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ORIGINAL ARTICLE
Year : 2021 | Volume
: 70
| Issue : 1 | Page : 54-59
An evaluation of metered-dose inhaler administration technique among patients of asthma and chronic obstructive pulmonary disease in Saudi Arabia
Abdulaziz M Alsufyani
College of Nursing, King Saud University,Taif Comprehensive Rehabilitation Center, Ministry of Human Resources and Social Development, Taif, Riyadh
Correspondence Address:
MSN, RN Abdulaziz M Alsufyani
College of Nursing, King Saud University, Taif, 11461, Saudi Arabia
Riyadh
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ejcdt.ejcdt_54_20
Context Patients with asthma and chronic obstructive pulmonary disease (COPD) are majorly prescribed inhaled medications. This prescription is based on their efficacy and few adverse effects.
Aim The study intends to evaluate metered-dose inhaler (MDI) administration technique among patients of asthma and COPD in Saudi Arabia.
Settings and design A retrospective, cross-sectional observational design was used, and it was performed at the chest out-patient clinic at King Faisal Medical Complex, Taif, Saudi Arabia.
Materials and methods A total of 144 Saudi patients who were diagnosed either for asthma and COPD were included. It also included patients with prescribed inhalation agents in the form of MDI.
Statistical analysis IBM SPSS (Statistical Package for the Social Sciences) version 23.0. was used. Demographic characteristics were presented in the form of percentages and frequencies, whereas descriptive statistics were also applied. The significance value was determined at P value less than or equal to 0.05.
Results Patients with asthma majorly used MDI technique, had unlimited attacks per month, and had experienced less than five attacks per month. The demographic evaluation showed that sex and age are insignificantly related to the use of MDI. However, education, medical diagnosis, number of asthmatic attacks per month, and duration of the MDI use were significantly related to the proper use of the MDI technique.
Conclusion The findings of the study recommend that although patients were aware of the correct use, more training needs to be initiated. Educational intervention programs should be initiated for improving the MDI technique use among patients.
Keywords: asthma, chronic obstructive pulmonary disease, inhaler techniques, metered-dose inhaler, Saudi Arabia
Chronic obstructive pulmonary disease (COPD) and asthma are the major chronic conditions that hold 78% of the direct respiratory disease health care costs [1]. Treatment of this chronic disease is significant, given the increasing adverse outcomes of the two diseases. For instance, the WHO reports that COPD accounts for three million deaths globally [2]. Most studies show that the use of inhalation technique helps improve its efficacy, prominent of which are metered-dose inhalers (MDIs) and dry-powder inhalers [3],[4]. However, improved health outcomes are achieved when the inhalation devices are properly adhered to and correctly used [4]. Although various research studies have assessed the feasibility of MDI, the correct use concerning MDIs remains limited [5]. Therefore, this study intends to evaluate the MDI techniques use among patients with asthma and COPD who had been diagnosed at the chest outpatient clinic at King Faisal Medical Complex (KFMC).
Materials and methodsResearch design
A retrospective, cross-sectional observational design was conducted in the chest outpatient clinic at KFMC, Taif, Saudi Arabia. The study involved 144 Saudi patients of either sex, diagnosed to have asthma and COPD and who are prescribed inhalation agents in the form of MDI. The study excluded non-Saudi patients because they visit different clinics (paid treatment), pregnant female, children, and those who receive MDI by others or caregivers owing to disabilities. The starting age of inclusion was 16 years old. The data were collected from August 2019 to December 2019.
Research instrument
Materials for data collection included an informed consent form, demographic survey, and a standardized checklist for assessing the patient’s use of MDI. The standardized checklist is developed by National Asthma Council Australia (NACA) as a standardized checklist for assessing the proper use of MDI (see https://www.nationalasthma.org.au/). The NACA’s checklist suggests eight essential steps for proper MDI use ([Table 1]). The NACA’s checklist validity is approved by four pulmonologists at KFMC. The patient’s demographic characteristics such as sex, age, and education levels were included in the demographic survey. It also included other characteristics that might influence the patient’s ability to demonstrate proper use of MDI. This includes information about the number of asthmatic attacks per month, the period of using MDI use as a treatment, and the patient’s educator for the use of MDI was also included.
