1. INTRODUCTION

1.1 BACKGROUND

The increasing prevalence of asthma is matters of concern, as of 2010 three hundred million

people were affected worldwide and 250,000 annual deaths attributed to the disease. It is

estimated that the number of people with asthma will grow by more than 100 million by 2025.

Approximately 250,000 people die prematurely each year from asthma and occupational asthma

contributes significantly to the global burden of asthma, since the condition accounts for

approximately 15% of asthma amongst adults. (1) Asthma cost the US about $3,300 per person

with asthma each year from 2002 to 2007 in medical expenses, missed school and work days,

and early deaths. Asthma costs in the US grew from about $53 billion in 2002 to about $56

billion in 2007, about a 6% increase. (2)

The exact spread in Sudan is not known, but different regional studies estimate that prevalence 5-

10%. Asthma disease is one of the 10 most leading causes of Hospitals admission, (its estimated

that in Khartoum state is about 14%). (3)

1.1.1 PROBLEM STATEMENT

There are two major types of inhalers used to deliver asthma medication: metered dose inhalers

(MDIs) and dry powder inhalers (DPIs). Because a large percentage of patients have difficulty

using MDIs, teaching patients the correct use of MDIs is absolutely essential. Inhaled

medications are the cornerstone of asthma therapy, but they can only be effective if they are used

properly. Using your inhaler correctly delivers the medication to your lungs, where it can work

to control your symptoms. Using an inhaler incorrectly means that little or no medicine reaches

the lungs. Metered dose inhaler (MDI) technique is a widely used technique to administer

medications like corticosteroid. However, correct inhalation technique plays a vital role in

effective asthma therapy alongside appropriate drug usage which otherwise may lead to

diminished therapeutic effect, poor control of symptoms and thereby insufficient disease

management.

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1.1.2 JUSTIFICATION FOR THE STUDY

Lack of knowledge and poor use of MDI (MDI technique) are some contributors to an increase

in asthma morbidity. The latter does not only affect the quality of life of asthmatic patients but

also places a huge economic burden on the health care systems of countries, especially

developing countries. These costs are not only related to the health services but also to loss of

school and work time, resulting in poor school performance and a decline in productivity and

adds more to the number of disability-adjusted life years (DALYs). (Mash et al 2009). (4)

1.2 LITERATURE REVIEW

The literature search of systematic reviews and randomized controlled clinical trials was

conducted using Internet search engines, mainly the United States National Library of Medicine

(MEDLINE), Google search and Cochrane Library databases. Pub Med, Sabinet, and to a lesser

extent EmBase were also undertaken. Online journals such as CHEST online, British Medical

Journal, Current Allergy and Clinical Immunology. A broad search strategy was employed

combining terms related to aerosol devices, patient’s knowledge and awareness on use of

metered dose inhalers.

The literature search was done using the following search words: aerosol inhalation, metered-

dose inhalers, knowledge and awareness on use of MDI by patients, knowledge and awareness

on clean of MDI by health providers, inhalation technique.

The literature review will be discussed under the following subheadings:

1.2.1 Metered-dose inhalers

1.2.2 Patient knowledge and awareness on asthma metered dose inhalers

1.2.1 Metered-Dose Inhalers (MDI)

The inhaled route is considered to be the best route to administer drugs for treating respiratory

diseases like asthma and chronic obstructive pulmonary disease (COPD), for both safety and

efficacy. Inhalation devices are classified into four types – pressurized metered dose inhalers

(pMDIs), dry powder inhalers DPI, breath actuated inhalers and nebulizers. The pMDIs are

portable, convenient, multi-dose devices and these advantages have made them very popular

with patients.

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Everard (2003) outlined a brief history of inhaled therapy. Inhaled therapy has been used for

many hundreds of years with plants that were believed to have beneficial properties when burnt

and inhaled. (5) The first portable inhaler used in modern times was the asthma cigarette’

launched about two hundred years ago. This cigarette provided some symptom relief, but it

presented with atropine-like side-effects. In the 1930s, jet nebulizers’ were developed which

were modified to portable hand-held glass and rubber bulb nebulizers’ used mainly for

adrenaline drugs. These were fragile and inconvenient, and were replaced by the development of

pressured MDIs in 1950. A metered-dose-inhaler, sometimes called ‘aerosol inhaler’ is a

pressurized canister that delivers a measured amount of medication to the lungs.

Lum (2004) in the article ‘How to use MDI’ described a metered-dose inhaler as a hand-held

portable device that delivers a specific amount of medication in aerosol form. (6) There are three

types of dispensers for lung deposition of drugs currently available: the traditional press-and-

breathe metered dose inhaler, dry powder inhaler and nebulizer.

