Inhaler Skills Research Articles

Asthmatic status in pediatric practice in patients with mild bronchial asthma

The main principle of the treatment of bronchial asthma is rational basic therapy, with priority appointment of inhaled glucocorticosteroids. The basis of the effectiveness of treatment is determined by the correct choice of the form of drug delivery, training the patient in inhalation skills and constant monitoring of the correct use of the inhaler. The article demonstrates the clinical observation of the formation of asthmatic status in a child with mild bronchial asthma. The deterioration of the condition and severe exacerbation was caused by insufficient intake of basic therapy funds into the respiratory tract due to improper inhalation techniques due to the patient's lack of skills in using an inhaler. At the same time, the patient was not trained and the necessary control over the correctness of the inhalation technique was not carried out at the outpatient stage.

Skills in handling Turbuhaler, Diskus in the west of China

ObjectiveThe purpose of this study was to evaluate the inhaler skills of patients with asthma and chronic obstructive pulmonary disease in a hospital in western China after receiving one medication education by pharmacists and the factors related to these skills.MethodsWe included 96 subjects using Turbuhaler and 74 subjects using Diskus in a hospital in western China. They were educated once by pharmacists before medication, and then their skills of operating these inhalers were visually evaluated the next time they were used. Using the seven-step inhalation administration method designed by AnnaMurphy, a clinical pharmacist at GLENFIELD Hospital in the UK, the inhaler use technique score scale was established and scored in turn. The age, sex, time of first illness, smoking status, education level and type of health insurance purchased by each patient were recorded to assess their relationship with overall inhaler skills.Results19.8% of the subjects who used Turbuhaler could not use it correctly, and 43.2% of the subjects who used Diskus could not use it correctly. The step with the highest error rate with Turbuhaler and Diskus is to "exhale slowly to residual volume". Chi-square test was carried out for each step of the operation of the two kinds of inhalers, and it was found that there was a significant difference in the operation accuracy of the two kinds of inhalers in the first, third and eighth steps. In univariate analysis, advanced age, female and low educational level were related to the lack of inhaler technology, but in multivariate analysis, only low educational level was a significant independent risk factor.ConclusionAmong the patients with asthma and chronic obstructive pulmonary disease in western China, some patients have good inhaler operation skills, but there are still many patients who can not use inhalers correctly, and the lower education level is significantly related to the incorrect use of inhalers.

The value of “General Practitioners–Specialists” mode: A focus group study of patients with asthma in mastering inhalation skills

This study focused on using “General Practitioners–Specialists” (GP-S) mode to teach the patients with asthma to master inhalation skills. 200 patients with asthma being admitted to the respiratory department of Shanghai Changhai Hospital were included in the study from January to December in 2018. There were 100 cases in the control group and 100 cases in the experimental group. The control groups received routine instruction and the experimental group adopted GP-S mode education, respectively, to learn mastering dry powder inhaler skills. The level of mastery and errors in the use of inhaled medications were recorded after each guidance. After four times’ instruction in two different ways, the patient’s mastery of inhalation skills gradually improved. After the guidance through the GP-S mode, the incidence of inhalation errors after each times instruction was 67%, 28%, and 7%, respectively. The later one was significantly lower than the previous one (67% vs. 28%, χ2 = 30.496, p < 0.001; 28% vs. 7%, χ2 = 15.273, p < 0.001). After twice instructions, the GP-S mode was associated with the lower incidence of inhaler device operating errors versus the regular guidance method (10% vs. 26%, χ2 = 8.672, p = 0.005); the same as the third guidance (2% vs. 11%, χ2 = 6.664, p = 0.018). Similarly, after thrice instructions, the incidence of inhalation method errors in the GP-S mode group was significantly lower than the regular guidance mode group (4% vs. 15%, χ2 = 7.037, p = 0.018), and there was still existing statistical difference of inhalation method errors between the two groups after four times instructions (3% vs. 11%, χ2 = 4.916, p = 0.049). General Practitioners–Specialists mode can effectively improve the patient’s mastery of inhalation skills, which significantly reduced the incidence of errors in the use of inhaled drugs and improved the overall management effectivity of asthma and patients’ compliance.

Impact of a Single Session of Inhalation Technique Training on Inhalation Skills and the Course of Asthma and COPD.

A significant percentage of patients with asthma and COPD do not use their inhalers properly. The aim of this study was to evaluate the impact of a single session of inhalation technique training on the frequency of inhalation errors and the course of asthma and COPD. This randomized controlled trial included adults who had been diagnosed with and treated for asthma or COPD with at least one inhaler use daily on a regular basis. All subjects were followed for 6 months, at which time their inhalation technique was assessed and an individual inhalation training (study group) or a sham procedure (control group) was applied. The number of mishandlings was calculated as the ratio of the number of errors to the number of inhalers used by an individual subject. The effect of training was evaluated after 3 months and again after 6 months. 50 subjects with asthma and 50 subjects with COPD were enrolled. Only 20% of subjects made no critical errors before the intervention. Subjects who were trained in the proper inhalation technique made fewer errors after 3 months (32 of 50 vs 20 of 50). The relative risk was 1.63 (95% CI 1.1-2.4, P = .01) and the number needed to treat was 3.9 (95% CI 2.2-15). Despite the improvement in the inhalation technique, we found no reduction in the number of asthma/COPD exacerbations, symptom severity, or the quality of life. After 3 consecutive months, the efficacy of the intervention decreased, and only 66% of the former responders maintained the lower ratio of errors per inhaler. After 6 months, there was no difference in the number of subjects with better inhalation technique between intervention (24 of 50) and control group (27 of 50) (P = .62). Although a single inhalation training leads to a reduction in the number of errors made during inhalation, it does not influence the course of asthma and COPD. The positive effect of a single inhalation technique training is temporary. (ClinicalTrials.gov registration NCT02131454.).

