In this session, experts highlighted the updates on inhalers for COPD and asthma. In addition, they discussed identifying the right inhalers, monitoring, and improving inhaler techniques and strategies for improving inhaler adherence.

This talk focused on understanding the differences between inhaler devices and identifying the right inhaler for the right patient. According to current clinical evidence, while current inhaled therapy for asthma has the potential to control disease in the majority of the patients, control is often not achieved in practice. Poor inhaler technique is one of the most common causes of poor control because no matter how good a drug is, it cannot be effective if it does not reach the targeted airways. The quality of instructions given by healthcare professionals (HCPs) to patients is an essential factor that can be improved to reduce inhaler technique. However, previous studies have demonstrated that HCPs often lack knowledge of inhalers and inhaler techniques. The poor understanding of the correct use of inhalers may prevent HCPs from adequately assessing and teaching proper inhalation techniques to their patients.

Inhalers are also used incorrectly by patients; their suboptimal use affects clinical efficacy. In addition, inhaler errors influence disease outcomes and health-economic burden. Usmani OS et al. showed a significant association between inhaler errors, poor disease outcomes (exacerbations), and a more significant health-economic burden. The CRITIKAL study showed that an insufficient inspiratory effect in dry powder inhalers (DPIs) is significantly associated with uncontrolled asthma and more exacerbations. After adjusting for patient factors, actuation before inhalation was associated with uncontrolled asthma. Furthermore, none of the metered-dose inhaler (MDI) errors was significantly associated with exacerbation rate.

The GOLD 2022 strategy recommends assessment of inhaler technique/adherence and adjustment of inhaler device as a part of the core management cycle. The choice of the device must be tailored to meet the patient's needs, preferences, and satisfaction while offering the requisite level of disease control. While choosing the appropriate inhaler device, one should assess, choose and train (ACT). According to the NICE guidelines, a clean inhaler mouthpiece, spacers, and peak flow should be used during the COVID-19 pandemic. The inhaler should not be shared with anyone. Inhalers are not a 'One size fits all device. Two companies have announced pressurized MDIs (pMDIs) with low global warming potential (GWP) propellant to be developed by 2025.

The next talk discussed ways to monitor and improve inhaler techniques. The GOLD 2020 and GINA 2022 recommend good inhaler technique and adherence to the prescribed dosage. Poor medication adherence is common and associated with poor disease control and outcomes. Adherence decreases with time and is difficult to identify. The overall and critical error rates are high across all inhaler devices, ranging from 50–100% and 14–92%, respectively. The CRITIKAL study showed that the frequency of errors was associated with poor asthma symptom control. A slow inhalation flow when using a pMDI is clinically essential. The ERS consensus states that when using an MDI, instruct the patient to inhale over 5 seconds (2-3 seconds for a child). According to the GOLD 2022 and GINA 2022, when inhalers are prescribed, their use should be monitored and optimized.

Smart inhalers, also referred to as e-inhalers, maybe the way forward. They contain sensors, including bluetooth, inside an e-module and are linked to an app-connected inhaler. These are smart inhalers as they measure adherence and an inhalation profile, providing real-life feedback on the inhalation technique and confirmation of an inhalation. Real-life peak inhalation flow and inhaled volume, as well as adherence, can help solve real-life inhaler technique problems, identify, and improve real-life adherence, reduce the need for frequent face-to-face counselling and provide early detection of exacerbations.

The last talk highlighted the basic concepts of medication adherence and explored strategies to enhance medication adherence using inhalers. The World Health Organization (WHO) defines medication adherence as "the degree to which the person's behaviour corresponds with the recommendations from a health care provider". Worldwide, up to 50% of patients with asthma and COPD are poorly adherent to their inhaled medication. Adherence to medications is the process by which patients take their medication as prescribed and is further classified into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. About 25% of the patients with asthma do not initiate a new prescription. 50-60% of the patients do not implement as prescribed. Patients miss a significant number of doses. Poor inhaler technique affects one-fourth of all inhalations. When combined, errors in inhaler technique and missed doses account for almost half of the prescribed doses.

Each behavioural type of non-adherence requires a tailored approach. In its report on medication adherence, the WHO states that "maximizing the effectiveness of adherence interventions may have a greater impact on the population's health than any improvement in specific medical treatment". Strategies to improve inhaler adherence include monitoring adherence, setting common goals, simplifying prescribed inhaler regimens, and solving inhaler technique issues. For example, a study demonstrated that electronic adherence monitoring with feedback and alarms improved adherence and decreased hospital admission and courses of oral steroids.

Smart inhalers appear to be very promising for monitoring and managing medication adherence; however, demonstrating their efficacy in improving clinical outcomes requires confirmation. They are cost-effective but not cost-saving. Patients' satisfaction with their inhalers is an essential factor driving treatment adherence in COPD. Employing a single inhaler device can improve clinical outcomes and reduce healthcare use compared to multiple-inhaler regimens for patients with asthma or COPD. Working closely with patients to establish a model of shared decision making, which takes patient behaviour and preferences into account when choosing treatment options, can improve adherence and overall patient outcomes.

European Respiratory Society (ERS) International Congress 2022, 3rd-6th Sept. 2022, Barcelona

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