Metered-dose inhaler technique among healthcare providers practising in Oman 39 ABSTRACT. Objective : To evaluate the correctness of metered-dose inhaler (MDI) technique in a sample of healthcare providers prac- tising in Oman, considering that poor inhaler technique is a common problem both in asthma patients and healthcare providers, which contributes to poor asthma control. Method: A total of 150 healthcare providers (107 physicians, 33 nurses and 10 pharmacists) who were participants in symposia on asthma management conducted in fi ve regions of Oman, volunteered for the study. After the partici- pants answered a questionnaire aimed at identifying their involvement in MDI prescribing and counselling, a trained observer assessed their MDI technique using a checklist of nine steps. Results : Of the 150 participants, 148 (99%) were involved in teaching inhaler tech- niques to patients, and 103 of 107 physicians (96%) had prescribed inhaled medications. However only 22 participants (15%) performed all steps correctly. Physicians performed signifi cantly better than non-physicians (20% vs. 2% , p <0.05) Among the physicians, internists performed better (26%) than general practitioners (5%) and accident and emergency doctors (9%). Conclusion: The majority of health- care providers responsible for instructing patients on the correct MDI technique were unable to perform this technique correctly indicat- ing the need for regular formal training programmes on inhaler techniques. Key Words: metered-dose inhaler, asthma management, inhaler technique A sthm a is one of the most common chronic conditions affecting both adults and children and there is evidence that its prevalence and severity are increasing.1 Despite the recent advances in the understand- ing of its pathophysiology and the availability of effective treatment, asthma continues to be a major cause of morbid- ity leading to a signifi cant economic burden to indi viduals and societies.2 Poor asthma control has been related to several common and important problems.1 These include: underdiagnosis and inadequate treatment,1 poor patient understanding of the disease and its treatment,3,4 non- compliance,5 and incorrect use of inhaler devices.6,7 Inhaled medications form the cornerstone of asthma treatment.6 However, incorrect patient inhaler technique has been identifi ed as a common and persistent problem by many studies worldwide.8–12 Up to 90% of adult patients have been reported to have inadequate inhaler technique with higher rates of errors in children and old patients.8–13 Poor inhaler technique reduces the drug delivery to the air- ways, decreasing the effi ciency of the inhaled drug.6,14 The high prevalence of incorrect inhaler technique by patients has been explained by several factors.15,16 Most squ journal for scientific research: Medical Sciences 2001, 1, 39 –43 ©sultan qaboos university Metered-dose inhaler technique among healthcare providers practising in Oman Sawsan A. Baddar1, Omar A. Al-Rawas2, Kassim A. Al-Riyami1, Elizabeth A. Wor thing1, Yolande I. Hanssens1 Aqeela M. Taqi1, *Bazdawi M.S. Al-Riyami2 1Department of Pharmacy, Sultan Qaboos University Hospital, P.O. Box: 38, Al-Khod 123, Muscat, Sultanate of Oman. 2Department of Medicine, College of Medicine, Sultan Qaboos University, P.O. Box: 35, Al-Khod 123, Muscat, Sultanate of Oman. *To whom correspondence should be addressed. E-mail: bazdawi@squ.edu.om b a d d a r e t a l40 healthcare providers do not spend suffi cient time educating patients on the correct use of the inhalers.17 Another prob- lem is the lack of regular periodic assessment of patients’ inhaler technique, essential to ensure proper use.12 More importantly, studies show that most providers themselves have poor inhaler technique.18–27 Thus, they may give incor- rect instructions to patients.26,27 In addition, the correct use of inhalers has been shown to be infl uenced by patients’ characteristics, such as their age,13 literacy,28 and their under- standing of asthma and its treatment.6 Therefore, the mag- nitude of the problem may vary in different populations. Furthermore, formal training and demonstration of the cor- rect use of inhalers have been shown to improve the skills of inhaler use in both patients and healthcare providers.29–33 Local baseline information is, therefore, essential for each country to develop its own asthma care services and educa- tional programmes targeted at their specifi c problems and needs.1 Asthma is common in Oman36 and most inhaler devices including M DI and dry powder inhalers (rota halers disk halers and turbohalers) are available for its treatment. However, there are no published data on the ability of patients and healthcare providers in Oman to use these inhalers correctly. This study, accordingly, aimed to evaluate the ability of healthcare providers in Oman to demonstrate the correct MDI technique. M E T H O D t h e pa rt i c i pa n t s Between December 1998 and November 1999, the respira- tory units at Sultan Qaboos University Hospital and Royal Hospital conducted a series of symposia on asthma manage- ment guidelines in fi ve different regions of Oman (Muscat, Dakhiliya, North Batinah, South Batinah, and Dhofar). All healthcare providers were invited to attend. Attendees included physicians (general