http://informahealthcare.com/jas ISSN: 0277-0903 (print), 1532-4303 (electronic) J Asthma, 2014; 51(4): 440–445 ! 2014 Informa Healthcare USA, Inc. DOI: 10.3109/02770903.2013.876650
ASTHMA CONTROL
A study to assess inhaler technique and its potential impact on asthma control in patients attending an asthma clinic C. M. Harnett, MB1, E. B. Hunt, MD1, B. R. Bowen, BSc1, O. J. O’Connell, MB, MD1, D. M. Edgeworth, MB1, P. Mitchell, MB1, J. A. Eustace, MB2, M. T. Henry, MB, MD1, M. P. Kennedy, MB, MD1, B. J. Plant, MB, MD1,2, and D. M. Murphy, MB, PhD1,2 1
The Department of Respiratory Medicine, Cork University Hospital, University College Cork, Cork, Ireland and 2HRB Clinical Research Facility, University College Cork, Cork, Ireland Abstract
Keywords
Objectives: The aim of this study was to evaluate inhaler technique and symptom control in patients with poorly controlled asthma at baseline and at follow-up in a dedicated asthma clinic in a tertiary hospital. We also investigated the impact of asthma on these patients’ quality of life. Methods: Patients referred to a newly established asthma clinic in Cork University Hospital were prospectively recruited over a 6-month period. Their inhaler technique was assessed by a pulmonary nurse specialist using a validated scoring system. They received instruction on inhaler usage when scores were suboptimal. Patients completed a validated asthma control questionnaire (ACQ) and asthma quality of life questionnaire (AQLQ). At followup 3–4 months later, the inhaler technique was reassessed and the ACQ questionnaire repeated. Results: Forty-six patients were recruited (female ¼ 74%), and 40/46 were followed up. Mean [SD] FEV1 % predicted at baseline ¼ 76.5% [21.5]. About 63% of the patients were classified as incorrectly using their inhaler at their initial assessment. This decreased to 20% at follow-up, indicating an overall significant improvement in inhaler usage post-training (p ¼ 0.003). ACQ scores improved significantly from median [interquartile range] 2.70 [1.66] to 2.00 [1.90] (p ¼ 0.002). Baseline measurement indicated that patients’ quality of life was moderately affected by asthma, with a median AQLQ score of 4.75 [1.97]. Conclusion: This study demonstrates the importance of educating and formally assessing inhaler technique in patients with asthma as a part of their ongoing clinical review.
Education, management/control, pharmacotherapy, quality of life, treatment
International asthma guidelines increasingly rely on pharmacological management with inhaled drugs, using an evidencebased stepwise approach to therapy [1]. Pressurised metered dose inhalers (pMDIs) and dry powder inhalers (DPIs) are the most commonly used devices. Dry powder inhalers were introduced as a more user-friendly alternative to the pMDI as they require less co-ordination between inhalation and device activation. On one hand, when used correctly, inhalers allow high pulmonary deposition of drug and minimise systemic bioavailability [2]. On the other hand, misuse of inhalers is associated with asthma instability, with each error made having the potential to significantly effects symptom control [3]. Ensuring optimal patient inhaler technique is therefore critical to asthma care. Studies examining the patient inhaler technique have taken place in a variety of settings – family practices, emergency departments, pharmacies, and specialised paediatric asthma units. However, irrespective of the setting, the patients’ Correspondence: Dr. Desmond M. Murphy, Consultant Respiratory Physician, The Department of Respiratory Medicine, University College Cork, Cork University Hospital, Cork, Ireland. Tel: +353 214922327. E-mail: [email protected]
Received 13 September 2013 Revised 5 December 2013 Accepted 14 December 2013 Published online 24 January 2014
inhaler technique has been found to be consistently poor, with levels of misuse ranging from 12% to 79%, depending on the type of inhaler and method of assessment [4,5]. These studies report pMDIs as the type of inhaler most frequently misused, with an average of 68% of the patients characterised as having incorrect technique. Errors of timing and co-ordination have been highlighted to be commonplace Current recommendations on the management of asthma emphasise regular monitoring and education of patients. Instruction on inhaler technique results in a more efficient use of inhalers [6]. After the initial instruction, however, patients’ inhaler technique quickly declines in the absence of ongoing instruction [7]. Patients who simply receive further inhaler instruction once after the initial instruction have better inhaler technique when compared with those who only received instruction at the time of prescription [8]. Similar results have been recently demonstrated in the community pharmacy setting emphasising the importance of a wide range of support services for the asthma population [9,10]. Risk factors for misuse previously identified include older age, lower schooling, and lack of instruction on inhaler technique by caregivers [5]. Studies demonstrate that inhalers are used poorly by patients prior to educational intervention and that incorrect use is associated with asthma instability [2–4]. However, few
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Introduction
History
Asthma inhaler technique
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studies to date have demonstrated whether clinical outcomes improve with improvements in the inhaler technique. Recently, subjective measures of health outcomes are being assigned ever increasing importance, in line with an overall shift towards the delivery of patient-centred care. It has been shown that patients’ psychosocial characteristics have an impact on adherence to medication regimens [11]. Subjective experience of a disease can differ from an objective clinical review. It has been demonstrated that both low FEV1 and female gender are associated with a decline in quality of life among young adults with asthma [12]. Conversely, it has also been shown that the effect of asthma on a patient’s quality of life is not fully accounted for by objective measures such as lung function [13]. There is very little data on the asthma-related quality of life of patients with poor levels of asthma control. The aim of this study was to assess the adequacy of the inhaler technique in a cohort of patients attending or referred to a dedicated asthma clinic, and to evaluate the benefit of a ‘‘Teach to goal’’ technique in those identified as inhaler misusers on asthma control at follow-up. In addition, we recorded the effect of asthma on quality of life in this cohort.
Methods
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Inhaler technique The inhaler technique was assessed at baseline by a trained pulmonary nurse specialist. Each patient demonstrated the inhaler technique with placebo devices of each type of inhaler they were using. Patients were asked to use their inhalers as they normally did at home. A validated checklist of steps specific for each device was used to score technique [14]. Patients were classified as ‘‘misusers’’ of a device if greater than or equal to one error was made. There is some discrepancy in the literature as to what classifies a patient as a misuser of a device, with some defining misuse as 570% of steps correct, and others 5100% of steps correct. As previous studies have shown that each error can have significant effect on asthma control we chose to classify patients as ‘‘misusers’’ if greater than or equal to 1 step was performed incorrectly [3]. If a suboptimal score (510/10) was achieved, the nurse instructed the patient on perfect usage of that particular inhaler device, utilising both verbal instructions and a demonstration of proper technique. The cycle was continued until mastery was achieved. This type of instruction and demonstration is considered the ‘‘Teach to Goal’’ technique. At a follow-up clinic, 3–4 months later, the technique was reassessed in the same manner by the nurse and the results were recorded.
