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What chance do patients have to manage their asthma and COPD properly when most healthcare professionals are unable to demonstrate how to use inhalers correctly?

LEARNING OBJECTIVE

After reading this article you should be able to:

€¢ Appreciate the important role pharmacy teams can play in ensuring patients are able to use their asthma and COPD inhalers correctly

EFFECTIVE MANAGEMENT of asthma and chronic obstructive pulmonary disease (COPD) depends on good inhaler technique. Yet despite a proliferation of devices €“ most recently the dry powder inhaler (DPI) Relvar Ellipta €“ patients often experience problems that undermine the effectiveness of these potentially lifesaving therapies. To add to their woes, most healthcare professionals don't get the technique right either. Now a new initiative aims to tackle this pervasive problem.

Numerous studies highlight the scale of the problem posed by poor inhaler technique. One review reported that only between 23 and 43 per cent of patients got all the steps right when using a metered dose inhaler (MDI). Just 55-57 per cent of those using a spacer with a MDI and 53-59 per cent of those using a DPI performed all the steps correctly¹.

Moreover, 10-15 per cent of people aged 20 to 40 years made a mistake using their DPI that affected the amount of drug they inhaled. This proportion increased to 40 and 60 per cent among people aged more than 60 and 80 years respectively².

They are not alone. According to Rita Bali, a pharmacist and executive development officer for Cambridgeshire and Peterborough LPC, 90 per cent of healthcare professionals (HCPs) cannot demonstrate inhaler technique correctly to their asthma and COPD patients.

A recent study revealed that just 7 per cent of 150 HCPs in primary and secondary care €“ including doctors, nurses and community pharmacy staff €“ got all seven steps needed for correct MDI technique right and showed appropriate, objectively measured, inspiratory flow. Only 9 per cent of the 113 HCPs who said they taught inhaler technique could demonstrate all seven steps³.

€Time and time again, poor inhaler technique emerges as an issue in the sub-optimal care of people with asthma or COPD,€ says Monica Fletcher, chief executive of the charity Education for Health. €Inhaler technique often gets forgotten, particularly when time is limited. Indeed, with so many people typically involved with the care of patients, many HCPs think that someone else has trained the patient. So community pharmacists and their staff have a vital role in improving inhaler technique.€

Training to make a difference

Effectively and efficiently training patients and professionals is essential to enhance inhaler technique and improve outcomes. Recently, for example, multi-disciplinary teams €“ including GPs, respiratory nurses and community matrons €“ on the Isle of Wight received training in inhaler technique. Community pharmacists who received MUR payments trained patients. After training, emergency admissions for asthma fell by 50 per cent (41 to 20 over three months) and deaths by 75 per cent, from eight to two over the same time. (To put these figures into context, the Isle of Wight's population is around 142,000.) Initial results also suggested that prescriptions for selective beta-agonist and corticosteroids declined by 25 and 5 per cent respectively €“ trends that seem to be continuing⁴.

90 per cent of HCPs cannot demonstrate correct inhaler technique to their patients

Against this background, a new programme developed by Napp Pharmaceuticals and Education for Health aims to both train HCPs in correct inhaler use and work with CCGs to audit outcomes.

During the training programme, Education for Health €concentrates on what's happening at a local level€ and prioritises teaching on inhalers that are in local formularies, says Monica Fletcher. Teaching sessions cover all the devices on the market, not just those sold by Napp. The meetings also look at ways to optimise the effectiveness of local primary healthcare teams, such as the interaction between practice nurses and pharm- acists. That said, there's a lot of ground to cover.

There are currently around 15 inhaler devices available and still more to come to market, says Monica Fletcher. €I believe we need innovation,€ she says, €but with so many available, it will get more and more confusing for HCPs and patients alike. The hope is, one day, a company will develop the perfect device but it seems we're not there yet. So pharmacists and other HCPs need to understand and be able to teach how to use a range of inhalers.€

Rita Bali agrees that community pharmacists need to keep up to date about the various inhaler devices. €Pharmacists should be the experts on new medicines. They should understand the subtle nuances of the different devices.€ Community pharmacists should use this expertise to aid the development of local formularies, she adds.

Piloting a new course in inhaler training

Pilot programmes with community pharmacists started last December in Gateshead, and Cambridgeshire and Peterborough CCG (see panel). €Community pharmacists generally have more contacts with patients than any other HCP,€ Rita Bali told Pharmacy Magazine, €so they are ideally placed to demonstrate inhaler technique to their patients. We received very good feedback from the participants.

€The meeting was over-subscribed and we plan to run further training sessions. There is definitely an interest in improving knowledge about inhaler technique and a recognition that intervention by community pharmacists can make a difference.€

Monica Fletcher adds that a pharmacist or other HCP should sign off on the patient's management plan that he or she has received inhaler technique training €“ something pharmacists could do during MURs or when counselling patients when they receive a new device.

€Checking inhaler technique improves the quality of the intervention without adding a burden to community pharmacists,€ says Rita Bali. Patients' ability to use an inhaler correctly gradually declines, so community pharmacists should check patients' technique €as often as possible, and certainly at least annually€, she says.

Monica Fletcher believes companies should offer more placebo inhalers and says HCPs also need anatomical teaching aids (e.g. images of lung deposition) to show the importance of the correct inhaler technique. She also believes there is a growing role for technology, such as an iPhone app that ensures people use the inhaler correctly by recording the breathing sound. €Patients often don't realise why good inhaler technique is so important,€ she comments.

€It is essential to ensure that asthma and COPD patients get the most benefit from drugs. A HCP wouldn't start a patient on insulin without explaining how to use a pen device. GPs, nurses and pharmacists need to take inhaler use much more seriously.€

_REFERENCES

_{1. Health Technology Assessment 2001; 5:26}

_{2. Lancet 2010; 376:803-13}

_{3. Thorax 2010; 65:A117}

_{4. Pharmacy management 2009; 25(3):15-19}