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| ORIGINAL ARTICLE |
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| Year : 2016 | Volume
: 30
| Issue : 2 | Page : 95-98 |
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The adequacy of inhaler technique in patients with chronic obstructive pulmonary disease and asthma attending a tertiary care hospital in Navi Mumbai
Akanksha Das, Abhay Uppe, Kanishk Sinha, TK Jayalakshmi, Girija Nair, Amit Nagpal
Department of Pulmonary Medicine, Dr. D. Y. Patil Hospital, Navi Mumbai, Maharashtra, India
| Date of Web Publication | 5-Dec-2016 |
Correspondence Address:
Akanksha Das
Department of Pulmonary Medicine, Dr. D. Y. Patil Hospital, Navi Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0972-6691.195253
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 2023 Apr 2];30:95-8. Available from: https://www.ijaai.in/text.asp?2016/30/2/95/195253 |
| Introduction | |  |
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 | | |
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
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 | Table 1.2: Patients MDI (with spacer) use assessment against the 9 steps for the correct use in the checklist
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 | Table 1.3: Patients DPI use assessment against the 7 steps for the correct use in the checklist
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| Results | | |
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 18–89 years)
for asthmatics, 66 years (range 35–89 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)
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 | Figure 2: The percentage of patients performing correct or incorrect steps of inhaler technique with metered dose inhaler (with spacer)
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 | Figure 3: The percentage of patients performing correct or incorrect steps of inhaler technique with dry powder inhaler
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 | Table 2.1: Baseline characteristics of patients participating in the study
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 | Table 2.2: Patient's MDI (without spacer) use assessment against the 9 steps for correct use in the checklist
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 | Table 2.3: Patient's MDI with spacer use assessment against the 9 steps for correct use in the checklist
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 | Table 2.4: Patient's DPI use assessment against the 7 steps for correct use in the checklist
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| Discussion | | |
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
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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 | | |
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 | | |
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[Figure 1], [Figure 2], [Figure 3]
[Table 1.1], [Table 1.2], [Table 1.3], [Table 2.1], [Table 2.2], [Table 2.3], [Table 2.4], [Table 3.1]
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