MDIs are the most frequently used forms of administering inhaled bronchodilator drugs and

corticosteroid therapy for chronic broncho-pulmonary diseases such as asthma and chronic

obstructive pulmonary diseases. They have become the mainstay of acute and maintenance

therapy for various allergic and respiratory conditions, as the medication is delivered to the site

of the disease process (Lum 2007). (6)

MDIs have been the most preferred dispensers because of their convenient small size (pocket

size) which makes them easy to carry anywhere and the ease of their use, that is, one can simply

press the MDI and it releases medication directly to the airways without any need of measuring

the dose beforehand. Therefore MDIs are easy to carry, highly effective, extremely safe and

allow accurate and consistent dose delivery. Compared to nebulizers metered-dose-inhalers have

added advantages of operating autonomously without any external energy source, and their

aerosolization time is short thus allowing accurate drug delivery with optimal use within

seconds. They are scarcely affected by the environmental influences and there is no need for any

specific maintenance except for regular cleaning (Melani 2007). (7)

Recently MDIs have received considerable interests compared with nebulisers in the

bronchodilatation of mechanically ventilated patients. Their cost- effectiveness, ease of

administration, less personnel time, reliability of dosage and lower risk of contamination are

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more appealing than the huge cost of nebulisation especially in the present era of limited

financial resources (Georgopoulos et al 2000). (8)

However, MDIs’ main limitation was and is still linked to the fact that many patients cannot use

them correctly, thereby reducing their clinical efficacy. The efficacy of inhaler therapy is

technique dependent, that is, its success depends on whether it is used correctly. The use of MDI

does not simply involve pressing of the MDI and release of the pre-measured dose of medication,

but involves certain maneuvers that aim to deliver maximum dosages to the diseased area.

Melani (2007) reported that the poor inhalation technique can be minimized by use of add-on

valve holding chambers, that is, spacers.(7) Koning (2010) in a review article, “Spacer devices

used with metered-dose-inhalers a breakthrough or gimmick”, concluded that spacer devices are

neither a breakthrough of such magnitude that their use should be mandatory for all users of

MDIs nor useless gimmicks because in patients with poor coordination such as the elderly, cone-

shaped and pear-shaped spacers might be more effective. In young children spacers with one-

way valve for example Aerochamber ® can be useful. (9)

According to the NICE guidelines (2000), all children under the age of five years should use

metered-dose-inhalers with spacers. Therefore spacers with one-way valve will be suitable for

those patients who cannot manage hand-breath coordination, non-cooperative patients (children

and the elderly) and those on ventilators. However the use of a spacer chamber is limited by its

cumbersomeness and the need for routine maintenance with standardized procedure (Melani

2007). (7)

1.2.2 Patient knowledge and awareness on asthma metered dose inhalers

Many types of inhalation devices are now available and current evidence indicates no difference

in the clinical effectiveness of one device over another provided they are used properly.

However, devices differ in the way they are used. The correct inspiration technique for a

pressurized metered-dose inhaler requires a slow deep breath, while a dry powder device requires

a faster initial breath. The correct technique is thus device-specific and treatment efficacy relies

on the method being taught effectively for each specific inhaler.

C. M. Harnett (2014) in the article “study to assess inhaler technique and its potential impact on

asthma control in patients attending an asthma clinic” this study demonstrates the importance of

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educating and formally assessing inhaler technique in patients with asthma as a part of their

ongoing clinical review.(10)

Uncontrolled asthma remains a frequent cause of emergency department (ED) visits and hospital

admissions. Improper asthma inhaler device use is most likely one of the major causes associated

with uncontrolled asthma and frequent ED visits.

Hamdan AL-Jahdali (2014) “Improper inhaler technique is associated with poor asthma control

and frequent emergency department visits”. (11) This study shows that improper asthma inhaler

technique is common among patients visiting ED in tertiary care centers in Saudi Arabia. This

improper technique is associated with poor asthma control and frequent ED visits. The lack of

appropriate asthma education is likely a major cause of improper device use. Furthermore,

national asthma studies are necessary to explore this problem and to prospectively study the

value of an interventional asthma education program to improve asthma inhaler device use and

clinical treatment outcomes.

Avijit Ganguly (2014) “Study of Proper use of Inhalational Devices by Bronchial Asthma or

COPD Patients Attending a Tertiary Care Hospital”. (12) It was concluded that use of MDI with

spacer most convenient method. Doctors often did not have sufficient time to train patients

regarding proper technique of inhaler use. With ever increasing and widespread use of inhalers

patients’ education is becoming more important. Proper training will surely make these drugs

more effective and cost benefit ratio more favorable.

Piyush Arora (2014), “Evaluating the technique of using inhalation device in COPD and

Bronchial Asthma patientsh” this study shown that the majority of patients using inhalation

devices made errors while using the device. (13) Proper education to patients on correct usage may

not only improve control of the symptoms of the disease but might also allow dose reduction in

long term.

An accurate use of these devices in administering the drugs invariably has a direct relationship

with the delivery and efficacy of the medications. When the technique of inhalation is poor, the

drugs are often not delivered appropriately to the site of action leading to poor treatment

outcomes. Poor inhalation technique leads to insufficient medication effects and to the

prescription of more or additional medication with a higher probability of side-effects and to

increased costs.