Study design and subjects Ethical approval was granted by the Clinical Research Ethics Committee of Cork teaching hospitals prior to commencement of this study (Informed consent was obtained from all participants in the study). Forty-six consecutive patients referred to a newly established tertiary clinic for severe asthma in Cork University Hospital were recruited from March to September 2011. Demographic data were gathered with the inhaler technique, asthma symptom control, and quality of life being assessed at baseline. Patients were followed up for 3–4 months after the initial clinic visit. Patient follow-up took place from June to December 2011. All patients 16 years of age attending the clinic, whose diagnosis of asthma was confirmed by a respiratory physician, were included. While patients were felt to have severe, difficult to control asthma by the referring physician, based on ACQ scores, spirometry, and GINA guidelines, this was not always the case when these patients were formally reviewed in clinic [1]. These patients were, however, included in the analysis. Study measures and procedures Demographics and medication Patients completed an interviewer-administered survey, which gathered information on demographics (age, gender, and years diagnosed with asthma). Smoking history was obtained, including the number of pack years for current or ex-smokers. Medication details were recorded and a change in the type or dose of baseline medication during or between the baseline and follow-up clinics was recorded. The atopic status of each patient was recorded based on eosinophil counts, IgE levels, and by RAST testing (for cat, dog, grass, and house dust mite) at the baseline clinic, unless these tests were previously performed, and the results available on the hospital system to the clinician.
Asthma control A validated questionnaire was completed at baseline and at follow-up by each participant in order to assess the level of asthma control prior to and following inhaler educational intervention. The Juniper et al. [15] validated asthma control questionnaire (ACQ) was used with the permission from the author. This questionnaire scores the five most important symptoms as well as the usage of rescue short-acting bronchodilator, and FEV1 % predicted. Patients were asked to recall their asthma symptoms over the preceding week including and a score based on a 7-point scale assigned (the minimal clinical important difference or change in score was 0.5). A score of 1.50 indicates poor control, with a positive predictive value ¼ 0.88 [15]. Asthma quality of life Patients’ quality of life was assessed using a validated asthma quality of life questionnaire (AQLQ) at the baseline clinic [16]. Permission to use the questionnaire was obtained from the author prior to commencing the study. The questionnaire contains 32 items relating to the day-to-day problems that patients with asthma find most troublesome and includes thirty-two questions within four domains: symptoms, activity limitations, emotional function, and environmental stimuli. Patients were asked to recall their experiences over the previous 2 weeks and respond to each question on a 7-point scale. This questionnaire assesses not only physical limitation but also the impact that asthma has on work, social life, sleep, and environmental issues. Statistical analysis Data were analysed using SPSS 18Ô (SPSS Inc., Chicago, IL). Preliminary analyses were performed to assess normality
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and to ensure no violation of test assumptions. Baseline and follow-up inhaler technique scores were compared for a statistically significant difference before and after the educational intervention. The Wilcoxon signed rank test was used to assess for statistical significance. Asthma symptom scores at baseline and follow-up clinics were also compared. The relationship between change in symptom scores and change in inhaler technique scores post-intervention was assessed using Spearman’s rank order correlation test. Asthma quality of life scores were analysed, and compared to other variables (ACQ score and FEV1), using Spearman’s rank order correlation test. A two-sided p value 50.05 was considered statistically significant.
Results Population characteristics Forty-six patients were recruited for this study, and forty were followed up. Five patients failed to follow-up or were rescheduled (thus falling outside the 3–4 month follow-up period), with one being unable to perform spirometry at followup due to recent abdominal surgery and thus was excluded from analysis. The 46 patients recruited at baseline were included in the recording of baseline demographic characteristics and asthma quality of life, but only the 40 patients who were followed up, were included for statistical analysis. The atopic status of the population was identified, with 80% having evidence of atopy, indicated by a positive RAST test (to grass, cat, dog or house dust mite), high eosinophil count, or raised IgE level. Other baseline characteristics are shown in Table 1. Evaluation of inhaler technique The most commonly used inhaler devices were the pMDI (61% of the patients) and TurbohalerÕ (Luton, UK) (52%). Other dry powder inhalers including DiskusÕ (London, UK) Table 1. Patients characteristics. % Patients (n) Female Age (years) Duration of asthma diagnosis (years) Smoker Ex-smoker Non-smoker Pack years Atopic Positive RAST test Raised IgE level (481 kU/l) Raised eosinophil count (40.4 109/L) FEV1 (% predicted) Medicationa Combined ICS/LABA Salbutamol reliever Tiotropium reliever Other anti-inflammatory Oral corticosteroids
Mean [SD]
74 (34) 44 [15.3] 24.8 [19.68] 9 (4) 26 (12) 65 (30) 19.6 [19.12] 80 50 57 44
(37) (23) (26) (20) 75 [21.44]
100 80 28 52 17
(46) (37) (13) (24) (8)
ICS, inhaled corticosteroids; LABA, long-acting bronchodilator. a Medication classifications are reliever (salbutamol, ipratropium), ICS (beclomethasone, budesonide, fluticasone), other anti-inflammatory medications (montelukast, theophylline), and LABA (salmeterol, formoterol).
(17%) and HandihalerÕ (Boehringer Ingelheim, Bracknell, UK) (17%) were used as well as the RespimatÕ (Boehringer Ingelheim, Bracknell, UK) devices (11%). Forty-four percent of the patients had two different types of inhaler device, 40% were using a single inhaler device, and 16% had three different inhaler devices. Most patients had received previous inhaler technique training, which was most commonly carried out by their general practitioner at the time of initial prescription (51%). Others were taught by a practice nurse (30%), or by a pharmacist (12%), with a minority of the patients unable to recall any demonstration of inhaler technique (7%). The TurbohalerÕ was the most poorly used device at baseline, with 88% of the patients making 1 error according to the validated checklist of steps for that inhaler. The most frequent errors made were failure to breathe out before inhalation (63%) and not breath-holding following inhalation of the drug (47%). The most common errors made by pMDI users were found to be the same as for the TurbohalerÕ – not exhaling prior to inhalation (37.5%) and failure to breath-hold following inhalation (75%). Overall, no significant relationship was found between patient age and level of inhaler misuse (p ¼ 0.4) or between the number of years diagnosed with asthma and inhaler misuse (p ¼ 0.5). Follow-up scores were improved overall for each type of the inhaler device (Figure 1). About 17% of the patients using the pMDI were classified as misusers at follow-up, and an overall significant improvement was associated with this device (p ¼ 0.001). Statistically significant improvements were also seen in users of the TurbohalerÕ ,** following the intervention (p ¼ 0.001), and similarly with the DiskusÕ inhaler (p ¼ 0.02). Asthma symptom control Of the 40 patients followed up, 26/40 were classified as having poorly controlled asthma at baseline (based on an ACQ score 1.5). Asthma Control Questionnaire score median [intequartile range] at baseline was 2.70 [1.66]. At follow-up, 24/40 remained poorly controlled with an ACQ score of 2.00 [1.90]. However, 17/40 (42%) had a clinically significant improvement in their symptoms at follow-up indicated by a change in score of 0.5. Clinically significant worsening of symptoms between baseline and follow-up was seen in 3/40 patients. Overall, there was a statistically significant (p ¼ 0.002) improvement in ACQ scores at follow-up (Figure 2). Of the 17 patients who had a clinically significant improvement, 5 patients had a change of medication at the baseline clinic (seven medication changes were recorded in these five patients). Montelukast was added to the medication regimen of two patients, tiotropium to two others, budesonide/ formoterol formulation to two, and fluticasone/salmeterol was prescribed for one patient. There was no change in medications for the other 12 patients whose symptoms improved. When the patients whose medication regimen was altered were excluded from analysis, a change in the symptom score was still found to be statistically significant (p ¼ 0.02). Correlation between improved ACQ scores and improved inhaler technique at follow-up did not reach statistical significance (r ¼ 0.37, p ¼ 0.3).
