Pharmacists’ training to improve inhaler technique of patients with COPD in Vietnam

Figures & data

Table

MDI	Turbuhaler^®
1. Remove cap	1. Remove cap
2. Shake well	2. Rotate grip until hear “click”
3. Breathe out	3. Breathe out
4. Breathe in + press canister and continue to breathe in slowly and deeply	4. Breathe in strongly and deeply
5. Hold breath for 5 seconds	5. Hold breath for 5 seconds

Table 1 Number of patients (%) who showed technique improvement in MDI usage, sorted by steps

Steps of MDI usage	T0 (n=208)	T1 (n=163)	T2 (n=163)	T3 (n=139)	T4 (n=102)
Step 1. Remove the cap	208 (100)	163 (100)	163 (100)	139 (100)	102 (100)
Step 2. Shake inhaler well	157 (75.5)	157 (96.3), p<0.001	155 (95.1), p<0.001	131 (94.2), p<0.001	96 (94.1), p=0.001
Step 3. Hold inhaler upright	192 (92.3)	159 (97.5), p=0.057	159 (97.5), p=0.057	138 (99.3), p=0.012	101 (99.0), p=0.008
Step 4. Breathe out all the way	50 (24.0)	71 (43.6), p<0.001	104 (63.8), p<0.001	88 (63.3), p<0.001	48 (47.1), p=0.002
Step 5. Place the inhaler mouthpiece between your lips (and teeth)	195 (93.8)	158 (96.9)	162 (99.4)	139 (100)	102 (100)
Step 6. Prime the inhaler just after starting a very slow and very deep breath in (until the lungs are full)	102 (49.0)	109 (66.9), p=0.003	141 (86.5), p<0.001	130 (93.5), p<0.001	75 (73.5), p<0.001
Step 7. Remove the inhaler from your mouth and hold your breath 5 seconds (or as long as possible)	156 (75.0)	159 (97.5), p<0.001	161 (98.8), p<0.001	134 (96.4), p<0.001	80 (78.4), p=0.864
Step 8. Breathe out slowly	206 (99.0)	162 (99.4)	162 (99.4)	139 (100)	102 (100)

Notes: T0, baseline; T1, after 1 month; T2, after 3 months; T3, after 6 months and T4, after 12 months. p: p-value of the McNemar’s test for comparison of percentage between time points T1, T2, T3, T4 and T0 (analyzed when appropriate).

Abbreviation: MDI, metered-dose inhaler.

Table 2 Number of patients (%) who showed technique improvement in Turbuhaler^® usage, sorted by steps

Steps of Turbuhaler usage	T0 (n=83)	T1 (n=63)	T2 (n=52)	T3 (n=42)	T4 (n=39)
Step 1. Remove mouthpiece cover	83 (100)	63 (100)	52 (100)	42 (100)	39 (100)
Step 2. Keep the inhaler upright	81 (97.6)	63 (100)	52 (100)	42 (100)	39 (100)
Step 3. Rotate the grip counter clockwise and then back until a “click” is heard	79 (95.2)	63 (100)	52 (100)	42 (100)	39 (100)
Step 4. Breathe out normally and away from mouthpiece	23 (27.7)	31 (49.2), p=0.078	33 (63.5), p<0.001	30 (71.4), p<0.001	20 (51.3), p=0.167
Step 5. Place the inhaler mouthpiece between your lips (and teeth)	81 (97.6)	63 (100)	52 (100)	42 (100)	39 (100)
Step 6. Inhale forcefully and deeply	66 (79.5)	50 (79.4), p=0.629	45 (86.5), p=0.549	36 (85.7), p=0.998	36 (92.3), p=0.016
Step 7. Hold breath for at least 5 seconds	67 (80.7)	60 (95.2), p=0.006	52 (100), p<0.001	42 (100), p=0.002	35 (89.7), p=0.344
Step 8. Exhale normally but not through inhaler	80 (96.4)	63 (100)	52 (100)	42 (100)	39 (100)

Notes: T0, baseline; T1, after 1 month; T2, after 3 months; T3, after 6 months and T4, after 12 months. p: p-value of the McNemar’s test for comparison of percentage between time points T1, T2, T3, T4 and T0 (analyzed when appropriate).

Table 3 Sociodemographic and disease-related characteristics of patients participating in the study

Characteristics
Age in years, mean (±SD)	66.6 (±8.2)
Gender, n (%)
Male	178 (84.4)
Female	33 (15.6)
Comorbidity, n (%)
Yesa	134 (63.5)
No	77 (36.5)
Education level, n (%)
Below high school	69 (32.7)
High school	75 (35.5)
Above high school	67 (31.8)
Ever a smoker, n (%)
Yes	171 (81.0)
No	40 (19.0)
Years suffering from COPD, n (%)
≤3	50 (23.7)
>3–5	42 (19.9)
>5	119 (56.4)
GOLD classification, n (%)
GOLD B	12 (5.7)
GOLD C	49 (23.2)
GOLD D	150 (71.1)
Years attending the COPD program, n (%)
<1	51 (24.2)
1–3	92 (43.6)
>3–5	56 (26.5)
>5	12 (5.7)

Notes:

a Hypertension, 25.6%; osteo-related conditions, 20.2%; gastrointestinal disorders, 10.7%; hyperlipidemia, 8.3%; diabetes type 2, 6.0%; other cardiovascular diseases/conditions, 13.7% and other minor ailments, 15.5%.

