Written Information on the Use of Aerosols in COPD patients. Can We Improve Their Use?
Información escrita sobre el uso de aerosoles en pacientes con enfermedad pulmonar obstructiva crónica. ¿Mejoramos su calidad de utilización?
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Can We Improve Their Use?" 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"etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "DUE, Centro de Salud de Beniaján, Murcia, Spain." "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Médico de Familia, Centro de Salud de Beniaján, Murcia, Spain." "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Información escrita sobre el uso de aerosoles en pacientes con enfermedad pulmonar obstructiva crónica. ¿Mejoramos su calidad de utilización?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:6 [ "identificador" => "fig1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "27v33n01-13056482fig03.jpg" "Alto" => 469 "Ancho" => 387 "Tamanyo" => 39270 ] ] ] ] "textoCompleto" => "<p class="elsevierStylePara">Introduction</p><p class="elsevierStylePara">Diseases of the respiratory system continue to pose substantial public health problems, given their high morbidity and mortality. One of the most prevalent respiratory diseases is chronic obstructive pulmonary disease (COPD), and appropriate health education for these patients is necessary for self-care and control of the disease. These patient should be encouraged to quit smoking, and should be taught to use prescription medications correctly. Inhaled medications should be the treatment of choice whenever possible, as they make it possible to administer high concentrations of the active principle directly to the site of action. This diminishes systemic side effects and increases therapeutic efficacy.<span class="elsevierStyleSup">1-4</span></p><p class="elsevierStylePara">However, the inhalation route also has some disadvantages, especially in that it requires some skill on the patient's part to ensure correct administration. To offset this disadvantage, several devices are available such as pressurized canister inhalers, spacers, and dry powder inhalers,<span class="elsevierStyleSup">5-8</span> although the most commonplace and widely used device is the pressurized canister inhaler.</p><p class="elsevierStylePara">To ensure the correct us of these devices, health professionals usually provide brief instruction, although large patient loads often leave little time for this. The pharmacist or a relative usually provides additional information. Nevertheless, there are a number of questions remain to be answered: do our patients use pressurized canister inhalers correctly? Which kind of health education is the most effective? Is verbal information as effective as written information?<span class="elsevierStyleSup">9,10</span></p><p class="elsevierStylePara">Because of these questions, and with the aim of improving inhalation techniques in our patients, we designed the present study with two main objectives:</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleItalic">1.</span> To determine whether the use of written information alone improved the performance of pressurized canister inhaler technique in patients with COPD.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">2.</span> To compare the effectiveness of written information alone on the use of inhalers with that of verbal information given by nursing staff members.</p><p class="elsevierStylePara">Material and Methods</p><p class="elsevierStylePara">This interventional study was done at an urban health center located outside the city center. The participants were 120 patients with a diagnosis of COPD who were prescribed daily treatment with pressurized canister inhalers for more than 3 months. We excluded patients who used inhalers on an as-needed basis only, or who used them only occasionally. Other criteria for exclusion were psychiatric disorder, dementia or neurological disease that might interfere with the patient's ability to coordinate the steps in the correct use of inhalers. Chronic obstructive pulmonary disease was diagnosed on the basis of spirometric criteria (FEV<span class="elsevierStyleInf">1</span>/FVC<70%).