International Journal of Science Annals, Vol. 6, No. 1, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa SOCIAL AND BEHAVIORAL SCIENCES. Rehabilitation ORIGINAL RESEARCH Inhalation Therapy: An Analysis of Inhalation Technique Errors in Metered-Dose Inhaler and Dry Powder Inhaler Users Authors’ Contribution: A – Study design; Chaudhary K. 1 ABCDEF , Kumar A. 1 ABCDEF B – Data collection; C – Statistical analysis; 1 Employees’ State Insurance Corporation Medical College, India D – Data interpretation; E – Manuscript preparation; F – Literature search; Received: 08.01.2023; Accepted: 08.02.2023; Published: 30.06.2023 G – Funds collection Abstract Background and Decreased efficacy of metered dose inhaler and dry powder inhalers are Aim of Study: associated with errors in inhalational techniques. The aim of the study: to study the association of errors in the technique for using two types of inhalers with demographic and other variables. Material and Methods: Five hundred adult patients with respiratory diseases who were currently using an inhaler device were enrolled in this study. Patient’s demographics and duration of inhaler therapy and assessment of inhaler technique were recorded by interview and direct observation. Results: Out of 500 enrolled patients, 465 patients were using the device with wrong technique. Among 465 patients, 188 patients were using metered dose inhaler and 277 patients were using dry powder inhalers. Technical errors were common in both the devices but more common with metered dose inhaler device. Failure to exhale before the inhale through device was most common error with metered dose inhaler (68.6%) and dry powder inhalers (71.4%). Association of errors with female gender is seen in both metered dose inhaler and dry powder inhalers users. Reduction in the numbers of errors is seen with increase in the duration of therapy and regular training on follow-up visits. Conclusions: Dry powder inhalers and metered dose inhalers are commonly used in management of respiratory patients. Therefore, the errors in using these devices, technique and handling errors are common in both dry powder inhalers and metered dose inhaler users. More error was found in old age, female and short- term users. However regular training on follows up visits can solve this current problem. Keywords: metered dose inhaler, dry powder inhalers, inhalational technique, technical errors, demographic, respiratory diseases, aerosol therapy Copyright: © 2023 Chaudhary K., Kumar A. Published by Archives of International Journal of Science Annals DOI and UDC DOI https://doi.org/10.26697/ijsa.2023.1.5 UDC 612.215 Conflict of interests: The authors declare that there is no conflict of interests Peer review: Double-blind review Source of support: This research did not receive any outside funding or support Information about Chaudhary Kamran – https://orcid.org/0000-0001-6697-2409; MD, Assistant the authors: Professor, Department of Pulmonary Medicine, Employees’ State Insurance Corporation Medical College, Faridabad, India. Kumar Avinash (Corresponding Author) – https://orcid.org/0000-0002-3009- 0866; akrshiv.dr@gmail.com; MD, Assistant Professor, Department of Pulmonary Medicine, Employees’ State Insurance Corporation Medical College, Faridabad, India. 47 International Journal of Science Annals, Vol. 6, No. 1, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Introduction Respiratory diseases such as asthma, chronic obstructive According to Newman et al. (1991), ideal technique to pulmonary disease (COPD) and post tuberculosis use MDI would be: shake before use, then remove the obstructive disease (PTOD) is affecting large population cape, breath out slowly to functional residual capacity globally. These diseases cause the third most frequent (FRC), wide open the mouth holding the device in cause of death worldwide (EBSCO, 2020). The between lips in upright position starting with slow abundance presence of beta-adrenergic, cholinergic and breathing and actuate MDI simultaneously, till total lung glucocorticoid in lungs, which lead to concept evolution capacity (TLC) continue inspiration, for 5-10 sec hold of inhalation therapy. The inhalation therapy holds breath, at last exhale for next puff, at least wait for a many advantages such as lower dosage needed, fast minute, after done washing and rinsing mouth is response and minimum side effect over systemic therapy important. as in even in pregnancy, hypertension, cardiac diseases Dry powder inhaler (DPI) contains medicine in powder and diabetes