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1.3 Aim of study:

This study aims of determine the awareness and knowledge of employed asthmatic patients

towards metered dose inhaler use in Khartoum chest Hospital.

1.4 Objectives of study:

1.4.1 To assess employed asthmatic patients understand of all steps of MDI technique correctly.

1.4.2 To evaluate employed asthmatic patients education in cleaning of MDI properly.

1.4.3 To assess the correct dose of medication that released by MDI.

1.4.4 To assess employed asthmatic patients detection in MDI canister is empty.

1.4.5 To enhance employed asthmatic patients’ adherence to MDI.

1.5 Research question:

“What do employed asthmatic patients in Khartoum Chest Hospital know and aware about the

use and how they clean of MDI?”

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2. METHODOLOGY

2.1 Study design

This was a cross-sectional observational study.

2.2 Study population:

All employed asthmatic patients attending Emergency department of Khartoum Chest Hospital

October– November 2014.

2.3 Sampling method and sample size:

Based on the study population of 60 asthmatic employed patients in Khartoum chest Hospital.

The sample size was 60. The sampling frame was done through the use of random numbers,

patient choosed as they came into the ER. The simplest formula N= PQZ2/d2 was used, where

N=sample size, P= prevalence factor, Q=1-p, Z= constant 95% occurred 1.96, d= desired margin.

2.4 Inclusion criteria

All asthmatic employed patients aged 20 years and above (old and newly diagnosed) who

attended the ER of Khartoum Chest hospital over a period of two month were included.

2.5 Exclusion criteria

These were the following exclusion criteria:

All employed asthmatic patients below 20 years of age.

All unemployed asthmatic patients below 20 years of age.

Patients with COPD, emphysema, chronic bronchitis, pulmonary oedema and cardiac

Failure.

Patients who were mentally incompetent

2.6 Data collection:

A pilot study using a designed questionnaire was conducted of socio-demographic status, the

characteristic related to use of inhaler and the knowledge on use of MDIs. It was designed using

steps of metered dose inhaler device adapted from the National Asthma Education and

Prevention Programmes of America (NAEPP), Asthma Society of Canada and in consultation

with the statistician who assisted with data. The questionnaire was discussed and the correct use

of MDIs was demonstrated to each participant. All the raw data was entered into the Microsoft

Excel spreadsheet software and exported to SPSS Version 17 for analysis.

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2.7 Data analysis:

Data was analyzed using Microsoft Excel spreadsheet and SPSS Version 17 soft-wares and

presented as frequency tables and figures. Association of variables was done using the socio-

demographic status versus questions on awareness and knowledge on the use of MDIs, using the

chi-square test and the student t-test. Assistance with data analysis was obtained from a qualified

statistician and overseen by my supervisor who is knowledgeable on the use of both soft- wares.

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3. RESULTS

3.1 Demographic characteristics of the participants

3.1.1 Distribution of the participants according to age

The sample size for this study was 60 participants; seventy three percent of the participants were

under the age of 50 years, which is 44/60. This was followed by the age group 50-59 years that

18.3%, the age group 60-69 years that 5%, the age groups 70-79 years 3.3% (Table 3.1 and

Figure33.1).

Table 3.1: Distribution of the participants according to age (n=60)

Age Frequency Percent (%)

From 20 years – 29 years 8 13.3

From 30 years – 39 years 16 26.7

From 40 years – 49 years 20 33.3

From 50 years – 59 years 11 18.3

From 60 years – 69 years 3 5

From 70 years – 79 years 2 3.3

Total 60 100.0

20 -29 years30 -39 years

40 -49 years 50 -59 years

60 -69 years70 -79 years

13.30%

26.70%33.30%

18.30%

5.00%3.30%

Age

Figure 3.1: Distribution of the participants according to age (n=60)

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3.1.2 Distribution of the participants according to sex

The study showed that a number of male patients 40% and female patients is 60% on (Figure 3.2

and Table 3.2).

Table 3.2: Distribution of the participants according to sex (n=60)

Gender Frequency Percent (%)

Male 24 40

Female 36 60

Total 60 100.0

Male Female

40.00%

60.00%

SexSex

Figure 3.2: Distribution of the participants according to sex (n=60)

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3.1.3 Distribution of the participants according to education

Almost of the participants (43.3%) completed primary – high school and the university level

(38.3%) as the highest level of education, while (10%) can be read and (8.3%) indicated that they

did not read (Table 3.3 and Figure 3.3).

Table 3.3: Distribution of the participants according to education (n=60)

The level of education Frequency Percent (%)

University 23 38.3

Primary – high school 26 43.3

Can read 6 10

Cannot read 5 8.3

Total 60 100.0

University Primary - High school Can read Cannot read

38.30%

43.30%

10.00% 8.30%

Education LevelEducation Level

Figure 3.3: Distribution of the participants according to education (n=60)

3.1.4 Distribution of the participants according to smoking 11

The study showed that (10%) of participants are smokers and (90%) non- smokers (Table 3.4 and

Figure 3.4).

