- Email: [email protected]
Brief Education Improves Proper Metered-Dose Inhaler Use
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–6, 2020 Ó 2020 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter
https://doi.org/10.1016/j.jemermed.2020.02.011
Education BRIEF EDUCATION IMPROVES PROPER METERED-DOSE INHALER USE Dwayne A. Kellman, MD,* Kenneth V. Iserson, MD, MBA, FACEP, FAAEM,*† Robert D. Levy, MD, FRCPC,‡ Belinda McIntosh, RN,§ and Yusiny Maxwell, RN§ *Department of Emergency Medicine, Georgetown Public Hospital, Georgetown, Guyana, †Department of Emergency Medicine, The University of Arizona, Tucson, Arizona, ‡Pulmonary Hypertension Program, Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada, and §Spirometry Clinic, Georgetown Public Hospital, Georgetown, Guyana Reprint Address: Kenneth V. Iserson, MD, MBA, FACEP, FAAEM, Not Available
, Abstract—Background: Inhaled b-agonists are the cornerstone of acute treatment for asthma and chronic lung disease. Upon emergency department (ED) discharge, patients optimally receive prescriptions for metered-dose inhalers (MDIs) with instructions on their proper use. Yet prior studies suggest that ED personnel have limited knowledge of proper MDI techniques. It is unclear how effectively brief education will improve this knowledge to enable them to provide adequate patient instructions. Objective: Our aim was to evaluate ED medical personnel’s baseline knowledge of MDI use and the utility of brief education on their ability to use MDIs. Methods: After providing written consent, a spirometry nurse evaluated emergency physicians and nurses on their ability to properly perform three (open-mouth/two-finger, spacer, and closed-mouth) MDI techniques. The same spirometry nurse then gave a short educational session demonstrating the proper MDI techniques. Two weeks later, the nurse re-evaluated the same personnel on their MDI techniques. Results: All emergency medical personnel initially performed poorly in demonstrating proper MDI technique, averaging 29.8% steps done correctly. Two weeks after their educational session, they improved greatly, averaging 89.4% steps done correctly. Conclusions: This study demonstrated both that ED personnel had poor initial knowledge about MDI techniques and that a brief educational intervention improved most people’s ability to use, and presumably to instruct patients/parents in proper use of, MDIs. Ó 2020 Elsevier Inc. All rights reserved.
INTRODUCTION Inhaled short-acting b-agonists are the cornerstone of acute treatment for asthma and chronic obstructive pulmonary disease (COPD) (1). While there are no cures for these diseases, using these medications correctly can help to adequately control acute intermittent symptoms, help patients have a normal quality of life, and prevent deaths (2). Optimally, upon emergency department (ED) discharge, patients receive prescriptions for metered-dose inhalers (MDIs) with instructions from ED personnel in their proper use. Although MDI effectiveness requires that patients use appropriate technique, many ED medical personnel lack the knowledge to effectively educate patients in their use. It was unclear whether a brief educational intervention could effectively improve this knowledge. This issue is particularly important in settings without a respiratory therapist active in the ED, such as is the case in our Guyana ED (3). For this reason, we performed this study to evaluate how well ED medical personnel’s knowledge of MDI use improved after a brief educational intervention.
MATERIALS AND METHODS During a 4-month period, physicians and registered nurses working in the ED of Georgetown Public Hospital Corporation, Georgetown, Guyana, a resource-poor country, were asked to participate in this study and to provide written consent.
, Keywords—inhalers; asthma; treatment; education; patient; emergency medicine
RECEIVED: 27 October 2019; FINAL SUBMISSION RECEIVED: 28 December 2019; ACCEPTED: 15 February 2020 1
