Proficiency of Pediatricians in the Use of Inhaled Medication Delivery Systems for the Management of Asthma

Objective: To evaluate the proficiency of pediatricians in the demonstration of the proper use of metered-dose inhalers (MDIs) and to assess their theoretical knowledge of inhalation devices used in the management of asthma. Design: Prospective cross-sectional survey. Setting: Two university-affiliated hospitals. Participants: Seventy-one pediatricians and pediatric house staff. Intervention: Each pediatrician's technique was graded by two trained observers using a checklist of six essential steps recommended by national guidelines. Theoretical knowledge of asthma devices was evaluated by a written questionnaire. Results: Twenty (35.2%) pediatricians performed at least five steps correctly, 28 (39.4%) performed three or four steps correctly, and 18 (25.4%) performed two steps or less correctly. The most common errors were failure to start inhalation from functional residual capacity, failure to inhale slowly, and failure to wait at least 20 seconds before the next puff. Senior pediatricians were more skillful in the practical use of MDIs than were pediatric house staff (p = 0.03). The most common deficiencies in theoretical knowledge were related to estimation of the amount of medication in the canister (8.5% correct) and how valved holding chambers (VHCs) improve drug delivery to the lung (15.5% correct). Conclusion: Pediatricians in Kuwait have significant deficiencies regarding the practical and theoretical aspects of MDIs and other inhalation devices.     

Association of emergency department albuterol dispensing with pediatric asthma revisits and readmissions

Introduction: Although pediatric asthma continues to be a highly studied disease, data to suggest clear strategies to decrease asthma related revisits or readmissions is lacking. The purpose of our study was to assess the effect of emergency department (ED) direct dispensing of beta-agonist metered dose inhalers on pediatric asthma ED revisit and readmission rates. Methods: We conducted a retrospective cohort study of pediatric patients discharged from the pediatric ED with a diagnosis of asthma. Our primary outcome measured the rate of asthma revisits to the ED or admissions to the hospital within 28 days. Logistic regression analysis was used to assess ED beta-agonist MDI dispensing and revisit and/or readmission as the outcome. Results: A total of 853 patients met eligibility for inclusion in the study, with 657 enrolled in the Baseline group and 196 enrolled in the ED-MDI group. The Baseline group experienced a revisit and readmission rate of 7.0% (46/657) versus 2.6% (5/196) in the ED-MDI group, (p = 0.026). ED direct dispensing of MDIs was found to be independently associated with a decreased risk of revisit or readmission (odds ratio 0.37; 95% confidence interval 0.14–0.95). Conclusions: In our study, ED direct dispensing of beta-agonist MDIs resulted in a reduction in 28-day revisit and readmission to the hospital. Further studies should be performed to evaluate the economic impact of reducing these revisits and readmissions against the costs of maintaining a dispensing program. Our findings may support modification of asthma programs to include dispensing MDIs from the emergency department.     

Using videos to teach children inhaler technique: a pilot randomized controlled trial

Abstract

Objective: This primary objective of this pilot randomized, controlled trial was to determine whether a brief video intervention delivered after a pediatric office visit could improve inhaler technique in children with asthma immediately and one month later. The intervention’s effect on children’s inhaler self-efficacy and asthma control was also evaluated. Methods: Children (n?=?91) ages 7–17 years with persistent asthma were recruited at two pediatric practices in North Carolina. Eligible children demonstrated their inhaler technique for metered dose inhalers (MDIs) either with or without a spacer. A trained research assistant used a validated inhaler technique checklist to record which steps children performed correctly. After a regularly scheduled office visit, children were randomized to watch either a 3-min MDI video (intervention group) or a nutrition video (control group) in English or Spanish. Children’s technique was assessed again after watching the video and one month later. Results: Children were primarily male (56%) and non-White (60%). When compared with the control group, children in the intervention group demonstrated a significant improvement in MDI technique post-intervention [mean?=?1.12 steps, 95% CI (0.73, 1.50)] but the improvement was not sustained at 1-month follow-up. The intervention did not lead to significant improvements in inhaler self-efficacy or asthma control. Conclusions: A brief video intervention offered during pediatric clinic visits can lead to immediate improvements in children’s inhaler technique. Future studies should evaluate whether booster training videos can help maintain improvements in children’s inhaler technique over time.     

