Inhaler Devices in Asthma and COPD - An assessment of use and patient preferences

2013/2014 Pedro Miguel Aparício Chorão Inhaler Devices in Asthma and COPD – An assessment of use and patient preferences março, 2014 Mestrado Integrado em Medicina Área: Imunoalergologia e Pneumologia Trabalho efetuado sob a Orientação de: Doutor João Almeida Lopes Fonseca Trabalho organizado de acordo com as normas da revista: Respiratory Medicine Pedro Miguel Aparício Chorão Inhaler Devices in Asthma and COPD – An assessment of use and patient preferences março, 2014 Projeto de Opção do 6º ano - DECLARAÇÃO DE INTEGRIDADE Eu, Pedro Miguel Aparício Chorão, abaixo assinado, nº mecanográfico 200807713, estudante do 6º ano do Ciclo de Estudos Integrado em Medicina, na Faculdade de Medicina da Universidade do Porto, declaro ter atuado com absoluta integridade na elaboração deste projeto de opção. Neste sentido, confirmo que NÃO incorri em plágio (ato pelo qual um indivíduo, mesmo por omissão, assume a autoria de um determinado trabalho intelectual, ou partes dele). Mais declaro que todas as frases que retirei de trabalhos anteriores pertencentes a outros autores, foram referenciadas, ou redigidas com novas palavras, tendo colocado, neste caso, a citação da fonte bibliográfica. Faculdade de Medicina da Universidade do Porto, 13/03/2014 Assinatura conforme cartão de identificação: Projecto de Opção do 6º ano – DECLARAÇÃO DE REPRODUÇÃO NOME Pedro Miguel Aparício Chorão CARTÃO DE CIDADÃO OU PASSAPORTE (se estrangeiro) E-MAIL TELEFONE OU TELEMÓVEL 13732086 [email protected] 00 351 916 676 075 NÚMERO DE ESTUDANTE DATA DE CONCLUSÃO 200807713 Março de 2014 DESIGNAÇÃO DA ÁREA DO PROJECTO Imunoalergologia e Pneumologia TÍTULO DISSERTAÇÃO Inhaler Devices in Asthma and COPD – An assessment of use and patient preferences ORIENTADOR Doutor João Almeida Lopes Fonseca COORIENTADOR (se aplicável) - É autorizada a reprodução integral desta Dissertação para efeitos de investigação e de divulgação pedagógica, em programas e projectos coordenados pela FMUP. Faculdade de Medicina da Universidade do Porto, 13/03/2014 Assinatura conforme cartão de identificação: Aos meus pais. À minha irmã. 1 INHALER DEVICES IN ASTHMA AND COPD – AN ASSESSMENT OF USE AND PATIENT PREFERENCES Authors Author 1: Pedro Chorão. Affiliations: Faculdade de Medicina da Universidade do Porto, Porto, Portugal. Author 2: Ana M Pereira. Affiliations: CIDES – Centro de Investigação em Tecnologias e Sistemas de Informação, Faculdade de Medicina da Universidade do Porto, Porto, Portugal; Unidades de Imunoalergologia CUF Porto, Porto, Portugal and Serviço de Imunoalergologia, Centro Hospitalar São João, Porto, Portugal. Author 3 (corresponding author): João A Fonseca. Affiliations: CIDES – Centro de Investigação em Tecnologias e Sistemas de Informação & CINTESIS, Faculdade de Medicina da Universidade do Porto, Porto, Portugal and Unidades de Imunoalergologia, CUF Porto, Porto, Portugal Address: Faculdade de Medicina da Universidade do Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal. Telephone: +351 914 767 661 Fax: +351 225 513 623 Email: [email protected] 2 Abstract Background: Incorrect use of inhaler devices remains an obstacle for respiratory diseases management. We aimed to evaluate the frequency of inhaler technique errors; to determine the devices perceived as the easiest and favourite to use; to study the association of device type, demographics and patient preferences with inhaler technique (IT). Methods: Cross-sectional assessment of 301 adults, with asthma (194) or chronic pulmonary obstructive disease, undergoing treatment with Aerolizer®, Autohaler®, Breezehaler®, Diskus®, Handihaler®, MDI without spacer, Miat-haler®, Novolizer®, Respimat® and/or Turbohaler®. Patients completed self-assessment questionnaires and face-to-face interview, with demonstration of inhaler technique. The rate of wrong steps (number of wrong steps ÷ number of total steps; RWS) was the primary outcome. Adjusted odds ratio (aOR) (95% confidence intervals [CI]) for presenting ≥1 IT errors were computed. Results: From the 464 