Comparative Study of Different Inhaler Devices in Asthmatic Children
2003; King Faisal Specialist Hospital and Research Centre; Volume: 23; Issue: 6 Linguagem: Inglês
10.5144/0256-4947.2003.349
ISSN0975-4466
Autores Tópico(s)Respiratory and Cough-Related Research
ResumoOriginal ArticlesComparative Study of Different Inhaler Devices in Asthmatic Children Mohammed Abdullah AlshehriMD, FRCP(c) Mohammed Abdullah Alshehri Correspondence to: Dr. Mohammed Alshehri, College of Medicine and Health Sciences, King Khalid University, P.O. Box 641, Abha, Saudi Arabia From the Department of Pediatrics, College of Medicine and Health Sciences, King Khalid University, Abha, Saudi Arabia Published Online:1 Nov 2003https://doi.org/10.5144/0256-4947.2003.349SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractBACKGROUNDThe inhaler is an important drug delivery system in the treatment of asthma, but inhaler technique is often inadequate. We assessed technique in children diagnosed with asthma, comparing the performance of three devices.PATIENTS AND METHODSIn a cross-sectional survey, 523 children (271 boys, 252 girls, ages 5 to 12 years; mean±SD 7.53±1.79 years) demonstrated inhalation technique according to Netherlands Asthma Foundation criteria during a first visit to a primary care clinic in Abha, Saudi Arabia. Patients used the device with which they were most familiar (either pMDI, Turbuhaler or Diskus).RESULTSTwo hundred children (38% of total population) used a pMDI, while 323 (62% of total population) used one of the dry powder inhalers‹173 (58%) the Turbuhaler and 150 (47%) the Diskus. Only 49 children (25% of the total population) completed the assessment without making a mistake. The remaining 474 (75% of the total population) performed one or more manuevers poorly. Only 80 children who used an MDI (40% of those using the device) completed 50% or more of the maneuvers correctly compared with 111 (69% of those using the device) and 100 (67% of those using the device) of those using the Turbuhaler and Diskus, respectively (P=0.001 for comparison of MDI with dry powder inhalers). Children whose mothers had intermediate school or higher education performed better than those whose mothers had less education (P=0.001). The father's education had no bearing on performance with the inhaler.CONCLUSIONThe inhaler technique of most asthmatic children is poor, but technique is better in children who use a dry powder compared a metered-dose inhaler. The level of the mother's education is positively associated with better inhalation technique in the child.IntroductionBronchial asthma is the most common chronic illness in children.1 An increase in the prevalence and severity of bronchial asthma in both children and adults worldwide has been noted in recent years.2 Hospital admissions are steadily increasing.3 Children with asthma face multiple challenges that encompass learning how to cope with and manage the unique demands of this illness. These demands can involve monitoring peak airflow, administering medications, modifying the environment to limit exposure to asthma triggers, and dealing with potential side effects.The inhaler is an important drug delivery system in the treatment of childhood asthma. Inhaler technique is inadequate in many adult asthmatics4 and many physicians caring for asthmatic patients have poor knowledge of the proper use of inhaler devices.5 Clear instruction with repetition is necessary when patients are about to use this type of medication for the first time. It is the responsibility of the physician to check that all patients who use inhaled medication are instructed on the correct use of their inhalers. Even if patients have been using an inhaler for a long time, regular checkups and frequent assessment of inhalation technique with follow-up education for patients with poor technique should lead to improved outcomes in patients with asthma.Inhalers have an advantage over oral forms of asthma medicine in that, with proper technique, medication is delivered directly to the target tissue site, bypassing the need for systemic absorption and possible metabolism. Inhalation decreases the time to onset of action and reduces systemic side effects. Furthermore, inhalation reduces the amount of medication required. However, correct use of an inhaler is more difficult than swallowing syrup or a tablet. And the effect of inhaled medication depends largely on the patient's inhalation technique.6,7 We performed this study to evaluate the technique of children with asthma and compare their performance with three different inhaler devices.PATIENTS AND METHODSIn this cross sectional survey, we recruited patients seen at Abha Medical Consultative Clinics, a primary care center located in southwestern Saudi Arabia. The survey was done during the patient's first visit to the chest clinic. Patients were asked to demonstrate inhalation technique, using the inhaler device with which they were most familiar. A single observer using standardized checklists designed by the Netherlands Asthma Foundation scored each step. Patients had previous instruction in use of the inhaler and had been using the inhaler device for more than two months. We studied the three most commonly used types of inhalation devices: the dry powder inhalers Turbuhaler and Diskus, and a metered dose inhaler (MDI). For each patient, the inhalation technique was assessed for only one inhaler. Patients who used more than one inhaler were free to choose whichever device they found familiar and easy to use.All data obtained were coded and entered into IBM compatible computer of the Family and Community Medicine Department, College of Medicine and Medical Sciences, King Khalid University, Abha, and analyzed using the Statistical Package for Social