Home Print this page Email this page Small font size Default font size Increase font size
Users Online: 144
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 30  |  Issue : 2  |  Page : 95-98

The adequacy of inhaler technique in patients with chronic obstructive pulmonary disease and asthma attending a tertiary care hospital in Navi Mumbai


Department of Pulmonary Medicine, Dr. D. Y. Patil Hospital, Navi Mumbai, Maharashtra, India

Date of Web Publication5-Dec-2016

Correspondence Address:
Akanksha Das
Department of Pulmonary Medicine, Dr. D. Y. Patil Hospital, Navi Mumbai, Maharashtra
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-6691.195253

Rights and Permissions
  Abstract 

Objectives: Chronic obstructive pulmonary disease (COPD) and asthma are major concerns to health-care system. Improper inhaler device used (metered dose inhaler/dry powder inhaler) is one of the major causes associated with inadequate control of the disease. This study was performed to evaluate the inhaler technique among patients and to investigate factors associated with improper use and whether age or gender was associated with poor inhaler technique. Materials and Methods: A cross-sectional study of all patients who visited the chest outpatient department with asthma and COPD over a 6-month-period in a tertiary care hospital in Navi Mumbai. Information was collected about demographic data and inhaler technique was assessed using a standard checklist. Results: There were 107 patients, 71 with asthma and 36 with COPD. Inhaler techniques of 95% of patients were found to be inadequate in some form or the other as per checklist. Of all the patients interviewed, only about 60% of patients recalled that demonstration was done by doctors or other health-care professionals. Twelve percent were instructed by pharmacists and remaining followed their friend's or relative's suggestions along with insert literature. Conclusions: The inhaler technique is inadequate among most patients. On every visit, patient's inhaler technique should be observed and adequate suggestions should be given to correct any deficiency.

Keywords: Adherence, asthma, chronic obstructive pulmonary disease, dry powder inhaler, inhaler technique, metered dose inhaler


How to cite this article:
Das A, Uppe A, Sinha K, Jayalakshmi T K, Nair G, Nagpal A. The adequacy of inhaler technique in patients with chronic obstructive pulmonary disease and asthma attending a tertiary care hospital in Navi Mumbai. Indian J Allergy Asthma Immunol 2016;30:95-8

How to cite this URL:
Das A, Uppe A, Sinha K, Jayalakshmi T K, Nair G, Nagpal A. The adequacy of inhaler technique in patients with chronic obstructive pulmonary disease and asthma attending a tertiary care hospital in Navi Mumbai. Indian J Allergy Asthma Immunol [serial online] 2016 [cited 2017 Apr 30];30:95-8. Available from: http://www.ijaai.in/text.asp?2016/30/2/95/195253


  Introduction Top


Chronic respiratory diseases (CRDs) which include asthma and chronic obstructive pulmonary disease (COPD) may account for an estimated burden of about 100 million individuals in India. Both asthma and COPD, known by the common name "dama," are important causes of morbidity and a major health-care burden. Medication delivery through inhalation is a mainstay for treatment of pulmonary diseases such as asthma and COPD. Drug classes used in the management of these illnesses include β-receptor agonists, anticholinergic agents, and corticosteroids. [1],[2] The clinical benefit of this mode of drug delivery is directly proportional to the inhaler technique which determines the adequacy of drug delivery to the site of action, i.e., lungs. There have been a continuously evolving newer innovative inhaler devices in the market to overcome the drawbacks of inhaler technique but proper inhaler technique is still the cornerstone of effective and adequate drug delivery. Improper inhaler technique has been associated with poor disease state outcomes and an increase in emergency room visits. [3] The objective of our study was to assess the technique of inhaler use by patients and to determine the factors associated with improper use and whether age or gender was associated with poor inhaler technique.


