Inhaler technique informs health care outcomes in COPD management and should be a primary focus in patient education priorities.
Jeffrey D. Dunn, PharmD, MBA: [Let’s talk about] patient perspective and adherence. We’ve talked about how dosing and the delivery device are much more complex and cumbersome in this area than for [managing] hypertension, where [patients are] taking 2 or 3 tablets but taking them once a day….What are some strategies that you’ve used to minimize this medication dosing issue and how does it impact a patient’s everyday life?
Mike Hess, MPH, RRT, RPFT: It comes down to education. We’ve talked about that a couple of times. You have to employ that. We talked a little…about a motivational interviewing approach where [you ask], “What are your goals? How do we get you to do the things that you want to do?” I frequently joke with [patients] that I know somebody with COPD [chronic obstructive pulmonary disease] who has run a couple of marathons, and I don’t think I can get you to that point, but if you buy into what I’m selling, then I can probably get you to walk around the park or walk around with your dog for a little while and not get quite short of breath.
Once we get them [to think], “Yes, this is a therapy that I can do,” then we start getting into teaching inhaler technique, making sure [patients] know how to use their inhalers, when to use their inhalers, when to use their controller and long-acting ones vs short-acting ones to get them out of a jam. Again, understanding their symptoms. We talked about the action plan earlier. It comes down to a lot of that discussion. I sound like a broken record, but I share that decision-making process and ask, “Is this something you’re comfortable with? Is this something that you feel is going to help you? Are you willing to give it a shot for a month or 3 or whatever the follow-up period is? Then if it doesn’t work, we can try something else.” It depends on building up that relationship and that level of trust so that they’re willing to cooperate.
Jeffrey D. Dunn, PharmD, MBA: We do the inhaler technique education [to make sure] they’re doing it correctly. Should we be doing that every 6 months or every year? It varies, but that’s an obvious question or issue, that this isn’t a one-and-done type of education approach.
Mike Hess, MPH, RRT, RPFT: That’s absolutely correct. There’s a growing body of research about the idea of technique decay, where you can train somebody to use it and they’ll demonstrate proper technique and get their full load of medication, and then 3, 6, or 12 months down the road, they’ll have completely forgotten how to use the thing. They’ll have 3 critical errors and everything will either go out into the air or in the back of their throat, and it isn’t going to do any good.
I had a fairly unique and special opportunity in which I could see [patients] on a monthly basis…in the primary care clinic until we got them solid with their technique. Then afterward I saw them—depending on their level of stability—every 3 to 6 months so that we could look at seasonal variations and things like that. But at every visit, we went over technique. I’d ask, “Do you know when to use these medications? How often are you using your short-acting ones?” It needs to be revisited regularly.
Courtney Crim, MD: It’s indeed critical. I’ve been amazed at some patients who use the inhaler very well when you initially teach them, but when they come back for a return visit, it’s as if they never learned the proper use of the inhaler. I agree that follow-up and having them demonstrate in the clinic their ability to use their inhaler is critical, because some patients can’t do it and some patients do it very well.
Jeffrey D. Dunn, PharmD, MBA: Not to overgeneralize or even stigmatize, but are there general predictors on who’s going to have worse inhaler technique? As far as things like age, education—going back to the social determinants of health—is there a patient type that we have to be more cognizant about?
Mike Hess, MPH, RRT, RPFT: I’d probably look at it from a slightly different perspective. There may be cohorts of patients who are more difficult to teach. But while these techniques are complicated, you can teach somebody to do it eventually. It may require you to do it over time. I had one person who I saw monthly for about 6 to 9 months. We did the inhaler technique each time, finally mastered it, and then let them go for about 3 months. Then they came back and, as Courtney was saying, they had completely forgotten how to use the thing. We did monthly visits again because we knew that was going to be the [solution].
It’s also going to depend on the type of device. Some of these devices are more complicated to use than others. [Patients] don’t like some of them. They may not like the taste of it or something like that. I don’t think there’s necessarily any particular group that’s going to have bad technique, but there are certainly groups that are going to take a little longer to teach the technique properly so that it sticks and that they’re comfortable with it.
Reynold Panettieri Jr, MD: I agree entirely, Mike. As a matter of fact, what I’m hearing is the adult learning technique called functional redundancy. If you don’t hear it 5 times during this podcast, then it isn’t important. The point is you have to reinforce. If you don’t reinforce, it’s like storytelling. If you look at stories over generations, the stories morph as people remember certain aspects and forget other aspects. It’s very important to teach and do functional redundancy.
Two other points I’d make is you have to do shared decision-making with drugs once a day vs twice a day. It’s very interesting. The older population feels that once a day isn’t enough medicine to take care of their illness, and they feel better when they get it twice a day. Even though the pharmacokinetics and everything else don’t speak to that, they want a drug twice a day rather than once a day. There are other [patients] who are very busy during the day and don’t want to use another drug at night, but you wouldn’t have known that a priori. From the hypertension data and literature, there’s no predictor of adherence. Education, socioeconomic status, race, ethnicity—none of those predict adherence, so you just don’t know.
Jeffrey D. Dunn, PharmD, MBA: That’s helpful. Where I was going with that was whether there’s a way to predict that as we build programs to intervene with these patients. Those were great answers. I want to dig into something that Mike touched on. But before I go there, to wrap this question up….Does it ever make sense to use multiple inhalers rather than a combination inhaler?
Reynold Panettieri Jr, MD: No. We touched on this before. The single reason to use multiple inhalers rather than 1 is that the MCO [managed care organization] doesn’t pay for it. If the co-pay is outrageous, no patient is going to use their medicine. Or worse, they’re going to drug ration. Instead of using it every day, they’re using it every other day. That’s probably the worst circumstance. [It’s important to] understand the financial situation of the patient. I’m not a fan of using multiple inhalers when there’s dual therapy in 1 inhaler. As Mike mentioned, it’s hard enough to get the inhaler technique consistent. Doing it across 2 devices—1 DPI [dry powder inhaler] vs 1 metered-dose inhaler [MDI]—becomes a prescription for disaster.
Mike Hess, MPH, RRT, RPFT: We have pretty clear data that tell us the more devices somebody has, the less likely they are to have good adherence, particularly if those devices are in the MDI vs DPI sense. If they have different techniques, [patients] are going to do 1 or both of them wrong or they aren’t going to stick with it. It’s pretty clear on that.
Transcript edited for clarity.