mellitus they are considered safe. form in which particle size is in respirable size and these Inhalation therapy is also known as aerosol drug therapy are present with carriers such as lactose or glucose with in which special device is used to deliver drug in a form which they make loose bound. Separation could happen of fine mist particles directly to the lungs, which may easily among micro sized individual respirable particles; use in treating various type of respiratory diseases. The carriers are needed to decrease cohesive forces in micro particle ideal size ranges from 1 to 5 microns as smaller sized medicine powder. Patient’s inspiratory flow particles acts as gas and passes though lungs like gas. provides all the energy needed to disaggregation (Prime Particles travelling speed (travelling very fast or very et al., 1997). In 1960s, the DPI was introduced since then slow) might damage the walls of the upper airways. The there are many types of DPI available in India market particle hit the target site when moves in right speed. some are single dose, some are multidose. The oral inhalation of medications is the first-line Single dose inhales are Lupihaler, Revolizer, treatment for lung diseases; inhaler technique comprises Respihaler, Rotahaler; and some of multidose inhalers a set of procedures for drug delivery to the respiratory are Diskhaler, Turohaler and Multihaler. In multidose system (Chorao et al., 2014). The advantages offered by inhalers, numbers of doses are inserted in the inhaler this method are financial affordability, convenience, already (Atkins, 2005). portability, quick and local action, and negligible Dry powder inhalers have many advantages, as they are systemic side effects (Virchow et al., 2008). portable, easy to carry with you due to their small size. The therapeutic index will be maximized, with direct They can be used easily with some training, but they do delivery of drug to the respiratory tract by inhale not need any hand breath coordination. They are devices. There are many anti-asthma drugs out there but ecofriendly because they do not have any cold freon efficiency depends on selection of right drug, device effect as propellant is not required in them. used and technique used. There are wide range of Despite all these advantages, they do hold few inhaling devices available in market, selecting the right disadvantages too, as they are quite expensive. They are one is very important, which is done on the bases of not ideal for acute situations and severe respiratory disease severity, patient type, and pricing or distress. They also need quite high inspiratory flow rate reimbursement controls (Pritchard & Giles, 2014). that is about 60L/min or even more. Lactose might cause There for it is necessary to have a proper study of device, some irritation cough mostly in lactose intolerant drug and patient education for the success of inhaler. patients. If not kept in dry area, the humidity might cause Metered dose inhalers, dry powder inhalers, and powder to aggregate and soften of capsule (Crompton, nebulizers are the most common inhaler devices used to 1991). administer aerosolized medication in routine respiratory In the opinion of Newman et al. (1991), ideal technique practice (Cochrane et al., 2000; Pritchard et al., 2015). of using DPI is: device assembling, if single, no shaking Metered dose inhaler (MDI) is most commonly used of the device, slowly exhale to FRC, around the mouth inhaler device. When it is activated, it releases fixed seal it, forcefully and deeply inhale, need to hold the amount of drug dose from multidose canister. Some breath for 4 to 8 sec, repeat the process if needed, after important elements of MDI are protective cover; finish gargle and rinsing mouth is important. medicine mixed with surfactant and propellant in Inhaler technique comprises a set of procedures for drug canister, which is fitted with valve; device body and delivery to the respiratory system. The technique of oral mouthpiece for the release of medicine. inhalation of medications is a major factor governing the Metered dose inhalers are inexpensive, compact, and efficiency of the inhaled medication. Using the proper portable, can be hold multidose. It can have fixed and inhaler technique ensures sufficient drug deposition in defined dose (Newman, 2005). the distal airways, optimizing therapeutic effects and Although after all these advantages MDI does have few reducing side effects (Usmani et al., 2018). Although disadvantages too such as they are not eco-friendly as metered dose inhalers are considered more difficult to chlorofluorocarbon (CFC) causes ozone depletion, use than dry powder inhalers, errors in inhaler technique patient need good coordination of hand and breath and are very common among COPD and asthma patients in needs training for hand breath coordination daily real-life practice. Inhaler mishandling is very (Tsangarides et al., 2018). common in patients with chronic airflow obstruction (Melani et al., 2011). 