2
D. A. Kellman et al.
Using a series of steps for each of the three methods (Table 1), a single spirometer-trained nurse evaluated each participant on their ability to use MDIs with the openmouth/two-finger technique, the technique with and without spacers, and the closed-mouth technique (Figure 1). At the time of the study, the nurse trainer-observer had worked solely in the spirometry clinic for the 3 previous years. She learned spirometry techniques from an academic pulmonologist and from a local physician and nurse who completed a 1-year pulmonary and spirometry course at the Lung Institute, Winnipeg, Manitoba, Canada. The list of steps was developed by an author (RL) from materials used at Vancouver Hospital and Health Sciences Centre, Vancouver, Canada. Table 1 lists the elements, in order, for each of these MDI methods. Participants were given 1 point for each step that was completed competently, and the results were collated. After the initial evaluations, the same spirometry trained nurse instructed each participant in all three techniques. In most instances, the nurse taught the techniques to participant groups in 10-min sessions, first discussing and then demonstrating each method. Two weeks later, participants were evaluated again, and their pre- and post-training scores were compared. All data collection forms were securely stored. Data were analyzed using Microsoft Excel (Microsoft, Redmond, WA). This study received institutional approval. RESULTS The 45 participants completing the study included 18 physicians and 27 registered nurses. Five others were enrolled
in the study but did not complete the follow-up. In the preeducation assessment, participants averaged 29.8% correct actions across the three different MDI techniques. Post-education, they averaged 89.4% across the three techniques, showing a 59.6% improvement (Table 2). All participant groups performed similarly in their pre- and post-education assessments. Post-education, 17 people (37.7%) were fully competent for the closed-mouth technique, 18 (40%) for the open-mouth technique, and 23 (51%) for using a spacer (Table 3). DISCUSSION Asthma is a chronic inflammatory disorder in which multiple stimuli cause reversible airflow obstruction (1,2). COPD is a partially reversible lung disease that chronically obstructs airflow during breathing (4). Asthma and COPD are the most common chronic respiratory diseases in the world (3). About 334 million persons have asthma worldwide, a number expected to increase another 100 million by 2025 (2,5,6). More than 64 million people have COPD, a number that is expected to double by 2030, when it may become the third leading cause of death worldwide (1,2). The annual economic burden of these two chronic lung diseases is estimated at $76 billion dollars annually in Europe (7). COPD alone cost the U.S. economy an estimated $50 billion in 2010 and the cost of health services for asthma in the U.S. was $56 billion in 2007, a cost that has been increasing steadily (1,6). There is no known cure for these chronic lung diseases, but appropriate medication use drastically improves symptoms, improves quality of life, and decreases hospital
Table 1. Metered-Dose Inhaler Skills/Steps for Different Techniques Closed-Mouth Technique
Open-Mouth/Two-Finger Technique
Spacer Technique
Start seated upright with a straight back Take the cap off the inhaler mouthpiece Hold the inhaler upright Shake the inhaler 10 times Breathe out and tip your chin up slightly (90–120 )
Start seated upright with a straight back Take the cap off the inhaler mouthpiece Hold the inhaler upright Shake the inhaler 10 times Breathe out and tip your chin up slightly (90–120 )
Place the chamber mouthpiece between the lips and the teeth; close the lips and keep the tongue from obstructing the mouthpiece Press the inhaler canister while breathing in deeply and slowly Continue to inhale until the lungs are full
Place two fingers in front of your lips so that the MDI can be placed two finger widths away from your mouth
Start seated upright with a straight back Take the cap off the inhaler mouthpiece Hold the inhaler upright Shake the inhaler 10 times Place MDI in chamber ensuring that the vent on the end of chamber is on the bottom side of MDI Breathe out and tip your chin up slightly (90–120 )
Remove your fingers
Press the inhaler canister
Press the inhaler canister while breathing in deeply and slowly
Place the chamber mouthpiece between the lips and the teeth; close the lips and keep the tongue from obstructing the mouthpiece Tip your chin up slightly and breathe in deeply and slowly Continue to inhale until the lungs are full Hold the breath while counting to 10 Breathe out slowly
Hold the breath while counting to 10
Continue to inhale until the lungs are full
Breathe out slowly
Hold the breath while counting to 10 Breathe out slowly
MDI = metered-dose inhaler.
Improving MDI Use
3
Figure 1. Three techniques for MDI use: open-mouth (two-finger) technique (left); using a spacer (center); and closed-mouth technique (right). Used under Creative Commons, Bruce Blaus, artist (https://commons.wikimedia.org/wiki/File:MeteredDose_Inhaler_(Adult).png#filelinks).
