Misuse of inhalers among COPD patients in a community hospital in Taiwan

Figures & data

Table 1 Demographic characteristics of patients (N=298)

	N	%
Age, years (mean ± SD)	72.10±8.98
<60	22	7.38
60–69	82	27.52
≥70	194	65.10
Gender
Male	284	95.30
Female	14	4.70
BMI, kg/m^2 (mean ± SD)	23.64±3.98
Education
Illiterate and elementary school	212	71.14
Higher than junior high school	86	28.86
Hearing
Good	195	65.44
Poor	103	34.56
Eyesight
Good	116	38.93
Poor	182	61.07
Number of inhalers used
<2	163	54.70
≥2	135	45.30
Duration of inhaler use, months (mean ± SD)	9.91±13.68
Type of inhalers
MDI with spacer	79	26.51
Diskus^®	20	6.71
Turbuhaler^®	21	7.05
Respimat^®	223	74.83
Breezhaler^®	100	33.56

Note: All data are presented as n (%) unless otherwise indicated.

Abbreviations: BMI, body mass index; MDI, metered-dose inhaler.

Table 2 Characteristics of pass and misuse groups of patients using different inhalers

	MDI with spacer		Diskus^®		Turbuhaler^®		Respimat^®		Breezhaler^®
	Pass	Misuse	Pass	Misuse	Pass	Misuse	Pass	Misuse	Pass	Misuse
Total	18 (22.78)	61 (77.22)	6 (30.00)	14 (70.00)	4 (19.05)	17 (80.95)	27 (12.11)	196 (87.89)	35 (35.00)	65 (65.00)
Age, years (mean ± SD)	69.39±8.49	72.21±9.53	68.17±7.68	70.71±11.52	68.50±11.24	70.54±11.21	69.85±8.35	72.21±8.74	71.20±8.27	73.46±80.84
<60	1 (5.56)	5 (8.20)	1 (16.67)	3 (21.43)	1 (25.00)	2 (11.76)	3 (11.11)	13 (6.63)	3 (8.57)	4 (6.15)
60–69	6 (33.33)	15 (24.59)	3 (50.00)	1 (7.14)	1 (25.00)	5 (29.41)	9 (33.33)	55 (28.06)	10 (28.57)	15 (23.08)
≥70	11 (61.11)	41 (67.21)	2 (33.33)	10 (71.43)	2 (50.00)	10 (58.82)	15 (55.56)	128 (65.31)	22 (62.86)	46 (70.77)
Gender
Male	17 (94.44)	56 (91.80)	6 (100.00)	13 (92.86)	4 (100.00)	16 (94.12)	26 (96.30)	191 (97.450)	34 (97.14)	63 (96.92)
Female	1 (5.56)	5 (8.20)	0 (0.00)	1 (7.14)	0 (0.00)	1 (5.88)	1 (3.70)	5 (2.55)	1 (2.86)	2 (3.08)
BMI (mean ± SD)	22.96±4.27	23.88±4.36	26.91±4.14	23.55±3.74	23.85±3.70	24.59±4.13	23.69±3.92	23.33±3.84	23.67±4.23	23.65±3.72
Education
Illiterate and elementary school	13 (72.22)	43 (70.49)	2 (33.33)	8 (57.14)	1 (20.00)	12 (70.59)	21 (77.78)	144 (73.47)	26 (74.29)	48 (73.85)
Higher than junior high school	5 (27.78)	18 (29.51)	4 (66.67)	6 (42.86)	3 (60.00)	5 (29.41)	6 (22.22)	52 (26.53)	9 (25.71)	17 (26.15)
Hearing
Good	16 (88.89)*	31 (50.82)	5 (83.33)	9 (64.29)	4 (100.00)	13 (76.47)	22 (81.48)	130 (66.33)	25 (71.43)	45 (69.23)
Poor	2 (11.11)	30 (49.18)	1 (16.67)	5 (35.71)	0 (0.00)	4 (23.53)	5 (18.52)	66 (33.67)	10 (28.57)	20 (30.77)
Eyesight
Good	8 (44.44)	23 (37.70)	3 (50.00)	4 (28.57)	2 (50.00)	8 (47.06)	12 (44.44)	74 (37.76)	15 (42.86)	25 (38.46)
Poor	10 (55.56)	38 (62.30)	3 (50.00)	10 (71.43)	2 (50.00)	9 (52.94)	15 (55.56)	122 (62.24)	20 (57.14)	40 (61.54)
Sedative agents	2 (11.11)	6 (9.84)	1 (16.67)	0 (0.00)	1 (25.00)	2 (11.76)	2 (7.41)	26 (13.27)	4 (11.43)	7 (10.77)
Number of acute exacerbation (mean ± SD)	0.61±0.70	0.43±0.83	0.17±0.41	0.21±0.43	0.25±0.50	0.18±0.39	0.30±0.47	0.37±0.65	0.26±0.44*	0.58±0.63
Number of inhalers used (mean ± SD)	1.72±0.75	1.61±0.61	1.67±0.82	1.71±0.73	1.50±0.58	1.35±0.49	1.78±0.64	1.63±0.55	1.94±0.54	1.94±0.50
<2	8 (44.44)	28 (45.90)	3 (50.00)	6 (42.86)	2 (50.00)	11 (64.71)	9 (33.33)	80 (40.82)	6 (17.14)	10 (15.38)
≥2	10 (55.56)	33 (54.10)	3 (50.00)	8 (57.14)	2 (50.00)	6 (35.29)	18 (66.67)	116 (59.18)	29 (82.86)	55 (84.62)
Duration of inhaler use, months (mean ± SD)	7.44±9.81*	13.76±15.43	17.83±14.82	26.50±23.72	43.50±25.98	34.42±29.92	8.33±7.14	9.75±8.40	2.27±1.78	3.08±2.43
Inhaler-related knowledge
Correct	11 (61.11)*	12 (19.67)	5 (83.33)	8 (57.14)	4 (100.0)*	4 (23.53)	19 (70.37)*	65 (33.16)	31 (88.57)*	37 (56.92)
Incorrect	7 (38.89)	49 (80.33)	1 (16.67)	6 (42.86)	0 (0.00)	13 (76.47)	8 (29.63)	131 (66.84)	4 (11.43)	28 (43.08)

