Demonstrating and assessing metered-dose inhaler-spacer technique: pediatric care providers' self-reported practices and perceived barriers

Recognizing and Tackling Inhaler Technique Decay in Asthma and Chronic Obstructive Pulmonary Disesase (COPD) Clinical Practice

A poor inhaler technique continues to represent a substantial barrier to effective asthma and chronic obstructive pulmonary disease management. It can result in perceived lack of treatment effectiveness even with apparent adherence to a prescribed regimen of inhaled maintenance therapies, potentially resulting in an unnecessary change or escalation of treatment. Many patients are not trained to inhaler mastery in real-world practice; furthermore, even where mastery is initially achieved, an ongoing assessment and education are seldom maintained. In this review, we present an overview of the evidence for deterioration of the inhaler technique over time after training, investigate the factors that contribute to this deterioration, and explore innovative approaches to addressing the problem. We also propose steps forward drawn from the literature and our clinical insights.

A randomized controlled trial of a community health worker delivered home-based asthma intervention to improve pediatric asthma outcomes

OBJECTIVE

The objective of this study was to evaluate the effects of using Community Health Workers (CHWs) to deliver the home-based Wee Wheezers asthma education program on asthma symptoms among children with persistent asthma.

METHODS

In this randomized controlled trial of 151 children aged 2-9 years with persistent asthma, we assigned 75 to the intervention and 76 to the control. The primary outcome was caregiver-reported asthma symptom days. Secondary outcomes included asthma-related healthcare utilization, caregivers' asthma knowledge, illness perception and management behaviors, MDI-spacer administration technique, and home environmental triggers. Outcomes were collected at baseline, 3, 6, 9 and 12 months. A repeated measurements analytic approach with generalized estimating equations was used. To account for missing data, multiple imputation methods were employed.

RESULTS

At 3 and 6 months, improvement in symptom days was not significantly different between groups. However, at 9 and 12 months, the reduction in asthma symptom days was 2.15 and 2.31 days more respectively for those in the intervention group compared to the control. Improvements in MDI-spacer technique, knowledge and attitudes were significant throughout follow-up. Improvement in habits regarding MDI use was significant at 3 and 6 months, and asthma routines were improved at 3 months. However, there was no change in asthma-related healthcare utilization or home environmental triggers.

CONCLUSION

Using CHWs to deliver a home-based asthma education program to caregivers of children with persistent asthma led to improvements in symptom days and several secondary outcomes. Expanding the use of CHWs to provide home-based interventions can help reduce disparities in children's health outcomes.

Association between inhaler technique and confidence among hospitalized children with asthma

OBJECTIVE

Proper use of respiratory inhalers is crucial to asthma self-management and associated with improved outcomes. Previous studies conducted in outpatient and community settings show parents and children are overconfident in children's ability to use inhalers properly, which may lead healthcare providers to not teach or review inhaler technique. This study examined whether children and parents' confidence were associated with proper inhaler technique among children hospitalized with asthma.

METHODS

Children between 5 and 10 years old hospitalized with asthma at an urban academic medical center demonstrated inhaler technique using metered dose inhalers and spacers. Technique was scored based on a validated 12-step scale. Confidence was measured using three items assessing 1. Knowledge to use inhaler, 2. Skills to use inhaler, and 3. Ability to independently use inhaler. These items were five-point scales and analyzed as binary variables. Independent t-tests were used to measure associations between confidence and number of steps performed correctly.

RESULTS

None of the confidence items, when asked to parents or children (n = 70), were associated with the number of steps performed correctly. Further, while the majority of children and parents (59-70%) were confident based on each item, the mean number of steps correctly completed was 6.4 out of 12.

CONCLUSIONS

Children and parents' confidence in children's knowledge, skills, and ability to independently use an inhaler were all poor proxies for proper inhaler technique. Inpatient healthcare professionals should objectively evaluate technique and teach proper inhaler use to all children with asthma to optimize outcomes.

What can be done to impact respiratory inhaler misuse: exploring the problem, reasons, and solutions

INTRODUCTION

Respiratory inhalers, when used correctly, provide critical treatments for managing pulmonary conditions. However, many patients misuse inhalers, negatively affecting disease control, quality of life, healthcare utilization, and costs. Numerous factors are associated with misuse and are nested within four levels of influence: individual, interpersonal, organizational/institutional, and policy.

AREAS COVERED

This review analyzed published literature and identified the most salient factors at each socio-ecological framework level. English language articles from any year were identified from PubMed, Google Scholar, and Embase databases. Misuse exists across clinical settings, patient populations, and device types. Several potential solutions are highlighted. Published interventions to improve inhaler technique have utilized handouts, in-person, virtual, and biofeedback approaches both inside and outside of healthcare settings with varied effectiveness. However, some interventions have superior effectiveness for improving technique and reducing acute care utilization.