48 International Journal of Science Annals, Vol. 6, No. 1, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Using inhalers without imparting adequate education suspected pregnancy, breastfeeding, allergy, sensitivity regarding proper technique of their usage may result in or intolerance to asthma or COPD therapy, and being on suboptimal clinical improvement and wastage of nebulizer therapy were the exclusion criteria of the medication. study. We evaluated the technique of patients using manually Demographic details of patients, type and duration of operated inhaler devices, metered dose inhaler and dry inhaler therapy, and assessment of inhaler technique powder inhalers to study the association of poor inhaler (correct, incorrect) were recorded. technique with patient demographics and other Inhaler technique was assessed using a protocol variables. described by Melani (2007). This protocol documents The aim of the study. To study the association of errors the performance of ten essential inhaler technique steps in the technique for using two types of inhalers with by means of closed dichotomous response options (well demographic and other variables. performed/poorly performed). All assessments were made by two investigators with ten years of experience Materials and Methods in the follow-up of asthma patients. After assessment, all A total of 500 adult patients with respiratory diseases patients were given supplemental instruction on inhaler who were currently using at least one inhaler device for technique by a health professional, in the form of a at least 1 month were included in this cross-sectional, demonstration. observational study conducted at Department of Tuberculosis and Chest Diseases, in a tertiary care Results hospital of North India. Out of 500 enrolled patients, 465 patients were using the Most commonly used devices metered dose inhaler and device with wrong technique. Out of these 465 patients, dry powder inhalers were assessed in this study. 188 were using metered dose inhaler (Table 1) and 277 Use of inhaler therapy for less than a month, lack of were using dry powder inhaler (Table 2). attendance of regular control visits, confirmed or Table 1 Errors in Inhalation Technique with Metered Dose Inhaler (n=188) Number of patients who made errors Inhalation technique people percentage Take off the inhaler cap 16 8.5 Shake the metered dose inhaler before use 79 42.0 Hold the metered dose inhaler in a vertical position 47 25.0 Hold your head in a vertical position 53 28.1 Exhale before use 129 68.6 Put the mouthpiece in your mouth, and close your lips 33 17.5 Press the canister when inhaling slowly 126 67.0 Inhale deeply 91 48.4 Hold your breath for 10 seconds 71 37.7 Exhale and wait for 30-60 seconds before the other puff 32 14.3 Table 2 Errors in Inhalation Technique with Dry Powder Inhaler (n=277) Number of patients who made errors Inhalation technique people percentage Pull off the aerolizer cover 19 6.8 Open the mouthpiece of dry powder inhaler 16 5.7 Remove the capsule from the package and put it into the space 47 16.9 Press the buttons on both sides of dry powder inhaler 79 28.5 Hold your head in a vertical position 61 22.0 Turn your head away from dry powder inhaler and exhale 198 71.4 Put the mouthpiece in your mouth, and close your lips 26 9.3 Inhale deeply 119 42.9 Hold your breath for 10 seconds 97 35.0 Dispose of the capsule and put the cover back on the dry powder inhaler 36 12.9 Each step of metered dose inhaler use is observed and (48.4%) did not inhale deeply after pressing canister. documented. Out of 188, 129 patients (68.6%) did not 79 patients (42.0%) did not shake the inhaler before use, exhale before inhaler use, 126 patients (67.0%) failed to 71 patients (37.7%) did not hold their breath for 10 press the canister while inhaling slowly, and 91 patients seconds, 47 patients (25.0%) failed to hold the inhaler in 49 International Journal of Science Annals, Vol. 6, No. 1, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa vertical position, while 53 patients (28.1%) failed to ability of hand-lung coordination and is therefore hold their head in vertical position. 