Notes: All data are presented as n (%) unless otherwise indicated. The number of acute exacerbation was investigated over the preceding 3 months.

* There was a significant distribution or difference between the pass and misuse groups (p<0.05).

Abbreviations: BMI, body mass index; MDI, metered-dose inhaler.

Table 3 Misuse rates of patients performing each step for the five inhaler types

Steps	MDI with spacer	Diskus^®	Turbuhaler^®	Respimat^®	Breezhaler^®
Assembling the inhaler
Yes	64 (81.01)	20 (100.00)	19 (98.48)	83 (37.22)	89 (89.00)
No	15 (18.99)	0 (0.00)	2 (9.52)	140 (62.78)	11 (11.00)
Holding the inhaler correctly
Yes	76 (96.20)	19 (95.00)	21 (100.00)	208 (93.27)	99 (99.00)
No	3 (3.80)	1 (5.00)	0 (0.00)	15 (6.73)	1 (1.00)
Breathing out fully
Yes	27 (34.18)	6 (30.00)	4 (19.05)	70 (31.39)	42 (42.00)
No	52 (68.82)	14 (70.00)	17 (80.95)	153 (68.61)	58 (58.00)
Sealing lips around the mouthpiece
Yes	70 (88.61)	19 (95.00)	19 (90.48)	187 (83.86)	99 (99.00)
No	9 (11.39)	1 (5.00)	2 (9.52)	36 (16.14)	1 (1.00)
Pressing down the inhaler
Yes	78 (98.73)	–	–	218 (97.76)	100 (100.00)
No	1 (1.27)	–	–	5 (2.24)	0 (0.00)
Not applicable	–	20 (100.00)	21 (100.00)	–	–
Press for the number of puffs specified
Correct	67 (84.81)	–	–	200 (89.69)	–
Incorrect	12 (15.19)	–	–	23 (10.31)	–
Not applicable	–	20 (100.00)	21 (100.00)	–	100 (100.00)
Inhalation timing
Adequate	61 (77.22)	–	–	191 (85.65)	–
Inadequate	18 (22.78)	–	–	32 (14.35)	–
Not applicable	–	20 (100.00)	21 (100.00)	–	100 (100.00)
Holding breath
Yes	48 (60.76)	13 (65.00)	11 (52.38)	130 (58.30)	71 (71.00)
No	31 (39.24)	7 (35.00)	10 (47.62)	93 (41.70)	29 (29.00)

Notes: All data are presented as the number (%) of patients undertaking the uncorrected step compared to the total number of observations. –, not applicable to the device.

Abbreviation: MDI, metered-dose inhaler.

