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ORIGINAL ARTICLE
Ahead of print publication  

A cross-sectional study of pre- and posttraining evaluation of inhaler use technique among outpatients with bronchial asthma or chronic obstructive pulmonary disease at a tertiary care hospital in India


1 Department of Pharmacology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
2 Department of Pulmonary Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

Date of Submission20-Oct-2020
Date of Decision04-Dec-2020
Date of Acceptance09-Dec-2020
Date of Web Publication01-Dec-2021

Correspondence Address:
Selvaraj Nitya,
Department of Pharmacology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry - 605 107
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/picr.picr_328_20

   Abstract 

Context: Management of asthma and chronic obstructive pulmonary disease (COPD) includes use of inhalers as an integral component of drug delivery. Awareness about inhaler devices along with demonstration of the usage of inhaler technique aids in the optimization of therapeutic outcome.
Aim: This study aimed to assess the correct use of inhaler technique following pre- and posttraining sessions for the management of COPD and asthma among pulmonary outpatients at a tertiary care hospital.
Settings: This prospective cross-sectional study was carried out among patients diagnosed with asthma or COPD and prescribed with inhaler medication in the form of pressurized metered-dose inhaler (pMDI), MDI with spacer, or dry powder inhaler (DPI).
Subjects and Methods: The inhaler device use by the patients was assessed initially, followed by a demonstration on inhaler device technique, and reassessed post training using a checklist.
Statistical Analysis: Comparison of the median total score of pretraining and posttraining inhaler technique was analyzed by Wilcoxon signed rank test. P < 0.05 was considered statistically significant.
Results: Out of 144 patients, 55.6%, 27.7%, and 16.7% of them were prescribed pMDI, MDI with spacer, and DPI, respectively. Post inhaler technique training, about 79.2% of the patients were able to demonstrate the inhaler technique correctly compared to 52.1% prior to training. A statistically significant difference in the median score of inhaler technique has been observed before and after training.
Conclusions: This study reports a significant improvement in the correct use of inhaler technique post training. In addition, the most frequent error among inhaler users was revealed to be in the breath actuation.

Keywords: Dry powder inhalers, metered dose inhalers, obstructive pulmonary disease



How to cite this URL:
Nitya S, Kiruthika S, Meenakshi R, Suriya H, Yuvarajan S. A cross-sectional study of pre- and posttraining evaluation of inhaler use technique among outpatients with bronchial asthma or chronic obstructive pulmonary disease at a tertiary care hospital in India. Perspect Clin Res [Epub ahead of print] [cited 2022 Jan 16]. Available from: https://www.picronline.org/preprintarticle.asp?id=331673


   Introduction Top


Chronic respiratory illnesses such as chronic obstructive pulmonary disease (COPD) and bronchial asthma affect millions of people worldwide. The overall disease burden in relation to chronic respiratory diseases accounts for 6.4% in India, which is about 32% of the global disability-adjusted life years due to chronic respiratory diseases.[1]

Management of asthma and COPD includes use of inhalers as an integral component of bronchodilator and corticosteroid delivery.[2] The amount of medication delivered to the lower respiratory tract depends on the patient's inhaler technique and also on the type of inhaler used.[3] Aerosol drug delivery devices used commonly are pressurized metered-dose inhaler (pMDI), MDI with spacer, and dry powder inhalers (DPIs).

Among many factors, insufficient patient education on proper inhalation technique also contributes to inadequate control of asthma.[4] Awareness about the inhaler devices along with demonstration of the usage of inhaler technique aids in the optimization of therapeutic outcome. Literature review has shown that only few studies had been done in India in this aspect. Hence, the objective of this study was to assess the correct use of inhaler technique following pre- and posttraining sessions for the management of COPD and asthma among pulmonary outpatients at a tertiary care hospital.


   Subjects And Methods Top


Study design and setting

This study was a prospective cross-sectional study carried out in the pulmonary medicine outpatients' department of a tertiary care hospital for a period of 2 months in 2017. Prior institutional human ethics committee clearance was obtained. The study was conducted as per the Good Clinical Practice guidelines.

Study participants

All the outpatients aged >18 years, attending the pulmonary department and diagnosed with asthma or COPD and prescribed with inhaler medication in the form of pMDI, MDI with spacer, or DPI, were included in the study after obtaining prior written informed consent. Patients not willing to give consent and on acute exacerbation were excluded from the study. The confidentiality of the participants was ensured and maintained throughout the study.

