| Abstract |
Introduction: Chronic Obstructive Pulmonary Disease represents a major public health issue worldwide, resulting in loss of health and functional independence, poorer quality of life, increased healthcare resource utilization and mortality risk. The dominant therapeutic strategy includes maintenance therapy with Long Acting Bronchodilators which are frequently delivered through Dry Powder Inhaler agents (DPIs). Adherence to medication, appropriate inhalation technique and achieving an optimal peak inspiratory flow rate (PIFR) are important determinants of the effectiveness of maintenance therapy.
Purpose: The main objective of the study, which was part of the international study PIFotal, was to evaluate the proper use of DPIs and to define the relationship between inhalation technique errors and health status (respiratory symptoms, functional status, mental health), using the CCQ questionnaire (Clinical COPD Questionnaire). Another goal was to examine the frequency of inhalation technique errors and to identify the most common ones. The effect of COPD in patients’ everyday life was evaluated using the CAT questionnaire (COPD Assessment Test) and their current adherence to prescribed medication was assessed using the TAI questionnaire (Test of the Adherence to Inhalers). Secondarily, we aimed to identify the most frequent comorbit conditions in patients with COPD and to recognize the healthcare professionals who most frequently provide patients with inhalation technique advice. The percentage of patients who presented with suboptimal PIFR was also assessed, using the In-Check DIAL device. Another objective of the present study was to try to correlate the age of the participants with the presence of inhalation technique errors, with their health status (CCQ questionnaire) and with their current adherence to inhaler medication. Finally, the researcher provided patients with information regarding the inhalation technique.
Methods: A cross-sectional observational study was conducted between January and April 2021. Data were collected after informed consent in primary care units of the Cretan district. 10 researchers participated (8 GPs and 2 pulmonologists). We used data from the 40 patients which the researcher included in the study from the 4th local primary care unit of Heraklion. We also used data from 3 other researchers, for the purposes of this master thesis - 20 patients from the Primary Health Care Center of Kastelli, 13 patiens from the Rural Practice of Archanes and 21 patients attended a private primary care unit. 94 patients in total were included. The data collaction included questionnaires that evaluated patients’ quality of life, health status and the impact of COPD in their everyday life (CCQ and CAT questionnaires), as well as their adherence to prescribed medication (TAI questionnaire) and the video recording of the inhalation procedure/technique. Finally, we provided the patients with inhalation technique instructions.
Results: After analyzing the video recordings and the questionnaires of all the 94 patients, we found that they had recived poor training regarding their DPI devices, since they presented with multiple difficulties handling them. The CCQ score of the patients with correct inhalation technique was higher (meaning that these patients had poorer health status), compared to the group of patients with poor inhalation technique. 71.3% of the patients had poor inhalation technique (at least one inhalation technique mistake) and the most common error was poor exhalation prior to inhaling the medication (67%). 42.5% of the patients did not hold their breath after the inhalation, as 34% didn’t have proper posture during inhalation. Other less common erros, regarding the preparation and placement of the device, were observed. The majority of the patients (53.2%) scored 10-20 points in CAT questionnaire (medium impact level in their everyday life). According to the 12-item TAI questionnaire, almost half of the patients (47.8%) appeared to present with sporadic non-adherence to the prescribed medication, as only 28.7% presented with good adherence.
Then we analyzed data from the 40 patients (25 men and 15 women, aged over 40) who attended the 4th local primary care unit of Heraklion, because in the time being we had the complete data only from these 40 interviews. Only 20% of the them did not report any comorbidities. 85% of the participants mentioned that they had received inhalation technique instructions from their pulmonologist and mostly during the visit that the inhalation device was first prescribed. 1/3 of them presented a suboptimal PIFR. Finally, we noticed a trend between older age and the presence of inhalation technique errors, while no significant correlation was noticed between age and CCQ score or 10-item TAI score.
Conclusions: The lack of effective patient education about inhalation technique was confirmed by the high prevalence of inhalation technique errors, that were video-recorded during patients’ demonstration of their inhalation effort. The most frequent inhalation technique error was the inadequate exhalation before inhalation. It is also important to consider the poor adherence to inhaler medication. Multimorbitity was, also, highly prevalent among patients in our sample, which complicates their management in daily practice. Therefore, it is crucial for the physicians not only to implement the practice guidelines that include evaluation of the co-morbidities, but also to take action regarding the education of their patients about the significance of proper inhalation technique as well as adherence to prescribed medication.
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