Assessment of inhalation technique in primary care asthmatic patients using metered-dose inhalers with or without a spacer

Critical Inhaler Administration Errors of Patients on Pressurized Meter Dose Inhaler (pMDI): A Hospital-Based Cross-Sectional Study in Malaysia

Background: Inhaler technique errors can affect the disease outcome through reduced deposition of medication in the lungs with certain errors were more likely to deter the optimum drug from reaching the lung. The objective of this study was to evaluate the pressurized metered-dose inhaler (pMDI) critical technique errors among asthma and COPD patients, and to investigate the predictors of those errors. Methods: A cross-sectional, observational, and multi-centered study conducted in 3 major hospitals in the state of Penang, Malaysia. Asthma and COPD patients aged 18 years or older consented to the study were consecutively recruited if they were at least on 1 pMDI without mouthpiece spacer or facemask space. Direct observation of the patient’s technique was recorded using a standard checklist and certain steps in the checklist were pre-determined as critical steps. The number of patients missed or incorrectly performed the steps including the critical steps were documented. Using logistic regression, the factors associated with the critical errors were determined, and the correlation was evaluated between age and pMDI knowledge score with critical inhalation steps score. Results: Of 209 patients observed, only less than half (40.7%) could perform all the critical pMDI steps correctly. Low education level was the only factor associated with critical inhaler errors. The increased knowledge of their inhaled medication was found to positively correlate with the correct critical inhalation steps. The critical errors also increase with the increased age of patients. Conclusion: The majority of the study population make inhalation error particularly in critical steps. Training and education intervention programs may help patients with lower education level, as well as those of advanced age and lack of knowledge of their inhaled medication because those populations are at a greater risk of committing critical errors in their use of pMDI.

The pharmacists' ability to use pressurized metered-dose inhalers with a spacer device and factors affecting it

Objective: The aim of this study is to evaluate the pharmacists' ability to use pMDIs with a spacer device and the factors that affect this ability.Method: Face to face interviews were conducted with the pharmacists. A nine item questionnaire was completed and the checklist for how to use pMDIs with a spacer device was filled out.Results: A total of 307 pharmacists voluntarily participated in this study. Fifty-six (18.2%) of the pharmacists stated that they did not know how to use pMDIs with a spacer device. These pharmacists were excluded and remaining 251 pharmacists included in the study. Only 100 (39.8%) pharmacists demonstrated all of the inhaler spacer device usage steps correctly. The step in which pharmacists made the most mistakes was "take 5-6 deep and slow breaths, hold for 10 s and slow breaths." Those pharmacists who were more likely to correctly use pMDIs with a spacer device were younger (p = 0.023), had dispensed more asthma medications per day (p < 0.001), had dispensed more asthma medications per day for patients younger than six years of age (p = 0.016), and sold inhaler spacer devices at their pharmacy (p = 0.042).Conclusion: Approximately one third of the pharmacists in the current study were able to correctly demonstrate all of the steps for proper usage of pMDIs with a spacer device, which indicates that pharmacists should be included in the training program and be provided continuous training on the use of pMDIs with a spacer device.

Outcome of illustrated information leaflet on correct usage of asthma-metered dose inhaler

Background

Research globally has shown that metered dose inhaler (MDI) technique is poor, with patient education and regular demonstration critical in maintaining correct use of inhalers. Patient information containing pictorial aids improves understanding of medicine usage; however, manufacturer leaflets illustrating MDI use may not be easily understood by low-literacy asthma patients.

Aim

To develop and evaluate the outcome of a tailored, simplified leaflet on correct MDI technique in asthma patients with limited literacy skills.

Setting

A rural primary health care clinic in the Eastern Cape, South Africa.

Methods

Pictograms illustrating MDI steps were designed to ensure cultural relevance. The design process of the leaflet was iterative and consultative involving a range of health care professionals as well as patients. Fifty-five rural asthma patients were recruited for the pre-post design educational intervention study. Metered dose inhaler technique was assessed using a checklist, and patients were then educated using the study leaflet. The principal researcher then demonstrated correct MDI technique. This process was repeated at follow-up 4 weeks later.

Results

The number of correct steps increased significantly post intervention from 4.6 ± 2.2 at baseline to 7.9 ± 2.7 at follow-up (p < 0.05). Statistically significant improvement of correct technique was established for 10 of the 12 steps. Patients liked the pictograms and preferred the study leaflet over the manufacturer leaflet.