burden and health care costs (2). The cornerstone of management for both asthma and COPD is inhaler-delivered medication (8). While there are many types of inhaler devices, MDIs, because of their cost-effectiveness ratio, are the most commonly used inhaler devices worldwide, including in Guyana (3,9,10). Their effectiveness, when used correctly, stems from delivering the prescribed medication in an aerosolized form directly to the lungs, thereby reducing side effects. With improper inhaler technique, patients receive suboptimal medication doses. Not only will this limit the drug’s effectiveness, but it also may cause side effects when the drug lodges in the back of the throat and mouth (8–11). Unfortunately, poor MDI technique is common. A review of 21 studies found that the number of patients incorrectly using MDIs ranges from 14% to 90%, with an estimated average of 50% (11). When incorrect inhaler use results in poor disease control, patients feel frustrated at their lack of improvement, despite using their MDI as prescribed (7–11). This attitude may lead to poor compliance, increased MDI dosages, arbitrary medication change, and, ultimately, poor symptom control and increased ED and hospital use (7–11). A French study of 3,955 patients showed a clear correlation between MDI misuse and poor asthma control, with lower peak expiratory flow rates and more frequent ED visits (10). Likewise, an Italian study of 1,664 asthma
patients found that those using MDIs incorrectly had an increased risk of ED visits, hospitalization, and poor symptom control, as measured with the Asthma Control Test (8). Many patients do not receive any inhaler training. One reason may be that MDI inhalers are viewed as so easy to use that patients and clinicians receive less adequate or no training in their use. Between 39% and 67% of nurses, doctors, and respiratory therapists are unable to adequately describe or perform critical steps for using inhalers (12). This might simply be because they have received no instruction in MDI techniques. While multiple clinical guidelines emphasize patient education as an essential component of care, a review of 40 medicine textbooks found that only two described the steps for proper inhaler use (13). Emergency medical personnel, despite being at the forefront of acute asthma and COPD care, lack the skills to properly use and demonstrate correct inhaler technique (14,15). Their deficiency is not unique. A review of 20 studies found that a wide spectrum of health care professionals, including medical students, nurses, respiratory therapists, and physicians, lacked the skills to properly use inhaler devices (13). Other studies revealed similar findings among internal medicine, family medicine, and pediatric physicians (16–18). The question, then, is: What methods can be used to improve this lack of knowledge? This study tested
Table 2. Medical Personnel’s Average Metered-Dose Inhaler Assessment Scores (n = 45) Technique
Pre-education Scores (% Correct)
Post-education Scores (% Correct)
MDI closed-mouth technique MDI open-mouth technique MDI with spacer
43.7 12.5 34
88.6 87.8 91.6
MDI = metered-dose inhaler.
4
D. A. Kellman et al.
Table 3. Number of Participants Competent in All Steps/ Skills Posteducation Technique
Participants Competent in All Steps/Skills, n
1. Closed-mouth technique 2. Open-mouth technique 3. With spacer
17 18 23
tests because they transferred to a different department or medical facility. Also, there are no data on the knowledge base of the eligible personnel who did not volunteer to participate in the study. Finally, evaluations were done through visual assessment and could have been open to subjective error. However, to counter this, a single spirometry nurse performed all teaching and assessments. CONCLUSIONS
whether a brief educational intervention could improve ED medical personnel’s MDI proficiency. Prior to the intervention, study participants showed limited competency in MDI use, which is consistent with findings in the literature. A brief educational intervention significantly increased their ability to properly use an MDI. Three basic MDI techniques were evaluated. Most candidates were familiar with the closed-mouth and spacer techniques, but not the open-mouth/two-finger technique, as evidenced by their low pre-education scores for this method. After receiving brief education, participants scored well on all three techniques—even 2 weeks later (Table 2). Correct MDI use involves several steps, some of which are more critical than others to providing appropriate medication delivery. These critical steps are as follows: 1) shaking the inhaler 10 times; 2) breathing out and tipping the chin up slightly (at a 90-degree to 120-degree angle with the anterior chest); 3) continuing to inhale until the lungs are full; and 4) holding the breath while counting to 10 (14,17,19). Scores for these elements were dismally low in the pre-education phase (17.7%, 0%, 0%, and 0%, respectively). There was marked improvement in the first two steps post-education, averaging 93.3% and 82.2% correct, but some participants, although improving, still struggled with steps 3 (continuing to inhale until the lungs are full) and 4 (holding the breath while counting to 10), averaging 40% and 64.4% correct, respectively. These two steps require more practice because some coordination is needed to successfully complete them (14,17,19). Both clinical staff and patients should receive similar short training sessions on a regular basis to ensure optimal medication delivery. In our ED, nursing residents developed posters that highlight these steps. We also provided adult patients and parents with pamphlets or simple printouts of the steps. Study Limitations While this study had a limited number of participants, the results were consistent within the group. Another limitation was that some participants could not complete the
This study showed that a brief educational intervention significantly improved the ability of ED medical personnel to use MDIs, but not all were fully able to use all techniques after the single brief educational intervention. Acknowledgments—We would like thank Drs. Nicolas Forget, Zulfikar Bux, and Waleema Baacchus-Ali for their support of this research project.
