Inhaler Technique Assessment Research Articles

Reliability in the Assessment of Videotaped Inhalation Technique

Inhalation medication is essential in the treatment of asthma and chronic obstructive pulmonary disease (COPD) patients. Incorrect inhalation technique reduces the effects of medication and has been reported to range from 22% to 95% from optimal. The objective of this study was to determine inter- and intraobserver reliability in inhalation technique assessment. For interobserver reliability three observers scored after three times viewing a total of 49 video recorded inhalation demonstrations using device-specific checklists and mutually agreed scoring rules. Intraobserver reliability was assessed for two observers after 8 months by scoring inhalation demonstrations a second time. Both inter- and intraobserver reliability were expressed by mean percent agreement and mean Kappa scores. All inhaler devices revealed a high mean percent agreement and a substantial or almost perfect Kappa scoring for both inter- and intraobserver reliability. Only one item, "exhale to residual volume," showed poor intraobserver reliability. Assessment of video recorded inhalation technique using device-specific checklists, triple viewing, and mutual agreed scoring rules is reliable. This method enables blind observation of inhalation technique.

Assessment of inhalation technique and determinants of incorrect performance among children with asthma

The objective of our study was to evaluate the pressurized metered dose inhaler (pMDI) with holding chamber technique of asthmatic children attending out patient pediatric chest clinic and determine factors associated with incorrect technique. All patients had previously received instructions regarding inhalation technique. The inhalation technique was assessed on a five-point checklist, four of which were considered essential. Two hundred and thirteen children (mean +/- SD age, 7.3 +/- 3.8 years; 151 boys) completed the study. Children were using their inhaler for a median duration of 6 months (range 1-96 months). One hundred and eighty-eight patients (88.3%) performed all essential steps correctly. The commonest mistake among the essential steps was not shaking the inhaler (n = 21, 9.9%) followed by inability to make a tight seal around the mouthpiece of the holding chamber (n = 12, 5.6%). Correct technique was not affected by gender, asthma severity and socio-economic indices: education level of parents, percapita monthly income, rural or urban background. Our study indicates that a large majority of children from a developing country setting, irrespective of lower education and income levels can be successfully educated to appropriately use inhalation device. Inhalation performance is not affected by socio-economic background of the patients. Comprehensive inhalation instructions and monitoring at each visit are however critical to ensure reliable and consistent performance of correct technique among asthmatic children.

Factors Influencing Individual Variability in the Therapeutic Response to Corticosteroids in Asthma

Corticosteroids are the most effective treatment for asthma but the therapeutic response varies markedly between individuals. Multiple factors including genetic, environmental, asthma related and concordance are likely to contribute to the heterogeneous response to corticosteroids. Genetic variations at the level of the glucocorticoid receptor have not been implicated to date, but polymorphisms of TBX21 and corticotrophin-releasing hormone receptor 1 genes are associated with enhanced efficacy to inhaled corticosteroids. Cigarette smoking is an important cause of insensitivity to corticosteroids. Mechanisms of corticosteroid insensitivity in smokers with asthma are currently unexplained, but could be due to alterations in airway inflammatory cell phenotypes, changes in glucocorticoid receptor α to β ratio, and/or reduced histone deacetylase activity. Exposure to allergens, infections and neutrophilic airway inflammation as well as race and the rare phenotype of corticosteroid resistant asthma are implicated in reduced efficacy. Poor concordance with treatment is of particular importance. Management involves advice on smoking cessation for smokers, assessment of concordance and inhaler technique, review of delivery of care and step up in treatment only after these issues have been addressed. In the future, corticosteroid treatment might be guided by pharmacogenetic assays and the use of alternative or additional drugs for specific corticosteroid insensitive groups such as smokers with asthma. Keywords: Corticosteroids, corticosteroid insensitivity, smoking, asthma, pharmacogenetics, concordance

Assessment of inhaler technique and treatment compliance of hospitalized patients and outpatients in a university hospital Bir üniversite hastanesinde poliklinik hastaları veyatan hastalarda inhaler

