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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 1  |  Page : 6-11

Effect of health education about proper inhaler technique among asthmatic children/caregivers


1 Department of Pediatrics, Faculty of Medicine, Cairo University, Giza, Egypt
2 Department of Public Health, Faculty of Medicine, Cairo University, Giza, Egypt

Date of Submission16-Feb-2019
Date of Acceptance01-Apr-2019
Date of Web Publication9-Sep-2019

Correspondence Address:
Nihal M El Rifai
Department of Pediatrics, Faculty of Medicine, Cairo University, Giza, 12611
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJOP.AJOP_9_19

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  Abstract 


Background Inhalation therapy is the cornerstone for asthma management, and it has been reported by several studies that a correct inhalation technique is required for achievement of proper disease control.
Objective This study attempted to assess the inhaler technique in Egyptian children with asthma, identify the factors affecting improper technique, and evaluate the effect of educational intervention in improving the technique and asthma control.
Patients and methods This pre–post clinical trial included a random sample of 350 asthmatic children aged 2–12 years, following up at the Allergy Clinic, Faculty of Medicine, Cairo University. They were diagnosed as having asthma according to GINA guidelines and were on inhaled corticosteroids using metered-dose inhaler (MDI) or dry-powder inhaler (DPI) for at least 3 months. Children’s inhalation technique was observed and assessed by the study researcher formerly, and then educational intervention was given, which was then followed by reassessment during the next follow-up visit, and the patient’s level of control was determined during each visit. The study was carried out from 30 June to 31 December 2018.
Results Longer duration of inhaler use, regular follow-up, maternal education, and receiving education from a qualified trainer were significantly associated with a proper educational technique (P<0.001). Patients with correct inhalation technique were found to be more controlled compared with incorrect users (P<0.001). The most frequent incorrect step for children using a MDI with spacer was shaking the inhaler, MDI without spacer was coordinating the actuation-slow deep inhalation (53.8%), and DPI was loading the dose properly before each use (65%). After educational training, significant improvement for most of the steps was found (P<0.001) and a significant better asthma control was reached (P<0.001).
Conclusion Repeated education, checking, and correction of the inhaler steps are required to reach a proper reliable inhalation technique and better asthma control.

Keywords: asthmatic, children, inhaler, technique


How to cite this article:
El Rifai NM, Rizk HI. Effect of health education about proper inhaler technique among asthmatic children/caregivers. Alex J Pediatr 2019;32:6-11

How to cite this URL:
El Rifai NM, Rizk HI. Effect of health education about proper inhaler technique among asthmatic children/caregivers. Alex J Pediatr [serial online] 2019 [cited 2020 Jan 20];32:6-11. Available from: http://www.ajp.eg.net/text.asp?2019/32/1/6/266413




  Introduction Top


Bronchial asthma is a common health problem in children with an increasing burden over time [1],[2]. Inhalation therapy is the mainstay of treatment [3]. Guidelines stress on inhaler technique, that every recommendation about treatment adjustment includes a reminder to check inhaler technique and adherence [4]. Using the lowest effective inhalation dose reduces the risk and severity of systemic adverse effects associated with medication use [5],[6].


  Aim Top


The study aimed to assess the inhaler technique in asthmatic children before and after giving proper inhalation medical orientation, identify the factors affecting improper technique, and evaluate the effect of improper inhaler technique on asthma control.


  Patients and methods Top


Study setting

The study was conducted at Allergy Clinic, Faculty of Medicine, Cairo University, Egypt.

Study design

This was a pre–post interventional study. Children’s inhalation technique was observed and assessed by the study researcher formerly, and then educational intervention on how to use the device correctly was given, which was then followed by reassessment by the same researcher later during the next follow-up visit, and the patient’s level of control was determined during each visit.

Study population

Children aged 2–12 years attending the Allergy clinic, accompanied by at least one of their parents and were diagnosed with asthma and asthma control were assessed according to GINA guidelines [3]. Patients were excluded if they did not meet the inclusion criteria or refused to participate in the study.

