Face-to-face Training as an Effective Approach for Instructing Rotahaler Technique in Newly Diagnosed Cases of Asthma and COPD: a Pilot Study

Inhaled medications are the keystone for the treatment of obstructive lung diseases1,2 and pressurized metered dose inhalers (pMDIs) and dry powder inhalers (DPIs) are the devices mostly used for delivering the medications to the lungs. However, large majority of the patients were unable to use their dry powder inhalers correctly3 that results in reduced therapeutic effect.4 The quality of initial instruction is a foundation for the outcomes of inhalation therapy.5 A study by Shrestha et al demonstrated that combination of video and demonstration was useful tool for improving rotahaler technique.6 Improvement of inhalation technique not only reduces the frequencies of total as well as nocturnal asthma symptoms but also reduces the frequencies of beta-2 agonist usage.4


INTRODUCTION
Inhaled medications are the keystone for the treatment of obstructive lung diseases 1,2 and pressurized metered dose inhalers (pMDIs) and dry powder inhalers (DPIs) are the devices mostly used for delivering the medications to the lungs.However, large majority of the patients were unable to use their dry powder inhalers correctly 3 that results in reduced therapeutic effect. 4he quality of initial instruction is a foundation for the outcomes of inhalation therapy. 5A study by Shrestha et al demonstrated that combination of video and demonstration was useful tool for improving rotahaler technique. 6Improvement of inhalation technique not only reduces the frequencies of total as well as nocturnal asthma symptoms but also reduces the frequencies of beta-2 agonist usage. 4 Nepal, most of the patients receive only verbal instruction but the effectiveness of face-to-face training approach for instructing rotahaler technique by healthcare professionals in newly diagnosed patients of asthma and chronic obstructive pulmonary disease has not been explored.Our study may be the first in such setting in Nepal to evaluate the effectiveness of face-to-face training approach for instructing rotahaler technique in newly diagnosed case of asthma and chronic obstructive pulmonary disease.
selected.Socio-demographic information was obtained and rotahaler technique was instructed through face-toface training using GINA guidelines (rotahaler specific checklist) 7 by a registered pharmacist.After two weeks of training, the pharmacist assessed the technique using the same rotahaler specific checklist.Each correct step was scored 'one' and incorrect or missed step was scored 'zero'.Descriptive statistics was performed using SPSS version 20.

DISCUSSION
Incorrect use of inhaler technique is a common problem worldwide.In our pilot study, we analyzed the effectiveness of face-to-face training approach for instructing rotahaler technique.In this study, fourteen patients (70%) were able to perform all the steps correctly after the training, giving an overall median (IQR) score of 8 (7-8).A study by Shrestha et al in Kathamandu demonstrated that before intervention, only 42.2% of the patients used their inhaler device correctly, and most of the patients overestimated their rotahaler technique despite the incorrect inhaler technique, while 61.1% had never received any previous instruction on the correct use of rotahaler. 6imilarly, study done by Graham claimed that 30% of patients had never been demonstrated the correct use of inhaler. 8 The patients included in our study were the newly diagnosed cases of asthma and COPD who received the instruction for the first time.Moreover, a study by Cochrane et al showed that patient's education on disease and technique not only improved inhalation techniques but also improved patients compliance to the therapy and lung deposition of drugs. 2 The incorrect use of the rotahaler device might be a result of inadequate quality and duration of instruction, and inability of reinforcement by lack of follow-up checks up. 3 However, we did not reinforce the technique, which could be useful to further improve the correct use of the rotahaler technique from what we have achieved.
In our study, even after training some patient failed to breath out gently before inhalation and hold breath for about ten second after inhalation.Other studies have also mentioned that these are the most common errors while using dry powder inhalers. 3,6This emphasize that the reinforcement should focus more on these steps.Furthermore, to ensure that the instructions are correctly provided to patients regarding rotahaler technique, the healthcare professionals should be well educated, trained on rotahaler technique and should have access to demonstration devices.Such approach also improves error detection capability of healthcare professionals. 4

CONCLUSIONS
Face-to-face training seems to be effective approach for instructing the rotahaler technique in patients with asthma and COPD.However, a larger scale study is necessary, together with regular assessment and reinforcement.

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Table 2 . Frequency of correct rotahaler checklist performance.
These results suggests that proper training in inhaler technique is lacking in Nepal.Studies have shown that training can lead to more accurate use of dry powder inhalers. 9,10Our study, which was led by pharmacist, also suggested that the correct use of rotahaler technique through face-to-face training was nearly 30% better than the percentage depicted by Shrestha et al.A Pharmacist-led intervention study to improve inhalation technique in asthma and COPD patients demonstrated that patients who had never received training in correct inhalation technique made more errors in performing inhalation at baseline than those who have had one or more instruction sessions. 11 Poudel et al.Face-to-face Training as an Effective Approach for Instructing Rotahaler Technique in Newly Diagnosed Cases...