Insights from Real-World Evidence on the Use of Inhalers in Clinical Practice
Authors: Calle Rubio Myriam , Adami Teppa Pedro José , Rodríguez Hermosa Juan Luis , García Carro Miriam , Tallón Martínez José Carlos , Riesco Rubio Consolación , Fernández Cortés Laura , Morales Dueñas María , Chamorro del Barrio Valeria , Sánchez-del Hoyo Rafael , Aragón Jorge García 
Published: February 2025

Background: Despite the ongoing innovations and the availability of numerous effective inhaled treatment options, achieving optimal disease control in most patients frequently remains disappointing. Unfortunately, although inhaled therapy is the cornerstone of respiratory disease management, the selection of the most appropriate inhaler is still overlooked or underestimated by some healthcare professionals, and inhaler misuse remains a significant challenge in managing chronic respiratory diseases which directly influences patients’ quality of life, clinical outcomes, and risk of disease progression. Materials and Methods: This is a unicentric, observational, cross-sectional study designed to evaluate the inhaled therapy prescribed in hospitalized patients and to analyze device changes after hospitalization, as well as the factors associated with these changes. A single face-to-face visit was performed during the patient’s hospitalization, where the inhaled therapy used prior to hospitalization was evaluated: technique (critical errors), compliance (TAI questionnaire), maximum peak inspiratory flow [PIF (L/min)], and level of inhaler handling-related knowledge. A binary logistic regression model was used to explore the association between changing device at discharge and the other independent variables Results: The inhaler most used during hospitalization was the metered-dose inhaler (MDI) with a chamber (51.9% of patients), with the dry powdered inhalers (DPI) being the inhalers used in 43% of maintenance inhaled therapies in the community setting prior to hospitalization. In addition, 90% of patients showed a maximum PIF ≥ 30 L/min, and 35.6% performed critical inhaler errors. These patients had statistically significantly lower maximum PIF values (52.1 L/min in patients with critical inhaler errors vs. 60.8 L/min without critical inhaler errors; p > 0.001) and were more likely to exhibit poor inhaler compliance compared to those without critical errors (50.5% vs. 31.0%, respectively). More than half of the patients who used MDI with spacer chamber made critical inhaler errors; 69.9% showed regular or poor treatment adherence, although 75.6% demonstrated good knowledge about inhaler handling. Only in 27% of the patients did the healthcare professional change the type of inhaler after hospitalization within clinical practice. The medical and nursing staff responsible for the patient’s hospitalization were not informed of the assessment carried out in the study. The probability of not performing a device change at discharge was lower in patients with previous at-home treatment with combined inhaled therapy with LABA + ICS (OR 0.3 [0.18–0.83], p = 0.016) and in patients under triple inhaled therapy (OR 0.3 [0.17–0.76], p = 0.007). No significant differences were observed in inhaler changes when considering the frequency of critical inhaler errors, inhaler handling-related knowledge or maximum PIF values. Conclusions: Our study highlights the urgent need for a more personalized inhaler selection and consistent monitoring by healthcare professionals to minimize inhaler misuse, increase treatment compliance and adherence, and improve disease management outcomes. It is essential to provide training and promote the role of nursing in the evaluation and education of inhaled therapy. Additionally, the use of standardized approaches and tools, such as the CHECK DIAL, is crucial to facilitate the adaptation of devices to patients’ needs.