- Email: [email protected]
Physician's Metered Dose Inhaler Technique After a Single Teaching Session
Physicians’ metered dose inhaler technique after a single teaching session David J Resnick, MD; Ruth L Gold, MD; Mary Lee-Wong, MD; B Robert Feldman, MD; Rajasekhar Ramakrishnan, ScD; and William J Davis, MD
Background: It is known that many housestaff physicians are unable to demonstrate perfect metered dose inhaler (MDI) technique. Objective: This study assessed whether a single teaching session for house staff physicians would significantly improve their MDI technique. Methods: Thirty-eight pediatric house staff physicians were asked to demonstrate MDI technique with a placebo MDI. The physicians were evaluated on the following seven steps: (1) shaking the MDI and removing the cap, (2) exhaling prior to MDI use, (3) holding the MDI upright, (4) proper timing of actuation, (5) a slow inspiratory effort, (6) one MDI actuation per breath, and (7) holding the breath ⱖ 5 seconds. A 20-minute teaching session and demonstration of proper MDI technique was then given. At the end of this session all residents were eventually able to demonstrate proper technique. Two months following this educational session the same house staff physicians were re-evaluated on their MDI technique. Results: Initially, ten participants (26%) demonstrated perfect technique. Two months postinstruction the same number of physicians (ten) demonstrated perfect technique. Only six physicians demonstrated perfect technique at both evaluations. Three of the seven steps showed enough change from the first evaluation to the second to permit statistical analysis. Step 4 (timing of actuation) had 11 physicians’ performances improve while three worsened (P ⫽ .03). Step 5 (a slow inspiratory effort) had nine physicians’ performances improve while three worsened (P ⫽ .073). For step 7 (holding the breath ⱖ 5 seconds), 11 physicians improved while 2 worsened (P ⫽ .006). Comparing global performance, there were 17 physicians that improved, 8 that worsened, and 13 with no change (P ⫽ .054). Conclusions: This study confirmed that many housestaff physicians do not demonstrate optimal MDI technique. While one educational session may somewhat improve their future performance, it is not sufficient to guarantee perfect technique. This suggests that repeated education needs to be given to housestaff physicians. Ann Allergy Asthma Immunol 1996;76:145– 8.
INTRODUCTION Bronchial asthma affects approximately 10 million Americans and accounts for 450,000 hospital admissions per year.1 The mortality from asthma has increased dramatically in the past decade.2 There are many possible causes for this including the underutilization and misuse of metered dose inhalers (MDIs). The MDI continues
* From the Department of Pediatrics, Division of Allergy, Columbia Presbyterian Medical Center, New York, New York. Received for publication June 21, 1995. Accepted for publication in revised form August 31, 1995.
VOLUME 76, FEBRUARY, 1996
to be the most frequently prescribed inhalation device. Various aerosol preparations are available containing -agonists, anticholinergic agents, steroids, cromolyn sodium, and nedocromil. Inhaled medication is preferable to oral medication because the drug is delivered directly to the airway receptor sites in the lung. Lower doses can therefore be used, the onset of action is usually more rapid, and the incidence of side effects is reduced.3,4 Although correct MDI usage requires adherence to a seemingly simple set of instructions, a significant proportion of patients find their instructions confusing and fail to use their
inhalers correctly.5,6 Studies have shown that because of misuse, less than 50% of children receiving inhalation therapy with MDIs benefit from this treatment.7 In order to prevent the improper use of MDIs, appropriate instructions must be given to each patient. Several studies have investigated how patients should be instructed in order to attain optimal results. Patients performed more steps correctly when given both verbal instruction and actual demonstrations with a placebo inhaler than when given the instruction leaflet alone.9 Physicians who instruct their patients on the use of MDIs should have mastered proper technique. In a previous study we investigated whether housestaff physicians do prescribe MDIs and examined their ability to demonstrate its correct use.11 All 53 participants had previously prescribed MDIs and 94% felt comfortable in their ability to instruct and demonstrate proper MDI technique to their patients. Only 10% of these physicians were able to demonstrate perfect MDI technique. With seven steps (described below) being evaluated the overall incidence of errors by participants was 2.4 per person. A study performed by Interiano and Guntupalli supported our findings.12 This clearly indicates the need to teach residents the correct MDI technique. In this study, we tested our residents and then educated our residents on proper MDI technique. All physicians demonstrated proper technique immediately after the teaching session. Two months after this session they were again tested to determine whether their improvement persisted over time.