EXPERT OPINION

To robustly address inhaler misuse, future solutions should focus on multi-level approaches to account for the myriad of factors contributing to inhaler misuse. Solutions should also streamline inhaler equipment, identify innovative technology-based solutions, support collaborations across healthcare and non-healthcare settings, and ensure reimbursement to healthcare professionals for inhaler education. Rigorous research studies must be funded and supported to identify and disseminate solutions.

Controller Inhalers: Overview of Devices, Instructions for Use, Errors, and Interventions to Improve Technique

Inadequate inhaler technique in persistent asthma is frequently reported. However, there is little consensus on inhaler checklists, and critical elements of technique are not uniformly described. In addition, inhaler error rates and risk factors for poor technique are variable across studies. This Clinical Commentary Review summarizes the literature on inhaler design, use, and interventions to improve technique. Our aim is to help clinicians identify patients with poor inhaler technique, recognize the most important errors, and correct technique using evidence-based interventions.

Aerosol Therapy in Asthma-Why We Are Failing Our Patients and How We Can Do Better

In order for inhaled corticosteroids to be delivered adequately to the airways they require patients to take them regularly using an effective technique. Patients often have a poor inhaler technique, and this has been shown to result in sub-optimal asthma control. It is important for all clinicians prescribing inhaled medication to be experienced in the correct technique, and take time to train children so that they have mastered corrected inhaler technique. Using Teach to Goal or teach back methodology is a simple and effective way to provide this in the clinic setting. More than one training session is typically needed before children can master correct inhaler technique. Adherence to inhaled therapy has been shown to be sub-optimal in pediatric populations, with studies showing an average rate of around 50%. Subjective methods of measuring adherence have been shown to be inaccurate and overestimate rates. The advent of new technology has allowed adherence rates to be measured electronically, and it has been shown that regular feedback of these data can be effective at improving asthma control. New mobile apps and smart technology aim to engage patients and families with their asthma care. Effective use of these apps in collaboration with health care professionals has a vast potential to improve adherence rates and inhaler technique, resulting in improved asthma control.

Effectiveness of Nurse-Driven Inhaler Education on Inhaler Proficiency and Compliance Among Obstructive Lung Disease Patients: A Quasi-Experimental Study

Background Health education on proper inhaler usage is the most feasible and accessible strategy to increase inhaler effectiveness. Purpose To assess the impact of nurse-driven inhaler education on the compliance and proficiency of using inhalers among inhaler users. Methods This single-center, quasi-experimental study included the implementation of an individualized 60-min educational session on inhalers use. Health education and pretest and posttest outcomes were assessed by the Inhaler Proficiency Schedule and Patient Reported Behaviour tools. Results One hundred and twenty-one participants joined the study. At pretest, participants showed inadequate knowledge of general inhaler use. No previous training had been received by participants and difficulty with use and complications from using the inhalers were reported. At posttest, participants reported improvement in inhaler proficiency scores from 5.72 to 8.60 ( t = 17.99, df = 220, p < 0.001). Likewise, they showed a significant reduction towards the noncompliant behaviors from 15.21 to 11.19 ( t = 16.388, df = 238, p < 0.001). Conclusions Nurse-driven inhaler education yielded positive outcomes in both inhaler proficiency and compliance. The patients' assessment of using inhalers is crucial to determine the patients' educational deficits.

A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers

BACKGROUND

Despite little evidence for its effectiveness, the breath-actuated nebulizer (BAN) is the default albuterol delivery method in our pediatric emergency department.

OBJECTIVE

We compared the clinical efficacy of BAN and the metered-dose inhaler (MDI) in treating subjects patients 2 to 17 years of age who presented with mild to moderate asthma exacerbations.

METHODS

This is a randomized, nonblinded, noninferiority study conducted at a single pediatric tertiary care emergency department. Subjects presenting with a Pediatric Asthma Score ranging from 5 to 11 received albuterol by BAN or MDI via standard weight-based and symptom severity dosing protocols. Aerosolized ipratropium (via BAN) and intravenous magnesium sulfate were given when clinically indicated. The primary outcome was patient disposition. The noninferiority margin for the primary outcome was an admission rate difference ≤10%. Analyses were adjusted for confounders that were significant at p ≤ 0.10.

RESULTS

We enrolled 890 subjects between October 2014 and April 2015. BAN and MDI groups were comparable for age, gender, and race but not for pretreatment symptom severity; 51% in the MDI group had a Pediatric Asthma Score of moderate severity (8-11) vs. 63% in the BAN group (p < 0.003). Unadjusted admission rates were 11.9% for MDI and 12.8% for BAN, for an unadjusted risk difference of -0.9% (95% confidence interval -5% to 3%). After adjusting for baseline confounder severity, the risk difference was 2% (95% confidence interval -4% to 7%), which met the criteria for noninferiority.

