Assessment of inhalation technique in older patients with COPD

The implications of these standards being missed are that patients are not effectively receiving the adequate treatment needed for their condition and this may be overlooked by prescribers. This can lead to polypharmacy by addition of other inhalers, and increase a patient’s side effect burden without achieving desired clinical effect.

This audit will assess whether patients who are prescribed inhalers have the right inhaler technique to gain the maximum benefits from this prescription. In doing so it will give us information on how big the problem is of poor inhaler technique in older patients with the possibility of using this information to implement a change which creates the first cycle of an audit.

Audit on COPD inhaler technique

The British Thoracic Society recommend the Asthma Society website for inhaler technique – this includes steps for every inhaler type. 100% of patients audited had their inhalation technique marked against these standards.²

Source: Videos on correct inhaler technique: How to use your inhaler

The sample consisted of inpatients on one elderly care ward in a 30-day period who had any type of inhaler prescribed on their electronic drug chart. Patients were asked to demonstrate how they would typically use their inhaler. Results were recorded as a “pass” or “fail” for each seven steps. Additional data collected included age, gender and type of inhaler used. The data was recorded on an excel spread sheet for analysis.

Results of COPD audit

The sample group consisted of 12 patients who were inpatients in Macdonald Ward, a complex elderly care ward, at Conquest Hospital from 22nd March 2022 to 22nd April 2022. This sample consisted of 58% males (n=7/12) and 41% females (n=5/12) with 75% (n=9/12) being over the age of 80.

Patients were selected if they had an inhaler prescribed on their electronic drug chart during this admission. 50% of patients were tested on their ability to use their salbutamol inhaler, the other patients were using Ellipta (n=3), Seretide (n=1), ipratropium  (n=1) and beclomethasone (n=1).

33% (n=4/12) of the patients demonstrated adequate inhaler technique – meaning they successfully performed all seven steps correctly. The two most common steps for failure were step three and six (“breathe out, fully and gently” and “remove inhaler from mouth and hold breath for up the 10 seconds”, respectively), with 66% (n=8/12) failing step three and 58% (n=7/12) failing step six. The steps that were most often performed correctly were step one (prepare the inhaler device) and step four (place inhaler in mouth and seal lips around mouthpiece) with 100% of participants showing correct technique in both steps.

Out of the four patients who had adequate inhaler technique, 75% (n=3/4) were using the Ellipta inhaler, meaning that 100% of the patients using Ellipta inhaler had adequate inhaler technique.

There were several limitations to this study. The first limitation resulted from the chosen ward having a longer than average length of hospital stays. This meant that when collecting data there was a slow turnover of new patients and reduced the opportunity to recruit more patients.

Secondly, there was a time restraint from doctors rotating to different areas of the hospital or community placements leading to a short period of sampling. Finally, some of the patients who had inhalers prescribed had to be excluded from the study this was mainly due to two reasons; being too unwell to demonstrate their inhaler technique or advanced dementia.

Conclusion

In conclusion, this sample of older inpatients demonstrated poor inhaler technique hence resulting in poor control of their underlying chronic obstructive lung disease. There are many possibilities of why this could be, ranging from lack of education from healthcare populations to a personal inability to carry out the steps, for example deteriorating memory and weak hand grip by arthritis.

This small sample size shows the need to check older patients’ inhaler technique regularly during hospital admissions. Many of these patients are hospitalised for extended periods of times and are therefore ideally suited to have their inhaler technique checked and improved during this period. It also shows that the type of inhaler patients is using effects their technique, the Ellipta inhaler being used most successfully.

Recommendations

Recommendations from this data include firstly, more frequent checks on the older patient’s inhalation technique during their inpatient stay in the presence of next of kin or a family member.

Secondly, to provide them with appropriate type of inhalers and devices which they can use easily considering their comorbidities. This will improve their inhalation technique and help manage their chronic obstructive lung disease better. It would be interesting to also collect data on whether once these patients have been taught inhaler technique in the hospital, they still manage to retain this information in the community.

Learning points

• Older patients should have their ability to use inhalers regularly assessed and corrected if necessary.
• Incorrect use of inhalers can lead to polypharmacy by addition of other inhalers, and increase a patient’s side effect burden without achieving desired clinical effect.
• This sample of older inpatients demonstrated poor inhaler technique hence resulting in poor control of their underlying chronic obstructive lung disease.
• More frequent checks on the older patient’s inhalation technique should be carried out during their inpatient stay.

Robinson E, FY1 East Sussex Hospitals Trust

Elsheik A, GPVTS East Sussex Hospitals Trust

Rahmani MJH, Consultant Physician East Sussex Hospital Trust

References

1. NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. https://www.nice.org.uk/guidance/ng115
2. Videos on correct inhaler technique: How to use your inhaler – https://www.asthma.org.uk/advice/inhaler-videos/