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PHARMACY PRACTICE TRAINING
You may be familiar with the episode of the TV series House, where a
patient complains that her asthma medication isn’t working.
When asked to demonstrate her inhaler
technique, the patient promptly
sprays her neck as if she’s spraying
perfume! I’m sure this scene resonates
with everyone, its comic intent aside.
Studies show that up to 94% of asthma
and chronic obstructive pulmonary
disease (COPD) patients use metered
dose inhalers (MDIs) and dry powder
inhalers (DPIs) incorrectly.
the newer DPI devices are more
user-friendly, as they don’t require
hand–breath coordination, patients still
have high incorrect technique rates.
DPIs need an inspiratory flow rate of
between 30 and 90 L/min for dose
actuation,5 depending on device, and a
common error is not breathing in deeply
enough or with enough force to deliver a
COPD and asthma are treatable diseases,
but incorrect use of inhaler devices
means that patients are not receiving the
optimal benefits of their medications.
Between 28 and 68% of patients are
reported not to use their inhalers well
enough to benefit from the prescribed
medication.5 This compromises
patients’ quality of life and long-term
outcomes, resulting in suboptimal
disease control and increasing the risk
of unnecessary increases in medication
dosage, hospitalisations, exacerbations
requiring oral corticosteroid treatment,
and potential side-effects.
Error rates in inhaler technique tend to
increase with both age and severity of
which is particularly
significant for COPD treatment.
In Australia, COPD affects an estimated
7.5% of people aged 40+ years, increasing
to almost 30% in people 75 and over.8
Patients with severe COPD may also
not have an adequate inspiratory flow
rate to activate DPIs, even with correct
inhaler technique,6 or may receive a
Newer inhaler devices
like the Respimat Soft MistTM Inhaler,
which generates an aerosol cloud
that is independent of the patient’s
inspiratory effort, help address this
10 An active press and breathe
device, it releases the aerosol cloud
11,12 which also reduces the need to
coordinate actuation with inspiration.
With high patient error rates with
currently available inhalers and more
devices in the pipeline, it is clear that
inhaler technique and appropriateness
of the device for the patient needs to
be reviewed regularly. The pharmacist
is ideally positioned to do this as
well as providing education on these
medications, due to their regular
contact with patients when dispensing
prescriptions and unique role as
overseers of quality use of medicines.
Numerous studies show that inhaler
technique interventions work6
including community pharmacy
interventions.2,13–15 The National Asthma
Council now recommends that patients’
inhaler technique is checked at each
encounter. They advise getting patients
to demonstrate their technique, which is
checked against a device-specific list of
steps. Any identified errors in technique
can then be corrected by repeated
instruction and demonstration.
In the following CPD article we look
at the practicalities of achieving this
in the pharmacy setting. Hopefully,
the end result will be better medication
adherence and health outcomes for your
patients, as well as adding value to your
1. F. Lavorini, A. Magnan, J. Christophe Dubus et al. Effect of
incorrect use of dry powder inhalers on management of
patients with asthma and COPD. Respir Med 2008; 102:
2. I.A . Basheti I, C.L . Armour, S.Z . Bosnic-Anticevich, H.K . Reddel.
Evaluation of a novel educational strategy, including
inhaler-based reminder labels, to improve asthma inhaler
technique. Patient Educ Couns 2008; 72: 26–33 .
3. A.S. Melani, M. Bonavia, V. Ciletni et al. Inhaler mishandling
remains common in real life and is associated with reduced
disease control. Respir Med 2011; 105: 930–8 .
4. V. Giraud, N. Roche. Misuse of corticosteroid metered-dose
inhaler is associated with decreased asthma stability. Eur
Respir J 2002; 19: 246–5 .
5. J.B. Fink, B.K . Rubin. Problems with inhaler use: a call for
improved clinician and patient education. Respir Care 2005;
6. National Asthma Council Australia. Inhaler technique in
adults with asthma or COPD. National Asthma Council
Australia, Melbourne, 2008.
7. S. Wieshammer, J. Dreyhaupt. Dry powder inhalers: which
factors determine the frequency of handling errors?
Respiration 2008; 75: 18–25 .
8. Toelle BG, Xuan W, Bird TE et al. Respiratory symptoms and
illness in older Australians: the Burden of Obstructive Lung
Disease (BOLD) study. Med J Aus 2013; 198: 144–8.
9. J.L . Rau. Practical problems with aerosol therapy in COPD.
Respir Care 2006; 51: 158–72.
10. R. Dalby, M. Spallak, T. Voshaar. A review of the development
of Respimat Soft Mist inhaler. Int J Pharm 2004 Sep 28;
11. D. Hochrainer, H. Hölz, C. Kreheret al. Comparison of the
aerosol velocity and spray duration of Respimat® Soft MistTM
Inhaler and pressurized metered dose inhalers. J Aerosol
Med. 2005;18: 273–82.