Study procedure

A total of 170 patients were approached for participating in the study, out of which 144 patients consented to participate in the study. All the details such as sociodemographic characteristics, diagnosis, duration of the illness and the type of inhaler used, history of smoking, history of hospitalized requirement due to exacerbation in the past 12 months, and information regarding their knowledge on the inhaler usage were noted initially from the prescription of the participants. A checklist for the correct use of inhalational devices such as pMDI, MDI with spacer, and DPI based on the standards of National Institutes of Health guidelines was used for the assessment.[5] The checklist was slightly modified according to the hospital's standard procedure in inhaler technique.

Later, the study participants were asked to demonstrate their prescribed inhaler device, which was assessed using the checklist regarding the usage of correct inhaler techniques by the investigator. This was taken as the pretraining score. Then, the correct use of inhaler technique was demonstrated using demonstration devices as a face-to-face training session by the same investigator to all the participants. After the training session, the participants were asked to attend the pulmonary outpatient department on the next day to re-demonstrate the procedure, which was again assessed for the correct steps in the use of inhaler by the investigator using the checklist. This was considered as the posttraining score. A score of “1” was allocated on the correct technique and “0” if incorrect for each step in the checklist on the use of inhaler devices. A total maximum score of “8” was given for pMDI and DPI inhaler devices and a maximum score of “9” for the MDI with spacer device.

Statistical analysis

Microsoft Excel was used for data entry and SPSS version 21 (IBM Corp., Armonk, NY, USA) for data analysis. Dependent variables were expressed as frequency and percentage. Binary logistic regression model was used to identify the factors that were associated with the dependent and independent variables. Comparison of the median total score of the pretraining and posttraining inhaler techniques was analyzed by Wilcoxon signed rank test. P < 0.05 was considered statistically significant.


   Results Top


Sociodemographic and other characteristics of the study population

The mean age of the included patients was 31.03 ± 8.8 years. Out of the 144 patients, about 110 (76.4%) and 34 (23.6%) patients were diagnosed with bronchial asthma and COPD, respectively. Majority (80 [55.6%]) of them were prescribed MDI, and 40 (27.7%) and 24 (16.7%) patients were using MDI with spacer and DPI, respectively. Before and after the training session, a statistically significant association was not observed between the use of inhaler technique and any of the characteristic factors mentioned in [Table 1].
Table 1: Sociodemographic and other characteristics of the study population

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The percentage of patients who were able to use the inhaler correctly and the errors encountered in the various steps of the inhaler technique are described in [Table 2], [Table 3], [Table 4].
Table 2: Assessment of the technique involved in the use of pressurized metered-dose inhaler by the study population

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Table 3: Assessment of the technique involved in the use of metered dose inhaler with spacer inhaler by the study population

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Table 4: Assessment of the technique involved in the use of dry powder inhaler by the study population

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Pretraining evaluation

About 75 (52.1%) patients were able to demonstrate the inhaler technique correctly prior to the training. The frequency of correct use of inhaler was 38 (47.5%), 27 (67.5%), and 10 (41.7%) in patients using pMDI, MDI with spacer, and DPI, respectively [Figure 1].
Figure 1: Frequency of correct and incorrect inhaler users prior to training

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Posttraining evaluation

Post training, about 114 (79.2%) patients were able to demonstrate the inhaler technique correctly. The frequency of correct use of inhaler was 67 (83.7%), 31 (77.5%), and 16 (66.7%) in patients using pMDI, MDI with spacer, and DPI, respectively [Figure 2]. A statistically significant (P < 0.001) difference in the median score of inhaler technique was observed before and after training [Table 5].
Figure 2: Frequency of correct and incorrect inhaler users post training

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Table 5: Comparison of the median total score of pre- and posttraining session for each inhaler device

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   Discussion Top


In this study, more than half of the study participants (55.6%) were prescribed with pMDI. The most commonly prescribed type of inhaler is pMDI as the medication is delivered in a precise amount as aerosol on every single use and do not require rapid or forceful inspiration.[6]

During the pretraining session, about 58.4% of the participants demonstrated the usage of DPI incorrectly, which is consistent with that of previous studies.[7],[8] The predominant incorrect step was “to take a fast, deep, forceful breath through mouth.” It is crucial that a rapid deep inhalation is taken to dissociate the medication and is forceful enough to deliver the dispersed powder to the lungs. After the training session on correct technique in the usage of the inhaler, the percentage of correct use increased from 41.7% to 66.7%.

Among the pMDI users, about 52.5% had their inhaler technique incorrect. The error most exhibited by them was in the step of “breathe in slowly and deeply while pressing down on the inhaler,” which is similar to that of the previous studies done in other countries as well.[9],[10] Furthermore, the most frequent error noticed in the use of MDI with spacer also pertained to breathing in slowly and deeply after pressing the canister. Although the breath actuation is not mandatory in an MDI with spacer, little or no delay is essential in coordination between inhalation and pressing the canister for effective delivery of the aerosol.[11] An overall significant improvement in inhalation technique was observed following the face-to-face training to a percentage of about 83.7% in pMDI and 77.5% in MDI with spacer users from the pretraining inhaler use of 47.5% and 67.5%, respectively.

