SUMMARIES FROM THE REVIEW PAPERS

	IMPROVING INHALER USE IN COPD AND THE ROLE OF PATIENT PREFERENCE

TOP IMPROVING INHALER USE IN... PATIENT NEEDS AND MEDICATION... EFFECTIVE COMMUNICATION WITH THE... PATIENT ADHERENCE WITH COPD... INHALER TREATMENT OPTIONS IN... PATIENT PREFERENCE FOR AND... INHALER CHOICE IN PRIMARY...

E.D. Bateman

The pathophysiology of chronic obstructive pulmonary diseaseand asthma differ, and require different treatment approaches.
Maintenance of sustained bronchodilation has been shown toimproveseveral key clinical and physiological features of disease.
The management of chronic obstructive pulmonary disease presentschallenges relating to the age and expectations of patients,and their readiness to use and ability to handle inhaled drugs.
Ensuring efficient delivery of drugs in chronic obstructivepulmonary disease patients is vital to treatment success buthas received little attention.
The three key factors in ensuringeffective inhalation therapyare: the characteristics of theinhalation device; the patient'sknowledge, attitudes and preference;and the physician's familiaritywith inhalers and their skillin understanding the patient'sneeds and preferences. Together,these factors influence satisfactionwith therapy, which mayaffect long-term adherence and clinicaloutcomes.

The need of chronic obstructive pulmonary disease patients forindependence, control of their condition and maintenance ofsocial functioning may conflict with their need to control theirsymptoms. Occasionally, some patients will trade-off symptomcontrol in order to satisfy these psychological needs.
Patientswith chronic obstructive pulmonary disease react totheir diseasein different ways and adopt a variety of self-carestyles inhow they manage it. Recognising these personal styleswill assistin effective management.
The typical health path for a chronicobstructive pulmonarydisease patient is a long-term deteriorationwith little orno chance of returning to "normality". This oftenmakes patientsconservative and stoical about their health goalsand theirexpectations of treatment benefits.
Patients withchronic obstructive pulmonary disease seem totake a pragmaticapproach towards choice of inhaler devicesand usually basetheir preference on how effective the drug–devicecombinationis perceived to be.

Humanity, respect and a people-focussed attitude are vital togood communication with patients.
The goals of good communicationare to avoid patient misunderstandingand uncertainty, improvingmanagement decisions by healthcareprofessionals and resultingin a more satisfied patient.
Physicians and nurses shouldaim to: achieve a shared understandingwith patients (concordance);involve them in decision-making;and encourage them to acceptresponsibility.
Greater patient satisfaction may improve concordanceand sobring about better outcomes.

Very few published studies focus on adherence to treatment regimensin chronic obstructive pulmonary disease, but evidence suggestsadherence is poor.
Patients' beliefs about their disease influenceadherence rates.
Healthcare professionals in primary or specialistcare who areprescribing treatment should ask the patient aboutadherenceas a vital part of the consultation.

A variety of portable inhaler devices are now available fortreating patients with chronic obstructive pulmonary diseaseand more new designs are in development; each type of devicehas advantages and disadvantages.
The plethora of inhalerswith differing instructions may confusepatients and healthcareproviders alike.
Any inhaler can be misused so that littleor no drug is depositedin the lungs.
"Crucial" errors ininhaler technique, resulting in no drugdeposition in the lungs,must be avoided.
There is increasing recognition that a successfultreatmentoutcome in chronic obstructive pulmonary disease dependsasmuch on the inhaler device as on the drug.
Inhaler choicein chronic obstructive pulmonary disease shouldtake into account:the likelihood of the patient using the inhalercorrectly; patientpreference; and likely compliance.

Inhaler preference is a valid patient-reported outcome worthyof scientific study.
Preference for and satisfaction withinhaler devices may beassociated with improved clinical outcomes,but this has notbeen proven to date.
Patients who have unstabledisease or are unable to use inhalersare usually excluded frompreference and satisfaction studies,and in everyday practice,patients rarely receive the degreeof instruction and coachinggiven in such studies.
Of the 29 studies found in the searchperformed for this article,only two used robust instrumentsfor measuring preference andsatisfaction.
Assessment andreporting of preference and satisfaction shouldbe subject tothe same rigorous regulatory standards as otherpatient-reportedoutcomes.

Primary practitioners should familiarise themselves with thecharacteristics of several inhalers and choose a device thata chronic obstructive pulmonary disease patient can use correctlyand that will be of benefit to them.
The selection of a devicefor a chronic obstructive pulmonarydisease patient may be influencedby patient comorbidities aswell as by the patient's abilityto handle the device and performthe necessary inhalation manoeuvres.
When selecting a device for the patient with respiratory disease,the primary practitioner should check that it is affordableand that the patient can handle it correctly. The patient'sand physician's preferences should also be taken into account.
The patient's ability to handle a device should be assessedby the practitioner or other trained professional. They shouldalso assess whether the patient can properly prepare and actuatethe device, take an adequate inspiration and coordinate actuationof a pressurised metered-dose inhaler with inspiration.