Incorrect Inhaler Use Research Articles

Knowledge and Attitudes of Nurses in Spain about Inhaled Therapy: Results of a National Survey.

The main problem with inhalation therapy is incorrect use of inhalers. Nurses' limited knowledge may contribute to this situation. This study aimed to assess the level of knowledge and attitudes of respiratory nurses about inhaled therapy. A 12-item multiple-choice questionnaire was sent to members in the Nursing Area of the Spanish Society of Pneumology and Thorax Surgery and to nurses working with respiratory patients using inhalers devices. The survey was voluntary, self-administered, and anonymous. It collected demographic characteristics, preferences, and knowledge and education about devices and inhalation technique. A total of 1496 nurses completed the questionnaire correctly. Results showed 65.4% preferred dry powder inhalers (DPI), 8.7% were familiar with all 12 devices listed, 59.6% identified "firing the device after beginning inspiration" as the most important step when using the pressurized metered dose inhaler (pMDI), 53.5% identified ''inhale deeply and forcefully'' as the most significant step using DPI, and 20.4% "always checked a patient's inhalation technique when a new inhaler was prescribed." A composite, variable, general inhaled therapy knowledge pooled the correct answers related to knowledge and showed only 14% of nurses had adequate knowledge of inhaled therapy. In spite of recent training activities, knowledge concerning use of inhaler devices among Spanish nurses managing patients with respiratory diseases continues to be poor. Improvements are also needed in patient education and follow-up of inhalation techniques. Undergraduate and postgraduate educational programs need to be further developed.

Incorrect use of metered-dose inhalers in adult patients at a hospital in Callao, Peru, 2014: cross-sectional study.

Inhalation therapy has proven to be the best way to control the asthma and chronic obstructive pulmonary disease symptoms. The most commonly used delivery system to control these symptoms is the metered-dose inhaler. The primary goal of this study is to demonstrate an association between incorrect inhaler use and patient age. This is a cross-sectional study, performed at Centro Médico Naval “Cirujano Mayor Santiago Távara”, in Callao, Peru, in 2014. Patients older than 18 years that used metered-dose inhalers were included. We used film recordings of patients using a metered-dose inhaler and compared their technique with the recommendations on the guidelines on the correct use of inhalers of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR). The main variables measured were age and incorrect inhaler use. The results were analyzed with the Chi squared test for bivariate analysis, and for multivariate analysis we used the Poisson regression model with robust variance. We included 378 patients in the analysis; 167 were older than 60 years. An association was found between incorrect inhalator technique and age (p=0.014) (PR 1.19 95% CI 1.03 to 1.37). The highest prevalence of incorrect technique was found in the young adult population (88%). There was no association between the incorrect technique and the person who taught it (p=0.114). Finally, this study showed that 81.2% of the study population presented an incorrect inhalation technique. The percentage of incorrect inhaler use, in the general population is high. Even if we found no association between an incorrect technique and the person who taught it; still, there is a high percentage of errors and it was even demonstrated that being instructed by a pulmonologist does not guarantee a correct performance of metered-dose inhaler inhalations.

Understanding the impact of inhaler technique on asthma and COPD

Ineffective inhaler technique is a common problem that can lead to poor disease management and an increase in the frequency of exacerbations. It is not always down to patients choosing to use inhalers in an inappropriate way, as evidence suggests health professionals are often found to be lacking in their ability to correctly teach inhaler technique. This article looks at the evidence regarding incorrect use of inhalers and the common themes associated with poor technique. It also provides a step-by-step guide on appropriate use of the more commonly prescribed inhalers.

Correct or incorrect use of inhalers in patients with dyspnea

Introduction: One of the medications used by patients with dyspnea and asthma is sprays whose the way of application is very important. If these medications are not used properly, they will not be effective. The purpose of this study was to investigate the correct or incorrect use of sprays by patients. Material and Method: This double-blind observational analytical study was conducted on patients attending clinics in Jahrom from 2009 to 2013 selected by convenience sampling method. After obtaining patient’s consent, a researcher-made questionnaire was completed by the patients and then they were asked to use spray in the presence of another researcher and then to complete the second questionnaire on how the patient should use the spray. Finally, the data were analyzed. Results: Of a total of 468 participants in this study, 43.6% (n=204) used sprays correctly, and 95.1% of them were trained in this regard. Incorrect use of sprays was observed more in men and older people and there was no relationship between the correct or incorrect use and patients’ education level. Conclusion: Training patients with dyspnea how to use sprays is the essential component of prescribing these medications, and physicians and healthcare providers should consider providing training on correct use of sprays to increase the effectiveness of medications.