</p><p class="elsevierStylePara">All patients were men aged between 60 and 75 years. We excluded patients who had not received primary education or who were illiterate. Women were excluded to maximize similarity<br></br> between groups, and because of the higher prevalence of COPD among men. Table 1 shows the distribution of patients according to smoking habit. All patients were recruited during the same 6-month period from among patients assigned to 5 family physicians at our health center, located in a suburban area.</p><p class="elsevierStylePara"><img src="27v33n01-13056482tab01.gif"></img></p><p class="elsevierStylePara">The 120 patients were divided randomly into 3 groups of 40 patients each, who did not differ significantly in any of the demographic characteristics. No intervention was used in the first group, verbal explanation was used as the intervention in the second group, and written information was provided as the intervention in the third group. The verbal intervention consisted of a detailed, 5-minute explanation of the inhalation technique (Table 2),<span class="elsevierStyleSup">11</span> provided by a member of the nursing staff. At the end of the explanation patients were asked to demonstrate their inhalation technique with a placebo. The written intervention consisted of giving the patient a pamphlet with printed instructions (Table 2). No verbal explanation was provided, and the patient's performance of the inhalation technique was not checked.</p><p class="elsevierStylePara"><img src="27v33n01-13056482tab02.gif"></img></p><p class="elsevierStylePara">The outcome measurement consisted of calculating percentage compliance with each of the 5 criteria for the correct use of inhalers at the start of the study and 3 months after the intervention in all groups. Age, sex, and level of education (no formal education, primary school, secondary school, university) were recorded for all patients. Data on the performance of inhalation technique were recorded by a nurse specially trained in the use of inhalation systems, who observed each patient as he or she performed 2 consecutive inhalations. The following criteria were evaluated:</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">­ Criterion 1: each patient with COPD who uses pressurized canister inhalers should exhale completely before pressing down on the canister.</p><p class="elsevierStylePara">­ Criterion 2: each patient who uses inhalers to treat COPD should breath in slowly after exhaling completely.</p><p class="elsevierStylePara">Inhalation was considered slow when it lasted more than 4 seconds.</p><p class="elsevierStylePara">­ Criterion 3: each patient who uses inhalers to treat COPD should depress the canister only after inhalation has begun. This criterion was considered to be performed correctly only when the canister was depressed during the first second of inhalation.</p><p class="elsevierStylePara">­ Criterion 4: each patient who uses inhalers to treat COPD should hold his or her breath for 10 seconds after inhaling the dose.</p><p class="elsevierStylePara">­ Criterion 5: each patient who uses inhalers to treat COPD should keep his or her lips closed firmly around the mouthpiece during the procedure.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">To compare the initial and follow-up findings, statistical analysis consisted of calculation, for each criterion, of absolute and relative improvement (referred to greatest possible improvement) and statistical significance (with one-tailed z tests for comparison of proportions). To create a database and analyze the data we used the SYSTAT program (version 5.0).<span class="elsevierStyleSup">12</span> A <span class="elsevierStyleItalic">P</span> value <0.05 was considered statistically significant. On the basis of our study design, a sample size of 40 for each group was considered sufficient.</p><p class="elsevierStylePara"><img src="27v33n01-13056482fig03.jpg"></img></p><p class="elsevierStylePara">Results</p><p class="elsevierStylePara">We found no significant differences between groups in age, sex, or level of education. At the initial evaluation inhalers were found to be used incorrectly by our patients with COPD: mean compliance with the criteria was 40% in all 3 groups. There were no significant differences between groups at this initial evaluation, a result that confirmed homogeneity of the sample of participants. In overall terms, criterion 4 (holding breath for 10 seconds after inhaling the dose) was performed correctly by only 8% of the patients. In contrast, overall compliance with criterion 3 at the initial evaluation (i.e., before the intervention) was 72.5% (Table 3).