Characteristics Predicting Incorrect Metered-Dose Inhaler Technique in Older Subjects

BackgroundResearch globally has shown that metered dose inhaler (MDI) technique is poor, with patient education and regular demonstration critical in maintaining correct use of inhalers. Patient information containing pictorial aids improves understanding of medicine usage; however, manufacturer leaflets illustrating MDI use may not be easily understood by low-literacy asthma patients.AimTo develop and evaluate the outcome of a tailored, simplified leaflet on correct MDI technique in asthma patients with limited literacy skills.SettingA rural primary health care clinic in the Eastern Cape, South Africa.MethodsPictograms illustrating MDI steps were designed to ensure cultural relevance. The design process of the leaflet was iterative and consultative involving a range of health care professionals as well as patients. Fifty-five rural asthma patients were recruited for the pre-post design educational intervention study. Metered dose inhaler technique was assessed using a checklist, and patients were then educated using the study leaflet. The principal researcher then demonstrated correct MDI technique. This process was repeated at follow-up 4 weeks later.ResultsThe number of correct steps increased significantly post intervention from 4.6 ± 2.2 at baseline to 7.9 ± 2.7 at follow-up (p < 0.05). Statistically significant improvement of correct technique was established for 10 of the 12 steps. Patients liked the pictograms and preferred the study leaflet over the manufacturer leaflet.ConclusionThe tailored, simple, illustrated study leaflet accompanied by a demonstration of MDI technique significantly increased correct MDI technique in low-literacy patients. Patients approved of the illustrated, simple text leaflet, and noted its usefulness in helping them improve their MDI technique.

IntroductionVerbal counselling (VC) is commonly used to train patients on correct inhaler technique. Patients forget the good inhaler use with time. Trainhaler (TH), Clement Clarke, UK, is a novel pressurised...

Physicians' metered dose inhaler technique after a single teaching session.

The inhaler is an important drug delivery system in the treatment of asthma, but inhaler technique is often inadequate. We assessed technique in children diagnosed with asthma, comparing the performance of three devices. In a cross-sectional survey, 523 children (271 boys, 252 girls, ages 5 to 12 years; mean+/-SD 7.53+/-1.79 years) demonstrated inhalation technique according to Netherlands Asthma Foundation criteria during a first visit to a primary care clinic in Abha, Saudi Arabia. Patients used the device with which they were most familiar (either pMDI, Turbuhaler or Diskus). Two hundred children (38% of total population) used a pMDI, while 323 (62% of total population) used one of the dry powder inhalers 173 (58%) the Turbuhaler and 150 (47%) the Diskus. Only 49 children (25% of the total population) completed the assessment without making a mistake. The remaining 474 (75% of the total population) performed one or more manuevers poorly. Only 80 children who used an MDI (40% of those using the device) completed 50% or more of the maneuvers correctly compared with 111 (69% of those using the device) and 100 (67% of those using the device) of those using the Turbuhaler and Diskus, respectively (P=0.001 for comparison of MDI with dry powder inhalers). Children whose mothers had intermediate school or higher education performed better than those whose mothers had less education (P=0.001). The father's education had no bearing on performance with the inhaler. The inhaler technique of most asthmatic children is poor, but technique is better in children who use a dry powder compared a metered-dose inhaler. The level of the mother's education is positively associated with better inhalation technique in the child.