practitioners, internists, paedi- atricians, and accident and emergency doctors), nurses and pharmacists. As part of the symposia activities, all at tendees were asked and encouraged to volunteer to demonstrate their inhaler technique without prior knowledge of the pur- pose of the study. p r o t o c o l After answering a brief verbal questionnaire aimed at iden- tifying involvement in asthma management and M DI tech- nique counselling, each participant was asked to demon- strate the use of the M DI by taking two puffs from a placebo M DI device (Glaxo/Welcome Inc. U K). One trained observer (a respiratory nurse with extensive involve- ment in the assessment and teaching of inhalers technique to both patients and healthcare providers) using a checklist of nine steps graded the correctness of each participant technique. The nine steps [Table 2] were based on manu- facturer’s instructions and international clinical guidelines on the MDI technique.37 Steps 1 and 4–6 were considered essential for proper delivery of the inhaled medications and the remaining steps were classifi ed as recommended for optimal delivery but not essential. Verbal questionnaire This consisted of three questions: (1) What is your spe- cialty? (2) Do you counsel patients on the use of inhalers? (3) Do you prescribe inhaler medications? Steps of MDI technique The acceptability of each step was defi ned as follows:37 the participant must shake the canister vigorously and breathe out slowly and completely before each puff. Positioning was considered correct if the canister was held in the upright position and either inserted between closed lips or up to four centimetres in front the open mouth. The participant must then begin a slow inhalation just before depressing the can- ister once (actuation). The timing of actuation (co-ordina- tion) was considered correct if it occurred anywhere during the fi rst third of the slow inspiration including simultane- ously with the start of inhalation. The slow inspiration must continue to total lung capacity after which the inhaler is removed and the lips kept closed, with breath-holding for at least ten seconds. Finally, the participants must wait at least 30 seconds before starting the second puff. Table 1. Participants’ specialties and involvement in MDI prescribing and counselling Total number of participants 150 A. Physicians 107 Adult internists 27 Paediatricians 19 General practitioners 39 Accident and emergency physicians 11 Other physicians 11 Number of physicians prescribing MDI 103 (96%) B. Non-physicians 43 Nurses 33 Pharmacists 10 Total number of participants who counsel patients on MDI use 148 (99%) m e t e r e d d o s e i n h a l a t i o n t e c h n i q u e 41 Data presentation and analysis Data were analysed using a statistical software (SPSS for Windows) and presented in terms of frequencies. The dif- ferent groups of participants were compared using the chi- square (χ2 ) test and p <0.05 was considered signifi cant. R E S U L T S t h e pa rt i c i pa n t s Table 1 shows the number of participants and their special- ties. 148/150 (99%) participants reported involvement in teaching patients on the use of inhalers. The entire group consisted of three categories of healthcare providers: 107 physicians (71%), 23 nurses (22%) and 10 pharmacists (7%). Because of their small number, the nurses and the pharmacists were analysed as a single group: ‘non-physi- cians’. The physicians group was heterogeneous consisting of internists, paediatricians, general practitioners, and A& E doctors. Ninety-six percent of the physicians acknowledged having prescribed inhaled medications. i n h a l e r t e c h n i q u e Table 2 lists the nine steps of correct MDI technique and the percentage of healthcare providers who had the correct technique for each step. Except for step 3 (holding the inhaler in upright position), the frequency of correct tech- nique was low (27–67%). The frequency of participants who made errors was similar for both essential and pre- ferred steps. Of the essential steps, shaking the inhaler and co-ordination (steps 1 and 6) had the highest frequency of errors (41 and 40% respectively), whereas inadequate breath-holding and waiting before starting a second puff (steps 8 and 9) were the most frequent non-essential (pre- ferred) steps in error (36 and 27% respectively). Figure 1 shows the frequency of participants’ correct inhaler technique. Only 22/150 (15%) participants per- formed all steps correctly. When only essential steps were considered, the overall performance increased to 28/150 (19%). Physicians performed signifi cantly better than non- physicians for all steps (20% vs. 2%, p < 0.05) and essential steps (22% vs. 9%, p < 0.05). Only one of the 43 non- physicians performed all steps correctly. Figure 2 shows the frequency of physicians with correct inhaler technique according to their specialty. While the overall performance was very poor, internists (in both gen- eral medicine and paediatrics) performed relatively better Table 2. The nine steps of correct metered-dose inhaler technique and the percentage of healthcare providers performing each step correctly Step Procedure % correct 1* Remove cap and shake the inhaler vigorously 41 2 Breathe out slowly and completely 51 3 Hold the inhaler in the upright position 93 4* Insert