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Baseline Technique Follow-up Technique
88
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83 80
70 63 60
%
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38
40
38 33
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Asthma quality of life Asthma Quality of Life Questionnaire score at baseline was found to be a median [interquartile range] of 4.75 [1.97], indicating that patients’ quality of life is moderately affected by their asthma. Patients’ AQLQ score strongly correlated with ACQ score (r ¼ 0.8), with poorer AQLQ coinciding with decreasing asthma control (p50.001). There is a 64% shared variance between the two measurements. Each domain of the AQLQ questionnaire independently correlated with asthma symptom control, including activity limitations (p ¼ 0.001), symptoms (p50.001), emotional function (p50.001), and environmental stimuli (p ¼ 0.001). Asthma Quality of Life Questionnaire score differed between males and females, with females reporting a poorer score of 4.3 [2.1] compared to men with 5.22 [1.0]. This difference was not replicated in the objective measurement of FEV1 at the baseline, with median FEV1 in females being 78% predicted and 74% predicted in men.
20 17 13
10
0 pMDI (n Turbohaler =28) (n=24)
Diskus (n=8)
Respimat Handihaler (n=5) (n=8)
Figure 1. Percentage incorrect users of each inhaler device at baseline and at a 4-month follow-up (n ¼ number of patients using inhaler type). All changes were statistically significant at p 0.02. TurbohalerÕ inhaler device used for SymbicortÕ (AstraZeneca, Luton, UK) (formoterol/ budesonide), PulmicortÕ (AstraZeneca, Luton, UK) (budesonide), and OxisÕ (AstraZeneca, Luton, UK) (formoterol). DiskusÕ inhaler device used for SeretideÕ (GlaxoSmithKline, London, UK) (salmeterol/ fluticasone), FlixotideÕ (GSK/Allen & Hanley, Uxbridge, UK) (fluticasone), and VentolinÕ (GSK, Uxbridge, UK) (salbutamol). RespimatÕ inhaler device used for SpirivaÕ (Boehringer Ingelheim, Bracknell, UK) (tiotropium). Handihaler inhaler device used for SpirivaÕ (tiotropium).
3.4
Median 25%-75%
3.2 3.0 2.8 2.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2 1.0 ACQ base ACQ follow up
Figure 2. Box and Whisker plot illustrating asthma symptom score (ACQ) at baseline and at follow-up. There was a significant improvement in ACQ score after inhaler technique education at 3–4 month follow-up from median 2.7–2.0 (p ¼ 0.002).
Discussion The findings of this study was parallel to those of the previous studies, in that the majority of the patients were making errors in the inhaler technique, irrespective of inhaler type [5,17]. Levels of misuse ranged from 88% in patients using the TurbohalerÕ , to 38% in patients using a HandihalerÕ device. Misuse of the most frequently used device, the pMDI, fell somewhere in between, with 63% of the patients making errors. This is in contrast to the findings of previous studies, where the pMDI was reported to be the most poorly used device [18]. Although this study was not designed to specifically compare ease of use of one type of inhaler over another, in our cohort, DPIs were misused at least as frequently as pMDIs (if not more so), despite DPIs being designed to be more ‘‘user friendly’’. There is some discrepancy within the literature as to what classifies a patient as a ‘‘misuser’’ of a device; and also between distinguishing critical errors from less important ones. Some studies have subdivided patients into those making ‘‘critical’’ and ‘‘non-critical’’ errors, while further studies have subgrouped patients with good and poor device co-ordination for pMDIs specifically. This study simply assessed whether the number of steps carried out was correct or incorrect when patients used their inhalers, according to a standardised checklist, with ‘‘misusers’’ classified as those making 1 error. The strict criteria we used may contribute to the large percentage of those identified as ‘‘misusers’’. The most common errors made were found to be ‘‘deviceindependent’’, which include failure to exhale before inhalation of the drug and failure to breath-hold after inhalation. This is in line with findings from previous studies [3,19,20]. It is not clearly understood why patients are most likely to omit these steps, or how this may affect the degree of drug deposition and efficacy of the medication. Each type of the inhaler device requires a specific technique, with pMDIs requiring slow and deep inhalation co-ordinated with actuation, while DPIs require forcible and rapid inhalation. As in other studies, our data suggest that the choice of inhaler device should be individualised to patient’s ability to use an inhaler type [21]. Our study further suggests that despite
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repeated technique assessments and trainings, some patients are unable to achieve perfect technique regardless of the type of inhaler device and this may, in turn, affect their clinical outcome. The use of home nebuliser therapy may indeed be the next step in the management of their asthma so as to ensure adequate drug delivery. We found that most patients (93%) had received prior instruction in the inhaler technique before evaluation at the asthma clinic. This was most commonly performed by a general practitioner at the time of prescription. This is an encouraging finding as the performance of verbal instruction is recommended at the time of prescription, with previous research showing that simply letting patients to read instructions is not adequate [22]. Despite previous education, we demonstrated that the number of patients making errors was still considerably high, and this decreased significantly at follow-up after instruction had been provided at the asthma clinic. Our findings highlight the value and importance of regular reassessment and instruction, even in patients who had long experience of using inhalers. For example, 63% of the patients using a pMDI at the baseline were making errors, while this fell to 17% at follow-up following the inhaler technique training session. Similar results were observed with the technique instruction for the other inhaler types. The benefit of reassessment and instruction has been demonstrated by studies in paediatric populations; however prior to our study, limited data were available in similar adult cohorts [23]. The patients in this study had been referred to the asthma clinic because their asthma had been perceived to be difficult to control by other physicians. One may have expected, given that the mean treatment duration for asthma was 24.8 years, that this cohort would have been both experienced and proficient in inhaler technique. Despite this, and the expected increased contact with healthcare professionals, their inhaler technique remained suboptimal. This further emphasises the need for constant education/re-education in the inhaler technique over the course of a patients’ lifetime. Very few studies have assessed the clinical outcomes of ‘‘poor’’ versus ‘‘good’’ inhaler technique. Two previous studies investigating the clinical impact of training the technique found that subjective improvements in quality of life and breathlessness occurred after instruction [24,25]. However, in these studies, no objective tool was used to assess improvement or otherwise in patients’ symptoms or quality of life, and details of device mishandling were not evaluated. One of the strengths of our study is that the change in asthma control was measured using a validated questionnaire which combines both objective (FEV1) and subjective (symptoms) data, in order to produce a balanced account of clinical outcome post-intervention. While we found that symptom scores improved overall in patients pre- and post-intervention (p ¼ 0.002), several potential confounding factors such as the intrinsic variability of the disease, poor compliance to medication and correct technique at home, and the small sample size exist. Furthermore, we cannot categorically state that improvements were not simply due to attendance at a dedicated asthma clinic. Five patients failed to return for follow-up. The results of the study may have been affected had these patients been followed-up and included in
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statistical analysis. Their reasons for failing to attend the second clinic may have been related to either an improvement or a disimprovement in asthma symptoms. The asthma quality of life of this cohort was measured at baseline for descriptive purposes. AQLQ score not surprisingly was found to be strongly correlated with the level of asthma control (p50.001). Moreover, each of the domains measured by the questionnaire was found to be independently correlated to ACQ scores. Females reported a poorer quality of life compared with males, despite little difference in FEV1 between genders, illustrating gender differences in selfreported impact of asthma on quality of life, despite similar objective lung function measures. Previous studies have highlighted female gender as a predictor of poorer asthma quality of life [12]. Asthma Quality of Life Questionnaire scores were not assessed at follow-up due to practical reasons; however, this would be a useful subjective measure of the impact of the intervention on patients’ quality of life in future studies. It is clear that even experienced patients whose asthma has been managed by healthcare professionals, for many years, continue to make inhaler technique errors. We have highlighted both the value of assessing and training patients on correct inhaler technique, as evidenced by significant improvements in technique scores following instruction, but also the need for ongoing reassessment of technique. Larger studies are now needed to both confirm and expand on our findings.