Although inhaled medications are effective therapies for COPD, many patients and providers use them incorrectly. We recruited providers who prescribe inhalers or teach inhaler technique and assessed their use of metered-dose inhalers (MDIs), various dry powder inhalers (DPIs), and Respimat using predefined checklists. Then they watched tablet-based multimedia educational videos that demonstrated correct inhaler technique by a clinical pharmacist with teach-back from a patient and were re-evaluated. We also recruited patients with COPD and assessed their use of their prescribed inhalers and then retested them after 3-6 months. Baseline and follow-up respiratory symptoms were measured by the COPD Assessment Test. Fifty-eight providers and 50 subjects participated. For all providers, correct inhaler technique (reported as percentage correct steps) increased after the videos: MDI without a spacer (72% vs 97%) MDI with a spacer (72% vs 96%), formoterol DPI (50% vs 94%), mometasone DPI (43% vs 95%), tiotropium DPI (73% vs 99%), and Respimat (32% vs 93%) (before vs after, P < .001 for all comparisons). Subjects also improved their inhaler use technique after viewing the educational videos: MDI without a spacer (69% vs 92%), MDI with a spacer (73% vs 95%), and tiotropium DPI (83% vs 96%) (before vs after, P < .001 for all comparisons). The beneficial effect of this educational intervention declined slightly for subjects but was durably improved after several months. COPD Assessment Test scores did not demonstrate any change in respiratory symptoms. A tablet-based inhaler education tool improved inhaler technique for both providers and subjects. Although this intervention did show durable efficacy for improving inhaler use by patients, it did not reduce their respiratory symptoms.

Context Patients with asthma and chronic obstructive pulmonary disease (COPD) are majorly prescribed inhaled medications. This prescription is based on their efficacy and few adverse effects. Aim The study intends to evaluate metered-dose inhaler (MDI) administration technique among patients of asthma and COPD in Saudi Arabia. Settings and design A retrospective, cross-sectional observational design was used, and it was performed at the chest out-patient clinic at King Faisal Medical Complex, Taif, Saudi Arabia. Materials and methods A total of 144 Saudi patients who were diagnosed either for asthma and COPD were included. It also included patients with prescribed inhalation agents in the form of MDI. Statistical analysis IBM SPSS (Statistical Package for the Social Sciences) version 23.0. was used. Demographic characteristics were presented in the form of percentages and frequencies, whereas descriptive statistics were also applied. The significance value was determined at P value less than or equal to 0.05. Results Patients with asthma majorly used MDI technique, had unlimited attacks per month, and had experienced less than five attacks per month. The demographic evaluation showed that sex and age are insignificantly related to the use of MDI. However, education, medical diagnosis, number of asthmatic attacks per month, and duration of the MDI use were significantly related to the proper use of the MDI technique. Conclusion The findings of the study recommend that although patients were aware of the correct use, more training needs to be initiated. Educational intervention programs should be initiated for improving the MDI technique use among patients.

This study aimed to analyze the quality, reliability, and content of YouTube videos related to the use technique of metered dose inhalers (MDIs). Considering the increasing use of digital platforms for health education, it is important to evaluate the accuracy and educational value of such online resources. This descriptive and cross-sectional study evaluated 377 YouTube videos retrieved through a systematic search. The video selection process was monitored using the PRISMA flow diagram according to predefined inclusion and exclusion criteria. The videos' content, quality, and reliability were assessed using the Modified DISCERN tool, Global Quality Scale, Patient Education Materials Assessment Tool, and a checklist containing MDI use steps. Statistical analyses were conducted to determine associations between evaluation scores and video characteristics. A total of 12 YouTube videos on MDI use were analyzed. Of these, 33.3% were uploaded in 2022, and 66.7% were produced by associations or unions in the health sector. The mean interaction index was 0.53 ± 0.32, and the Video Power Index was 0.08 ± 0.15. The mean reliability level of the videos was 2.91 ± 0.75, quality level 4.16 ± 0.76, understandability level 80.83 ± 18.75, actionability level 81.66 ± 18.16, information level 77.00 ± 15.06, and information accuracy level 76.25 ± 15.80. YouTube videos on MDI use were largely adequate in terms of content but demonstrated some deficiencies in reliability. It is recommended that digital health information be produced under professional supervision and in collaboration with health authorities to ensure accuracy and trustworthiness.

