What do pediatricians in training know about the correct use of inhalers and spacer devices?

ELLIPTA Dry Powder Versus Metered-Dose Inhalers in an Optimized Clinical Trial Setting

BACKGROUND

Reduced error rates have been demonstrated with the ELLIPTA inhaler versus other commonly used devices.

OBJECTIVE

This phase IV, randomized, crossover study evaluated correct use of ELLIPTA compared with 2 commonly prescribed metered-dose inhalers (MDIs) in adults with asthma and optimized inhaler technique.

METHODS

The study comprised 2 crossover substudies (ELLIPTA vs MDI-1 and ELLIPTA vs MDI-2). Inhaler use was assessed at the start of each period, following instruction from a health care professional, and after 28 days of use without instruction. Data for each inhaler were pooled within substudies, irrespective of treatment sequence; study objectives were addressed in each substudy. The primary end point, percentage of participants making 0 errors after 28 days of use, was analyzed separately for each substudy using a Mainland-Gart test for each ELLIPTA versus MDI comparison.

RESULTS

Correct use rates after 28 days were higher with ELLIPTA than with MDI-1 and MDI-2 (ELLIPTA vs MDI-1, 96% vs 84%; ELLIPTA vs MDI-2, 98% vs 91%). Among discordant cases, statistically significantly more participants correctly used ELLIPTA but made 1 or more overall error with MDIs than did those who correctly used the MDIs but made 1 or more overall error using ELLIPTA (87% vs 13% in both substudies; P < .001 and P = .007 for ELLIPTA vs MDI-1 and ELLIPTA vs MDI-2, respectively). More participants made multiple device errors with MDIs than with ELLIPTA.

CONCLUSIONS

Inhaler technique can be optimized in trial settings. In such settings, ELLIPTA is associated with higher rates of correct use and lower error rates than are MDIs.

Fixed versus variable practice for teaching medical students the management of pediatric asthma exacerbations using simulation

Simulation-based trainings represent an interesting approach to teach medical students the management of pediatric asthma exacerbations (PAEs). In this study, we compared two pedagogical approaches, training students once on three different scenarios of PAEs versus training students three times on the same scenario of PAE. Eighty-five third-year medical students, novice learners for the management of PAEs, were randomized and trained. Students were assessed twice, 1 week and 4 months after the training, on a scenario of PAE new to both groups and on scenarios used during the training. The main outcome was the performance score on the new scenario of PAE at 1 week, assessed on a checklist custom-designed for the study. All students progressed rapidly and acquired excellent skills. One week after the training, there was no difference between the two groups on all the scenarios tested, including the new scenario of PAE (median performance score (IQR) of 8.3 (7.4-10.0) in the variation group versus 8.0 (6.0-10.0) in the repetition group (p = 0.16)). Four months later, the performance of the two groups remained similar.

CONCLUSION

Varying practice with different scenarios was equivalent to repetitive practice on the same scenario for novice learners, with both methods leading to transfer and long-term retention of the skills acquired during the training. What is known: • Simulation-based trainings represent an interesting approach to teach medical students the management of pediatric asthma exacerbations. • It is unclear whether students would benefit more from repetitive practice on the same scenario of asthma exacerbation or from practice on different scenarios in terms of transfer of skills. What is new: • An individual 30-min training on the management of pediatric asthma exacerbations using simulation allows transfer and long-term retention of the skills acquired. • Varying practice with different scenarios is equivalent to repetitive practice on the same scenario in terms of transfer of skills.

[Health care providers' knowledge and abilities to use inhalation devices and spacers]

INTRODUCTION

Inhaled therapy is the mainstay of asthma treatment due to its local and rapid action. However, its efficiency relies on the teaching of a good inhalation technique by health care providers. We assessed health care providers' knowledge and practical skills in the use of inhalation devices.

METHODS

An observational multicenter study was conducted in the pulmonology and paediatric wards in Marseille. The departments' common practices, theoretical knowledge and practical skills were assessed through a questionnaire and a demonstration using a spacer device.

RESULTS

Forty health care providers were interviewed (9 attending physicians, 14 residents, 16 nurses and 1 physiotherapist), in 8 different pulmonology and paediatric wards. A total of 42.5% reported previous training in inhalation device technique. When evaluating theoretical knowledge, we found a mean of 54% correct answers. Attending physicians did significantly better than residents and nurses. With regard to practical skills, we found a mean of 1.12 failed steps out of 7. Here again attending physicians did significantly better than residents and nurses.