inhaler technique performances, the median RWS was 18%. Turbohaler® (21%) and Diskus® (19%) were chosen as easiest and Novolizer® (18%), Diskus® (18%), Turbohaler® (17%) as favourite for daily use. Females (aOR 2.68 [95% CI 1.55-4.65]; vs. males] and patients with >64 yr. (aOR 2.73 [95% CI 1.15-6.48]; vs <45 yr.) were more likely to perform IT errors; otherwise, no association was found, including with using the favourite device (aOR 1.43 [95% CI 0.84-2.42]). Conclusion: The frequency of inhaler technique errors was high and no device was clearly preferred over the others. Using the preferred inhaler device was not associated with less errors. Keywords: Asthma, COPD, inhaler device, inhaler technique, patient preference 3 Introduction Inhaled therapy is the cornerstone in the management of asthma and chronic obstructive pulmonary disease (COPD). There are two main groups of inhaler devices: metered dose inhalers (MDI) and dry powder inhalers (DPI). Many devices have been developed and each has specificities on how to prepare the dose and deliver the drug to the airways. Although different devices have technological improvements to airway drug delivery, important limitations remain.1 In fact, decades after the introduction of inhaler devices, their incorrect use remains an obstacle to achieve optimal disease outcomes.2 The correct use of inhaler devices is one of the most important aspects to be taken into account when evaluating individuals with asthma or COPD, and guidelines3, 4 emphasize the importance of assessing inhaler technique to improve the efficiency of drug delivery. Furthermore, it is recognized that inadequate use of inhaler devices is one of the most common reasons for failure to achieve asthma control.3 A recent review reports a high percentage of inhaler technique errors, but with great variability among studies.5 To understand how to improve the use of inhalers, different aspects have been studied, such as types of devices;2, 6-9 patient factors (age, gender, education);2, 8, 10, 11 and patient preferences.7, 12 Yet, research results regarding the interaction between patient, device and technique are insufficient and inconsistent. The aims of this study are: 1) to evaluate the frequency of errors in the inhaler technique of asthma and COPD patients; 2) to determine which inhaler device is perceived as the easiest and which is considered the favourite for daily use; 3) to study the association of device type, demographic characteristics and patient preference variables with inhaler technique. Material and Methods Study design and participants This was a cross-sectional observational study, carried out in the Allergology and Pneumology outpatient clinics of the Centro Hospitalar São João, a tertiary university hospital in Porto, Portugal, from April to August 2013. Adult patients attending the outpatient clinics were invited to participate and were included if they had a medical diagnosis of asthma or COPD and were currently using an inhaler device. In this study, we assessed the most commonly used devices 4 from those available in Portugal: Aerolizer®, Autohaler®, Breezehaler®, Diskus®, Handihaler®, MDI without spacer, Miat-haler®, Novolizer®, Respimat® and Turbohaler®. Patients using different inhaler devices or those who were unable to read and/or write were excluded. This study was conducted according to the principles of the Helsinki Declaration. Written informed consent was obtained from all participants. The study procedures were approved by the Ethics Committee of Centro Hospitalar São João. We have followed STROBE recommendations for reporting observational studies.13 Instruments and Data collection Data were collected using a structured written questionnaire (filled autonomously by the patient) and a face-to-face interview. First, the participant answered a questionnaire which evaluated the self-perception on his/her inhaler technique (“I perform correctly the technique of my inhaler”), satisfaction with the inhaler device, including comfort with public use (“I feel satisfied with my inhaler” and “I feel comfortable