Poor inhalation technique, even after inhalation instructions, in children with asthma

The aim of this study was to evaluate the effect of instructions to children with asthma (given by general practitioners or by pharmacy assistants) on how to inhale from metered dose inhalers with spacers (MDI/s) or dry powder inhalers (DPI). We scored inhalation technique of asthmatic children according to criteria defined by the Netherlands Asthma Foundation, and related the performance to the inhalation instructions given. For each inhaler, a number of steps were considered essential for reliable drug delivery. Patients newly referred for asthma were asked to demonstrate their inhalation technique and to fill out a questionnaire on the inhalation instruction received prior to referral. Children participating in a clinical trial, who had received repeated comprehensive inhalation instructions, served as a control group. Sixty-six newly referred patients (1-14 years of age, median age 5 years; 37 boys) and 29 control patients (5-10 years of age, median age 7 years; 21 boys) completed the study. Sixty patients (91%) had received inhalation instruction prior to referral. Only 29% of these patients, using a dry powder inhaler, performed all essential steps correctly, compared to 67% of children using a metered dose inhaler/spacer combination (P < 0.01). Children who had received comprehensive inhalation instructions with repeated checks of proper inhalation technique at the pharmacy or in the clinical trial setting were more likely to perform all essential steps correctly (79% and 93%, respectively) than children who had received a single instruction by a general practitioner (39%, P < 0.01). Many asthmatic children use their inhalers devices too poorly to result in reliable drug delivery, even after inhalation instruction. Comprehensive inhalation instruction and repeated check-ups are needed to assure reliable inhalation technique.     

Happy Air®: A School-Based Educational Program to Maximize Detection of Asthma in Children

Objective. To investigate whether an active partnership among school, parents, and pediatricians allows early identification and treatment of asthmatic children. Methods: An asthma educational program (Happy Air®), based on a strong family-physician-school interrelationship, was performed in six primary schools (2,765 children) before administering a screening questionnaire to the parents. Results. A high response rate (96%) demonstrated 2,649 responders available for the asthma screening: 135 children (5%) received a diagnosis of asthma, of which 37 (27%) were recognized de novo. Conclusion. The active participation of school and parents is the determining factor for the success of an asthma screening program.     

Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD

BACKGROUND: Incorrect usage of inhaler devices might have a major influence on the clinical effectiveness of the delivered drug. This issue is poorly addressed in management guidelines. METHODS: This article presents the results of a systematic literature review of studies evaluating incorrect use of established dry powder inhalers (DPIs) by patients with asthma or chronic obstructive pulmonary disease (COPD). RESULTS: Overall, we found that between 4% and 94% of patients, depending on the type of inhaler and method of assessment, do not use their inhalers correctly. The most common errors made included failure to exhale before actuation, failure to breath-hold after inhalation, incorrect positioning of the inhaler, incorrect rotation sequence, and failure to execute a forceful and deep inhalation. Inefficient DPI technique may lead to insufficient drug delivery and hence to insufficient lung deposition. As many as 25% of patients have never received verbal inhaler technique instruction, and for those that do, the quality and duration of instruction is not adequate and not reinforced by follow-up checks. CONCLUSIONS: This review demonstrates that incorrect DPI technique with established DPIs is common among patients with asthma and COPD, and suggests that poor inhalation technique has detrimental consequences for clinical efficacy. Regular assessment and reinforcement of correct inhalation technique are considered by health professionals and caregivers to be an essential component of successful asthma management. Improvement of asthma and COPD management could be achieved by new DPIs that are easy to use correctly and are forgiving of poor inhalation technique, thus ensuring more successful drug delivery.     