To examine the frequency of proper use of inhalation devices and influence of age and training on it. One hundred and five subjects of bronchial asthma and Chronic Obstructive Pulmonary Disease (COPD); aged between 18 to 75 y (mean ± SD; 46 ± 28.55) were studied. Subjects were enrolled over a period of three months. Data like weight, height and concomitant medications were recorded. It was an observational and questionnaire based study. Parameters were chosen to demonstrate the inhalational technique, errors committed in different steps of use & nature of medical, paramedical, nursing personals and others imparting training for use of inhaler device and time devoted for it. Of total 105 patients, 31 were using dry powdered inhalers (DPI), 50 on metered dose inhalers (MDI), and 24 on MDI with spacer devices. Among study population 83.81% were trained by healthcare professionals (doctors, nurse, pharmacists, paramedical or representatives of Pharmaceutical companies) and 16.19% are trained by general people. Among the MDI users (n=50) only 6%, 16.12% among the DPI users, 20.8%, among MDI with spacer users could use inhalers correctly. At 95% confidence limit there was significance of errors committed between DPI and MDI users (difference of SE is 2.56) and between spacer and MDI users (difference of SE 2.92). There was no difference found in regard of frequency of errors committed in taking different devices according to patient's socioeconomic, educational background and trainer. It was concluded that use of MDI with spacer most convenient method. Doctors often did not have sufficient time to train patients regarding proper technique of inhaler use. With ever increasing and widespread use of inhalers patients' education is becoming more important. Proper training will surely make these drugs more effective and cost benefit ratio more favourable.

To evaluate the impact of a booklet based training by a nurse on the development of skills regarding use of metered dose inhaler (MDI) among the teachers of the selected schools of Chandigarh, India. The present study was undertaken by randomly selecting government schools of Chandigarh from where 91 school teachers were enrolled. A booklet on asthma management containing information regarding asthma, its triggers, signs and symptoms, treatment, types of inhalers and steps of using MDI with spacer was used for training the subjects. Their knowledge and skills were evaluated through observation checklist. Three return demonstrations were taken from each teacher on three successive days. Main outcome measure was skill development of the teachers in the use of MDI with spacer. Pre and post tests scores were compared by repeated measures ANOVA. Most of the teachers didn't know theoretical or practical aspects of MDI. After training all the teachers performed correctly most of the steps of MDI use. Some teachers performed poorly in giving instruction to breathe in/out slowly and hand washing before/after MDI administration. There was a statistical significant improvement in the performance scores of the teachers after each return demonstration (p < 0.0005). Training strategy used in the study involving nursing personnel was successful in improving teachers' skills in MDI use for asthma management. More focus should be given on breathe in/out instructions and on hand washing before/after MDI use.

Thirty-six acutely III, hospitalized patients with acute exacerbations of obstructive airway disease and a greater than 10% increase in forced expiratory volume in 1 s after administration of aerosolized bronchodilator were randomized to receive either metaproterenol sulfate delivered by updraft-compressor nebulization (UDN) or terbutaline sulfate delivered by metered-dose inhaler (MDI) with a spacer. Serial analyses of pulmonary function measurements were performed with the use of 95% confidence intervals for the percentage response ratios of MDI to UDN. The response to MDI was at least equivalent to that of UDN, and MDI use was associated with no prolongation of hospital stay. Equivalent bronchodilation was achieved with MDI therapy with a lower daily charge for therapy for each patient and less respiratory therapist time. In hospitalized bronchodilator-responsive patients with acute exacerbations of obstructive airway disease, the MDI/spacer combination is the preferred approach when the status of the patient allows its use.

Climate change is currently the greatest global health threat. As the planet experiences rising temperatures due to global warming, widespread health impacts are emerging, including extreme weather events, food insecurity due to droughts, and forced relocation of populations. From a respiratory health perspective, patients with lung disease experience negative health consequences due to high temperatures, risks from heat-related illnesses, exposure to wildfire smoke that causes poor air quality, and increased severity and duration of pollen seasons. The resulting health consequences contribute to increased use of healthcare services, which in turn generate their own contributions to healthcare pollution, thus further worsening the climate crisis. In fact, the health sector contributes more than 5.2% of net global greenhouse gas emissions. In Canada, healthcare activities are responsible for 4.6% of the country’s total greenhouse gas emissions, placing Canada’s healthcare system among the top four emitters per capita by country. In terms of the contributions of various healthcare sectors to greenhouse gas emissions, England’s National Health Service (NHS) demonstrated that anesthetic gases and metered dose inhalers (MDIs) play a significant role; MDIs alone contribute to 3.1% of the NHS’s total healthcare emissions. MDIs rely on hydrofluorocarbon (HFC) propellants to deliver medication, which act as potent greenhouse gases when released into the atmosphere. Depending on the formulation, one aerosol inhaler can have a carbon footprint equivalent to driving a gasoline-powered car up to 170 km. In Canada, short-acting beta-agonist (SABA) inhalers constitute 71% of total inhaler use, the majority of which are delivered via MDI devices. For these reasons, strategies that reduce the use of MDIs have the potential to reduce negative environmental consequences of respiratory care.