145
METHODS The initial phase of the study was conducted in July, 1993. Thirty-eight pediatric housestaff physicians from our institution who were on site the day of the study were asked to participate. Information was obtained concerning their level of pediatric training and whether or not they had participated in our original study. Participation in our first study made them ineligible for this project. Each participant was given an MDI with a placebo cartridge and asked to demonstrate proper MDI technique. All subjects had their technique evaluated by a full-time faculty member or a fellow in the allergy division at The Babies and Children’s Hospital of NY. There were seven steps evaluated, which constituted optimal use of the MDI: (1) shaking the MDI and removing the cap; (2) exhaling prior to MDI use, (3) holding the MDI upright, (4) proper timing of MDI actuation (at the start of inspiration), (5) a slow inspiratory effort to vital capacity, (6) only one MDI actuation per breath, and (7) holding the breath for at least 5 seconds. Either an open or closed mouth technique was accepted. After each participant was evaluated, a 20-minute teaching session was given by a full-time allergy attending on proper MDI technique. The session initially consisted of a discussion on proper technique. An explanation was given on proper technique for each individual step. The residents were educated on the common errors made for each step. A full-time allergy attending then demonstrated perfect technique to the residents. A 5-minute question and answer period then occurred. Immediately after the session all participants were retested. Eventually all residents were able to demonstrate proper technique. Some needed individual instruction. All physicians participating in the study were then provided with an MDI containing a placebo cartridge so they could demonstrate for their patients its correct use. Two months after their educational session they were again asked to demonstrate proper MDI tech-
146
Figure 1. Average number of errors in using metered dose inhalers by residency year. PGY — postgraduate year.
nique and were again evaluated by the same observers. Statistical Methods The results of each resident’s performance on all seven steps were recorded both before and 2 months after instruction. In order to determine whether there was a difference between these two performances, we compared the number of individuals whose performance improved as opposed to those whose performance worsened. Improvement was judged to have taken place if a previously incorrectly performed step was done correctly 2 months after the educational session. Worsening was judged to be the reverse. Performance data were evaluated for each step. Overall performance for each subject was also evaluated. Improvement was judged to have occurred if an individual performed fewer errors after the educational session than before. Worsening
was judged to be the reverse. Data were analyzed using the method for comparing proportions in paired samples.13 A P value of .05 or less was considered statistically significant. RESULTS All 38 physicians who were asked to participate were uninvolved with our previous study and were therefore all eligible for inclusion in this study. The total group consisted of 17 post graduate year 1s, 12 postgraduate year 2s, and 9 postgraduate year 3s. The results of each year’s performance are shown in Figure 1. The number of physicians in each postgraduate year was not large enough for separate statistical analyses. Analyses were done on the 38 physicians taken together. Of the 38 participants only ten (26%) demonstrated perfect MDI technique initially and only ten demonstrated perfect MDI technique 2 months after instruc-
Table 1. Number of Participants (out of 38) Who Were in Error for Each Individual Step Before and Two Months After Instruction
1. 2. 3. 4. 5. 6. 7.
Shaking MDI* & removing cap Exhaling prior to actuation Holding MDI upright Properly timing actuation A good inspiratory effort Activating only once Holding breath ⱖ5 seconds
PRE
POST
2 7 2 22 21 1 11
3 8 0 14 15 1 2
* MDI ⫽ metered dose inhaler.
ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
tion. Six individuals demonstrated perfect technique both before and 2 months after instruction. The most common errors initially were poor timing of actuation in 22 (58%), poor inspiratory effort in 21 (55%), and failure to hold the breath at least 5 seconds in 11 (29%) (Table 1). Two of the participants held the MDI upside down. After instruction the most common errors were poor inspiratory effort in 15 (39%), poor timing of actuation in 14 (37%), and failure to exhale prior to inhalation in 8 (21%). Table 2 compares improved and worsened performance for each of the seven steps. Statistical analysis for steps 1, 2, 3, and 6 could not be carried out for lack of sufficient changes in performance before and after the educational session. For step 4, timing of actuation, 11 individuals improved, while 3 worsened. This was statistically significant (P ⫽ .03). For step 5, a good inspiratory effort, there were nine individuals who improved while three worsened which was not statistically significant (P ⫽ .073). There was statistical significance for step 7, holding the breath at least 5 seconds, which had 11 participants improve and 2 worsen (P ⫽ .006). The global performance scores revealed that seventeen individuals made fewer total errors, eight made more total errors, seven exhibited no change, and six demonstrated perfect technique both before and after the instructional session. The P value for the overall performance was .054.
DISCUSSION The use of MDIs in the treatment of hyperreactive airway disease has become increasingly widespread. Even with excellent technique it is possible to deliver no more than 15% of a single dose to the distal airways.3,14 Numerous studies have documented the misuse of MDIs by patients.5,6,15–18 Even after formal training many asthmatic patients continue to misuse MDIs.15 Shim and Williams found that even after patients demonstrated a proficiency in MDI technique with appropriate instruction, only 50% of patients used the MDI correctly 1 to 30 days later.19 With these facts and the knowledge that verbal instructions and actual demonstrations improve patient MDI use, it is crucial that patients receive repeated appropriate instruction in proper MDI use. It would be nice to assign an expert team the task of educating every patient prescribed a MDI. Unfortunately, our hospital as well as other hospitals do not have the manpower to do this, so in most cases it is left to the physician.15 Two studies performed suggested that lack of proficiency in the proper use of MDIs by healthcare providers contributes to improper use of MDIs by the patients.12,15 Physicians who prescribe aerosolized medications should therefore master the use of the MDI before serving as instructors for their patients.15,20 In a previous study we documented that housestaff physi-
cians do prescribe MDIs for their patients.11 But, in general their ability to use a MDI was rather poor. We had recommended that these physicians be instructed in the proper use of MDIs early in their residency training period. Our present study confirmed the fact that many housestaff physicians do not demonstrate optimal technique in the use of MDIs. Two months after our educational session we were able to demonstrate an improvement for two of seven components of the technique. For overall performance there was no statistical difference. It must be stressed that we cannot prove the changes noted were due to the educational session. It is possible that residents obtained education and/or instruction from other sources which could have contributed to the improvement seen. It is also possible that passage of time or the influence of repeat testing may have played a role. Originally, only ten housestaff physicians (26%) exhibited perfect MDI technique. It is disappointing that following the educational session that number remained the same. Since we know that housestaff physicians do prescribe MDIs and will serve as instructors for their patients, only a perfect technique should be acceptable for these physicians. This study demonstrates that a single educational session for housestaff physicians may improve their performance but it certainly does not guarantee that they will thereafter demonstrate perfect technique. It is absolutely
Table 2. Comparison of Participant Performance for Each Step Before and Two Months After Instruction* Correct Both Times 1. 2. 3. 4. 5. 6. 7. 8.
