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Predictors of incorrect inhalation technique in patients with asthma or copd: a study using a validated videotaped scoring method
JOURNAL OF AEROSOL MEDICINE AND PULMONARY DRUG DELIVERY
Volume 23, Number 5, 2010ª Mary Ann Liebert, Inc.
Pp. 1–6DOI: 10.1089=jamp.2009.0785
Predictors of Incorrect Inhalation Technique in Patients
with Asthma or COPD: A Study Using a Validated
Videotaped Scoring Method
Geert N. Rootmensen, M.D.,1 Anton R.J. van Keimpema, M.D., Ph.D.,1,2
Henk M. Jansen, M.D., Ph.D.,1 and Rob J. de Haan, Ph.D., R.N.3
Background: Inadequate technique reduces the effects of inhalation medication. Errors in inhalation techniquehave been reported to range up to 85%. Not only various patients' characteristics but also the device has an effecton correct inhalation technique. The purpose of this study was to determine the effect of patients' characteristicsand type of inhaler device on inhalation technique in patient with asthma or chronic obstructive pulmonarydisease (COPD).
Methods: A validated scoring method was used that consisted of triple viewing of video-recorded inhalations,using device-specific checklists. The following patient characteristics were investigated: gender, age, educationlevel, diagnosis, treatment by a pulmonary physician, previously received inhalation instruction, exacerbationfrequency, knowledge, self-management competence, pulmonary function, and use of multiple inhaler devices.
Chi-square statistics were used for univariate associations between potential determinants and correctness ofinhalation technique. Relevant determinants were entered into a multivariate logistic regression model. More-over, inhalation technique errors were examined for six inhaler devices: three prefilled dry powder inhalers, onesingle-dose dry powder inhaler, a pressurized metered-dose inhaler (pMDI) and a pMDI with a spacer.
Results: Overall, 40% of the patients made at least one essential mistake in their inhalation technique. Patientswho never received inhalation instruction and patients who used more than one inhaler device made signifi-cantly more errors (odds ratio both 2.2). Comparison between devices showed that a correct inhalation techniquemost likely occurred with the use of prefilled dry powder devices.
Conclusion: Incorrect inhalation technique is common among asthma and COPD patients in a pulmonaryoutpatient clinic. Our study suggests that the use of prefilled dry powder inhalers as well as inhalation in-struction increases correct inhalation technique. Simultaneous use of different types of inhalation devices has tobe discouraged.
Key words: asthma, chronic obstructive pulmonary disease, COPD, inhalation technique, inhaler device, deter-minants, drug therapy
Furthermore, incorrect technique has been reported in up to94% of patients.(3–5) Patient-related determinants like sex,(6–8)
Inhalation medication is the cornerstone of therapy for age,(9–12) educational level,(13) emotional problems,(14) sever-
patients with asthma and chronic obstructive pulmonary
ity of obstruction,(10) and diagnosis(15) have been associated
disease (COPD). Inadequate inhaler instruction and poor in-
with incorrect inhalation technique. Also, the type of inhala-
halation technique moderates the effectiveness of the medi-
tor device is an important determinant of incorrect inhala-
cation and are a major cause of poor disease control.(1,2)
tion technique.(15–17) Some studies have demonstrated that
1Department of Pulmonology, Academic Medical Centre, Amsterdam, The Netherlands.
2Asthma Centre Heideheuvel, Hilversum, The Netherlands.
3Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands.
ROOTMENSEN ET AL.
patients using a pressured metered-dose inhaler (pMDI)
was adapted from the validated interview-based question-
made significantly more mistakes than users of dry powder
naire developed by Kolbe et al.(25) Because patients use
inhalers,(15,17) whereas another study showed better inha-
different types of medication, which influence the self-
lation technique through the use of pMDIs.(9) A review by
management strategy, a maximum score (indicating optimal
Brocklebank et al.(3) did not demonstrate significant differ-
self-management ability) was calculated for each individual
ence between pMDIs and dry powder inhalators. Despite the
patient according to the types of medications that were used.
