Inhaler technique of elderly patients: comparison of metered-dose inhalers and large volume spacer devices
Reversible airways disease has a prevalence of up to 41% in the elderly population , with the prevalence of asthma quoted at between 6.5% and 17% . Inhaled therapy with beta-agonists, anti-cholinergics and corticosteroids minimizes drug side-effects and has been the mainstay of maintenance treatment for many years. The inhaled route is recommended in current national guidelines . High doses of inhaled corticosteroids administered through metered-dose inhalers (MDIs) do, however, produce systemically measurable effects on cortisol metabolism and bone turnover but these can be reduced by the use of large volume spacer devices (LVSs) [6-9].
However, despite widespread perception to the contrary , there is no objective evidence that elderly patients are able to use large volume spacers satisfactorily or that these have any advantage over MDIs in terms of inhaler technique or patient preference. The present study aimed to compare inhaler technique and preference with MDIs and LVSs in inhaler-naive elderly patients with reversible obstructive airways disease.
Subjects comprised men and women aged 70 years or above with newly diagnosed but stable chronic obstructive airways disease (including asthma) showing at least 15% ‘reversibility’ (i.e. 15% improvement in forced expiratory volume in 1 s [[FEV.sub.1]] following 2.5 mg salbutamol and 0.5 mg ipratropium administered by nebulizer). No subject had ever previously used any form of inhaled medication, and subjects with acute or chronic confusional states (Abbreviated Mental Test [AMT] score [less than or equal to] 7/10 ) were excluded. Verbal consent was obtained and the project was approved by Central Manchester Health Authority Research Ethics Committee.
Patients were seen alone (day 1) in a quiet environment without visual or auditory distractions. Inhaler technique was demonstrated with placebo medication using the standard MDI and the LVS [either ‘Volumatic’ (Allen and Hanbury’s Ltd, Uxbridge, Middlesex) or ‘Nebuhaler’ (Astra Pharmaceuticals Ltd, Kings Langley, Hertfordshire)]. Patients were tutored in the use of both types of device for 10 minutes, with repeated demonstration, observation and criticism of technique. Technique was then assessed as (a) perfect, (b) minor errors not preventing adequate use of the device, or (c) inadequate (Table I). Patients were asked which device they preferred and were then prescribed inhaled beta-agonist and steroid to take on a regular basis using the device with which they were the most competent. Those equally competent with both MDI and LVS were given one device chosen randomly.
Patients were seen again 28 days later (day 29) in the same environment. It was initially ensured that the patient had received no interim reinstruction in technique from health professionals or others. Technique was then reassessed as above.
Table I. Potential errors in use of large volume spacer (LVS) and
metered-dose inhaler (MDI)
Problems with MDI co-ordination due to impaired hand-grip strength can be ameliorated by use of a ‘Haleraid’ (Allen and Hanbury Ltd, Uxbridge, Middlesex). Unfortunately when the Haleraid is in place on the MDI the latter cannot be inserted into the LVS. Two of the three patients who were unable to use the LVS in the present study failed because of inability to trigger the MDI owing to poor hand-grip strength. A ‘Haleraid’ designed for use with the LVS would be a significant advance.
A further advantage of LVSs, not examined in the present study, is that they can be triggered by caters or relatives if the patients themselves cannot use them. This overcomes the problems of hand-grip weakness, insertion of the MDI into the LVS and (presumably) repetitive activation. Any consequent extra delay between triggering and inhalation is unlikely to have a significant effect on lung deposition .
In light of the fact that LVSs reduce systemic absorption of inhaled steroid, and in view of their advantages for elderly patients in terms of inhaler technique and patient preference demonstrated in the present study, LVSs should be regarded as the preferred alternative to MDIs for use by elderly patients with reversible airflow obstruction.
I am grateful to Dr Paul Bannister for his advice on the preparation of the manuscript.
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M. J. CONNOLLY Department of Geriatric Medicine University of Manchester, Barnes Hospital, Cheadle, Cheshire SK8 2NY
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