Shaking MDI† & removing cap Exhaling prior to actuation Holding MDI upright Properly timing actuation A good inspiratory effort Activating only once Holding breath ⱖ 5 seconds Overall
33 26 36 13 14 36 26
Improved
Worsened
No Change
2 4 2 11 9 1 10 17
3 5 0 3 3 1 1 8
33 29 36 24 26 36 27 13
Incorrect Both Times
P Value
0 3 0 11 12 0 1
NS‡ NS NS .03 .073 NS .006 .054
* Given are numbers of participants who improved, worsened, or showed no change. “Improved” indicates a participant who initially performed the step incorrectly and after instruction performed it correctly. “Worsened” indicates the reverse. † MDI ⫽ metered dose inhaler. ‡ NS ⫽ not significant.
VOLUME 76, FEBRUARY, 1996
147
necessary that follow-up sessions be given to the residents in order to improve their technique. Once it has been demonstrated that they are consistent in their use of an MDI, we can be more confident that they will demonstrate proper technique to their patients. This will assist in patient education and result in patients gaining maximal benefit from their medications and better control of their asthma.
7.
8. 9.
REFERENCES 1. Evans R III, Mullally DI, Wilson RW, et al. National trends in the morbidity and mortality of asthma in the US: prevalence, hospitalization and death from asthma over two decades: 1965–1984. Chest 1987;91:65S–74S. 2. Center for Disease Control. AsthmaUnited States, 1980 –1987. MMWR 1990;39:493–7. 3. Newman SP. Aerosol deposition considerations in inhalation therapy. Chest 1985;88:152S– 60S. 4. Newman SP, Clark SW. Therapeutic aerosols 1 -physical and practical considerations. Thorax 1983;38:881– 6. 5. Buckley D. Assessment of inhaler technique in general practice. Irish J Med Sci 1989;158:297–9. 6. Hilton S. An audit of inhaler technique
148
10.
11.
12.
13. 14.
among asthma patients of 34 general practitioners. Br J Gen Prac 1990;40: 505– 6. Pederson S, Frost L, Arnfred T. Errors in inhalation technique and efficiency in inhaler use in asthmatic children. Allergy 1986;41:118 –24. Pederson S. Inhaler use in children with asthma. Danish Med Bull 1987; 34:234 – 49. Roberts RJ, Robinson JD, Doering PL, et al. A comparison of various types of patient instruction in the proper administration of metered inhalers. Drug Intell Clin Pharm 1982;16:53–9. Detullio PL, Corson ME. Effect of pharmacist counseling on ambulatory patients’ use of aerosolized bronchodilators. Am J Hosp Pharm 1987;44: 1802– 6. Mas JC, Resnick DJ, Firschein DE, et al. Misuse of metered dose inhalers by house staff members. Am J Dis Chil 1991;146:783–5. Interiano B, Guntupalli KK. Metereddose inhalers: do health care providers know what to teach? Arch Intern Med 1993;153:81–5. Snedecor GW, Cochran WG. Statistical Methods, Seventh Edition. Iowa State Univ. Press, 1980:121– 4. Kemp JP, Meltzer EO. Beta-2 adrenergic agonists: oral or aerosol for the
15.
16.
17.
18. 19. 20.
treatment of asthma? Asthma 1990;27: 149 –57. Thompson J, Irvine T, Gratwohl K, Roth B. Misuse of metered-dose inhalers in the hospitalized patients. Chest 1994;105:715–7. De Blaquiere P, Christensen DB, Carter WB, Martin TR. Use and misuse of metered-dose inhalers by patients with chronic lung disease. Am Rev Respir Dis 1989;140:910 – 6. Manzella BA, Brooks CM, Richards JM, et al. Assessing the use of metered dose inhalers by adults with asthma. J Asthma 1989;26:223–30. Crompton GK. The adult patient’s difficulties with inhalers. Lung 1990; (Suppl)658 – 62. Shim C, Williams MH. The adequacy of inhalation of aerosol from canister nebulizers. Am J Med 1980;69:891– 4. Frew AJ. Poor inhaler technique may be perpetuated by clinical staff. Practitioner 1984;228:883.
