, Faculty of Medicine, University of Brussels. He is a member of ADMIT, a consortium of European respiratory physicians with expertise in inhalation therapy. ADMIT reviews published evidence to examine ways of improving the treatment of obstructive pulmonary airway diseases in Europe. Vincken is convinced that apart from the inhaled drugs themselves, benefit from and adherence to inhalation therapy in asthma and COPD patients depend to an equal extent on the choice and the correct handling of the inhaler devices. Together with the ADMIT group, he aims to enhance the interest of patients, doctors and their instructors in this much neglected aspect of asthma and COPD therapy.


1. Vincken et al. on behalf of ADMIT, Primary Care Respiratory Journal (2010); 19(1): 10-20.

2. European Aerosol Drug Management Improvement Team.

3. Dolovich et al. Chest 2005; 127:335-71.

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