Data collection procedure
Data were collected only from the patients who met the inclusion criteria and agreed to participate in the study. The participants were asked to demonstrate (with a placebo) how to use MDI at home, so that the steps could be assessed and compared with the NACA’s checklist, which was then recorded by the researcher and two pharmacists, who were trained in technique assessment using a standardized checklist as NACA’s checklist. Based on the recommendations of NACA’s checklist and pulmonologists at KFMC, the proper use of MDI is achieved when the patient performed all of the eight essential steps of the proper MDI use, otherwise the performance is considered inadequate. This data collection method is centered on achieving the following objectives:
To assess the prevalence of the improper use of MDI among Saudi patients of asthma or COPD diagnosis.To determine whether any difference exist between the selected demographics and the participant’s ability to properly use the MDI.To determine whether any difference exist between the number of asthmatic attacks per month and participant’s ability to properly use the MDI.To determine whether any difference exists between the participant’s educator for using the MDI and his/her ability to properly use the MDI.Ethical consideration
This study was approved by the Institutional Ethics Committee and was started after taking permission from the KFMC’s administration representative to collect data. All of the participants were instructed about the purpose of the current study, its confidentiality, their right to refuse or withdraw from the study at any time without any penalties, and the anonymity of the data. In addition, participants were confirmed that any presentation of publication based on the current study’s findings will not present the participants’ information.
Data analysis
The analysis of the collected data was performed using IBM SPSS (Statistical Package for the Social Sciences) Version 23.0 (IBM Corp., Armonk, NY, USA). The demographic characteristics were assessed using percentage and frequency, whereas descriptive statistics such as χ2 was used for evaluating the significance of the studies variable.
Results[Table 2] presents the demographic characteristics of the patients. It shows that most patients were male, that is, (n=78) as compared with females (n=66). The age group concerning the patients showed that the majority of participants with ages ranging from 40 to 59 years (n=73), followed by participants with ages above 60 years (n=57), and 16 to 39 years (n=14). The education level of the patients showed that the sample constitutes most of the patients who had either completed their higher secondary school or had above qualification (n=51). The participants who had completed their intermittent secondary school were 45, primary school education students were 29, whereas the remaining 19 patients were illiterate.
The medical diagnosis of the patients showed that the majority had asthma (n=86) than COPD (n=58). Concerning the number of asthmatic attacks per month, it was found that the majority of the sample patients had unlimited attacks per month (n=51) followed by patients who experience less than 5 attacks per month (n=48). A total of 33 patients experienced asthmatic attacks once a month, whereas 12 patients experienced 5–10 asthmatic attacks per month. The duration of the use of MDI was also assessed among the respondents. The findings showed that a similar number of patients used MDI for more than 12 months (n=65), and less than 12 months (n=67), whereas every few used it for less than 6 months (n=12). The researcher also evaluated the source which explained to them their treatment procedure. The results showed that patients who use/consume the same drug were the major information sources, whereas physicians as knowledge sources were reported by 49 patients, and specialized nurses were reported by 41.
[Table 3] shows the significant differences between the selected demographics and the use of MDI among the respondents. The incorrect use was mostly performed by the males (n=32) as compared with females (n=17), where the percentages of the correct use were similar for both male and female (n=46, and n=49, respectively). It shows the sex had an insignificant difference with the use of MDI (P=0.054). The age group shows that correct use was mostly held by the age group 40–59 years (65.8%), followed by patients above 60 years (63.2%). A similar insignificant difference was found for the age group and the use of MDI (P=0.551). Patients who had completed their higher secondary school education or above correctly used it (96.1%), had asthma (79.1%), and less than five attacks per month (91.7%). These were also found to substantially affect the proper use of MDI among the respondents (P=<0.05, i.e., 0.000). Duration of the use of MDI and the source of information also affected the patient’s use of MDI (P=0.008 and 0.000, respectively).
Table 3 Association between the selected demographics and the use of metered-dose inhaler[Figure 1] presents the percentage of correct performance for each step related to the proper use of MDI among participants. All the steps were almost adequately performed by the participants, though major difficulty arose in step 6 (70.1%) and step 5 (75.7%).
DiscussionThe findings of the study suggest that the use of MDI helps enhance the outcomes of the patients. The findings of the study suggest that sex and age had an insignificant association with the correct use of MDI. However, education, medical diagnosis, number of asthmatic attacks per month, and duration of the MDI use were significantly related to the use of the MDI technique.
Similarly, the present study results showed that education had a substantial effect on the correct use of MDI. Similar results have been concluded by the study of Chauhan et al. [6], which showed that students with secondary education adhered more to the essential steps as compared with the patients with primary education or no education. It is because these patients generally perceive physicians as their ultimate savior and follow the suggested instructions blindly [7]. Barbara et al. [1] finding corroborate with the study results showing no correlation between age and correct use of the inhaler technique. Belachew et al. [8] also showed that sex had no effect on the effective or adherence to the MDI technique use. Chorao et al. [9] showed that this may also be owing to the patient’s lower education level, which increases the patient’s chances to miss the steps.