INHALATION THERAPY IN CHILDREN: ISSUES AND OPTIONS

Today inhalation therapy forms the basis of treatment for children and adults with bronchial asthma. In the current market there is a great number of various drug delivery systems, such as: nebulisers, pressurised metered-dose inhalers and dry powder inhalers. Guidelines for diagnosis and management of bronchial asthma present preferred and alternative devices for treatment of children in their age group. Although choosing an inhaler device one should consider not only age and cognitive peculiarities in each patient, but also his individual preferences. Poor compliance with treatment in bronchial asthma is often due to the fact that a patient experiences problems using a dosage device. Though it is known that the effective inhalation therapy is achieved by following correct inhalation techniques given in guidelines to the concrete device. Incorrect inhaler use causes loss of asthma control. Meanwhile just one half of patients can use the medication correctly after self-studying of guidelines. Consequently, a physician should train a patient to use the device and control his actions. Up-to-date delivery systems for inhalation therapy and principles of their selection in children’s treatment are considered in the article. The survey of research data concerning the use of dry powder inhaler type-easyhaler is presented as well.

Factors related to the incorrect use of inhalers by asthma patients

OBJECTIVE:To evaluate inhaler technique in outpatients with asthma and to determine associations between the correctness of that technique and the level of asthma control.METHODS:This was a cross-sectional study involving patients > 14 years of age with physician-diagnosed asthma. The patients were recruited from the Asthma Outpatient Clinic of the Hospital de Clínicas de Porto Alegre, in the city of Porto Alegre, Brazil. The patients completed two questionnaires (a general questionnaire and an asthma control questionnaire based on the 2011 Global Initiative for Asthma guidelines), demonstrated their inhaler technique, and performed pulmonary function tests. Incorrect inhaler technique was defined as the incorrect execution of at least two of the predefined steps.RESULTS:We included 268 patients. Of those, 81 (30.2%) showed incorrect inhaler technique, which was associated with poor asthma control (p = 0.002). Logistic regression analysis identified the following factors associated with incorrect inhaler technique: being widowed (OR = 5.01; 95% CI, 1.74-14.41; p = 0.003); using metered dose inhalers (OR = 1.58; 95% CI, 1.35-1.85; p < 0.001); having a monthly family income < 3 times the minimum wage (OR = 2.67; 95% CI, 1.35-1.85; p = 0.008), and having > 2 comorbidities (OR = 3.80; 95% CI, 1.03-14.02; p = 0.045).CONCLUSIONS:In the sample studied, incorrect inhaler technique was associated with poor asthma control. Widowhood, use of metered dose inhalers, low socioeconomic level, and the presence of > 2 comorbidities were associated with incorrect inhaler technique.

Incorrect Inhaler Technique Compromising Quality of Life of Asthmatic Patients

Introduction: The inhalation route is widely used for the treatment of asthma. It is considered that inadequate inhaler technique is the leading cause of therapy failure. Objective: To determine the proportion of incorrect inhaler use and associated factors in asthmatic patients compromising quality of life. Methodology: It is a cross sectional study conducted at Specialist Chest Clinic Fatima Bhai Hospital Karachi from September 2010 to March 2011. A sample size of 215 was selected by Non-probability purposive sampling technique. Trained health care workers in presence Chest specialist requested patients to demonstrate their inhaler technique and assessed it according to the checklist. If any of the steps was missing or done incorrectly, it was marked as incorrect technique. Information was also collected through a structured questionnaire on socio-demographic variables such as age, gender, education, duration of asthma, duration of inhaler use, and patient education of inhaler technique. Data was entered and analyzed on SPSS-14. Results: There was an inverse relationship between education level and incorrect inhaler technique (p&lt;0.05). Education of inhaler usage provided by doctors was more effective as compared to education provided by nurses (p&lt;0.038). There was no significant relationship between age, sex, duration of asthma, duration of inhaler use, frequency of inhaler use and incorrect inhaler technique. Conclusion: Quality of life of a large percentage of patients is compromised by incorrect inhaler use and education level of patients had significant relationship with incorrect inhaler technique.DOI: http://dx.doi.org/10.3329/jom.v13i1.7980 JOM 2012; 13(1): 16-21

Is It Possible to Achieve Better Asthma Control by Using the Same Inhaler Device?