Table 3.4: Distribution of the participants according to smoking (n=60)

Smoking Status Frequency Percent (%)

Present 6 10

Absent 54 90

Total 60 100.0

Present Absent

10.00%

90.00%

Smoking status

Figure 3.4: Distribution of the participants according to smoking (n=60)

3.1.5 Distribution of the participants according to health insurance

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The study showed that a number of people who have health insurance about 61.7% and 38.3%

that who have not health insurance (Table 3.5 and Figure 3.5).

Table 3.5: Distribution of the participants according to health insurance (n=60)

Health Insurance Frequency Percent (%)

Present 37 61.7

Absent 23 38.3

Total 60 100.0

Present Absent

61.7%

38.3%

Health Insurance Health Insurance

Figure 3.5: Distribution of the participants according to health insurance (n=60)

3.2 Patient Characteristic Related To Use Of Inhaler

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3.2.1 Distribution of the participants according to source of learning on use of MDI

When asked who taught them how to use the MDI, the participants identified more than one

source of information. The Pharmacist, Specialist Physician and General Practitioner were the

frequent educators on the use of MDIs.

General Practitioner and pharmacists most frequently provided information there are (26.7%) at

the same ratio, followed by Specialist Physician (25%). Littlie participants (11.7%) were no body

taught on the use of MDI. Only (1.7%) participants were taught by Nurse and Leaflet, while

there were (6.7%) participants who received any education from a friend or caregiver (Table 3.6

and Figure 3.6).

Table 3.6: Distribution of the participants according to source of learning on use of MDI

(n=60)

The Source of learning Frequency Percent (%)

Specialist physician 15 25Pharmacist 16 26.7

General practitioner 16 26.7Nurse 1 1.7

Caregiver or friends 4 6.7Leaflet 1 1.7

No body 7 11.7Total 60 100.0

Specialist physician Pharmacist General

practitioner Nurse Caregiver or friends Leaflet No body

25% 26.7% 26.7%

1.7%6.7%

1.7%11.7%

The Source of learning

Figure 3.6: Distribution of the participants according to source of learning on use of MDI

(n=60)

3.2.2 Distribution of the participants according to duration time since use of MDI

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The vast majority of the participants (53.3%) reported to have had their asthma for less than five

years and only (46.7%) participants had the disease for more than 5 years. (Table 3.7 and Figure

3.7).

Table 3.7: Distribution of the participants according to duration time on use of MDI (n=60)

Duration time Frequency Percent (%)

less than 1 year 12 20

1 – 5 years 20 33.3

6 – 10 years 9 15

More than 10 years 19 31.7

Total 60 100.0

less than 1 year 1 – 5 years 6 – 10 years More than 10 years

20%

33.3%

15%

31.3%

Duration time

Figure 3.7: Distribution of the participants according to duration time on use of MDI

(n=60)

3.2.3 Distribution of the participants according to perform peak flow reading at home

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The study showed that use of the device to determine lung function and to evaluate the patient

symptoms reduce and comfortable after use MDI, they found that 96.7% did not use the device

and 3.3% was used (Table 3.8 and Figure 3.8). The participants not used device most common

are satisfy after use inhaler 65% and 33.8% not satisfy (Table 3.9 and Figure 3.9)

Table 3.8: Distribution of the participants according to perform peak flow reading at home

(n=60)

Peak flow reading at home Frequency Percent (%)

Present 2 3.3

Absent 58 96.7

Total 60 100.0

Present Absent

2%

98%

Peak flow reading at home

Figure 3.8: Distribution of the participants according to perform peak flow reading at

home (n=60)

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Table 3.9: Distribution of the participants according to satisfy with the relief after the

inhaler administration (n=60)

Satisfy after the inhaler use Frequency Percent (%)

Yes 39 65

No 21 35

Total 60 100.0

Yes No

65%

35%

Satisfy after the inhaler use

Figure 3.9: Distribution of the participants according to satisfy with the relief after the

inhaler administration (n=60)

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3.3 Metered Dose Inhaler

3.3.1 Distribution of the participants according to priming and press the MDI into the Air

The study proved that (66.7%) of respondents did not press the MDI into air on away from the

face if new or has not been used for several days or weeks and (33.3%) can prime the inhaler

(Table 3.10 and Figure 3.10).

Table 3.10: Distribution of the participants according to priming and press the MDI into

the Air (n=60)

Priming or press the MDI into the air

Frequency Percent (%)

Yes 20 33.3

No 40 66.7

Total 60 100.0

Yes No

33.3%

67.3%

Priming or press the MDI into the air

Figure 3.10: Distribution of the participants according to priming and press the MDI into

the Air (n=60)

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3.3.2 Distribution of the participants according to all steps of inhalation technique of MDI

The majority of participants used the MDI is about 91.7% used incorrectly and 8.3% follow all

steps of MDI correctly (Table 3.11 and Figure 3.11).

