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

Discussion

In the literature, there is a lack of agreement on the checklists used for inhaler technique for different inhalers and type of critical errors. Hence, we used the checklist created by Batternick et al8 for the purpose of this study. In the present study, 70% of patients made at least one critical error, which is much higher than the study carried out by Batternick et al8 in hospitalized patients, where 59% committed one or more critical errors, but smaller than a study carried out in outpatient clinics11 where 92.4% of the patients had committed at least one critical error. A study which was conducted in the community pharmacy,10 47.5% of patients made at least one critical error. Another study3 carried out in the chest clinics in Italy reported 12% of patients committed at least one critical error. We evaluated patients whose pulmonary condition had been exacerbated; hence, it is more likely that they used their inhalers incorrectly compared with the previous studies performed from the outpatient population.3,7,10,11 Most hospital patients were using the MDI and at least one critical error was committed by 73% of patients, which was comparatively low in comparison with the previous study,8 where 93% of hospital patients using MDI committed at least one critical error. n outpatient clinics, 94.2% of patients using MDI and 53% of patients in the community pharmacy setting committed at least one critical error.10,11 In our study, most patients were using the MDI and we concentrated on the incorrect performance of critical steps in this device. Forty-one percent of patients using MDI did not perform step 2 correctly (namely, shake the device well before use), which was similar to the results of Souza et al,11 where 41.8% of patients performed step 2 incorrectly. In previous studies,8,10 step 2 was incorrectly performed by 37% and 30% of the patients. In addition, 71% of patients in our study incorrectly performed step 6 (namely, inhale slowly, actuating once during first half of the inhalation), a common problem that has been identified in previous studies.3,7,8,10 The most common reason for this problem has been reported as patients’ lack of understanding, as a result of not having been shown the correct inhalation technique by their health care professionals.8 We observed that step 7 (continue slow and deep inhalation) was incorrectly performed in 66% of our inpatients as compared with the study of Batternick et al,8 where 70% of inpatients performed this incorrectly. In another 2 studies,29%3 and 5%10 of patients did not perform step 7 correctly.

In Saudi Arabia, the inhaler device that is prescribed to the patient is generally determined by the physician. An interesting finding of the present study is that the number of patients who used a spacer with their MDI device was small, which is also similar to the results of other studies7,10,11 (use of a spacer with MDI devices eliminates the need for coordination, required for actuation and inhalation, in Step 6).

One or more critical errors in the inhaler technique results in 50% increase in the course of corticosteroids, hospital admissions, or emergency visits.12 Treatment failure in patients who suffer from asthma or COPD occurs as a result of incorrect use of inhaled medications due to lack of counseling, inadequate counseling, educational strategies not suited to the learning styles of the patients, poor vision of patients, and the quality of instructions given. The lack of educational support may be due to various factors, including the fact that health care professionals (HCP’s) themselves are not always adequately trained in providing instruction on inhaler technique.12 A study in Saudi Arabia on patients with asthma found that 45% of patients did not use their device properly, 40% had not received education on how to use the inhaler, and only 6-7% had been educated by a certified asthma educator or a pharmacist.5 Another study13 carried out in Saudi Arabia to assess the inhaler technique skill of HCP’s showed that most of them did not have skill in using an MDI and spacer device. Pharmacists are usually the patients last point of contact with the health care system before discharge. They have an important role to play in ensuring that patients are using their inhalers correctly. However, it has been reported that many pharmacists and respiratory therapists lack the skills required to demonstrate correct inhaler technique.13 In support of greater efforts to improve this situation, the PHARMACOP (effectiveness of pharmaceutical care for patients with chronic obstructive pulmonary disease) trial demonstrated that pharmacist care programs improve inhaler technique and medication adherence.14 The cost-effect analysis of the PHARMACOP trial15 showed a saving of €227 per patient per year and decreased 0.07 hospital treated exacerbations per patient for the first 3 months as compared with the usual care.

One of the strengths of the present study is that evaluations were performed by 2 pharmacists, with good overall concordance. The limitation is the small number of patients from a single hospital due to which potential associations could not be explored between inhaler misuse and various sociodemographic characteristics. Additionally, we were unable to establish whether the patients had previously been educated on inhaler technique (and if so, by whom), or to ascertain the type and quality of any instruction they may have received. Determining the financial cost, in terms of wasted medication due to inhaler misuse, was beyond the scope of the present study as there is a lack of a system in the hospital to receive, and determine the cost sof returned or wasted medications. Future studies that address these aspects may help to highlight the economic cost and health burden due to misuse of inhaler devices by inpatients in Saudi Arabia.

In conclusions, the results of our study clearly demonstrate that the inhaler technique among the inpatients admitted due to exacerbation of BA and COPD in our hospital is unsatisfactory. Health care professionals should understand that the importance of reassessing and educating patients on a regular basis is crucial for effective management of their disease. Additionally, HCP’s should also reassess their own knowledge and skills at regular intervals, so that they can provide effective instruction on correct inhaler technique. We recommend that patients receive education on inhaler technique upon admission, and re-education on the day of discharge. Furthermore, their technique should be reassessed at each clinic visit, according to the published recommendations. The importance of correct inhaler technique is emphasized to patient’s education on the use of an MDI with a spacer should also be provided.