REFERENCES 1. Rowe BH, Edmonds ML, Spooner CH, Camargo CA. Evidence-based treatments for acute asthma. Respir Care 2001; 46:1380–90. 2. World Health Organization. Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach. Available at: https://www.who.int/gard/publications/GARD% 20Book%202007.pdf?ua=1. Accessed March 3, 2020. 3. Johnston JC, Rempel C, Sanders C, et al. Introduction of spirometry into clinical practice in Georgetown, Guyana: quality and diagnostic outcomes. Int J Tuberc Lung Dis 2016;20:1270–4. 4. Marks G, Pearce N, Strachan D, Asher I. Global burden of disease due to asthma. In: Global Asthma Report 2014. Auckland, New Zealand: Global Asthma Network; 2014. Available at: http://www.globala sthmareport.org/2014/. Accessed March 11, 2020. 5. World Health Organization. Chronic respiratory diseases. COPD: definition. Available at: www.who.int/respiratory/copd/definition/ en/. Accessed October 22, 2019. 6. American Academy of Asthma. Allergy and Immunology. Asthma Statistics: United States. Available at: www.aaaai.org/about-aaaai/ newsroom/asthma-statistics. Accessed March 11, 2020. 7. Gibson GJ, Loddenkemper R, Lundba¨ck B, Sibille Y. Respiratory health and disease in Europe: the New European lung white book. Eur Respir J 2013;42:559–63. 8. Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med 2011;105:930–8. 9. 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. 10. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002; 19:46–51. 11. Price D, Bosnic-Anticevich S, Briggs A, et al. Inhaler Error Steering Committee. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med 2013; 107:37–46. 12. Fink JB, Rubin BK. Problems with inhaler use: a call for improved clinician and patient education. Respir Care 2005; 50:1360–74.
Improving MDI Use 13. Self TH, Arnold LB, Czosnowski LM, Swanson JM, Swanson H. Inadequate skill of healthcare professionals in using asthma inhalation devices. J Asthma 2007;44:593–8. 14. O’Donnell J, Birkinshaw R, Burke V, Driscoll PA. The ability of A&E personnel to demonstrate inhaler technique. Emerg Med J 1997;14:163–4. 15. Jones JS, Holstege CP, Riekse R, White L, Bergquist T. Metereddose inhalers: do emergency health care providers know what to teach? Ann Emerg Med 1995;26:308–11. 16. Leung JM, Bhutani M, Leigh R, Pelletier D, Good C, Sin DD. Empowering family physicians to impart proper inhaler teaching to pa-
5 tients with chronic obstructive pulmonary disease and asthma. Can Respir J 2015;22:266–70. 17. Plaza V, Sanchis J, Roura P, et al. Physicians’ knowledge of inhaler devices and inhalation techniques remains poor in Spain. J Aerosol Med Pulm Drug Deliv 2012;25:16–22. 18. Alamoudi OS, Al-Mohammadi R. Internists in training; what do they know about inhalers? East Mediterr Health J 2007; 13:160–7. 19. Plaza V, Giner J, Rodrigo GJ, Dolovich MB, Sanchis J. Errors in the use of inhalers by health care professionals: a systematic review. J Allergy Clin Immunol Pract 2018;6:987–95.
6
D. A. Kellman et al.
ARTICLE SUMMARY 1. Why is this topic important? Emergency department (ED) personnel are expected to instruct patients in metered-dose inhaler (MDI) use. A simple method to improve their knowledge of these techniques is vital. 2. What does this study attempt to show? This study demonstrated (again) that ED personnel lack knowledge of correct inhaler use, which improves with a brief educational intervention. 3. What are the key findings? Emergency physicians and nurses initially performed poorly in demonstrating knowledge of inhaler techniques. Two weeks after a brief educational intervention, they demonstrated substantial improvement in their knowledge at a 2-week post-education re-evaluation. 4. How is patient care affected? Patients with asthma and chronic obstructive pulmonary disease demonstrate better outcomes with fewer ED visits and hospitalizations if they learn proper MDI techniques.