using my inhaler in public”) and the perception on how his/her preferences were taken into account at the time of inhaler‟s prescription (“I feel that my physician took into account my opinion and preferences when choosing my inhaler”). These questions were answered using Visual Analogic Scales (VAS), ranging from 0 (worst) to 100 (best) millimetres. On a second phase, each participant was asked to demonstrate the usual inhaler technique he/she followed with his/her current device(s), using a placebo inhaler. The inhaler technique for each device was evaluated using checklists based on the manufacturers‟ instructions available in the Portuguese drug agency database.14 Summarized lists of the recommended inhaler steps for each device are presented in Supplementary Tables 1, 2 and 3. The interviewer registered if each step was performed properly and in an adequate order. On a third phase, the interviewer explained the adequate inhaler technique for the participant‟s device(s) and demonstrated how to use the remainder inhalers. After the explanation and demonstration of use, each participant had the opportunity to test the available inhalers by him/herself. Finally, each participant was asked to elect the device perceived as the easiest and the one they would prefer for daily use; the reason(s) underlying the choice of the inhaler for daily use were inquired through an open question. 11 Lenney et al7 previously reported that prescribing the preferred device to the patient might improve inhaler technique. In that study, the authors recruited patients referred for inhaler assessment and evaluated inhaler technique for all the devices immediately after giving verbal instruction and demonstrating their use. In our study, data does not support an association between using the preferred inhaler device and the correctness of inhaler technique. However, we invited participants with different backgrounds of inhaler use from an outpatient clinic and inhaler technique was assessed prior to any demonstration from the interviewer, which represents a more reliable approach to a real-life clinical setting. In conclusion, incorrect inhaler technique is frequent, especially in older patients and female patients. No inhaler device had a significant lower rate of wrong steps or was clearly preferred by the majority of the patients. Our data suggests that prescribing the patient‟s preferred inhaler is not associated with a better inhalation technique. Acknowledgments We thank all the physicians, nurses and technicians from the Allergology and Pneumology outpatient clinics of the Centro Hospitalar São João that cooperated with the patient selection and recruitment. Conflict of interests Pedro Chorão and Ana M Pereira have no conflicts of interest to declare. João A Fonseca declares having received lecture fees from AstraZeneca, Novartis and GlaxoSmithKline; and participating in advisory boards of Novartis. 12 References 1. Virchow JC, Crompton GK, Dal Negro R, Pedersen S, Magnan A, Seidenberg J, et al. Importance of inhaler devices in the management of airway disease. Respiratory Medicine. 2008;102(1):10-9. 2. Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med 2011;105:930-8. 3. Global Strategy for Asthma Management and Prevention. Global initiative for asthma (gina). 2012; Available at http://www.ginasthma.org/. Accessed October 2013. 4. Global Strategy for the Diagnosis Management and Prevention of COPD. Global initiative for chronic obstructive lung disease (gold). 2014; Available at http://www.goldcopd.org/. Accessed February 2014. 5. Sanchis J, Corrigan C, Levy ML, Viejo JL. Inhaler devices - from theory to practice. Respir Med 2013;107:495-502. 6. Khassawneh BY, Al-Ali MK, Alzoubi KH, Batarseh MZ, Al-Safi SA, Sharara AM, et al. Handling of inhaler devices in actual pulmonary practice: Metered-dose inhaler versus dry powder inhalers. Respir Care 2008;53:324-8. 7. Lenney J, Innes JA, Crompton GK. Inappropriate inhaler use: Assessment of use and patient preference of seven inhalation devices. Edici. Respir Med 2000;94:496-500. 