the mouthpiece into mouth between closed lips 67 5* Depress the canister once and … 58 6* … at the same time begin slow deep inhalation (co-ordination) 40 7 Remove the inhaler with closed lips 42 8 Hold breath for 10-15 seconds 36 9 Wait for 20-30 seconds before starting the second puff 27 *The essential steps. % o f p ar tic ip an ts w ith co rr ec t t ec hn iq ue Figure 1. Percentage of health care providers who performed MDI steps correctly 0% 5% 10% 15% 20% 25% Physicians N=107 Non-physicians N=43 All participants N=150 All steps Essential steps Figure 2. Percentage of physicians in different specialities who performed all MDI steps correctly 0 5 10 15 20 25 30 GPs (N=39) A&E (11) Paed (19) Med (27) Others (11) % o f p ar tic ip an ts w ith c or re ct te ch ni qu e b a d d a r e t a l42 (26% each) than accident and emergency physicians (9%) and general practitioners. D I S C U S S I O N The change from oral to inhaled medications as the pre- ferred route of administration has been one of the most important developments in asthma treatment.1 Inhaler therapy is now the preferred mode of delivery of many drugs used in the treatment of asthma and chronic obstruc- tive pulmonary disease.6,11 It is the only way to deliver some drugs such as anticholenergics and sodium cromoglycate and is the preferred mode of delivery for B-agonists and cortico steroids. The major advantage of inhalation therapy is the direct delivery of medications in much smaller effec- tive doses compared to systemic routes, thus reducing side- effects.11 In addition, inhaled bronchodilators act more quickly.11 The important limitation of inhaler devices is that they are more diffi cult to use and less convenient than tablets. Each inhaler device has its own specifi c sequence of steps for optimal drug delivery and it is therefore nec- essary to give careful and correct instruction to patients.1 MDI , the most commonly used device, requires the patient to co-ordinate inhalation with action of the device (actua- tion) which can be diffi cult for some.6,16 Patients with asthma have been shown to have poor inhaler technique, an important cause of poor asthma control.8–14 The problem is common in both children and adults affecting as many as 60 to 90% patients.8,15,16,25 As a result, international asthma management clinical guide- lines emphasise the importance of demonstrating the cor- rect inhaler technique at initial diagnosis and correcting patient performance at each follow-up visit.1 Unfortunately, numerous studies consistently show that healthcare provid- ers have poor inhaler technique.18–27 The reported rate of correct inhaler technique among various groups of physi- cian is in the range of 28–69% in different studies with respiratory specialist and internists performing relatively better than others.21–27 For nurses, the reported rate of cor- rect inhaler technique is in the range of 15–66%.20,27 In one study, respiratory therapists performed better than phy- sicians.21 In another study, asthmatic patients performed better than both physicians and nurses.27 However, this universal problem have been shown to improve by formal and regular training of both patients and healthcare providers.30–36 Asthma is common in Oman.36 The present study is part of a comprehensive project evaluating the different aspects of asthma in this country to design a national pro- gramme for the management of asthma. The results of this study show that poor M DI technique was very common in this sample of healthcare providers. Despite being involved in patients counselling on inhalers, only 15% of the partici- pants were able to perform all steps correctly, which was substantially lower than reports from the literature. In addi- tion, errors were equally frequent for both essential and non-essential (preferable) steps. Of the essential steps, the greatest number of errors occured in shaking the inhaler and co-ordination (steps 1 and 6), whereas inadequate breath-holding and waiting before a second puff (steps 8 and 9) were the most frequent non-essential steps in error. Although internists performed relatively better than other participants (26% had correct technique), this was still unacceptably low. Of special concern was the very poor performance of general practitioners, accident and emergency doctors, nurses and pharmacists. The burden of asthma has become so big that general practitioners and accident emergency doctors are the frontline physicians looking after asthmatic patients with the responsibility to teach them the correct use of inhalers. Because of their position, nurses and pharmacists also have opportunity to educate patients on this. It is therefore essential that all pro- viders master the correct technique. Training programmes involving instructions and dem- onstration of the inhaler technique have been shown to improve the skills of patients and providers.29–35 The very poor inhaler technique observed in our study is most prob- ably due to the lack of any formal training for healthcare providers on the correct use of inhalers. C O N C L U S I O N Healthcare providers’ skill in the M DI technique in Oman is very limited, indicating the need for establishing regular educational programmes for both patients and providers. 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