Abbreviations: GOLD, Global Initiative for Chronic Obstructive Lung Disease; SD, standard deviation.

Figure 1 Flow diagram for the time of assessing technique and dropout rates.

Figure 2 Comparison of the percentage of patients performing the correct inhaler technique over the study period.

Notes: T0, baseline; T1, after 1 month; T2, after 3 months; T3, after 6 months and T4, after 12 months. p: p-value of the McNemar’s test determined the difference in the percentage of patients who performed the correct technique (all the correct steps) between time points T1, T2, T3, T4 and T0.
Abbreviation: MDI, metered-dose inhaler.

Figure 3 Comparison of the mean technique score for MDI across the study period.

Notes: T0, baseline; T1, after 1 month; T2, after 3 months; T3, after 6 months and T4, after 12 months. p: p-value of ANOVA and post hoc tests in comparison of the score between after the training (T1, T2, T3, T4) and before training (T0).

Abbreviations: ANOVA, analysis of variance; MDI, metered-dose inhaler; SD, standard deviation.

Figure 4 Comparison of the mean technique score for Turbuhaler^® across the study period.

Notes: T0, baseline; T1, after 1 month; T2, after 3 months; T3, after 6 months and T4, after 12 months. p: p-value of ANOVA and post hoc tests in comparison of the score between T1, T2, T3, T4 and T0.
Abbreviations: ANOVA, analysis of variance; SD, standard deviation.

Table 4 Patients’ age and improvement in technique score with MDI

Time	<60 years, mean (±SD)	60–75 years, mean (±SD)	>75 years, mean (±SD)	p-value
T0	6.77 (0.94)	6.00 (1.25)	6.10 (1.96)	0.01
T1	7.19 (0.75)	6.96 (0.81)	6.85 (1.07)	0.32
T2	7.50 (0.65)	7.45 (0.71)	7.05 (1.11)	0.04
T3	7.78 (0.42)	7.41 (0.74)	7.39 (0.79)	0.07
T4	6.81 (0.91)	6.93 (0.90)	7.00 (0.91)	0.84

Notes: T0, baseline; T1, after 1 month; T2, after 3 months; T3, after 6 months and T4, after 12 months. p: p-value of the ANOVA test for comparison of mean score between age groups.

Abbreviations: ANOVA, analysis of variance; MDI, metered-dose inhaler; SD, standard deviation.

Table 5 Years of suffering from COPD and improvement in technique score with MDI

Time	≤3 years, mean (±SD)	>3–5 years, mean (±SD)	>5 years, mean (±SD)	p-value
T0	5.69 (1.50)	5.90 (1.16)	6.31 (1.22)	0.01
T1	6.97 (0.80)	6.97 (0.91)	6.99 (0.83)	0.98
T2	7.44 (0.56)	7.29 (0.86)	7.44 (0.80)	0.63
T3	7.35 (0.84)	7.26 (0.66)	7.58 (0.67)	0.08
T4	6.95 (1.02)	7.00 (0.98)	6.88 (0.83)	0.85

Notes: T0, baseline; T1, after 1 month; T2, after 3 months; T3, after 6 months and T4, after 12 months. p: p-value of the ANOVA test for comparison of mean score between groups with different periods of suffering from COPD.

Abbreviations: ANOVA, analysis of variance; MDI, metered-dose inhaler; SD, standard deviation.

Table 6 Years of attending the program and improvement in technique score with MDI

Time	<1 year, mean (±SD)	1–3 years, mean (±SD)	>3–5 years, mean (±SD)	>5 years, mean (±SD)	p-value
T0	5.65 (1.64)	6.14 (1.08)	6.30 (1.22)	6.42 (1.38)	0.04
T1	7.14 (0.83)	6.91 (0.87)	6.93 (0.77)	7.38 (0.74)	0.33
T2	7.45 (0.67)	7.30 (0.82)	7.48 (0.75)	8.00 (0.00)	0.08
T3	7.62 (0.57)	7.36 (0.78)	7.49 (0.68)	7.83 (0.41)	0.25
T4	7.10 (0.85)	6.96 (0.95)	6.78 (0.85)	6.60 (0.89)	0.54

Notes: T0, baseline; T1, after 1 month; T2, after 3 months; T3, after 6 months and T4, after 12 months. p: p-value of the ANOVA test for comparison of mean score between groups with different periods of attending the program.

Abbreviations: ANOVA, analysis of variance; MDI, metered-dose inhaler; SD, standard deviation.