8. Wieshammer S, Dreyhaupt J. Dry powder inhalers: Which factors determine the frequency of handling errors? Respiration 2008;75:18-25. 9. van der Palen J, Klein JJ, van Herwaarden CL, Zielhuis GA, Seydel ER. Multiple inhalers confuse asthma patients. Eur Respir J 1999;14:1034-7. 10. Hashmi A, Soomro JA, Memon A, Soomro TK. Incorrect inhaler technique compromising quality of life of asthmatic patients. J Medicine 2012;13:16-21. 11. Fayas S, Estivals M, Gontier B, Têtu L, Rafalimanana G, Didier A. Facteurs déterminants la qualité de la prise des traitements inhalés dans l‟asthme. Rev Fr Allergol Immunol Clin 2003;43:364-8. 12. Ronmark E, Jogi R, Lindqvist A, Haugen T, Meren M, Loit HM, et al. Correct use of three powder inhalers: Comparison between diskus, turbuhaler, and easyhaler. J Asthma 2005;42:173-8. 13 13. Vandenbroucke JP, von Elm E, Altman DG, Gotzsche PC, Mulrow CD, Pocock SJ, et al. Strengthening the reporting of observational studies in epidemiology (strobe): Explanation and elaboration. PLoS Med 2007;4:e297. 14. Infarmed – Autoridade Nacional do Medicamento e Produtos de Saúde I.P. Informed – drugs for human use database. Available at http://www.infarmed.pt/infomed/inicio.php. Accessed February 2013. 15. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002;19:246-51. 16. Press VG, Arora VM, Shah LM, Lewis SL, Charbeneau J, Naureckas ET, et al. Teaching the use of respiratory inhalers to hospitalized patients with asthma or copd: A randomized trial. J Gen Intern Med 2012;27:1317-25. 17. The Cambridge Consortium. Evaluation of inhaler technique improvement project. 2012; Available at http://wessexhiecpartnership.org.uk/wires/knowledge-resources/inhaler-technique-theinhaler-technique-improvement-project/. Accessed February 2014. 18. Dolovich MB, Ahrens RC, Hess DR, Anderson P, Dhand R, Rau JL, et al. Device selection and outcomes of aerosol therapy: Evidence-based guidelines: American college of chest physicians/american college of asthma, allergy, and immunology. Chest 2005;127:335-71. 19. Temprano J, Mannino DM. The effect of sex on asthma control from the national asthma survey. J Allergy Clin Immunol 2009;123:854-60. 20. Lopez Varela MV, Montes de Oca M, Halbert RJ, Muino A, Perez-Padilla R, Talamo C, et al. Sex-related differences in copd in five latin american cities: The platino study. Eur Respir J 2010;36:1034-41. 21. Kickbusch I, Pelikan JM, Apfel F, Tsouros AD. Health literacy – the solid facts. World health organization regional office for europe. 2013; Available at http://www.euro.who.int. Accessed December 2013. 14 Tables Table 1 – Participants diagnosis, demographics and number of different inhalers used (n=301). n % Diagnosis Asthma 194 64 COPD 107 36 Gender (females) 181 60 Age (mean, SD) 53 17 < 45 90 30 45-64 132 44 >64 79 26 School years 1-4 138 46 5-9 67 22 10-12 62 21 > 12 34 11 1166 55 2108 36 ≥3 27 9 Number of current different inhalers All 301 15 Table 2 – Devices used, perception of correct technique and satisfaction with current inhaler (n=464). Footnote: *Visual analogic scale, range 0-100(best). n % P50 (P25-P75) P50 (P25-P75) Turbohaler 128 27 86 (74-97) 79 (74-97) Diskus 90 19 95 (74-97) 90 (74-97) Handihaler 77 17 96 (75-97) 93 (74-97) Aerolizer 64 14 96 (75-97) 93 (75-97) MDI 54 12 92 (74-97) 92 (74-97) Respimat 18 497 (76-97) 95 (74-98) Novolizer 12 378 (74-97) 74 (50-94) Breezehaler 11 296 (85-98) 96 (78-97) Miat-haler 8 2 59 (12-97) 62 (8-75) Autohaler 2 <1 62 (49-74) 50 (49-50) Devices (n=464) Frequency of use Self-evaluation of correct technique* Satisfaction with current device* 16 Table 3 – Motives stated by participants for choosing a device as favourite for daily use, sorted by preference for daily use (see figure 2). Footnote: The reasons stated by the participants were grouped according to its general type: 'Practical' includes 'practical' and 'fast to use'; 'Physic Characterist.' includes 'colour control window' (only for Novolizer), 'small size', 'hygienic', 'dosage counter', 'design' and 'discretion'. n % n % n % n % Novolizer 1 1 5 8 6 9 54 82 Diskus 14 21 19 29 25 38 812 Turbohaler 27 44 914 15 24 11 18 MDI 9 21 18 41 14 31 3 7 Autohaler 1 4 18 67 622 2 7 Breezehaler 2 7 6 21 517 16 55 Aerolizer 5 23 941 627 2 9 Handihaler 5 26 421 737 316 Respimat 2 10 421 737 632 Miat-haler 2 100 18% 26% 26% 30% Accustomed to Easy Practical Physic Characterist. 