Table 3.11: Distribution of the participants according to doing all steps of inhalation

technique of MDI (n=60)

All steps of inhalation technique

Frequency Percent (%)

Yes 5 8.3

No 55 91.7

Total 60 100.0

Yes No

8.3%

91.7%

All steps of inhalation technique

Figure 3.11: Table 12: Distribution of the participants according to steps of inhalation

technique of MDI (n=60)

Table 3.12: Distribution of the participants according to all steps of inhalation technique of

MDI (n=60)19

Step Instruction Yes No

1 Shake the contents well 76.5 % (46) 23.5 %(14)

2 Remove the cap 98.3 % (59) 1.7 % (1)

3 Hold the inhaler upright 83.3 % (50) 16.7 %(10)

4 Tilt the head back slightly 53.3 % (32) 46.7 % (28)

5 Breath out slowly 60 % (36) 40 % (24)

6 Open mouth with inhaler 1 to 2 inches away or in the mouth with the lips

tightly sealed around it

53.3 % (32) 46.7 % (28)

7 Begin breath in slowly and deeply through the mouth and

actuate the canister once

58.3 % (35) 41.7 % (25)

8 Hold your breath for 10 second 40 % (24) 60 % (36)

9 Exhale & wait one minute before the second dose 55% (33) 45 % (27)

10 Shake again before the second dose 55 % (33) 45 % (27)

11 After use, replace the mouth piece cove 83.3 % (50) 16.7 % (10)

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 Step 10 Step 110.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

Yes No

Figure 3.12: Distribution of the participants according to all steps of inhalation technique

of MDI (n=60)

3.3.3 Distribution of the participants according to all steps of cleaning metered dose inhaler

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The majority participants in this study were not cleaned the MDI 73.3 and 26.7% did clean MDI

(Table 3.13 and Figure 3.13).

Table 3.13: Distribution of the participants according to steps of cleaning metered dose

inhaler (n=60)

Step Instruction Yes No

1 Take metal canister out of plastic container. 21.7%(13) 78.3%(47)

2 Rinse plastic container with warm water. 18.3%(11) 81.7%(49)

3 Let plastic container air dry. 25%(15) 75%(75)

4 Replace metal canister in plastic container. 23.3%(14) 76.7%(37)

5 Test the MDI by releasing a puff into the air. 23.3%(14) 76.7%(37)

Step 1 Step 2 Step 3 Step 4 Step 5

22.7%18.3%

23.3% 23.3% 23.3%

78.3%81.7%

76.7% 76.7% 76.7%

Yes No

Figure 3.13: Distribution of the participants according to steps of cleaning metered dose

inhaler (n=60)

3.3.4 Distribution of the participants according to frequency of cleaning MDI

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The study proved that (73.3%) of participants did not clean MDI while other (16.7%)

participants clean MDI weekly, (6.7%) per month and (3.3%) daily (Table 3.14 and Figure 3.14).

Table 3.14: Distribution of the participants according to duration time of cleaning MDI

(n=60)

Duration time of cleaning Frequency Percent (%)

No clean 44 73.3

Daily 2 3.3

Weekly 10 16.7

Monthly 4 6.7

Total 60 100.0

No clean Daily Weekly Monthly

73.3%

3.3%

16.7%

6.7%

Duration time of cleaning

Figure 3.14: Distribution of the participants according to duration time of cleaning MDI

(n=60)

3.3.5 Distribution of the participants according to the quantity of actuation in MDIs

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The study identified that the number of participants who did not know the number of doses on

the MDI (65%), while those who know about (35%) (Table 3.15 and Figure 3.15).

Table 3.15: Distribution of the participants according to the quantity of actuation in MDI

(n=60)

The knowledge the quantity of actuation in MDIs

Frequency Percent (%)

Yes 21 35

No 39 65

Total 60 100.0

Yes No

35%

65%

The knowledge the quantity of actuation in MDIs

Figure 3.15: Distribution of the participants according to the quantity of actuation in MDI

(n=60)

3.3.6 Distribution of the participants according to a count of remain dose in MDI after use

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The study has found that about 50% of the participants did not know how to calculate the

remaining dose, and the remaining 50 were know (Table 3.16 and Figure 3.16), the way by

which dose calculated is shaking the bottle which are approximately 100% either did not

calculate dose by dose counting scheduled inhalers (Table 3.17 and Figure 3.17).