CONCLUSION

Based on the results of our study, we recommend that attending physicians provide training of inhalation technique to nurses and residents, as they did significantly better theoretically and practically.

Empowering family physicians to impart proper inhaler teaching to patients with chronic obstructive pulmonary disease and asthma

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) and asthma depend on inhalers for management, but critical errors committed during inhaler use can limit drug effectiveness. Outpatient education in inhaler technique remains inconsistent due to limited resources and inadequate provider knowledge.

OBJECTIVE

To determine whether a simple, two-session inhaler education program can improve physician attitudes toward inhaler teaching in primary care practice.

METHODS

An inhaler education program with small-group hands-on device training was instituted for family physicians (FP) in British Columbia and Alberta. Sessions were spaced one to three months apart. All critical errors were corrected in the first session. Questionnaires surveying current inhaler teaching practices and attitudes toward inhaler teaching were distributed to physicians before and after the program.

RESULTS

Forty-one (60%) of a total 68 participating FPs completed both before and after program questionnaires. Before the program, only 20 (49%) reported providing some form of inhaler teaching in their practices, and only four (10%) felt fully competent to teach patients inhaler technique. After the program, 40 (98%) rated their inhaler teaching as good to excellent. Thirty-four (83%) reported providing inhaler teaching in their practices, either by themselves or by an allied health care professional they had personally trained. All stated they could teach inhaler technique within 5 min. Observation of FPs during the second session by certified respiratory educators found that none made critical errors and all had excellent technique.

CONCLUSION

A physician inhaler education program can improve attitudes toward inhaler teaching and facilitate implementation in clinical practices.

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

BACKGROUND

While initial education and regular evaluation of inhaler technique in patients are emphasized in the management of asthma and chronic obstructive pulmonary disease, health care professionals are not experienced in using inhalers. This study assessed whether internal medicine residents used common inhalers correctly and whether a single teaching session successfully improved their performance.

METHODS

We evaluated 142 internal medicine residents from six university hospitals in Korea for their techniques with three different inhaler devices: a metered dose inhaler (MDI), Diskus, and Turbuhaler. We assessed whether participants completed each step in using the three inhalers and classified overall performance as good, adequate, or inadequate for each inhaler type. To estimate the effect of a single teaching session, reassessment was performed 2 months after education.

RESULTS

Performance grade was inadequate for 50.7% of participants with a MDI, 43.0% for Diskus, and 51.4% for Turbuhaler. An early year of residency was associated significantly with inappropriate technique for Diskus (p = 0.003), but not for MDI and Turbuhaler. After a single teaching session, overall skills improved significantly for all three inhalers. The proportion of subjects with good or adequate skill changed notably from 39.7% to 83.8% for MDI (p = 0.001), from 50.0% to 86.8% for Diskus (p = 0.001), and from 44.1% to 88.2% for Turbuhaler (p = 0.001).

CONCLUSIONS

These findings demonstrate that a high proportion of internal medicine residents cannot use inhalers correctly and just a single teaching can effectively enhance their inhaler technique.

MDI inhalers: do nursing home support staff have correct technique?

Many elderly patients in nursing homes in the United States use metered-dose inhaler (MDI) medications for a variety of lung diseases. We wondered how much the nursing support staff knew about correct MDI inhaler technique. Thirty-eight nursing home support staff were asked to demonstrate correct use of a placebo MDI inhaler on themselves. The staff completed an average of 6.9 steps out of 8 correctly. The most common error demonstrated was the staff did not hold their breath for 10 seconds at full inspiration after inhaling the medication. The results suggest that the support staff have incorrect MDI inhaler technique.

The Diskus: a review of its position among dry powder inhaler devices

The use of dry powder inhalers (DPIs) to administer treatments for respiratory diseases has increased significantly in recent years. There is now a wide range of DPIs available that vary considerably in design, required operational techniques, output characteristics and drug delivery across a range of inhalation patterns. Different patient populations may find individual types of DPI easier to use correctly than others and selecting the right DPI for particular patient requirements will improve compliance with therapy. For example, some DPIs offer a greater resistance against inspirational flow rate than others which affects the total emitted dose and also fine particle mass of the aerosol released. An individual patient may therefore receive different amounts of drug when inhaling from different DPIs. Therefore, it is important that the prescriber is fully aware of the characteristics of the different types of DPI, so that he or she can prescribe the device that is most appropriate to an individual patient's needs. This review explores the characteristics of currently available DPIs and evaluates their efficacy and patient acceptability. The differences in output characteristics, ease of use and patient preferences between available devices is shown to affect treatment efficacy and patient compliance with therapy. Changing the DPI prescribed to a patient to a cheaper or generic device may therefore adversely affect disease control and thereby increase the cost of treatment.

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.

Factors influencing the responsiveness to inhaled glucocorticoids of patients with moderate-to-severe asthma

STUDY OBJECTIVES

Inhaled glucocorticoids (GCs) are the most effective control therapy for asthma. Although the clinical effects of inhaled GCs vary, there are few data on the differences in the responsiveness of individuals to inhaled GCs. The purpose of this study was to identify those factors that are associated with responsiveness to high-dose inhaled GCs in patients with moderate-to-severe asthma.

DESIGN

This study was a prospective analysis.

SETTING

Outpatient clinics of tertiary hospitals.

PATIENTS

Eighty-six adult outpatients with moderate-to-severe asthma.

METHODS

Eighty-six patients with asthma who had initial FEV1 values of < 80% predicted after they had received inhaled GCs (fluticasone propionate, 1,000 microg/d) for 4 weeks. The primary end points were FEV1, FEV1/FVC ratio, forced expiratory flow (midexpiratory phase), and the score at presentation in the asthma-related quality-of-life questionnaire (AQLQ).

RESULTS

The inhalation of GCs for 4 weeks had significant improvements in the FEV1% predicted and in the AQLQ score compared with the baseline values. Asthmatic patients with responses of > 12% (n = 46, 53.4%) in the change in FEV1 (deltaFEV1 = [FEV1 at 4 weeks--baseline FEV1]/baseline FEV1 x 100) also had significantly higher proportions of blood eosinophils and lower FEV1 values (in liters) prior to treatment. The change in FEV1 values correlated with the number of sputum eosinophils prior to GC inhalation (r = 0.242; p < 0.05) and correlated inversely with the FEV1 percent predicted values prior to GC inhalation (r = -0.462; p < 0.001).

CONCLUSION

The FEV1 percent predicted and the blood and sputum eosinophil levels prior to GC inhalation are associated with the responsiveness to inhaled GCs in patients with moderate-to-severe asthma.

Effect of high dose inhaled glucocorticoids on quality of life in patients with moderate to severe asthma

Asthma is a chronic disorder that can place considerable restrictions on the physical, emotional, and social aspects of the lives of patients. Inhaled glucocorticoids (GCs) are the most effective controller therapy. The purpose of this study was to evaluate the effect of inhaled GCs on quality of life in patients with moderate to severe asthma. Patients completed the asthma quality of life questionnaire (AQLQ) and pulmonary function test at baseline and after 4 wks treatment of GCs. We enrolled 60 patients who had reversibility in FEV1 after 200 microgram of albuterol of 15% or more and/or positive methacholine provocation test, and initial FEV1% predicted less than 80%. All patients received inhaled GCs (fluticasone propionate 1,000 microgram/day) for 4 wks. The score of AQLQ was significantly improved following inhaled GCs (overall 51.9+/-14.3 vs. 67.5+/-12.1, p<0.05). The change from day 1 to day 28 in FEV1 following inhaled GCs was diversely ranged from -21.0% to 126.8%. The improvement of score of AQLQ was not different between at baseline and after treatment of GCs according to asthma severity and GCs responsiveness. Quality of life was improved after inhaled GCs regardless of asthma severity and GCs responsiveness in patients with moderate to severe asthma.

Increasing asthma awareness among physicians: impact on patient management and satisfaction

Our objective was to investigate the impact of increased asthma awareness among primary care physicians on the asthma control and satisfaction of their patients. Physicians attended an asthma education session with emphasis on patient-physician partnership followed by 4 month monitored follow-up of patients aged 5-44 years with mild to moderate asthma. Findings were compared with a group of patients whose physician attended the session but did not participate in the follow-up and two other control groups. The study included pediatricians and general practitioners of Maccabi Healthcare Services and their patients. Asthma symptoms were rated by patients and physicians. Data on drug prescription and use were derived from the Maccabi central database. Patient response and satisfaction and physician satisfaction were evaluated by telephone interviews. Mean asthma symptom score improved from 2.0 to 1.1 in the study group of patients (p < 0.001). The use of reliever drugs decreased concomitantly with a rise in controller drugs in all patients. An improvement in asthma status was reported by 64% of the study patients and 39% of non-participating patients (p = 0.007). Fifty-eight percent of the patients rated their competence to deal with asthma as high before the intervention compared to 62% of the participating and 55% of the non-participating patients after the intervention (p = 0.002). Most physicians claimed that simply increasing their awareness on asthma led to beneficial results in their patients. Physician education followed by monitored follow-up enhanced asthma control and patient satisfaction. Nevertheless, physician education alone appears to have a significant isolated impact on asthma control.

Inhaled medication for asthma management: evaluation of how asthma patients, medical students, and doctors use the different devices

Asthma results from a combination of three essential features: airflow obstruction, hyperresponsiveness of airways to endogenous or exogenous stimuli and inflammation. Inadequacy of the techniques to use different inhalation devices is one of the causes of therapeutic failure. The main purpose of this study was to evaluate how 20 medical students, 36 resident physicians of Internal Medicine/Pediatrics, and 40 asthma patients used three devices for inhalation therapy containing placebo. All patients were followed at the Pulmonary Outpatient Service of Botucatu Medical School and had been using inhaled medication for at least six months. The following devices were evaluated: metered dose inhalers (MDI), dry powder inhalers (DPI), and MDI attached to a spacer device. A single observer applied a protocol containing the main steps necessary to obtain a good inhaler technique to follow and grade the use of different devices. Health care professionals tested all three devices and patients tested only the device being used on their management. MDI was the device best known by doctors and patients. MDI use was associated with errors related to the coordination between inspiration and device activation. Failure to exhale completely before inhalation of the powder was the most frequent error observed with DPI use. In summary, patients did not receive precise instruction on how to use inhaled medication and health care professionals were not well prepared to adequately teach their patients.

Results of a programme to improve house staff use of metered dose inhalers and spacers

PURPOSE

Metered dose inhalers (MDIs) and spacers are used widely in the treatment of asthma. Medical personnel who are responsible for training patients must themselves be proficient with the devices. The proficiency of a group of new medical interns with use of MDI and spacer devices was determined, and improvement in their use of these devices was sought.

SUBJECTS

Fifty six medical interns tested at the start of their first house staff training year.

METHODS

The ability of medical interns to use MDIs and spacers was assessed using a visual scoring system before and after a large group lecture emphasising proper device use and once again after an intensive one-on-one training session with an attending physician.

RESULTS

Initially, only 5% used an MDI perfectly. This improved to 13% after a lecture and demonstration, and 73% after an intensive one-on-one session. Almost no new interns could use a collapsible or tube spacer properly initially. This improved to 15% and 29% respectively after a lecture. After one-on-one training, correct technique was increased to 69% for collapsible spacer and 95% for the tube spacer. Analysis of individual steps of MDI use showed that interns had particular difficulty in coordinating actuation with inhalation. The tube spacer appeared easiest to learn.

CONCLUSIONS

Incoming medical house staff have limited ability to use MDI with and without spacers. A large group lecture is relatively ineffective when compared with a one-on-one training session in training with these devices.

Use of a paper disposable cup as a spacer is effective for the first-aid management of asthma

OBJECTIVE

There are many settings in which a spacer device is not available for the administration of bronchodilator. Therefore, we tested whether a paper disposable cup is as effective as a commercially produced spacer to administer bronchodilator.

METHODOLOGY

Randomised controlled trial. 50 subjects aged 16-50 years who had wheeze and a greater than 10% decrease in FEV1 after histamine inhalation test (HIT). Subjects were randomised to either the 150 ml paper disposable cup group (CUP) or the commercially produced spacer group (SPACER). Twenty minutes after 400 microg salbutamol was administered FEV1 was measured. The recovery index measured post-bronchodilator FEV1 as a percentage of baseline FEV1. Also, analysis of covariance tested whether recovery of FEV1 was related to the magnitude of the fall following the HIT.

RESULTS

There were no statistically significant differences between CUP and SPACER groups in any characteristics. There was no difference for the recovery index (t48=1.14, P=0.26). Regression analyses showed that the relation between the magnitude of the fall in FEV1 during the HIT and the percent recovery was not different between the CUP and SPACER groups (t=-1.2, P<0.23).

CONCLUSIONS

A paper disposable cup was effective for the reversal of mild to moderate bronchoconstriction. Therefore, a paper disposable cup can be used for the first-aid management of asthma when there is concern about cross-infection and a commercially produced spacer is not available.

Evolution of dry powder inhaler design, formulation, and performance

Many companies are now prioritizing the development of dry powder inhalers (DPIs) above pressurized formulations of asthma drugs. A well-designed DPI and an appropriate powder formulation can optimize the effectiveness of inhaled drug therapy. A DPI must be able to deliver medications effectively for most patients, and an ideal inhaler would provide a dose that does not vary with inspiratory flow rate. Recent regulatory guidelines, among which the U.S. FDA draft guidance is the most stringent, demand consistent dose delivery from an inhaler throughout its life and consistency of doses from one inhaler to another. However, the properties of free micronized powders often interfere with drug handling and with drug delivery reducing dose consistency. Recent advances in formulation technology can increase lung dose and reduce its variability. While a perfect DPI may never exist, both device and formulation technology are evolving to rectify perceived deficiencies in earlier systems.

Inhalation treatment: errors in application and difficulties in acceptance of the devices are frequent in wheezy infants and young children

The recent availability of small-volume spacers has facilitated the general use of inhaled treatment in infants. The purpose of this study was to evaluate any errors made by parents when using this new inhalation technique and the child's behavior during the inhalation. Ninety-four young children (61% boys) under 5 years of age were enrolled in the study. Inhalation treatment was recommended either by a general practitioner or by a pediatrician. Data concerning treatment regimens, the ability of parents to use the spacer and metered-dose inhalers (MDIs), and the acceptance of the devices, were collected by means of a demonstration and questionnaire. Unexpectedly, the doses, administration times, and duration of the treatments varied from one child to the next. No explanation or training in administering the treatment via the spacers was given to 12% and 47% of the parents, respectively. Fourteen per cent of parents did not shake the MDIs, 12% did not monitor the valves, and 22% allowed too short a time for inhalation. The lack of explanation increased the occurrence of errors in manipulation of the devices. The procedure was judged to be easy to follow by 78% of the parents, but the face mask was accepted with difficulty by 22% of the children. Repeated crying during administration of the treatment was observed in 38% of the patients, particularly the youngest. Crying influenced the acceptance of the face mask, reduced parental compliance, and made the use of the devices more difficult. Errors altering the efficiency of inhalation treatment in infants are frequent. Most of these errors could be avoided by spending more time to inform the parents about correct usage. Furthermore, repeated crying during inhalation is common in young children and this problem should to be taken into consideration in the evaluation of treatment.

[Method for using inhalation chambers with facial masks in asthma. Evaluation in 60 children below four years of age]

Spacers with face masks are widely used for the treatment of asthma in young children. A poor inhalation technique may compromise the treatments efficiency.

METHODS

The inhalation technique of spacers with face masks was evaluated in a prospective study of 60 children below four years of age. A checklist of 12 items was used, each one being coded by zero or one, and a total score < or = 12 points was calculated.

RESULTS

Mean total score was 8.93 +/- 1.84 (extremes: 6-12). The canister was shaken before use in 48.3% of cases, one puff delivered when the child was breathing in 71.7% and the valve's mobility checked in 85%. The canister was shaken before the second puff in 13.3% of cases and two consecutive puffs individualized in 28%.

DISCUSSION

The usual mistakes are lacking to shake the canister and consecutive puffs' individualization. Medical partners and families education should be reinforced.

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.

[Evaluation of the ability of asthmatic children to use a breath-actuated pressurized inhaler]

BACKGROUND

Poor inhaler technique in asthmatics is well documented. The objective of this study was to evaluate the influence of reading the instruction leaflet and the consultant's explanations on the use of the new breath-actuated inhaler (Autohaler 3M).

METHODS

In this study were participating 379 asthmatic children and adolescents, aged from four to 17 years (mean age: 10; 64% boys), recruited by 80 pediatricians. The use of the Autohaler device was considered to be correct if the shaking, lip position, deep inhalation and apnea were all properly performed.

RESULTS

The Autohaler was used correctly by 42% of the subjects simply after reading the instruction leaflet (phase I), and by 75% of the subjects who, having failed phase I, received the consultant's explanations (phase II). At the end of phases I and II, the device was correctly used by 84% of the subjects. In multivariate analysis, those under the age of nine years and those with no prior use of inhaler systems accounted for a significant amount of the incorrect use of the Autohaler during phase I. In phase II, only the fact of being less than nine years old was significantly related to incorrect use.

CONCLUSION

More than four-fifths of the asthmatic children and adolescents properly used the Autohaler after merely reading the instructions and after receiving additional explanation from the consultant. The marked improvement obtained after medical explanations underlines the essential educative role of the physician when prescribing. Young children require specific training and particularly careful attention.

The choice of inhalers in adults and children over six

Available delivery systems for ambulatory use include the conventional suspension pressurized metered dose inhaler (MDI), the conventional MDI with add-on devices such as spacing chambers and several powder delivery systems. Gas-driven or ultrasonic nebulizers are also available but are generally reserved for in-hospital use or for the treatment of the most severely obstructed patients. It is difficult to select one best system for use in older children, adolescents and adults; all available systems have their deficiencies and these are outlined here. The most widely prescribed device, the MDI, is misused by some patients with claims of up to one-third of clinic patients showing inadequate inhaler technique. In the 1990s, the MDI has also been criticized for liberating chlorofluorocarbons (CFCs). On occasion, the adjuvants are said to precipitate cough. In some countries, the production of generic or second entry inhalers has been accompanied by vexing concerns over the bioequivalence of therapeutic aerosols. The problem of patient coordination with the inhaler is meant to be dealt with by a variety of add-on devices. Spacing chambers and reservoir systems improve drug delivery and treatment efficacy for some patients. Unfortunately, there are relatively few data on patient spacer technique or optimal teaching methods. There is considerable potential for patient misuse of these superficially simple devices. One common problem is that the devices become dirty and worn but are seldom replaced by patients. A more subtle problem is electrostatic drug adherence to the spacing chamber thereby reducing drug delivery.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of structured versus conventional inhaler education in medical housestaff

Despite the importance of adequate inhaler technique in the care of asthma and chronic obstructive pulmonary disease, physicians have often been shown to have poor knowledge of correct inhaler use. At present, postgraduate teaching programs appear to leave physicians to acquire inhaler handling skills informally in the context of day-to-day patient care. We undertook the present study to determine if one brief structured educational intervention would be adequate to teach postgraduate physicians inhaler skills that would be retained over long periods of time. We also compared the efficacy of this intervention to traditional education methods. We recruited 52 postgraduate trainees in internal medicine at a large university hospital; 26 were in the educational intervention group and 26 were in the control group. Physicians in the intervention group were asked to respond to a questionnaire on inhaler use and to demonstrate the correct use of a metered-dose inhaler (MDI), an MDI with a pacing chamber and a multidose dry-powder inhaler. These intervention subjects were then instructed on proper inhaler usage by a qualified nurse educator. Eight months later, testing was repeated in the intervention group and was undertaken in the control group. Questionnaire scores were significantly higher in the intervention group at the 8-month follow-up than at baseline (59% vs. 42%; p < 0.05). Similarly, the scores of the intervention group at follow-up were significantly higher than those of the control group (59% vs. 39%; p < 0.05). There was no significant difference between the baseline scores of the intervention group and those of the control group. The mean demonstration score was significantly higher in the intervention group at follow-up than at baseline (68% vs. 39%; p < 0.001) and was also higher than that of the control group (68% vs. 44%; p < 0.001). There was no significant difference between the scores for all devices between the intervention group before education and the control group. Our data show that one brief teaching session is sufficient to produce a sustained improvement in knowledge and handling of inhalers by postgraduate physicians. The knowledge and skills of the physicians educated in our study were not only better than before they had received instruction, but were better than the knowledge and skills of postgraduate trainees from the same institution who had received no formal training. This latter observation suggests a failure of traditional unstructured postgraduate training programs to teach this practical patient care skill.

Medication compliance and asthma: overlooking the trees because of the forest

A number of reviews have described medication compliance and asthma. The consensus emerging from the analyses and discussion of the topic is that compliance to treatment regimens is generally poor. The current article describes several trees overlooked in the forest of data generated about compliance and asthma. The paper focuses on neglected issues concerning determinants of compliance, assessment, and changing noncompliant behavior. Based on available data, the conclusion is that it is time for health care personnel and patients to share the blame for the lack of medication compliance in asthma.