Sample type and size

Systematic random sampling was used. Sample size was calculated by using Epi info software [7] at the confidence level of 95%, α=0.05, and 50% prevalence of improper inhaler technique. Target population 2–12 years of age attending the clinic throughout the 6 months was 3050 children. The minimum sample size was calculated to be 341. A sample of 350 children from 30 June to 31 December 2018 was studied.

Eligibility criteria

Patients were included if they were aged 2–12 years of both sexes, were accompanied by at least one of their parents, were diagnosed as having asthma according to GINA guidelines, and were on inhaled corticosteroids using meter-dose inhaler (MDI) or dry-powder inhaler (DPI) for at least 3 months. Patients and their accompanying parents were excluded if they did not meet the inclusion criteria or refused to participate in the study.

Data collection tool and technique

Patient’s history was collected including demographic and socioeconomic data such as age of the child, sex, residence, parents’ education, occupation, social class, and duration of inhaler use. Additional data were gathered on who provided the instructions on how to use their inhalers if any (qualified: physician, nurse or pharmacist/nonqualified: friend, relative or no one). Patient’s social class was determined by the social scoring system suggested by the National Nutrition Institute of Egypt in 1995 [8]. The study researcher then asked the child to demonstrate the use of his/her inhaler device in two different settings − one before and one after educating the child and/or his/her caregiver with the proper inhalation technique for his/her device − during the study period. Level of control was determined during each visit according to GINA guidelines [3].

Ethical considerations

Policy of data confidentiality was strictly followed. The aim and nature of the study was explained for each parent before inclusion. An informed written consent was obtained from parents before enrollment. The study design conformed to the requirements of Revised Helsinki Declaration of Bioethics [9]. The study protocol was approved by the scientific research committee of Pediatrics Department, Faculty of Medicine, Cairo University.

Statistical analysis

Pre-coded data were entered on Microsoft Office Excel Program for Windows, 2007. Data were analyzed using IBM statistical package for social sciences (SPSS version 17, SPSS Inc., Chicago, lllinois, United States of America). Data were explored for normally distributed using Kolmogorov–Smirnov test and Shapiro–Wilk test for data that were not normally distributed. Quantitative data were described as median and quartiles, whereas qualitative data were presented by frequency. χ2-Test, Fisher’s exact test, and McNemar test were used to detect differences between qualitative variables. Mann–Whitney test was used to detect differences between median in quantitative variables. P value was considered significant if up to 0.05. All tests were two tailed.


  Results Top


Patients’ characteristics

A total of 350 asthmatic children using different types of inhalers completed the study. The median age of patients was 7 years (1st and 3rd quartiles were 4 and 9 years, respectively), with minimum of 2 years and maximum of 12 years. Two hundred and thirty-eight (68%) were residents of urban area. One hundred and ninety-five (55.7%) were using inhalers for less than 6 months duration, whereas 155 (44.3%) for more than 6 months. One hundred and ninety-two (54.9%) were regularly following up in the allergy clinic. One hundred and thirty-four (38.3%) were controlled, whereas 216 (61.7%) were uncontrolled. Comparison of characteristics of asthmatic children demonstrating correct or incorrect inhalation technique with their inhalers whether a MDI − with or without a spacer − or a DPI is presented in [Table 1]. Patients with correct inhalation technique were found to be more controlled compared with incorrect users (P<0.001). Two hundred and eleven (60.3%) asthmatic children were using a MDI with spacer, 119 (34%) were using a MDI alone, and 20 (5.7%) were using a DPI. Duration of inhaler use more than 6 months, regular follow-up, maternal education, and receiving education from a qualified trainer were significantly associated with the correct inhalation technique (P<0.001).
Table 1 Comparison of characteristics of asthmatic children demonstrating correct or incorrect inhalation technique

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Inhalation technique for asthmatic children using meter-dose inhaler with spacer

[Table 2] shows asthmatic children’s performance in using a MDI with spacer before and after educational training (before and after intervention). Their median age was 4.5 years (1st and 3rd quartiles were 2.5 and 8 years, respectively). In the first setting, 20.6% performed all the steps correctly compared with 52% in the second setting after educational intervention (P<0.001). Initially, the most common errors found in the first setting were for steps 2, 3, 4, and 5. After educational training, significant improvement for all four steps was found (P<0.001), and a significant better asthma control was reached (37.3% before vs. 60% after intervention; P<0.001).
Table 2 Asthmatic children’s correct performance in handling a meter-dose inhaler with spacer before and after intervention

