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• Stress the importance of exhaling gently for a few seconds before inhaling (deeply and slowly for a metered dose inhaler, and deeply and rapidly for most dry powder inhalers). C
• Observe the inhaler technique of every patient receiving inhalation therapy on more than one occasion. C
• Don’t rely on self-reports regarding inhaler technique; despite claims of proficiency, most patients make at least one mistake. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
For patients with asthma or chronic obstructive pulmonary disease (COPD), inhalation therapy is the foundation of treatment. Yet all too often, patients don’t get the full value of their inhaled medications because they use their inhaler incorrectly. When technique is markedly flawed, suboptimal outcomes typically result.
Given the number of Americans with asthma (at least 22 million)1 and COPD (more than 13 million adults),2 faulty inhaler technique is a major public health problem. In fact, the number of people suffering from COPD may be even larger: Close to 24 million US adults are believed to have impaired lung function.3,4 For patients with asthma or COPD—many of whom are treated by family physicians—comprehensive education with a focus on correct use of an inhaler is essential.
In this review, we present evidence of frequent inhaler errors (from clinical studies) and highlight some of the more common mistakes (based on our clinical experience [TABLE]5). Finally, we offer ‘‘time-efficient’’ solutions to inhaler problems—steps that physicians in busy primary care practices can take to ensure that patients with asthma or COPD get the maximum benefit from inhalation therapy.
TABLE
Caution patients about these device-specific mistakes*
| Metered dose inhaler |
|---|
|
| Metered dose inhaler plus spacer/VHC |
|
| Dry powder inhaler |
|
| *These are examples based on the experience of the authors; other errors are possible. †Timing is not as crucial as it is for an MDI without a spacer, but the drug is still lost if inhalation is delayed. ‡Correct use varies by type of product (see product literature for specifics). DPI, dry powder inhaler; MDI, metered dose inhaler; VHC, valved holding chamber. Source: Adapted with permission from Self TH, et al. Consultant. 2003.5 |
Inhaler error is well documented
Since 1965, when it was first reported that many patients used metered dose inhalers (MDIs) incorrectly,6 evidence has accumulated supporting the magnitude of the problem.7-12 (Studies conducted in family practice settings are described in “Researchers look at inhaler problems in primary care” and in TABLE W1.13-20)
A number of studies of various sizes (from 41 to 3955 patients) have assessed inhaler technique in patients being treated by clinicians in primary care. The researchers used a variety of scoring methods, as well. Among them were a simple 4-step (0-4) rating system, a 9-step system, a standardized inhaler-specific checklist, and a system that tracked the number of omissions patients made.13-20 All found significant problems with inhaler technique. (You’ll find a detailed look at the studies in TABLE W1 at jfponline.com.)
In one study of 422 patients,13 including young children, adolescents, and adults, participants received one point for correctly performing each of the following steps:
- Adequate preparation (shaking well for those using a metered dose inhaler [MDI]; loading correctly for patients using a dry powder inhaler [DPI])
- Adequate expiration, correct head position
- Adequate inspiratory technique
- Holding breath afterwards.
The researchers found that 25% of the patients had inadequate technique (≤2 on a 0-4 point scale). In this study, as in others that included patients using various types of devices, use of an MDI was associated with a higher rate of incorrect technique.
Another much-smaller study14 used the same 4-step system to assess the technique of 50 patients, all of whom had the same type of DPI and had received extensive training in the correct use of the device. Despite the training, 27% of the patients received scores of ≤2 (inadequate technique). Sixty-eight percent received a score of 3 (adequate); only 5% received a score of 4 (good).
The 2 largest studies—one including 3955 patients using MDIs20 and the other looking at 3811 patients using various kinds of devices18—found high levels of errors, as well. In the latter study, 76% of patients with MDIs made at least one error vs 49% to 55% of patients using DPIs.18 The results convinced a large majority of the physicians caring for these patients of the need to check inhaler technique more frequently. In the study of MDI users alone, 71% of the patients made at least one mistake.20 inhaler misuse was associated with higher asthma instability scores, this study showed.
More recently, a researcher assessed the effects of an integrated primary care model on the management of asthma and/or COPD in middle-aged and elderly patients, in a study of 260 patients in 44 family practices.19 The study included an evaluation of inhaler technique.
Participants were divided into an intervention group—137 patients who received education regarding inhaler use from a nurse—and a usual care group (123 patients). After 2 years, correct inhaler technique among those in the intervention group went from 41% at baseline to 54%. At the same time, the proportion of those in the usual care group with correct technique fell from 47% to 29%.19
Error rates vary widely from one clinical trial to another, depending on study criteria, type of device, and extent of patient education, among other factors. Nonetheless, several studies (spanning 3 decades) found the error rate to be close to, or greater than, 90%.7,10,21
The most recent of these, published in 2009,21 was based on observation of the inhaler technique used by patients with asthma or COPD directly following appointments in an outpatient clinic. The authors found that, although >98% of the study participants claimed to know how to use their inhalers, 94% committed at least one error. In this study and a number of others, user error was more likely in patients using MDIs.13,18,21,22
Adding a spacer (eg, a valved holding chamber such as the AeroChamber) can be helpful, as the spacer affords the patient more time to inhale the medication. But patients who use an MDI with a spacer often make mistakes, too, and patient education is essential.23-26
Breath-activated dry powder inhalers (DPIs)—such as the Flexhaler, HandiHaler, Aerolizer, and Diskus—also reduce the likelihood of error. DPIs eliminate a step that MDI users often struggle with: the need to simultaneously press down on the canister and begin a slow, deep inhalation.
What’s more, DPIs do not have to be shaken before use. Nonetheless, using a DPI still involves a series of actions. For the HandiHaler and Aerolizer, patients must load the dose, and some patients fail to read the directions and swallow the capsule instead of loading it into the device. Patients must remember to exhale away from the device (ie, not into the dry powder) before inhaling, then hold their breath for approximately 10 seconds. There is potential for error at each step.
Stress the need to exhale before using the inhaler
Forgetting to exhale before inhaling is a common, and significant, mistake regardless of the type of device. It is paramount to stress the need to exhale gently for a few seconds before inhaling (slowly and deeply for patients using an MDI, rapidly and deeply with most DPIs). For MDI users, poor timing, described earlier, is another common and serious mistake. Patients using an MDI with a valved holding chamber sometimes inhale for too long before pressing down on the inhaler, then are unable to continue inhaling although the aerosol is still in the chamber. A common error made by patients using multidose DPIs is simply to forget to load the dose.