importance of correct inhalation technique, previous studies
Scores for both questionnaires range from 0 to 100%, with
did not use validated instruments for the assessment of in-
higher scores indicating better knowledge and performance
halation technique. In this study, we used a validated scoring
(questionnaires available on request).
method that consists of triple viewing of video-recorded in-
Pulmonary function was expressed as the percentage of
halation demonstration using device specific checklists and
predicted forced expiratory volume in one second (FEV1)
mutually agreed scoring rules. This method revealed a high
and forced expiratory volume=vital capacity (FEV1=VC).
percent agreement and substantial or almost perfect Kappascores for both inter- and intraobserver reliability for a broad
Devices and inhalation technique
range of devices.(18)
This study investigates the inhalation technique of asthma
Six types of inhaler devices were examined: three types of
and COPD patients in a pulmonary outpatient clinic, in re-
prefilled dry powder inhalers, Diskus=Accuhaler (Glaxo
lation to patient characteristics. Moreover, we separately ex-
Smith Kline, UK), Diskhaler (Glaxo Smith Kline), and
amined inhalation technique errors between different types
Turbuhaler (AstraZeneca, Sweden), the single-dose dry
of inhaler devices.
powder inhaler (Cyclohaler or inhaler Ingelheim), thepressurized metered-dose inhalator (pMDI), and the pMDI
Materials and Methods
with spacer. We developed a checklist that measures stepsrequired for adequate drug delivery, the number of steps
Patients were recruited from a clinical randomised trial,
needed varied from 6 to 11.(9,17) Furthermore, we defined
investigating the effect of nursing care added to regular care
so-called essential steps for each device.(17) When one or more
by a pulmonary physician in an outpatient clinic in Am-
errors were made regarding these essential steps, we con-
sterdam, The Netherlands.(19) All patients were older than
sidered it unlikely that a significant amount of medicine
18 years and diagnosed in accordance with GINA and ERS
would be inhaled. In these cases inhalation technique was
criteria for asthma and COPD, respectively.(20,21) There were
defined as incorrect. Our method of assessment of inhalation
no formal exclusion criteria. The study was approved by the
technique was investigated in terms of inter- and intra-
Medical Ethics Committee.
observer reliability. Briefly, the method consists of viewingthe video recorded inhalation demonstrations three times,
using device specific checklists and mutually agreed scoring
During an interview, information was obtained about
rules.(18) Scoring rules were consented drawn up by three
gender, age, educational level (low: primary school, middle:
investigators in a 6-h training session.
high school, high: bachelor or higher), diagnosis, whetherpatients were treated by a pulmonary physician for the pre-
vious 2 years, if patients had received inhalation instruc-
Chi-square statistics were used to investigate univariate
tions, whether patients experienced an exacerbation in the
associations between patient characteristics and inhalation
previous 6 months, knowledge, self-management, pulmo-
technique. Relevant determinants of an incorrect inhalation
nary function, and the number and type of inhaler devices
technique ( p < 0.40) were entered into a multivariate logistic
were recorded. We defined an exacerbation as worsening
regression model. Effect sizes were expressed in odds ratios
of respiratory symptoms that required treatment with oral
(OR) with their 95% confidence intervals (CIs).
steroids for both asthma and COPD patients. The patient's
Additionally, we calculated the percentages of essential
knowledge of disease and level of self-management was
mistakes per device, and analyzed the relation between type
assessed using a self-administered questionnaire previously
of device and incorrect inhalation technique. In this approach
used.(19) The knowledge questionnaires was adapted form ex-
we also used multivariate logistic regression. All analyses
isting questionnaires and supplemented with self-formulated
were done with SPSS=PC Statistics 16.0 (SPSS Inc., Chicago,
questions.(22–24) The 18-item questionnaire contained 14 gen-
eral questions (e.g., ‘‘it does not really matter how patientswith an airway disease take their inhalation medication''),
and was supplemented with four diagnosis-specific ques-tions for both asthma and COPD patients (e.g., for asthma
A total of 156 patients performing a total of 204 inhalation
patients ‘‘the narrowing of the airways is mainly caused by
demonstrations were included in the study. Patient charac-
the contraction of the muscles in the wall of the airways,''
teristics are presented in Table 1. The mean age of the par-
and for COPD patients: ‘‘in emphysema the narrowing of
ticipants was 61 years (SD ¼ 14), 42% were female, 58% were
the airways is mainly caused by decreased elasticity of the
diagnosed with COPD, and 44 patients (28%) used multiple
lungs''). The response categories from the questionnaire were
types of inhaler devices. A total of 63 patients (40%) per-
‘‘true,'' ‘‘false,'' or ‘‘do not know.'' The category ‘‘do not
formed at least one essential step incorrectly.