33 patients (17.5%) considered inherently more difficult to use than dry forgot to close their lips after putting mouthpiece in powder inhalers (Pothirat et al., 2015; Rootmensen et mouth, 32 patients (14.3%) did not wait before for 30- al., 2010). 60 seconds before next inhalation, 16 patients (8.5%) Therefore, errors related to device handling were did not take off the inhaler cap. common among metered dose inhaler users than among The most common error while using dry powder inhaler dry powder inhalers users. Failure to exhale before using is patient did not exhale before using inhaler like the metered dose inhaler is the most common error, metered dose inhaler users. Out of 277, 198 patients followed by lack of coordination and failure to inhale (71.4%) did not exhale before the use of inhaler, 119 deeply. patients (42.9%) fail to inhale deeply, and 97 patients In dry powder, inhaler users the most common error is (35.0%) did not hold the breath for 10 seconds. The most to exhale before using dry powder inhalers, followed by uncommon error was, not removing cap of inhaler like failure to inhale deeply and failure to hold breath for 10 in metered dose inhaler users. seconds. It was observed dry powder inhalers is the most These errors are more common with female gender as commonly used device as shown by other studies study shows that the errors in using the inhaler devices (Castel-Branco et al., 2017; Chorao et al., 2014; Melani both metered dose inhaler and dry powder inhalers are et al., 2011). Poor inhaler technique and device handling more common in females. These errors are reduced with is common in both metered dose inhaler and dry powder increasing duration of therapy and regular training. inhalers users. That metered dose inhalers require a good (Table 3). Table 3 Correlation of Errors with Various Parameters Age of patient Gender of patients Duration of therapy Regular training on Parameters (Mean, years) Male Female (Mean, years) every visit Take off the inhaler cap Incorrect use 61 11.9 88.1 1.2 7.9 Correct use 54 59.1 38.9 5.8 68.9 P-value >0.001 <0.001 <0.001 <0.001 Hold the metered dose inhaler in a vertical position Incorrect use 65 27.8 72.2 1.8 9.1 Correct use 52 36.3 63.7 6.1 79.6 P-value >0.001 <0.001 <0.001 <0.001 Hold your head in a vertical position Incorrect use 62 20.4 79.6 2.1 6.7 Correct use 56 32.7 57.3 7.3 76.9 P-value >0.005 <0.001 <0.001 <0.001 Reduction in the numbers of errors is seen with increase forced expiration” (46=61.3%) and “no 10 second apnea in the duration of therapy and regular training on follow- after inhalation” (51=68.0%); in the 16p metered dose up visits. inhalers techniques common errors were “lack of hand- lung coordination” (7=43.8%), “no previous forced Discussion exhalation” (8=50.0%), and “no apnea after inhalation” Not many researches have been conducted in India to (10=62.5%). This is similar to observations made in our study the errors in inhalation techniques of metered dose study. inhaler and dry powder inhalers users. In another study conducted by Melani et al. (2011), the It was observed that inhaler technique errors are very errors in technique of inhalation was evaluated in trained common and regular training can significantly reduce the patient. Independently of the inhaler, they found a strong disease burden. Errors were more common with dry association between inhaler misuse and older age powder inhalers than with metered dose inhaler. (p=0.008), lower schooling (p=0.001) and lack of Although, the study done by Nainwal et al. (2022), DPI instruction received for inhaler technique by health are considered, more advanced and more advantageous caregivers (p<0.001). Inhaler misuse was associated with due to its stability and ability to deliver a high dose of the increased risk of hospitalization (p=0.001), emergency drug to the lungs. Inability to exhale properly before use room visits (p<0.001), courses of oral steroids (p<0.001) is the most common error followed by error in shaking and antimicrobials (p<0.001) and poor disease control the device before use. evaluated as an Asthma Control Test (ACT) score for the Similar results were observed in other studies. In a study asthmatics (p<0.0001) and the whole population conducted by Castel-Branco et al. (2017), similar results (p<0.0001). This was similar to our study, where we were obtained. The study involved 67 patients from four observed older age and lesser training was