Conclusion

The tailored, simple, illustrated study leaflet accompanied by a demonstration of MDI technique significantly increased correct MDI technique in low-literacy patients. Patients approved of the illustrated, simple text leaflet, and noted its usefulness in helping them improve their MDI technique.

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.

A cross-sectional observational study to assess inhaler technique in Saudi hospitalized patients with asthma and chronic obstructive pulmonary disease

Objectives:

To assess the proportion of critical errors committed while demonstrating the inhaler technique in hospitalized patients diagnosed with asthma and chronic obstructive pulmonary disease (COPD).

Methods:

This cross-sectional observational study was conducted in 47 asthmatic and COPD patients using inhaler devices. The study took place at King Abdulaziz Medical City, Riyadh, Saudi Arabia between September and December 2013. Two pharmacists independently assessed inhaler technique with a validated checklist.

Results:

Seventy percent of patients made at least one critical error while demonstrating their inhaler technique, and the mean number of critical errors per patient was 1.6. Most patients used metered dose inhaler (MDI), and 73% of MDI users and 92% of dry powder inhaler users committed at least one critical error.

Conclusion:

Inhaler technique in hospitalized Saudi patients was inadequate. Health care professionals should understand the importance of reassessing and educating patients on a regular basis for inhaler technique, recommend the use of a spacer when needed, and regularly assess and update their own inhaler technique skills.

Misuse and/or treatment delivery failure of inhalers among patients with asthma or COPD: A review and recommendations for the conduct of future research

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) are widespread chronic conditions with medication frequently delivered by inhalers. These can be challenging to use correctly, but the scale of misuse and the specific aspects of failure are unclear.

METHODS

We used systematic review methods to search 9 databases in May 2015 to identify and review studies that assessed adults (18 years or older) with asthma or COPD using inhalers of various types including pressurised metered dose inhalers (pMDIs), dry powder inhalers and the Respimat inhaler. Studies must have reported the scale of inhaler misuse, variation by type of inhaler or which steps patients had difficulty completing accurately.

RESULTS

The types of inhalers, inhaler interventions and definitions of failure and misuse varied widely in the 38 studies identified. It was not possible to draw conclusions on the differential failure rates between different types of inhalers or any patient characteristics. Of the studies reporting failure or misuse rates, the majority ranged between 0 and 20%. Studies were inconsistent regarding the number of inhaler steps collected, reported and labelled as critical.

CONCLUSIONS

There is evidence for all identified inhalers that some people may be using them incorrectly, but it is unclear which inhalers have higher rates of misuse or which steps within the inhaler technique are most difficult for patients. The optimal techniques for using inhalers are not standardised. Researchers undertaking future inhaler studies are respectfully directed to our recommendations for future research.

The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children

This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children

This an updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have updated guidelines, which are simple to understand and easy to use by non-asthma specialists, including primary care and general practice physicians. This new version includes updates of acute and chronic asthma management, with more emphasis on the use of Asthma Control Test in the management of asthma, and a new section on "difficult-to-treat asthma." Further, the section on asthma in children was re-written to cover different aspects in this age group. The SINA panel is a group of Saudi experts with well-respected academic backgrounds and experience in the field of asthma. The guidelines are formatted based on the available evidence, local literature, and the current situation in Saudi Arabia. There was an emphasis on patient-doctor partnership in the management that also includes a self-management plan. The approach adopted by the SINA group is mainly based on disease control as it is the ultimate goal of treatment.

The Saudi Initiative for Asthma

The Saudi Initiative for Asthma (SINA) provides up-to-date guidelines for healthcare workers managing patients with asthma. SINA was developed by a panel of Saudi experts with respectable academic backgrounds and long-standing experience in the field. SINA is founded on the latest available evidence, local literature, and knowledge of the current setting in Saudi Arabia. Emphasis is placed on understanding the epidemiology, pathophysiology, medications, and clinical presentation. SINA elaborates on the development of patient-doctor partnership, self-management, and control of precipitating factors. Approaches to asthma treatment in SINA are based on disease control by the utilization of Asthma Control Test for the initiation and adjustment of asthma treatment. This guideline is established for the treatment of asthma in both children and adults, with special attention to children 5 years and younger. It is expected that the implementation of these guidelines for treating asthma will lead to better asthma control and decrease patient utilization of the health care system.