On Inhaler Demonstrations and Technique Checks, or Lack Thereof
I lied earlier. I told Dia I’d only ever had one inhaler demonstration when Dr. Smartypants recently showed me how to use the Spiriva Respimat inhaler. This, it turns out, is not entirely true. I once had my family doctor show me how to use the Symbicort Turbuhaler, my first time using it.
The fact remains, though, I have taken far more doses of pressurized metered dose inhalers in the last ten years (over 26,500 puffs in just the last six years per my quick calculation!), far more than on the Turbuhaler, and nobody has ever a) showed me how to “correctly” use an MDI, b) checked my inhaler technique using an MDI, or c) ever recommended I use a spacer.
Am I using this thing right?
Like most patients claim to, I’m pretty sure I know what I’m doing. Or at least I think so. Up to 94% of people using inhalers for asthma and COPD aren’t using them correctly per a 2017 literature review1, so who am I to be in the correct 6%? I figure I have enough “practice", but without coaching, practice doesn’t even make perfect, it just enforces bad, hard to correct, technique. EVERYBODY ELSE PROBABLY FIGURES THAT THEY’RE DOING IT RIGHT, TOO. We can’t ALL be in the correct 6%!
Who’s being taught? We don’t know.
As I said, nobody’s ever showed me how to use an MDI. And when they’ve shown me how to use other devices, they’ve only shown me how to load the device, which is only half the battle—it’s not even the part where you get the medication into your lungs.
The problem is, I can’t find a statistic on how many patients overall actually get education from a member of their medical team—I even put a shout out to lung Twitter for help and texted the doctor in my pocket who gives me only interesting tidbits, not medical advice. (The next question: are gaps in research indicative of clinical practice problems?) The one study I did find buried this statistic of one hospital, citing a 1994 study, and noted “[D]espite a hospital-wide effort to prepare physicians, nurses, and respiratory therapists to provide training in [pressurized metered dose inhaler] use to in-patients, only 27% of eligible patients actually received instruction.”2,3 When cited, this primary source was already a decade old, and the secondary source quoting it is now 13 years old—and it is reasonable to believe physicians have only become busier since.
A bigger research gap
Issues physicians cited for why they don’t demonstrate are time pressures, unfamiliarity with the device (that they are prescribing, mind you), as well as lack of an appropriate device available4, and—I presume—the inability to just dose yourself on an actual, drug-filled device, in absence of an empty demonstration device. Frequently, physicians (as well as nurses and other medical professionals) do not possess mastery themselves in use of these inhaler devices.5-7
The reality is though, we don’t know which patients, or how many, are being taught how to use their inhalers correctly—and how many patients are getting consistent follow-up technique checks—because there’s no research on this. As the physician I inquired with noted, as to why we don’t have statistics on this, “[…] but really, would anyone admit to not doing their job?!?”
Correct, oh how correct this is. I replied, "I had thoughts about how this study could be a challenge… how might we study this, I wonder…"
This is why respiratory therapists and asthma educators need to be better utilized, more regularly—while we’re asking how might we get to that point, we’re still failing the 94% of patients who don’t know how to use their inhalers correctly.
What can you do as a patient
Ask your doctor to show you how to use your inhaler correctly and/or check your technique. If they note reasons why they cannot, or you’re unsatisfied, ask to be referred to a certified asthma educator or respiratory therapist in the practice (or at a local hospital). If we’re not taking our inhalers correctly, the medicine is not reaching our lungs, and that’s not the point. Whether you’ve been using your inhaler for a long time, or are struggling with it, ask for a review!
In ten years, I’ve had 2 demonstrations by doctors, and once had my ability to effectively use a Turbuhaler checked by a respiratory therapist/certified asthma educator. Where I live in Canada, the doctors refer people with asthma to asthma educators, if they identify a need for that. I've been referred to an asthma educator, only once, so far. And now reading that sobering statistic, there’s a very real possibility that as a “patient-expert” I’m doing something wrong, and that’s ridiculous. It's notable that my pharmacists have also not asked to check my inhaler technique. There need to be more checks.
I’m about ready to book a video consultation with one of our experts (which is possibly not even a legitimate service they can legally provide 😉). So, best to ask your doc or RT next time you’re in the clinic.
Have you ever experienced an itchy chin prior to or during asthma attacks?