Physicians need to brush up on their skills, too
It’s not just patients who lack proficiency in inhaler technique. Numerous studies have demonstrated poor skill among physicians and other health care professionals.27-34 Evidence also shows that targeted education results in substantial improvement.32,35
In one study undertaken to evaluate family medicine residents’ proficiency in using asthma inhalers, participants (an intervention group at one clinic and a control group at another) all were given a pretest. The intervention group then received educational materials and a tutorial, as well as the opportunity for hands-on practice, after which both groups were given a post-test. The residents who received the training had a 170% jump, on average, in proficiency score, vs a 55% increase for the control group (P<.001).35
Inhaled Medication Instructional Videos
Courtesy of: National Jewish Health
Go to http://www.nationaljewish.org/healthinfo/medications/lung-diseases/devices/instructional-videos
Another study—this one involving first-year interns—looked at level of improvement based on the type of education provided. Initially, only 5% of the interns could use an MDI without error. After a lecture and demonstration, 13% had an error-free technique. But when each intern participated in an intensive one-on-one session, the error-free rate reached 73%. The researchers’ conclusion: Lectures are relatively ineffective in teaching interns inhaler technique compared with a one-on-one approach.32
The Chicago Breathe Project,36 a new program aimed at improving education in the use of asthma inhalers for physicians and minority patients, provides further evidence of the value of clinician education. After a series of workshops for residents at 5 academic institutions, the physicians’ knowledge of proper use of inhalers rose dramatically—from just 5% preprogram to 91% postprogram (P<.001). Six months after the educational activity, the residents (n=161) were more likely (44% vs 11% preprogram) to assess patients’ inhaler technique.36
Teaching patients when time is tight
National and international guidelines stress the need to teach patients correct use of asthma and COPD inhalers.1,37,38 Providing the requisite education includes observation of each patient’s inhaler technique with proper use demonstrated, as needed.
The problem, of course, is how to provide that level of patient education within the time constraints of a busy family practice. We recommend these time-efficient solutions:
Enlist the help of other clinicians. While it is important that someone in your office be well trained and able to instruct patients in the proper use of inhalers, that individual need not be you. The National Institutes of Health recommends that the “principal clinician” introduce key educational messages, which can be reinforced and expanded on by other members of the health care team.1
After you advise patients that it is crucial for them to be trained in and adhere to proper inhaler technique, another health care professional—often a clinic nurse or pharmacist who has had special training—can provide the hands-on education. Studies have shown that when pharmacists who are competent in asthma management, including inhaler technique, work with physicians to optimize the education and overall management of patients with asthma, better outcomes often result, including a reduction in both emergency department visits and hospitalizations.1,39,40
Use videos to demonstrate correct technique. Videos are an effective teaching tool,9 and many of them are device-specific. National Jewish Health, which is world renowned for its asthma care, has a set of instructional videos posted on You-Tube and accessible from its Web site (http://www.nationaljewish.org/healthinfo/medications/lung-diseases/devices/instructional-videos). In addition to videos that demonstrate the use of an MDI alone and an MDI plus a valved holding chamber, the site has links to 6 DPI videos, each covering a different device.
Use intermittent observation. After the patient views the appropriate video, you or a member of your staff will still need to observe the patient’s inhaler technique to ensure correct use. Ideally, this should occur at every visit.1,37 When that’s not possible, use intermittent observation, starting with the first 2 or 3 visits after the introduction of inhalation therapy and then switching to periodic observation to ensure that the patient is maintaining good technique.
In determining how often observation is necessary, keep in mind that simply asking patients whether they are having inhaler problems is not sufficient.1 Patients tend to say they have little or no trouble when, in fact, most struggle, at times, with the devices. What’s more, good technique tends to decrease over time, and repetitive education is important.
To motivate patients, try this communication technique
Motivational interviewing, a technique that has been used to help patients battle obesity, quit smoking, and control hypertension,41-43 among other health problems, can help you identify inhaler problems that need to be addressed. It involves the use of open-ended questions (eg, “What worries you most about your asthma?”), affirmations (“You’ve done a great job testing your peak flow level every morning”), reflective listening (“You’re tired of taking medicine every day”), and summary statements (“You know you should take your medicine every day but you’re having trouble remembering it. Is that right?”).
A pilot study44 showed that when this technique was incorporated into an asthma education session, patient motivation increased. The ratio of perceived advantages vs disadvantages of taking asthma medication correctly improved, as well. Another study45 found that when motivational interviewing was used during home visits to inner-city African American adolescents for asthma care, the patients’ motivation, readiness to adhere to treatment, and asthma-related quality of life improved, although self-reported adherence to asthma medication did not. Further studies involving patients with asthma are under way (www.clinicaltrials.gov/ct2/results?term=asthma).
It is important to note that the use of motivational interviewing does not require a lengthy visit. One study found that on average, visits in which primary care physicians used this communication technique lasted less than 10 minutes.46
CORRESPONDENCE Timothy H. Self, PharmD, University of Tennessee Health Science Center, 881 Madison Avenue, Room 235, Memphis, TN 38163; tself@uthsc.edu
1. National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; 2007.
2. Centers for Disease Control and Prevention. National Center for Health Statistics: National health interview survey raw data, 2008. Analysis performed by American Lung Association Research and Program Services.
3. American Lung Association. COPD—Helping the missing millions. February 24, 2010. Available at: http://www.lungusa.org/about-us/our-impact/top-stories/copd-helping-the-missing.html. Accessed November 9, 2011.
4. Centers for Disease Control and Prevention. Chronic obstructive pulmonary disease surveillance—United States, 1971-2000. MMWR Surveill Summ. 2002;51(6):1-16.
5. Self TH, Kilgore KE, Shelton V. MDIs, spacers, and dry powder inhalers: what patients are likely to do wrong. Consultant. 2003;49:702-705.
6. Saunders KB. Misuse of inhaled bronchodilator agents. Br Med J. 1965;1:1037-1038.
7. Epstein SW, Manning CPR, Ashley MJ, et al. Survey of the clinical uses of pressurized aerosol inhalers. Can Med Assoc J. 1979;120:813-816.
8. Shim C, Williams MH. The adequacy of inhalation of aerosol from canister nebulizers. Am J Med. 1980;69:891-894.
9. Self TH, Brooks JB, Lieberman P, et al. The value of demonstration and role of the pharmacist in teaching the correct use of pressurized bronchodilators. Can Med Assoc J. 1983;128:129-131.
10. Hartert TV, Windom HH, Peeples RS, et al. Inadequate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med. 1996;100:386-394.
11. Goodman DE, Israel E, Rosenberg M, et al. The influence of age, diagnosis, and gender on proper use of metered-dose inhalers. Am J Respir Crit Care Med. 1994;150:1256-1261.
12. Newman SP, Pavia D, Clarke SW. How should a pressurized beta-adrenergic bronchodilator be inhaled? Eur J Respir Dis. 1981;62:3-21.
13. Hilton S. An audit of inhaler technique among asthma patients of 34 general practitioners. Br J Gen Pract. 1990;40:505-506.
14. Dompeling E, Van Grunsven PM, Van Schayck GP, et al. Treatment with inhaled steroids in asthma and chronic bronchitis: long-term compliance and inhaler technique. Fam Pract. 1992;9:161-166.
15. Verver S, Poelman M, Bogels A, et al. Effects of instruction by practice assistants on inhaler technique and respiratory symptoms of patients. A controlled randomized videotaped intervention study. Fam Pract. 1996;13:35-40.
16. Dickinson J, Hutton S, Atkin A, et al. Reducing asthma morbidity in the community: the effect of a targeted nurse-run asthma clinic in an English general practice. Respir Med. 1997;91:634-640.
17. Hesselink AE, Penninx BW, Wijnhoven HA, et al. Determinants of an incorrect inhalation technique in patients with asthma or COPD. Scand J Prim Health Care. 2001;19:255-260.