</p><p class="elsevierStylePara"><img src="27v33n01-13056482tab04.gif"></img></p><p class="elsevierStylePara">After verbal or written information was given, performance improved significantly for all criteria (<span class="elsevierStyleItalic">P</span><.05) in both intervention groups, with no significant differences between them (ns). Mean final compliance for all criteria in the group that received written information was 74%, versus 82% in the group that received verbal information. Compliance with criterion 4, which was only 8% at the initial evaluation, increased to 55.5% in the group that received verbal information, and to 37.5% in the group that received written information. These figures indicate that additional improvements in compliance are desirable. Compliance with criterion 3, which was already high in the initial evaluation, increased further to 97% in the verbal intervention group, and to 95% in the written intervention group. Compliance with the other three criteria also improved significantly (Table 3).</p><p class="elsevierStylePara">In the group that received no intervention we found no significant improvements in compliance in the second evaluation. This group served as a control to facilitate the identification of variables that might have interfered with the results.</p><p class="elsevierStylePara">Discussion</p><p class="elsevierStylePara">The present study evaluates inhalation techniques used with the inhalation system indicated most frequently by health professionals. Initially we found that pressurized canister inhalers were being used incorrectly by patients with COPD. This indicated that despite correct prescribing practices by physicians, the results obtained are not those anticipated by the patient or the health professional. Performance improved significantly in both intervention groups, with no significant differences between the two. Hence a specific intervention for this type of treatment significantly enhances its efficacy. The results of studies such as the present one are increasingly important to maintain the viability of the current national health system in Spain.</p><p class="elsevierStylePara">We note that there were no significant differences in the results between the groups that were given verbal and written instructions about the correct technique for using pressurized canister inhalers. This may represent considerable time saved at each patient-physician contact, as simply handing the patient a pamphlet and urging the patient to read it carefully may achieve the same results as spending a few minutes to explain the technique verbally. We also found that if the patient is given no verbal or written information about how to use pressurized canister inhalers, the results will be poor, and treatment will not have the expected effect.</p><p class="elsevierStylePara">Madueño et al<span class="elsevierStyleSup">13</span> investigated whether primary care physicians in training had adequate theoretical and practical knowledge about inhalation systems. These authors found that inhalation systems were often misused, and recommended specific training for primary care professionals in the use of inhaled drug therapy. Their findings indicate that if health professionals are not familiarized with the use of these devices, we will not be able to explain to our patients how to use them appropriately. Other studies<span class="elsevierStyleSup">14-17</span> have also analyzed how patients use inhalers, and have found performance of inhalation techniques to be poor. These findings suggest that greater emphasis should be placed on inhalation techniques, and that physicians should ensure that the patients knows how to use the inhaler correctly. It is important to emphasize here that using an inhaler incorrectly is equivalent to not taking any medication at all.</p><p class="elsevierStylePara">Among the potential biases in this study is the limitation imposed by including only patients with COPD, as pressurized canister inhalers are also widely used for chronic diseases such as asthma and interstitial disorders, as well as for acute diseases such as bronchitis and pneumonia. It should be recalled that patients with an acute disease have less experience, hence the rate of incorrect inhalation technique can be assumed to be higher among them. Another potential source of bias is the fact that when we designed the study, we did not take into account measures by the pharmaceutical industry to improve patients' inhalation technique by producing improved devices that require less coordination to use correctly. It would be interesting to compare the different devices now available on the market.