https://doi.org/10.1016/j.jemermed.2020.02.011
Education BRIEF EDUCATION IMPROVES PROPER METERED-DOSE INHALER USE Dwayne A. Kellman, MD,* Kenneth V. Iserson, MD, MBA, FACEP, FAAEM,*† Robert D. Levy, MD, FRCPC,‡ Belinda McIntosh, RN,§ and Yusiny Maxwell, RN§ *Department of Emergency Medicine, Georgetown Public Hospital, Georgetown, Guyana, †Department of Emergency Medicine, The University of Arizona, Tucson, Arizona, ‡Pulmonary Hypertension Program, Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada, and §Spirometry Clinic, Georgetown Public Hospital, Georgetown, Guyana Reprint Address: Kenneth V. Iserson, MD, MBA, FACEP, FAAEM, Not Available
, Abstract—Background: Inhaled b-agonists are the cornerstone of acute treatment for asthma and chronic lung disease. Upon emergency department (ED) discharge, patients optimally receive prescriptions for metered-dose inhalers (MDIs) with instructions on their proper use. Yet prior studies suggest that ED personnel have limited knowledge of proper MDI techniques. It is unclear how effectively brief education will improve this knowledge to enable them to provide adequate patient instructions. Objective: Our aim was to evaluate ED medical personnel’s baseline knowledge of MDI use and the utility of brief education on their ability to use MDIs. Methods: After providing written consent, a spirometry nurse evaluated emergency physicians and nurses on their ability to properly perform three (open-mouth/two-finger, spacer, and closed-mouth) MDI techniques. The same spirometry nurse then gave a short educational session demonstrating the proper MDI techniques. Two weeks later, the nurse re-evaluated the same personnel on their MDI techniques. Results: All emergency medical personnel initially performed poorly in demonstrating proper MDI technique, averaging 29.8% steps done correctly. Two weeks after their educational session, they improved greatly, averaging 89.4% steps done correctly. Conclusions: This study demonstrated both that ED personnel had poor initial knowledge about MDI techniques and that a brief educational intervention improved most people’s ability to use, and presumably to instruct patients/parents in proper use of, MDIs. Ó 2020 Elsevier Inc. All rights reserved.
INTRODUCTION Inhaled short-acting b-agonists are the cornerstone of acute treatment for asthma and chronic obstructive pulmonary disease (COPD) (1). While there are no cures for these diseases, using these medications correctly can help to adequately control acute intermittent symptoms, help patients have a normal quality of life, and prevent deaths (2). Optimally, upon emergency department (ED) discharge, patients receive prescriptions for metered-dose inhalers (MDIs) with instructions from ED personnel in their proper use. Although MDI effectiveness requires that patients use appropriate technique, many ED medical personnel lack the knowledge to effectively educate patients in their use. It was unclear whether a brief educational intervention could effectively improve this knowledge. This issue is particularly important in settings without a respiratory therapist active in the ED, such as is the case in our Guyana ED (3). For this reason, we performed this study to evaluate how well ED medical personnel’s knowledge of MDI use improved after a brief educational intervention.
MATERIALS AND METHODS During a 4-month period, physicians and registered nurses working in the ED of Georgetown Public Hospital Corporation, Georgetown, Guyana, a resource-poor country, were asked to participate in this study and to provide written consent.
, Keywords—inhalers; asthma; treatment; education; patient; emergency medicine
RECEIVED: 27 October 2019; FINAL SUBMISSION RECEIVED: 28 December 2019; ACCEPTED: 15 February 2020 1
