COPD Stakeholder Summit: Utilizing Peak Inspiratory Flow Rates to Individualize Treatment and Improve Outcomes - Episode 3

COPD and Inadequate Inhaler Use

Challenges associated with inadequate use of inhalers to treat chronic obstructive pulmonary disease and their impact on patients and the health care system.

Neil Minkoff, MD: One of the things we had already touched on was patients ending up in the hospital in the emergency department [ED], and the overall clinical and economic ramifications of the exacerbation. I was wondering if Dr Drummond and Dr Lopes could touch on how there is that intersection between inhaler use or inadequate inhaler use and what it means to those downstream outcomes both from a clinical and cost point of view.

M. Bradley Drummond, MD, MHS: I’m happy to jump in first. As I mentioned earlier, a substantial driver of health care utilization, and specifically COPD [chronic obstructive pulmonary disease] exacerbations, is related to inadequate disease control. Exacerbations are associated with increased cost, ED visits, hospitalizations, and the need for increased COPD therapies, which can have their own short- and long-term [adverse] effects. And as Dr Mahler mentioned, the other factor here is that exacerbations can lead to declines in lung function, which can lead to more exacerbations, which begins the COPD spiral, if you will, where these patients are stuck in a circle.

We know that inhaled therapies can reduce exacerbations when prescribed and used appropriately. We have large clinical trials dating back to 2007, and most recently in 2018 and 2020, that have shown that appropriate inhaled therapies can reduce the time to the next exacerbation and potentially reduce mortality. But the reality is that these devices only work if they’re prescribed and used properly.

The first issue about prescription is that there is an underdiagnosis of COPD. Smokers with respiratory symptoms are told they have bronchitis, or are just out of shape, or getting old. Maybe they’re told it’s their heart issues. They never get any spirometry testing to confirm the diagnosis of COPD and ultimately start the therapies. That’s the first piece of the puzzle in my mind.

The second piece of the puzzle happens to deal with the complexity of the devices. The devices come in many forms and have different techniques to ensure proper drug delivery. Critical errors—those that compromise drug delivery—can occur in as much as nearly 50% of inhalation assessments in some studies. These can include things like not inhaling through the device, blowing on a device that has a powder that’s ready to be inhaled, insufficient inhalation duration or force, such as peak inspiratory flow, not inserting the capsule into the device, or not having synchrony between the hand actuation and the inhalation. These critical errors related to the device, or the lack of sufficient device prescription, can certainly impact our health care utilization in COPD.

Neil Minkoff, MD: Dr Lopes, that also has been part of the work you’ve done around population health.

Maria Lopes, MD, MS: Absolutely. I couldn’t agree more. The best drug in the world is not going to work unless it’s adhered to and taken properly. On the issue of incorrect inhalation technique, how do we capture this information? This is now an area of interest with some digital devices and solutions that can help enhance what we know about the patient and hopefully lead to better, more targeted, and more timely education to correct some of these critical errors that may lead to hospitalizations.

As Dr Drummond mentioned, we know that incorrect inhalation techniques are associated with as much as a 50% increased risk of hospitalizations, ED [visits], and oral corticosteroids. So, how do we identify these? How do we correct for them? It becomes critically important for clinicians, at the time of an office visit, to be able to review somebody’s adherence patterns, medications, what they have been on, and what they have missed. It’s also critically important to rapidly identify if you have an adherence problem, a technique issue, or an efficacy issue to be able to escalate treatments appropriately and overcome some of the clinical inertia.

It’s all critically important in order to enhance, not only patient engagement, but clinician engagement and the proper treatment of patients with COPD.

Neil Minkoff, MD: Somebody build on that a little bit. Mr Hess, you spend a lot of time working directly with patients on their appropriate inhaler usage and other medication usage. What tools do you use with that? And how do you use something like a PIF [peak inspiratory flow rate] to try to help your patients understand where they are?

Michael Hess, MPH, RRT, RPFT: That’s a great point. I want to highlight that the rate of these critical errors, as Dr Drummond mentioned in his piece, has essentially stayed the same for about 40 years. There have been a couple of meta-analyses that have come out that tell us that we have previously not done a great job of educating. Now, we do have new tools that are coming out, the smart inhalers. We have some other devices that we can use to monitor metered dose inhaler technique, in addition to the peak inspiratory flow meters that Dr Mahler has mentioned. We can look very closely at how people are interacting with their devices. That does a great job with helping people adhere to their medications as well. Most people aren’t going to do something if they don’t feel it works. But if we can demonstrate to them perhaps why it’s not working, or identify gaps in our instruction, then we can give them the tools they need to be successful.

This activity is supported by an educational grant from Boehringer Ingelheim.