  Materials and Methods Top


The present cross-sectional study was conducted in 2015, in a tertiary care hospital in Navi Mumbai, for 6 months from January 2016 to July 2016. The patients suffering from bronchial asthma and COPD visiting the respiratory medicine outpatient department were included in the study, after getting their consent and obtaining approval from the Institutional Review Board. Patients not fluent in Hindi, English, and Marathi were excluded from the study as they were unable to effectively communicate during the interview. Detailed history and demographic data of each patient were recorded and clinical examination was done. Each patient was asked to demonstrate the inhaler technique in the presence of the health-care professional which was subsequently assessed using a standard checklist [Table 1.1], [Table 1.2] and [Table 1.3]. The written informed consent was obtained from all the participants.
Table 1.1: Patients MDI (without spacer) use assessment against the 9 steps for the correct use in the checklist

Click here to view
Table 1.2: Patients MDI (with spacer) use assessment against the 9 steps for the correct use in the checklist

Click here to view
Table 1.3: Patients DPI use assessment against the 7 steps for the correct use in the checklist

Click here to view



  Results Top


Overall 107 patients gave consent to be interviewed for the study. Majority of the patients were male (61%) with more asthmatics (66%). Mean age was 49.75 years (range 1889 years)

for asthmatics, 66 years (range 3589 years) and 32% for patients with COPD. Majority of the patients were demonstrated the correct inhaler technique by doctors and health-care professionals (64%). The metered dose inhaler (MDI) without spacer was prescribed to most of the patients (38%).

Improper use of inhaler device was observed in almost all the patients (95%) [Table 2.1]. Interview with patients revealed that most of the patients did the initial steps correctly but founded it difficult to exhale maximally from mouth away from inhaler during the correct inhaler technique [Table 2.1], [Table 2.2], [Table 2.3] and [Table 2.4] and [Figure 1], [Figure 2] and [Figure 3].
Figure 1: The percentage of patients performing correct or incorrect steps of inhaler technique with metered dose inhaler (without spacer)

Click here to view
Figure 2: The percentage of patients performing correct or incorrect steps of inhaler technique with metered dose inhaler (with spacer)

Click here to view
Figure 3: The percentage of patients performing correct or incorrect steps of inhaler technique with dry powder inhaler

Click here to view
Table 2.1: Baseline characteristics of patients participating in the study


Click here to view
Table 2.2: Patient's MDI (without spacer) use assessment against the 9 steps for correct use in the checklist


Click here to view
Table 2.3: Patient's MDI with spacer use assessment against the 9 steps for correct use in the checklist


Click here to view
Table 2.4: Patient's DPI use assessment against the 7 steps for correct use in the checklist

Click here to view



  Discussion Top


Chronic pulmonary conditions such as asthma and COPD are managed primarily with inhaled medications which are most effective as it quickly delivers drugs to the site of action. Use of inhaled medications, when used at the lowest effective dose, also reduces the risk and severity of systemic side effects associated with medication use. [4],[5],[6] However, their efficacy not only depends on the drug itself but also on how it is taken, i.e., inhaler technique. Poor inhaler technique is associated with worse clinical outcomes and wastes resources. MDIs and dry powder inhalers seem simple to use, but these are not easy to use. Up to 90% of patients do not take their inhaler properly, [3],[7] meaning much of the money spent on inhaled therapy is wasted: The least cost effective medicine is the one that is not taken properly. Not only there are economic consequences of poor inhaler technique but also patients with poor inhaler technique are more likely to have persistent symptoms, to end up in emergency departments, to be admitted to hospital, or to need to use rescue courses of antibiotics or steroids (Melani et al., 2011). [3] When asked, most patients think that they know how to use their inhaler (or inhalers - as many have more than one device) correctly, yet when watched only around one in ten have a good technique. [8] A number of factors are associated with an increased chance of having a poor technique [Table 3.1]. [9]
Table 3.1: Factors associated with an increased risk of poor inhaler technique

Click here to view


Cognitive impairment in the elderly is an increasingly important factor leading to poor inhaler technique as other aspects of aging such as poor eyesight, reduced hand strength, and manual dexterity. As many as one in five patients across the age spectrum may have difficulty in reading the instruction leaflet while in others English may not be their first language. People who are housebound or living alone are also at increased risk of not using their inhaler correctly as they have no one to remind them of the correct technique. Some of the mistakes that people make have limited impact on the effectiveness of their therapy, but others, so-called critical errors, can render the therapy useless. [10] Examples of this are incorrect loading of the device, failure to coordinate actuation with inhalation, or incorrect inspiratory flow rates for the device.

