Transcript Slide 1

Oral presenter (FAPA):
Dr Nahlah Elkudssiah
Ismail PhD., R.Ph., MMPS,
MCRS
Clinical BioPharmaceutics Research Group
(CBRG), Brain & Neuroscience Core,
Faculty of Pharmacy, Universiti Teknologi
MARA Puncak Alam Campus, 42300
Bandar Puncak Alam, Selangor, Malaysia
*Corresponding email:
[email protected]
FB: Nahlah Elkudssiah Ismail AlMasry
Evaluation of different inhalational delivery devices techniques among
the community pharmacists in urban areas in Selangor, Malaysia
I. Nahlah Elkudssiah, A. Lokman Hakim, Z. Muhammad Khalis, N. K. Muhammad Anwar
INTRODUCTION
↑ Morbidity &
Mortality [1]
Chronic lung disease –
inflammation of airways,
bronchoconstriction, bronchial
hyper-responsiveness; SOB, cough,
chest tightness, wheeze [3]
1. Nadi, E., & Zeraati, F. (2005). Evaluation of the metered-dose
inhaler technique among healthcare providers. Acta Medica Iranica,
43(4), 268–272.
2. Masoli, M., Fabian, D., Holt, S., Beasley, R., & Program, G. I. for A.
(GINA). (2004). The global burden of asthma: executive summary of
the GINA Dissemination Committee Report. Allergy, 59(5), 469–478.
doi:10.1111/j.1398-9995.2004.00526.x
3. GINA (2012)
ASTHMA
Control: Treatment
(pharmacological, nonpharmacological approach)
↑ Prevalence
[2]
Inhaled medications
•Inhaler technique [2]
•Adherence
•Preference
•Cost
•Front-line health professional
•Patient’s education/counselling
(proper, understandable and
easy way of using various
inhalers) [4]
Pharmacist
(Health
professional)
Asthmatics
•MDI, Spacer, DPI,
Nebulisers
•Deliver inhaled drug
particles to reach
targeted site
(airways-lungs) 
desired therapeutic
action(s) [1]
•↓ Systemic adverse
effect [2] [3]
Inhalational
delivery devices
1.Zainudin, B. M. (1993). Therapeutic aerosol: principles and practices. The Medical Journal of Malaysia, 48(3), 259–268
2.Şen, E., Uğur Gönüllü, Zuhal Ekici, & Nazmiye Kurşun. (2006). Assessment of inhaler technique and treatment compliance of hospitalized patients and outpatients in a university hospital.
Retrieved from http://acikarsiv.ankara.edu.tr/browse/4846/
3.Pauwels, R., Newman, S., & Borgstrom, L. (1997). Airway deposition and airway effects of antiasthma drugs delivered from metered-dose inhalers. European Respiratory Journal, 10(9), 2127–
2138.
4.Baddar, S. A., Al-Rawas, O. A., Al-Riyami, K. A., Worthing, E. A., Yolande I. Hanssens Aqeela M Taqi, & Al-Riyami, B. M. S. (2001). Metered-Dose Inhaler Technique Among Healthcare Providers
Practicing in Oman. Sultan Qaboos University Medical Journal, 3(1), 39–43.
MAIN OBJECTIVE
• This study determined the knowledge level of
the community pharmacists regarding their
ability to educate patients on how to use the
metered dose inhaler (MDI) and dry powder
inhalers (DPIs) mainly accuhaler and
turbuhaler.
METHODOLOGY
Ethics approval (Research
Management Institute (RMI),
UiTM)
Part A (Socio-demographic Data)
(community pharmacists)
Part B (inhaler checklist)
(researcher) [1, 2}
Various urban areas (n = 6) in
Selangor, Malaysia [Shah Alam,
Klang, Petaling Jaya, Kelana Jaya,
Subang Jaya, Puchong]
Data collection period: January May 2013
5% margin of error, 90%
confidence level, 50% response
distribution; recommended
sample size = 77
Verbal demonstrations of the
respective study inhalers were
recorded and transferred to
inhaler checklist for scoring
Descriptive and inferential
statistical analysis using SPSS
(version 19) were employed
where appropriate; p value of <
0.05 = statistically significant
1.GINA (2012)
2.Khan, T. M., & Azhar, S. (2012). A study investigating the community pharmacist knowledge about the appropriate use of inhaler, Eastern Region AlAhsa, Saudi Arabia. Saudi