CONCLUSIONS

Albuterol therapy by MDI is noninferior to BAN for the treatment of mild to moderate asthma exacerbations in children 2 to 17 years of age.

Inhalation devices, delivery systems, and patient technique

BACKGROUND

In real-life clinical settings, physicians often consider the properties of various inhaled corticosteroids (ICSs), but typically little consideration is given to the properties of different inhalers and formulations.

OBJECTIVE

To discuss the effects of inhalation devices and user technique on efficacy, safety, and adherence with the aim of improving asthma management.

METHODS

Relevant publications were selected to augment discussion.

RESULTS

There are many types of devices available, each with advantages, disadvantages, ease of use, and rate of misuse. Aerosol particle size influences the deposition pattern of a drug in the lungs, and the optimal particle size range is 1 to 5 μm. Retrospective reviews suggest that smaller particles (1-2 μm) could provide improved asthma control, but randomized, prospective studies are needed. Multiple studies have demonstrated high misuse rates in patients for pressurized metered-dose inhalers and dry powder inhalers. Because of this, repeated education should include physical demonstrations of using the device, checking the patient's technique, correcting the technique, and rechecking the technique. This also means that dedicated, trained staff and placebo devices should be available for instructing patients. Furthermore, the device should be selected to be cost effective and to fit the patient's preference and ability to use it correctly to enhance compliance. Asthma management guidelines and algorithms are available to guide the clinician.

CONCLUSION

The choice of inhaler device should depend on cost effectiveness and the patient's preference and ability to use it correctly. Patient inhaler technique should be checked and, if necessary, corrected and rechecked, with retraining if needed, at every opportunity.

[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.

Are children with asthma overconfident that they are using their inhalers correctly?

OBJECTIVE

The objectives of this study were to quantify the extent to which children with asthma are overconfident that they are using their inhalers correctly and determine whether demographic and clinical characteristics are associated with children being overconfident.

METHODS

Children (n = 91) ages 7-17 with persistent asthma were recruited at two pediatric practices in North Carolina and demonstrated their inhaler technique for metered dose inhalers during an office visit. Children were dichotomized into two groups based on how confident they were that they were using their inhalers correctly: "completely confident" or "not completely confident". The mean number of inhaler steps (out of 8) children performed incorrectly was examined. We applied linear regression models for children in the "completely confident" group to determine whether demographic and clinical factors predicted their overconfidence, defined as the number of inhaler steps performed incorrectly.

RESULTS

Children were primarily male (56%) and non-Hispanic White (60%). Sixty-eight (75%) children were "completely confident" that they were using their inhalers correctly. The "completely confident" group missed an average of 1.5 steps. In the "completely confident" group, males (p < 0.04) missed significantly more steps than females. The two most common errors were forgetting to shake the inhaler and holding their breath for 10 s.

CONCLUSION

Regardless of their confidence level, children in our sample missed an average of 1-2 steps on an inhaler technique assessment. Findings from this study provide new evidence that it is insufficient to ask children if they are using their inhalers correctly. Therefore, it is vital that providers ask children to demonstrate their inhaler technique during health encounters.

Evaluation of asthma control, parents' quality of life and preference between AeroChamber Plus and AeroChamber Plus Flow-Vu spacers in young children with asthma

OBJECTIVE

The AeroChamber Plus (AC) valved holding chamber has been enhanced to include the Flow-Vu (FV) inspiratory flow indicator that provides visual inhalation feedback during use. We have investigated if FV alters asthma control and whether parents accept it.

METHODS

At visit 1, children with asthma, age 1-5 years, used an AC with their pressurised metered dose inhaler and 2 weeks later (visit 2) they were randomised to use either AC or FV. Subjects returned 6 (visit 3) and 12 (visit 4) weeks later. The Asthma Control (ACQ) and Paediatric Asthma Caregiver's Quality of Life (PACQLQ) questionnaires were scored at each visit, and their peak inhalation flow (PIF) when they used their spacer was measured.

RESULTS

Forty participants in each group completed the study. There was no difference in the ACQ scores from visits 2 to 4 between the two groups. The improvements in the PACQLQ scores were greater in the FV group (p = 0.029). The mean difference (95% confidence interval) for the change from visits 2 to 4 between FV and AC groups was 0.05 (-0.33, 0.43) and 0.39 (0.035, 0.737) for the ACQ and PACQLQ, respectively. Most parents preferred the FV (p < 0.001). There was no difference in the PIF rates at each visit and between the two spacers.

CONCLUSIONS

There was no change in asthma control of the young children but that of their parents improved. Parents preferred the FV and this could be related to their improved perception of their children's asthma control by better PACQLQ scores.