Science software (SPSS-Version 10). The frequency and percentage of patients who failed to perform steps of the inhalation technique were recorded, and the frequency and percentage of mistakes were calculated per inhaler. The relationship between age, gender, parent education and proper inhalation technique was analyzed by the chi-square test. The limit of statistical significance was set at P 0.05) (Table 1).Table 1. Distribution of patients according to sex and age.Table 1. Distribution of patients according to sex and age.Only 25% of the children completed the assessment without making at least one mistake. Seventy-five percent performed poorly on one or more items. Only 54% completed 50% or more of the steps correctly (Figure 1). Only 40% using the MDI completed 50% or more of the steps correctly as compared with 69% and 67% of patients using the Turbuhaler and Diskus, respectively. The difference between MDI and the other two inhalers was statistically significant (c2=76.3, P=0.001) (Figure 1). Forty-four percent of male patients performed correctly 50% or more of the steps as compared with 47.6% of female patients. This difference was not statistically significant (P=0.08).Figure 1. Percentage of children performing 50% or more of steps correctly.Download FigureAmong the 173 patients using the Turbuhaler, 94 (54.3%), had difficulty with the item "hold breath for ten seconds" and 82 (47.4%) had difficulty with the item "inhale forcefully and deeply" (Table 2). Sixty-five patients (37.6%) did not hold the inhaler device in the horizontal position, and 56 patients (32.4%) did not take the inhaler device out of the mouth. Lastly, 38 (22%) missed the item "prepare the inhaler device before the maneuver."Table 2. Steps in the correct use of Turbuhaler, Diskus, and metered-dose inhaler devices and error rates for each step.Table 2. Steps in the correct use of Turbuhaler, Diskus, and metered-dose inhaler devices and error rates for each step.Among the 150 patients using the Diskus inhalers, 77 (51%) had difficulty in performing the item "continue slow and deep inhalation" and 75 patients (50%) could not perform the item "hold breathing for 10 seconds" (Table 2). Fifty-seven children (38%) did not hold the device in the horizontal position and 50 children (33.3%) did not know how to slide the protective cover. Forty-four patients (29%) did not take the inhaler device out of the mouth. Thirty-four patients (22.7%) did not prepare the inhaler device. Lastly, 16 patients (10.7%) missed the item "place the mouthpiece between lips and teeth."Among the 200 patients using an MDI (Table 2), 139 (69.5%) had difficulty with the item "inhale slowly and simultaneously activate the canister and continue deep inhalation" and 135 (67.5%) had difficulty with item "exhale to residual lung volume." One hundred twenty-three patients (61.5%) did not hold the breath for ten seconds and 107 (53.5%) did not shake the canisters before the maneuver. Eighty-one patients (40.5%) did not place the inhaler device between the lip and teeth properly and did not take the inhaler device out of the mouth. Seventy patients (35%) did not hold the canister upright. Thirty-five patients (17.5%) forgot to "remove the protective cap."Forty-two percent of children whose mother's education reach intermediate school or more completed all the inhalation technique steps without difficulty as compared to 16.7% of children with mothers with less education (P=0.001). The difference between children whose father's education reached intermediate school or more and those with less education was not statistically significant (P=0.14).DISCUSSIONSuccessful management of asthmatic patients depends on achieving adequate delivery of inhaled drug to the lung. The first pressurized aerosol inhaler was introduced in the 1950s.8 One of the first clinical trials was published by Freedman in 1956,9 using a pressurized inhaler called Medihaler (Riker Laboratories). Metered-dose inhalers have become a cornerstone in the management of asthma, with production exceeding 300 million per year.10 However, there is increasing evidence to show that a large proportion of asthmatic patients do not benefit fully from their anti-asthma drugs simply because of poor inhaler technique with MDIs.11 This has resulted in the development of user-friendly dry powder inhalers. In spite of growing awareness that proper inhalation technique is important in patients diagnosed with asthma,12 our results show that 75% of the patient sample could not use their inhaler as prescribed. One explanation for this may be that direct physician observation of inhaler technique may be infrequent or inaccurate. This may be because clinicians do not realize the importance of technique assessment, because of time constraints during clinic visits and because many other health professionals responsible for patient education in inhaler technique often do not understand the factors responsible for the optimal delivery of the inhaled medication.13The steps included in the inhalation technique are very important in achieving the maximum benefit from the inhaler device. For example, to mix the medication with the propellant, an MDI must be shaken well before the inhalation maneuver. The mouthpiece has to be placed between the lips and teeth to prevent the medication from setting on the lips or teeth. The patient has to activate the canister while simultaneously inhaling slowly. The slow inhalation should be continued after the activation and the patient should hold his or her breath for 10 seconds. If the patient inhales too fast, impaction in the pharynx is increased. Breath holding is necessary to avoid the medication being exhaled before it can enter into the lungs. The dry powder inhalers have to be prepared before