Our evaluation was done at a tertiary care hospital in Navi Mumbai, India, with a sample size of 107 patients of asthma and COPD. Our study was designed to estimate incorrect inhaler technique and associated factors among our patients. The authors concluded that more than 90% of the patients fail to use the inhaler technique correctly, which means that our findings showed a much higher incorrect usage in India than anywhere in the world.


  Conclusions Top


This study highlights the adequacy of inhaler technique in patients with asthma and COPD in a tertiary care hospital. There are many types of inhalers used by patients. Multiple steps are required to adequately use the variety of inhalers and this can create the opportunity for patients to misuse their inhalers and limit the health benefits they could receive from them. We recommend that assessments of inhaler technique and measurements of patient compliance with their prescribed treatments should be considered for inclusion at each hospital visit in the current assessment tools.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Barnes PJ. Asthma. In: Longo DL, Fauci AS, Kasper DL, Hauser DL, Jameson JL, Loscalzo J, editors. Harrison's Principles of Internal Medicine. 18 th ed., Ch. 254. Columbus, OH: McGraw Hill Education; 2016.  Back to cited text no. 1
    
2.
Reilly JJ, Silverman EK, Shapiro SD. Chronic obstructive pulmonary disease. In: Longo DL, Fauci AS, Kasper DL, Hauser DL, Jameson JL, Loscalzo J, editors. Harrison's Principles of Internal Medicine. 18 th ed., Ch. 260. Columbus, OH: McGraw Hill Education; 2016.  Back to cited text no. 2
    
3.
Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med 2011;105:930-8.  Back to cited text no. 3
    
4.
Toogood JH. Side effects of inhaled corticosteroids. J Allergy Clin Immunol 1998;102:705-13.  Back to cited text no. 4
    
5.
Hanania NA, Chapman KR, Kesten S. Adverse effects of inhaled corticosteroids. Am J Med 1995;98:196-208.  Back to cited text no. 5
    
6.
Barnes PJ, Pedersen S, Busse WW. Efficacy and safety of inhaled corticosteroids. New developments. Am J Respir Crit Care Med 1998;157(3 Pt 2):S1-53.  Back to cited text no. 6
    
7.
Broeders ME, Sanchis J, Levy ML, Crompton GK, Dekhuijzen PN; ADMIT Working Group. The ADMIT series - Issues in inhalation therapy 2. Improving technique and clinical effectiveness. Prim Care Respir J 2009;18:76-82.  Back to cited text no. 7
    
8.
Souza ML, Meneghini AC, Ferraz E, Vianna EO, Borges MC. Knowledge of and technique for using inhalation devices among asthma patients and COPD patients. J Bras Pneumol 2009;35:824-31.  Back to cited text no. 8
    
9.
Dolovich MB, Ahrens RC, Hess DR, Anderson P, Dhand R, Rau JL, et al. Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest 2005;127:335-71.  Back to cited text no. 9
    
10.
Chrystyn H, Price D. Not all asthma inhalers are the same: Factors to consider when prescribing an inhaler. Prim Care Respir J 2009;18:243-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1.1], [Table 1.2], [Table 1.3], [Table 2.1], [Table 2.2], [Table 2.3], [Table 2.4], [Table 3.1]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusions
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed287    
    Printed11    
    Emailed0    
    PDF Downloaded40    
    Comments [Add]    

Recommend this journal