Table 4 Logistic regression analysis of the patient characteristics associated with inhaler misuse

	MDI with spacer		Diskus^®		Turbuhaler^®		Respimat^®		Breezhaler^®
	cOR (95% CI)	aOR (95% CI)	cOR (95% CI)	aOR (95% CI)	cOR (95% CI)	aOR (95% CI)	cOR (95% CI)	aOR (95% CI)	cOR (95% CI)	aOR (95% CI)
Age	1.03 (0.98–1.09)	1.05 (0.96–1.15)	1.03 (0.93–1.13)	1.14 (0.03–48.21)	1.02 (0.92–1.12)	0.16 (<0.01–>999.9)	1.03 (0.99–1.08)	1.02 (0.96–1.08)	1.03 (0.98–1.08)	1.04 (0.97–1.11)
Female (vs male)	1.52 (0.17–13.89)	4.32 (0.20–92.88)	>999.9 (<0.01–>999.9)	10.21 (<0.01–>999.9)	>999.9 (<0.01–>999.9)	<0.01 (<0.01–>999.9)	0.68 (0.08–6.06)	0.68 (0.06–7.43)	1.08 (0.09–12.33)	0.13 (<0.01–128.95)
BMI	1.05 (0.93–1.20)	1.05 (0.89–1.25)	0.79 (0.59–1.06)	0.26 (<0.01–>999.9)	1.05 (0.79–1.40)	12.63 (<0.01–>999.9)	0.98 (0.88–1.08)	0.99 (0.88–1.12)	1.00 (0.90–1.11)	1.02 (0.89–1.15)
Educational level
Higher than junior high school (vs illiterate and elementary school)	1.09 (0.34–3.50)	1.73 (0.29–10.17)	0.38 (0.05–2.77)	>999.9 (<0.01–>999.9)	0.14 (0.01–1.68)	<0.01 (<0.01–>999.9)	1.26 (0.48–3.30)	2.03 (0.70–6.02)	1.02 (0.40–2.62)	1.22 (0.35–4.27)
Hearing
Poor (vs good)	7.74 (1.64–36.60)	9.85 (1.40–69.30)	2.78 (0.25–30.91)	>999.9 (<0.01–>999.9)	>999.9 (<0.01–>999.9)	>999.9 (<0.01–>999.9)	2.23 (0.81–6.17)	1.55 (0.49–4.88)	1.11 (0.45–2.74)	0.78 (0.21–2.97)
Eyesight
Poor (vs good)	1.32 (0.46–3.83)	0.66 (0.13–3.46)	2.50 (0.35–18.04)	>999.9 (<0.01–>999.9)	1.13 (0.13–9.94)	>999.9 (<0.01–>999.9)	1.32 (0.59–2.97)	1.30 (0.50–3.40)	1.20 (0.52–2.77)	0.90 (0.27–2.95)
Sedative agents	0.87 (0.16–4.75)	0.49 (0.07–3.69)	<0.01 (<0.01–>999.9)	<0.01 (<0.01–>999.9)	0.40 (0.03–5.96)	<0.01 (<0.01–>999.9)	1.91 (0.43–8.55)	1.30 (0.27–6.28)	1.94 (0.25–3.44)	0.800 (0.15–4.21)
Number of acute exacerbations	0.77 (0.42–1.41)	0.62 (0.26–1.48)	1.36 (0.11–16.58)	>999.99 (<0.01–>999.9)	0.64 (0.05–8.51)	<0.01 (<0.01–>999.9)	1.22 (0.59–2.52)	1.36 (0.55–3.38)	2.97 (1.27–6.85)	4.07 (1.50–11.08)
Number of inhalers used <2 (vs ≥2)	0.94 (0.33–2.71)	2.30 (0.51–10.32)	1.33 (0.20–9.08)	>999.99 (<0.01–>999.9)	0.55 (0.06–4.91)	>999.9 (<0.01–>999.9)	0.73 (0.31–1.70)	0.65 (0.25–1.68)	1.14 (0.38–3.44)	1.65 (0.37–7.43)
Duration of inhaler use (months)	1.05 (0.99–1.11)	1.03 (0.96–1.11)	1.02 (0.97–1.08)	1.65 (0.15–18.44)	0.99 (0.95–1.03)	0.77 (0.04–15.88)	1.02 (0.97–1.08)	1.02 (0.96–1.08)	1.21 (0.96–1.51)	1.33 (0.99–1.78)
Inhaler-related knowledge
Incorrect (vs correct)	6.42 (2.06–20.04)	9.58 (2.14–42.80)	3.75 (0.34–41.08)	>999.99 (<0.01–>999.9)	>999.9 (<0.01–>999.9)	>999.9 (<0.01–>999.9)	4.79 (1.99–11.51)	5.14 (2.07–12.76)	5.87 (1.86–18.55)	6.98 (1.95–25.08)

Notes: The number of acute exacerbation was investigated over the preceding 3 months. The association between the patient characteristics and misuse was calculated using a logistic regression model.

Abbreviations: BMI, body mass index; MDI, metered-dose inhaler; cOR, crude odds ratio; aOR, adjusted odds ratio; CI, confidence interval.