Every patient should be trained in essential skills and guided asthma self-management
Nagpur: A correct knowledge on therapy/ devise use-ability can lead to increased patient satisfaction, better health outcomes, and reduced use of health care resources. In asthma, it becomes critical as a lot depends on the inhaled medicines – which are integral to the management of respiratory diseases. They deliver drugs directly to the lungs and hence act faster and at a lower dose, thereby reducing the risk of side effects. Inhaled medications have been shown to improve disease status, control symptoms, reduce the number and severity of exacerbations and improve quality of life. Hence, if not used correctly, it can hamper the condition.
In Maharashtra, chronic respiratory disease is the number one leading cause of death in the 40-69-year age group and the second leading cause of death in the 15-39 years age group. Further, COPD has moved from the ninth leading cause of death and disability in 1990 to number second leading cause in 2016. This shows the burden of respiratory disease and the burning need to control it.6 While the PERCEPT study, which assessed the physicians’ knowledge and practice of inhalation therapy in India, showed that incorrect device technique and non-adherence to inhalation therapy were responsible for poor outcomes to therapy by nearly 61% and 67% of physicians, respectively.1Education and awareness on asthma management is the need of the hour, patients need to be viewed as involved participants in their asthma management plan. This will not only ensure better healthcare outcomes but will also instill confidence in patients about managing their asthma. The various inhaler devices available include the pressurized metered-dose inhalers (MDIs), dry powder inhalers (DPIs) and nebulizers.
Approximately 90% of physicians in India reported prescribing inhaler devices to at least 40% of their asthma and COPD patients in the first clinic visit.1 Manypatients findpMDIsdifficultto use correctly. Poor hand-breath co-ordination is one of the most commonly reported errors with pMDIs. DPIs are breath-actuated and hence overcome the problem of hand-breath coordination. However, a significant proportion of patients fail to use their DPI correctly as well. One of the common errors made by patients with a DPI is the failure to inhale forcefully and deeply through the device, leading to insufficient drug delivery.
According to, Dr. Vikrant Deshmukh, Pulmonologist, Nagpur Chest Centre, “A partnership between the patient and their health care provider is important for effective asthma management. Simultaneously, patient-level treatment decisions should take in to account individual characteristics, risk factors and co-morbidities. A strategy of assessment, adjustment of treatment and review of the response to the treatment needs to be considered. Every treatment plan needs to be planned to keep in mind the patient’s lifestyle conditions and treatment goals.
Although contemporary inhaled therapy for asthma has the potential to control disease, control is often not achieved in real-life practice in most patients. As per the Asia-Pacific Asthma Insights Management (AP-AIM) Survey, all asthma patients in India are either uncontrolled or partly controlled.2 Poor inhaler technique is a key reason for this poor control.”
The scores of doctors were significantly better as compared to nurses and patients, it was still quite inadequate compared to the total score (mean score for doctors – 6.35/10). The nurses, in fact, had almost as poor technique as the patients themselves (4.70 vs. 4.65). Thus, in a situation where nurses have an important responsibility towards patient education, it will not be surprising that the patients will have poor inhaler techniques. There have been few studies describing the inhaler technique among doctors and nurses (Mullerpattan, et al.: Inhaler technique in patients and HCW’s)9
According to Dr. Vinit Niranjane, Pulmonologist, Breathe Easy Chest Care Center,Ramdaspeth“The key challenges in the management of asthma and COPD include improving compliance and developing effective and easy-to-use inhalers. Many patients frequently underutilise their medications or use their inhalers incorrectly, which can be detrimental to maintaining disease control. This can cause them to switch to oral therapy, which can be disastrous.Though there have been developments in inhaled delivery platforms over the years, incorrect inhaler technique has remained unacceptably high, resulting in poor patient outcomes.”
Most patients (up to 80%) cannot use their inhaler correctly. This contributes to poor symptom control and exacerbation9. To ensure effective inhaler use:
•Choose the most appropriate device for the patient before prescribing: consider medication, physical problems e.g. arthritis, patient skills and cost; for ICS by pressurized metered dose inhaler, prescribe a spacer.
•Check inhaler technique at every opportunity. Ask the patient to show you how they use the inhaler. Check their technique against a device-specific checklist.
•Correct using a physical demonstration, paying attention to incorrect steps. Check technique again, up to 2-3 times if necessary.
Complexity of device and the difficulty in using it were considered the major factors by physicians for reduced adherence and satisfaction with treatment.
The development of breath-actuated inhalers represents a significant transformation in inhaled drug delivery. Educating patients on the benefits of inhalation therapy and the correct inhaler technique can help increase the acceptance, adherence and correct usage of inhalers, which can result in better disease control.
1. PERCEPT study, Presented at APSR Conference, 2015
2. Respirology 2013; 18(6): 957-67
3. Eur Respir J 2002; 19, 246–251
4. Chronic Respiratory Disease 2017, Vol. 14(3) 309–320
5. Respir Med. 2008; 102, 4, 593–604
6. India: Health of the Nation’s States – The India State-level Disease Burden Initiative 2017
7. INSPECT survey. Presented at IPCRG Scientific Meeting, Singapore, May 30, 2015
8. SCRIP News February 20, 2018