18. Molimard M, Raherison C, Lignot S, et al. Assessment of handling of inhaler devices in real life: An observational study in 3811 patients in primary care. J Aerosol Med. 2003;16:249-254.
19. Meulepas MA, Jacobs JE, Smeenk FW, et al. Effect of an integrated primary care model on the management of middle-aged and old patients with obstructive lung diseases. Scand J Prim Health Care. 2007;25:186-192.
20. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J. 2002;19:246-251.
21. Souza ML, Meneghini AC, Ferraz E, et al. Knowledge of and technique for using inhalation devices among asthma patients and COPD patients. J Bras Pneumol. 2009;35:824-831.
22. Rootmensen GN, van Keimpema AR, Jansen HM, et al. Predictors of incorrect inhalation technique in patients with asthma or COPD: a study using a validated videotaped scoring method. J Aerosol Med Pulm Drug Deliv. 2010;23:323-328.
23. Rachelefsky GS, Rohr AS, Wo J, et al. Use of a tube spacer to improve the efficacy of a metered dose inhaler in asthmatic children. Am J Dis Child. 1986;140:1191-1193.
24. Demirkan K, Tolley E, Mastin T, et al. Salmeterol administration by metered-dose inhaler alone vs metered-dose inhaler plus valved holding chamber. Chest. 2000;117:1314-1318.
25. Pedersen S, Ostergaard PA. Nasal inhalation as a cause of inefficient pulmonal aerosol inhalation technique in children. Allergy. 1983;38:191-194.
26. Dolovich MD, Ahrens RS, Hess DR, et al. Device selection an outcomes of aerosol therapy: evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest. 2005;127:335-371.
27. Interiano B, Guntupalli KK. Metered-dose inhalers: do health care providers know what to teach? Arch Intern Med. 1993;153:81-85.
28. Hanania NA, Wittman R, Kesten S, et al. Medical personnel’s knowledge of and ability to use inhaling devices. Metered-dose inhalers, spacing chambers, and breath-actuated dry powder inhalers. Chest. 1994;105:111-116.
29. Amirav I, Goren A, Pawlowski NA. What do pediatricians in training know about the correct use of inhalers and spacer devices? J Allergy Clin Immunol. 1994;94:669-675.
30. Chopra N, Oprescu N, Fask A, et al. Does introduction of new “easy to use” inhalational devices improve medical personnel’s knowledge of their proper use? Ann Allergy Asthma Immunol. 2002;88:395-400.
31. Self TH, Arnold LB, Czosnowski LM, et al. Inadequate skill of healthcare professionals in using asthma inhalation devices. J Asthma. 2007;44:593-598.
32. Lee-Wong M, Mayo PH. Results of a programme to improve house staff use of metered dose inhalers and spacers. Postgrad Med J. 2003;79:221-225.
33. Muchao FP, Pern SL, Rodriques JC, et al. Evaluation of the knowledge of health professionals at a pediatric hospital regarding the use of metered dose inhalers. J Bras Pneumol. 2008;34:4-12.
34. Kim SH, Kwak HJ, Kim TB, et al. Inappropriate techniques used by internal medicine residents with three kinds of inhalers (a metered dose inhaler, Diskus, and Turbuhaler): changes after a single teaching session. J Asthma. 2009;46:944-950.
35. Kelcher S, Brownoff R. Teaching residents to use asthma devices. Assessing family residents’ skill and a brief intervention. Can Fam Physician. 1994;40:2090-2095.
36. Press VG, Pincayage AT, Pappalardo AA, et al. The Chicago Breathe Project: a regional approach to improving education on asthma inhalers for resident physicians and minority patients. J Natl Med Assoc. 2010;102:548-555.
37. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2010. Available at: www.ginasthma.org. Accessed November 9, 2011.
38. Executive Summary: global strategy on the diagnosis and management and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Workshop Report, 2009. Available at: www.goldcopd.com. Accessed November 9, 2011.
39. Self TH, Chrisman CR, Mason DL, et al. Reducing emergency department visits and hospitalizations in African American and Hispanic patients: a 15-year review. J Asthma. 2005;42:807-812.
40. Armour C, Bosnic-Anticevich S, Brillant M, et al. Pharmacy asthma care program (PACP) improves outcomes for patients in the community. Thorax. 2007;62:496-502.
41. DiLillo V, Nicole J, West DS. Incorporating motivational interviewing into behavioral obesity treatment. Cogn Behav Pract. 2003;10:120-130.
42. Borrelli B, Novak S, Hecht J, et al. Home health care nurses as a new channel for smoking cessation treatment: outcomes from project CARES (Community-nurse Assisted Research and Education on Smoking). Prev Med. 2005;41:815-821.
43. Woollard L, Beilin L, Lord T, et al. A controlled trial of nurse counselling on lifestyle change for hypertensives treated in general practice: preliminary results. Clin Exp Pharmacol Physiol. 1995;22:466-468.
44. Schmaling K, Blume A, Afari N. A randomized controlled pilot study of motivational interviewing to change attitudes about adherence to medications for asthma. J Clin Psych Med Settings. 2001;8:167-172.
45. Riekert KA, Borrelli B, Bilderback A, et al. The development of a motivational interviewing intervention to promote medication adherence among inner-city, African-American adolescents with asthma. Patient Educ Couns. 2011;82:117-122.
46. Butler C, Rollnick S, Cohen D, et al. Motivational consulting versus brief advice for smokers in general practice: a randomized trial. Br J Gen Pract. 1999;49:611-616.
• Stress the importance of exhaling gently for a few seconds before inhaling (deeply and slowly for a metered dose inhaler, and deeply and rapidly for most dry powder inhalers). C
• Observe the inhaler technique of every patient receiving inhalation therapy on more than one occasion. C
• Don’t rely on self-reports regarding inhaler technique; despite claims of proficiency, most patients make at least one mistake. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
For patients with asthma or chronic obstructive pulmonary disease (COPD), inhalation therapy is the foundation of treatment. Yet all too often, patients don’t get the full value of their inhaled medications because they use their inhaler incorrectly. When technique is markedly flawed, suboptimal outcomes typically result.
Given the number of Americans with asthma (at least 22 million)1 and COPD (more than 13 million adults),2 faulty inhaler technique is a major public health problem. In fact, the number of people suffering from COPD may be even larger: Close to 24 million US adults are believed to have impaired lung function.3,4 For patients with asthma or COPD—many of whom are treated by family physicians—comprehensive education with a focus on correct use of an inhaler is essential.
In this review, we present evidence of frequent inhaler errors (from clinical studies) and highlight some of the more common mistakes (based on our clinical experience [TABLE]5). Finally, we offer ‘‘time-efficient’’ solutions to inhaler problems—steps that physicians in busy primary care practices can take to ensure that patients with asthma or COPD get the maximum benefit from inhalation therapy.