Amaç: Obstrüktif akciğer hastalıklarının tedavisinde inhalasyon yolu yaygın olarak kullanılmaktadır. Yetersiz inhaler tekniği tedavi başarısızlığının başlıca nedeni olarak kabul edilmektedir. Bu çalışma hastaların doğru inhaler tekniği kullanmaları ve tedavi uyumu üzerine etkili parametreleri değerlendirmeyi amaçlamıştır. Gereç ve Yöntem: Bir üniversite hastanesine başvuran obstrüktif akciğer hastalığı olan ve inhaler cihazlar kullanan hastalara 200 hastaya ( 145 poliklinik hastası ve 55 yatan hasta) anket uygulandı. Bulgular: Poliklinik ve yatan hastalarda en fazla seçilen inhaler tedavi formu ölçülü doz inhalerdi (ÖDİ). Genç yaştaki hastalar inhalerlerini yaşlı olanlara gore daha doğru kullanıyorlardı (p < 0,05). Tedavi süresi ile doğru kullanım tekniği arasında pozitif bir ilişki olduğu belirlendi (p < 0,05). Başlangıçta inhaler kullanım eğitiminin verilmesi ile doğru uygulama tekniği arasında istatistiksel olarak anlamlı bir ilişki vardı (p < 0,001). Hastaların eğitim düzeyleri ile doğru uygulama tekniği, tanılarını bilmeleri ve tedavilerini sürdürmeleri arasında ilişki saptanmadı. Hastaneye yatış sayısı ile hastaların tanılarını bilmeleri, doğru tekniği kullanmaları ve inhaler tedaviyi kullanmayı sürdürmeleri arasındaki ilişki anlamlıydı. Hastalık tanılarını bilen hastalar inhaler cihazlarını doğru olarak kullanıyorlardı.Sonuç: Başlangıç olarak uygun bir kullanım eğitiminin verilmesi ile inhaler teknik belirgin olarak iyileştirilebilir. Başlangıçta yeterli bir kullanım eğitimi verilmediğinde, hastanın eğitim düzeyi doğru kullanım oranına etkili olmamaktadır. Hastanede yatan hastalarda, inhaler tekniği eğitimi için bu süreç bir fırsat olabilir ve bireysel olarak uygun inhaler tedavi seçeneğini belirlemeyi sağlayabilir.

A specialist nurse led liaison model of care reduced unscheduled care for acute asthma in a deprived multiethnic area

Griffiths C, Foster G, Barnes N, et al . Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high...

Comparative Study of Different Inhaler Devices in Asthmatic Children

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.

Assessment of Inhalation Technique in Primary Care Asthmatic Patients Using Metered-Dose Inhalers with or without a Spacer

Asthma is a chronic disease with increasing morbidity and mortality. Although the development of metered-dose inhalers (MDIs) was a landmark in asthma management, their use is burdened by inappropriate training. Inadequate inhalation technique is reported in 24% to 89% of patients. We assessed how a sample of adult asthmatic patients seen in primary healthcare clinics (PHCs) in Riyadh used their metered-dose inhalers (MDI). We conducted a cross-sectional survey of asthmatic adults â yen 18 years of age who attended PHCs and used an MDI with or without a spacer device. Patient inhalation technique was observed independently by the primary researcher and a respiratory therapist using a checklist based on US (National Heart, Lung and Blood Institute) asthma management guidelines. The mean age of the 191 patients in the survey was 40.64 years (range, 18 to 80 years). Fifty-nine percent were females and 41% were males. Most (77%) were illiterate and most (86%) had received previous education on MDI inhalation technique. Ninety-three percent were using an MDI without a spacer, but none could use their MDI without committing at least one error in both groups. In patients using an MDI without a spacer, the most common error was not tilting the head backward slightly and breathing out to residual volume (85%), followed by not breathing in slowly (84%). In patients using an MDI with a spacer, the most common errors were not tilting the head back slightly and breathing out slowly to residual volume (77%), and not holding the breath for 10 seconds (77%). Despite that MDIs are a mainstay in the management of our asthmatic patients, inhalation technique is very poor among our patients.

The inhalation manager: a new computer-based device to assess inhalation technique and drug delivery to the patient.

The rational choice of an inhalation device is a cornerstone in the effective management of asthma and COPD. In this publication, we describe the development of a new system, the Inhalation Manager, which, for the first time, offers the possibility to assess the entire inhalation maneuver of patients using original devices under everyday conditions. So far the Inhalation Manager allows the measurement of inspiratory maneuvers of patients through placebo inhalation devices of the most common breath-actuated CFC-free inhalers in the market for the three main glucocorticosteroids Budesonide [Turbohaler (TH), dry powder inhaler (DPI)], Beclomethasone dipropionate [Autohaler (AH), breath-actuated pressurized metered dose inhaler (pMDI)], and Fluticasone propionate [Diskus (DI), DPI] by means of a pneumotachometer. In addition, it allows allocation of the individual maneuver to the expected drug delivery values (mass output and particle size distribution) of these three devices. In a field trial, the inhalation technique of 628 (TH), 794 (AH), and 795 (DI) patients, respectively, was tested in 72 pulmonologist practices with the Inhalation Manager. For patients in the 18-59-year-old group, the Inhalation Manager detected the following percentages needing improvement: 1.5% for the Autohaler device, 16.7% for the Diskus, and 38.9% for the Turbohaler. In the 60-99-year-old group, percentages needing improvement were 1.5%, 31.5%, and 66.1% for the Autohaler, Diskus, and Turbohaler, respectively. Therefore, the Inhalation Manager could become an essential tool in asthma management by finding the most suitable inhaler for an individual patient and by training the optimal inhalation technique.