Spacers versus nebulizers in treatment of acute asthma – a prospective randomized study in preschool children

Objective: To compare administration of bronchodilators by nebulizers with delivery by metered dose inhalers (MDIs) with spacers and to evaluate the clinical effect of the treatment of acute asthma in preschool children. Methods: A prospective randomized clinical trial in a pediatric emergency department (PED). Preschool children who were admitted for virus induced wheezing or acute asthma exacerbation were randomly allocated to receive bronchodilator treatment by nebulizer or by metered dose inhaler. The accompanying parents completed a questionnaire. Results: The length of stay in the PED and the hospitalization rate were similar and no difference was seen in the parents' view of ease of use and device acceptance. Baseline data were similar for both groups apart from the family history of asthma and atopic disease that was greater in the nebulizer group. No significant differences were seen in heart rate, respiratory rate and oxygen saturation at baseline and after the treatment. According to the parents 40% of the participants had asthma diagnosis though up to 66% had some kind of asthma medication. Conclusions: Our data suggests that MDIs with spacers are at least as effective as nebulizers in the delivery of beta agonists to treat preschool children with virus induced wheezing or acute exacerbations of asthma in the PED. Parents may underestimate the gravity of their children's asthma. It is mandatory to provide adequate information to the staff and parents in order to treat pediatric acute asthma successfully.     

Assessment of inhalation technique and determinants of incorrect performance among children with asthma

The objective of our study was to evaluate the pressurized metered dose inhaler (pMDI) with holding chamber technique of asthmatic children attending out patient pediatric chest clinic and determine factors associated with incorrect technique. All patients had previously received instructions regarding inhalation technique. The inhalation technique was assessed on a five-point checklist, four of which were considered essential. Two hundred and thirteen children (mean +/- SD age, 7.3 +/- 3.8 years; 151 boys) completed the study. Children were using their inhaler for a median duration of 6 months (range 1-96 months). One hundred and eighty-eight patients (88.3%) performed all essential steps correctly. The commonest mistake among the essential steps was not shaking the inhaler (n = 21, 9.9%) followed by inability to make a tight seal around the mouthpiece of the holding chamber (n = 12, 5.6%). Correct technique was not affected by gender, asthma severity and socio-economic indices: education level of parents, percapita monthly income, rural or urban background. Our study indicates that a large majority of children from a developing country setting, irrespective of lower education and income levels can be successfully educated to appropriately use inhalation device. Inhalation performance is not affected by socio-economic background of the patients. Comprehensive inhalation instructions and monitoring at each visit are however critical to ensure reliable and consistent performance of correct technique among asthmatic children.     

Asthma management and inhalation techniques among community pharmacists in 2009: a comparison with the 1999 survey

Objective: In a 1999 survey, community pharmacists from the Alsace region of France had a reasonably good knowledge of asthma treatment and prevention, but their skill in the use of asthma inhalation devices left room for improvement. Since then, health authorities have encouraged the involvement of community pharmacists in patient care and education in order to improve asthma control. The aim of this study was to assess the change in the knowledge of asthma management and inhaler technique skills of community pharmacists in the same geographic area after a 10-year interval. Methods: In 2009, 86 randomly selected community pharmacists from the Alsace region answered a standardized questionnaire about their theoretical knowledge of and practical attitude toward asthma management and inhaled delivery systems, following which their skills in the use of four inhalation devices (pressurized metered-dose inhaler (pMDI) with/without a spacer, breath-actuated pMDI and dry powder inhaler (DPI)) were evaluated. Results: Very few pharmacists were required to manage an acute asthma exacerbation at the pharmacy, but all responded well by administering a short-acting inhaled β2-agonist. Theoretical knowledge of asthma management (criteria of severity of asthma exacerbation, guidelines and drugs triggering asthma exacerbations) was still average. Compared with 1999, they were twice as confident in demonstrating inhaler use, and their skills in using the pMDI, breath-actuated pMDI and DPI had improved significantly (p?Conclusions: Since 1999, pharmacists’ skill in the use of inhalers has improved, but theoretical knowledge of asthma management is still average, pointing to the importance of continuing pharmaceutical education.     