TABLE
Caution patients about these device-specific mistakes*
| Metered dose inhaler |
|---|
|
| Metered dose inhaler plus spacer/VHC |
|
| Dry powder inhaler |
|
| *These are examples based on the experience of the authors; other errors are possible. †Timing is not as crucial as it is for an MDI without a spacer, but the drug is still lost if inhalation is delayed. ‡Correct use varies by type of product (see product literature for specifics). DPI, dry powder inhaler; MDI, metered dose inhaler; VHC, valved holding chamber. Source: Adapted with permission from Self TH, et al. Consultant. 2003.5 |
Inhaler error is well documented
Since 1965, when it was first reported that many patients used metered dose inhalers (MDIs) incorrectly,6 evidence has accumulated supporting the magnitude of the problem.7-12 (Studies conducted in family practice settings are described in “Researchers look at inhaler problems in primary care” and in TABLE W1.13-20)
A number of studies of various sizes (from 41 to 3955 patients) have assessed inhaler technique in patients being treated by clinicians in primary care. The researchers used a variety of scoring methods, as well. Among them were a simple 4-step (0-4) rating system, a 9-step system, a standardized inhaler-specific checklist, and a system that tracked the number of omissions patients made.13-20 All found significant problems with inhaler technique. (You’ll find a detailed look at the studies in TABLE W1 at jfponline.com.)
In one study of 422 patients,13 including young children, adolescents, and adults, participants received one point for correctly performing each of the following steps:
- Adequate preparation (shaking well for those using a metered dose inhaler [MDI]; loading correctly for patients using a dry powder inhaler [DPI])
- Adequate expiration, correct head position
- Adequate inspiratory technique
- Holding breath afterwards.
The researchers found that 25% of the patients had inadequate technique (≤2 on a 0-4 point scale). In this study, as in others that included patients using various types of devices, use of an MDI was associated with a higher rate of incorrect technique.
Another much-smaller study14 used the same 4-step system to assess the technique of 50 patients, all of whom had the same type of DPI and had received extensive training in the correct use of the device. Despite the training, 27% of the patients received scores of ≤2 (inadequate technique). Sixty-eight percent received a score of 3 (adequate); only 5% received a score of 4 (good).
The 2 largest studies—one including 3955 patients using MDIs20 and the other looking at 3811 patients using various kinds of devices18—found high levels of errors, as well. In the latter study, 76% of patients with MDIs made at least one error vs 49% to 55% of patients using DPIs.18 The results convinced a large majority of the physicians caring for these patients of the need to check inhaler technique more frequently. In the study of MDI users alone, 71% of the patients made at least one mistake.20 inhaler misuse was associated with higher asthma instability scores, this study showed.
More recently, a researcher assessed the effects of an integrated primary care model on the management of asthma and/or COPD in middle-aged and elderly patients, in a study of 260 patients in 44 family practices.19 The study included an evaluation of inhaler technique.
Participants were divided into an intervention group—137 patients who received education regarding inhaler use from a nurse—and a usual care group (123 patients). After 2 years, correct inhaler technique among those in the intervention group went from 41% at baseline to 54%. At the same time, the proportion of those in the usual care group with correct technique fell from 47% to 29%.19
Error rates vary widely from one clinical trial to another, depending on study criteria, type of device, and extent of patient education, among other factors. Nonetheless, several studies (spanning 3 decades) found the error rate to be close to, or greater than, 90%.7,10,21
The most recent of these, published in 2009,21 was based on observation of the inhaler technique used by patients with asthma or COPD directly following appointments in an outpatient clinic. The authors found that, although >98% of the study participants claimed to know how to use their inhalers, 94% committed at least one error. In this study and a number of others, user error was more likely in patients using MDIs.13,18,21,22
Adding a spacer (eg, a valved holding chamber such as the AeroChamber) can be helpful, as the spacer affords the patient more time to inhale the medication. But patients who use an MDI with a spacer often make mistakes, too, and patient education is essential.23-26
Breath-activated dry powder inhalers (DPIs)—such as the Flexhaler, HandiHaler, Aerolizer, and Diskus—also reduce the likelihood of error. DPIs eliminate a step that MDI users often struggle with: the need to simultaneously press down on the canister and begin a slow, deep inhalation.
What’s more, DPIs do not have to be shaken before use. Nonetheless, using a DPI still involves a series of actions. For the HandiHaler and Aerolizer, patients must load the dose, and some patients fail to read the directions and swallow the capsule instead of loading it into the device. Patients must remember to exhale away from the device (ie, not into the dry powder) before inhaling, then hold their breath for approximately 10 seconds. There is potential for error at each step.
Stress the need to exhale before using the inhaler
Forgetting to exhale before inhaling is a common, and significant, mistake regardless of the type of device. It is paramount to stress the need to exhale gently for a few seconds before inhaling (slowly and deeply for patients using an MDI, rapidly and deeply with most DPIs). For MDI users, poor timing, described earlier, is another common and serious mistake. Patients using an MDI with a valved holding chamber sometimes inhale for too long before pressing down on the inhaler, then are unable to continue inhaling although the aerosol is still in the chamber. A common error made by patients using multidose DPIs is simply to forget to load the dose.
Physicians need to brush up on their skills, too
It’s not just patients who lack proficiency in inhaler technique. Numerous studies have demonstrated poor skill among physicians and other health care professionals.27-34 Evidence also shows that targeted education results in substantial improvement.32,35
In one study undertaken to evaluate family medicine residents’ proficiency in using asthma inhalers, participants (an intervention group at one clinic and a control group at another) all were given a pretest. The intervention group then received educational materials and a tutorial, as well as the opportunity for hands-on practice, after which both groups were given a post-test. The residents who received the training had a 170% jump, on average, in proficiency score, vs a 55% increase for the control group (P<.001).35
Inhaled Medication Instructional Videos
Courtesy of: National Jewish Health
Go to http://www.nationaljewish.org/healthinfo/medications/lung-diseases/devices/instructional-videos
Another study—this one involving first-year interns—looked at level of improvement based on the type of education provided. Initially, only 5% of the interns could use an MDI without error. After a lecture and demonstration, 13% had an error-free technique. But when each intern participated in an intensive one-on-one session, the error-free rate reached 73%. The researchers’ conclusion: Lectures are relatively ineffective in teaching interns inhaler technique compared with a one-on-one approach.32
The Chicago Breathe Project,36 a new program aimed at improving education in the use of asthma inhalers for physicians and minority patients, provides further evidence of the value of clinician education. After a series of workshops for residents at 5 academic institutions, the physicians’ knowledge of proper use of inhalers rose dramatically—from just 5% preprogram to 91% postprogram (P<.001). Six months after the educational activity, the residents (n=161) were more likely (44% vs 11% preprogram) to assess patients’ inhaler technique.36
Teaching patients when time is tight
National and international guidelines stress the need to teach patients correct use of asthma and COPD inhalers.1,37,38 Providing the requisite education includes observation of each patient’s inhaler technique with proper use demonstrated, as needed.
The problem, of course, is how to provide that level of patient education within the time constraints of a busy family practice. We recommend these time-efficient solutions:
Enlist the help of other clinicians. While it is important that someone in your office be well trained and able to instruct patients in the proper use of inhalers, that individual need not be you. The National Institutes of Health recommends that the “principal clinician” introduce key educational messages, which can be reinforced and expanded on by other members of the health care team.1
After you advise patients that it is crucial for them to be trained in and adhere to proper inhaler technique, another health care professional—often a clinic nurse or pharmacist who has had special training—can provide the hands-on education. Studies have shown that when pharmacists who are competent in asthma management, including inhaler technique, work with physicians to optimize the education and overall management of patients with asthma, better outcomes often result, including a reduction in both emergency department visits and hospitalizations.1,39,40
Use videos to demonstrate correct technique. Videos are an effective teaching tool,9 and many of them are device-specific. National Jewish Health, which is world renowned for its asthma care, has a set of instructional videos posted on You-Tube and accessible from its Web site (http://www.nationaljewish.org/healthinfo/medications/lung-diseases/devices/instructional-videos). In addition to videos that demonstrate the use of an MDI alone and an MDI plus a valved holding chamber, the site has links to 6 DPI videos, each covering a different device.