17 Table 4 – Odds ratio (OR) from univariate (crude) and multivariate (adjusted) logistic regression analysis for the presence of at least one error in the inhaler technique. Footnote: NI - Not included Diagnosis Asthma 1.02 (0.62-1.66) COPD Reference NI Male Reference Reference Female 2.01 (1.23-3.29) 2.68 (1.55-4.65) <45 Reference Reference 45-64 2.18 (1.23-3.86) 2.29 (1.11-4.75) >64 2.13 (1.12-4.06) 2.73 (1.15-6.48) 1-4 Reference Reference 5-9 1.80 (0.86-3.76) 3.11 (1.31-7.37) 10-12 0.75 (0.40-1.40) 1.27 (0.57-2.86) > 12 0.58 (0.28-1.21) 0.87 (0.36-2.09) 1 Reference NI >1 1.80 (1.10-2.94) Inhaler device Aerolizer 3.46 (1.27-9.42) 3.24 (1.13-9.32) Diskus 1.36 (0.69-2.68) 1.51 (0.73-3.11) Handihaler 3.47 (1.37-8.79) 3.71 (1.38-10.02) MDI 1.47 (0.64-3.35) 1.07 (0.45-2.57) Other 0.86 (0.40-1.82) 0.97 (0.43-2.18) Turbohaler Reference Reference Time of inhaler use (years) <1 Reference NI 1 to 5 1.36 (0.73-2.53) >5 1.28 (0.65-2.53) Yes Reference NI No 1.26 (0.77-2.08) Yes Reference NI No 1.43 (0.84-2.42) Crude OR (95% CI) Adjusted OR (95% CI) Already using the favourite device Number of diferent devices School years Gender Age groups (years) Already using the easiest device 18 Figures Figure 1 – Percentage of participants with flawless inhaler technique performances (diamonds) and distribution of rate of wrong steps (boxes and whiskers). Footnote: Percentage of users with flawless inhaler technique performances is represented by the diamond symbol. Distribution of the rate of wrong steps (number of wrong steps ÷ total number of steps; RWS) for the more frequently used devices. Box represents 25-75 percentiles and rectangle box the median. Whiskers represent 5 and 95 percentiles. Pearson Chi-Square test was used to test for statistical significant differences in the percentage of flawless inhaler technique executions and Mann-Whittney U test was performed to test for statistically significant differences in the RWS. * p=0.006 for Turbohaler vs Handihaler. ¥ p=0.011 for Turbohaler vs Aerolizer. † p=0.001 for Turbohaler vs Handihaler. ‡ p=0.020 for Turbohaler vs Aerolizer. # p=0.015 for Turbohaler vs MDI. § p=0.038 for Diskus vs Handihaler. 19 Figure 2 – Percentage of patients reporting each device as the preferred, considering the easiest (left panel) and the favourite for daily use (right panel) devices, n=301 patient. 20 AGRADECIMENTOS Agradeço: Ao Professor Doutor João Almeida Lopes Fonseca, orientador desta Tese, pelo incondicional apoio concedido, pelo constante incentivo, pela disponibilidade para a leitura do que se ia escrevendo e pelos reparos construtivos feitos ao longo deste trabalho; À Dr.a Ana Margarida Pereira, agradeço a ajuda preciosa e a disponibilidade constante para apaziguar algumas das preocupações que um trabalho como este naturalmente suscita; Aos médicos do Serviço de Imunoalergologia e de Pneumologia do Centro Hospitalar São João, EPE, por me terem proporcionado as condições que permitiram a elaboração da presente Dissertação; Aos enfermeiros e técnicos do Serviço de Imunoalergologia e de Pneumologia do Centro Hospitalar São João, EPE, pelo acolhimento e por todo o apoio necessário ao desenvolvimento deste trabalho; A todos aqueles que, com o seu estímulo, dedicação, amizade e paciência, tornaram possível a concretização deste projeto. 27 Abstract An abstract of your manuscript summarizing the content, at a maximum of 250 words, should be provided as a separate submission item. 