2
D. A. Kellman et al.
Using a series of steps for each of the three methods (Table 1), a single spirometer-trained nurse evaluated each participant on their ability to use MDIs with the openmouth/two-finger technique, the technique with and without spacers, and the closed-mouth technique (Figure 1). At the time of the study, the nurse trainer-observer had worked solely in the spirometry clinic for the 3 previous years. She learned spirometry techniques from an academic pulmonologist and from a local physician and nurse who completed a 1-year pulmonary and spirometry course at the Lung Institute, Winnipeg, Manitoba, Canada. The list of steps was developed by an author (RL) from materials used at Vancouver Hospital and Health Sciences Centre, Vancouver, Canada. Table 1 lists the elements, in order, for each of these MDI methods. Participants were given 1 point for each step that was completed competently, and the results were collated. After the initial evaluations, the same spirometry trained nurse instructed each participant in all three techniques. In most instances, the nurse taught the techniques to participant groups in 10-min sessions, first discussing and then demonstrating each method. Two weeks later, participants were evaluated again, and their pre- and post-training scores were compared. All data collection forms were securely stored. Data were analyzed using Microsoft Excel (Microsoft, Redmond, WA). This study received institutional approval. RESULTS The 45 participants completing the study included 18 physicians and 27 registered nurses. Five others were enrolled
in the study but did not complete the follow-up. In the preeducation assessment, participants averaged 29.8% correct actions across the three different MDI techniques. Post-education, they averaged 89.4% across the three techniques, showing a 59.6% improvement (Table 2). All participant groups performed similarly in their pre- and post-education assessments. Post-education, 17 people (37.7%) were fully competent for the closed-mouth technique, 18 (40%) for the open-mouth technique, and 23 (51%) for using a spacer (Table 3). DISCUSSION Asthma is a chronic inflammatory disorder in which multiple stimuli cause reversible airflow obstruction (1,2). COPD is a partially reversible lung disease that chronically obstructs airflow during breathing (4). Asthma and COPD are the most common chronic respiratory diseases in the world (3). About 334 million persons have asthma worldwide, a number expected to increase another 100 million by 2025 (2,5,6). More than 64 million people have COPD, a number that is expected to double by 2030, when it may become the third leading cause of death worldwide (1,2). The annual economic burden of these two chronic lung diseases is estimated at $76 billion dollars annually in Europe (7). COPD alone cost the U.S. economy an estimated $50 billion in 2010 and the cost of health services for asthma in the U.S. was $56 billion in 2007, a cost that has been increasing steadily (1,6). There is no known cure for these chronic lung diseases, but appropriate medication use drastically improves symptoms, improves quality of life, and decreases hospital
Table 1. Metered-Dose Inhaler Skills/Steps for Different Techniques Closed-Mouth Technique
Open-Mouth/Two-Finger Technique
Spacer Technique
Start seated upright with a straight back Take the cap off the inhaler mouthpiece Hold the inhaler upright Shake the inhaler 10 times Breathe out and tip your chin up slightly (90–120 )
Start seated upright with a straight back Take the cap off the inhaler mouthpiece Hold the inhaler upright Shake the inhaler 10 times Breathe out and tip your chin up slightly (90–120 )
Place the chamber mouthpiece between the lips and the teeth; close the lips and keep the tongue from obstructing the mouthpiece Press the inhaler canister while breathing in deeply and slowly Continue to inhale until the lungs are full
Place two fingers in front of your lips so that the MDI can be placed two finger widths away from your mouth
Start seated upright with a straight back Take the cap off the inhaler mouthpiece Hold the inhaler upright Shake the inhaler 10 times Place MDI in chamber ensuring that the vent on the end of chamber is on the bottom side of MDI Breathe out and tip your chin up slightly (90–120 )
Remove your fingers
Press the inhaler canister
Press the inhaler canister while breathing in deeply and slowly
Place the chamber mouthpiece between the lips and the teeth; close the lips and keep the tongue from obstructing the mouthpiece Tip your chin up slightly and breathe in deeply and slowly Continue to inhale until the lungs are full Hold the breath while counting to 10 Breathe out slowly
Hold the breath while counting to 10
Continue to inhale until the lungs are full
Breathe out slowly
Hold the breath while counting to 10 Breathe out slowly
MDI = metered-dose inhaler.
Improving MDI Use
3
Figure 1. Three techniques for MDI use: open-mouth (two-finger) technique (left); using a spacer (center); and closed-mouth technique (right). Used under Creative Commons, Bruce Blaus, artist (https://commons.wikimedia.org/wiki/File:MeteredDose_Inhaler_(Adult).png#filelinks).