PAR9: VALIDATION OF A RATING INSTRUMENT ASSESSING THE INHALATION SKILLS OF CHILDREN WITH ASTHMA

OBJECTIVES: Despite their complexity appropriate use of asthma inhaled medicines is crucial to ensure optimal drug delivery to the airways. We describe the validation of an instrument to assess inhalation skills in children. METHODS: The instrument includes a breakdown of the steps necessary for appropriate inhalation. We videotaped 25 children taking a placebo inhaler (metered dose inhaler (MDI), MDI with AeroChamber® (MDI-AE®), and Diskus®). A gold standard (GS) was developed by agreement of two asthma experts watching the videotaped demonstrations. Twenty-one raters scored the randomly ordered demonstrations twice within a 2-week interval (sessions 1 and 2). Intra-class correlation coefficients (ICCs) were calculated to assess validity (comparing GS to raters' scores), interrater reliability, and test-retest reliability for each step of the inhalation. RESULTS: ICCs varied considerably by both, the device and the step. In session 1, a small proportion of raters agreed with the GS on whether patients actuated the MDI and inhaled simultaneously (9.5%, ICCs 0.62 to 0.74) and whether patients hold their breath (19%, ICCs 0.62 to 1.00). A better agreement was observed for the MDI-AE® where actuation (43%, ICCs 0.43 to 0.56) and inhalation (57%, ICCs 0.43) are two separate steps. The best interrater agreement was on the shaking of the MDI (ICC = 0.83) and the MDI-AE® (ICC = 0.74). Agreement for the Diskus® was poor for all steps. Results for session 2 were similar. The best intra-rater agreement was for the Diskus® (ICCs = 1 for 5 steps), though only a small proportion of raters agreed on these steps (5% to 21%). CONCLUSIONS: There was large variability within and between raters' scores. Some steps were better assessed than others. These results suggest that in addition to a detailed instrument, training of raters is crucial to obtain a valid assessment of the childrens' inhalation technique.

Helping patients to master correct inhaler techniques: nursing role.

The use of inhalers is widespread for asthma and conditions such as chronic obstructive pulmonary disease and yet many people have difficulties in mastering correct inhaler technique. Elderly people and children have specific problems with inhaler use and require both targeted and appropriate help in order to improve their inhaler technique and minimize waste of inhaled medication and therefore lack of therapeutic effect. Nurses need to be able to not only demonstrate correct inhaler technique themselves, but also identify what is going wrong and be knowledgeable concerning the various options available. Frequent assessment of inhaler technique needs to become a regular feature of health promotion for all patients using these devices.

Técnica inadecuada en el empleo de inhaladores en pacientes atendidos en una consulta de neumología

To assess inhalation technique in out-patient attending a respiratory ward who were using inhaler devices, and to identify factors associated with misuse of these therapies. One hundred and seven patients were prospectively studied, of whom 100 completed the study; Inhalation technique was evaluated using a previously elaborated check list. We searched for significant differences between individuals with good or bad inhalation technique. Mean age: 68 +/- 11 years. 68 males and 32 females. Only 31% of cases were observed to make no inhalation errors when first evaluated. Individuals using metered-dose inhalers without spacer chamber made significantly more mistakes than patients using other devices. The main factor associated with poor inhalation technique was found to be the absence of adequate supervised instruction when the treatment was first prescribed. General practitioners were less likely to offer this instruction than other specialists. We did not find significant associations between inhaler misuse and patients' age, sex or the setting (hospital or ambulatory ward) where the treatment was first prescribed. Incorrect use of inhalers is a frequent finding, and an adequate instruction seems to associate with improvement of patients' skills with use of these devices. Health personnel should be aware that inhalation technique instruction is essential ingredient of patients' management.

