Assessment of Correct Technique of Inhalational Devices in patients with Obstructive Airway Diseases in A Tertiary Care Hospital

 

Dr. Kavitha. R¹, Dr. Deepti. V.D.²*, Sangeetha. S³

¹Professor, Department of Pharmacology, Sri Ramachandra Medical College and Research Institute, Chennai.

²Assistant Professor, Department of Pharmacology, PES Institute of Medical Sciences and Research, Kuppam

³Final Year MBBS, Karpaga Vinayaga Institute of Medical sciences, Madhuranthagam

 

ABSTRACT:

The study is designed to assess the correct technique of inhalational devices with the standard checklist and to evaluate the errors committed in different steps of use. Eighty-two patients with bronchial asthma and COPD aged between 18 - 60 years of age were enrolled for the study. It was a cross-sectional study which was done for a period of 2 months. The inhalational technique used by the patient with COPD or bronchial asthma was assessed based on the checklist provided and the errors committed in different steps of use were observed and recorded. Of the total 82 study subjects, 68 were using pressurized Metered Dose Inhaler (pMDI) and 14 were using Dry Powder Inhaler (DPI); among them 14.7% of the pMDI users and 14.3% of the DPI users were able to perform all the steps correctly. There was no difference found in the frequency of errors committed in taking different devices according to the patient’s socioeconomic or educational background. This study shows that irrespective of the knowledge gained, many of them were committing mistakes in different steps while using inhaler devices, so it is necessary to conduct a health education program and repeated hands-on training to use the inhalers correctly to achieve the desired effects among the patients with bronchial asthma and COPD.

 

 

INTRODUCTION:

Bronchial Asthma and Chronic Obstructive Pulmonary Disease (COPD) are the common obstructive airway diseases, which are estimated to affect some 300 million people worldwide¹. The common symptom associated with these diseases is breathlessness, which is a most distressing symptom, affecting their day to day activities. The breathlessness is mainly due to the bronchospasm, which can be relieved by the use of an inhaler.

 

An inhaler is a medical device used for delivering medication into the body via the lungs which can be carried anywhere because it is a small device.

 

There are different types of inhaler such as metered dose inhaler and dry powder inhaler. The most commonly used inhaler is the pressurized metered dose inhaler (pMDI).

 

In pressurized metered dose inhaler (pMDI), the medication is stored in the form of solution in a pressurized canister that contains a propellant. On pressing the canister, the metered dose inhaler releases a fixed dose of medication in aerosol form. The medication commonly used contains a bronchodilator or a corticosteroid or a combination of both⁷. The metered dose inhalers are sometimes used with the spacer, which are tubes attached to the inhaler that act as a reservoir or holding chamber and reduce the speed at which the aerosol enters the mouth. They serve to hold the medication that is sprayed by the inhaler and ensures that more of the medication enters the lung instead of going out. Spacers can be helpful to those who find a regular metered dose inhaler hard to use.

 

The dry powder inhaler (DPI) is an alternative to the aerosol-based inhalers which delivers the medication in the form of a dry powder into the lungs. The medication is commonly held either in a capsule for manual loading or a proprietary from inside the inhaler, which does not contain any propellant. Since the amount of force needed to inhale the drug is more it can lead to reduced dose delivery.

 

The advantages of inhaler is that it is easy to use, has rapid onset of action and provides immediate relief of symptoms, because the drugs need not to be absorbed through the digestive system, it is directly delivered to the airways and provides local pulmonary effects avoiding the systemic side effects associated with oral therapy, the dose required is also in micrograms and not in milligrams².

 

Since the dose is in micrograms it is essential that the device should be used properly to achieve the desired effects,⁵ but at least 90% of asthmatics tend to use their inhaler devices incorrectly or with mistakes missing on most of the beneficial effects it may provide, so they are not getting relieved of their of symptoms. Although all these inhalers are designed to improve use, still significant rates of incorrect use were seen among COPD and bronchial asthma patients.

 

Hence, this study of assessing the correct technique of inhaler devices among bronchial asthma and chronic obstructive pulmonary disease (COPD) patients was attempted in a tertiary care hospital to reveal the importance of proper technique of inhalation.

 

MATERIALS AND METHODS:

The current study is conducted on patients with Chronic obstructive pulmonary disease and bronchial asthma attending internal medicine OPD at Karpaga Vinayaga Institute of medical sciences, Madhuranthagam. The study was intended to conduct for a period of 2 months with sample size of 82 patients. The sampling was done based on convenient sampling. The patients who were included in the study are 18-60 years of either sex and hemodynamically stable. Those patients with acute exacerbation who requires hospitalization and on nebulizer treatment are excluded. Pregnant women and pediatric age group are also excluded.