know'' was included to discourage guessing, and was scored
Univariate analysis of the determinants showed statisti-
as incorrect. The self-management questionnaire describes
cally significant associations of incorrect inhalation technique
two slow onsets and one rapid onset of exacerbations, and
for older age and absence of received inhalation instruction
DETERMINANTS OF INCORRECT INHALATION TECHNIQUE
Table 1. Baseline Characteristics
Table 2. Patient Determinants in Relation
of the Patients (n ¼ 156)
to Incorrect Inhalation Device;
Univariate Analysis (n ¼ 156)
Gender female (%)
Educational level (%)a
Mean FEV1 % predicted (SD)b
Mean FEV=VC (SD)b
Received inhalation instruction (%)c
Exacerbation previous half year (%)c
Treatment by a pulmonary physician
previous 2 years (%)
Mean knowledge score (%)a
Mean self-management score (%)a
Multiple devices (%)
bFEV1 ¼ forced expiratory volume in one second; VC ¼ vital
(Table 2). No associations could be observed regarding
knowledge and self-management. Multivariate logistic re-
gression revealed that there were two independent explan-
atory factors of incorrect inhalation technique (Table 3);
namely, patients who never received inhalation instruction
FEV1 % predictedd
and patients using multiple types of inhaler devices (OR
For the analysis per device, a total of 204 inhalation
demonstrations were used from the 156 patients. Essential
steps, scores per step and total score per device are pre-
sented in Table 4. Essential errors were recorded least in theprefilled dry powder devices Diskus (15%), Turbuhaler
(18%), and Diskhaler (21%). Forty-five percent of the dem-
FEV1 ¼ forced expiratory volume in one second; VC ¼ vital
onstrations with single-dose dry powder inhalers showed at
least one essential error. Most errors were seen in demon-
strations with pMDIs with or without spacer (respectively,
COPD, chronic obstructive pulmonary disease.
47 and 81%). For the pMDI the steps concerning hand-lungcoordination; that is, ‘‘activate canister in beginning of slowinhalation'' and ‘‘continue to inhale slowly and deeply,'' were
Table 3. Patient Determinants in Relation
most frequently performed incorrectly (respectively, 72 and
to Incorrect Inhalation; Multivariate
Logistic Regression (n ¼ 156)
Multivariate analysis (Diskus device set as reference
group) revealed no differences between prefilled dry pow-
der devices (ORs Turbuhaler and Diskhaler 1.1 and 1.5),whereas single-dose dry powder devices and pMDI with or
without spacer significantly showed significant more errors
(ORs 5.2, 4.4, and 25.7, respectively).
In our study, 40% of all asthma and COPD patients made
at least one essential mistake in their inhalation technique.
Although univariate analysis showed that the younger pa-
tients made fewer errors, this outcome was not found in the
The considerable number of mistakes regarding inhalation
technique is in line with previous studies. In the literature,
bFEV1 ¼ forced expiratory volume in one second; VC ¼ vital
the prevalence of incorrect inhalation shows considerable
variability,(3,4) which may be caused by, among other factors,
differences in scoring methods. Some studies scored patients'
OR, odds ratio; CI, confidence interval.
ROOTMENSEN ET AL.
