Does mixing inhaler devices lead to unchecked inhaler technique errors in patients with COPD? Findings from the cross-sectional observational MISMATCH study

Lars Dijk; Marjan Kerkhof; Merijn Driessen; Yoran H Gerritsma; Sinthia Bosnic-Anticevich; Jaime Correia-de-Sousa; P N Richard Dekhuijzen; Marika Leving; David B Price; Ioanna Tsiligianni; Omar Usmani; Huib A M Kerstjens; Janwillem W H Kocks

doi:10.1136/bmjresp-2023-001821

Does mixing inhaler devices lead to unchecked inhaler technique errors in patients with COPD? Findings from the cross-sectional observational MISMATCH study

BMJ Open Respir Res. 2023 Dec 22;10(1):e001821. doi: 10.1136/bmjresp-2023-001821.

Authors

Lars Dijk¹, Marjan Kerkhof¹, Merijn Driessen¹, Yoran H Gerritsma¹, Sinthia Bosnic-Anticevich^{2

3}, Jaime Correia-de-Sousa⁴, P N Richard Dekhuijzen⁵, Marika Leving¹, David B Price^{6

7}, Ioanna Tsiligianni⁸, Omar Usmani⁹, Huib A M Kerstjens^{10

11}, Janwillem W H Kocks^{12

7

11}

Affiliations

¹ General Practitioners Research Institute, Groningen, The Netherlands.
² Macquarie University, Sydney, New South Wales, Australia.
³ University of Sydney, Woolcock Institute of Medical Research, Sydney, New South Wales, Australia.
⁴ Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal.
⁵ Radboud University Nijmegen, Nijmegen, The Netherlands.
⁶ Centre of Academic Primary Care, Division of Applied Health Sciences, Univ Aberdeen, Aberdeen, UK.
⁷ Observational and Pragmatic Research Institute, Singapore.
⁸ Department of Social Medicine, Health Planning Unit, Faculty of Medicine, University of Crete, Rethimno, Greece.
⁹ Airway Disease, National Heart and Lung Institute (NHLI), Imperial College London, London, UK.
¹⁰ Department of Pulmonology, University Medical Center, Groningen, The Netherlands.
¹¹ University Medical Center Groningen, GRIAC Research Institute, Groningen, Netherlands.
¹² General Practitioners Research Institute, Groningen, The Netherlands janwillem@gpri.nl.

Abstract

Background: Patients with chronic obstructive pulmonary disease (COPD) may be prescribed multiple inhalers that require different techniques for optimal performance. Mixing devices has been associated with poorer COPD outcomes suggesting that it leads to inappropriate inhaler technique. However, empirical evidence is lacking.

Aims: Compare the nature and frequency of dry powder inhaler (DPI) technique errors in patients with COPD using (1) a single DPI or (2) mixed-devices (a DPI and pressurised metered dose inhaler (pMDI)).

Methods: Data from the PIFotal study-a cross-sectional study on Peak Inspiratory Flow in patients with COPD using a DPI as maintenance therapy, capturing data from 1434 patients on demographic characteristics, COPD health status and inhaler technique-were used to select 291 patients using mixed-devices. Frequency matching based on country of residence and DPI device type was used to select 291 patients using a DPI-only for comparison. Predetermined checklists were used for the evaluation of DPI video recordings and complemented with additional errors that were observed in ≥10%. Error proportions were calculated for the (1) individual and total number of errors, (2) number of critical errors and (3) number of pMDI-related errors.

Results: The study sample contained 582 patients (mean (SD) age 69.6 (9.4) years, 47.1% female). DPI technique errors were common, but not significantly different between the groups. The majority of patients made at least one critical error (DPI-only: 90.7% vs mixed-devices: 92.8%). Proportions of total, 'pMDI-related' and critical errors did not significantly differ between the groups.

Conclusion: The nature and frequency of inhaler technique errors did not substantially differ between patients prescribed with a single DPI and mixed-devices. Currently, 'pMDI-related errors' in DPI use are not accounted for in existing checklists.

Trial registration number: ENCEPP/EUPAS48776.

Keywords: COPD Pharmacology; Inhaler devices; Pulmonary Disease, Chronic Obstructive.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Administration, Inhalation
Aged
Cross-Sectional Studies
Dry Powder Inhalers
Female
Humans
Male
Metered Dose Inhalers / adverse effects
Pulmonary Disease, Chronic Obstructive*