</p><p class="elsevierStylePara">Future studies in this area should be designed to analyze the efficacy of information provided to the patient at the pharmacy, and to compare this information with that provided at the health center. Fomenting cooperation between pharmacies and health center professionals is a key step toward improving compliance with therapy and providing effective health education for these patients.</p><p class="elsevierStylePara">In conclusion, the use of written information about inhalation techniques for the use of aerosols by patients with COPD significantly improves performance, and the improvements are similar to those obtained when patients are given a verbal explanation of how to use the inhaler.</p><p class="elsevierStylePara"><img src="27v33n01-13056482fig05.jpg"></img></p>" "pdfFichero" => "27v33n01a13056482pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec692349" "palabras" => array:5 [ 0 => "Aerosoles" 1 => "EPOC" 2 => "Utilización" 3 => "Intervención" 4 => "Técnica inhalatoria" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec692348" "palabras" => array:5 [ 0 => "Aerosols" 1 => "COPD" 2 => "Utilization" 3 => "Intervention" 4 => "Inhalation technique" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Objectives. To determine whether the use of written information alone improved inhalation technique with pressurized canister inhalers in patients with chronic obstructive pulmonary disease (COPD). To compare the effectiveness of written information versus verbal explanation provided by nursing personnel on the use of inhalers. Design. Interventional study. Setting. Urban health center located outside the city center. Participants. 120 patients with COPD treated with pressurized canister inhalers. Interventions. The participants were divided randomly into three groups of 40 patients each. In one group no intervention was used, in the second group verbal explanations were provided, and in the third group written information was provided. Main measures. We recorded percentage compliance with 5 criteria for the correct use of inhalers at the start of the study and 3 months after the intervention in all groups. Results. Initially, performance of the inhalation technique by patients with COPD was poor (mean compliance 40%). Performance improved significantly in both intervention groups, with no significant difference between them. Final mean compliance was 74% in the written information group and 82% in the verbal information group. Conclusions. The use of written information about the use of inhalers for patients with COPD significantly improved utilization to a degree similar to that obtained with verbal explanations." ] "es" => array:1 [ "resumen" => "Objetivos. Identificar si el empleo de información escrita exclusivamente mejora la calidad de uso de aerosoles presurizados en pacientes con enfermedad pulmonar obstructiva crónica (EPOC). Comparar la eficacia de la información escrita exclusiva sobre el uso de aerosoles frente a la explicación oral del uso de estos dispositivos por parte del personal de enfermería. Diseño. Estudio de intervención. Emplazamiento. Centro de salud de la periferia de nuestra ciudad. Participantes. Un total de 120 pacientes con EPOC en tratamiento con aerosoles presurizados. Intervenciones. División aleatoria en tres grupos de 40 personas. En uno de ellos no se aplica ninguna intervención; en otro, intervención mediante explicación oral y en el tercero intervención mediante información escrita. Mediciones principales. Porcentaje de cumplimiento de 5 criterios sobre el correcto uso de aerosoles inicialmente y 3 meses después de la intervención en todos los grupos. Resultados. Inicialmente se aprecia una baja calidad en el uso de aerosoles presurizados en los pacientes con EPOC (cumplimiento medio de criterios del 40%). La calidad de uso aumenta significativamente en ambos grupos de intervención no se aprecián diferencias significativas entre ellos. <br /> El cumplimiento medio final de criterios en el grupo de información escrita fue del 74%, frente a un 82% en el grupo de información oral. Conclusiones. El