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Remove the protective cover 2.0 Prepare the dose 2 3 2.1 Open the inhaler 2.2 Insert the capsule and close 2 3 2.3 Perfurate the capsule once and release the lateral trigger(s) 19 30 436 27 35 2.4 Mouthpiece oriented upwards 3.0 Exhale as much as confortably possible 31 48 218 32 42 3.1 Do not exhale into the mouthpiece 11 17 327 12 16 4.0 Inhale rapid and forcefully 21 33 218 20 26 4.1 Inhale only through the mouth 1 9 1 1 4.2 Close the lips around the mouthpiece 4.3 Do not cover the air entrance holes 7 11 327 NA NA 5. Apnoea after inhalation 23 36 218 11 14 Hold breath at least 10 seconds 20 31 327 39 51 6. Exhale naturally 1 1 6.1 Do not exhale into the mouthpiece 2 3 6 8 7. Repeat steps 3 through 6 NA NA NA NA 31 40 8. Open the inhaler and check if there is any medication left in the capsule 11 17 21 27 Aerolizer Breezehaler Handihaler 64 11 77 Footnote: NA – Not applicable. Blank spaces represent steps with no errors observed. Error in step 2.3 was considered when patient primed the lateral trigger more than once. Only 2 patients using Handihaler failed to perform step 2.3. For step 5. the apnoea period was evaluated and two types of error were considered (holding breath for less than 10 seconds and expelling air immediately). Supplementary Table 1 – Evaluation of technique errors in Aerolizer®, Breezehaler® and Handihaler®. 32 n % n % n % n % 1. Open the inhaler 2. Prepare the dose 5 63 13 19 3.0 Exhale as much as confortably possible 27 30 338 1 8 36 28 3.1 Do not exhale into the mouthpiece 24 27 113 217 28 22 4.0 Inhale rapid and forcefully 26 29 563 217 24 19 4.1 Inhale only through the mouth 3 2 4.2 Close the lips around the mouthpiece 1 1 1 13 1 8 1 1 5. Apnoea after inhalation 14 16 338 217 19 15 Hold breath at least 10 seconds 37 41 338 542 46 36 6. Exhale naturally 3 2 6.1 Do not exhale into the mouthpiece 9 10 10 8 Diskus Miat-haler Novolizer Turbohaler (n=90) (n=8) (n=12) (n=128) Footnote: NA – Not applicable. Blank spaces represent steps with no errors observed. In Diskus dose preparation was evaluated by pulling down the trigger, in Novolizer by the colour change in the indicator, in Miat-haler by pressing the lid fully down and then upwards and in Turbohaler by full rotation and counter-rotation. In Novolizer, rapid and forcefully inhalation was evaluated by the colour change in the indicator. For step 5. the apnoea period was evaluated and two types of error were considered (holding breath for less than 10 seconds and expelling air immediately). Supplementary Table 2 – Evaluation of technique errors in Diskus®, Miat-haler®, Novolizer® and Turbohaler®. 33 n % n % n % 1. Prepare the dose (Autohaler: Step 2) NA NA 2. Remove the protective cover 3. Shake the inhaler 20 37 NA NA NA NA 4. Exhale as much as confortably possible 19 35 844 5.0 Inhale slow and deeply 2 4 5.1 Coordinate the beggining of the inhalation with the firing of the inhaler 5 9 NA NA 422 5.2 Continue to inhale after firing the inhaler 13 24 528 5.3 Inhale only through the mouth 3 6 5.4 Close the lips around the mouthpiece 1 2 5.5 Hold the inhaler upright (MDI/Autohaler) or horizontally (Respimat) 1 2 5.6 Do not cover the air entrance holes NA NA NA NA 528 6. Apnoea after inhalation 6 11 528 Hold breath at least 10 seconds 34 63 150 739 MDI Autohaler Respimat 54 2 18 Footnote: NA – Not applicable. Blank spaces represent steps with no errors observed. In Autohaler preparing the dose consisted in placing the valve upwards with the inhaler held upright and in Respimat rotating the base 180º degrees. For step 5. the apnoea period was evaluated and two types of error were considered (holding breath for less than 10 seconds and expelling air immediately). Supplementary Table 3 - Evaluation of technique errors in MDI without spacer, Autohaler® and Respimat®. 34 Questionário Questionário Número:_______ Data:___/___/_____ Dados sociodemográficos: Sexo:  Feminino  Masculino Idade:____ Escolaridade:___________________ Dados relativos à doença:  Diagnóstico:______________________________________________________________________ Número Inalador Tempo de Utilização Actual      Inquérito 1 As seguintes perguntas pretendem saber a sua opinião relativamente à parte prática da utilização do seu inalador (se a técnica é fácil ou difícil) e ao seu aspecto físico (como, por exemplo, a forma ou o tamanho). Nenhuma pergunta se refere ao efeito que o medicamento (que se encontra dentro do inalador) tem nos seus