12. F. Lavorini. The challenge of delivering therapeutic aerosols
to asthma patients. ISRN allergy 2013; http://dx.doi.
13. Mehuys E, Van Bortel L, De Bolle L et al. Effectiveness of
pharmacist intervention for asthma control improvement.
Eur Respir J 2008; 31: 790−9 .
14. N.J. Gray, N.C . Long, N. Mensah. Report of the Evaluation
of the Greater Manchester Community Pharmacy Inhaler
Technique Service, 2014.
15. E. Tommelein, E. Mehuys, T. van Hees et al. Pharmaceutical
care for patients with chronic obstructive pulmonary
disease (PHARMACOP): a randomized controlled trial. Br J
Clin Pharmacol 2013; 77: 756–66 .
16. National Asthma Council Australia. Australian Asthma
Handbook, Version 1.1 . National Asthma Council
Australia, Melbourne, 2015. Available from: http://www.
Be proactive in
PBS information: Restricted benefit. Chronic obstructive pulmonary disease.
Please review Product Information before prescribing. Full Product Information
is available at files.boehringer.com.au/files/PI/Spiriva%20Respimat%20PI.pdf
Further Information is available from Boehringer Ingelheim Pty Ltd.
SPIRIVA® RESPIMAT® (tiotropium bromide) solution for inhalation. INDICATIONS: COPD: Long term maintenance treatment of bronchospasm and dyspnoea associated
with chronic obstructive pulmonary disease (COPD). Prevention of COPD exacerbations. Asthma: Add-on maintenance bronchodilator treatment in adult patients with
asthma, currently treated with the maintenance combination of inhaled corticosteroids (≥800 μg budesonide/day or equivalent) and long-acting ß2 agonists and who experienced
one or more severe exacerbations in the previous year. CONTRAINDICATIONS: Hypersensitivity to tiotropium bromide, atropine or its derivatives, or to any of the excipients.
PRECAUTIONS: Should not be used for: treatment of acute episodes of bronchospasm, relief of acute symptoms, first-line treatment for asthma. Immediate hypersensitivity
reactions, narrow-angle glaucoma, prostatic hyperplasia, bladder-neck obstruction, urinary retention, micturition difficulties, dry mouth, inhalation-induced bronchospasm, recent
myocardial infarction (<6 months), unstable or life-threatening cardiac arrhythmia within past year, hospitalisation for heart failure within past year, moderate to severe renal
impairment (CrCL ≤50 mL/min), pregnancy, lactation, children. Avoid solution or mist entering eyes. INTERACTIONS: Co-administration with anticholinergic drugs.
ADVERSE EFFECTS: Common: Dry mouth, usually mild. Others, see full PI. DOSAGE: For oral inhalation. 5 μg tiotropium given as two puffs once daily, at the same time each day.
Do not exceed recommended dose. Cartridges to be used only with RESPIMAT inhaler. July 2015.
References: 1. Dalby R et al. Int J Pharm 2004; 283: 1–9. 2. McDonald V. Medicine Today 2015; 16 (Suppl.): 21–27. 3. SPIRIVA Respimat approved Product Information
(22 May 2015). 4. Zierenberg B. J Aerosol Med 1999; 12 (Suppl 1): S19–S24. 5. Respimat package insert (June 2015). 6. Hochrainer D et al. J Aerosol Med 2005; 18: 273–282.
7. Newman SP et al. J Aerosol Med 1999; 12: S25–31. 8. Hodder R et al. Int J Chron Obstruct Pulmon Dis 2009; 4: 225–232. 9. Schürmann W et al. Treat Respir Med 2005;
4: 53–61. 10. Kardos P et al. Eur Respir J 2005; 26(Suppl 49): 338s (abstract 2213). 11. Spallek M et al. Respiratory Drug Delivery 2002;
8: 375–378. 12. Wachtel H, Ziegler J. Respiratory Drug Delivery 2002; 8: 379–382.
TMTrademark. ®Registered Trademark. Boehringer Ingelheim Pty Ltd. ABN 52 000 452 308. 78 Waterloo Road, North Ryde, NSW 2113.
AUS/SPI-151454j. McCann Health SPR0585. SEPTEMBER 2015.
†Approx. 66% of the aerosol cloud is contained as fine
particles (<5.8 μm)1,4,11,12
Respimat: Precision engineered to
optimise lung deposition1,4,7
pMDI, pressurised metered-dose inhaler.
THE FIRST AND ONLY
SOFT MISTTM INHALER
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