Conclusion Reassessment and re-education of asthmatic patients in the inhaler technique is a fundamental component of their ongoing clinical management. Poor asthma control related to insufficient technique should be considered at each point evaluation by the treating physician, even in patients with longstanding asthma. This study emphasises the necessity for interval monitoring and training in correct inhaler technique for all asthmatic patients. It also highlights the association of poor asthma control with poorer quality of life.
Declaration of interest D. M. M. has received speaker’s fees from Astra Zeneca, GSK, Boehringer Ingelheim, Bayer, Novartis and MSD and acted on advisory boards for Nycomed, Mundipharm, Boehringer Ingelheim, and Novartis. The other authors have no declared conflicts of interest.
References 1. Global Initiative for Asthma 2009 guidelines. Available from: http://www.ginasthma.com [last accessed 01 Dec 2013]. 2. Roche N, Chinet T, Huchon G. Ambulatory inhalation therapy in obstructive lung diseases. Respiration 1997;64:121–130. 3. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002;19: 246–251. 4. Melani A, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, Serra M, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med 2011;105: 930–938. 5. Shrestha M, Parupia H, Andrews B, Kim S, Martin MS, Park DI, Gee E. Metered-dose inhaler technique of patients in
Asthma inhaler technique
DOI: 10.3109/02770903.2013.876650
6. 7.
8. 9.
10.
11. 12. 13.
14.
15. 16.
an urban ED: prevalence of incorrect technique and attempt at education. Am J Emerg Med 1996;14:380–384. Broeders ME, Molema J, Hop WC, Folgering HT. Inhalation profiles in asthmatics and COPD patients: reproducibility and effect of instruction. J Aerosol Med 2003;16:131–141. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol 2007;119:1537–1538. Gracia-Antequera M, Morales Suarez-Varela MM. An intervention to improve the inhalatory technique of children and adolescents with asthma. Allergol Immunopathol 1999;27:255–260. Takemura M, Mitsui K, Ido M, Matsumoto M, Koyama M, Inoue D, Takamatsu K, et al. Impact of a network system for providing proper inhalation technique by community pharmacists. J Asthma 2012;49:535–541. Amour Cl, Reddel HK, LeMay KS, Bandana S, Smith LD, BosnicAnticevich SZ, Song YJ, et al. Feasibility and effectiveness of an evidence-based asthma service in Australian Community Pharmacies: a pragmatic cluster randomized trial. J Asthma 2013;50:302–309. Annett R. Assessment of health status and quality of life outcomes for children with asthma. J Allergy Clin Immunol 2001;107: S473–S481. Sundberg R, Palmgvist M, Tunsater A, Toren K. Health related quality of life in young adults with asthma. Respir Med 2009;103: 1580–1585. Rosenzweig JR, Edwards L, Lincourt W, Dorinsky P, ZuWallack RL. The relationship between health related quality of life, lung function and daily symptoms in patients with persistent asthma. Respir Med 2004;98:1157–1165. Armour C, Bosnic-Anticevich S, Brillant M, Burton D, Emmerton L, Krass I, Saini B, et al. Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community. Thorax 2007;62: 496–502. Juniper EF, Byrne PM, Guyatt AG, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J 1999;14:902–907. Juniper EF, Guyett GH, Epstein R, Ferrie P, Jaeschke R, Hiller T. Evaluation of impairment of health related quality of life in
17.
18.
19.
20.
21.
22.
23.
24.
25.
445
asthma: development of a questionnaire for use in clinical trials. Thorax 1992;47:76–83. Molimard M, Raherison C, Lignot M, Depont F, Abouelfath A, Moore N. Assessment of handling of inhaler devices in real life: an observational study in 3811 patients in primary care. J Aerosol Med 2003;16:249–254. Brocklebank D, Ram F, Wright J, Barry P, Cates C, Davies L, Douglas G, et al. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess 2001;5:1–149. Lavorini F, Magnan A, Dubus J, Voshaar T, Corbetta L, Broeders M, Dekhuijzen R, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med 2008;102:593–604. Scarfone R, Capraro G, Zorc J, Zhao H. Demonstrated use of metered dose inhalers and peak flow meters by children and adolescents with acute asthma exacerbations. Arch Pediatr Adolesc Med 2002;156:378–383. Haughney J, Price D, Barnes NC, Virchow JC, Roche N, Chrystyn H. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respir Med 2010;104:1237–1245. Nimmo CJ, Chen DN, Martinusen SM, Ustad TL, Ostrow DN. Assessment of patient acceptance and inhalation technique of a pressurised aerosol inhaler and two breath-activated devices. Ann Pharmacother 1993;27:922–927. Foland A, Stern T, Ramacciotti T, Martin J, Gilbert I, Cohn R. Improvement of metered-dose inhaler administration technique: the effect of training sessions at a specialised pediatric asthma compliance and technique clinic. Curr Therap Res 2002;63: 142–147. Verver S, Poelman M, Bogels A, Chisholm SL, Dekker FW. Effects of instruction by practice assistants on inhaler technique and respiratory symptoms of patients. Fam Pract 1996;13: 35–40. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler based reminder labels, to improve asthma inhaler technique. Patient Educ Couns 2008;72:26–33.
