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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 Original Research 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.
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, Patient characteristics 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- Statistical analysis 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 (%) physician previous bFEV1 ¼ forced expiratory volume in one second; VC ¼ vital Received inhalation Exacerbation previous (Table 2). No associations could be observed regarding knowledge and self-management. Multivariate logistic re- gression revealed that there were two independent explan- Self-management scoreb 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 aChi-square test.
(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).
Educational levela In our study, 40% of all asthma and COPD patients made at least one essential mistake in their inhalation technique.
Received inhalation 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.
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 aEsential step.
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.
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