associated community pharmacies. In the dry powder inhalers with more errors in inhalation technique. techniques, the most frequent errors were “no previous 50 International Journal of Science Annals, Vol. 6, No. 1, 2023 рrint ISSN: 2617-2682; online ISSN: 2707-3637; DOI:10.26697/ijsa Chorao et al. (2014) observed that patients over 60 years Chorao, P., Pereira, A. M., & Fonseca, J. A. (2014). vs. younger age (p=0.002) and COPD vs. asthma patients Inhaler devices in asthma and COPD – An (p=0.016) required more attempts to ensure correct use. assessment of inhaler technique and patient 41.0% of the study participants chose one of the devices preferences. Respiratory Medicine, 108(7), 968- they already used as the most preferred inhaler. 975. https://doi.org/10.1016/j.rmed.2014.04.019 In another study conducted on COPD patients of mean Cochrane, M. G., Bala, M. V., Downs, K. E., age 70.9±8.3 years using metered-dose inhaler by Mauskopf, J., & Ben-Joseph, R. H. (2000). Choomuang et al. (2022). It was observed that only 16% Inhaled corticosteroids for asthma therapy: patient (p<0.001) was using correct technique, 25% (p<0.026) compliance, devices, and inhalation technique. was having correct flow and only 7% (p<0.001) was Chest, 117(2), 542-550. using both correct technique and correct flow but after https://doi.org/10.1378/chest.117.2.542 one month of training 34% (p<0.001) was using correct Crompton, G. K. (1991). Dry powder inhalers: technique, 37% (p<0.026) was having correct flow and Advantages and limitations. Journal of Aerosol only 22% (p<0.001) was using both correct technique Medicine, 4(3), 151-156. and correct flow. https://doi.org/10.1089/jam.1991.4.151 Thus, incorrect use of inhaler is a prevalent problem EBSCO. (2020, November 16). Dynamic health in across countries. The problem can be significantly action: COPD. reduced with proper training and retraining. https://www.ebsco.com/resources/dynamic- health-action-copd Conclusions Melani, A. S., Bonavia, M., Cilenti, V., Cinti, C., It is observed that errors in using the device and handling Lodi, M., Martucci, P., Serra, M., Scichilone, N., are common in both dry powder inhalers and metered Sestini, P., Aliani, M., & Neri, M. (2011). Inhaler dose inhaler users. But in old age, female and short-term mishandling remains common in real life and is users more errors were found compared to young age, associated with reduced disease control. male and long-term users. The error associated with both Respiratory Medicine, 105(6), 930-938. users are mainly with handling the devices, technique of https://doi.org/10.1016/j.rmed.2011.01.005 using the devices and safekeeping of the devices. To Melani, A. S. (2007). Inhalatory therapy training: A overcome problems related to these devices people need priority challenge for the physician. Acta Bio- more and proper regular training of handling and using Medica: Atenei Parmensis, 78(3), 233-245. these devices. Patient needs training in how to keep https://pubmed.ncbi.nlm.nih.gov/18330086/ devices clean and use it safely. Patient needs more follow Nainwal, N., Sharma, Y., & Jakhmola, V. (2022). Dry up visits in which proper training could be provided. powder inhalers of antitubercular drugs. Tuberculosis (Edinburgh, Scotland), 135, Ethical Approval 102228. The study protocol was consistent with the ethical https://doi.org/10.1016/j.tube.2022.102228 guidelines of the 1975 Declaration of Helsinki as Newman, S. P. (2005). Principles of metered-dose reflected in a prior approval by the Institution’s Human inhaler design. Respiratory Care, 50(9), 1177- Research Committee. 1190. https://pubmed.ncbi.nlm.nih.gov/16122401/ Funding Source Newman, S. P., Weisz, A. W., Talaee, N., & Clarke, S. This research did not receive any outside funding or (1991). Improvement of drug delivery with a support. breath actuated pressurised aerosol for patients with poor inhaler technique. 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Thorax, https://doi.org/10.1016/j.rmed.2007.07.031 73(Suppl. 4), A193-A194 https://doi.org/10.1136/thorax-2018-212555.327 Cite this article as: Chaudhary, K., & Kumar, A. (2023). Inhalation therapy: An analysis of inhalation technique errors in metered-dose inhaler and dry powder inhaler users. International Journal of Science Annals, 6(1), 47–52. https://doi.org/10.26697/ijsa.2023.1.5 The electronic version of this article is complete. It can be found online in the IJSA Archive https://ijsa.culturehealth.org/en/arhiv This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/deed.en). 52