burden and health care costs (2). The cornerstone of management for both asthma and COPD is inhaler-delivered medication (8). While there are many types of inhaler devices, MDIs, because of their cost-effectiveness ratio, are the most commonly used inhaler devices worldwide, including in Guyana (3,9,10). Their effectiveness, when used correctly, stems from delivering the prescribed medication in an aerosolized form directly to the lungs, thereby reducing side effects. With improper inhaler technique, patients receive suboptimal medication doses. Not only will this limit the drug’s effectiveness, but it also may cause side effects when the drug lodges in the back of the throat and mouth (8–11). Unfortunately, poor MDI technique is common. A review of 21 studies found that the number of patients incorrectly using MDIs ranges from 14% to 90%, with an estimated average of 50% (11). When incorrect inhaler use results in poor disease control, patients feel frustrated at their lack of improvement, despite using their MDI as prescribed (7–11). This attitude may lead to poor compliance, increased MDI dosages, arbitrary medication change, and, ultimately, poor symptom control and increased ED and hospital use (7–11). A French study of 3,955 patients showed a clear correlation between MDI misuse and poor asthma control, with lower peak expiratory flow rates and more frequent ED visits (10). Likewise, an Italian study of 1,664 asthma
patients found that those using MDIs incorrectly had an increased risk of ED visits, hospitalization, and poor symptom control, as measured with the Asthma Control Test (8). Many patients do not receive any inhaler training. One reason may be that MDI inhalers are viewed as so easy to use that patients and clinicians receive less adequate or no training in their use. Between 39% and 67% of nurses, doctors, and respiratory therapists are unable to adequately describe or perform critical steps for using inhalers (12). This might simply be because they have received no instruction in MDI techniques. While multiple clinical guidelines emphasize patient education as an essential component of care, a review of 40 medicine textbooks found that only two described the steps for proper inhaler use (13). Emergency medical personnel, despite being at the forefront of acute asthma and COPD care, lack the skills to properly use and demonstrate correct inhaler technique (14,15). Their deficiency is not unique. A review of 20 studies found that a wide spectrum of health care professionals, including medical students, nurses, respiratory therapists, and physicians, lacked the skills to properly use inhaler devices (13). Other studies revealed similar findings among internal medicine, family medicine, and pediatric physicians (16–18). The question, then, is: What methods can be used to improve this lack of knowledge? This study tested
Table 2. Medical Personnel’s Average Metered-Dose Inhaler Assessment Scores (n = 45) Technique
Pre-education Scores (% Correct)
Post-education Scores (% Correct)
MDI closed-mouth technique MDI open-mouth technique MDI with spacer
43.7 12.5 34
88.6 87.8 91.6
MDI = metered-dose inhaler.
4
D. A. Kellman et al.
Table 3. Number of Participants Competent in All Steps/ Skills Posteducation Technique
Participants Competent in All Steps/Skills, n
1. Closed-mouth technique 2. Open-mouth technique 3. With spacer
17 18 23
tests because they transferred to a different department or medical facility. Also, there are no data on the knowledge base of the eligible personnel who did not volunteer to participate in the study. Finally, evaluations were done through visual assessment and could have been open to subjective error. However, to counter this, a single spirometry nurse performed all teaching and assessments. CONCLUSIONS
whether a brief educational intervention could improve ED medical personnel’s MDI proficiency. Prior to the intervention, study participants showed limited competency in MDI use, which is consistent with findings in the literature. A brief educational intervention significantly increased their ability to properly use an MDI. Three basic MDI techniques were evaluated. Most candidates were familiar with the closed-mouth and spacer techniques, but not the open-mouth/two-finger technique, as evidenced by their low pre-education scores for this method. After receiving brief education, participants scored well on all three techniques—even 2 weeks later (Table 2). Correct MDI use involves several steps, some of which are more critical than others to providing appropriate medication delivery. These critical steps are as follows: 1) shaking the inhaler 10 times; 2) breathing out and tipping the chin up slightly (at a 90-degree to 120-degree angle with the anterior chest); 3) continuing to inhale until the lungs are full; and 4) holding the breath while counting to 10 (14,17,19). Scores for these elements were dismally low in the pre-education phase (17.7%, 0%, 0%, and 0%, respectively). There was marked improvement in the first two steps post-education, averaging 93.3% and 82.2% correct, but some participants, although improving, still struggled with steps 3 (continuing to inhale until the lungs are full) and 4 (holding the breath while counting to 10), averaging 40% and 64.4% correct, respectively. These two steps require more practice because some coordination is needed to successfully complete them (14,17,19). Both clinical staff and patients should receive similar short training sessions on a regular basis to ensure optimal medication delivery. In our ED, nursing residents developed posters that highlight these steps. We also provided adult patients and parents with pamphlets or simple printouts of the steps. Study Limitations While this study had a limited number of participants, the results were consistent within the group. Another limitation was that some participants could not complete the
This study showed that a brief educational intervention significantly improved the ability of ED medical personnel to use MDIs, but not all were fully able to use all techniques after the single brief educational intervention. Acknowledgments—We would like thank Drs. Nicolas Forget, Zulfikar Bux, and Waleema Baacchus-Ali for their support of this research project.
