Inhaled pharmacological treatment and critical inhaler technique errors in patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is an inflammatory lung disease characterised by persistent respiratory symptoms and a high risk of exacerbations. Preventive and maintenance pharmacological treatment is primarily administered through handheld inhalers, which are available in several different device-drug combinations. This thesis is about increasing the quality of drug treatment in COPD, where problems related to inhaled drugs are common. The overall aim was to assess and evaluate inhaled pharmacological treatment and critical inhaler technique errors in patients with COPD. The four studies included in this thesis derived from the Tools for Identifying Exacerbations study, which is an observational multicentre study in primary and secondary care in Sweden including 571 patients with COPD. The consequences of a change in the Global Initiative for Obstructive Lung Disease guidelines were investigated (Paper I). The refined COPD assessment of symptoms/risk of exacerbations lead to a high proportion of patients being reclassified to a lower risk group, which in turn had consequences for patients’ pharmacological treatment. The patients’ inhaled pharmacological treatments were assessed (Paper II). A high prevalence of inhaled corticosteroids (ICS) was identified, especially as a triple treatment, i.e., in combination with dual long-acting bronchodilators. Based on a previously developed tool, discontinuation of ICS could be tried in more than half of the patients. Proper inhaler technique is a prerequisite for adequate COPD treatment. Video-recorded demonstrations of inhaler technique were analysed (Paper III). Two-thirds of the patients made at least one critical inhaler technique error. The majority of the patients used a combination of different inhaler device models, which was the only factor associated with critical inhaler technique errors. The changes in inhaled pharmacological COPD treatment and inhaler technique were investigated one year after an initial evaluation and training (Paper IV). A reduction in the proportion of patients making critical inhaler technique errors was found but not in the subgroup of patients who had switched device models during the year. However, no association with COPD symptoms or exacerbations could be detected. The overall results contribute to increased knowledge and understanding of drug treatment in COPD. In order to optimise pharmacological treatment, it is essential to assess disease severity and inhaler technique, particularly in patients who switch device models. Further research is warranted to determine the most optimal educational intervention regarding inhaler technique, which has not yet been settled