ORIGINAL ARTICLE
Year : 2022 | Volume
: 5 | Issue : 3 | Page : 102--105
Effectiveness of educating proper inhaler technique in chronic obstructive airway disease patients visiting pulmonology outpatient department
Aishwarya Alavandar, Vinod Govindasaami, Dhanasekar Thangaswamy, Koushik Muthuraja
Department of Respiratory Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
Correspondence Address:
Dr. Aishwarya Alavandar
Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu
India
Abstract
Objective: Inhaler usage plays a key role in the treatment of chronic obstructive airway diseases. Improper usage technique is the most common but correctable aspect of the inhaler therapy, which leads to poor disease control, additional medications, morbidity, repeated exacerbations, and admissions. The usage of proper inhaler technique ensures good treatment outcome.
Methods:
- This was a prospective study using a sample size of 66 adult patients of varying age group attending the Pulmonology Outpatient Department (OPD) in Sri Ramachandra Medical College and Research Institute – Porur, Chennai
- Data were collected using questionnaire
- Assessing and scoring the patient's inhaler technique on 1st visit to pulmonology OPD followed by teaching them proper inhaler technique using simple 4-step method
- Reviewing the same patient after 1 month, assessing and scoring to grade the outcome as good (4 scores), adequate (3 scores), and inadequate (2 or less).
Results: The number of patients with inhaler technique adequacy (scores of 3 and 4) was 44% in the study's initial phase. The study participants were trained on each stage of the inhaler technique till a level of accuracy is reached and the patient is made aware about the proper technique. The participants during the review process exhibited improved levels of technique adequacy. Overall inhaler technique adequacy (score of 3 and 4) of the study participants reached 91% in the review stage (after 1 month). Part of patient care to educate the patients regarding proper inhaler technique has been found to be highly effective. Conclusion: Proper education on correct method of inhaler technique may not only improve the symptoms of the disease but also helps in dose reduction in long-term. Health professionals should encourage and instruct on correct inhalation technique and regularly re-evaluate the patient's inhalation technique during every OPD visit. Thus, proper counseling for the inhaler use in patients must be encouraged as it is closely related in quality of life of patient.
How to cite this article:
Alavandar A, Govindasaami V, Thangaswamy D, Muthuraja K. Effectiveness of educating proper inhaler technique in chronic obstructive airway disease patients visiting pulmonology outpatient department.J Assoc Pulmonologist Tamilnadu 2022;5:102-105
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How to cite this URL:
Alavandar A, Govindasaami V, Thangaswamy D, Muthuraja K. Effectiveness of educating proper inhaler technique in chronic obstructive airway disease patients visiting pulmonology outpatient department. J Assoc Pulmonologist Tamilnadu [serial online] 2022 [cited 2023 May 29 ];5:102-105
Available from: https://www.japt.in//text.asp?2022/5/3/102/370807 |
Full Text
Background
Chronic obstructive airway disease (COAD) is a chronic respiratory disease, i.e., highly prevalent in developing countries. A global survey by the WHO has shown that COAD is one among the leading cause of death in noncommunicable disease (NCD) category. More than 3 million people died due to COAD in 2012 which accounts to around 6% of the global deaths. The National Health Policy of India has aimed to reduce the mortality rate from NCDs by 25% in 2025. COAD is the 3rd leading contributor to mortality and morbidity.
COAD is one of the common preventable and treatable NCD characterized by persistent respiratory symptoms and airflow limitations due to airway obstruction. Hospitalization is more common due to exacerbations of COAD. Major treatment guidelines for COAD suggest the use of bronchodilators through inhaler devices. The challenge in treating COAD is to the delivery drug by proper method to achieve therapeutic benefits. There are numerous reasons for the lack of disease control in COAD patients. One of the most associated reasons is poor knowledge about inhalation technique and noncompliance to the prescribed treatment plan by the patient. The treatment goal is to reduce symptoms, risk of hospital admission due to exacerbations, control disease progression, and improve quality of living.
As per the Global Initiative for Chronic obstructive lung disease guidelines, emphasizes the use of bronchodilators with proper inhaler technique and regular follow-up to ensure ideal drug delivery. It is therefore very important to educate the patients about inhaler usage and counsel them to use inhalers regularly as prescribed by health professionals.
Against this backdrop, the present study was planned to assess the inhaler technique in patients with COPD visiting the pulmonology outpatient department (OPD) and assess the factors affecting improper techniques and teach them proper inhaler techniques using a simple easy 4-step method and reassess after 1 month and score the outcome.
Objectives
To assess technique of inhaler usage, to know the effectiveness of educating proper inhaler technique
Methods
This was a prospective study using sample size of 66 adult patients using inhalers of varying age group attending Pulmonology OPD in Sri Ramachandra Medical College and Research Institute – Porur.
Inclusion criteria
All patients who use inhalers (dry powder inhaler/Metered dose inhaler [DPI/MDI]) for COAD for more than 6 months in the age of above 18 years were included in this study.
Exclusion criteria
Patients who did not give consent for the study were excluded from this study.
Study procedure
Patients who are diagnosed COPD/bronchial asthma using either DPI or MDI visiting pulmonology OPD was taken for the study. The patient's medical history is noted. Data were collected using pro forma.
Assessing and scoring the patient's inhaler technique on 1st visit to pulmonology OPD is done and followed by teaching them proper inhaler technique using simple 4-step method.