Use intermittent observation. After the patient views the appropriate video, you or a member of your staff will still need to observe the patient’s inhaler technique to ensure correct use. Ideally, this should occur at every visit.1,37 When that’s not possible, use intermittent observation, starting with the first 2 or 3 visits after the introduction of inhalation therapy and then switching to periodic observation to ensure that the patient is maintaining good technique.
In determining how often observation is necessary, keep in mind that simply asking patients whether they are having inhaler problems is not sufficient.1 Patients tend to say they have little or no trouble when, in fact, most struggle, at times, with the devices. What’s more, good technique tends to decrease over time, and repetitive education is important.
To motivate patients, try this communication technique
Motivational interviewing, a technique that has been used to help patients battle obesity, quit smoking, and control hypertension,41-43 among other health problems, can help you identify inhaler problems that need to be addressed. It involves the use of open-ended questions (eg, “What worries you most about your asthma?”), affirmations (“You’ve done a great job testing your peak flow level every morning”), reflective listening (“You’re tired of taking medicine every day”), and summary statements (“You know you should take your medicine every day but you’re having trouble remembering it. Is that right?”).
A pilot study44 showed that when this technique was incorporated into an asthma education session, patient motivation increased. The ratio of perceived advantages vs disadvantages of taking asthma medication correctly improved, as well. Another study45 found that when motivational interviewing was used during home visits to inner-city African American adolescents for asthma care, the patients’ motivation, readiness to adhere to treatment, and asthma-related quality of life improved, although self-reported adherence to asthma medication did not. Further studies involving patients with asthma are under way (www.clinicaltrials.gov/ct2/results?term=asthma).
It is important to note that the use of motivational interviewing does not require a lengthy visit. One study found that on average, visits in which primary care physicians used this communication technique lasted less than 10 minutes.46
CORRESPONDENCE Timothy H. Self, PharmD, University of Tennessee Health Science Center, 881 Madison Avenue, Room 235, Memphis, TN 38163; tself@uthsc.edu
• Stress the importance of exhaling gently for a few seconds before inhaling (deeply and slowly for a metered dose inhaler, and deeply and rapidly for most dry powder inhalers). C
• Observe the inhaler technique of every patient receiving inhalation therapy on more than one occasion. C
• Don’t rely on self-reports regarding inhaler technique; despite claims of proficiency, most patients make at least one mistake. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
For patients with asthma or chronic obstructive pulmonary disease (COPD), inhalation therapy is the foundation of treatment. Yet all too often, patients don’t get the full value of their inhaled medications because they use their inhaler incorrectly. When technique is markedly flawed, suboptimal outcomes typically result.
Given the number of Americans with asthma (at least 22 million)1 and COPD (more than 13 million adults),2 faulty inhaler technique is a major public health problem. In fact, the number of people suffering from COPD may be even larger: Close to 24 million US adults are believed to have impaired lung function.3,4 For patients with asthma or COPD—many of whom are treated by family physicians—comprehensive education with a focus on correct use of an inhaler is essential.
In this review, we present evidence of frequent inhaler errors (from clinical studies) and highlight some of the more common mistakes (based on our clinical experience [TABLE]5). Finally, we offer ‘‘time-efficient’’ solutions to inhaler problems—steps that physicians in busy primary care practices can take to ensure that patients with asthma or COPD get the maximum benefit from inhalation therapy.
TABLE
Caution patients about these device-specific mistakes*
| Metered dose inhaler |
|---|
|
| Metered dose inhaler plus spacer/VHC |
|
| Dry powder inhaler |
|
| *These are examples based on the experience of the authors; other errors are possible. †Timing is not as crucial as it is for an MDI without a spacer, but the drug is still lost if inhalation is delayed. ‡Correct use varies by type of product (see product literature for specifics). DPI, dry powder inhaler; MDI, metered dose inhaler; VHC, valved holding chamber. Source: Adapted with permission from Self TH, et al. Consultant. 2003.5 |
Inhaler error is well documented
Since 1965, when it was first reported that many patients used metered dose inhalers (MDIs) incorrectly,6 evidence has accumulated supporting the magnitude of the problem.7-12 (Studies conducted in family practice settings are described in “Researchers look at inhaler problems in primary care” and in TABLE W1.13-20)
A number of studies of various sizes (from 41 to 3955 patients) have assessed inhaler technique in patients being treated by clinicians in primary care. The researchers used a variety of scoring methods, as well. Among them were a simple 4-step (0-4) rating system, a 9-step system, a standardized inhaler-specific checklist, and a system that tracked the number of omissions patients made.13-20 All found significant problems with inhaler technique. (You’ll find a detailed look at the studies in TABLE W1 at jfponline.com.)
In one study of 422 patients,13 including young children, adolescents, and adults, participants received one point for correctly performing each of the following steps:
- Adequate preparation (shaking well for those using a metered dose inhaler [MDI]; loading correctly for patients using a dry powder inhaler [DPI])
- Adequate expiration, correct head position
- Adequate inspiratory technique
- Holding breath afterwards.
The researchers found that 25% of the patients had inadequate technique (≤2 on a 0-4 point scale). In this study, as in others that included patients using various types of devices, use of an MDI was associated with a higher rate of incorrect technique.
Another much-smaller study14 used the same 4-step system to assess the technique of 50 patients, all of whom had the same type of DPI and had received extensive training in the correct use of the device. Despite the training, 27% of the patients received scores of ≤2 (inadequate technique). Sixty-eight percent received a score of 3 (adequate); only 5% received a score of 4 (good).
The 2 largest studies—one including 3955 patients using MDIs20 and the other looking at 3811 patients using various kinds of devices18—found high levels of errors, as well. In the latter study, 76% of patients with MDIs made at least one error vs 49% to 55% of patients using DPIs.18 The results convinced a large majority of the physicians caring for these patients of the need to check inhaler technique more frequently. In the study of MDI users alone, 71% of the patients made at least one mistake.20 inhaler misuse was associated with higher asthma instability scores, this study showed.
More recently, a researcher assessed the effects of an integrated primary care model on the management of asthma and/or COPD in middle-aged and elderly patients, in a study of 260 patients in 44 family practices.19 The study included an evaluation of inhaler technique.