Pharmaceutical Journal. doi:10.1016/j.jsps.2012.07.004
MDI
1. Shake the inhaler and remove the cap
2. Breathe out slowly and completely
3. Hold the inhaler in upright position
4. Insert the mouthpiece into mouth between closed lips
5. Depress the canister once
6. At the same time breathe in slowly for deep inhalation
7. Remove the inhaler with the closed lips
8. Hold your breath for 5 - 10s
9. Wait for 20 - 30s before starting the second puff
10. Gargle (if taking steroid medication)
DPI
TURBUHALER
1. Remove the cap from the inhaler
2. Keep inhaler upright
3. Rotate grip anti-clockwise then turn back
until a click is heard
ACCUHALER
1. Open inhaler
2. Push lever back completely
3. Exhale to residual volume
4. Exhale away from mouthpiece.
4. Exhale away from mouthpiece
5. Place mouthpiece between teeth and lips
6. Inhale forcefully and deeply
5. Place mouthpiece between teeth and lips
7. Hold breath for 5 sec
6. Inhale forcefully and deeply
8. Exhale away from mouthpiece
7. Hold breath for 5 seconds
9. Gargle (if taking steroid medication)
8. Exhale away from mouthpiece
9. Close inhaler
RESULTS & DISCUSSION
• Recruited: 81 urban community pharmacists
• Independent variables: Age (26-35; 36-45; 4655 years old), gender (M/F), ethnicity (Malay,
Chinese, Indian), highest education (Degree,
Master), number of practicing years (1- 10;
11-20; 21- 30), counsel patient (Y/N), inhaler
preference (MDI/DPI).
MDI
Sequentially
answered with
other missing
step/s (n = 62)
N, (%)
Not
sequentially
answered with
other missing
step/s (n = 19)
N, (%)
Respondents who did
not answer the
following step
N, (%) (n = 81)
58 (93.5)
14 (73.7)
9 (11.1)
1
Step
Shake the inhaler vigorously and remove
the cap
2
Breathe out slowly and completely
56 (90.3)
15 (78.9)
10 (12.3)
3
56 (90.3)
15 (78.9)
10 (12.3)
57 (91.9)
14 (73.7)
10 (12.3)
55 (88.7)
14 (73.7)
12 (14.8)
6
Hold the inhaler in upright position
Insert the mouthpiece into mouth between
closed lips
Depress the canister once
At the same time breathe in slowly for
deep inhalation
57 (91.9)
16 (84.2)
8 (9.8)
7
Remove the inhaler with the closed lips
57 (91.9)
15 (78.9)
9 (11.1)
58 (93.5)
16 (84.2)
7 (8.6)
50 (80.6)
15 (78.9)
16 (19.8)
0 (0)
0 (0)
81 (100)
No
4
5
9
Hold your breath for 5 - 10s , then breathe
out gently away from the mouth piece
Wait for 20 - 30s before starting the
second puff
10
Gargle (if taking steroid medication)
8
Range of scores
MDI
Group
Sequentially
Answered
N (%)
Group Not
Sequentially
Answered
N (%)
Pharmacists
(n = 62)
Pharmacists
(n = 19)
10 (8.7)
5 (11.9)
8 - 10 (good)
5-7
(moderate)
52 (45.2)
14 (33.3)
≤ 4 (poor)
0 (0)
0 (0)
Mean, ±SD,
Min, Max
Mean
6.67
Mean
7.16
SD
0.88
SD
0.76
Min
5
Min
6
Max
8
Max
9
1.Baddar, S. A., Al-Rawas, O. A., Al-Riyami, K. A., Worthing, E. A., Yolande I. Hanssens Aqeela M
Taqi, & Al-Riyami, B. M. S. (2001). Metered-Dose Inhaler Technique Among Healthcare
Providers Practicing in Oman. Sultan Qaboos University Medical Journal, 3(1), 39–43
2.Odili, V. U., & Okoribe, C. O. (2010). Assessment of Pharmacists’ knowledge on correct inhaler
technique, 1(3), 768.
Chi-square test:
Ethnicity (p = 0.037)
A study done in Oman found that only a
small portion of healthcare providers
(physicians, nurses and pharmacists) able to
demonstrate the proper way on how to use
the MDI. The results obtained indicated that
the healthcare providers still have poor
knowledge of MDI techniques [1].