Request for reprints should be addressed to: David J Resnick, MD Department of Pediatrics Division of Allergy Columbia Presbyterian Medical Center 3959 Broadway New York, NY 10032
ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
Background: It is known that many housestaff physicians are unable to demonstrate perfect metered dose inhaler (MDI) technique. Objective: This study assessed whether a single teaching session for house staff physicians would significantly improve their MDI technique. Methods: Thirty-eight pediatric house staff physicians were asked to demonstrate MDI technique with a placebo MDI. The physicians were evaluated on the following seven steps: (1) shaking the MDI and removing the cap, (2) exhaling prior to MDI use, (3) holding the MDI upright, (4) proper timing of actuation, (5) a slow inspiratory effort, (6) one MDI actuation per breath, and (7) holding the breath ⱖ 5 seconds. A 20-minute teaching session and demonstration of proper MDI technique was then given. At the end of this session all residents were eventually able to demonstrate proper technique. Two months following this educational session the same house staff physicians were re-evaluated on their MDI technique. Results: Initially, ten participants (26%) demonstrated perfect technique. Two months postinstruction the same number of physicians (ten) demonstrated perfect technique. Only six physicians demonstrated perfect technique at both evaluations. Three of the seven steps showed enough change from the first evaluation to the second to permit statistical analysis. Step 4 (timing of actuation) had 11 physicians’ performances improve while three worsened (P ⫽ .03). Step 5 (a slow inspiratory effort) had nine physicians’ performances improve while three worsened (P ⫽ .073). For step 7 (holding the breath ⱖ 5 seconds), 11 physicians improved while 2 worsened (P ⫽ .006). Comparing global performance, there were 17 physicians that improved, 8 that worsened, and 13 with no change (P ⫽ .054). Conclusions: This study confirmed that many housestaff physicians do not demonstrate optimal MDI technique. While one educational session may somewhat improve their future performance, it is not sufficient to guarantee perfect technique. This suggests that repeated education needs to be given to housestaff physicians. Ann Allergy Asthma Immunol 1996;76:145– 8.
INTRODUCTION Bronchial asthma affects approximately 10 million Americans and accounts for 450,000 hospital admissions per year.1 The mortality from asthma has increased dramatically in the past decade.2 There are many possible causes for this including the underutilization and misuse of metered dose inhalers (MDIs). The MDI continues
* From the Department of Pediatrics, Division of Allergy, Columbia Presbyterian Medical Center, New York, New York. Received for publication June 21, 1995. Accepted for publication in revised form August 31, 1995.
VOLUME 76, FEBRUARY, 1996
to be the most frequently prescribed inhalation device. Various aerosol preparations are available containing -agonists, anticholinergic agents, steroids, cromolyn sodium, and nedocromil. Inhaled medication is preferable to oral medication because the drug is delivered directly to the airway receptor sites in the lung. Lower doses can therefore be used, the onset of action is usually more rapid, and the incidence of side effects is reduced.3,4 Although correct MDI usage requires adherence to a seemingly simple set of instructions, a significant proportion of patients find their instructions confusing and fail to use their
inhalers correctly.5,6 Studies have shown that because of misuse, less than 50% of children receiving inhalation therapy with MDIs benefit from this treatment.7 In order to prevent the improper use of MDIs, appropriate instructions must be given to each patient. Several studies have investigated how patients should be instructed in order to attain optimal results. Patients performed more steps correctly when given both verbal instruction and actual demonstrations with a placebo inhaler than when given the instruction leaflet alone.9 Physicians who instruct their patients on the use of MDIs should have mastered proper technique. In a previous study we investigated whether housestaff physicians do prescribe MDIs and examined their ability to demonstrate its correct use.11 All 53 participants had previously prescribed MDIs and 94% felt comfortable in their ability to instruct and demonstrate proper MDI technique to their patients. Only 10% of these physicians were able to demonstrate perfect MDI technique. With seven steps (described below) being evaluated the overall incidence of errors by participants was 2.4 per person. A study performed by Interiano and Guntupalli supported our findings.12 This clearly indicates the need to teach residents the correct MDI technique. In this study, we tested our residents and then educated our residents on proper MDI technique. All physicians demonstrated proper technique immediately after the teaching session. Two months after this session they were again tested to determine whether their improvement persisted over time.