use; each inhaler has its own procedure. If such inhalers are not prepared well before usage, no medication is available for inhalation. Just as with the MDI, the mouthpiece of the dry powder inhalers has to be placed between the lips and teeth. Unlike with MDIs, patients using a dry powder inhaler should inhale strongly and deeply. Strong inhalation is necessary because the medication must have enough momentum to reach the lungs. After the inhalation, breath holding for ten seconds is also required with dry powder inhalers.Approximately half of the patients using the Turbuhaler did not hold their breath for ten seconds, and did not inhale forcefully and deeply. One-third did not hold their Turbuhaler horizontally and did not take the inhaler out of their mouth. Half of the patients using the Diskus inhalers were not able to continue slow and deep inhalation and hold their breath for ten seconds. One-third could not hold their Diskus device in the horizontal position and did not know how to slide the protective cover. Approximately two-thirds of patients using a MDI did not exhale to residual lung volume and did not inhale slowly and deeply with simultaneous activation of the canister. Other Dutch and international studies have found these two items as common errors.14 More than half of the patients did not hold their breath for ten seconds and half did not shake the canister before the maneuver. One-third of the patients did not place the mouthpiece between the lips and teeth and did not take the canister device out of their mouth. These findings correspond with those of other international studies.14 Our results showed no relationship between correct performance and the child's gender, which is in agreement with other findings.15 The educational level of the child's mother was associated with better performance of inhalation technique of asthmatic children in contrast to the father's education.Only one-quarter of patients succeeded in performing all maneuvers correctly. About two-thirds of patients using the Turbuhaler and Diskus inhalers performed more than half the maneuver items correctly as compared to the one-third of patients using the MDI. Therefore, poor inhalation technique was observed more frequently in children using a MDI than in children using Turbuhaler and Diskus devices. This suggests that correct performance with the former inhaler is more difficult to achieve than with the other devices. These findings are in agreement with other studies16-18 that showed that the Turbuhaler inhalation technique is easier than metered-dose inhalation technique. However, this is the first study that compared the Diskus inhaler device with other inhalers as far as we know.It is important to mention that our study did not include other factors that may affect the performance of inhalation technique in asthmatic patients—factors like the source of education on inhalation technique and the time spent with the patient and the frequency of clinic visits. In addition, children who use a MDI with an aero-chamber or spacer were not included in this survey. We concluded that the inhalation technique of the children with asthma in this study was poor regardless of the type of inhaler device used. Turbuhaler and Diskus technique was easier to perform as compared to the MDI. Physicians should be encouraged to prescribe dry powder inhaler devices, particularly when children with asthma need prophylactic inhaler treatment. In addition, comprehensive inhalation instructions are needed to assure reliable inhalation technique, and technique must be checked repeatedly at follow-up visits. Longitudinal studies indicate that inhaler technique deteriorates over time, with most patients again developing poor technique.19ARTICLE REFERENCES:1. Newacheck PW, Tayor WR. "Childhood chronic illness: Prevalence, severity, and impact." Am J Public Health.. 1992; 82:364-371. Google Scholar2. Bucher L, Dryer C, Hendrix E, Wong N. "Statewide assessment of school-age children with asthma in Delaware." J Schs Health.. 1998; 68:276-281. Google Scholar3. Mitchell EA. "International trends in hospital admission rates for asthma." Arch Dis Child.. 1985; 60:376-378. Google Scholar4. Orehek J, Gayrard P, Grimaud Cet al.. "Patient error inuse of bronchodilator metered dose aerosol." 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"Use and acceptance of vent Olin rotacaps and the rotahaler in 1235 asthmatic patients." Clin Ther.. 1993; 15(12):321-329. Google Scholar17. Zanon P. "Inhalation anti-asthma therapy with spacer; technical aspects." Monaldi Arch Chest Dis.. 1994; 49:258-264. Google Scholar18. King D, Eamshaw SM, Delaney JC. "Pressurized aerosol inhalers: the cost of misuse." Br J Cli Pract.. 1991; 45:48-49. Google Scholar19. Arvid WA, Kamps B, Ruurd JR. "Poor Inhalation Technique, Even after Inhalation Instructions in Children with Asthma." Pediatr Pulmonol.. 2000; 29:39-42. Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byBanjar H (2003) Inhalation Devices in Asthma, Annals of Saudi Medicine, 23:6, (347-348), Online publication date: 1-Nov-2003. Volume 23, Issue 6November-December 2003 Metrics History Accepted1 July 2003Published online1 November 2003 Keywordsasthmachildrenmetered-dose inhalerdry powder inhalerACKNOWLEDGEMENTI thank Dr. Yacoub Arshid from Department of Pharmacology Department and Dr. Mostafa Arafa and Dr. Ismail Abdelmoneim from Department of Family and Community Medicine, College of Medicine and Medical Sciences, King Khalid University, Abha for their meticulous review of the protocol and manuscript of this survey.The investigators received no financial support from device manufacturers.InformationCopyright © 2003, Annals of Saudi MedicinePDF download
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