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ASTHMA CONTROL
A study to assess inhaler technique and its potential impact on asthma control in patients attending an asthma clinic C. M. Harnett, MB1, E. B. Hunt, MD1, B. R. Bowen, BSc1, O. J. O’Connell, MB, MD1, D. M. Edgeworth, MB1, P. Mitchell, MB1, J. A. Eustace, MB2, M. T. Henry, MB, MD1, M. P. Kennedy, MB, MD1, B. J. Plant, MB, MD1,2, and D. M. Murphy, MB, PhD1,2 1
The Department of Respiratory Medicine, Cork University Hospital, University College Cork, Cork, Ireland and 2HRB Clinical Research Facility, University College Cork, Cork, Ireland Abstract
Keywords
Objectives: The aim of this study was to evaluate inhaler technique and symptom control in patients with poorly controlled asthma at baseline and at follow-up in a dedicated asthma clinic in a tertiary hospital. We also investigated the impact of asthma on these patients’ quality of life. Methods: Patients referred to a newly established asthma clinic in Cork University Hospital were prospectively recruited over a 6-month period. Their inhaler technique was assessed by a pulmonary nurse specialist using a validated scoring system. They received instruction on inhaler usage when scores were suboptimal. Patients completed a validated asthma control questionnaire (ACQ) and asthma quality of life questionnaire (AQLQ). At followup 3–4 months later, the inhaler technique was reassessed and the ACQ questionnaire repeated. Results: Forty-six patients were recruited (female ¼ 74%), and 40/46 were followed up. Mean [SD] FEV1 % predicted at baseline ¼ 76.5% [21.5]. About 63% of the patients were classified as incorrectly using their inhaler at their initial assessment. This decreased to 20% at follow-up, indicating an overall significant improvement in inhaler usage post-training (p ¼ 0.003). ACQ scores improved significantly from median [interquartile range] 2.70 [1.66] to 2.00 [1.90] (p ¼ 0.002). Baseline measurement indicated that patients’ quality of life was moderately affected by asthma, with a median AQLQ score of 4.75 [1.97]. Conclusion: This study demonstrates the importance of educating and formally assessing inhaler technique in patients with asthma as a part of their ongoing clinical review.
Education, management/control, pharmacotherapy, quality of life, treatment
International asthma guidelines increasingly rely on pharmacological management with inhaled drugs, using an evidencebased stepwise approach to therapy [1]. Pressurised metered dose inhalers (pMDIs) and dry powder inhalers (DPIs) are the most commonly used devices. Dry powder inhalers were introduced as a more user-friendly alternative to the pMDI as they require less co-ordination between inhalation and device activation. On one hand, when used correctly, inhalers allow high pulmonary deposition of drug and minimise systemic bioavailability [2]. On the other hand, misuse of inhalers is associated with asthma instability, with each error made having the potential to significantly effects symptom control [3]. Ensuring optimal patient inhaler technique is therefore critical to asthma care. Studies examining the patient inhaler technique have taken place in a variety of settings – family practices, emergency departments, pharmacies, and specialised paediatric asthma units. However, irrespective of the setting, the patients’ Correspondence: Dr. Desmond M. Murphy, Consultant Respiratory Physician, The Department of Respiratory Medicine, University College Cork, Cork University Hospital, Cork, Ireland. Tel: +353 214922327. E-mail: [email protected]
Received 13 September 2013 Revised 5 December 2013 Accepted 14 December 2013 Published online 24 January 2014
inhaler technique has been found to be consistently poor, with levels of misuse ranging from 12% to 79%, depending on the type of inhaler and method of assessment [4,5]. These studies report pMDIs as the type of inhaler most frequently misused, with an average of 68% of the patients characterised as having incorrect technique. Errors of timing and co-ordination have been highlighted to be commonplace Current recommendations on the management of asthma emphasise regular monitoring and education of patients. Instruction on inhaler technique results in a more efficient use of inhalers [6]. After the initial instruction, however, patients’ inhaler technique quickly declines in the absence of ongoing instruction [7]. Patients who simply receive further inhaler instruction once after the initial instruction have better inhaler technique when compared with those who only received instruction at the time of prescription [8]. Similar results have been recently demonstrated in the community pharmacy setting emphasising the importance of a wide range of support services for the asthma population [9,10]. Risk factors for misuse previously identified include older age, lower schooling, and lack of instruction on inhaler technique by caregivers [5]. Studies demonstrate that inhalers are used poorly by patients prior to educational intervention and that incorrect use is associated with asthma instability [2–4]. However, few
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Introduction
History
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studies to date have demonstrated whether clinical outcomes improve with improvements in the inhaler technique. Recently, subjective measures of health outcomes are being assigned ever increasing importance, in line with an overall shift towards the delivery of patient-centred care. It has been shown that patients’ psychosocial characteristics have an impact on adherence to medication regimens [11]. Subjective experience of a disease can differ from an objective clinical review. It has been demonstrated that both low FEV1 and female gender are associated with a decline in quality of life among young adults with asthma [12]. Conversely, it has also been shown that the effect of asthma on a patient’s quality of life is not fully accounted for by objective measures such as lung function [13]. There is very little data on the asthma-related quality of life of patients with poor levels of asthma control. The aim of this study was to assess the adequacy of the inhaler technique in a cohort of patients attending or referred to a dedicated asthma clinic, and to evaluate the benefit of a ‘‘Teach to goal’’ technique in those identified as inhaler misusers on asthma control at follow-up. In addition, we recorded the effect of asthma on quality of life in this cohort.
Methods
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Inhaler technique The inhaler technique was assessed at baseline by a trained pulmonary nurse specialist. Each patient demonstrated the inhaler technique with placebo devices of each type of inhaler they were using. Patients were asked to use their inhalers as they normally did at home. A validated checklist of steps specific for each device was used to score technique [14]. Patients were classified as ‘‘misusers’’ of a device if greater than or equal to one error was made. There is some discrepancy in the literature as to what classifies a patient as a misuser of a device, with some defining misuse as 570% of steps correct, and others 5100% of steps correct. As previous studies have shown that each error can have significant effect on asthma control we chose to classify patients as ‘‘misusers’’ if greater than or equal to 1 step was performed incorrectly [3]. If a suboptimal score (510/10) was achieved, the nurse instructed the patient on perfect usage of that particular inhaler device, utilising both verbal instructions and a demonstration of proper technique. The cycle was continued until mastery was achieved. This type of instruction and demonstration is considered the ‘‘Teach to Goal’’ technique. At a follow-up clinic, 3–4 months later, the technique was reassessed in the same manner by the nurse and the results were recorded.
