Although correct inhaler utilization is extremely important in reducing complaints that can be experienced by COPD patients, many studies have revealed that a lot of patients misuse inhalers [8–10, 18]. In this study, similar to the literature, it was found that patients made a lot of errors in all types of inhaler. As a result of the failure of effective expiration before using the drug which is the leading cause of the errors, drug particles cannot find the opportunity to be stored in the airways [19]. Göriş et al [9] and Özel et al [18] reported in their studies in that expiration was not performed before using the drug. In addition, the drug must be inhaled at appropriate flow rate in order for the drug particles to reach the airways in the periphery [19]. Takaku et al [10] revealed in their studies in 2017 that the flow rate of the drugs was not appropriate. Similar to the literature, in this study, it was found that patients did not expire before inhaler utilization and were not able to inhale at the appropriate flow rate.
Keeping the drug by holding breath for a certain period of time after the application of the drug is an important step that must be done for sedimentation of the drug particles in the airways. This time is suggested to be approximately 10 seconds [20]. In this study, it was observed that the patients did not pay attention to this step at the first follow-up, but they kept breath for a suitable period after training.
When the differences in scores are examined according to the inhaler types used by the patients it was observed that the lowest score difference in I1 group was in the handihaler group (Table 3). It is thought that this is due to the fact that the patients made errors in the steps related to breath most during the first follow-up and the breathing exercises given to the I1 group were effective. In addition, it has been supported by many studies that handihaler, which is dry powder inhaler type, provides easier use compared to other inhaler types [9, 10, 18]. According to the first follow-up comparison test in Table 3, the groups are similar in terms of the inhaler types used (p>0.05). In the same way, the fact that I1 and I2 group difference comparison test was not significant in all inhaler types means that the trainings given were similar (p>0.05).
It has been reported in the literature that breathing exercises can increase the volume that patients will inhale before inhaler drug use [19]. In particular, it has been reported that PLB will reduce dyspnea and the number of breath per minute, provide ventilation efficiency so that inhaler drugs will perform better [11]. In this study, the patients in the I1 group were asked to apply PLB at least twice a day for 10 minutes. Initially, only a few of the patients who did not have any knowledge of breathing exercise were seen to try to give their breath as if they were whistling when their symptoms increased with their own effort, but it was understood that they could not perform the application correctly. It was determined at the end of the training that PLB was learned. It has been reported in the literature that PLB exercise provides various benefits for patients with COPD. Decrease in severity of dyspnea and the number of ventilation per minute and increase in oxygen saturation and exercise capacity are among these benefits [13, 21]. In this study, it was observed that patients in I1 group who were taught PLB had superiority over CAT (p=.002) and mMRC dyspnea severity (p=.040) compared to I2 group (Table 4).
While the symptoms caused by COPD affect daily work of an individual, it also determines the perception of the disease on the individual. Problems created by COPD in patients were evaluated with CAT. It was found that the CAT score of both groups decreased and the results were significant (p<0.001). When the score differences between the groups were examined, the greater effect in the I1 group reveals that breathing exercise applied in addition to inhaler training contributed positively to COPD assessment (Table 4). Similarly, in the literature [22, 23], in studies involving inhaler training and breathing exercises given to patients with COPD it was reported that the total CAT score of the intervention group patients decreased and the result was significant compared to the control group (p<0.05).
The effect of trainings on dyspnea severity of patients was evaluated by mMRC scale. Accordingly, it was revealed that the trainings given were effective in I1 group (p<0.001) and I2 group (p=.001). According to the score differences between the groups, the effect in the I1 group was higher and it was found that breathing exercise applied in addition to inhaler training contributed positively to perception of dyspnea (Table 4). In the literature [5, 9, 11, 22, 24, 25], many studies reporting that the training given to patients with COPD contributed positively to the severity of dyspnea supports the results of this study.
Airway obstruction and accompanying symptoms in COPD have a negative effect on the quality of life [5, 6]. In the study, the effect of the training given to the patients on the quality of life was examined and it was seen that there were improvements in both groups in the sub-dimensions and overall score of the quality of life scale at the last follow-up compared to the first follow-up. Reporting in the studies conducted with COPD patients that the given trainings improve the quality of life [5, 9, 25–27] is similar to the quality of life findings of this study.
In the study, quality of life did not make any difference in terms of trainings given to I1 and I2 groups. It is an expected situation according to the literature that PLB exercise given to the I1 group, unlike I2 group, creates significance in terms of quality of life [3, 5, 9]. In the study conducted by Doğan [23] within the planned training given to the patients with COPD, it was reported that after the PLB training, the scores of sub-dimensions of quality of life scale and total scale score of the intervention group decreased and quality of life increased. Similarly, in this study, it was seen that total quality of life score of I1 group which included patients given PLB training was better compared to I2 group. However, there was no statistical significance between the two groups in terms of the quality of life scale (Table 5). Some features of the I2 group in the study were thought to affect this significance. Especially, the longer time of diagnosis of I2 group shows that the patients adapt better to COPD. Studies have reported that as the time of diagnosis increases, learning to live with the disease can be positively affected [9, 28]. In addition, the statements of the patients in the I2 group that they received more inhaler training when they were first diagnosed, stayed less in the hospital in the last year and their stay was shorter, and they experienced less symptoms such as shortness of breath, fatigue, and insomnia, are the factors that may cause difference between the two groups. The increase in shortness of breath, which is one of the important symptoms of COPD, brings with it the symptoms of insomnia and fatigue. These symptoms affecting the patient significantly decrease the quality of life [2, 6, 29].
The feeling of shortness of breath, in particular, is an important factor that affects the daily routine and care actions of an individual, ultimately decreasing their quality of life. In his study, Demir et al [3] examined the relationship between dyspnea and quality of life and reported that the quality of life decreased as the severity of dyspnea increased. In their systematic review Geddes et al [30] reported that the quality of life will increase with the decrease in the severity of dyspnea in COPD patients, but more detailed studies are needed to provide evidence-level thesis. In this study, the fact that the dyspnea level of the patients was found to be high and quality of life was low showed similarity with the literature.