145
METHODS The initial phase of the study was conducted in July, 1993. Thirty-eight pediatric housestaff physicians from our institution who were on site the day of the study were asked to participate. Information was obtained concerning their level of pediatric training and whether or not they had participated in our original study. Participation in our first study made them ineligible for this project. Each participant was given an MDI with a placebo cartridge and asked to demonstrate proper MDI technique. All subjects had their technique evaluated by a full-time faculty member or a fellow in the allergy division at The Babies and Children’s Hospital of NY. There were seven steps evaluated, which constituted optimal use of the MDI: (1) shaking the MDI and removing the cap; (2) exhaling prior to MDI use, (3) holding the MDI upright, (4) proper timing of MDI actuation (at the start of inspiration), (5) a slow inspiratory effort to vital capacity, (6) only one MDI actuation per breath, and (7) holding the breath for at least 5 seconds. Either an open or closed mouth technique was accepted. After each participant was evaluated, a 20-minute teaching session was given by a full-time allergy attending on proper MDI technique. The session initially consisted of a discussion on proper technique. An explanation was given on proper technique for each individual step. The residents were educated on the common errors made for each step. A full-time allergy attending then demonstrated perfect technique to the residents. A 5-minute question and answer period then occurred. Immediately after the session all participants were retested. Eventually all residents were able to demonstrate proper technique. Some needed individual instruction. All physicians participating in the study were then provided with an MDI containing a placebo cartridge so they could demonstrate for their patients its correct use. Two months after their educational session they were again asked to demonstrate proper MDI tech-
146
Figure 1. Average number of errors in using metered dose inhalers by residency year. PGY — postgraduate year.
nique and were again evaluated by the same observers. Statistical Methods The results of each resident’s performance on all seven steps were recorded both before and 2 months after instruction. In order to determine whether there was a difference between these two performances, we compared the number of individuals whose performance improved as opposed to those whose performance worsened. Improvement was judged to have taken place if a previously incorrectly performed step was done correctly 2 months after the educational session. Worsening was judged to be the reverse. Performance data were evaluated for each step. Overall performance for each subject was also evaluated. Improvement was judged to have occurred if an individual performed fewer errors after the educational session than before. Worsening
was judged to be the reverse. Data were analyzed using the method for comparing proportions in paired samples.13 A P value of .05 or less was considered statistically significant. RESULTS All 38 physicians who were asked to participate were uninvolved with our previous study and were therefore all eligible for inclusion in this study. The total group consisted of 17 post graduate year 1s, 12 postgraduate year 2s, and 9 postgraduate year 3s. The results of each year’s performance are shown in Figure 1. The number of physicians in each postgraduate year was not large enough for separate statistical analyses. Analyses were done on the 38 physicians taken together. Of the 38 participants only ten (26%) demonstrated perfect MDI technique initially and only ten demonstrated perfect MDI technique 2 months after instruc-
Table 1. Number of Participants (out of 38) Who Were in Error for Each Individual Step Before and Two Months After Instruction
1. 2. 3. 4. 5. 6. 7.
Shaking MDI* & removing cap Exhaling prior to actuation Holding MDI upright Properly timing actuation A good inspiratory effort Activating only once Holding breath ⱖ5 seconds
PRE
POST
2 7 2 22 21 1 11
3 8 0 14 15 1 2
* MDI ⫽ metered dose inhaler.
ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY
tion. Six individuals demonstrated perfect technique both before and 2 months after instruction. The most common errors initially were poor timing of actuation in 22 (58%), poor inspiratory effort in 21 (55%), and failure to hold the breath at least 5 seconds in 11 (29%) (Table 1). Two of the participants held the MDI upside down. After instruction the most common errors were poor inspiratory effort in 15 (39%), poor timing of actuation in 14 (37%), and failure to exhale prior to inhalation in 8 (21%). Table 2 compares improved and worsened performance for each of the seven steps. Statistical analysis for steps 1, 2, 3, and 6 could not be carried out for lack of sufficient changes in performance before and after the educational session. For step 4, timing of actuation, 11 individuals improved, while 3 worsened. This was statistically significant (P ⫽ .03). For step 5, a good inspiratory effort, there were nine individuals who improved while three worsened which was not statistically significant (P ⫽ .073). There was statistical significance for step 7, holding the breath at least 5 seconds, which had 11 participants improve and 2 worsen (P ⫽ .006). The global performance scores revealed that seventeen individuals made fewer total errors, eight made more total errors, seven exhibited no change, and six demonstrated perfect technique both before and after the instructional session. The P value for the overall performance was .054.
DISCUSSION The use of MDIs in the treatment of hyperreactive airway disease has become increasingly widespread. Even with excellent technique it is possible to deliver no more than 15% of a single dose to the distal airways.3,14 Numerous studies have documented the misuse of MDIs by patients.5,6,15–18 Even after formal training many asthmatic patients continue to misuse MDIs.15 Shim and Williams found that even after patients demonstrated a proficiency in MDI technique with appropriate instruction, only 50% of patients used the MDI correctly 1 to 30 days later.19 With these facts and the knowledge that verbal instructions and actual demonstrations improve patient MDI use, it is crucial that patients receive repeated appropriate instruction in proper MDI use. It would be nice to assign an expert team the task of educating every patient prescribed a MDI. Unfortunately, our hospital as well as other hospitals do not have the manpower to do this, so in most cases it is left to the physician.15 Two studies performed suggested that lack of proficiency in the proper use of MDIs by healthcare providers contributes to improper use of MDIs by the patients.12,15 Physicians who prescribe aerosolized medications should therefore master the use of the MDI before serving as instructors for their patients.15,20 In a previous study we documented that housestaff physi-
cians do prescribe MDIs for their patients.11 But, in general their ability to use a MDI was rather poor. We had recommended that these physicians be instructed in the proper use of MDIs early in their residency training period. Our present study confirmed the fact that many housestaff physicians do not demonstrate optimal technique in the use of MDIs. Two months after our educational session we were able to demonstrate an improvement for two of seven components of the technique. For overall performance there was no statistical difference. It must be stressed that we cannot prove the changes noted were due to the educational session. It is possible that residents obtained education and/or instruction from other sources which could have contributed to the improvement seen. It is also possible that passage of time or the influence of repeat testing may have played a role. Originally, only ten housestaff physicians (26%) exhibited perfect MDI technique. It is disappointing that following the educational session that number remained the same. Since we know that housestaff physicians do prescribe MDIs and will serve as instructors for their patients, only a perfect technique should be acceptable for these physicians. This study demonstrates that a single educational session for housestaff physicians may improve their performance but it certainly does not guarantee that they will thereafter demonstrate perfect technique. It is absolutely
Table 2. Comparison of Participant Performance for Each Step Before and Two Months After Instruction* Correct Both Times 1. 2. 3. 4. 5. 6. 7. 8.
Shaking MDI† & removing cap Exhaling prior to actuation Holding MDI upright Properly timing actuation A good inspiratory effort Activating only once Holding breath ⱖ 5 seconds Overall
33 26 36 13 14 36 26
Improved
Worsened
No Change
2 4 2 11 9 1 10 17
3 5 0 3 3 1 1 8
33 29 36 24 26 36 27 13
Incorrect Both Times
P Value
0 3 0 11 12 0 1
NS‡ NS NS .03 .073 NS .006 .054
* Given are numbers of participants who improved, worsened, or showed no change. “Improved” indicates a participant who initially performed the step incorrectly and after instruction performed it correctly. “Worsened” indicates the reverse. † MDI ⫽ metered dose inhaler. ‡ NS ⫽ not significant.