Impact of training on use of inhalational techniques of different inhaler devices: A single institutional cross sectional observation study

ObjectiveTo assess the impact of training on use of inhalational techniques of different inhaler devices in spirometry proved cases of COPD and Bronchial Asthma in a tertiary care centre.MethodsA total of 128 spirometry proved cases of Asthma and COPD were enrolled. They were equally distributed in four groups comprising of 32 patients each according to their inhalation devices namely pMDI, Rotahaler, Accuhaler and Turbohaler. Patients were asked to demonstrate their inhalation technique and errors were noted according to their inhaler specific checklist. Patients were also interviewed regarding their knowledge about inhalation devices. Training about proper inhalation techniques was given to every participant. Rechecking of inhalation technique was again done at the second visit after 2 wks in the similar manner. Correct and incorrect steps of inhalation technique again evaluated by filling the checklist of the individual device to see post training improvement.ResultIn our study, out of total cases more than one third of the patients were >60 yrs of age (41.4%) and most of the patients were males (62.5%). During the interview at first visit, almost 92% patients claimed to know how to use the inhalation device correctly but in reality most of the patients (around 96.1%) had committed at least one mistakes in their inhalation technique among all the inhalation steps. Errors were noted in different steps of inhalation including the essential steps among all the four devices. Statistically significant improvement in inhalation techniques including the essential steps were found among all the four devices after educational intervention and demonstration of sequential steps involved in particular inhaler.ConclusionOur study confirmed a significant increase in the percentage of improvement in inhalation technique after proper demonstration and training about the inhalation devices. Inhalation technique including essential steps of inhalation significantly improved in all the four devices used.     

Gaps in asthma care of the oldest adults

OBJECTIVES: To assess the adequacy of asthma care reported by a group of older adults who were subsequently hospitalized for their asthma. DESIGN: Prospective cohort study. SETTING: Fifteen managed care organizations in the United States. PARTICIPANTS: Adults with asthma, enrolled in managed care. MEASUREMENTS: Patient survey of demographics, asthma symptoms, health status, comorbid conditions, asthma treatment, asthma knowledge, and asthma self-management at baseline and 1 year later. RESULTS: Of 254 older adults, 38 (15.0%) reported being hospitalized for asthma at 1-year follow-up. Of these, 22.9% owned a peak flow meter (PFM). Of those with allergies, only about half (56.0%) had been told how to avoid allergens and had been referred for formal allergy testing. Adrenergic drug use was high in some patients. Nearly all (94.6%) used beta-agonist metered-dose inhalers (MDIs); 60.0% reported theophylline; 17.1% reported beta-agonist MDI overuse (>8 puffs per day); 10.5% reported beta-agonist MDI over-use and theophylline; and 13.2% reported both beta-agonist MDI over-use and oral beta-agonist use. Only 18.4% of respondents rated their overall asthma attack knowledge as excellent. Compared with nonhospitalized older adults, the hospitalized group reported care that was more consistent with guidelines, but also higher rates of potentially toxic combinations of adrenergic drugs. Compared with younger hospitalized adults, older hospitalized adults had clear deficiencies, including lower use of PFMs (55.3% vs 22.9%) and worse asthma self-management knowledge. CONCLUSIONS: There are many opportunities to improve both the pharmacologic and non-pharmacologic care of older adults with asthma. Overuse of and potentially toxic combinations of inhaled and oral sympathomimetics should probably be avoided. Older asthmatics may also benefit from increased specialty referral, PFM use, allergy testing, and asthma teaching.     