Participants were divided into an intervention group—137 patients who received education regarding inhaler use from a nurse—and a usual care group (123 patients). After 2 years, correct inhaler technique among those in the intervention group went from 41% at baseline to 54%. At the same time, the proportion of those in the usual care group with correct technique fell from 47% to 29%.19
Error rates vary widely from one clinical trial to another, depending on study criteria, type of device, and extent of patient education, among other factors. Nonetheless, several studies (spanning 3 decades) found the error rate to be close to, or greater than, 90%.7,10,21
The most recent of these, published in 2009,21 was based on observation of the inhaler technique used by patients with asthma or COPD directly following appointments in an outpatient clinic. The authors found that, although >98% of the study participants claimed to know how to use their inhalers, 94% committed at least one error. In this study and a number of others, user error was more likely in patients using MDIs.13,18,21,22
Adding a spacer (eg, a valved holding chamber such as the AeroChamber) can be helpful, as the spacer affords the patient more time to inhale the medication. But patients who use an MDI with a spacer often make mistakes, too, and patient education is essential.23-26
Breath-activated dry powder inhalers (DPIs)—such as the Flexhaler, HandiHaler, Aerolizer, and Diskus—also reduce the likelihood of error. DPIs eliminate a step that MDI users often struggle with: the need to simultaneously press down on the canister and begin a slow, deep inhalation.
What’s more, DPIs do not have to be shaken before use. Nonetheless, using a DPI still involves a series of actions. For the HandiHaler and Aerolizer, patients must load the dose, and some patients fail to read the directions and swallow the capsule instead of loading it into the device. Patients must remember to exhale away from the device (ie, not into the dry powder) before inhaling, then hold their breath for approximately 10 seconds. There is potential for error at each step.
Stress the need to exhale before using the inhaler
Forgetting to exhale before inhaling is a common, and significant, mistake regardless of the type of device. It is paramount to stress the need to exhale gently for a few seconds before inhaling (slowly and deeply for patients using an MDI, rapidly and deeply with most DPIs). For MDI users, poor timing, described earlier, is another common and serious mistake. Patients using an MDI with a valved holding chamber sometimes inhale for too long before pressing down on the inhaler, then are unable to continue inhaling although the aerosol is still in the chamber. A common error made by patients using multidose DPIs is simply to forget to load the dose.
Physicians need to brush up on their skills, too
It’s not just patients who lack proficiency in inhaler technique. Numerous studies have demonstrated poor skill among physicians and other health care professionals.27-34 Evidence also shows that targeted education results in substantial improvement.32,35
In one study undertaken to evaluate family medicine residents’ proficiency in using asthma inhalers, participants (an intervention group at one clinic and a control group at another) all were given a pretest. The intervention group then received educational materials and a tutorial, as well as the opportunity for hands-on practice, after which both groups were given a post-test. The residents who received the training had a 170% jump, on average, in proficiency score, vs a 55% increase for the control group (P<.001).35
Inhaled Medication Instructional Videos
Courtesy of: National Jewish Health
Go to http://www.nationaljewish.org/healthinfo/medications/lung-diseases/devices/instructional-videos
Another study—this one involving first-year interns—looked at level of improvement based on the type of education provided. Initially, only 5% of the interns could use an MDI without error. After a lecture and demonstration, 13% had an error-free technique. But when each intern participated in an intensive one-on-one session, the error-free rate reached 73%. The researchers’ conclusion: Lectures are relatively ineffective in teaching interns inhaler technique compared with a one-on-one approach.32
The Chicago Breathe Project,36 a new program aimed at improving education in the use of asthma inhalers for physicians and minority patients, provides further evidence of the value of clinician education. After a series of workshops for residents at 5 academic institutions, the physicians’ knowledge of proper use of inhalers rose dramatically—from just 5% preprogram to 91% postprogram (P<.001). Six months after the educational activity, the residents (n=161) were more likely (44% vs 11% preprogram) to assess patients’ inhaler technique.36
Teaching patients when time is tight
National and international guidelines stress the need to teach patients correct use of asthma and COPD inhalers.1,37,38 Providing the requisite education includes observation of each patient’s inhaler technique with proper use demonstrated, as needed.
The problem, of course, is how to provide that level of patient education within the time constraints of a busy family practice. We recommend these time-efficient solutions:
Enlist the help of other clinicians. While it is important that someone in your office be well trained and able to instruct patients in the proper use of inhalers, that individual need not be you. The National Institutes of Health recommends that the “principal clinician” introduce key educational messages, which can be reinforced and expanded on by other members of the health care team.1
After you advise patients that it is crucial for them to be trained in and adhere to proper inhaler technique, another health care professional—often a clinic nurse or pharmacist who has had special training—can provide the hands-on education. Studies have shown that when pharmacists who are competent in asthma management, including inhaler technique, work with physicians to optimize the education and overall management of patients with asthma, better outcomes often result, including a reduction in both emergency department visits and hospitalizations.1,39,40
Use videos to demonstrate correct technique. Videos are an effective teaching tool,9 and many of them are device-specific. National Jewish Health, which is world renowned for its asthma care, has a set of instructional videos posted on You-Tube and accessible from its Web site (http://www.nationaljewish.org/healthinfo/medications/lung-diseases/devices/instructional-videos). In addition to videos that demonstrate the use of an MDI alone and an MDI plus a valved holding chamber, the site has links to 6 DPI videos, each covering a different device.
Use intermittent observation. After the patient views the appropriate video, you or a member of your staff will still need to observe the patient’s inhaler technique to ensure correct use. Ideally, this should occur at every visit.1,37 When that’s not possible, use intermittent observation, starting with the first 2 or 3 visits after the introduction of inhalation therapy and then switching to periodic observation to ensure that the patient is maintaining good technique.
In determining how often observation is necessary, keep in mind that simply asking patients whether they are having inhaler problems is not sufficient.1 Patients tend to say they have little or no trouble when, in fact, most struggle, at times, with the devices. What’s more, good technique tends to decrease over time, and repetitive education is important.
To motivate patients, try this communication technique
Motivational interviewing, a technique that has been used to help patients battle obesity, quit smoking, and control hypertension,41-43 among other health problems, can help you identify inhaler problems that need to be addressed. It involves the use of open-ended questions (eg, “What worries you most about your asthma?”), affirmations (“You’ve done a great job testing your peak flow level every morning”), reflective listening (“You’re tired of taking medicine every day”), and summary statements (“You know you should take your medicine every day but you’re having trouble remembering it. Is that right?”).
A pilot study44 showed that when this technique was incorporated into an asthma education session, patient motivation increased. The ratio of perceived advantages vs disadvantages of taking asthma medication correctly improved, as well. Another study45 found that when motivational interviewing was used during home visits to inner-city African American adolescents for asthma care, the patients’ motivation, readiness to adhere to treatment, and asthma-related quality of life improved, although self-reported adherence to asthma medication did not. Further studies involving patients with asthma are under way (www.clinicaltrials.gov/ct2/results?term=asthma).
It is important to note that the use of motivational interviewing does not require a lengthy visit. One study found that on average, visits in which primary care physicians used this communication technique lasted less than 10 minutes.46
CORRESPONDENCE Timothy H. Self, PharmD, University of Tennessee Health Science Center, 881 Madison Avenue, Room 235, Memphis, TN 38163; tself@uthsc.edu
1. National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; 2007.
2. Centers for Disease Control and Prevention. National Center for Health Statistics: National health interview survey raw data, 2008. Analysis performed by American Lung Association Research and Program Services.
3. American Lung Association. COPD—Helping the missing millions. February 24, 2010. Available at: http://www.lungusa.org/about-us/our-impact/top-stories/copd-helping-the-missing.html. Accessed November 9, 2011.