Reviewing the same patient after 1 month, assessing and scoring to grade the improvement and to understand patient's gained knowledge about the proper technique.
Scoring is given according to their outcome as follows:
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Overview of study
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Results
Gender
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Of the study population, the inadequate inhaler technique was comparatively higher in the females (59% vs. 53%).
Age
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In the study population, there is no significant difference in the inhaler technique erroring between various age groups.
mMRC grade
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In the present study group, the inhaler technique inadequacy was maximum in grade 4 mMRC breathlessness patients (100%), followed by grade II.
Education level and inhaler technique adequacy
In the study population, the subjects who are illiterate form 58% of the group while literates are 42%.
Pre intervention
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It has been observed during preintervention that the illiterate participants had a slightly higher inadequate inhaler score (2 or less) at 58% compared to 54% in the literate participants.
Postintervention, the results are as tabulated below:
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It is observed that the literate participants were able to learn proper technique and achieve 100% (from 46%) adequate inhaler score while the illiterate participants improved their adequate inhaler score from 42% to 84%. Lower education level patients need repetitive education for inhaler training to improve their techniques.
Inhaler technique: Dry powder inhaler versus metered dose inhaler
The study population had 79% of the participants using the MDI technique while DPI technique is used by the remaining 21%.
Preintervention
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It is observed that the majority of the MDI technique users (at 62%) had inadequate inhaler score (2 or less) compared to the DPI technique users (at 36%) before intervention.
Postintervention
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It is observed that postintervention both the MDI and DPI technique users were able to achieve significant gains and reach over 90% of adequate inhaler score (3 or 4).
Inhaler usage technique
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In the present study, the most common step erred was step 2 (positioning and breath out gently) and step 3 (adequate inspiratory effort), both the steps were correctly followed only by 32 out of 66 participants. Breath holding was correctly done by 56% of patients; preparation of the device was done correctly by almost one-fourth of the study population.
Post intervention
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The adequacy of the inhaler technique had improved from 44% to 91% postintervention. The interventions done were physical demonstration, video demonstration, and pamphlets.
Discussion
The slight proclivity to female gender in inadequate inhaler usage technique was comparable to Goodman et al.,[1] who found the inhaler usage technique was more proper in males compared to females. However, they found a wider discrepancy in the error between the sex compared to our study which showed it to be minimal. This may be attributed to (i) small study population, (ii) different geographic population, (iii) their study group had assessed only MDI using population, and (iv) that their study was done 20 years ago. Similar findings were noted by Ocakli et al. in their study.[2]
No age correlation with inhaler technique adequacy is consistent with the study done by Goodman et al.[1] who found no difference in the inhaler technique between younger and older subjects. However, a systematic review done by Barbara et al. showed a negative correlation between advancing age and correct inhaler technique.[3] This variation across studies could be due to differing study population size, geography, educational status, and period of the study. It is observed that lower education level patients need repetitive education for inhaler training to improve their techniques. During the study, though there are score differences between inhaler devices imparting proper teaching yields desired results.
In the present study, the severity of the breathlessness as a separate factor does not directly lead to errors in inhaler technique. Inhaler technique errors are documented to be more in patients with severe disease and to be less in well-controlled disease in a south Indian study.[4] In our study, the bias could be due to the small study group.
The most common step error was comparable to a systematic review done by Sanchis et al.,[5] who mentioned that expiration was the most common error noticed in both metered dose and dry powdered inhaler devices. In another study done by Khassawneh et al.,[6] inspiratory effort was found to be the mistaken step. Both these steps are found to be the most errored steps in our study.
The adequacy of the inhaler technique had improved from 44% to 91% postintervention. The interventions done were physical demonstration, video demonstration, and pamphlets. In a systematic review done by Klijn et al.,[7] it was found that educational interventions effectively improve the technique in the short-term and that periodical reinforcement is required for the long-term.
Conclusion
Inhaler therapy, being the cornerstone of the treatment of obstructive airway disease, has to be given a proper consideration during practice for adequate disease control and improving outcomes. The errors in using the device have been a known factor which happens at the same rate even in this tech savvy era.
Acknowledgment
We would like to thank the Department of Respiratory Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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| 2 | Ocakli B, Ozmen I, Tuncay EA, Gungor S, Ozalp A, Yasin Y, et al. Influence of gender on inhaler technique. Respir Care 2020;65:1470-7. |
| 3 | Barbara S, Kritikos V, Bosnic-Anticevich S. Inhaler technique: Does age matter? A systematic review. Eur Respir Rev 2017;26:170055. |
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| 5 | Sanchis J, Gich I, Pedersen S, Aerosol Drug Management Improvement Team (ADMIT). Systematic review of errors in inhaler use: Has patient technique improved over time? Chest 2016;150:394-406. |
| 6 | Khassawneh BY, Al-Ali MK, Alzoubi KH, Batarseh MZ, Al-Safi SA, Sharara AM, et al. Handling of inhaler devices in actual pulmonary practice: Metered-dose inhaler versus dry powder inhalers. Respir Care 2008;53:324-8. |
| 7 | Klijn SL, Hiligsmann M, Evers SM, Román-Rodríguez M, van der Molen T, van Boven JF. Effectiveness and success factors of educational inhaler technique interventions in asthma & COPD patients: A systematic review. NPJ Prim Care Respir Med 2017;27:24. |
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