Study design and subjects Ethical approval was granted by the Clinical Research Ethics Committee of Cork teaching hospitals prior to commencement of this study (Informed consent was obtained from all participants in the study). Forty-six consecutive patients referred to a newly established tertiary clinic for severe asthma in Cork University Hospital were recruited from March to September 2011. Demographic data were gathered with the inhaler technique, asthma symptom control, and quality of life being assessed at baseline. Patients were followed up for 3–4 months after the initial clinic visit. Patient follow-up took place from June to December 2011. All patients 16 years of age attending the clinic, whose diagnosis of asthma was confirmed by a respiratory physician, were included. While patients were felt to have severe, difficult to control asthma by the referring physician, based on ACQ scores, spirometry, and GINA guidelines, this was not always the case when these patients were formally reviewed in clinic [1]. These patients were, however, included in the analysis. Study measures and procedures Demographics and medication Patients completed an interviewer-administered survey, which gathered information on demographics (age, gender, and years diagnosed with asthma). Smoking history was obtained, including the number of pack years for current or ex-smokers. Medication details were recorded and a change in the type or dose of baseline medication during or between the baseline and follow-up clinics was recorded. The atopic status of each patient was recorded based on eosinophil counts, IgE levels, and by RAST testing (for cat, dog, grass, and house dust mite) at the baseline clinic, unless these tests were previously performed, and the results available on the hospital system to the clinician.
Asthma control A validated questionnaire was completed at baseline and at follow-up by each participant in order to assess the level of asthma control prior to and following inhaler educational intervention. The Juniper et al. [15] validated asthma control questionnaire (ACQ) was used with the permission from the author. This questionnaire scores the five most important symptoms as well as the usage of rescue short-acting bronchodilator, and FEV1 % predicted. Patients were asked to recall their asthma symptoms over the preceding week including and a score based on a 7-point scale assigned (the minimal clinical important difference or change in score was 0.5). A score of 1.50 indicates poor control, with a positive predictive value ¼ 0.88 [15]. Asthma quality of life Patients’ quality of life was assessed using a validated asthma quality of life questionnaire (AQLQ) at the baseline clinic [16]. Permission to use the questionnaire was obtained from the author prior to commencing the study. The questionnaire contains 32 items relating to the day-to-day problems that patients with asthma find most troublesome and includes thirty-two questions within four domains: symptoms, activity limitations, emotional function, and environmental stimuli. Patients were asked to recall their experiences over the previous 2 weeks and respond to each question on a 7-point scale. This questionnaire assesses not only physical limitation but also the impact that asthma has on work, social life, sleep, and environmental issues. Statistical analysis Data were analysed using SPSS 18Ô (SPSS Inc., Chicago, IL). Preliminary analyses were performed to assess normality
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and to ensure no violation of test assumptions. Baseline and follow-up inhaler technique scores were compared for a statistically significant difference before and after the educational intervention. The Wilcoxon signed rank test was used to assess for statistical significance. Asthma symptom scores at baseline and follow-up clinics were also compared. The relationship between change in symptom scores and change in inhaler technique scores post-intervention was assessed using Spearman’s rank order correlation test. Asthma quality of life scores were analysed, and compared to other variables (ACQ score and FEV1), using Spearman’s rank order correlation test. A two-sided p value 50.05 was considered statistically significant.
Results Population characteristics Forty-six patients were recruited for this study, and forty were followed up. Five patients failed to follow-up or were rescheduled (thus falling outside the 3–4 month follow-up period), with one being unable to perform spirometry at followup due to recent abdominal surgery and thus was excluded from analysis. The 46 patients recruited at baseline were included in the recording of baseline demographic characteristics and asthma quality of life, but only the 40 patients who were followed up, were included for statistical analysis. The atopic status of the population was identified, with 80% having evidence of atopy, indicated by a positive RAST test (to grass, cat, dog or house dust mite), high eosinophil count, or raised IgE level. Other baseline characteristics are shown in Table 1. Evaluation of inhaler technique The most commonly used inhaler devices were the pMDI (61% of the patients) and TurbohalerÕ (Luton, UK) (52%). Other dry powder inhalers including DiskusÕ (London, UK) Table 1. Patients characteristics. % Patients (n) Female Age (years) Duration of asthma diagnosis (years) Smoker Ex-smoker Non-smoker Pack years Atopic Positive RAST test Raised IgE level (481 kU/l) Raised eosinophil count (40.4 109/L) FEV1 (% predicted) Medicationa Combined ICS/LABA Salbutamol reliever Tiotropium reliever Other anti-inflammatory Oral corticosteroids
Mean [SD]
74 (34) 44 [15.3] 24.8 [19.68] 9 (4) 26 (12) 65 (30) 19.6 [19.12] 80 50 57 44
(37) (23) (26) (20) 75 [21.44]
100 80 28 52 17
(46) (37) (13) (24) (8)
ICS, inhaled corticosteroids; LABA, long-acting bronchodilator. a Medication classifications are reliever (salbutamol, ipratropium), ICS (beclomethasone, budesonide, fluticasone), other anti-inflammatory medications (montelukast, theophylline), and LABA (salmeterol, formoterol).
(17%) and HandihalerÕ (Boehringer Ingelheim, Bracknell, UK) (17%) were used as well as the RespimatÕ (Boehringer Ingelheim, Bracknell, UK) devices (11%). Forty-four percent of the patients had two different types of inhaler device, 40% were using a single inhaler device, and 16% had three different inhaler devices. Most patients had received previous inhaler technique training, which was most commonly carried out by their general practitioner at the time of initial prescription (51%). Others were taught by a practice nurse (30%), or by a pharmacist (12%), with a minority of the patients unable to recall any demonstration of inhaler technique (7%). The TurbohalerÕ was the most poorly used device at baseline, with 88% of the patients making 1 error according to the validated checklist of steps for that inhaler. The most frequent errors made were failure to breathe out before inhalation (63%) and not breath-holding following inhalation of the drug (47%). The most common errors made by pMDI users were found to be the same as for the TurbohalerÕ – not exhaling prior to inhalation (37.5%) and failure to breath-hold following inhalation (75%). Overall, no significant relationship was found between patient age and level of inhaler misuse (p ¼ 0.4) or between the number of years diagnosed with asthma and inhaler misuse (p ¼ 0.5). Follow-up scores were improved overall for each type of the inhaler device (Figure 1). About 17% of the patients using the pMDI were classified as misusers at follow-up, and an overall significant improvement was associated with this device (p ¼ 0.001). Statistically significant improvements were also seen in users of the TurbohalerÕ ,** following the intervention (p ¼ 0.001), and similarly with the DiskusÕ inhaler (p ¼ 0.02). Asthma symptom control Of the 40 patients followed up, 26/40 were classified as having poorly controlled asthma at baseline (based on an ACQ score 1.5). Asthma Control Questionnaire score median [intequartile range] at baseline was 2.70 [1.66]. At follow-up, 24/40 remained poorly controlled with an ACQ score of 2.00 [1.90]. However, 17/40 (42%) had a clinically significant improvement in their symptoms at follow-up indicated by a change in score of 0.5. Clinically significant worsening of symptoms between baseline and follow-up was seen in 3/40 patients. Overall, there was a statistically significant (p ¼ 0.002) improvement in ACQ scores at follow-up (Figure 2). Of the 17 patients who had a clinically significant improvement, 5 patients had a change of medication at the baseline clinic (seven medication changes were recorded in these five patients). Montelukast was added to the medication regimen of two patients, tiotropium to two others, budesonide/ formoterol formulation to two, and fluticasone/salmeterol was prescribed for one patient. There was no change in medications for the other 12 patients whose symptoms improved. When the patients whose medication regimen was altered were excluded from analysis, a change in the symptom score was still found to be statistically significant (p ¼ 0.02). Correlation between improved ACQ scores and improved inhaler technique at follow-up did not reach statistical significance (r ¼ 0.37, p ¼ 0.3).