VOLUME 76, FEBRUARY, 1996
147
necessary that follow-up sessions be given to the residents in order to improve their technique. Once it has been demonstrated that they are consistent in their use of an MDI, we can be more confident that they will demonstrate proper technique to their patients. This will assist in patient education and result in patients gaining maximal benefit from their medications and better control of their asthma.
7.
8. 9.
REFERENCES 1. Evans R III, Mullally DI, Wilson RW, et al. National trends in the morbidity and mortality of asthma in the US: prevalence, hospitalization and death from asthma over two decades: 1965–1984. Chest 1987;91:65S–74S. 2. Center for Disease Control. AsthmaUnited States, 1980 –1987. MMWR 1990;39:493–7. 3. Newman SP. Aerosol deposition considerations in inhalation therapy. Chest 1985;88:152S– 60S. 4. Newman SP, Clark SW. Therapeutic aerosols 1 -physical and practical considerations. Thorax 1983;38:881– 6. 5. Buckley D. Assessment of inhaler technique in general practice. Irish J Med Sci 1989;158:297–9. 6. Hilton S. An audit of inhaler technique
148
10.
11.
12.
13. 14.
among asthma patients of 34 general practitioners. Br J Gen Prac 1990;40: 505– 6. Pederson S, Frost L, Arnfred T. Errors in inhalation technique and efficiency in inhaler use in asthmatic children. Allergy 1986;41:118 –24. Pederson S. Inhaler use in children with asthma. Danish Med Bull 1987; 34:234 – 49. Roberts RJ, Robinson JD, Doering PL, et al. A comparison of various types of patient instruction in the proper administration of metered inhalers. Drug Intell Clin Pharm 1982;16:53–9. Detullio PL, Corson ME. Effect of pharmacist counseling on ambulatory patients’ use of aerosolized bronchodilators. Am J Hosp Pharm 1987;44: 1802– 6. Mas JC, Resnick DJ, Firschein DE, et al. Misuse of metered dose inhalers by house staff members. Am J Dis Chil 1991;146:783–5. Interiano B, Guntupalli KK. Metereddose inhalers: do health care providers know what to teach? Arch Intern Med 1993;153:81–5. Snedecor GW, Cochran WG. Statistical Methods, Seventh Edition. Iowa State Univ. Press, 1980:121– 4. Kemp JP, Meltzer EO. Beta-2 adrenergic agonists: oral or aerosol for the
15.
16.
17.
18. 19. 20.
treatment of asthma? Asthma 1990;27: 149 –57. Thompson J, Irvine T, Gratwohl K, Roth B. Misuse of metered-dose inhalers in the hospitalized patients. Chest 1994;105:715–7. De Blaquiere P, Christensen DB, Carter WB, Martin TR. Use and misuse of metered-dose inhalers by patients with chronic lung disease. Am Rev Respir Dis 1989;140:910 – 6. Manzella BA, Brooks CM, Richards JM, et al. Assessing the use of metered dose inhalers by adults with asthma. J Asthma 1989;26:223–30. Crompton GK. The adult patient’s difficulties with inhalers. Lung 1990; (Suppl)658 – 62. Shim C, Williams MH. The adequacy of inhalation of aerosol from canister nebulizers. Am J Med 1980;69:891– 4. Frew AJ. Poor inhaler technique may be perpetuated by clinical staff. Practitioner 1984;228:883.
Request for reprints should be addressed to: David J Resnick, MD Department of Pediatrics Division of Allergy Columbia Presbyterian Medical Center 3959 Broadway New York, NY 10032
ANNALS OF ALLERGY, ASTHMA, & IMMUNOLOGY