Device use errors with soft mist inhalers: A global systematic literature review and meta-analysis

Abstract

Inhaled bronchodilators are the cornerstone of treatment for chronic obstructive pulmonary disease (COPD). Soft mist inhalers (SMIs) are devices that deliver bronchodilators. Although correct device use is paramount to successful medication delivery, patient errors are common. This global systematic literature review and meta-analysis examined device use errors with SMIs among patients with obstructive lung diseases. PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were searched to identify studies published between 2010 and 2019 that met the following inclusion criteria: (a) English language; (b) a diagnosis of COPD, bronchitis, or emphysema; and (c) reported device use errors among adults receiving long-acting bronchodilator treatment with Respimat® SMI (i.e. Spiriva®, Stiolto®, Spiolto®, and Striverdi®). Descriptive statistics examined sociodemographics, clinical characteristics, and device use errors. Meta-analysis techniques were employed with random-effects models to generate pooled mean effect sizes and 95% confidence intervals (CIs) for overall and step-by-step errors. The I² statistic measured heterogeneity. Twelve studies (n = 1288 patients) were included in this meta-analysis. Eighty-eight percent of patients had COPD, and most had moderate/very severe airflow limitation (Global Initiative for Chronic Obstructive Lung Disease spirometric stages II to IV). Aggregate results revealed that 58.9% (95% CI: 42.4-75.5; I² = 92.8%) of patients made ≥1 device use errors. Among 11 studies with step-by-step data, the most common errors were failure to (1) exhale completely and away from the device (47.8% (95% CI: 33.6-62.0)); (2) hold breath for up to 10 seconds (30.6% (95% CI: 17.5-43.7)); (3) take a slow, deep breath while pressing the dose release button (27.9% (95% CI: 14.5-41.2)); (4) hold the inhaler upright (22.6% (95% CI: 6.2-39.0)); and (5) turn the base toward the arrows until it clicked (17.6% (95% CI: 3.0-32.2)). Device use errors occurred in about 6 of 10 patients who used SMIs. An individualized approach to inhalation device selection and ongoing training and monitoring of device use are important in optimizing bronchodilator treatment.

Keywords: COPD; Meta-analysis; Respimat®; chronic obstructive pulmonary disease; inhaler errors; soft mist inhaler; systematic literature review.

Figure 1.

PRISMA flowchart. PRISMA: Preferred Reporting Item for Systematic Reviews and Meta-Analyses; SMI: soft mist inhaler.

Figure 2.

Meta-analysis of device use errors among patients using Respimat® Soft Mist Inhaler™. I ² = 92.8%; test for heterogeneity: Q(df = 1) = 273.6, p < 0.001. CI: confidence interval.

Figure 3.

Forest plot showing weighted average percentage of errors by device use step for Respimat® Soft Mist Inhaler™. CI: confidence interval.

Figure 4.

Forest plot showing sensitivity analysis. CI: confidence interval.

Figure 5.

Funnel plot with 95% confidence limits showing publication bias. Five studies outside the funnel include, from left to right, Steinberg and Pervanas, Ohbayashi et al., Molimard et al., Liang et al., and Ding et al.. The rest of studies were Ngo et al., Bournival et al., de Oliveira et al., Windisch et al., Takaku et al., Chorao et al., and Asakura et al.. Proportion of patients with at least 1 device use error was not significantly different between the five outlier studies (57.5% (95% CI: 21.2–93.9)) and the rest of studies (59.8% (95% CI: 51.3–68.4)). CI: confidence interval.