Impairments That Affect Correct Inhaler Use in COPD

To prescribe inhaled therapy for patients with COPD, health care professionals (HCPs) must make three decisions: short vs long-acting medication, medication class (beta2 agonists, muscarinic antagonists and/or corticosteroids) and delivery system.

At present, there is no guidance by national and international groups of experts on selecting the most appropriate delivery system for patients with COPD. On the other hand, there is a general belief among HCPs that there is no difference in efficacy among pressurized metered dose inhalers (pMDIs), slow mist inhalers (SMIs), dry powder inhalers (DPIs), and nebulizer delivery if the patient uses correct inhaler technique. Unfortunately, there is extensive evidence that patients with COPD exhibit numerous errors using hand-held devices. Experts have opined that HCPs should consider prescribing nebulizer medications for patients with COPD based on various factors or conditions, particularly cognitive impairment and problems with manual dexterity. However, there is little if any supportive evidence for these recommendations.

In stable out-patients with an established diagnosis of moderate to very severe COPD (pulmonary function tests within the last 12 months that demonstrate FEV1 < 60% Predicted required for screening purposes), we hypothesize the following:

• Cognitive impairment (mild to severe) is present in > 20% of this COPD population
• Impaired manual dexterity (minimally functional to nonfunctional) is present in > 20% of this COPD population
• Both cognitive impairment and impaired manual dexterity are associated with patient errors using their current hand-held inhalers.

The objectives of this study are:

• To determine the prevalence of both cognitive impairment and impaired manual dexterity in stable out-patients with COPD
• To assess the relationships of cognitive impairment and impaired manual dexterity with patient errors using their current pMDIs, SMIs, and/or DPIs.

Inclusion criteria

• Age > 60 years
• > 10 pack-years smoking cigarettes
• Diagnosis of COPD based on GOLD Criteria
• Pulmonary function tests showing FEV1 < 60% predicted (pre-BD).
• Current use of one or more hand-held inhalers (pMDIs, SMIs, and/or DPIs).

Exclusion criteria

• Current diagnosis of dementia or known cognitive impairment -OR-
• Current diagnosis of impairment in manual dexterity including severe rheumatoid arthritis, severe arthritis/weakness of the hand/wrist, Parkinson's disease, and/or history of a previous cerebral vascular accident (CVA) resulting in significant musculoskeletal deficit (in judgement of PI).