4. Centers for Disease Control and Prevention. Chronic obstructive pulmonary disease surveillance—United States, 1971-2000. MMWR Surveill Summ. 2002;51(6):1-16.
5. Self TH, Kilgore KE, Shelton V. MDIs, spacers, and dry powder inhalers: what patients are likely to do wrong. Consultant. 2003;49:702-705.
6. Saunders KB. Misuse of inhaled bronchodilator agents. Br Med J. 1965;1:1037-1038.
7. Epstein SW, Manning CPR, Ashley MJ, et al. Survey of the clinical uses of pressurized aerosol inhalers. Can Med Assoc J. 1979;120:813-816.
8. Shim C, Williams MH. The adequacy of inhalation of aerosol from canister nebulizers. Am J Med. 1980;69:891-894.
9. Self TH, Brooks JB, Lieberman P, et al. The value of demonstration and role of the pharmacist in teaching the correct use of pressurized bronchodilators. Can Med Assoc J. 1983;128:129-131.
10. Hartert TV, Windom HH, Peeples RS, et al. Inadequate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med. 1996;100:386-394.
11. Goodman DE, Israel E, Rosenberg M, et al. The influence of age, diagnosis, and gender on proper use of metered-dose inhalers. Am J Respir Crit Care Med. 1994;150:1256-1261.
12. Newman SP, Pavia D, Clarke SW. How should a pressurized beta-adrenergic bronchodilator be inhaled? Eur J Respir Dis. 1981;62:3-21.
13. Hilton S. An audit of inhaler technique among asthma patients of 34 general practitioners. Br J Gen Pract. 1990;40:505-506.
14. Dompeling E, Van Grunsven PM, Van Schayck GP, et al. Treatment with inhaled steroids in asthma and chronic bronchitis: long-term compliance and inhaler technique. Fam Pract. 1992;9:161-166.
15. Verver S, Poelman M, Bogels A, et al. Effects of instruction by practice assistants on inhaler technique and respiratory symptoms of patients. A controlled randomized videotaped intervention study. Fam Pract. 1996;13:35-40.
16. Dickinson J, Hutton S, Atkin A, et al. Reducing asthma morbidity in the community: the effect of a targeted nurse-run asthma clinic in an English general practice. Respir Med. 1997;91:634-640.
17. Hesselink AE, Penninx BW, Wijnhoven HA, et al. Determinants of an incorrect inhalation technique in patients with asthma or COPD. Scand J Prim Health Care. 2001;19:255-260.
18. Molimard M, Raherison C, Lignot S, et al. Assessment of handling of inhaler devices in real life: An observational study in 3811 patients in primary care. J Aerosol Med. 2003;16:249-254.
19. Meulepas MA, Jacobs JE, Smeenk FW, et al. Effect of an integrated primary care model on the management of middle-aged and old patients with obstructive lung diseases. Scand J Prim Health Care. 2007;25:186-192.
20. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J. 2002;19:246-251.
21. Souza ML, Meneghini AC, Ferraz E, et al. Knowledge of and technique for using inhalation devices among asthma patients and COPD patients. J Bras Pneumol. 2009;35:824-831.
22. Rootmensen GN, van Keimpema AR, Jansen HM, et al. Predictors of incorrect inhalation technique in patients with asthma or COPD: a study using a validated videotaped scoring method. J Aerosol Med Pulm Drug Deliv. 2010;23:323-328.
23. Rachelefsky GS, Rohr AS, Wo J, et al. Use of a tube spacer to improve the efficacy of a metered dose inhaler in asthmatic children. Am J Dis Child. 1986;140:1191-1193.
24. Demirkan K, Tolley E, Mastin T, et al. Salmeterol administration by metered-dose inhaler alone vs metered-dose inhaler plus valved holding chamber. Chest. 2000;117:1314-1318.
25. Pedersen S, Ostergaard PA. Nasal inhalation as a cause of inefficient pulmonal aerosol inhalation technique in children. Allergy. 1983;38:191-194.
26. Dolovich MD, Ahrens RS, Hess DR, et al. Device selection an outcomes of aerosol therapy: evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest. 2005;127:335-371.
27. Interiano B, Guntupalli KK. Metered-dose inhalers: do health care providers know what to teach? Arch Intern Med. 1993;153:81-85.
28. Hanania NA, Wittman R, Kesten S, et al. Medical personnel’s knowledge of and ability to use inhaling devices. Metered-dose inhalers, spacing chambers, and breath-actuated dry powder inhalers. Chest. 1994;105:111-116.
29. Amirav I, Goren A, Pawlowski NA. What do pediatricians in training know about the correct use of inhalers and spacer devices? J Allergy Clin Immunol. 1994;94:669-675.
30. Chopra N, Oprescu N, Fask A, et al. Does introduction of new “easy to use” inhalational devices improve medical personnel’s knowledge of their proper use? Ann Allergy Asthma Immunol. 2002;88:395-400.
31. Self TH, Arnold LB, Czosnowski LM, et al. Inadequate skill of healthcare professionals in using asthma inhalation devices. J Asthma. 2007;44:593-598.
32. Lee-Wong M, Mayo PH. Results of a programme to improve house staff use of metered dose inhalers and spacers. Postgrad Med J. 2003;79:221-225.
33. Muchao FP, Pern SL, Rodriques JC, et al. Evaluation of the knowledge of health professionals at a pediatric hospital regarding the use of metered dose inhalers. J Bras Pneumol. 2008;34:4-12.
34. Kim SH, Kwak HJ, Kim TB, et al. Inappropriate techniques used by internal medicine residents with three kinds of inhalers (a metered dose inhaler, Diskus, and Turbuhaler): changes after a single teaching session. J Asthma. 2009;46:944-950.
35. Kelcher S, Brownoff R. Teaching residents to use asthma devices. Assessing family residents’ skill and a brief intervention. Can Fam Physician. 1994;40:2090-2095.
36. Press VG, Pincayage AT, Pappalardo AA, et al. The Chicago Breathe Project: a regional approach to improving education on asthma inhalers for resident physicians and minority patients. J Natl Med Assoc. 2010;102:548-555.
37. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2010. Available at: www.ginasthma.org. Accessed November 9, 2011.
38. Executive Summary: global strategy on the diagnosis and management and prevention of chronic obstructive pulmonary disease. NHLBI/WHO Workshop Report, 2009. Available at: www.goldcopd.com. Accessed November 9, 2011.
39. Self TH, Chrisman CR, Mason DL, et al. Reducing emergency department visits and hospitalizations in African American and Hispanic patients: a 15-year review. J Asthma. 2005;42:807-812.
40. Armour C, Bosnic-Anticevich S, Brillant M, et al. Pharmacy asthma care program (PACP) improves outcomes for patients in the community. Thorax. 2007;62:496-502.
41. DiLillo V, Nicole J, West DS. Incorporating motivational interviewing into behavioral obesity treatment. Cogn Behav Pract. 2003;10:120-130.
42. Borrelli B, Novak S, Hecht J, et al. Home health care nurses as a new channel for smoking cessation treatment: outcomes from project CARES (Community-nurse Assisted Research and Education on Smoking). Prev Med. 2005;41:815-821.
43. Woollard L, Beilin L, Lord T, et al. A controlled trial of nurse counselling on lifestyle change for hypertensives treated in general practice: preliminary results. Clin Exp Pharmacol Physiol. 1995;22:466-468.
44. Schmaling K, Blume A, Afari N. A randomized controlled pilot study of motivational interviewing to change attitudes about adherence to medications for asthma. J Clin Psych Med Settings. 2001;8:167-172.
45. Riekert KA, Borrelli B, Bilderback A, et al. The development of a motivational interviewing intervention to promote medication adherence among inner-city, African-American adolescents with asthma. Patient Educ Couns. 2011;82:117-122.
46. Butler C, Rollnick S, Cohen D, et al. Motivational consulting versus brief advice for smokers in general practice: a randomized trial. Br J Gen Pract. 1999;49:611-616.
1. National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; 2007.
2. Centers for Disease Control and Prevention. National Center for Health Statistics: National health interview survey raw data, 2008. Analysis performed by American Lung Association Research and Program Services.
3. American Lung Association. COPD—Helping the missing millions. February 24, 2010. Available at: http://www.lungusa.org/about-us/our-impact/top-stories/copd-helping-the-missing.html. Accessed November 9, 2011.
4. Centers for Disease Control and Prevention. Chronic obstructive pulmonary disease surveillance—United States, 1971-2000. MMWR Surveill Summ. 2002;51(6):1-16.
5. Self TH, Kilgore KE, Shelton V. MDIs, spacers, and dry powder inhalers: what patients are likely to do wrong. Consultant. 2003;49:702-705.
6. Saunders KB. Misuse of inhaled bronchodilator agents. Br Med J. 1965;1:1037-1038.
7. Epstein SW, Manning CPR, Ashley MJ, et al. Survey of the clinical uses of pressurized aerosol inhalers. Can Med Assoc J. 1979;120:813-816.
8. Shim C, Williams MH. The adequacy of inhalation of aerosol from canister nebulizers. Am J Med. 1980;69:891-894.
9. Self TH, Brooks JB, Lieberman P, et al. The value of demonstration and role of the pharmacist in teaching the correct use of pressurized bronchodilators. Can Med Assoc J. 1983;128:129-131.
10. Hartert TV, Windom HH, Peeples RS, et al. Inadequate outpatient medical therapy for patients with asthma admitted to two urban hospitals. Am J Med. 1996;100:386-394.
11. Goodman DE, Israel E, Rosenberg M, et al. The influence of age, diagnosis, and gender on proper use of metered-dose inhalers. Am J Respir Crit Care Med. 1994;150:1256-1261.
12. Newman SP, Pavia D, Clarke SW. How should a pressurized beta-adrenergic bronchodilator be inhaled? Eur J Respir Dis. 1981;62:3-21.
13. Hilton S. An audit of inhaler technique among asthma patients of 34 general practitioners. Br J Gen Pract. 1990;40:505-506.
14. Dompeling E, Van Grunsven PM, Van Schayck GP, et al. Treatment with inhaled steroids in asthma and chronic bronchitis: long-term compliance and inhaler technique. Fam Pract. 1992;9:161-166.
15. Verver S, Poelman M, Bogels A, et al. Effects of instruction by practice assistants on inhaler technique and respiratory symptoms of patients. A controlled randomized videotaped intervention study. Fam Pract. 1996;13:35-40.
16. Dickinson J, Hutton S, Atkin A, et al. Reducing asthma morbidity in the community: the effect of a targeted nurse-run asthma clinic in an English general practice. Respir Med. 1997;91:634-640.
17. Hesselink AE, Penninx BW, Wijnhoven HA, et al. Determinants of an incorrect inhalation technique in patients with asthma or COPD. Scand J Prim Health Care. 2001;19:255-260.
18. Molimard M, Raherison C, Lignot S, et al. Assessment of handling of inhaler devices in real life: An observational study in 3811 patients in primary care. J Aerosol Med. 2003;16:249-254.
19. Meulepas MA, Jacobs JE, Smeenk FW, et al. Effect of an integrated primary care model on the management of middle-aged and old patients with obstructive lung diseases. Scand J Prim Health Care. 2007;25:186-192.
20. Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J. 2002;19:246-251.
21. Souza ML, Meneghini AC, Ferraz E, et al. Knowledge of and technique for using inhalation devices among asthma patients and COPD patients. J Bras Pneumol. 2009;35:824-831.
22. Rootmensen GN, van Keimpema AR, Jansen HM, et al. Predictors of incorrect inhalation technique in patients with asthma or COPD: a study using a validated videotaped scoring method. J Aerosol Med Pulm Drug Deliv. 2010;23:323-328.
23. Rachelefsky GS, Rohr AS, Wo J, et al. Use of a tube spacer to improve the efficacy of a metered dose inhaler in asthmatic children. Am J Dis Child. 1986;140:1191-1193.
24. Demirkan K, Tolley E, Mastin T, et al. Salmeterol administration by metered-dose inhaler alone vs metered-dose inhaler plus valved holding chamber. Chest. 2000;117:1314-1318.
25. Pedersen S, Ostergaard PA. Nasal inhalation as a cause of inefficient pulmonal aerosol inhalation technique in children. Allergy. 1983;38:191-194.
26. Dolovich MD, Ahrens RS, Hess DR, et al. Device selection an outcomes of aerosol therapy: evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest. 2005;127:335-371.
27. Interiano B, Guntupalli KK. Metered-dose inhalers: do health care providers know what to teach? Arch Intern Med. 1993;153:81-85.
28. Hanania NA, Wittman R, Kesten S, et al. Medical personnel’s knowledge of and ability to use inhaling devices. Metered-dose inhalers, spacing chambers, and breath-actuated dry powder inhalers. Chest. 1994;105:111-116.
29. Amirav I, Goren A, Pawlowski NA. What do pediatricians in training know about the correct use of inhalers and spacer devices? J Allergy Clin Immunol. 1994;94:669-675.
30. Chopra N, Oprescu N, Fask A, et al. Does introduction of new “easy to use” inhalational devices improve medical personnel’s knowledge of their proper use? Ann Allergy Asthma Immunol. 2002;88:395-400.
31. Self TH, Arnold LB, Czosnowski LM, et al. Inadequate skill of healthcare professionals in using asthma inhalation devices. J Asthma. 2007;44:593-598.
32. Lee-Wong M, Mayo PH. Results of a programme to improve house staff use of metered dose inhalers and spacers. Postgrad Med J. 2003;79:221-225.
33. Muchao FP, Pern SL, Rodriques JC, et al. Evaluation of the knowledge of health professionals at a pediatric hospital regarding the use of metered dose inhalers. J Bras Pneumol. 2008;34:4-12.
34. Kim SH, Kwak HJ, Kim TB, et al. Inappropriate techniques used by internal medicine residents with three kinds of inhalers (a metered dose inhaler, Diskus, and Turbuhaler): changes after a single teaching session. J Asthma. 2009;46:944-950.
35. Kelcher S, Brownoff R. Teaching residents to use asthma devices. Assessing family residents’ skill and a brief intervention. Can Fam Physician. 1994;40:2090-2095.
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