Alhomoud, Farah Kais; (2014) The Use of Multiple Inhalation Devices for Chronic Obstructive Pulmonary Disease: A Study of Older Patients in Primary Care. Doctoral thesis , UCL (University College London).

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Abstract

Background Chronic obstructive pulmonary disease (COPD) is a long term condition characterised by progressive narrowing of the airways and premature ageing of the lungs. By 2020, it is estimated to be the third biggest cause of death in the UK, after heart disease and stroke. COPD imposes a large financial burden on health services and is among the most costly diseases in the UK. Inhalation therapies are central to the management of COPD; they include pressurised metered dose inhalers (pMDIs), dry powder inhalers (DPIs), and nebulisers. Although, findings from previous studies reveal suboptimal use and a wide range of problems with inhaler handling among COPD patients, very little is known about how and why problems arise. Therefore, the aim of this study was to examine how older patients made decisions regarding the use of inhalers especially when combination of inhalation devices were used at home, how those decision and difficulties contributed to suboptimal outcomes and treatment failures. Method A cross-sectional study design using semi-structured face to face interviews, observations of inhalation device users, with patients in their own homes, was conducted with 46 patients. Based on previous studies among patients with respiratory diseases, it was anticipated that the sample of 60 patients would enable us to achieve the study objectives and would be able to reach saturation level, additionally, this sample size was achievable within the time and resources of the study. Patients were recruited from Pinn Medical Centre and identified by the staff through patients’ medical notes. All COPD patients, registered at Pinn Medical Centre, and prescribed a combination of at least two different inhalation devices were invited to participate. The practice population includes patients of different ages, duration and experience of inhalation therapies, ethnicity and disease severity. The data were audio recorded for verbatim transcription. Qualitative and quantitative analysis were conducted using Nvivo and SPSS programme, respectively. The study was approved by Newcastle & North Tyneside 2 Research Ethics Proportionate Review Sub-Committee. Results 46 patients have been interviewed. Male (N=24) and female (N=22), the mean age was 77 years (63-100). Two-thirds of participants (N=31), 67%, used a combination of both pMDIs and DPIs, 10 participants (22%), used a combination of DPIs, three participants (7%) used three different kinds of inhalation devices (pMDIs, DPIs, and nebulisers), whereas the least used group was a combination of pMDIs with just two participants (4%). Differing expectations of treatment (e.g. regarding immediacy and extent of response), and preferences for different type of device were expressed. Treatment failures were of concern to patients who had experienced multiple episodes of exacerbation. The study identified factors which were potential contributors to treatment failures. These included adherence decisions which were influenced by their beliefs about inhalation therapies and concerns of side effects, especially with the long term such as steroids, and willingness to use devices in public. The study findings also revealed practical and technical issues in manipulation and cleaning the inhalation devices especially with the use of DPIs. Discussion and Conclusion Treatment failures are a major concern for COPD patients. Most patients experienced problems with inhalation devices used at home. To improve treatment, continuous education and follow up needs to be done for COPD patients in order to provide all the necessary assistance in the future tailored to each patient who is at high risk of treatment failures and/or experiencing problems.

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