Chest
Volume 104, Issue 5, November 1993, Pages 1332-1337
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Clinical Investigations: Asthma: Comparative Study: Journal Article: Research Support, Non-U.S. Gov't
A Comparison of Breath-Actuated and Conventional Metered-Dose Inhaler Inhalation Techniques in Elderly Subjects

https://doi.org/10.1378/chest.104.5.1332Get rights and content

Background

Poor coordination of canister actuation and inspiration often prevents adequate metered-dose inhaler (MDI) usage by patients, perhaps especially so among the elderly. Breath-actuated inhalers (BAI) have been developed to prevent this problem.

Methods

We compared the adequacy of inhaler technique and patient preferences between MDI and BAI in a group of elderly subjects (mean age, 70.8±5.4 years). Half of the subjects were regular MDI users; half had never before used one. Two trained observers assessed the adequacy of MDI and BAI usage subjectively while performance was monitored objectively using a light source and infrared system to detect canister actuation and a spirometer to measure the inspiratory volume. If canister actuation was not followed by at least a 50 percent vital capacity, inhaler use was deemed unsuccessful. A brief teaching session preceded inhaler usage.

Results

By subjective assessment, BAI was used successfully more often than MDI (79 vs 60 percent, p<0.05). By objective assessment, BAI was used successfully more often than MDI (64 vs 36 percent, p<0.0005), although the percentage of inhalations scored adequate was lower than when assessment was subjective. Neither device was used correctly as often by those unfamiliar with MDIs as by those who were regular users. A significantly higher percentage of patients preferred BAI to MDI (71 vs 19 percent, p<0.005), similar preferences being reported by MDI familiar and MDI unfamiliar groups.

Conclusions

We conclude that (1) elderly subjects frequently handle inhalers poorly, (2) mishandling is better detected by objective than subjective monitoring, and (3) BAI is used correctly and preferred by patients more often than conventional MDIs.

Section snippets

Subjects

Elderly subjects familiar with the use of MDIs were recruited from the population of patients referred for pulmonary function testing to the Pulmonary Function Laboratory of The Toronto Hospital, Western site. Elderly volunteers unfamiliar with the use of MDIs were recruited by word of mouth and by posted advertisement in the hospital and adjacent senior citizen facilities. Subjects were considered eligible for participation in the study if they were aged 63 years and older, indicated a

Student Characteristics

Eighty elderly subjects were recruited for participation in the study, 40 (24 men, 16 women) who were familiar with the use of MDIs and 40 (17 men, 23 women) who were unfamiliar with these devices. The mean age was 70.8±5.4 years (range, 63 to 85 years), the average age not being significantly different between MDI-familiar and MDI-unfamiliar groups. Spirometric endpoints differed significantly between MDI-familiar and MDI-unfamiliar groups. The FVC was 2.65± 0.95 L in the familiar group and

Discussion

Our data show clearly that elderly subjects use conventional MDIs poorly whether familiar with or unfamiliar with these devices. However, elderly subjects, regardless of previous MDI experience, handle a breath-actuated inhaler more successfully. Although subjective monitoring of inhaler use will often detect patients who use these devices poorly, objective monitoring is more stringent and will detect more patients who have problems with inhalation technique.

Our finding of frequent improper use

ACKNOWLEDGMENTS

The authors are indebted to Dr. J. Szalai for his expert statistical advice, to Mr. A. Salmon for his technical aid, and to Ms. A. Norton for her assistance with preparation of the manuscript.

References (16)

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    For example, older patients with decreased cognitive function had poorer inhaler technique.81 To improve medication delivery and adherence, older patients can be prescribed breath-activated medication devices,82 spacers to attach to metered dose inhalers, or medications that can be delivered by nebulizer (including corticosteroids for daily controller use, although this is not currently a Food and Drug Administration indication for patients older than 12 years with asthma), or an Ellipta dry powder inhaler device.83 Furthermore, like treatment of other medical conditions in geriatric medicine, there are issues of polypharmacy, drug-drug interactions, and cost of medications, which can significantly impact optimal treatment.

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The work was supported in part by a grant from the Asthma Society of Canada and by educational grants from Glaxo Canada and 3M Pharmaceuticals, United States.

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