A study carried out in Benin-City, Nigeria, by
Odili and Okoribe (2010), found that the
average knowledge score of pharmacists
before and after educational intervention
was 4.18 ± 2.5 (38% ± 22.7%) and 9.39 ± 1.5
(85.4% ± 13.6%), respectively. This study
showed that pharmacists who had received
an additional PharmD degree had a higher
score than others (p = 0.03) [2].
DPI (Turbuhaler)
No
1
2
3
4
Step
Remove the cap from the inhaler
Keep inhaler upright
Rotate grip anti-clockwise then back until a
click is heard
Exhale away from mouthpiece to residual
volume
Place mouthpiece between teeth and lips
Sequentially
answered with
other missing
step/s
(n = 62)
N (%)
57 (91.9)
53 (85.5)
Not sequentially
answered with Respondents who
other missing did not answer the
step/s (n = 19)
following step
N (%)
N (%)
17 (89.5)
7 (8.6)
16 (84.2)
12 (14.8)
57 (91.9)
15 (78.9)
9 (11.1)
56 (90.3)
16 (84.2)
9 (11.1)
16 (84.2)
15 (78.9)
14 (73.7)
9 (11.1)
9 (11.1)
11 (13.6)
5
6
7
Inhale forcefully and deeply
Hold breath for 5-10 seconds
56 (90.3)
57 (91.9)
56 (90.3)
8
Exhale away from mouthpiece
55 (88.7)
14 (73.7)
12 (14.8)
9
Gargle (if taking steroid medication)
0 (0)
0 (0)
81 (100)
DPI (Turbuhaler)
Group
Sequentially
Answered
N (%)
Range of scores
Pharmacists
(n = 62)
Group Not
Sequentially
Answered
N (%)
Pharmacists
(n = 19)
8 - 10 (good)
4 (3.4)
3 (7.1)
5 - 7 (moderate)
58 (50.5)
16 (38.1)
≤ 4 (poor)
0 (0)
0 (0)
Mean, ±SD, Min,
Max
Mean
6.4
Mean
6.47
SD
0.73
SD
0.96
Min
5
Min
5
Max
8
Max
8
Chi-square test:
Ethnicity (p = 0.011)
DPI (Accuhaler)
No
Sequentially
Not sequentially Respondents who did
answered with
answered with
not answer the
other missing step/s other missing
following step
(n = 62)
step/s (n = 19)
(n = 81)
N (%)
N (%)
N (%)
Step
1
Open inhaler
58 (93.5)
17 (89.5)
6 (7.4)
2
Push lever back completely
57 (91.9)
17 (89.5)
7 (8.6)
3
Exhale to residual volume
57 (91.9)
15 (78.9)
9 (11.1)
4
Exhale away from mouthpiece
Place mouthpiece between teeth
and lips
56 (90.3)
14 (73.7)
11 (13.6)
57 (91.9)
16 (84.2)
8 (9.8)
57 (91.9)
17 (89.5)
7 (8.6)
7
Inhale forcefully and deeply
Hold breath for 5 seconds
55 (88.7)
17 (89.5)
9 (11.1)
8
Exhale away from mouthpiece
54 (87.1)
16 (84.2)
11 (13.6)
9
Close inhaler
55 (88.7)
14 (73.7)
12 (14.8)
0 (0)
0 (0)
81 (100)
5
6
Gargle
(if
10 medication)
taking
steroid
DPI (Accuhaler)
Group
Sequentially
Answered N (%)
Group Not
Sequentially
Answered
N (%)
Range of scores
Pharmacists
(n = 62)
Pharmacists
(n = 19)
8 - 10 (good)
1 (0.9)
0 (0)
5 - 7 (moderate)
≤ 4 (poor)
60 (52.2)
1 (0.9)
18 (42.8)
1 (2.4)
Mean, ±SD, Min,
Max
Mean
SD
Min
Max
5.79
0.83
4
8
Mean
SD
Min
Max
5.84
0.89
4
7
• Multiple linear regression:
– The model = not significant.
– There were no predictors entered into the model
that made statistically significant contribution to
the marks of different types of inhalers in this
study.
CONCLUSION & RECOMMENDATION
• The overall level of knowledge in demonstrating
inhaler techniques amongst urban community
pharmacists was moderate (5 – 7 score). Many
respondents were unable to obtain good score (8 to
10) for all types of inhalers.
• Additional training via continuous professional
development programmes should be provided to
further equip the respondents with proper inhaler
techniques for them to demonstrate the best
inhaler techniques to the patients.