Table 4. Percentage of Mistakes per Step, Total Percentage of Patients Making
at Least One Mistake per Device, and Multivariate Analysis per Device
dry powder inhaler
Shake inhaler thoroughly
Remove duster cap
Keep inhaler in upright position
Twist the grip to the right and twist back
until the ‘‘click''sound
Place inhaler in horizontal position
Open and close device
Place canister correctly in spacer
Open device in vertically position
Place capsule in the device
Turn back mouthpiece
Push the buttons once
Sit upright or stand
Breathe out to residual volume
Tilt head back (hyperextend)
Close lips on inhaler
Activate canister in beginning
of Slow inhalation
Continue to inhale slowly and deeply
Inhale forcefully and deeply
Activate inhaler once
Breath in and out through mouthpiece
at least three times
Hold breath for at least 5 sec
Brath out away from mouthpiece
Patients performing at least one essential
95% confidence interval
Percentage of patients performing at least one step incorrectly does not have to be sum of the essential steps separately since per
demonstration multiple essential steps can be performed incorrectly. Odds ratio from Diskus is reference value for other devices.Odds ratioswere adjusted for whether or not receiving inhalation instruction.pMDI, pressurized meter dose inhaler.
technique only by right or wrong, whereas others divided
difficult to fill out by the patients, and therefore could have
the inhalation procedure into up to 15 steps per device and
influenced the results. Patients who received inhalation in-
gave weighted scores per step accordingly.(26,27) It is com-
structions in the past were more likely to inhale correctly.
plicated to observe, measure, and judge inhalation technique,
This result supports the recommendations in guidelines and
mostly because of the velocity in which direct observed in-
previous studies.(20,21,28,29) Health professionals should be
halation takes place. By their nature most studies examining
instructed and trained in the use of each individual device
inhalation technique are subjective by design as teachers
before they can educate patients.(28–32) The preparation and
often assess the technique themselves. Moreover, investiga-
manipulation for loading each device, as well as the general
tors are often not blinded, and no information is given about
maintenance required, should be provided in the form of
the kind of training received. This type of study design raises
clear instructions for patients.(32) There should be enough
the possibility of observer bias and the likelihood of poor
time for checking and intensive training of inhalation tech-
intraobserver repeatability. Hence, we used videotaped
nique. This should be repeated, because patients tend to
demonstrations that were judged three times, using a pre-
forget the appropriate inhaler technique and sometimes in-
defined checklist. Unlike a previous study that used video-
troduce new errors in time.(33–35) Group instruction seemed
recorded inhalation demonstrations,(14) this method was
to be more effective than personal or video instructions,(17)
validated, proving to be valuable as a research tool.(18)
whereas in another study written instruction alone was
Unlike previous studies, the patient characteristics of sex,
inadequate.(36) Unfortunately, data about the type of in-
education level, level of obstruction, and diagnosis were not
structions previously received and the time between the in-
associated with the inhalation technique of patients suffering
structions and the actual inhalation demonstration were not
from asthma and COPD.(6–12,15,24) Moreover, no associations
available. Not surprisingly, because patients using multi-
were found for knowledge and self-management scores. The
ple devices had to perform more essential steps, they were
developed self-management questionnaire turned out to be
more prone to perform incorrect inhalation techniques.
DETERMINANTS OF INCORRECT INHALATION TECHNIQUE
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Author Disclosure Statement
17. van der Palen J., Klein JJ, Kerkhoff AH, and van Herwaarden
CL: Evaluation of the effectiveness of four different inhalers
The authors declare that no competing financial interests
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Department of Pulmonology
Academic Medical Centre, F5-258
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from Lester R. Brown, Eco-Economy: Building an Economy for the Earth (W. W. Norton & Co., NY: 2001) © 2001 Earth Policy Institute®. All Rights Reserved. Stabilizing Population by Reducing Fertility by Reducing Fertility World population has more than doubled since 1950. Those bornbefore 1950 are members of the first generation in history to wit-ness such a doubling during their lifetime. Stated otherwise, morepeople have been added to the world's population since 1950 thanduring the 4 million preceding years since we first stood upright.1
PART I: Sexual Anatomy PART II: Physiology of Sexual Functions PART III: Sex Hormones and the Reproductive Period PART IV: Conception, Pregnancy and Childbirth PART V: Contraception (Birth Control) PART VI: Abortion PART VII: Sexually Transmitted Infections (STI'S) Sex lies at the root of life, and we can never learn to reverence life until we know how to understand sex. -Havelock Ellis