The demonstration of inhaler technique made a significant increase in the percentage of correct use of inhaler device, however about 20% of the patients made errors in the technique even after the training. Literature shows that long-term control of asthma is less in poor coordinators of actuation of canister with inhalation than those who use the pMDI correctly.[12],[13]

This study did not reveal any significant predictors in the correct use of inhaler, however male gender and education level have been the consistent strong predictors in the correct usage of inhaler devices.[14],[15]

The strength of the study is the inclusion of the inhaler technique for all types of inhaler devices frequently prescribed in the hospital. The limitations of the study are the cross-sectional design and that the study was conducted at a single center.


   Conclusions Top


This study reports a significant improvement in the correct use of inhaler technique post training. Furthermore, periodic assessment and retraining on a regular basis maximize the effective usage of inhaler devices for optimum drug delivery among bronchial asthma and COPD patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
India State-Level Disease Burden Initiative CRD Collaborators. The burden of chronic respiratory diseases and their heterogeneity across the states of India: The global burden of disease study 1990-2016. Lancet Glob Health 2018;6:e1363-74.  Back to cited text no. 1
    
2.
Usmani OS. Choosing the right inhaler for your asthma or COPD patient. Ther Clin Risk Manag 2019;15:461-72.  Back to cited text no. 2
    
3.
Global Strategy for the Diagnosis Management and Prevention of COPD Global Initiative for Chronic Obstructive Lung Disease (GOLD); 2014. Available from: http://www.goldcopd.org/. [Last accessed on 2014 Mar 13].  Back to cited text no. 3
    
4.
Virchow JC, Crompton GK, Dal Negro R, Pedersen S, Magnan A, Seidenberg J, et al. Importance of inhaler devices in the management of airway disease. Respir Med 2008;102:10-9.  Back to cited text no. 4
    
5.
National Asthma Education and Prevention Program. National Institutes of Health; 2013. Available from: https://www.nhlbi.nih. gov/files/docs/public/lung/asthma_tipsheets.pdf. [Last accessed 2013 May 29].  Back to cited text no. 5
    
6.
Sanchis J, Corrigan C, Levy ML, Viejo JL, ADMIT Group. Inhaler devices-from theory to practice. Respir Med 2013;107:495-502.  Back to cited text no. 6
    
7.
Shrestha S, Shrestha S, Baral MR, Bhandari S, Chand S, Tamrakar R, et al. Evaluation of inhalation technique in patients using a dry powder device (DPI) at chest clinic in Dhulikhel Hospital – Kathmandu University Hospital, and the effect of patient education on it. Clin Med (Lond) 2019;19 Suppl 3:64-6.  Back to cited text no. 7
    
8.
Sapkota D, Amatya YR. Assessment of Rotahaler inhalation technique among patients with chronic obstructive pulmonary disease in a teaching hospital in Nepal. J Kathmandu Med Coll 2017;5:11-7.  Back to cited text no. 8
    
9.
Pothirat C, Chaiwong W, Phetsuk N, Pisalthanapuna S, Chetsadaphan N, Choomuang W, et al. Evaluating inhaler use technique in COPD patients. Int J Chron Obstruct Pulmon Dis 2015;10:1291-8.  Back to cited text no. 9
    
10.
Ramadan WH, Sarkis A, Aderian SS, Milane A. Asthma and COPD patients' perception of appropriate metered dose inhaler technique. Dose Response 2020;18:1559325820917832.  Back to cited text no. 10
    
11.
Vincken W, Levy ML, Scullion J, Usmani OS, Dekhuijzen PNR, Corrigan CJ. Spacer devices for inhaled therapy: why use them, and how? ERJ Open Res. 2018;4:00065-2018.  Back to cited text no. 11
    
12.
Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002;19:246-51.  Back to cited text no. 12
    
13.
Lavorini F. The challenge of delivering therapeutic aerosols to asthma patients. ISRN Allergy 2013;2013:102418.  Back to cited text no. 13
    
14.
Rootmensen GN, van Keimpema AR, Jansen HM, de Haan RJ. Predictors of incorrect inhalation technique in patients with asthma or COPD: A study using a validated videotaped scoring method. J Aerosol Med Pulm Drug Deliv 2010;23:323-8.  Back to cited text no. 14
    
15.
Bartolo K, Balzan M, Schembri EL, Asciak R, Mercieca Balbi D, Pace Bardon M, et al. Predictors of correct technique in patients using pressurized metered dose inhalers. BMC Pulm Med 2017;17:47.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

 
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