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Baseline Technique Follow-up Technique
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38
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38 33
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Asthma quality of life Asthma Quality of Life Questionnaire score at baseline was found to be a median [interquartile range] of 4.75 [1.97], indicating that patients’ quality of life is moderately affected by their asthma. Patients’ AQLQ score strongly correlated with ACQ score (r ¼ 0.8), with poorer AQLQ coinciding with decreasing asthma control (p50.001). There is a 64% shared variance between the two measurements. Each domain of the AQLQ questionnaire independently correlated with asthma symptom control, including activity limitations (p ¼ 0.001), symptoms (p50.001), emotional function (p50.001), and environmental stimuli (p ¼ 0.001). Asthma Quality of Life Questionnaire score differed between males and females, with females reporting a poorer score of 4.3 [2.1] compared to men with 5.22 [1.0]. This difference was not replicated in the objective measurement of FEV1 at the baseline, with median FEV1 in females being 78% predicted and 74% predicted in men.
20 17 13
10
0 pMDI (n Turbohaler =28) (n=24)
Diskus (n=8)
Respimat Handihaler (n=5) (n=8)
Figure 1. Percentage incorrect users of each inhaler device at baseline and at a 4-month follow-up (n ¼ number of patients using inhaler type). All changes were statistically significant at p 0.02. TurbohalerÕ inhaler device used for SymbicortÕ (AstraZeneca, Luton, UK) (formoterol/ budesonide), PulmicortÕ (AstraZeneca, Luton, UK) (budesonide), and OxisÕ (AstraZeneca, Luton, UK) (formoterol). DiskusÕ inhaler device used for SeretideÕ (GlaxoSmithKline, London, UK) (salmeterol/ fluticasone), FlixotideÕ (GSK/Allen & Hanley, Uxbridge, UK) (fluticasone), and VentolinÕ (GSK, Uxbridge, UK) (salbutamol). RespimatÕ inhaler device used for SpirivaÕ (Boehringer Ingelheim, Bracknell, UK) (tiotropium). Handihaler inhaler device used for SpirivaÕ (tiotropium).
3.4
Median 25%-75%
3.2 3.0 2.8 2.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2 1.0 ACQ base ACQ follow up
Figure 2. Box and Whisker plot illustrating asthma symptom score (ACQ) at baseline and at follow-up. There was a significant improvement in ACQ score after inhaler technique education at 3–4 month follow-up from median 2.7–2.0 (p ¼ 0.002).
Discussion The findings of this study was parallel to those of the previous studies, in that the majority of the patients were making errors in the inhaler technique, irrespective of inhaler type [5,17]. Levels of misuse ranged from 88% in patients using the TurbohalerÕ , to 38% in patients using a HandihalerÕ device. Misuse of the most frequently used device, the pMDI, fell somewhere in between, with 63% of the patients making errors. This is in contrast to the findings of previous studies, where the pMDI was reported to be the most poorly used device [18]. Although this study was not designed to specifically compare ease of use of one type of inhaler over another, in our cohort, DPIs were misused at least as frequently as pMDIs (if not more so), despite DPIs being designed to be more ‘‘user friendly’’. There is some discrepancy within the literature as to what classifies a patient as a ‘‘misuser’’ of a device; and also between distinguishing critical errors from less important ones. Some studies have subdivided patients into those making ‘‘critical’’ and ‘‘non-critical’’ errors, while further studies have subgrouped patients with good and poor device co-ordination for pMDIs specifically. This study simply assessed whether the number of steps carried out was correct or incorrect when patients used their inhalers, according to a standardised checklist, with ‘‘misusers’’ classified as those making 1 error. The strict criteria we used may contribute to the large percentage of those identified as ‘‘misusers’’. The most common errors made were found to be ‘‘deviceindependent’’, which include failure to exhale before inhalation of the drug and failure to breath-hold after inhalation. This is in line with findings from previous studies [3,19,20]. It is not clearly understood why patients are most likely to omit these steps, or how this may affect the degree of drug deposition and efficacy of the medication. Each type of the inhaler device requires a specific technique, with pMDIs requiring slow and deep inhalation co-ordinated with actuation, while DPIs require forcible and rapid inhalation. As in other studies, our data suggest that the choice of inhaler device should be individualised to patient’s ability to use an inhaler type [21]. Our study further suggests that despite
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repeated technique assessments and trainings, some patients are unable to achieve perfect technique regardless of the type of inhaler device and this may, in turn, affect their clinical outcome. The use of home nebuliser therapy may indeed be the next step in the management of their asthma so as to ensure adequate drug delivery. We found that most patients (93%) had received prior instruction in the inhaler technique before evaluation at the asthma clinic. This was most commonly performed by a general practitioner at the time of prescription. This is an encouraging finding as the performance of verbal instruction is recommended at the time of prescription, with previous research showing that simply letting patients to read instructions is not adequate [22]. Despite previous education, we demonstrated that the number of patients making errors was still considerably high, and this decreased significantly at follow-up after instruction had been provided at the asthma clinic. Our findings highlight the value and importance of regular reassessment and instruction, even in patients who had long experience of using inhalers. For example, 63% of the patients using a pMDI at the baseline were making errors, while this fell to 17% at follow-up following the inhaler technique training session. Similar results were observed with the technique instruction for the other inhaler types. The benefit of reassessment and instruction has been demonstrated by studies in paediatric populations; however prior to our study, limited data were available in similar adult cohorts [23]. The patients in this study had been referred to the asthma clinic because their asthma had been perceived to be difficult to control by other physicians. One may have expected, given that the mean treatment duration for asthma was 24.8 years, that this cohort would have been both experienced and proficient in inhaler technique. Despite this, and the expected increased contact with healthcare professionals, their inhaler technique remained suboptimal. This further emphasises the need for constant education/re-education in the inhaler technique over the course of a patients’ lifetime. Very few studies have assessed the clinical outcomes of ‘‘poor’’ versus ‘‘good’’ inhaler technique. Two previous studies investigating the clinical impact of training the technique found that subjective improvements in quality of life and breathlessness occurred after instruction [24,25]. However, in these studies, no objective tool was used to assess improvement or otherwise in patients’ symptoms or quality of life, and details of device mishandling were not evaluated. One of the strengths of our study is that the change in asthma control was measured using a validated questionnaire which combines both objective (FEV1) and subjective (symptoms) data, in order to produce a balanced account of clinical outcome post-intervention. While we found that symptom scores improved overall in patients pre- and post-intervention (p ¼ 0.002), several potential confounding factors such as the intrinsic variability of the disease, poor compliance to medication and correct technique at home, and the small sample size exist. Furthermore, we cannot categorically state that improvements were not simply due to attendance at a dedicated asthma clinic. Five patients failed to return for follow-up. The results of the study may have been affected had these patients been followed-up and included in
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statistical analysis. Their reasons for failing to attend the second clinic may have been related to either an improvement or a disimprovement in asthma symptoms. The asthma quality of life of this cohort was measured at baseline for descriptive purposes. AQLQ score not surprisingly was found to be strongly correlated with the level of asthma control (p50.001). Moreover, each of the domains measured by the questionnaire was found to be independently correlated to ACQ scores. Females reported a poorer quality of life compared with males, despite little difference in FEV1 between genders, illustrating gender differences in selfreported impact of asthma on quality of life, despite similar objective lung function measures. Previous studies have highlighted female gender as a predictor of poorer asthma quality of life [12]. Asthma Quality of Life Questionnaire scores were not assessed at follow-up due to practical reasons; however, this would be a useful subjective measure of the impact of the intervention on patients’ quality of life in future studies. It is clear that even experienced patients whose asthma has been managed by healthcare professionals, for many years, continue to make inhaler technique errors. We have highlighted both the value of assessing and training patients on correct inhaler technique, as evidenced by significant improvements in technique scores following instruction, but also the need for ongoing reassessment of technique. Larger studies are now needed to both confirm and expand on our findings.