REFERENCES 1. Rowe BH, Edmonds ML, Spooner CH, Camargo CA. Evidence-based treatments for acute asthma. Respir Care 2001; 46:1380–90. 2. World Health Organization. Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach. Available at: https://www.who.int/gard/publications/GARD% 20Book%202007.pdf?ua=1. Accessed March 3, 2020. 3. Johnston JC, Rempel C, Sanders C, et al. Introduction of spirometry into clinical practice in Georgetown, Guyana: quality and diagnostic outcomes. Int J Tuberc Lung Dis 2016;20:1270–4. 4. Marks G, Pearce N, Strachan D, Asher I. Global burden of disease due to asthma. In: Global Asthma Report 2014. Auckland, New Zealand: Global Asthma Network; 2014. Available at: http://www.globala sthmareport.org/2014/. Accessed March 11, 2020. 5. World Health Organization. Chronic respiratory diseases. COPD: definition. Available at: www.who.int/respiratory/copd/definition/ en/. Accessed October 22, 2019. 6. American Academy of Asthma. Allergy and Immunology. Asthma Statistics: United States. Available at: www.aaaai.org/about-aaaai/ newsroom/asthma-statistics. Accessed March 11, 2020. 7. Gibson GJ, Loddenkemper R, Lundba¨ck B, Sibille Y. Respiratory health and disease in Europe: the New European lung white book. Eur Respir J 2013;42:559–63. 8. Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med 2011;105:930–8. 9. 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. 10. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002; 19:46–51. 11. Price D, Bosnic-Anticevich S, Briggs A, et al. Inhaler Error Steering Committee. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respir Med 2013; 107:37–46. 12. Fink JB, Rubin BK. Problems with inhaler use: a call for improved clinician and patient education. Respir Care 2005; 50:1360–74.
Improving MDI Use 13. Self TH, Arnold LB, Czosnowski LM, Swanson JM, Swanson H. Inadequate skill of healthcare professionals in using asthma inhalation devices. J Asthma 2007;44:593–8. 14. O’Donnell J, Birkinshaw R, Burke V, Driscoll PA. The ability of A&E personnel to demonstrate inhaler technique. Emerg Med J 1997;14:163–4. 15. Jones JS, Holstege CP, Riekse R, White L, Bergquist T. Metereddose inhalers: do emergency health care providers know what to teach? Ann Emerg Med 1995;26:308–11. 16. Leung JM, Bhutani M, Leigh R, Pelletier D, Good C, Sin DD. Empowering family physicians to impart proper inhaler teaching to pa-
5 tients with chronic obstructive pulmonary disease and asthma. Can Respir J 2015;22:266–70. 17. Plaza V, Sanchis J, Roura P, et al. Physicians’ knowledge of inhaler devices and inhalation techniques remains poor in Spain. J Aerosol Med Pulm Drug Deliv 2012;25:16–22. 18. Alamoudi OS, Al-Mohammadi R. Internists in training; what do they know about inhalers? East Mediterr Health J 2007; 13:160–7. 19. Plaza V, Giner J, Rodrigo GJ, Dolovich MB, Sanchis J. Errors in the use of inhalers by health care professionals: a systematic review. J Allergy Clin Immunol Pract 2018;6:987–95.
6
D. A. Kellman et al.
ARTICLE SUMMARY 1. Why is this topic important? Emergency department (ED) personnel are expected to instruct patients in metered-dose inhaler (MDI) use. A simple method to improve their knowledge of these techniques is vital. 2. What does this study attempt to show? This study demonstrated (again) that ED personnel lack knowledge of correct inhaler use, which improves with a brief educational intervention. 3. What are the key findings? Emergency physicians and nurses initially performed poorly in demonstrating knowledge of inhaler techniques. Two weeks after a brief educational intervention, they demonstrated substantial improvement in their knowledge at a 2-week post-education re-evaluation. 4. How is patient care affected? Patients with asthma and chronic obstructive pulmonary disease demonstrate better outcomes with fewer ED visits and hospitalizations if they learn proper MDI techniques.