Table 3.16: distribution of the participants according to a count of remain dose in MDI

after use (n=60)

The a count of remain dose in MDI after use

Frequency Percent (%)

Yes 50 50

No 50 50

Total 60 100.0

Yes No

50% 50%

The a count of remain dose in MDI after use

Figure 3.16: distributions of the participants according to a count of remain dose in MDI

after use (n=60)

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Table 3.17: Distribution of the participants according to the method of remain dose in MDI

(n=60)

The method of remain dose in MDI

Frequency Percent (%)

Shaking MDI 60 100

Dose counting scheduled inhalers

0 0

Total 60 100.0

Shaking MDI Dose counting scheduled inhalers

100%

0%

The method of remain dose in MDI

Figure 3.17: Distribution of the participants according to the method of remains dose in

MDI (n=60)

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3.4 Association of variables

3.4.1 Distribution of the participants according to association of perform peak flow reading

at home and learning of MDI technique

The Pearson’s chi-square test shows that there was no significant association between the

perform peak flow reading at home and learning of MDI technique. X² = 5.690, p = 0.459 (Table

3.18).

Table 3.18: Chi-square test for association of perform peak flow reading at home and

learning of MDI technique (n=60)

Chi-Square Tests

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square

Likelihood Ratio

Linear-by-Linear Association

N of Valid Cases

5.690a

5.481

1.740

60

6

6

1

0.459

0.481

0.187

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3.4.2 Distribution of the participants according to association of press MDI into air if new

or not used for several weeks and learning of MDI technique

The Pearson’s chi-square test shows that there was weak significant association between

association the MDI press into air if new or not used for several weeks and learning of MDI

technique. X² =11.593, p= 0.072 (Table 3.19).

Table 3.19: Chi-Square test for association of press MDI into air if new or not used for

several weeks and learning of MDI technique (n=60)

Chi-Square Tests

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square

Likelihood Ratio

Linear-by-Linear Association

N of Valid Cases

11.593a

13.288

5.721

60

6

6

1

0.072

0.039

0.017

27

3.4.3 Distribution of the participants according to association of the all the steps of metered

dose inhaler use and learning of MDI technique

The Pearson’s chi-square test shows that there was weak significant association between the all

the steps of metered dose inhaler use and learning of MDI technique. X² = 10.909, p = 0.091

(Table 3.20).

Table 3.20: Chi-Square test for association of the all the steps of metered dose inhaler use

and learning of MDI technique (n=60)

Chi-Square Tests

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square

Likelihood Ratio

Linear-by-Linear Association

N of Valid Cases

10.909a

11.927

11.259

60

6

6

1

0.091

0.064

0.262

3.4.4 Distribution of the participants according to association of the cleaning metered dose

inhaler and learning of MDI technique

The Pearson’s chi-square test shows that there was no association of the cleaning metered dose

inhaler and level of education. X² =10.603, p= 0.910 (Table 3.21).

Table 3.21: Chi-Square test for association of the cleaning metered dose inhaler and

learning of MDI technique (n=60)

Chi-Square Tests

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square

Likelihood Ratio

Linear-by-Linear Association

N of Valid Cases

10.603a

13.254

2.619

60

18

18

1

0.910

0.776

0.106

28

3.4.5 Distribution of the participants according to association of know the quantity of

actuation in MDI and level of education

The Pearson’s chi-square test shows that there was no significant association of know the

quantity of actuation in MDI and level of education. X² =5.694, p = 0.127 (Table 3.22).

Table 3.22: Chi-Square test for association of know the quantity of actuation in MDI and

level of education (n=60)

Chi-Square Tests

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square

Likelihood Ratio

Linear-by-Linear Association

N of Valid Cases

5.694a

7.245

2.763

60

3

3

1

0.127

0.064

0.096

3.4.6 Distribution of the participants according to association of count the remain dose in

MDI after use and level of education

The Pearson’s chi-square test shows that there was significant association count the remain dose

in MDI after use and level of education. X² = 6.087, p = 0.107 (Table 3.23).

Table 3.23: Chi-Square test for association of count the remain dose in MDI after use and

level of education (n=60)

Chi-Square Tests

Value df Asymp. Sig. (2-sided)

Pearson Chi-Square

Likelihood Ratio

Linear-by-Linear Association

N of Valid Cases

6.087a

8.027

4.592

60

3

3

1

0.107

0.045

0.032

29

4. DISCUSSION

The results will be discuss according to subheading emerging from the results and this will be

grounded in the literature. Comparisons will be made between the findings of this study and what

is currently known.

4.1 RESULTS

4.1.1 Socio-demographic status of participants

Almost half of the participants (43.3%) completed primary – high school and the university level

(38.3%) as the highest level of education, while (10%) can be read and (8.3%) indicated that they

did not read. The participants’ low level of education might have affected their understanding on

their inhaler technique, cleaning, priming and dose counting. Savage and Dikmen (2006)

demonstrated that translated patient information leaflet (PIL) used alone is of less benefit than

the same leaflet used together with own-language verbal advice. (14) Many patients with poor

reading skills did not understand when to take “as needed” asthma medication and did not realize

the importance of using an inhaler properly.

In this study the majority of participants have health insurance (37/60) and this lead to additional

cost to the public health insurance when the inhaler not used properly.