The need to improve inhalation technique in Europe: a report from the Aerosol Drug Management Improvement Team

Although the principles of asthma management are well established in Europe, the available data indicate that asthma in patients is not well controlled. Many patients derive incomplete benefit from their inhaled medication because they do not use inhaler devices correctly and this may compromise asthma control. The Aerosol Drug Management Improvement Team (ADMIT), incorporating clinicians from the UK, Germany, France, Italy, Spain and The Netherlands, reviewed published evidence to examine ways to improve the treatment of reversible airways disease in Europe. Data indicate that there is a clear need for specific training of patients in correct inhalation technique for the various devices currently available, and this should be repeated frequently to maintain correct inhalation technique. Devices which provide reassurance to patients and their physicians that inhalation is performed correctly should help to improve patient compliance and asthma control. Educational efforts should also focus on primary prescribers of inhaler devices. ADMIT recommends dissemination of information on the correct inhalation technique for each model of device by the use of an accessible dedicated literature base or website which would enable to match the appropriate inhaler to the individual patient. There is also a need for standardisation of prescribing practices throughout Europe. Regular checking of inhalation technique by prescribers is crucial as correct inhalation is one of the keystones of successful asthma management.     

Multiple inhalers confuse asthma patients.

This study investigated the influence of the use of different types of inhalers on the adequacy of inhalation technique among adult asthmatics. Three hypotheses were tested: first, patients using only one type of inhaler will demonstrate adequate inhalation technique more often than those with two or more types. Secondly, patients using a combination of dry powder inhalers (DPIs) will demonstrate correct inhalation technique more often than those using the combination of a metered dose inhaler (MDI) and a DPI. Thirdly, some inhalers or combinations of inhalers are more prone to erroneous inhalation technique than others. Adult outpatients with asthma who regularly used inhaled steroid therapy (n=321) participated in the study. The inhalers investigated were MDIs on the one hand, and the DPIs Turbuhaler, Diskhaler, Cyclohaler, Inhaler Ingelheim and Rotahaler on the other. Of 208 adult asthmatics with only one inhaler, 71% made no inhalation errors versus 61% of 113 patients with two or more different inhalers. Of patients with a combination of DPIs 68% performed all essential checklist items correctly, versus 54% of patients with the combination of "regular" MDI and DPI. Patients using only the Diskhaler made fewest errors. Whenever possible, only one type of inhaler should be prescribed. If a combination is unavoidable, combinations of DPIs are preferable to MDI and DPI. The Diskhaler seems to be the most foolproof device.     

Thai pediatricians' current practice toward childhood asthma

Background: Childhood asthma is a substantial health burden in Thailand. Due to a lack of pediatric respiratory specialists (pediatric pulmonologists and allergists; RS), most Thai children are cared for by general pediatricians (pediatric primary care providers (PCP)). Objectives: We investigated whether current practices of Thai pediatricians complied with asthma guidelines and compared practices (diagnosis and treatments) provided by PCP and RS. Methods: A cross-sectional study was conducted using electronic surveys including four case scenarios of different asthma phenotypes distributed to Thai pediatricians. Asthma diagnosis and management were evaluated for compliance with standard guidelines. The practices of PCP and RS were compared. Results: From 800 surveys distributed, there were 405 respondents (51%). Most respondents (81%) were PCP, who preferred to use clinical diagnosis rather than laboratory investigations to diagnose asthma. For acute asthmatic attacks, 58% of the pediatricians prescribed a systemic corticosteroid. For uncontrolled asthma, 89% of the pediatricians prescribed at least one controller. For exercise-induced bronchospasm, 55% of the pediatricians chose an inhaled bronchodilator, while 38% chose a leukotriene receptor antagonist (LTRA). For virus-induced wheeze, 40% of the respondents chose an LTRA, while 15% chose inhaled corticosteroids (ICS). PCP prescribed more oral bronchodilators (31% vs. 18%, p = 0.02), antibiotics (20% vs. 6%, p < 0.001), and antihistamines (13% vs. 0%, p = 0.02) than RS for the management of an acute asthmatic attack. Conclusions: Most of the Thai pediatricians' practices toward diagnosis and treatment of acute asthmatic attack and uncontrolled asthma conform to the guidelines. PCP prescribed more oral bronchodilators, antibiotics, and antihistamines than RS.     

