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
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
In his review 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, 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
- 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
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
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
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
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
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 Vincken´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
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
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.
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
- 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.