4.1.2 Characteristic related to use of inhaler

4.1.2.1 Distribution of the participants according to source of learning on use of MDI

When asked who taught them how to use the MDI, the participants identified more than one

source of information. The Pharmacist, Specialist Physician and General Practitioner were the

frequent educators on the use of MDIs. General Practitioner and pharmacists most frequently provided

information there are (26.7%) at the same ratio, followed by Specialist Physician (25%). Littlie

participants (11.7%) were no body taught on the use of MDI. Only (1.7%) participants were taught by

Nurse and Leaflet, while there were (6.7%) participants who received any education from a friend or

caregiver. In our study indicated that some medical practitioners assumed that pharmacists

reviewed the use of MDI by their patients while others cited lack of time. The study by Osman A

(2012) in Khartoum state demonstrated that the majority of community pharmacists, who were

expected to educate asthma patients on their dispensed inhalers, lack the basic knowledge of

proper use of commonly dispensed asthma inhaler devices. (15) The study Hussen D Ali,

30

(2014)“Competence in metered dose inhaler technique among dispensers in Mekelle” this study

shows that very poor MDI technique in healthcare providers. The healthcare provider’s skill in

the MDI technique among pharmacists and druggists in Mekelle town is very limited, indicating

that need for establishing regular educational programs for health care providers especially

pharmacist. (16)

4.1.2.2 Distribution of the participants according to duration time on use of MDI

The vast majority of the participants fifty three percent reported to have had their asthma for less

than five years and only forty seven percent of participants had the disease for more than 5 years.

4.1.3 Association of variables

4.1.3.1 Distribution of the participants according to association of perform peak flow

reading at home and learning of MDI technique

There was no significant association between the participants use the perform peak flow reading

at home and learning of MDI technique. The participants did not know about peak flow reading

this means that poor monitoring for MDI use.

4.1.3.2 Distribution of the participants according to association of press MDI into air if new

or not used for several weeks and learning of MDI technique

There was weak significant association between the MDI press into air if new or not used for

several weeks and learning of MDI technique. The majority of participants no aware by priming

of MDI this may lead to missed dose.

4.1.3.3 Distribution of the participants according to association of the all the steps of

metered dose inhaler use and learning of MDI technique

Only eight percent in the participants performed all the inhalation steps correctly. The most

common error and in this study was failure to Begin breath in slowly and deeply through the

mouth and actuate the canister once 41.7%, hold your breath for 10 second 60%.This finding

raises concerns as it is the single most important step of the whole inhalation technique since

lesser amounts of the inhaled drug would reach the lungs, which would result in poor asthma

control. The study by CC, Onyedum (2014) “Evaluation of Inhaler techniques Among Asthma

Patients Seen in Nigeria “this study showed that majority of asthma patients used their inhalers

31

inaccurately. (17) Patient-dependent factors were identified as the cause of incorrect technique of

inhaler use. Prof. Fusun Yildiz (2013) “Importance of inhaler device use status in the control of

asthma in adults” this study revealed that the asthma control rate increased during follow up in

adult outpatients with persistent asthma, moving from 61.5% to 87.0% after 6 months, regardless

of patient demographics, smoking, educational, or employment status. (18)This study in turkey

show improve patients technique after enhance knowledge on MDI use. The Pearson’s chi-

square test shows that there was weak significant association between the all the steps of metered

dose inhaler use and learning of MDI technique. X² = 10.909, p = 0.091 that means no relation

between inhaler use and the source of learning. There is need for increased awareness among all

the health-care personnel involved in asthma care most especially the Pharmacists ensuring they

know the correct inhaler technique since most patients from our study were actually taught by

doctors on the use of the inhalers.

4.1.3.4 Distribution of the participants according to association all steps the metered dose

inhaler cleaning and learning of MDI technique

The Pearson’s chi-square test shows that there was no association between the cleaning metered

dose inhaler and learning of MDI technique that show more than 73.3% not clean MDI that

means medications or MDI can become sticky and clog up the hole of the mouthpiece and may

lead dose reduction.

4.1.3.5 Distribution of the participants according to association of know the quantity of

actuation in MDI and level of education

The Pearson’s chi-square test shows that there was no significant association between patients

know the quantity of actuation in MDI and level of education. X² = 5.694, p = 0.127. This is

indicate the level of education may affect on knowledge in canister is empty.

4.1.3.6 Distribution of the participants according to association of count the remain dose in

MDI after use and level of education

The Pearson’s chi-square test shows that there was no significant association between count the

remain dose in MDI after use and level of education. X² = 6.087, p = 0.107 the all participants

have no knowledge on dose counting scheduled method but the majority use shaking the inhaler

that not learn on actual dose remaining in inhaler .

32

5. CONCLUSIONS AND RECOMMENDATIONS

5.1 Conclusions

The correct use of MDI was found to be difficult for most employed patients. The majority of the

patients lacked knowledge and skill for effective use of MDI. The inefficient Inhalation

technique seems to be a common problem, resulting in poor drug delivery to the lungs and

increased asthma morbidity can leading is a common cause of lost workdays.The patients’ poor

awareness of cleaning, priming of MDI.

