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. 2023 Dec 22;10(1):e001821.
doi: 10.1136/bmjresp-2023-001821.

Does mixing inhaler devices lead to unchecked inhaler technique errors in patients with COPD? Findings from the cross-sectional observational MISMATCH study

Lars Dijk  1 , Marjan Kerkhof  1 , Merijn Driessen  1 , Yoran H Gerritsma  1 , Sinthia Bosnic-Anticevich  2   3 , Jaime Correia-de-Sousa  4 , P N Richard Dekhuijzen  5 , Marika Leving  1 , David B Price  6   7 , Ioanna Tsiligianni  8 , Omar Usmani  9 , Huib A M Kerstjens  10   11 , Janwillem W H Kocks  12   7   11
Affiliations

Does mixing inhaler devices lead to unchecked inhaler technique errors in patients with COPD? Findings from the cross-sectional observational MISMATCH study

Lars Dijk et al. BMJ Open Respir Res. .

Abstract

Background: Patients with chronic obstructive pulmonary disease (COPD) may be prescribed multiple inhalers that require different techniques for optimal performance. Mixing devices has been associated with poorer COPD outcomes suggesting that it leads to inappropriate inhaler technique. However, empirical evidence is lacking.

Aims: Compare the nature and frequency of dry powder inhaler (DPI) technique errors in patients with COPD using (1) a single DPI or (2) mixed-devices (a DPI and pressurised metered dose inhaler (pMDI)).

Methods: Data from the PIFotal study-a cross-sectional study on Peak Inspiratory Flow in patients with COPD using a DPI as maintenance therapy, capturing data from 1434 patients on demographic characteristics, COPD health status and inhaler technique-were used to select 291 patients using mixed-devices. Frequency matching based on country of residence and DPI device type was used to select 291 patients using a DPI-only for comparison. Predetermined checklists were used for the evaluation of DPI video recordings and complemented with additional errors that were observed in ≥10%. Error proportions were calculated for the (1) individual and total number of errors, (2) number of critical errors and (3) number of pMDI-related errors.

Results: The study sample contained 582 patients (mean (SD) age 69.6 (9.4) years, 47.1% female). DPI technique errors were common, but not significantly different between the groups. The majority of patients made at least one critical error (DPI-only: 90.7% vs mixed-devices: 92.8%). Proportions of total, 'pMDI-related' and critical errors did not significantly differ between the groups.

Conclusion: The nature and frequency of inhaler technique errors did not substantially differ between patients prescribed with a single DPI and mixed-devices. Currently, 'pMDI-related errors' in DPI use are not accounted for in existing checklists.

Trial registration number: ENCEPP/EUPAS48776.

Keywords: COPD Pharmacology; Inhaler devices; Pulmonary Disease, Chronic Obstructive.

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Conflict of interest statement

Competing interests: LD, MK, MD, YG and ML were employed by the General Practitioners Research Institute (GPRI) at the time of the study. In the past 4 years (2019–2022), GPRI conducted investigator-initiated and sponsor-initiated research funded by non-commercial organisations, academic institutes and pharmaceutical companies (including AstraZeneca, Boehringer Ingelheim, Chiesi, GSK, Mundipharma, Novartis and Teva). SB-A has received grants from TEVA, and personal fees from TEVA, Boehringer Ingelheim, AstraZeneca, GSK, Sanofi and Mylan. JC-d-S reports or personal fees from AstraZeneca, Bial, Boehringer Ingelheim, GSK, Medinfar, Mundipharma and Sanofi. PNRD has received grants and personal fees from TEVA, Boehringer Ingelheim, AstraZeneca, GSK, Chiesi, Focus Care, and Glenmark. HAMK has performed consultancies for, received unrestricted research and educational grants from, and has participated in clinical trials on a per patient fee basis for: AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline and Novartis. All renumerations were non personal and were received by his institution. DBP reports grants and personal fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Mylan, Novartis, Regeneron Pharmaceuticals, Sanofi Genzyme, Theravance and Zentiva (Sanofi Generics); grants from the British Lung Foundation, Respiratory Effectiveness Group, UK National Health Service, and AKL Research and Development; personal fees from Cipla, GlaxoSmithKline, Kyorin, Merck, Mundipharma, Airway Vista Secretariat, EPG Communication Holdings, FIECON, Fieldwork International, OM Pharma SA, PeerVoice, Phadia AB, Spirosure, Strategic North Limited, Synapse Research Management Partners S.L., Talos Health Solutions, and WebMD Global; non-financial support from Efficacy and Mechanism Evaluation programme and Health Technology Assessment; stock/stock options from AKL Research and Development, which produces phytopharmaceuticals; owns 74% of the social enterprise Optimum Patient Care (Australia and UK) and 92.61% of Observational and Pragmatic Research Institute Pte Ltd (Singapore); and 5% shareholding in Timestamp, which develops adherence monitoring technology. IT reports grants and personal fees from GSK, AstraZeneca, Boehringer Ingelheim, Menarini, Novartis, Chiesi and Elpen. OU reports grants and personal fees from AstraZeneca, Boehringer Ingelheim, Edmond Pharma, Chiesi and GSK; grants from Edmond Pharma; and personal fees from Napp, Mundipharma, Sandoz, Takeda, Cipla, COVIS, Novartis, Mereobiopharma, Orion and Menarini. JWHK reports grants, personal fees and non-financial support from AstraZeneca, grants, personal fees and non-financial support from Boehringer Ingelheim, grants and personal fees from Chiesi, grants, personal fees and non-financial support from GSK, non-financial support from Mundi Pharma, grants and personal fees from Teva, personal fees from MSD, personal fees from COVIS Pharma, grants from Valneva outside the submitted work; and JWHK holds <5% shares of Lothar Medtec and 72.5% of shares in the General Practitioners Research Institute.

Figures

Figure 1
Figure 1
Flow diagram showing study groups derived from the PIFotal study. DPI, dry powder inhaler.
Figure 2
Figure 2
OR (and frequency) of inhaler technique errors in patients with COPD using mixed-devices compared with patients using a DPI only. The size of the rectangle indicates the frequency of the errors. COPD, chronic obstructive pulmonary disease; DPI, dry powder inhaler; pMDI, pressurised metered dose inhaler.
Figure 3
Figure 3
Differences between the groups in the proportion of (1) total number of DPI technique errors, (2) pMDI-related errors while using a DPI and (3) critical DPI technique errors. ORs were adjusted for the following confounders: total errors: concomitant asthma; CCQ; maintenance therapy; body mass index; smoking status; number of moderate exacerbations in the previous year. pMDI-related errors: maintenance therapy; CCQ; smoking status; age. Critical errors: CCQ; maintenance therapy; number of moderate exacerbations in the previous year; smoking status.
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