Asthma and chronic obstructive pulmonary disease (COPD) are common conditions among general population. The prevalence of asthma is 1% to 18% whereas COPD affects 6% of adult population [1] They are two different diseases with differences in etiology, symptoms, type of inflammation, inflammatory cells, mediators, consequences of inflammation and response to therapy, course[2].one common factor in these obstructive diseases is the fact that the most vital part of  their treatment is the route of drug administered , which is inhalational route by Metered dose inhalers[MDI] . Pressurized metered dose inhaler [pMDI] is the one of the most used MDI.  MDI provide multiple advantages as financial affordability, convenience of use , portability, quickness, local action, and negligible systemic side effects and hence increases the adherence of the patient{3} which is very vital in treatment of chronic diseases like asthma &copd. Multiple studies have brought to light that error in the technique of using MDI has compromised all these advantages. For instance pMDI require slow, deep inhalation coordinated with actuation. It is essential for the dose to be released at the same time or very soon after the patient starts inhaling – not before. Any error in these, the medicine is more likely to be deposited in the oropharynx and fail to penetrate the airways {4}. Global Initiative for Asthma (GINA) and Global Initiative for Chronic Obstructive Lung Disease (GOLD) both give significant prominence to assessing and correcting poor inhalation technique. both suggest to evaluate the technique before escalating drug therapy {5,6}. This study is done to evaluate the wrong techniques in using mdi seen in patients and correct it

considering the fact that MDI technique is not only a vital part of pharmacotherapy of the patient , but also it directly impacts adherence , quality of life & overall management of the diseases it is very crucial to assess the techniques the patient follows , correct it, thereby evaluating  the impact it has on the disease outcome\improvement . This will not only contribute to improve the management goals but also the long term improvement in the patient well being

Objectives; 1] To evaluate the technique of using pmdi in the patients using 12 steps utilization checklist by WHO {4}

                    2] Correction of the wrong technique by counseling & demonstration

Patients with asthma or COPD were included in the study. Inclusion criteria: patients above 18year with asthma or copd using pressurized metred dose inhaler as part of their treatment , willing to give consent and participate were included Exclusion criteria: patients having severe breathlessness and pregnant female’s were not included. Also patients with other respiratory illness using pMDI were excluded Written informed consent was taken from the patients with right to refuse the study. On first contact the patient will be given A placebo pMDI and asked to demonstrate how they use it. Each step in patient’s technique will be evaluated will WHO checklist with +1 for correct and 0 for wrong step. No interference will be done till the patient finishes. The patient will be now educated regarding their mistake. Counseling will include proper demonstration by taking above checklist as guideline and addressing any query the patient has. Statistical analysis: Sample size estimation was done using open epi software version 2.3.1.At 95% confidence level, and 80% power of the study the standard normal deviate for α = Zα = 1.960 .the standard normal deviate for β = Zβ = 0.84.According to the study conducted by Jolly GP {7).Proportion of Study subjects who knew proper usage of inhaler according to NIH expert panel 3 guideline at baseline =0.1%(p1).Proportion of Study subjects who knew proper usage of inhaler according to NIH expert panel 3 guideline after one intervention =23.7%(p2).Sample size estimated is 64, which is rounded off to 70. Formula used: n = (Zα/2+Zβ)2 * (p1(1-p1)+p2(1-p2)) / (p1-p2)2.

The step-wise assessment was done for all the 70patients for each of 12 steps of WHO checklist & percentage of error and correct technique was analyzed for each steps statistically.

(Table: FREQUENCIES VARIABLES=Step1 Step2 Step3 Step4 Step5 Step6 Step7 Step8 Step9 Step10 Step11 Step12)

(Table : percentage of error in each step )

After analyzing the readings it was observed 94% patients did errors only 6% did all the steps correct. As seen from the table, in our study patients step-8 was with highest percentage of error (57%) followed by step-2 (40%) & step-6,9(38.6%). All the patients did steps-1, 3, 11&12 correctly

PMDI technique is not only a vital part of pharmacotherapy of the patient, but also it directly impacts adherence, quality of life & overall management of the diseases. It is very crucial to assess the techniques the patient follows, correct it, thereby evaluating the impact it has on the disease outcome\improvement. This will not only contribute to improve the management goals but also the long term improvement in the patient well being. Patient adherence, is likely to have an additional important impact on the control of symptoms in patients(11) Global Initiative for Asthma (GINA)(5) and Global Initiative for Chronic Obstructive Lung Disease (GOLD)(6) both give significant prominence to assessing and correcting poor inhalation technique. Both suggest evaluating the technique before escalating drug therapy. Keeping this in mind we assessed the above objectives. As it’s seen above those 94% patients do errors in the methods and only 6% use it with 100% correct technique. Many errors were made in vital steps like holding breathe, check the dose, co-ordination of slowly breathing & pressing the canister at same time , placing the mouth piece between teeth. It’s important to note that all the above errors are correctable and were corrected after counseling. Evidences from randomised clinical trials have shown that patients’ inhaler technique can be improved by education from a health care professional . The amount of instruction on inhaler technique given by health care professional’s influences patients’ likelihood of correct technique(8) Active measures should be taken to improve patients' basic knowledge regarding asthma diagnosis and inhaler technique. Apart from demonstrating complete steps of use of different inhalers, verbal guidance and visual demonstration in small groups or video tutorials should also be provided to improve measures(9) . this study also imphasises on the role of drug counseling in enhancing positive outcome of the disease. Acxknowledgement : We acknowledge Rajiv Gandhi University of Health Sciences for funding this study

1.    Maheshwari P. Health related quality of life measurement in asthma and COPD. Res. J Pharm. Technol.2016; 9(5): 518-520.
2. https://pmc.ncbi.nlm.nih.gov/articles/PMC3633485/
3. Importance of inhaler devices in the management of airway disease. Virchow JC, Crompton GK, Dal Negro R, Pedersen S, Magnan A, Seidenberg J, Barnes PJ. Respir Med. 2008;102:10–19. doi: 10.1016/j.rmed.2007.07.031
4. https://extranet.who.int/ncdccs/Data/AUS_D1_Inhaler_Technique_Infopaper-FULL-UPDATED-11-1.pdf
5. Global initiative for chronic obstructive lung disease: pocket guide to COPD diagnosis, management and prevention [http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf] Accessed: 26 May 2017.
6. Global initiative for asthma: pocket guide for asthma management and prevention [http://ginasthma.org/2017-pocket-guide-for-asthma-management-and-prevention/] Accessed: 25 July 2017
7. https://www.ijcdas.com/doi/pdf/10.5005/ijcdas-57-1-17
8. Ganguly A, Das AK, Roy A, Adhikari A, Banerjee J, Sen S. Study of Proper use of Inhalational Devices by Bronchial Asthma or COPD Patients Attending a Tertiary Care Hospital. J Clin Diagn Res. 2014 Oct;8(10):HC04-7. doi: 10.7860/JCDR/2014/9457.4976. Epub 2014 Oct 20. PMID: 25478367; PMCID: PMC4253185.
9. https://www.ijrc.in/abstractArticleContentBrowse/IJRC/30896/JPJ/fu