Shared Decision-Making Facilitates Inhaler Choice in Patients with Newly-Diagnosed Chronic Obstructive Pulmonary Disease: A Multicenter Prospective Study

Consideration and Assessment of Patient Factors When Selecting an Inhaled Delivery System in COPD

Because guidelines and strategies for pharmacologic treatment of COPD focus on specific classes of inhaled medications, there is an unmet need for information to guide health care professionals for selecting an inhaled medication delivery system that matches the unique characteristics of individual patients. This article provides guidance for selecting an inhaled medication delivery system based on three "key" patient factors: cognitive function, manual dexterity/strength, and peak inspiratory flow. In addition, information is provided about specific tests to assess these patient factors. Cognitive impairment with an estimated prevalence of 25% among patients with COPD adversely affects patients' ability to correctly use a handheld device. To our knowledge, the prevalence of impaired manual dexterity/strength has not been reported in those with COPD. However, 79% of patients with COPD have reported one or more physical impediments that could influence their ability to manipulate an inhaler device. The measurement of peak inspiratory flow against the simulated resistance (PIFr) of a dry powder inhaler establishes whether the patient has the inhalation ability for creating optimal turbulent energy within the device. A suboptimal PIFr for low to medium-high resistance dry powder inhalers has been reported in 19% to 84% of stable outpatients with COPD. Health care professionals should consider cognitive function, manual dexterity/strength, and PIFr in their patients with COPD when prescribing inhaled pharmacotherapy. Impairments in these patient factors are common among those with COPD and can affect the individual's competency and effectiveness of using inhaled medications delivered by handheld devices.

Clinical Practices Surrounding the Prescription of Home Oxygen in Patients With COPD and Desaturation

Purpose

While home oxygen therapy increases survival in patients with chronic obstructive pulmonary disease (COPD) who have severe resting hypoxemia, recent evidence suggests that there is no survival benefit of home oxygen for patients with COPD who have isolated exertional desaturation. We aimed to understand clinician practice patterns surrounding the prescription of home oxygen for patients with COPD.

Methods

We conducted semi-structured qualitative interviews via videoconference with 15 physicians and 3 nurse practitioners who provide care for patients with COPD. Clinicians were recruited through the American Lung Association Airways Clinical Research Centers. Interview guides were created with the assistance of patient investigators and included questions regarding clinician practices surrounding the prescription of oxygen for patients with COPD and the use of clinical guidelines. Interviews were recorded, transcribed, and coded for themes.

Results

Of the 18 clinician interviewees, one-third were women, with most participants (n=11) being < 50 years old. Results of the semi-structured interviews suggested research evidence, clinical experience, and patient preferences contributed to clinician decision-making. Most clinicians described a shared decision-making process for prescribing home oxygen for patients, including discussion of risks and benefits, and developing an understanding of patient values and preferences. Clinicians did not use a structured tool to conduct these conversations.

Conclusions

Clinicians consider a number of patient and clinical factors when prescribing home oxygen therapy, often using a shared decision-making process. Tools to support shared decision-making about the use of home oxygen are needed.

Personalizing Selection of Inhaled Delivery Systems in Chronic Obstructive Pulmonary Disease

It can be challenging for healthcare professionals (HCPs) to prescribe inhaled therapy for patients with chronic obstructive pulmonary disease (COPD) because of the multiple individual and combinations of inhaled medications available in numerous delivery systems. Guidance on the selection of an inhaled delivery system has received limited attention compared with the emphasis on prescribing the class of the inhaled molecule(s). Although numerous recommendations and algorithms have been proposed to guide the selection of an inhaled delivery system for patients with COPD, no specific approach has been endorsed in COPD guidelines/strategies or by professional organizations. To provide recommendations for an inhaler selection strategy at initial and follow-up appointments, we examined the impact of patient errors using handheld inhalers on clinical outcomes and performed a focused narrative review to consider patient factors (continuity of the inhaled delivery system, cognitive function, manual function/dexterity, and peak inspiratory flow) when selecting an inhaled delivery system. On the basis of these findings, five questions are proposed for HCPs to consider in the initial selection of an inhaler delivery system and three questions to consider at follow-up. We propose that HCPs consider the inhaled medication delivery system as a unit and to match appropriate medication(s) with the unique features of the delivery system to individual patient factors. Assessment of inhaler technique and adherence together with patient outcomes/satisfaction at each visit is essential to determine whether the inhaled medication delivery system is providing benefits. Continued and repeated education on device features and correct technique is warranted to optimize efficacy.