بحث ماجستير صيدلة
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Transcript of بحث ماجستير صيدلة
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
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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
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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
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