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

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.

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.

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.

Published on:August 2022Journal of Young Pharmacists, 2022; 14(3):327-332Original Article | doi:10.5530/jyp.2022.14.64 Authors: Sara Shahid1,2,*, Fahad Ahmed3, Gul Shahnaz1, Muhammad Saqlain1, Muhammad Ans4, Anosh Sana1, Abdul Nazer Ali5, Ahmad Kamal Ariffin Abdul Jamil6, Asma Fareed Khan7,8, Saba Naeem9, Shakeel Ahmad9, Aiman Mahmood4,9, Qandeel Rafi9, Asifa Anwar2, Rabeel Khan2, Naeem Mubarak2 1Department of Pharmacy, Faculty of Biological Sciences, Quaid-i-Azam University, Islamabad, PAKISTAN. 2Department of Pharmacy Practice, Lahore Pharmacy College, Lahore Medical and Dental College, University of Health Sciences, Lahore, PAKISTAN.3Faculty of Pharmacy, University of Sargodha, Sargodha, PAKISTAN.4University College of Pharmacy, University of the Punjab, Lahore, PAKISTAN.5Department of Pharmacy Practice, Geethanjali College of Pharmacy, Hyderabad, Telangana, INDIA.6Department of Clinical Pharmacy & Pharmacy Practice, Faculty of Pharmacy, UniSZA, Besut, Terengganu, MALAYSIA.7Disciplines of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, MALAYSIA. 8Children’s Hospital & University of Child Health Sciences, Lahore, PAKISTAN. 9Department of Pharmaceutics, Lahore Pharmacy College, Lahore Medical and Dental College, University of Health Sciences, Lahore, PAKISTAN. Abstract: Background: Asthma is rapidly increasing globally. Inhalation therapy is the backbone for asthma management due to localized delivery and rapid onset of action. Currently, metered dose inhalers (MDIs) are the most widely prescribed and dispensed inhaler devices worldwide due to the advantage of portability, multiple dose delivery and better efficacy. Objectives: The current study aimed to access the effect of educational intervention on asthma patients’ competency regarding pressurized metered dose inhaler (pMDI) technique. Methods: Asthma patients were recruited from Pakistan Institute of Medical Sciences (PIMS) Islamabad, Pakistan. Inhaler technique steps based upon “National Asthma Education and Preventive Program” (NAEPP) criteria was set as evaluating tool to evaluate competency of asthma patients regarding MDI appropriate technique. Intervention involved educating study subjects (asthma patients) practically through placebo inhaler and theoretically through inhaler technique directed literature brochures. Pre intervention and post intervention inhaler technique competency was accessed and evaluated statistically. Results: Among 207 asthma patients, majority were never instructed by healthcare professional regarding inhaler technique (78.8%). However, most of the patients were observed to have inadequate inhaler technique (76.3%) at baseline. As the result of educational intervention, the competency of patients regarding inhaler technique was significantly enhanced from 11.6% pre-intervention to 34.8% post-intervention (p<0.001), statistically analyzed by McNemar testing. Conclusion: Originally, inhaler technique competency of majority of asthma patients was observed to be inappropriate. However, educational intervention proved to be effective in substantially enhancing the competency of study subjects regarding MDI technique. Keywords: Asthma, Inhalation therapy, Metered-dose inhalers, Educational intervention, National Asthma Education and Preventive Program.