uso de información escrita sobre el uso de aerosoles en pacientes con EPOC mejora significativamente su calidad de utilización, en grado similar a su explicación oral." ] ] "multimedia" => array:10 [ 0 => array:6 [ "identificador" => "tbl1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v33n01-13056482tab01.gif" "imagenAlto" => 214 "imagenAncho" => 408 "imagenTamanyo" => 9765 ] ] ] ] ] ] 1 => array:6 [ "identificador" => "tbl2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v33n01-13056482tab02.gif" "imagenAlto" => 361 "imagenAncho" => 405 "imagenTamanyo" => 15517 ] ] ] ] ] ] 2 => array:6 [ "identificador" => "fig1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "27v33n01-13056482fig03.jpg" "Alto" => 469 "Ancho" => 387 "Tamanyo" => 39270 ] ] ] 3 => array:6 [ "identificador" => "tbl3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "27v33n01-13056482tab04.gif" "imagenAlto" => 295 "imagenAncho" => 831 "imagenTamanyo" => 22272 ] ] ] ] ] ] 4 => array:6 [ "identificador" => "fig2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "27v33n01-13056482fig05.jpg" "Alto" => 530 "Ancho" => 391 "Tamanyo" => 55279 ] ] ] 5 => array:5 [ "identificador" => "tbl4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 6 => array:5 [ "identificador" => "tbl5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 7 => array:5 [ "identificador" => "fig3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 8 => array:5 [ "identificador" => "tbl6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 9 => array:5 [ "identificador" => "fig4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Inhalation technique in patients with chronic respiratory diseases. 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ISSN: 02126567Original language: English
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| 2020 August | 14 | 8 | 22 |
| 2020 July | 22 | 7 | 29 |
| 2020 June | 16 | 7 | 23 |
| 2020 May | 17 | 10 | 27 |
| 2020 April | 14 | 7 | 21 |
| 2020 March | 19 | 6 | 25 |
| 2020 February | 23 | 5 | 28 |
| 2020 January | 18 | 4 | 22 |
| 2019 December | 26 | 12 | 38 |
| 2019 November | 22 | 5 | 27 |
| 2019 October | 8 | 8 | 16 |
| 2019 September | 13 | 2 | 15 |
| 2019 August | 10 | 4 | 14 |
| 2019 July | 9 | 4 | 13 |
| 2019 June | 76 | 14 | 90 |
| 2019 May | 183 | 18 | 201 |
| 2019 April | 86 | 10 | 96 |
| 2019 March | 12 | 4 | 16 |
| 2019 February | 19 | 10 | 29 |
| 2019 January | 9 | 3 | 12 |
| 2018 December | 22 | 6 | 28 |
| 2018 November | 19 | 4 | 23 |
| 2018 October | 18 | 14 | 32 |
| 2018 September | 5 | 5 | 10 |
| 2018 August | 6 | 5 | 11 |
| 2018 July | 3 | 2 | 5 |
| 2018 June | 4 | 0 | 4 |
| 2018 May | 3 | 3 | 6 |
| 2018 April | 4 | 9 | 13 |
| 2018 March | 2 | 0 | 2 |
| 2018 February | 5 | 1 | 6 |
| 2018 January | 1 | 0 | 1 |
| 2017 December | 6 | 0 | 6 |
| 2017 November | 11 | 2 | 13 |
| 2017 October | 9 | 1 | 10 |
| 2017 September | 7 | 0 | 7 |
| 2017 August | 3 | 1 | 4 |
| 2017 July | 12 | 1 | 13 |
| 2017 June | 20 | 3 | 23 |
| 2017 May | 17 | 1 | 18 |
| 2017 April | 29 | 7 | 36 |
| 2017 March | 21 | 19 | 40 |
| 2017 February | 20 | 5 | 25 |
| 2017 January | 16 | 0 | 16 |
| 2016 December | 30 | 3 | 33 |
| 2016 November | 22 | 1 | 23 |
| 2016 October | 43 | 7 | 50 |
| 2016 September | 26 | 1 | 27 |
| 2016 August | 20 | 0 | 20 |
| 2016 July | 18 | 1 | 19 |
| 2016 June | 31 | 16 | 47 |
| 2016 May | 31 | 7 | 38 |
| 2016 April | 18 | 7 | 25 |
| 2016 March | 17 | 5 | 22 |
| 2016 February | 17 | 2 | 19 |
| 2016 January | 16 | 3 | 19 |
| 2015 December | 17 | 3 | 20 |
| 2015 November | 25 | 1 | 26 |
| 2015 October | 27 | 5 | 32 |
| 2015 September | 23 | 4 | 27 |
| 2015 August | 42 | 2 | 44 |
| 2015 July | 25 | 4 | 29 |
| 2015 June | 13 | 2 | 15 |
| 2015 May | 13 | 6 | 19 |
| 2015 April | 20 | 3 | 23 |
| 2015 March | 16 | 6 | 22 |
| 2015 February | 15 | 1 | 16 |
| 2015 January | 32 | 3 | 35 |
| 2014 December | 40 | 5 | 45 |
| 2014 November | 24 | 0 | 24 |
| 2014 October | 33 | 3 | 36 |
| 2014 September | 32 | 2 | 34 |
| 2014 August | 16 | 1 | 17 |
| 2014 July | 22 | 3 | 25 |
| 2014 June | 23 | 3 | 26 |
| 2014 May | 23 | 2 | 25 |
| 2014 April | 18 | 1 | 19 |
| 2014 March | 17 | 1 | 18 |
| 2014 February | 17 | 2 | 19 |
| 2014 January | 15 | 1 | 16 |
| 2013 December | 10 | 1 | 11 |
| 2013 November | 14 | 2 | 16 |
| 2013 October | 16 | 2 | 18 |
| 2013 September | 10 | 2 | 12 |
| 2013 August | 12 | 1 | 13 |
| 2013 July | 13 | 1 | 14 |
| 2004 January | 799 | 0 | 799 |
Show all