5.2 Recommendations

o The patient’s inhalation techniques should be assessed by the pharmacist at all reviews, to

check that the correct technique is maintained, because skills deteriorate with time.

o Regular education of healthcare professional likely to be of paramount importantance to

insure that able to adequately teach patients technique.

o Video media (e.g. video) must be found in all asthmatic centers to show patients correct

MDI use, priming and cleaning.

o It should be mandatory for all health professionals especially the pharmacist to teach all

patients with obstructive airway diseases especially asthma; the nature of the disease,

preventive measures, the need for use of an inhaler and demonstrate how the aerosol

inhaler should be use.

o Patient information leaflets should be translated into the local language.

33

REFERENCE

1. World Health Organization. Global surveillance, prevention and control of chronic

respiratory diseases: a comprehensive approach, 2007.

2. Centers for Disease Control and Prevention, Vital Signs, May 2011.

3. www.fmoh.gov.sd

4. Mash, B., Rhode, H., Pather, M., Ainslie, G., Irusen, E., Bheekie, A., & Mayers, P.

(2009), “Quality of asthma care: Western Cape Province, South Africa”, Original

Articles, vol 99, pp 12.

5. Everard, M. L. (2003), “Role of inhaler competence and contrivance in difficult asthma”.

Pediatric Respiratory Reviews, vol. 4, pp 135-142.

6. Lum, L. (2004) “How to use an MDI: use your MDI correctly for maximum benefit”,

Canadian Pharmaceutical Journal, vol. 137, pp 8.

7. Melani, A. S. (2007), “Inhalatory therapy training: a priority challenge for the physician”,

ACTA BOIMED, vol. 78, pp 233-245.

8. Georgopoulos, D., Mouloudi, E., Kondili, E., & Klimathianaki. (2000), “Bronchodilator

delivery with metered-dose inhaler during mechanical ventilation”, Critical Care, vol. 4,

pages 227-234.

9. Konig, P. (1985). “Spacer devices used with metered-dose inhalers, breakthrough or

gimmick”, American College of Chest Physicians, vol 88, pp 276-284.

10. C. M. Harnett, E. B. Hunt, B. R. Bowen, O. J. O’Connell, D. M. Edgeworth, P. Mitchell,

J. A. Eustace, M. T. Henry, M. P. Kennedy, B. J. Plant, and D. M. Murphy (2014), “study

to assess inhaler technique and its potential impact on asthma control in patients

attending an asthma clinic”, Journal of Asthma, Vol. 51, No. 4 , Pages 440-445.

11. Hamdan AL-Jahdali, Anwar Ahmed, Abdullah AL-Harbi, Mohd Khan, Salim Baharoo,

Salih Bin Salih, Rabih Halwani and Saleh Al-Muhsen (2013) “Improper inhaler

technique is associated with poor asthma control and frequent emergency department

visits” Allergy, Asthma & Clinical Immunology , doi:10.1186/1710-1492-9-8

12. Avijit Ganguly, Anup Kumar Das, Anindya Roy, Anjan Adhikari, Joyashree Banerjee, and

Sumitra Sen “Study of Proper use of Inhalational Devices by Bronchial Asthma or COPD

Patients Attending a Tertiary Care Hospital”(2014), Journal of Clinical and Diagnostic

Research, vol. 8(10): HC04–HC07.

34

13. Piyush Arora, Lokender Kumar,,Vikram Vohra, Rohit Sarin, Anand Jaiswal, M.M. Puri,

Deepti Rathee, Pitambar Chakraborty “Evaluating the technique of using inhalation

device in COPD and Bronchial Asthma patients “ (2014) Respiatory, Volume 108, Issue

7, Pages 992–998.

14. Goodyer, L., Savage, I., & Dikmen, Z. (2006), “Inhaler technique in Turkish people with

poor English: a case of information discrimination?” Pharm World Sci, vol. 28, pp 107-

114.

15. Osman A, Ahmed Hassan IS, Ibrahim MIM. “Are Sudanese community pharmacists

capable to prescribe and demonstrate asthma inhaler devices to patrons? A mystery

patient study” Pharmacy Practice (Internet) 2012 Apr-Jun; 10(2):110-115.

16. Hussen D Ali, Gubena S Worku, Asfaw A Alemayehu and W/aregay H Gebrehiwot

“Competence in metered dose inhaler technique among dispensers in

Mekelle” ,2014,.Allergy, Asthma & Clinical Immunology 10:18

17. CC, Onyedum.”Evaluation of Inhaler Techniques Among Asthma Patients Seen in

Nigeria “,(2014), Ann Med Health Sci Rres.4(1):67-73 doi:10.4103/2141-9248.126617.

18. Fusun Yildiz, “Importance of inhaler device use status in the control of asthma in adults”,

(2013), Respiratory care. Doi: 10.4187/respcare.02478

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