Assessment of Inhalation Technique in Primary Care Asthmatic Patients Using Metered-Dose Inhalers with or without a Spacer

Abstract

Background: Asthma is a chronic disease with increasing morbidity and mortality. Although the development of metered-dose inhalers (MDIs) was a landmark in asthma management, their use is burdened by inappropriate training. Inadequate inhalation technique is reported in 24% to 89% of patients. We assessed how a sample of adult asthmatic patients seen in primary healthcare clinics (PHCs) in Riyadh used their metered-dose inhalers (MDI). Patients and Methods:We conducted a cross-sectional survey of asthmatic adults ≥ 18 years of age who attended PHCs and used an MDI with or without a spacer device. Patient inhalation technique was observed independently by the primary researcher and a respiratory therapist using a checklist based on US (National Heart, Lung and Blood Institute) asthma management guidelines. Results: The mean age of the 191 patients in the survey was 40.64 years (range, 18 to 80 years). Fifty-nine percent were females and 41% were males. Most (77%) were illiterate and most (86%) had received previous education on MDI inhalation technique. Ninety-three percent were using an MDI without a spacer, but none could use their MDI without committing at least one error in both groups. In patients using an MDI without a spacer, the most common error was " not tilting the head backward slightly and breathing out to residual volume" (85%), followed by not "breathing in slowly" (84%). In patients using an MDI with a spacer, the most common errors were" not tilting the head back slightly and breathing out slowly to residual volume" (77%), and " not holding the breath for 10 seconds" (77%). Conclusion: Despite that MDIs are a mainstay in the management of our asthmatic patients, inhalation technique is very poor among our patients.

Inhalation Devices in Asthma

“…In a study of pharmacist dispensing of pMDIs, it was shown that specific instruction on pMDI technique during the training period and periodic continuing education during professional practice promotes better patient education. 15 We believe the same is true for pediatricians.…”

“…It is tempting to suggest but hard to prove that errors committed by patients are the result of the lack of skill in use of the devices among physicians. 14 Other investigators 15 found that patients with asthma whose physicians were more skillful with inhalers were significantly more competent themselves with inhalers than were patients whose physicians were less skillful. In a study of pharmacist dispensing of pMDIs, it was shown that specific instruction on pMDI technique during the training period and periodic continuing education during professional practice promotes better patient education.…”

“…14 Al-Wasil et al 15 studied the use of asthma inhalers in an adult population in Saudi Arabia in a primary health care setting and found that 93% of patients who used pMDI without a spacer and 85% with a spacer have committed at least one error in the use of these inhalers; 77% of the study population were illiterate. It is tempting to suggest but hard to prove that errors committed by patients are the result of the lack of skill in use of the devices among physicians.…”

“…In addition, patient education is frequently performed by other caregivers (respiratory therapists, nurses, and pharmacists), limiting the residents' exposure to teaching and reducing their need to acquire these skills. Most authors [14][15][16] therefore believe that it is important to address these deficiencies during residency training. This can be done in general pediatrician clinics, in subspecialty clinics, or during the care and teaching of hospitalized patients with asthma.…”

The Saudi Initiative for asthma

“…Factors leading to nonadherence may be related to poor inhaler technique, a regimen with multiple drugs, concern regarding side effects from the drugs, or the cost of medications. [9899100] Other factors include: lack of knowledge about asthma, lack of partnership in the management, inappropriate expectations, underestimation of asthma control, use of unconventional therapy and cultural issues. [101102]…”