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Inhalation technique for asthmatic children using meter-dose inhaler alone

[Table 3] shows asthmatic children’s performance in using a MDI before and after educational training. Their median age was 8 years (1st and 3rd quartiles were 4.5 and 10 years, respectively). In the first setting, 16.8% performed all the steps correctly compared with 52.7% in the second setting (P<0.001). Initially, the most common errors found were for steps 2, 5, and 6. After educational training, significant improvement for all three steps was found (P≤0.001) and a significant better asthma control was reached (37.8% before vs. 75.7% after intervention P<0.001).
Table 3 Asthmatic children’s correct performance in handling a meter-dose inhaler before and after intervention

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Inhalation technique for asthmatic children using dry-powder inhaler (turbuhaler)

[Table 4] shows asthmatic children’s performance in using a DPI before and after educational training. Their median age was 9.5 years (1st and 3rd quartiles were 9.5 and 11.5 years, respectively). In the first setting, 37.5% performed all the steps correctly compared with 43.8% in the second setting (P<0.001). The most common errors detected were for steps 3 and 6, and significant improvement for these steps was found after educational training (P<0.001). Furthermore, a significant better asthma control was reached (31.3% before vs. 75% after intervention, P=0.016).
Table 4 Asthmatic children’s correct performance in handling a dry-powder inhaler before and after intervention

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  Discussion Top


Inhalation therapy for asthma allows delivering medications quickly to the site of action. Thus, using the lowest effective dose ensures decreasing the risk of systemic adverse effects [10],[11].

This study demonstrated that longer duration of inhaler use, regular follow-up, maternal education, and receiving education from a qualified trainer were significantly associated with a proper inhalation technique, whereas sex, residence, and parent’s occupation were not found to correlate. It is interesting that several studies demonstrated that children with longer duration of inhaler use, educated caregivers [12],[13],[14], and having a trained technician as the first instructor [14] were the most common factors associated with correct inhalation technique. Similarly, a study in India [15] − a developing country as ours − indicated that the correct technique was not affected by sex, income, urban or rural background. In this study, children who had been using the inhaler for longer duration and those visiting the clinic regularly probably had more opportunity for re-evaluation and correction of their technique compared with recent users. Moreover, the finding that educated mothers were associated with correct technique reflects the importance of the caregiver alertness of the importance and the accuracy of each step of the inhalation technique.

In this study, the percentage of patients performing all the inhalation steps correctly for patients using a MDI with a spacer, a MDI without a spacer, or a DPI were 20.6, 20.3, and 37.5%, respectively. A previous study conducted in North Carolina [12] reproduced similar results for children using a MDI, whereas a comparably higher percentage of patients using a DPI correctly was present in this study. This finding can be attributed to the fact that our clinic offers DPIs to a small percentage of older asthmatic children after checking that they succeed in using the inhalation whistle. Although asthmatic children assessed were following up for at least 3 months in our asthma clinic, they were still facing difficulty in handling their inhaler devices. Being a clinic inside a tertiary hospital, it is always overcrowded with patients and the health providers depend on the nurse staff who are busy with dispensing patients’ medications and/or inhalers to educate the children/caregivers on how to use their inhalers.

In contrary to our results, a study performed in the Netherlands on children attending a hospital-based asthma clinic stated that 78% of patients using a MDI with spacer or a DPI were performing all the steps correctly. However, their patients reported receiving one or more proper educational instructions and their researchers demonstrated that repetition of instructions was significantly associated with a correct inhalation technique [16].

To our knowledge, our study is one of the few studies assessing the effect of educational intervention on the improvement of inhalation technique and asthma control in the pediatric age group. On comparing asthma control before and after educational intervention, a significant increase in the percentage of asthmatic children with controlled asthma was detected for those using a MDI with a spacer, without a spacer, or a DPI (37.7, 37.8, and 31.3% before intervention to 60, 75.7, and 75% after intervention, respectively). Several studies have demonstrated that educational intervention was effective in promoting better asthma management [10],[17],[18].

