Previous studies have shown that the improper use of inhaler devices decreases drug delivery, patient’s regimen adherence and drug effectiveness contributes to uncontrolled asthma and multiple ED visits [14, 15, 17–22]. In this study, we tried to identify the relationship between improper inhaler device use, asthma control and number of ED visits. To the best of our knowledge, this is the first study in Saudi Arabia to examine the factors possibly leading to improper asthma inhaler use. We believe that this study has a sound methodology, being conducted by personal interview, and patient information was confirmed by reviewing medical records for each patient. A trained investigator confirmed the inhaler device use against a standard checklist. Similar to other studies, this study demonstrated that improper inhaler use is common in our population and results from avoidable causes. Furthermore, we demonstrated that improper inhaler device use is associated with poor asthma control and frequent ED visits [17–22]. Interestingly, improper asthma device use is mainly due to a lack of knowledge regarding asthmatic disease.
In this study, a majority (92%) of the patients were using metered-dose inhalers (MDI). This finding is consistent with Saudi Arabian practice for this disease, as most of the patients were seen at primary health care and family medicine clinics where the most common form of inhalers are MDIs. However, this should not be accepted as the cause for improper inhaler use. In fact, studies have shown that newer dry powder inhalers (DPIs) are not associated with an improved inhalation technique. Devices should be selected based on a patient’s acceptance and preferences . Selecting a device based on the patients’ preference is cost effective in the long term, even if the device is more expensive than the standard devices . However, studies have shown that good educational practice results in the proper use of MDI which will be more cost effective in the long-term [16, 25, 26].
Importantly, we found that 40% of the patients did not receive any formal education by any health care professionals regarding the proper use of inhaler devices. This was mostly due to a lack of asthma education programs. Almost half of our patients used asthma devices improperly, resulting in more visits to the ED due to subsequently poor asthma control. The major avoidable factors for improper device use were a lack of education regarding asthma as a disease and how the patient use inhaler device correctly. Therefore, our health care system should emphasize establishing asthma education programs to educate patients on asthma and its management, particularly regarding the use of inhaler devices. These asthma education programs require continuous effort to educate patients and their caregivers. Studies have shown that standardized asthma education programs, education focused on self-management and behavioral change improves inhaler device use, adherence to treatment and asthma control [27, 28]. Studies have shown that almost 50% of the patients used the devices correctly and this improved to more than 80% after instruction regardless of the device being used [29, 30]. In this study, approximately 59% of the patients received education about how to use the inhaler devices. The education was given by physicians in 44% of cases. However, 30% still improperly used the medication. Furthermore, asthma educators and pharmacists only educated approximately 6-7% of patients about the proper use of inhalers. Similar to other studies, there was no difference in the appropriate use of device stratified by patient age or gender .
One limitation of our study was the documentation of specific education that was given to the patients. We had to rely on the patients’ recollection of the education, as the education was not documented in the medical records. Additionally, we were not able to evaluate the quality of the teaching and how many educational sessions our patients received by health care professionals. We also had no background information on the psychosocial factors of this group of patients with poor inhaler device use, as this was beyond the scope of our study. Another limitation of this study was that we did not assess the side effects of improper inhaler use and how much this might contribute to poor compliance with medication, asthma control and ED visits. However, studies have shown that trained asthma educators, respiratory therapists and pharmacists are better qualified to teach patients than other health care providers [32, 33]. We previously documented that only 5% of our patients seen at tertiary care clinics are completely in control of their asthma , and we also documented that many of our patients have a false belief and misconception about asthma pathophysiology and inhaled steroid use . Also, in this study we only assessed the essential steps required for proper drug delivery. We did not score each step separately or count the number of errors or omissions. In addition to our previous studies [9, 34], the finding of this study clearly demonstrates some limitations in our health care system. There is an urgent need for a national asthma education program at all level of medical care. We believe that the lack of an appropriate asthma education program in our system leads to improper device use, lack of the patient’s knowledge about asthma, false beliefs and misconceptions about ICS. These deficiencies result in poor asthma control and increased ED visits. This study was limited to two academic centers in the Riyadh-central region. Most likely it does not represent the asthma care at the national level; thus, there is a need for national epidemiological studies to assess different aspects of asthma management.