Introduction

Respiratory inhalers are the cornerstone of COPD management, and effective therapy depends on the appropriate inhalation technique.1–3 The use of inhaled medication reduces the occurrence of systemic adverse reactions, and medicines are delivered directly to the airways (target zone), it requires individual instruction,4 multiple steps for use,5 and patients should understand the different series of device-specific directions.6 Management of symptoms may be affected by the inappropriate inhaler technique subsequently of inadequate the dosage.7,8

Patients who use inhalers incorrectly have lower treatment success rates, which increases their need for emergency departments, raises the expense of their illness, and diminishes their quality of life.9 Risk factors for inhaler misuse are use of multiple devices,10 inadequate instruction,11 older age,12 and low health literacy.10 Unfortunately, misuse of respiratory inhalers is a common issue around the world.8,13,14 Despite this, the rate of inhaler misuse is still unknown in Kabul.

The objective of this study was to evaluate the techniques of respiratory inhaler use among inpatients with COPD in Ali Abad Teaching Hospital, since the rate of inhaler misuse in this hospital is unclear. Additionally, we intended to evaluate the type of inhaler device, the number of IDs used by each patient, and the demographic characteristics of patients.

Materials and MethodsStudy Population, Parameters and Design

This cross-sectional study was conducted between April 2020 and October 2022 at the cardio-respiratory department of Ali-Abad Teaching Hospital, which is a 200-bed teaching hospital in Kabul, Afghanistan. Patients who were admitted with a diagnosis of COPD, and agree became study participants. The inclusion criterion was the use of at least one inhaler device. Patients who were admitted with diagnosis of asthma diagnosis, dementia, coma or other structural lung diseases were excluded from study.

Demographic characteristics, including the patient’s age, gender, education level, vision, type, and number of inhalers, were collected using structured questionnaires. The poor vision subgroup included patients who required a health care worker to read the questionnaires and write down their responses. Participants with good vision could independently read and respond to the questionnaires.

Checklists for Evaluating Proper Inhaler Technique

An educated health care worker was involved in assessing the accuracy of the respiratory inhaler technique step by step by using detailed checklists. The checklists were developed according to the manufacturers’ references and reports in the available literature.11,15

The knowledge of respiratory inhalers included three items: the inhaler dosage, the time frame for using the inhaler, and washing the mouth to avoid oral ulcers.16,17

Statistical Analysis

Descriptive statistics, such as means, standard deviations, and proportions, were used to describe the demographic characteristics of patients. Statistical significance was accepted at P<0.05. All of the analyses were conducted using SPSS version 21.

Ethical Issues

Informed consent was obtained from the study participants prior to study commencement. Every patient was evaluated regarding inhaler use on an advised schedule (mentioned in the patient file). In a case of misuse, the patient was educated about the correct use of the inhaler at the end of the interview by the health care worker. This research was approved by the institutional review board of Kabul University of Medical Sciences (Reference: 38/3-13/05/2020) and the study was conducted according to the principles of the Declaration of Helsinki.

ResultsSample Characteristics

Of the 338 participants who were eligible, 318 patients (94.02%) were enrolled. Twenty participants (6.28%) declined to participate in the study. The demographic characteristics of patients are described in Table 1. The total inhalation maneuvers were 398, with five different IDs. pMDI users (n = 261, 65.57%) were the highest among the enrolled population, followed by pMDI with spacer users (n = 54, 13.56%), Respimat® users (n = 45, 11.30%), Handihaler® users (n = 21, 5.27%), and Accuhaler® users (n = 17, 4.27%). Participants were currently using one (74.8%), two (20.44%), or three inhalers (4.17%). Regardless of having received prior instructions for the proper use of inhalers, all participants mentioned using them for longer than a week. Most of the participants were illiterates (54.72%), and 43.4% of individuals were current smokers. The mean (SD) patient age was 59.1 (9.8) years (range: 49–71 years), and most were men (82.07%).

Table 1 Demographic Characteristics of Patients (N=318)

Inhalation Misuse by IDs

311 patients (97.7%) performed at least one essential step incorrectly for all inhaler devices. Across all studied inhalation maneuvers, the maximum number of misuses was observed in those using the Respimat (97.7%), and the minimum number of misuses was observed in those using the Accuhaler (58.8%). For the pMDI, the steps “take a deep breath after activating the inhaler (orally)” and “hold the breath a few seconds after inhalation activation” were most frequently inaccurately performed. Regarding the pMDI with spacer, the steps “exhale gently to residual volume” were most commonly carried out in mistake. Meanwhile, for the Accuhaler and Handihaler, the step “exhale gently to residual volume” and “hold the breath a few seconds after inhalation activation” were most frequently done incorrectly. For the Respimat, the steps “hold the breath a few seconds after inhalation activation” and “exhale fully” were most frequently inaccurately performed.