Achieving asthma control is central to optimizing patient quality of life and clinical outcomes. This definition of asthma control has two components: achieving current clinical asthma control and reducing future risk.1 The level of clinical asthma control is defined by the Global Initiative for Asthma (GINA) using a composite score comprising five measures. Reducing asthma exacerbations is a key factor for preventing future risk.2 The regular use of inhaled corticosteroids (ICS) is essential for controlling asthma symptoms and reducing asthma exacerbations. A previous study found that a history of exacerbations, poor asthma control, poor inhaler technique, a history of lower respiratory tract infections, poor adherence to medication, and the presence of co-morbid conditions all predicted the future risk of asthma exacerbation.3 Most control medications, including ICS, are delivered via inhalation. The correct use of inhaler devices is critical for optimizing drug delivery and obtaining clinical benefits.4 However, inhaler use still represents an important challenge for most asthmatic patients. The correct inhalation maneuver differs markedly for different inhaler types. The problems and prevalence of incorrect inhaler use have been the subject of several recent reviews.5-7 Improper technique remains common for both metered dose (MDIs) and dry power (DPIs) inhalers, and was associated with poor clinical control and increased unscheduled health-care demands in asthma clinics.8 Inhaler mishandling continues to be common among experienced outpatients referred to asthma clinics and is associated with increased unscheduled health care resource use.8 Nevertheless, inhaler technique status has not been included in most analyses examining the predictors of asthma exacerbation. Poor adherence to asthma medication is a dilemma, as it decreases the chance of achieving and maintaining proper asthma control. Education of both patients and health care professionals regarding proper inhaler technique will improve asthma control.9,10 The study by Price et al.11 in this issue is the first to compare outcomes for asthmatic patients prescribed the same inhaler device versus mixed device types for asthma control and relief therapy. This retrospective observational study identified patients with asthma (age 4-80 years) in a large primary care database who were prescribed an ICS. They compared outcomes for patients prescribed the same breath-actuated inhaler (BAI) for both the ICS controller and salbutamol reliever versus those using two devices (a BAI for the controller and a pressurized metered-dose inhaler [pMDI] for the reliever). Patients prescribed the same device (n=3,428) were significantly more likely to achieve asthma control (adjusted odds ratio, 1.15) and had significantly lower severe exacerbation rates (adjusted rate ratio, 0.79; 95%) than those prescribed two devices (n=5,452). These finding suggest that prescribing the same device for both ICS and reliever therapy improves asthma control. A previous study evaluated the skill at handling inhalers and factors associated with these skills in 145 patients with asthma under the care of asthma specialists in Korea.12 When their skill at using the inhalers was assessed visually, the performance was inadequate for 12.8% of the participants using Turbuhaler, 6.2% using Diskus, and 23.4% using pMDIs. Most showed excellent skill at using their inhalers. However, older age and the absence of previous instructions for handling the inhalers were associated with inadequate techniques, indicating that this population requires more education to improve their inhalation technique. Several studies used repeated inhaler instructions as a method to improve inhaler technique.9,13 Educational adherence support should be a collaborative effort between the patient and health care professional.14 One limitation of this study is that it includes the potential for unrecognized confounding factors, including selection bias, as it was a retrospective study.11 This study examined a database of primary physicians in the U.K. As such, there were missing data for some patients, including smoking history, which could influence outcomes. There is no assurance that patients actually took the medications as prescribed. However, this study enrolled a larger cohort of patients using ICS, included for a 1-year outcome period, and provided good evidence of improved asthma outcome with improved adherence to medications using the same BAI device for both controller ICS and reliever salbutamol therapy.

Teaching inhaler use in chronic obstructive pulmonary disease patients

To review barriers to the successful use of inhalers in patients with chronic obstructive pulmonary disease (COPD), and the role of the nurse practitioner (NP) in facilitating optimum inhaler use. Review of the national and international scientific literature. Pharmacologic treatment of COPD patients comprises mainly inhaled medications. Incorrect use of inhalers is very common in these individuals. Some of the consequences of poor inhaler technique include reduced therapeutic dosing, medication adherence, and disease stability, which can lead to increased morbidity, decreased quality of life, and a high burden on the healthcare system. Knowledgeable evaluation and frequent reassessment of inhaler use coupled with education of patients, caregivers, and healthcare professionals can significantly improve the benefits COPD patients derive from inhaled therapy. Patient education is vital for correct use of inhalers and to ensure the effectiveness of inhaled medications. The NP has a critical role in assessing potential barriers to successful learning by the patient and improving inhaler technique and medication management. The NP can also facilitate success with inhaled medications by providing up-to-date inhaler education for other healthcare team members, who may then act as patient educators.

Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD

Incorrect usage of inhaler devices might have a major influence on the clinical effectiveness of the delivered drug. This issue is poorly addressed in management guidelines. This article presents the results of a systematic literature review of studies evaluating incorrect use of established dry powder inhalers (DPIs) by patients with asthma or chronic obstructive pulmonary disease (COPD). Overall, we found that between 4% and 94% of patients, depending on the type of inhaler and method of assessment, do not use their inhalers correctly. The most common errors made included failure to exhale before actuation, failure to breath-hold after inhalation, incorrect positioning of the inhaler, incorrect rotation sequence, and failure to execute a forceful and deep inhalation. Inefficient DPI technique may lead to insufficient drug delivery and hence to insufficient lung deposition. As many as 25% of patients have never received verbal inhaler technique instruction, and for those that do, the quality and duration of instruction is not adequate and not reinforced by follow-up checks. This review demonstrates that incorrect DPI technique with established DPIs is common among patients with asthma and COPD, and suggests that poor inhalation technique has detrimental consequences for clinical efficacy. Regular assessment and reinforcement of correct inhalation technique are considered by health professionals and caregivers to be an essential component of successful asthma management. Improvement of asthma and COPD management could be achieved by new DPIs that are easy to use correctly and are forgiving of poor inhalation technique, thus ensuring more successful drug delivery.

Asthma inhalation delivery systems: the patient's viewpoint.

International guidelines for asthma management state that inhalation is the preferred route of drug delivery. Consequently, it is important to select an appropriate delivery device and to take account of a patient's preference and lifestyle, as incorrect inhaler use may lead to treatment failure. A large number of devices are available from which to select, but it may be difficult for healthcare professionals to provide guidance to the patient unless they are familiar with the characteristics and correct use of each device. Many factors affect the success of a device in a patient's hands: the device's features; the patient's psychosocial status, cultural beliefs, and language skills; and consistent instruction on inhalation technique. Constant education is essential to establish and maintain the patient's confidence in the treatment regimen. It is important that at least one member of the respiratory healthcare team should remain abreast of medical and pharmaceutical developments in the respiratory field. In this way, the choice of delivery device can be reviewed and changed to suit the changing needs of the patient.

A survey of Epi-PEN use in patients with a history of anaphylaxis

A recent report on the incorrect use of metered-dose inhalers by asthmatic patients1 and a survey that showed the deficiency of physicians in providing aftercare instructions to patients with Hymenoptera sting–induced anaphylaxis2,3 prompted us to observe closely how patients and their parents are instructed to use Epi-PEN or Epi-PEN Jr (Dey Laboratories, Napa, Calif), life-saving epinephrine injectors. Epi-PEN Jr is indicated for children whose body weight is less than 30 kg (66 lb). The device is designed for the emergency treatment of systemic allergic reactions (anaphylaxis) caused by allergens, such as insect venom, foods, drugs, and latex products.

Characteristics Predicting Incorrect Metered-Dose Inhaler Technique in Older Subjects

To determine whether cognitive status, hand strength, and demographic variables are predictive of correct use of metered-dose inhalers by older subjects. Clinic patients (n = 29) and healthy volunteers (n = 42) older than 50 years with no previous or limited metered-dose inhaler use were enrolled. After cognitive (Mini-Mental State Examination) and hand strength assessments, subjects received extensive instruction in proper metered-dose inhaler technique. Technique was independently assessed by two evaluators immediately after instruction and 1 week later. Correct technique was defined as (1) activating the canister in the first half of inhalation, (2) continuing to inhale slowly and deeply, and (3) holding breath at full inspiration (5 seconds). Data for the two subject groups were pooled for analyses. The mean age of the subjects was 69.7 years. Forty subjects (56%) demonstrated correct metered-dose inhaler technique at 1 week. Logistic regression showed that hand strength measurement (odds ratio, 0.68; 95% confidence interval, 0.55 to 0.84), Mini-Mental State Examination score less than 24 (odds ratio, 3.66; 95% confidence interval, 1.07 to 12.4), and male gender (odds ratio, 5.01; 95% confidence interval, 1.07 to 23.5) were significant predictors of incorrect inhaler use. Correct use of the metered-dose inhaler was unrelated to age, education, or subject status. Clinicians should consider cognitive status and hand strength when metered-dose inhaler therapy is initiated for an older adult. Patients with cognitive impairment and hand strength deficits may require more extensive training, frequent follow-up, or alternative dosage forms.