Effect of hospital asthma nurse appointment on inpatient asthma care

While asthma nurses are funded by many health authorities within the U.K. National Health Service, for the improvement of clinical management in both inpatient and outpatient settings in secondary care, the effect of asthma nurse appointment on acute asthma care in hospitalized children has been inadequately studied. Here, we test the hypothesis that the employment of a full-time hospital asthma nurse improves quality of care for children admitted to hospital with acute asthma.Prospective in design, the study compares analyses of indicators of good clinical practice for hospitalized asthmatic children (2–16 yrs) before and after the appointment of a hospital asthma nurse.Both management [oxygen saturation check (35/106 vs. 111/126, P<0·05)] and discharge planning [self management plan/asthma education (17/106 vs. 49/126, P<0·05), follow-up arrangements with general practice (8/106 vs. 25/126, P<0·05)] improved. There was, however, no significant change in oral steroid administration, peak flow check, inhaler technique assessment, inhaled drug prophylaxis or arrangements for hospital follow-up at discharge.Employment of a hospital-based children's asthma nurse leads to significant improvement in aspects of routine in-patient asthma management. However, other important areas of in-patient asthma care did not improve following nurse-led interventions. A clearer evidence base may improve compliance with asthma management guidelines, and could make the role of hospital asthma nurse more effective.

Turbutest in the training of asthmatic Turbuhaler users.

Correct utilization of inhalation devices is a key factor in asthma management. Objective assessment of the ability to use inhaler devices is therefore fundamental. The objective was to assess objectively the inhalation technique of Turbuhaler users who reported having no difficulty in using such a device. A total of 600 asthmatic patients of our allergology outpatient department, daily users of Turbuhaler devices, were evaluated with Turbutest. This is a simple portable apparatus which connects a Turbuhaler inhaler with an electronic device to allow semiquantitative assessment of inhalation technique, with a score ranging from 0 (worst) to 3 (best), readily visualized on the apparatus. Patients were allowed to practice with Turbutest, assisted by an allergologist, until they improved their scores. A second Turbutest assessment was performed at a 2-month follow-up visit. On the first assessment, one-third of the patients had scores inadequate to allow a good inhalation, and only 20% achieved a score of 3. On the second assessment, significantly higher Turbutest scores were observed. Turbutest is a valuable tool in asthmatic patients' training, allowing identification and improvement of an inadequate inhalation technique with Turbuhaler.

Asthma in older people.

From the clinical perspective, asthma in the older patient may be difficult to diagnose because of the non-specificity of presentation and the wide range of differential diagnoses. Prior to confirmation of asthma in the older patient, both respiratory and cardiac investigation may be necessary. Polypharmacy is inherent in treating older people and accurate drug histories are essential in order to identify patients with drug-induced bronchospasm and avoid interactions with asthma medication. Patient and carer education is vital, and a structured approach to follow-up which includes measurement of lung function and assessment of inhaler technique should be carried out in every asthmatic regardless of age. Finally, there is a great need for health services and those in the commercial sector that are involved in asthma care to ensure that future research and development rises to the challenge of an ageing population.

Importance of Assessment of Metered‐Dose Inhaler Technique in the Elderly

Journal of the American Geriatrics SocietyVolume 42, Issue 1 p. 82-84 Importance of Assessment of Metered-Dose Inhaler Technique in the Elderly Sophia Daniels PharmD, Sophia Daniels PharmD the Gainesville Veterans Affairs Medical Center, Gainesville, Florida.Search for more papers by this authorJohn Meuleman MD, Corresponding Author John Meuleman MD the Gainesville Veterans Affairs Medical Center, Gainesville, Florida.DVAMC, 1601 Archer Road, Gainesville, FL 32608-1197.Search for more papers by this author Sophia Daniels PharmD, Sophia Daniels PharmD the Gainesville Veterans Affairs Medical Center, Gainesville, Florida.Search for more papers by this authorJohn Meuleman MD, Corresponding Author John Meuleman MD the Gainesville Veterans Affairs Medical Center, Gainesville, Florida.DVAMC, 1601 Archer Road, Gainesville, FL 32608-1197.Search for more papers by this author First published: January 1994 https://doi.org/10.1111/j.1532-5415.1994.tb06078.xCitations: 10Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume42, Issue1January 1994Pages 82-84 RelatedInformation

Assessment of inhaler technique in general practice.

71 Patients who were using inhalers in an inner city Dublin teaching practice were assessed by the author over a four month period to see if they were using their inhalers properly. 18 (25%) had perfect technique, 26 (37%) had adequate technique and 27 (38%) had poor technique. The patients most likely to have poor technique were those using a Metered Dose Inhaler (M.D.I.), patients using inhalers for less than one year and patients with a diagnosis of C.O.A.D. as opposed to Asthma. Of the 53 patients who had less than perfect technique 37 showed an initial improvement with training. This Author suggests that all patients should be fully evaluated before starting on inhalers and the most appropriate delivery system selected for them. They should be carefully instructed on its correct use and arrangements made for regular follow up to ensure good inhaler technique. This should lead to a greater clinical response and improved patient compliance.