Impact of Sex on Proper Use of Inhaler Devices in Asthma and COPD: A Systematic Review and Meta-Analysis

Abstract

Despite females being more often affected by asthma than males and the prevalence of COPD rising in females, conflicting evidence exists as to whether sex may modulate the correct inhaler technique. The aim of this study was to assess the impact of sex on the proper use of inhaler devices in asthma and COPD. A pairwise meta-analysis was performed on studies enrolling adult males and females with asthma or COPD and reporting data of patients making at least one error by inhaler device type (DPI, MDI, and SMI). The data of 6,571 patients with asthma or COPD were extracted from 12 studies. A moderate quality of evidence (GRADE +++) indicated that sex may influence the correct use of inhaler device in both asthma and COPD. The critical error rate was higher in females with asthma (OR 1.31, 95%CI 1.14−1.50) and COPD (OR 1.80, 95%CI 1.22−2.67) using DPI vs. males (p < 0.01). In addition, the use of SMI in COPD was associated with a greater rate of critical errors in females vs. males (OR 5.36, 95%CI 1.48−19.32; p < 0.05). No significant difference resulted for MDI. In conclusion, choosing the right inhaler device in agreement with sex may optimize the pharmacological treatment of asthma and COPD.

Keywords: COPD; asthma; inhaler device; inhaler technique; meta-analysis; sex.

Figure 1

PRISMA 2020 flow diagram for the identification of the clinical studies included in the qualitative and quantitative syntheses. CENTRAL: Cochrane Central Register of Controlled Trials; PIF: peak inspiratory flow; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Figure 2

Forest plots of the association between the frequency of making at least one overall error (A) [51,52,54,60] or one critical error (B) [53,56,59,61] in the use of inhaler devices in asthma. DPI: dry powder inhaler; MDI: metered-dose inhaler; OR: odds ratio; 95%CI: 95% confidence interval.

Figure 3

Forest plots of the association between the frequency of making at least one overall error (A) [31,54,57,58] or one critical error (B) [31,55] in the use of inhaler devices in COPD. DPI: dry powder inhaler; MDI: metered-dose inhaler; OR: odds ratio; SMI: soft mist inhaler; 95%CI: 95% confidence interval.

Figure 4

Assessment of the risk of bias via the Cochrane RoB 2 tool displayed by means of a traffic light plot of the risk of bias of the included randomized clinical study (A) [31], and weighted plot for the distribution of the overall risk of bias within each bias domain via the Cochrane RoB 2 tool (B) (n = 1 clinical study). Traffic light plot reports five risk of bias domains: D1, bias arising from the randomization process; D2, bias due to deviations from intended intervention; D3, bias due to missing outcome data; D4, bias in measurement of the outcome; D5, bias in selection of the reported result. Yellow circle indicates some concerns on the risk of bias, green circle represents low risk of bias, and blue circle indicates no information. RoB: risk of bias.