Study links cognitive function, hand dexterity to proper inhaler use in COPD
Nearly 3 in 10 participants made at least 2 errors when using medication
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Choosing the right inhaler to deliver treatment for people with chronic obstructive pulmonary disease (COPD) may require considering their cognitive function, hand dexterity, and ability to breathe in forcefully, according to data from a large observational study in the U.S.
Researchers found that nearly three in every 10 participants in the study, called INHALE (NCT06135324), made at least two errors when using their prescribed inhaled medication. Cognitive impairment and reduced ability to breathe in forcefully were significantly associated with incorrect use of dry-powder inhalers, while limited hand dexterity was linked to incorrect use of inhalers that deliver medication as a spray or fine mist.
Participants who used their inhalers correctly experienced significantly greater improvements in lung function measures soon after taking their inhaled medication than those who made at least two errors. Among five inhaler steps assessed, holding the breath for 5 to 10 seconds after inhaling was the only one associated with greater lung function improvements.
“Proper inhaler technique remains one of the most important and modifiable factors in COPD treatment,” Donald A. Mahler, MD, the study’s first author and a professor of medicine at Geisel School of Medicine at Dartmouth, said in a press release from the COPD Foundation, which conducted the observational study. “Our findings reinforce that selecting the right inhaled medication delivery system requires more than understanding a person’s lung function alone.”
The findings were described in the study “Inhaler Technique in Chronic Obstructive Pulmonary Disease: Patient Impairments and Bronchodilation,” which was published in the Annals of the American Thoracic Society.
Inhaler misuse can reduce the treatment’s effectiveness
COPD is a progressive lung disease in which chronic inflammation and damage narrow the airways, leading to symptoms. Bronchodilators, medications that relax the muscles around the airways to keep them open, are a cornerstone of COPD treatment and are usually delivered through handheld inhalers.
More than 20 different devices are available worldwide, including dry-powder inhalers, which contain medication in powdered form; pressurized metered-dose inhalers, which release a measured dose of medication as a spray; and soft-mist inhalers, which deliver the medication as a slow-moving mist.
Despite their widespread use, however, “there is extensive evidence that patients with COPD commit various errors using handheld inhalation devices,” the researchers wrote. This misuse can prevent enough medication from reaching the lungs and reduce the treatment’s effectiveness.
To investigate whether a person’s cognitive function, hand dexterity, and ability to breathe forcefully influences how well inhalers are used — and, in turn, how much patients benefit from treatment — the COPD foundation launched the INHALE study.
A total of 503 adults with COPD were recruited at nine U.S. sites from December 2023 through April 2025. Participants had a mean age of 70, 55% were men, and all were using at least one handheld inhaler as maintenance bronchodilator therapy. The most commonly used handheld devices were pressurized metered-dose inhalers (60%), dry-powder inhalers (59%), and soft-mist inhalers (18%).
Factors associated with poor inhaler technique differed by device
Participants were instructed to use their prescribed inhalers as they did at home. Trained investigators then evaluated five key steps using standardized checklists specific to each device. Completing four or five steps correctly was considered acceptable technique, while making at least two errors was considered unacceptable.
Among participants, 71% demonstrated acceptable inhaler technique, meaning that nearly three in 10 made at least two critical errors while using their inhaler. Correct inhaler use was most common among users of dry-powder inhalers (83%), followed by soft-mist inhalers (74%) and pressurized metered-dose inhalers (69%).
Overall, 10.3% of participants had cognitive impairment, 34.8% had impaired hand dexterity, and 20.5% had reduced ability to breathe in forcefully. All three factors were significantly associated with incorrect inhaler use.
Statistical analyses accounting for potential influencing factors showed that cognitive impairment was the strongest predictor of unacceptable technique across all inhalers, increasing the odds of making critical errors about threefold.
Health care providers should consider cognitive function, manual dexterity, and inhalation ability when choosing and reviewing inhaled therapies to ensure people receive the greatest possible benefit from their prescribed treatments.
However, the factors associated with poor inhaler technique differed by device. Cognitive impairment and reduced ability to breathe in forcefully were significantly linked to incorrect use of dry-powder inhalers, while impaired hand dexterity was the only significant factor associated with incorrect use of pressurized metered-dose and soft-mist inhalers.
The researchers also assessed patients’ lung function before and 30 minutes after bronchodilator treatment. This was done by measuring forced expiratory volume in one second (FEV1), the amount of air exhaled in one second, and forced vital capacity (FVC), the total amount of air exhaled after taking a deep breath.
Participants with acceptable inhaler technique experienced significantly greater improvements in both FEV1 and FVC 30 minutes after treatment than those who made at least two errors. Holding the breath for 5 to 10 seconds after inhaling was the only step associated with significantly greater improvements in both lung function measures.
“Health care providers should consider cognitive function, manual dexterity, and inhalation ability when choosing and reviewing inhaled therapies to ensure people receive the greatest possible benefit from their prescribed treatments,” Mahler said.
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