Educational intervention for correct pressurised metered dose inhaler technique in Trinidadian patients with asthma

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Abstract

Correct pressurised metered dose inhalers (pMDI) usage is reportedly sub-optimal in patients and data for Caribbean populations is not available. We studied proficiency of inhaler use in Trinidadian patients, and determined sub-groups to be targeted for educational interventions. Inhaler use by 331 consecutive stable patients with airway disease (over 7 years) was observed and marked on a standard checklist. From direct observation only 41% of patients correctly inhaled, though 92% were confident of accurate technique. Few elderly patients (6%) received appropriate instructions on inhaler technique and only 35% (n=23/66) understood the rationale for two different inhaler therapies (P<0.001). More children (33%) and elderly patients (21%) reported escaping drug with use. Multiple regression analysis indicated the independent predictors of correct pMDI were age (P<0.01) and correct understanding of different inhalers. Intensive patient education in Trinidadian children and elderly patients with airway disorders can enable active participation in disease management and maximal benefit from medication.

Introduction

The prevalence of asthma among children and young adults [1], [2], [3] is reportedly increasing, particularly in affluent countries and it is now called a disease of the industrialized 20th century [4]. Evidence suggests asthma is an emergent disease in urban areas of developing countries like Africa and Asia too [5]. The International Consensus Report on the Diagnosis and treatment of Asthma [6] recommends first ‘to educate patients to develop a partnership in asthma management’. Current treatment strategies emphasize the importance of self-administered therapy with the inhaler for patients suffering from asthma and chronic pulmonary disease [7], [8], and cost-efficacy education programs encourage patients to take greater control of their condition to enhance self-management [9]. Pressurised metered dose inhalers (pMDI) are the most common drug delivery systems for aerosolized therapy [10], providing a cost-effective and safe method of drug delivery to the lungs. Therapeutic success depends on adequate lung deposition of drug and this factor is influenced by the technique used by the patient to inhale the aerosol [11], [12]. It is a common perception that patients do not use their inhaler in the correct fashion and studies have shown that a large percentage of patients have a faulty technique when using the pMDI [13], [14].

There are no published Caribbean reports on the efficient use of the pMDI by patients with airway disorders. This study was designed to evaluate how well patients with airway disorders in Trinidad use their inhalers and to determine whether any patient sub-groups should be targeted for educational intervention.

Section snippets

Subjects

The study was conducted at the Chest Clinic after receiving the permission of the Director and consultants. Ethics Committee approval was obtained from the Faculty of Medical Sciences, St. Augustine campus of the University of the West Indies, in Trinidad.

The study was conducted over a period of one year between February 1997 and March 1998. In Trinidad, patients suffering from respiratory diseases (including asthma) are generally managed at the Ministry of Health’s Chest Clinic which operates

Subject characteristics

All patients consented to participate (100% response rate). The sample comprised 331 patients, of whom 274 came from the Eric Williams Medical Sciences Complex (EWMSC) and 57 came from the San Fernando General Hospital (SFGH). Thirty-three responses were from children (10%), 23 from adolescents (8%), 209 from adults (62%), and 66 came from the elderly (20%), (Table 1). There were 212 females (64%) in the sample. The mean age for all subjects was 44.1 (±22.4) years and ranged between 7 and 87

Discussion

The pMDI is difficult to use [14], [16], [17], [18], [19], and as much as 70% of patients reportedly do not perform a correct maneuver [14], [16], [17], [18], [19]. We investigated the technique of pMDI use in patients regularly using the device for asthma management, in Trinidad. It was encouraging to see nearly all our patients (90%) were instructed on technique, compared with data from the UK where only 63% of patients received a demonstration of inhaler technique [20]. That just 60% of them

Acknowledgements

Dr Martyn Partridge made invaluable comments on the patient questionnaire and the manuscript. Dr S. Begley contributed to the pilot study. We are grateful to A. Cassim (GlaxoWellcome Caribbean) for her assistance in liaison with the Institutions and consultants, and to Dr Albert Persaud (Director, Chest Clinic) for permitting the study.

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