Understanding of the correct use of the device is integral for its effectiveness. Previous research concerning it has shown that mishandling of inhaler techniques resulted in increased emergence of the critical errors by 50% in the corticosteroids’ course, hospital admissions, and the number of visits in an emergency [10]. For instance, the study results of Al Ammari et al. [11] have demonstrated that patients with asthma or COPD have faced treatment failures because of incorrect use of inhaler techniques and medication. The primary reasons identified in the research include the lack of adequate counseling, proper education regarding inhaler technique is not provided to patients or sometimes their educational strategies do not suit their learning style, and some patients have a poor vision about asthma.
The lack of educational support might occur owing to different factors. This includes that health care professionals are not properly trained to guide or educate their patients regarding inhaler medication and techniques. The study by Hamdan et al. [12] further highlighted the training, where 45% of Saudi Arabian patients with asthma did not use asthma devices properly, 40% did not attend training session regarding ‘how to use the inhaler devices,’ and only 6–7% were educated by the asthma educators or pharmacists. It has been reported that many respiratory therapists and pharmacists lack skills that are required to educate correct inhaler devices. Great effort has been put forward to improve this condition. The PHARMACOP (patients of COPDs are cared for by effective pharmaceutical care programs) trials show that this program is designed to improve inhaler medication and techniques adherence. The PHARMACOP trials are also cost-effective, and analysis showed that around €277 amount is saved on per-patient every year and hospital-treated exacerbation of patients is decreased by 0.07 in the first three months, comparative to the casual care.
Health care professionals familiar with the importance of the inhaling technique should educate patients and reassess and revise their knowledge skills from time to time so that they can provide proper education on the correct use of inhaler techniques. The study suggests that patients will get the education regarding inhaler techniques upon their admission, and will be re-educated on the discharge day. Moreover, their techniques must be revised every time they visit the clinic.
The incorrect use was majorly related to the inappropriate holding of breath and failing to twist the grip as of the mentioned techniques. A comparison of the study findings with the literature report finding suggests the inappropriate use of inhaler devices. Although unfortunately, this condition has not improved over the past 40 years [13]. Therefore, the breath-hold and breathing pattern and the head position at the time of inhaling were three complicated steps that led toward the inappropriate use of inhaling devices by asthmatic patients. Some common suggestions were found that these issues can be minimized by careful instructions and observe the inhalation technique used by patients with asthma. A health care expert can combine the theoretical knowledge with actual demonstration helpful in training and its repetitive session. Proper inhalation therapy and appropriate use of inhaling devices are the key factors that help in treating asthma. In particular, physicians should identify the factor to improve inhalation technique with various devices used by asthma.
Inhalation techniques followed by patients were unsatisfactory, given the low education level of the patients. This research suggests establishing and prioritizing the appropriate practice of inhaling techniques to better handle patients and provide them a better quality life. The findings of the study are found to be limited, given its restriction to a certain demographic profile and region. The main limitation included in this study is the use of a finite number of patients from a single hospital as a source of patients.
Two pharmacists and the principal investigator evaluated the patients’ overall performance for using the MDI, which is one of the strengths of the current study. A statistical difference was not obtained between the inhaler mishandling and many socio-demographic factors because very few patients were taken from the single hospital. Moreover, the study failed to establish whether the patient had taken education program concerning the proper using of inhaler devices in the past and if they had, then by whom and for how many days.
Moreover, limited exploration of quality and the type of prior education given to the patient can affect the use of the device. However, the results of the study can be used as the tip of an iceberg, requiring further exploration and urgent consideration. Future studies can overcome these deficiencies by including patients from a diverse population and regions. Larger sample size can also be included for improving the study findings. Along with it, new inhaler techniques based on digital infrastructure and engineered design can also be implemented, which is likely to improve the study’s significance. Future research studies can also explore how much cost is wasted in misuse of inhaler techniques, as it is not the scope of the current study.
ConclusionInhalation techniques followed by patients were unsatisfactory given the low education level of the patients. The findings of the study recommend that although patients were aware of the correct use, more training needs to be instigated. Educational intervention programs should be instigated for improving the MDI technique use among patients. In addition, there is a lack of proper system in the hospitals and determined how much money is wasted on returned and wasted medications. Further studies should be carried out addressing these factors, which may help to determine the economic cost and health concern owing to the mishandling of inhaler devices by the patients of Saudi Arabia.
Acknowledgements
The author is very thankful to all the associated personnel in any reference that contributed to/for this research.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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