To determine the prescription characteristics of beta-agonist metered-dose inhalers (MDI), we retrospectively investigated all prescriptions containing one of five types of beta-agonist MDIs available at Yamagata University Hospital in 1997, as well as patients' characteristics. The total number of asthmatic patients was 225 (age, 11-79, mean, 47.2) in 1997. Fenoterol MDI was prescribed to patients who visited the hospital at regular periods and had more severe asthma. Isoprenaline MDI also was not prescribed for first-time patients. Patients who were prescribed tulobuterol MDI had mild or moderate asthma and some of them were only occasional or first-time visitors. Salbutamol and procaterol MDIs were also prescribed for first-time patients; however, tulobuterol MDI was the most frequently prescribed for first-time patients. Patients prescribed fenoterol and isoprenaline MDIs had adequate knowledge of proper asthma management, because sufficient information had been provided about the use of MDIs in the past. Patients prescribed tulobuterol MDI should be provided with detailed instructions because they had little knowledge of handling MDIs and self-management of asthma as many of them were first or intermittent visitors. Patients prescribed salbutamol or procaterol MDIs should be evaluated regarding their past medications and some of them should be instructed regarding the use of the MDI. Although these clinical aspects might be applicable only to our hospital, the same or other prescription patterns will be found in other hospitals and/or by other physicians. Adequate instructions to individual patients who are prescribed a particular beta-agonist MDI should be provided by the medical staff, especially to outpatients, to reduce hospitalization and death from asthma.

Inhaled medications, critical for asthma treatment, are self-administered through metered dose inhalers (MDI). Asthma self-management hinges on adherence to these medications and to proper MDI technique. To assess predictors of proper MDI technique, and MDI technique as a tool to identify patients with low adherence to inhaled medications. Prospective cohort of asthmatics from clinics in New York, NY and New Brunswick, NJ. MDI technique was assessed using a standardized checklist. Adherence to inhaled asthma controller medication was evaluated with the Medication Adherence Report Scale. Predictors of MDI technique were evaluated using regression analyses. The distribution of number of MDI technique steps missed was compared in adherent vs. non-adherent asthmatics. Overall, 326 patients were included (55% Hispanic, 27% Black). In adjusted analyses, age < 55 years was significantly associated with MDI technique (P = 0.03). Overall, 12%, 34%, 40% of asthmatics missed 5-6, 3-4, or 1-2 MDI steps; 16% received a perfect MDI technique score. Adherence rates were 20%, 39%, 48%, and 62% among those who missed 5-6, 3-4, 1-2, or none of the steps in the MDI technique checklist (P < 0.001). Poor MDI technique is common among inner-city patients with asthma and is associated with poor adherence to controller medications. Older patients with asthma are at higher risk of improper MDI technique. Assessment of MDI technique may be a simple clinical aid to identify patients with low adherence to controller medications.

The Potential of a 2Tone Trainer To Help Patients Use Their Metered-Dose Inhalers

To the Editor: Incorrect use of metered-dose inhalers continues to be a problem in clinical practice. Although misuse is commonly related to poor coordination between actuation and inhalation, failure to inhale slowly, or inadequate holding of breath, patients occasionally misuse their inhalers in unusual ways. The following cases are examples. Patient 1 was a 62-year-old man with a recent diagnosis of chronic obstructive lung disease who came to our clinic reporting shortness of breath and lack of effect of his β-adrenergic-receptor agonist metered-dose inhaler. He stated that he had been given the inhaler for the first time two weeks earlier . . .