Critical Error Frequency and the Impact of Training with Inhalers Commonly used for Maintenance Treatment in Chronic Obstructive Pulmonary Disease

David J Collier; Pascal Wielders; Job van der Palen; Logan Heyes; Dawn Midwinter; Kathryn Collison; Andy Preece; Neil Barnes; Raj Sharma

doi:10.2147/COPD.S224209

Critical Error Frequency and the Impact of Training with Inhalers Commonly used for Maintenance Treatment in Chronic Obstructive Pulmonary Disease

Int J Chron Obstruct Pulmon Dis. 2020 Jun 9:15:1301-1313. doi: 10.2147/COPD.S224209. eCollection 2020.

Authors

David J Collier^{1

2}, Pascal Wielders³, Job van der Palen^{4

5}, Logan Heyes⁶, Dawn Midwinter⁶, Kathryn Collison⁷, Andy Preece⁶, Neil Barnes^{1

6}, Raj Sharma⁶

Affiliations

¹ William Harvey Research Institute, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.
² Wolfson Institute of Preventive Medicine, Barts & The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.
³ Department of Pulmonary Diseases, Catharina Hospital, Eindhoven, Netherlands.
⁴ Department of Pulmonology, Medisch Spectrum Twente, Enschede, Netherlands.
⁵ Department of Research Methodology, Measurement, and Data Analysis, University of Twente, Enschede, Netherlands.
⁶ Respiratory Therapy Area Unit, GlaxoSmithKline Plc., Stockley Park, Uxbridge, UK.
⁷ Respiratory Medical Franchise, GlaxoSmithKline Plc., Research Triangle Park, Durham, NC, USA.

Abstract

Introduction: Training in correct inhaler use, ideally in person or by video demonstration, can minimize errors but is rarely provided in clinics. This open-label, low-intervention study evaluated critical error rates with dry-powder inhalers (DPIs), before and after training, in patients with chronic obstructive pulmonary disease.

Methods: Patients prescribed an inhaled corticosteroid (ICS)/long-acting β₂-agonist (LABA) (ELLIPTA, Turbuhaler, or DISKUS), long-acting muscarinic antagonist (LAMA)/LABA (ELLIPTA or Breezhaler), or LAMA-only DPI (ELLIPTA, HandiHaler, or Breezhaler) were enrolled. Critical errors were assessed before training (Visit 1 [V1]; primary endpoint) and 6 weeks thereafter (Visit 2 [V2]; secondary endpoint). Logistic regression models were used to calculate odds ratios (ORs) for between-group comparisons.

Results: The intent-to-treat population comprised 450 patients. At V1, fewer patients made ≥1 critical error with ELLIPTA (10%) versus other ICS/LABA DPIs (Turbuhaler: 40%, OR 4.66, P=0.005; DISKUS: 26%, OR 2.48, P=0.114) and other LAMA or LAMA/LABA DPIs (HandiHaler: 34%, OR 3.50, P=0.026; Breezhaler: 33%, OR 3.94, P=0.012). Critical error rates with the primary ICS/LABA DPI were not significantly different between ELLIPTA ICS/LABA (10%) and ICS/LABA plus LAMA groups (12-25%). Critical errors with the primary ICS/LABA DPI occurred less frequently with ELLIPTA ICS/LABA with or without LAMA (11%) versus Turbuhaler ICS/LABA with or without LAMA (39%, OR 3.99, P<0.001) and DISKUS ICS/LABA with or without LAMA (26%, OR 2.18, P=0.069). Simulating single-inhaler versus multiple-inhaler triple therapy, critical error rates were lower with ELLIPTA fluticasone furoate/vilanterol (FF/VI; 10%) versus ELLIPTA FF/VI plus LAMA (22%), considering errors with either DPI (OR 2.50, P=0.108). At V2, critical error rates decreased for all DPIs/groups, reaching zero only for ELLIPTA. Between-group comparisons were similar to V1.

Conclusion: Fewer patients made critical errors with ELLIPTA versus other ICS/LABA, and LAMA or LAMA/LABA DPIs. The effect of "verbal" training highlights its importance for reducing critical errors with common DPIs.

Keywords: ELLIPTA; critical errors; inhaled corticosteroid; inhaler technique; long-acting muscarinic antagonist; long-acting β2-agonist.

MeSH terms

Administration, Inhalation
Adrenal Cortex Hormones / therapeutic use
Adrenergic beta-2 Receptor Agonists / adverse effects
Bronchodilator Agents / adverse effects
Dry Powder Inhalers
Humans
Muscarinic Antagonists / adverse effects
Pulmonary Disease, Chronic Obstructive* / diagnosis
Pulmonary Disease, Chronic Obstructive* / drug therapy

Substances

Adrenal Cortex Hormones
Adrenergic beta-2 Receptor Agonists
Bronchodilator Agents
Muscarinic Antagonists

Grants and funding

This study was funded by GlaxoSmithKline plc. (ClinicalTrials.gov number NCT02982187; GlaxoSmithKline plc. study 204981).