pulmões e o que sente após a sua utilização. Uso correctamente a técnica do meu inalador: Inalador:_______ Sinto-me satisfeito com o meu inalador: Uso correctamente a técnica do meu inalador: Inalador:_______ Sinto-me satisfeito com o meu inalador: Totalmente Incorrecto Totalmente Correcto Totalmente Insatisfeito Totalmente Satisfeito Totalmente Incorrecto Totalmente Correcto Totalmente Insatisfeito Totalmente Satisfeito 35 Questionário Número:_______ Data:___/___/_____ Uso correctamente a técnica do meu inalador: Inalador:_______ Sinto-me satisfeito com o meu inalador: Inquérito 2 Senti que o médico teve em conta a minha opinião e preferências na escolha do meu inalador: Sinto-me confortável em usar o meu inalador em público: Pós Intervenção: De todos os inaladores observados:  Mais fácil de usar no dia a dia:________________________________________________________  Caso pudesse tomar a medicação em qualquer dispositivo, qual escolheria:____________________ o Motivos:____________________________________________________________________ Não teve nada em conta Teve tudo em conta Completamente à vontade Nunca usaria em público Totalmente Incorrecto Totalmente Correcto Totalmente Insatisfeito Totalmente Satisfeito 36 Listas de Verificação da Técnica dos Dispositivos Inalatórios DPI – Aerolizer Asmatec [UCB Pharma], Foradil [Novartis Farma], Formeterol Generis [Generis], Formeterol Winthrop [Winthrop], Miflonide [Novartis Pharma] Correto Parcialmente Incorreto Incorreto Não realizado Passos  --- ---  1. Remover a tampa protetora Comentário:     2. Preparar a dose Abrir o inalador Colocar a cápsula e fechar Perfurar a cápsula 1 vez e libertar os botões laterais Bocal orientado para cima Comentário:    --- 3. Expirar até onde for confortável Não expirar para o bocal Comentário:    --- 4. Inspirar rápido e profundamente Inalar pela boca apenas Cerrar os lábios em volta do bocal Não ocluir os orifícios de entrada de ar Comentário:  ---   5. Suster a respiração durante 10 segundos Comentário:    --- 6. Expirar normalmente Não expirar para o bocal Comentário:  --- ---  7. Abrir o inalador e verificar se há fármaco na cápsula Comentário: 43 DPI – Novolizer Inaladores: Budenosido Novolizer [Meda Pharma], Formeterol Novolizer [Meda Pharma] Correto Parcialmente Incorreto Incorreto Não realiz. Passos  --- ---  1. Remover a tampa protetora Comentário:  ---   2. Preparar a dose (cor do indicador muda para verde) Comentário:    --- 3. Expirar até onde for confortável Não expirar para o bocal Comentário:    --- 4. Inspirar rápido e profundamente Inalar pela boca apenas Cerrar os lábios em volta do bocal Comentário:  ---   5. Suster a respiração durante 10 segundos Comentário:    --- 6. Expirar normalmente Não expirar para o bocal Comentário: 44 MDI – Respimat Inaladores: Spiriva Respimat [Boehringer Ingelheim] Correto Parcialmente Incorreto Incorreto Não realiz. Passos  --- ---  1. Preparar a dose (rotação da base do inalador) Comentário:  --- ---  2. Abrir a tampa de proteção  ---  --- 3. Expirar até onde for confortável Comentário:    --- 4. Inalar a dose lenta e profundamente Coordenar libertação da dose com início da inspiração Continuar a inspiração após libertação da dose Inalar pela boca apenas Cerrar os lábios em volta do bocal Dispositivo na horizontal Não ocluir os orifícios de entrada de ar Comentário:  ---   5. Suster a respiração durante 10 segundos Comentário: 45 DPI – Turbohaler Inaladores: Assimie Turbohaler [Tecnifar], Bricanyl Turbohaler [AstraZeneca], Oxis Turbohaler AstraZeneca], Pulmicort Turbohaler [AstraZeneca], Symbicort Turbohaler [AstraZeneca] Correto Parcialmente Incorreto Incorreto Não realiz. Passos  --- ---  1. Remover a tampa protetora Comentário:  ---   2. Preparar a dose (rotação e contra-rotação) Comentário:    --- 3. Expirar até onde for confortável Não expirar para o bocal Comentário:    --- 4. Inspirar rápido e profundamente Inalar pela boca apenas Cerrar os lábios em volta do bocal Comentário:  ---   5. Suster a respiração durante 10 segundos Comentário:    --- 6. Expirar normalmente Não expirar para o bocal Comentário: