Assessment of Hospice Nurses' Technique in the Use of Inhalers and Nebulizers

Understanding the Knowledge Gap and Assessing Comfort Level among Healthcare Professionals Who Provide Inhaler Education

Inhaled medications play a pivotal role in the management of COPD and asthma. Provider knowledge and ability to teach various devices is paramount as poor inhaler technique directly correlates with worse disease control. The goal of our survey was to assess the knowledge and comfort level with various inhaled devices among providers involved in patient inhaler education. We constructed a 20-question survey consisting of a five-question Likert scale-based comfort assessment and a 15-question multiple-choice inhaler knowledge test that was distributed both internally and nationwide. Groups surveyed included internal medicine residents, family medicine residents, pulmonary fellows, respiratory therapists, nursing staff, and pharmacists. A total of 557 providers responded to the survey. The overall correct response rate among all respondents was only 47%. There was no significant difference between correct response rates among prescribers (internal medicine residents, family medicine residents, and pulmonary fellows) and non-prescribers (respiratory therapists, nursing staff, and pharmacists), 47% and 47%, respectively (p = 0.6919). However, respiratory therapists had the overall highest correct response rate of 85%. Over 72% of respondents indicated that they educate patients on inhaler technique as part of their clinical duties. Furthermore, the correct response rates for various inhaler devices varied with 55% among metered dose inhalers, 52% among dry powder inhalers, and 34% among soft-mist inhalers. Our study reveals that there is a continued need for education on the subject of inhaler devices among providers given their overall poor knowledge, particularly in an era of fast-changing inhaler devices. We continue without knowing what we teach.

Management of Breathlessness in Palliative Care: Inhalers and Dyspnea-A Literature Review

INTRODUCTION

Dyspnea is prominently observed in palliative care (PC). Dyspnea can be multifactorial, primarily caused by obstructive or restrictive lung diseases or secondarily induced by various comorbidities. Numerous interventions exist, with route of administration and efficacy requiring further discussion. Despite opioids being the first line of treatment, their adverse effects lead to reluctance on the side of patients to take them, creating limitations in patient management planning.

OBJECTIVES

This paper reviews and highlights the role of inhalers for dyspnea management in PC.

METHODS

The CINAHL, CENTRAL, and OVID databases were searched for scholarly articles on the role of inhalers in dyspnea management from 1998 to the present. A grey literature Internet search was also performed via Google, the World Health Organization, and CareSearch. Twenty-five articles relevant to the subject at hand were located and summarized. The Cochrane Systematic Reviews of Health Promotion and Public Health Interventions Handbook was consulted for structuring.

RESULT

Isolated bronchodilators can be effective in dyspnea management. However, combination with opioids leads to a 52% reduction of dyspnea, demonstrating efficacy of their combined use. There is a role for conventional inhalers not only in patients afflicted with chronic obstructive pulmonary disease, but also in those where obstruction is reversible, and in cases of dyspnea not yet diagnosed.

CONCLUSION

Inhalers can be utilized as adjuvant therapy to opioids, to limit opioid use, augment responses to dyspnea, and/or minimize opioid side effects, especially in opioid-naïve patients. Correct administration can increase the efficacy of short-acting beta-agonists, long-acting beta-agonists, short- and long-acting anticholinergic agents, and inhaled corticosteroids, achieving reduction and alleviation of dyspnea.

Errors in the Use of Inhalers by Health Care Professionals: A Systematic Review

BACKGROUND

Inefficient inhaler technique (IT) compromises the optimal delivery of medication. However, the IT knowledge of health care professionals (HCPs) has received scant attention.

OBJECTIVE

The objective of this study was to perform a systematic review of published reports assessing the IT proficiency of HCPs in using pressurized metered dose (pMDI) and dry powder (DPI) inhalers.

METHODS

Studies published between 1975 and 2014 that directly assessed the IT skills of HCPs were selected according to predefined selection criteria.

RESULTS

Data were extracted from 55 studies involving 6,304 HCPs who performed 9,996 tests to demonstrate their IT proficiency. Overall, the IT was considered correct in 15.5% of cases (95% confidence interval [CI], 12-19.3), decreasing over time from 20.5% (95% CI, 14.9-26.8) from the early period (defined as 1975-1995) to 10.8% (95% CI, 7.3-14.8) during the late period (1996-2014). The most common errors in the use of pMDIs were as follows: not breathing out completely before inhalation (75%; 95% CI, 56-90), lack of coordination (64%; 95% CI, 29-92), and postinhalation breath-hold (63%; 95% CI, 52-72). The most common errors using DPI were deficient preparation (89%; 95% CI, 82-95), not breathing out completely before inhalation (79%; 95% CI, 68-87), and no breath-hold (76%; 95% CI, 67-84).

CONCLUSIONS

HCPs demonstrated inadequate knowledge of the proper use of inhalers. The poor understanding of the correct use of these devices may prevent these professionals from being able to adequately assess and teach proper inhalation techniques to their patients.

Variability in Delivered Dose from Pressurized Metered-Dose Inhaler Formulations Due to a Delay Between Shake and Fire

BACKGROUND

Pressurized metered-dose inhalers (pMDIs) should be shaken before use to prevent creaming or sedimentation of the drugs in solution; however, data published on this topic are limited, and it is rarely specified how soon after shaking the device should be actuated. Delays between shaking and firing the pMDI have previously been shown to cause significant inhomogeneity in delivered dose. We studied the effect of various shake-fire delays on the drug delivered from five commercially available pMDIs commonly prescribed for asthma and chronic obstructive pulmonary disease to assess the potential variability in delivered dose.

METHODS

The pMDI formulations tested were the Flovent HFA, Ventolin Evohaler, Airomir Inhaler, and Symbicort (suspension pMDIs), and the QVAR 100 Inhaler (solution pMDI). Each pMDI was shaken for 5 seconds before attachment to a dosage unit sampling apparatus collection tube and filter, and it was actuated once with shake-fire delays of 0, 5, 10, 20, 30, 40, 50, and 60 seconds. Analysis of the eluates from the collection tubes and filters was performed by using high-performance liquid chromatography. Three of each pMDI were tested twice with each time delay.

RESULTS

All of the suspension pMDIs produced variable amounts of drug over the shake-fire delays tested. A comparison of the delivered doses after the 0- and 60-second delays showed that the drug delivered increased for the Flovent HFA (320%), Ventolin Evohaler (346%), and Airomir Inhaler (230%) pMDIs; decreased for the Symbicort budesonide (75%) and formoterol fumarate (76%) pMDI; and remained consistent for the QVAR 100 Inhaler pMDI.

CONCLUSIONS

The amount of drug delivered can vary widely over different shake-fire delays with suspension pMDIs. Therefore, guidance should be given to users/caregivers on the timing of firing after shaking their device, particularly with pediatrics, who may take time to become receptive to accepting their medication after pMDI shaking and before dose administration.

Nurses' knowledge of inhaler technique in the inpatient hospital setting

PURPOSE/OBJECTIVES

High rates of inhaler misuse in patients with chronic obstructive pulmonary disease and asthma contribute to hospital readmissions and increased healthcare cost. The purpose of this study was to examine inpatient staff nurses' self-perception of their knowledge of proper inhaler technique compared with demonstrated technique and frequency of providing patients with inhaler technique teaching during hospitalization and at discharge.

DESIGN

A prospective, descriptive study.

SETTING

A 495-bed urban academic medical center in the Midwest United States.

SAMPLE

A convenience sample of 100 nurses working on inpatient medical units.

METHODS

Participants completed a 5-item, 4-point Likert-scale survey evaluating self-perception of inhaler technique knowledge, frequency of providing patient education, and responsibility for providing education. Participants demonstrated inhaler technique to the investigators using both a metered dose inhaler (MDI) and Diskus device inhaler, and performance was measured via a validated checklist.

FINDINGS

Overall misuse rates were high for both MDI and Diskus devices. There was poor correlation between perceived ability and investigator-measured performance of inhaler technique. Frequency of education during hospitalization and at discharge was related to measured level of performance for the Diskus device but not for the MDI.

CONCLUSIONS

Nurses are a key component of patient education in the hospital; however, nursing staff lack adequate knowledge of inhaler technique.

IMPLICATIONS

Identifying gaps in nursing knowledge regarding proper inhaler technique and patient education about proper inhaler technique is important to design interventions that may positively impact patient outcomes. Interventions could include one-on-one education, Web-based education, unit-based education, or hospital-wide competency-based education. All should include return demonstration of appropriate technique.

Evaluation of MDI-spacer utilization and technique in caregivers of urban minority children with persistent asthma

OBJECTIVE

Incorrect Metered-Dose Inhaler (MDI)-spacer technique can result in decreased drug delivery to distal airways and poor asthma outcomes. There is lack of research to examine whether the caregivers utilize proper technique when applying an MDI-spacer delivery system for young minority children with persistent asthma in the United States. The objective of this study was to evaluate MDI-spacer utilization and technique among the caregivers of Bronx minority children with persistent asthma and to determine characteristics associated with correct use.

METHODS

We analyzed data from 169 caregivers of urban minority children with persistent asthma (aged 2-9 years). MDI-spacer device technique was assessed using a 10-step checklist derived from the national guidelines, literature and manufacturers' instructions. Based on the median MDI-technique score of six steps demonstrated accurately, caregivers were categorized as correct (seven or more) or incorrect (six or less) users.

RESULTS

Of the 169 caregivers, 95% were mothers, mean age 32.3 years (SD 7.6), 56% were unemployed; 74% of the children were Hispanic, 87% had either "not well controlled" or "very poorly controlled" asthma, 92% had a spacer at home and 71% used it "all" or "most" of the time. Only one caregiver correctly demonstrated all 10 steps of the MDI-spacer technique. Child's having one or more asthma-related hospitalizations in the past 12 months and higher caregiver educational level were independent predictors of correct MDI-spacer technique.

CONCLUSIONS AND RELEVANCE

The caregivers of urban, minority children with persistent asthma lack proper MDI-spacer technique, suggesting the potential value of both targeted short- and long-term educational interventions.

[Evaluation of an education program for patients with asthma who use inhalers]

PURPOSE

This study was done to evaluate the effectiveness of an education program for patients with asthma who use inhalers.

METHODS

The research design for this study was a non-equivalent control group quasi-experimental study. Participants in this study were 36 patients for the control group, and 43 patients for the experimental group. The experimental group participated in the education program. The control group received the usual care. Data were collected before and 1 month and 2 months after the program finished and were analyzed using the SPSS 12.0 program.

RESULTS

The experimental group had significantly higher scores of knowledge of inhalers, and inhalation technique compared to the control group. However, no significant differences were found between two groups for PEFR, asthma instability, and satisfaction with inhalers.

CONCLUSION

According to the results, the education program was effective in improving knowledge of inhalers, and inhalation technique. Therefore, it is recommended that this education program be used in clinical practice as an effective nursing intervention for patients with asthma on inhalers.