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CONTINUING PROFESSIONAL DEVELOPMENT
Associate Professor Bandana Saini is a Senior Lecturer,
Pharmacy Practice, at The University of Sydney, NSW.
After reading this article, pharmacists should be
Describe the different types of inhaler devices
used for asthma management
Identify common errors in technique when using
Discuss counselling points with patients using
asthma inhaler devices.
Competencies addressed: 1.3 .1, 1.3 .2, 4.2 .3, 6.2 .1,
6.2.2, 6.2.4, 6.3.3.
Accreditation number: CAP160909A
Inhaler use in patients with
asthma – what research and
guidelines tell us
BY ASSOCIATE PROFESSOR BANDANA SAINI
Carol is a 39-year-old veterinary assistant, working in country New South Wales.
She was diagnosed with asthma 2 years ago. She has been prescribed Seretide
Accuhaler 250/50 one inhalation twice daily and Ventolin pMDI as needed.
Carol has come to see you today to get a
Ventolin inhaler. She tells you she always
uses her Seretide Accuhaler twice daily, and
uses her Ventolin pMDI most days. She does
not use a spacer with her Ventolin inhaler.
Her use of her Ventolin inhaler most days
suggests her asthma is not well-controlled
by her Seretide Accuhaler.
Carol’s inhaler technique
You decide to check Carol’s inhaler
technique. When you ask her how she is
going with her inhalers, she says: ‘I am
fine, I have been using these inhalers for
a couple of years’.
Issues with inhaler use
The inhaled route of medicine delivery is
the cornerstone of therapy in asthma and
other chronic lung conditions. Clinically,
the vast alveolar surface area available
for absorption, quicker and onsite action,
avoidance of the first-pass effect and
lower systemic levels of medicines, make
this route of delivery quite attractive.
The recent entry on the market of new
devices now allows reasonable choice
of device types to patients. These new
devices also offer several innovative
features, such as fewer steps required
for inhalation, ease of use, novel
methods of delivering the medicine,
or environmentally friendly inhalers.
Unfortunately, as most devices depend
on conscious effort by patients, there is
still a high proportion of patients who
do not obtain the maximum derivable
benefit from their medicine, due to
suboptimal inhaler use. For example,
two Australian studies conducted with
community pharmacy patients using
pressurised metered dose inhalers
(pMDIs) or dry powder inhalers (DPIs),
indicate that up to 90% of patients may
have suboptimal inhaler technique.
Studies elsewhere with patients using
pMDIs or breath-actuated MDIs indicate
a similar figure.3 Evidence suggests
that suboptimal inhaler technique is
associated with lower asthma control,
with a moderate effect on quality of
life. Significant improvements in inhaler
technique lead to significantly improved
In a large-scale study of 623 asthma
patients, 341 (55%) made one or more
serious inhaler technique errors in using
A demographic analysis of
these errors indicated that these patients
were also significantly more likely to have
been hospitalised for asthma over the
past year, have poor asthma control over
the past 4 weeks, be obese, be female,
and not have had an inhaler technique
review over the past year.
have shown young children, females, and
older adults (>64 years) are more likely to
use inhalers incorrectly.
study in patients with chronic obstructive
pulmonary disease (COPD) found that
even experienced users often made
critical inhaler technique errors.8
Poor inhalation technique is also quite
costly. An Italian study in patients with
asthma found that suboptimal inhaler
technique was associated with significantly
higher rates of hospitalisations, emergency
room visits, and pharmacological
treatments (steroids and antimicrobials).
A health economics study used these
results to estimate that inhalation errors
could be associated with an increase in
Italian national healthcare expenditure
of €44,104/year (around $65,000AUD/
year).9 Therefore, it is imperative that
inhaler technique be optimised in patients
prescribed or dispensed inhaler devices.
Types of inhalers
Although there are many different brands of
devices available, they can mostly be divided
COUNSELLING IN PRACTICE
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