BackgroundLong-acting muscarinic antagonist (LAMA) and long-acting β2-agonist (LABA) bronchodilators are key to the pharmacologic treatment of chronic obstructive pulmonary disease (COPD). This Phase IIb study investigated the safety and efficacy of four doses of the LAMA glycopyrronium (GP) delivered using co-suspension delivery technology via metered dose inhaler (MDI). The study was part of a wider clinical trial program performed to determine the optimal dose of GP MDI, the LABA formoterol fumarate dihydrate (FF) MDI, and glycopyrronium/formoterol fumarate dihydrate (GFF) MDI fixed-dose combination to be taken forward into Phase III studies.MethodsIn this randomized, double-blind, 7-day chronic-dosing, three-period incomplete block, cross-over study, patients with moderate-to-severe COPD received two of the four doses of GP MDI (28.8 μg, 14.4 μg, 7.2 μg, and 3.6 μg) twice daily (BID), and either placebo MDI BID or open-label ipratropium MDI 34 μg four times daily. The primary efficacy endpoint was forced expiratory volume in 1 s (FEV1) area under the curve from 0 to 12 h (AUC0–12) relative to baseline on Day 7. Secondary and exploratory efficacy endpoints were assessed on Days 1 and 7. Safety and tolerability were evaluated throughout the study.ResultsAll GP MDI treatments were superior to placebo MDI for the primary efficacy endpoint (all p < 0.0001). However, only GP MDI 28.8 μg and 14.4 μg demonstrated statistical superiority to placebo MDI for all secondary efficacy endpoints analyzed in this study, with the exception of GP MDI 14.4 μg versus placebo MDI for the proportion of patients achieving ≥12% improvement in FEV1. No nominally significant differences were observed between GP MDI 28.8 μg and GP MDI 14.4 μg for any of the endpoints. All doses of GP MDI were well tolerated, with no unexpected safety findings.ConclusionsThis study indicated that there was no advantage of GP MDI 28.8 μg compared with GP MDI 14.4 μg. It therefore added to the evidence from the Phase I/II clinical trial program, which identified GP MDI 14.4 μg as the most appropriate dose for use in the Phase III clinical studies.Trial registrationClinicalTrials.gov (NCT01350128). Registered May 09, 2011.

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...

To determine whether cognitive status, hand strength, and demographic variables are predictive of correct use of metered-dose inhalers by older subjects. Clinic patients (n = 29) and healthy volunteers (n = 42) older than 50 years with no previous or limited metered-dose inhaler use were enrolled. After cognitive (Mini-Mental State Examination) and hand strength assessments, subjects received extensive instruction in proper metered-dose inhaler technique. Technique was independently assessed by two evaluators immediately after instruction and 1 week later. Correct technique was defined as (1) activating the canister in the first half of inhalation, (2) continuing to inhale slowly and deeply, and (3) holding breath at full inspiration (5 seconds). Data for the two subject groups were pooled for analyses. The mean age of the subjects was 69.7 years. Forty subjects (56%) demonstrated correct metered-dose inhaler technique at 1 week. Logistic regression showed that hand strength measurement (odds ratio, 0.68; 95% confidence interval, 0.55 to 0.84), Mini-Mental State Examination score less than 24 (odds ratio, 3.66; 95% confidence interval, 1.07 to 12.4), and male gender (odds ratio, 5.01; 95% confidence interval, 1.07 to 23.5) were significant predictors of incorrect inhaler use. Correct use of the metered-dose inhaler was unrelated to age, education, or subject status. Clinicians should consider cognitive status and hand strength when metered-dose inhaler therapy is initiated for an older adult. Patients with cognitive impairment and hand strength deficits may require more extensive training, frequent follow-up, or alternative dosage forms.

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.

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.

Salmeterol Administration by Metered-Dose Inhaler Alone vs Metered-Dose Inhaler Plus Valved Holding Chamber

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.

Conventional press-and-breathe metered dose inhalers (MDIs) are widely prescribed but are often difficult for many patients to properly use. A total of 501 patients from different medical specialties were enrolled in this study, which evaluated how the patients used their MDIs. Using a conservative method (minimum number of errors) of determining errors, we found that 388 (77.5%) of the patients made at least one error when demonstrating how they use their MDI for two observers. Using a liberal (maximum number of errors) method of analysis, we found that 447 (89.2%) of the patients made at least one error. There was no difference in errors made stratified by patient gender, patient age, or the medical specialty that treated the patient's pulmonary disease. The two most common errors made by patients were failure to breathe out to functional residual capacity before actuation (225 by minimum method, 280 by maximum method) and not actuating the canister at the start of inhalation (207 by minimum method, 323 by maximum method). Of the patients with improper timing of actuation, the majority (121 patients by minimum method and 187 patients by maximum method) actuated the canister early. In this large patient sample, regardless of which medical specialty provided the treatment, the majority of the patients evaluated had less than optimal MDI technique. Routine assessment of MDI technique should be instituted as standard practice 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.

Development of a scale to measure children's metered-dose inhaler and spacer technique.

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.