哮喘儿童吸入性糖皮质激素使用情况及用药依从性评价

目的探讨哮喘儿童吸入性糖皮质激素(Inhaled corticosteroids,ICS)使用情况及用药依从性。方法选择2016年1月至2018年1月期间本院儿科住院部和门诊收治的哮喘儿童共350例。采用问卷调查了解哮喘儿童的一般情况下、ICS使用情况和用药依从性,并分析用药依从性差的影响因素。结果350例儿童哮喘病例中,布地奈德、氟替卡松和倍氯卡松的使用率分别为81.14%、10.29%、8.57%。雾化器、压力定量气雾剂和干粉吸入剂的使用率分别为62.29%、27.43%和10.29%。哮喘儿童ICS用药依从性差占74.86%,而用药依从性佳仅占25.14%。儿童哮喘ICS用药依从性差的原因主要包括担心ICS的安全性、家庭经济困难、不配合治疗、自认痊愈而停药和吸入方法不正确等。单因素分析显示,哮喘严重程度、父母受教育程度、掌握ICS吸入装置、家庭经济困难、父母对哮喘认知、父母对医护人员的信任程度与ICS用药依从性具有紧密的关系。多因素logistic回归分析显示,哮喘病情程度、父母受教育程度、父母对哮喘认知程度和父母对医护人员的信任程度越高,儿童哮喘ICS用药依从性越高。结论哮喘儿童ICS的使用以布地奈德雾化吸入为主,但用药依从性与多种因素具有紧密的关系,针对上述因素进行有效干预可有利于提高用药依从性,最终改善治疗效果。     

Assessment of the ability of young children to use a powder inhaler device (Turbuhaler)

The purpose of the study was to determine the age at which young asthmatic children could master the use of a new powder inhaler device (Turbuhaler). We studied 59 children with asthma between the ages of 3 and 6 years who consecutively attended the asthma clinic of the pediatric department. Efficiency of inhalation and the pharmacological effect of the terbutaline in the inhaler were measured by scores for inhalation technique and clinical response. None of the 3-year-old children used the device efficiently, but 43% of the 4-year-old, 67% of the 5-year-old, and 80% of the 6-year-old children used the inhaler correctly. Although inhaler technique was not perfect in the younger age group, 50% of the 3-year-old children demonstrated clinical improvement of asthma symptoms after inhalation. In the older age groups, 79%, 92%, and 100% of the 4, 5, and 6-year-old children demonstrated clinical improvement of asthma symptoms after inhalation. It is concluded that the new mode of dry powder delivery system (Bricanyl Turbuhaler) can be used in young asthmatic children who are 4 years of age and above. Pediatr Pulmonal. 1994;18:77–80. © 1994 Wiley-Liss, Inc.     

Lack of Awareness of Need to Clean CFC-Free Metered-Dose Inhalers

Background. Chlorofluorocarbon (CFC)-free metered-dose inhalers (MDIs) were introduced into Australia in 1999. Device care instructions were modified (e.g., CFC-free salbutamol inhalers to be washed weekly), but this information was not communicated directly to health care professionals. Objective. This pilot study aimed to assess the level of awareness of device care protocols for CFC-free MDIs by patients and their pharmacists. Setting and Design. Purchasers of CFC-free MDIs were recruited from four community pharmacies. They were interviewed regarding information sources, knowledge of propellant change, and awareness of and adherence to device care protocols. The dispensing pharmacists were interviewed for knowledge of CFC-free device care. The primary outcome variable was awareness of the relevant device care protocol. Results. Thirty-nine patients were interviewed. Most patients (77%) were aware of the change to CFC-free propellant. Only nine patients (23%) were aware of the need to wash the device holder, and four patients (10% of total) complied with the specified protocol. One of the ten dispensing pharmacists could describe correct device care protocols for the CFC-free MDIs. Conclusions. Although most patients are aware that MDIs are now CFC-free, there is a low level of awareness of the device care required for these inhalers, and a very low rate of compliance with recommended practice. Although the clinical impact of failing to wash the device holder is unclear, this added instruction may have substantial implications for patient satisfaction and medication delivery. Pharmaceutical manufacturers need to highlight to health care professionals any clinically important changes in device care instructions, so that appropriate information may be passed on to patients.     