Patient Characteristics Related to Misuse of Inhalers

The correct and misused frequencies for each inhaler according to age, gender, education, vision, and knowledge of respiratory inhalers are presented in Table 2. Except for pMDI with spacer, the misuse of other inhalers was higher in the older age group (≥60 years) as compared to those under 60 years old. According to gender, the misuse was less in females for all studied inhalers as a compared to male (p<0.05); moreover, in the male group, the misuse of Handihaler was more as compared to other inhalers (p<0.05). Meanwhile, higher proportion of literate participant correctly used all types of inhalers as compared to the illiterate patients (p<0.05). Further, among of illiterate group the misuse of Respimat was more as compared to other inhalers (n=26, 86.6%). Participants with poor vision were more likely to misuse all types of respiratory inhalers compared to those with good vision (p<0.05). Furthermore, when compared to other inhalers, misuse of Respimat was higher in the poor vision group (n = 23, 76.6%). According to the findings of this study, the majority of patients (77.6%) lacked knowledge of proper inhaler technique (p<0.05).

Table 2 Characteristics of Correct and Misuse of Different Inhalers

Discussion

This study demonstrates that a significant majority of COPD patients receiving regular care from internal medicine doctors misused their inhalers by performing at least one essential step for medicine delivery incorrectly. Patients who used the Accuhaler device had the highest percentage of accurate techniques, whereas those who used Respimat and pMDI made the most mistakes (Table 3).

Table 3 Misuse Rates for Each Step of the Five Types Inhaler

This is in accordance with the reports of other studies in which the misuse of Respimat was higher as compared to others inhalers.17,18 According to previous studies, a greater percentage of individuals misused the MDI than those who used other inhalers.18,19 Additionally, a prior study revealed that a higher percentage of MDI with spacer users (20.8%) correctly handle the device when compared to MDI users (6.0%) and dry power inhaler (DPI) users (16.12%).20

The steps that were most likely to be carried out inaccurately across all of the inhalers were “exhale gently to residual volume”, “holding breath” and “Take a deep breath after activating the inhaler (orally).” These mistake in accordance with the report of other study.17

The steps that caused the greatest mistakes while handling the pMDI were “Take a deep breath after activating the inhaler (orally)” and “hold the breath a few seconds after inhalation activation.”

Due to the hand-lung coordination needed to use the pMDI, it is generally more difficult. Adding a spacer to the pMDI helps eliminate this issue.21 Previous studies have shown that healthcare professionals, such as doctors, nurses, pharmacists, and respiratory technicians, may not be familiar about proper device handling.13,22

The results of this study reveal that a relatively high rate of mistakes occurred in the steps “hold breath”, and “exhale gently to residual volume” which was consistent with the results of the previous study.7,17,23

Misuse of inhalers were significantly associated with incorrect inhaler-related knowledge, this finding is consistent with earlier study.16,17

Except for pMDI with spacer, the misuse of other inhalers was higher in the older age group (≥60 years) as compared to those under 60 years old. This is consistent with another study, which reveals that older age is a risk factor for inhaler misuse.12

Based on gender the misuse rate of all studied inhalers was lower among female compared to male. However, other studies that have been published found no differences in inhaling technique associated with gender.12,24 Another study discovered that females are more likely to use incorrect inhalation technique.25

In the present study, a higher proportion of literate participants correctly used all types of studied inhalers as compared to the illiterate patients. This result is inconsistent with the findings of the study, in which they discovered that patients with higher levels of education had fewer errors during the essential step.8,24,25 However, other studies showed that handling inhalers incorrectly did not increase with lower levels of education.17,26

Additionally, our findings showed incorrect inhaler techniques was higher among poor vision patients (Table 2). Similarly, A previous study found that poor vision was related to Diskus misuse but not to MDI misuse.6

This study also has some limitations. First, keep in mind that any technique that a manufacturer suggests might be inaccurate. Second, there is now no “optimal” way to evaluate inhaling technique, however, using checklists is somewhat subjective. Third, the small sample size of patients handling the pMDI with a spacer, Respimat, Handihaler, and Accuhaler.

This study offers the first evidence on the misuse inhaler in Kabul. Community pharmacy employees and other medical personnel could be helpful in enhancing patients’ MDI method.

Conclusion

The misuse rates were high for all studied inhalers; however, among studied inhalers, the Accuhaler had the greatest proportion of correct inhalation techniques. In order to ensure proper inhaler technique, patients should be educated before receiving inhaler medicines. Therefore, it is crucial for doctors, nurses, and other healthcare professionals to comprehend the problems with the performance and proper usage of these inhaler devices.

Acknowledgments

The authors wish to thank the patients who kindly participated in this research and acknowledge the staff members of the hospital and Khalidullrahman Hamidy for his considerable assistance in the data analysis.

Disclosure

The authors report no conflicts of interest in this work.

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