Conclusion Reassessment and re-education of asthmatic patients in the inhaler technique is a fundamental component of their ongoing clinical management. Poor asthma control related to insufficient technique should be considered at each point evaluation by the treating physician, even in patients with longstanding asthma. This study emphasises the necessity for interval monitoring and training in correct inhaler technique for all asthmatic patients. It also highlights the association of poor asthma control with poorer quality of life.
Declaration of interest D. M. M. has received speaker’s fees from Astra Zeneca, GSK, Boehringer Ingelheim, Bayer, Novartis and MSD and acted on advisory boards for Nycomed, Mundipharm, Boehringer Ingelheim, and Novartis. The other authors have no declared conflicts of interest.
References 1. Global Initiative for Asthma 2009 guidelines. Available from: http://www.ginasthma.com [last accessed 01 Dec 2013]. 2. Roche N, Chinet T, Huchon G. Ambulatory inhalation therapy in obstructive lung diseases. Respiration 1997;64:121–130. 3. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002;19: 246–251. 4. Melani A, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, Serra M, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med 2011;105: 930–938. 5. Shrestha M, Parupia H, Andrews B, Kim S, Martin MS, Park DI, Gee E. Metered-dose inhaler technique of patients in
Asthma inhaler technique
DOI: 10.3109/02770903.2013.876650
6. 7.
8. 9.
10.
11. 12. 13.
14.
15. 16.
an urban ED: prevalence of incorrect technique and attempt at education. Am J Emerg Med 1996;14:380–384. Broeders ME, Molema J, Hop WC, Folgering HT. Inhalation profiles in asthmatics and COPD patients: reproducibility and effect of instruction. J Aerosol Med 2003;16:131–141. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol 2007;119:1537–1538. Gracia-Antequera M, Morales Suarez-Varela MM. An intervention to improve the inhalatory technique of children and adolescents with asthma. Allergol Immunopathol 1999;27:255–260. Takemura M, Mitsui K, Ido M, Matsumoto M, Koyama M, Inoue D, Takamatsu K, et al. Impact of a network system for providing proper inhalation technique by community pharmacists. J Asthma 2012;49:535–541. Amour Cl, Reddel HK, LeMay KS, Bandana S, Smith LD, BosnicAnticevich SZ, Song YJ, et al. Feasibility and effectiveness of an evidence-based asthma service in Australian Community Pharmacies: a pragmatic cluster randomized trial. J Asthma 2013;50:302–309. Annett R. Assessment of health status and quality of life outcomes for children with asthma. J Allergy Clin Immunol 2001;107: S473–S481. Sundberg R, Palmgvist M, Tunsater A, Toren K. Health related quality of life in young adults with asthma. Respir Med 2009;103: 1580–1585. Rosenzweig JR, Edwards L, Lincourt W, Dorinsky P, ZuWallack RL. The relationship between health related quality of life, lung function and daily symptoms in patients with persistent asthma. Respir Med 2004;98:1157–1165. Armour C, Bosnic-Anticevich S, Brillant M, Burton D, Emmerton L, Krass I, Saini B, et al. Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community. Thorax 2007;62: 496–502. Juniper EF, Byrne PM, Guyatt AG, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J 1999;14:902–907. Juniper EF, Guyett GH, Epstein R, Ferrie P, Jaeschke R, Hiller T. Evaluation of impairment of health related quality of life in
17.
18.
19.
20.
21.
22.
23.
24.
25.
445
asthma: development of a questionnaire for use in clinical trials. Thorax 1992;47:76–83. Molimard M, Raherison C, Lignot M, Depont F, Abouelfath A, Moore N. Assessment of handling of inhaler devices in real life: an observational study in 3811 patients in primary care. J Aerosol Med 2003;16:249–254. Brocklebank D, Ram F, Wright J, Barry P, Cates C, Davies L, Douglas G, et al. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess 2001;5:1–149. Lavorini F, Magnan A, Dubus J, Voshaar T, Corbetta L, Broeders M, Dekhuijzen R, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med 2008;102:593–604. Scarfone R, Capraro G, Zorc J, Zhao H. Demonstrated use of metered dose inhalers and peak flow meters by children and adolescents with acute asthma exacerbations. Arch Pediatr Adolesc Med 2002;156:378–383. Haughney J, Price D, Barnes NC, Virchow JC, Roche N, Chrystyn H. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respir Med 2010;104:1237–1245. Nimmo CJ, Chen DN, Martinusen SM, Ustad TL, Ostrow DN. Assessment of patient acceptance and inhalation technique of a pressurised aerosol inhaler and two breath-activated devices. Ann Pharmacother 1993;27:922–927. Foland A, Stern T, Ramacciotti T, Martin J, Gilbert I, Cohn R. Improvement of metered-dose inhaler administration technique: the effect of training sessions at a specialised pediatric asthma compliance and technique clinic. Curr Therap Res 2002;63: 142–147. Verver S, Poelman M, Bogels A, Chisholm SL, Dekker FW. Effects of instruction by practice assistants on inhaler technique and respiratory symptoms of patients. Fam Pract 1996;13: 35–40. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler based reminder labels, to improve asthma inhaler technique. Patient Educ Couns 2008;72:26–33.
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