 

Enrolled patients were assessed for inhalation technique compliance at their routine medical visits without prior notification. They were asked to say each step as they were performing it, so that all of the steps could be clearly observed. This assessment was performed with a standard checklist based on the instructions provided by the manufacturer and from previous studies. The study was conducted after obtaining the IEC approval and informed consent from the patient.

Statistical Analysis:

The statistical analysis is done by Excel data analysis tools. Primary data were entered in MS Excel spread sheet, Where qualitative data were expressed as frequencies and percentages.

 

RESULTS :

Table 1: Demographic profile of the patients

 

The data depicted in the above table shows the demographic profile of the patients who have participated in our study. Our study includes the patients of either sex with male (48.8%) and female (51.2%) patients. More number of patients were around the age group of 51-60 years (48.8%). Bronchial asthma (70.7%) patients were more compared to COPD (29.3%). And most of the patients were found to use pMDI and they find it easy to use.

 

Table 2: Distribution of patients based on occupation, education and socioeconomic status

 

Table 3: Distribution based on co-morbidities

 

Based on the occupation, most of the participants in the study were unemployed (48.7%) and they have less knowledge of using the inhaler by correct technique. Almost half of the patients were completed middle school (26.3%) and primary school (29.3%) Based on the educational status. Most patients belong to the socioeconomic scale of lower middle (41.5%)

 

Table 4: Distribution of patients based on family history and personal history

 

Comparing the family history, there is no positive family history in (82.9%). Most of the patients are not associated with any co-morbidities (73.3%).

 

 

Graph 1: Distribution of patients based on the usage of inhalational devices

 

Graph 2: Distribution of patients based on the drug used

 

Most commonly used drug in all the patients were salbutamol (51.2%). Most of the incorrect techniques were followed by the patients using pMDI in comparison to DPI. Table 5 shows that majority of the study subjects were correctly doing the steps 1 (100%), 5 (91.2%), 7(97.1%), 12 (100%), and majority were wrongly doing the steps 2 (85.3%), 4 (70.6%), 6 (70.6%), 10 (58.8%). DPI users are almost doing all the steps correctly. Table 6 shows that majority of the DPI steps were correctly performed, except steps 3 (85.7%) and 7 (85.7%).

Table 5: pMDI steps correctly done or not

 

Table 6: DPI steps correctly done or not

 

DISCUSSION:

Most patients with asthma or COPD do not use their inhalers properly, and most have not had their technique checked or corrected by a health professional. Poor asthma symptom control is often due to poor technique. Incorrect inhaler technique increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD and also increases the risk of side-effects like dysphonia and oral thrush. Using the inhaler has become a great task to many person, because there are many steps to be followed.

 

In 2014, the National Review of Asthma Deaths (NRAD) reported that misunderstanding and misuse of inhalers was thought to have contributed to a significant number of the 195 asthma deaths during 2012⁸. Although the preferred and safe method of management of bronchial asthma and COPD is inhalation, a previous study suggests that many patients are unable to use their inhalers effectively⁹. Despite many studies results vary, percentage of inhaler errors include up to 90% of patients using pressurized metered dose inhalers (pMDIs)^9,10,11 and up to 54% of patients using dry powder inhalers (DPIs)^9,11. Improper inhaler technique reduces drug deposition to the lungs, wastes medication and may lead to ineffective management, decreased quality of life, increased emergency hospital admissions and higher treatment costs^12,13. Many studies were conducted on the proper inhalational techniques. There is increasing evidence to suggest that correct inhaler technique plays an important role in improving medicine adherence, clinical outcomes, quality of life and use of health care resources^14,15,16,17.

 

As previous studies reported that Patients committed more errors when using metered dose inhalers than using the dry powder inhalers, in our study also we observed that, among 82 patients majority of them were using pMDI (82.9%) compared to the DPI (17.1%) and the errors committed were more among the pMDI (34.8%) users than the DPI (28.6%) users.

 

CONCLUSION:

Nowadays, the prevalence of bronchial asthma and COPD are more, so proper training of the inhalational device steps are necessary for the effective control of the disease.

 

This study shows that irrespective of the knowledge gained, many of them were committing mistakes in different steps, so it is necessary to conduct a health education program and repeated hands-on training about the different types of inhaler devices and the ways to properly use the inhalers to achieve the desired effects.

 

CONFLICTS OF INTEREST:

Nil.

 

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18.   The National Institute for Health and Care Excellence guideline [CG101]. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care 2010. Available at: http://www.nice.org.uk/guidance/CG101/ (accessed July 2016).

 

 

Accepted on 22.11.2019           © RJPT All right reserved

Research J. Pharm. and Tech 2020; 13(6): 2873-2876.