This study showed that there is a significant increase in the percentage of patients performing all the inhalation steps correctly for patients using a MDI with spacer after a single educational intervention (20.6% before intervention to 52% after intervention). Similarly, a study performed in Malaysia on asthmatic children using a MDI with spacer, there was a significant improvement of skills in handling the inhalation technique after a single interventional session [10]. The most frequent incorrect steps were not shaking the inhaler before each use (59.4% were correct) and not taking 5–6 normal breaths after actuation (49.7% of children performed the step correctly without hurrying to leave the device). However, after training the child and the caregiver about the proper technique and the importance of each step, a significant increase in the percentage performing these steps correct was achieved (68.6 and 72%, respectively), in addition to improvement of most of the other steps. Similarly, the Malaysian study [10] demonstrated that there was a significant improvement of each step in handling a MDI with spacer inhalation technique after a single interventional session, and the most frequent incorrect step for their children was not taking 5–6 normal breaths after pressing the inhaler. In addition, not shaking the canister was reported as the most common error for patients using a MDI with spacer in other studies [16],[17].

Our study showed that there is a significant increase in the percentage of patients performing all the inhalation steps correctly for patients using a MDI after a single educational intervention (20.3% before intervention to 52.7% after intervention). The most frequent incorrect steps were not shaking the inhaler before each use (40.5% were correct), lack of breathing out before inhaling (35.1% were correct), and not coordinating the actuation inhalation step (56.8% were correct). However, after training the child and his/her caregiver about the technique and the importance of each step, a significant increase in the percentage performing these steps correct was achieved (71.6, 100, and 73%, respectively), in addition to improvement of most of the other steps. Interestingly, the study conducted in North Carolina [12] also reported that their frequent incorrect step was lack of breathing out before inhalation; however, their children were better in coordinating the actuation − slow deep inhalation step (84% were correct). A recent review article stated that the most common errors reported for the use of MDIs are lack of coordination between actuation and inhalation, halting inhalation when the cool spray hits the back of the throat, not holding the breath long enough (>5 s) after inhalation, no exhalation before actuation, and not shaking the suspension before use [19].

For the DPI, this study showed that there is a significant increase in the percentage of patients performing all the inhalation steps correctly after a single educational intervention (37.5% before intervention to 43.8% after intervention), and patients having their asthma controlled showed a significant increase after intervention. The most frequent incorrect steps were not loading the dose properly before each use, lack of breathing out before inhaling, and not holding breath for 10 s after inhaling the dose (68.8, 37.5, and 43.8% were correct, respectively), and a significant improvement in these steps after training the child and the caregiver about the technique and the importance of each step was reached. The study that was conducted in North Carolina [12] reported similar frequent incorrect steps (breathing out before placing the mouthpiece between lips and holding breath after inhalation). It is important to point out that the previous study performed in the Netherlands [17] reported that more inhalation educational sessions were needed to ensure that the majority of children using a DPI were performing the correct technique than those using a MDI with spacer. Their findings explain the small − although significant − rise in the percentage of patients performing all the DPI inhalation steps correctly after a single educational intervention (37.5% before intervention to 43.8% after intervention).

Interestingly, a recent study on patients hospitalized for asthma using different types of inhalers reported that their hospitalized patients achieved correct inhaler technique after training and maintained better technique when followed up after 3 months than on admission [20].


  Conclusion Top


This study concludes that repeated education, checking, and correction of the inhaler steps are required to reach a proper reliable inhalation technique and better asthma control.

Study limitations

Our study is limited by generalizability, being conducted in a single-tertiary care hospital. Other limitation was that we assessed the effect of a single educational intervention. Therefore, large-scale interventional studies are required to assess the inhalation technique and the effect of multi-educational intervention on asthma management. Finally, practices should consider employing trained health professionals to demonstrate, assess, check, and correct the inhaler steps to asthmatic children/caregivers at every single visit to ensure proper inhalation technique and asthma management.

Acknowledgements

The research was supported by Cairo Faculty of Medicine.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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