Prevalence of Probable Mental Disorders Among Pediatric Asthma Patients in an Inner-City Clinic

Objective. To determine the screen-positive prevalence of anxiety disorders and depression among pediatric asthma patients in an inner-city asthma clinic and to investigate the association between probable diagnoses of anxiety disorders and depression and medical service use among inner-city pediatric asthma patients. Method. In this pilot study, a consecutive sample of pediatric asthma patients aged 5-11 in the waiting room of an inner-city asthma clinic was screened for mental disorders using the DISC Predictive Scales (DPS), which produces probable DSM-IV diagnoses. In addition, data on health service use for asthma were collected. Statistical analyses were performed to examine the relationship between probable anxiety disorders and depression and health service use for asthma among pediatric asthma patients. Results. Approximately one in four (25.7%) pediatric asthma patients in an inner-city asthma clinic met criteria for a probable diagnosis of current anxiety disorders or depression (past 4-week prevalence). Specifically, childhood separation anxiety disorder was common among 8.1%, panic among 14.9%, generalized anxiety disorder among 4.1%, agoraphobia among 5.4%, and 2.7% had depression. Having more than one anxiety disorder or depression diagnosis was associated with higher levels of inpatient and outpatient medical services, compared with patients who were negative on screening for anxiety or depressive disorders, although differences failed to reach statistical significance. Conclusions. These findings are the first to provide preliminary evidence suggesting that mental health problems are common among pediatric asthma patients in an inner-city clinic. The results also suggest that mental health problems in pediatric asthma patients may be associated with elevated levels of medical service use for asthma. Replication of this pilot study is needed with a larger sample, more precise diagnostic methodology, and a comparison group with chronic medical illness.     

Assessment of inhaler techniques employed by patients with respiratory diseases in southern Brazil: a population-based study

OBJECTIVE:

To identify incorrect inhaler techniques employed by patients with respiratory diseases in southern Brazil and to profile the individuals who make such errors.

METHODS:

This was a population-based, cross-sectional study involving subjects ≥ 10 years of age using metered dose inhalers (MDIs) or dry powder inhalers (DPIs) in 1,722 households in the city of Pelotas, Brazil.

RESULTS:

We included 110 subjects, who collectively used 94 MDIs and 49 DPIs. The most common errors in the use of MDIs and DPIs were not exhaling prior to inhalation (66% and 47%, respectively), not performing a breath-hold after inhalation (29% and 25%), and not shaking the MDI prior to use (21%). Individuals ≥ 60 years of age more often made such errors. Among the demonstrations of the use of MDIs and DPIs, at least one error was made in 72% and 51%, respectively. Overall, there were errors made in all steps in 11% of the demonstrations, whereas there were no errors made in 13%.Among the individuals who made at least one error, the proportion of those with a low level of education was significantly greater than was that of those with a higher level of education, for MDIs (85% vs. 60%; p = 0.018) and for DPIs (81% vs. 35%; p = 0.010).

CONCLUSIONS:

In this sample, the most common errors in the use of inhalers were not exhaling prior to inhalation, not performing a breath-hold after inhalation, and not shaking the MDI prior to use. Special attention should be given to education regarding inhaler techniques for patients of lower socioeconomic status and with less formal education, as well as for those of advanced age, because those populations are at a greater risk of committing errors in their use of inhalers.