A IMPACT OF A PHARMACIST-LED EDUCATIONAL INTERVENTION ON QUALITY OF LIFE AMONG PATIENTS WITH ASTHMA

Objectives: Asthma is a chronic disease resulting in reduced quality of life (QoL) of most affected individuals. Training in asthma-related knowledge, inhaler skills, medicine usage, and the prevention of adverse drug events is demonstrated to improve asthma patients’ QoL. Therefore, the research was conducted to evaluate the effectiveness of education intervention undertaken by pharmacists on QoL of patients with asthma.
 Methods: We conducted a clinical randomized controlled trial among asthmatic outpatients aged 18 years or older in the Department of Screening Respiratory Function, University Medical Center, Ho Chi Minh City, Vietnam. Patients were randomized into an intervention group (IG) and a non-IG (NIG). The clinical pharmacists’ intervention program included training in asthma-related knowledge, inhaler technique, recognition, prevention of adverse drug events, and lifestyle adjustment. Participant screening was conducted using the telephone on a monthly basis. QoL was measured using the Vietnamese Version of the Mini Asthma QoL Questionnaire (MiniAQLQ). The main outcome was the difference in QoL scores between IG and NIG after 3 months follow-up.
 Results: After 3 months, the number of patients with asthma in the IG and in the NIG was 173 and 96, respectively. QoL mean scores in the IG patients were significantly higher than those in their NIG counterparts (1.79±1.01 vs. 1.06±0.93, respectively, p<0.001). Pharmacist-based interventions overall QoL scores (multivariate-adjusted regression coefficient =0.362; p<0.001).
 Conclusions: Clinical pharmacist-led counseling can improve asthmatic patients’ QoL.

Mishandling of pMDI and DPI inhalers in asthma and COPD – Repetitive and non-repetitive errors

BackgroundPharmacological treatment of asthma and chronic obstructive pulmonary disease (COPD) is based mainly on inhaled medications. There is a continuous need to examine and train patients in their inhalation technique. The objective of the presented study is to determine whether the errors which patients made during inhalations are repetitive, and therefore easier to eradicate, or rather accidental, hence require more attention and effort from the health care professionals. MethodsIt was a prospective, cohort study which included adults with asthma or COPD, who have used at least one inhaler daily on a regular basis. Inhalation technique was evaluated twice in a six months interval basing on a list of the most common errors in the inhalation technique. There was no training of inhalation skills between visits. ResultsThere were 92 patients (46 asthmatics, 46 with COPD; median age 66 years, median duration of the disease 10 years) included into the analysis. 92% of patients made at least one error during their inhalation. Among pMDI users the most common device mishandlings were: no or too short breath-holding after inhalation (60% of the patients during the first visit; 50% during the 2nd), too rapid and too forceful inhalation (52%; 61%) and lack of exhalation before the use of the medicine (48%; 43%). Among the DPI users, the most numerous errors were: no or too short (less than 3 s) breath-holding after inhalation (62%; 55%) and slow and not forceful enough inhalation (38%; 36%).When comparing the mishandlings in the inhalation technique conducted during the first and second visit the majority of the errors conducted by the patients were repetitive. However, some errors such as too early termination of inhalation (p = 0.016), inhalation through the nose during actuation (p = 0.002) among pMDI users and lack of expiration before inhalation (p = 0.027) among DPI users, were non-permanent. ConclusionsImproper inhalation technique is very common and the majority of errors made in inhalation technique are repetitive. This emphasizes the role of an ongoing verification and training of a proper inhalation technique in all patients that are regularly treated with inhalers.

Virtual Teach-To-Goal™ Adaptive Learning of Inhaler Technique for Inpatients with Asthma or COPD

Asthma and chronic obstructive pulmonary disease (COPD) result in more than 1 million hospitalizations annually. Most hospitalized patients misuse respiratory inhalers. This misuse can be corrected with in-person education; however, this strategy is resource intensive and skills wane quickly after discharge. The objective of this study was to develop and pilot a virtual teach-to-goal™ (V-TTG™) inhaler skill training module, using innovative adaptive learning technology. Eligible adults with asthma or COPD completed a V-TTG™ metered-dose inhaler session with tailored rounds of narrated demonstration and self-assessments. The primary outcome was the proportion of participants with inhaler misuse post- versus pre-V-TTG™; secondary analyses tested mastery, self-efficacy, and perceived versus actual inhaler skills. Analyses were tested with McNemar's χ2 test (P < .05). Among 90 enrolled participants, the majority were African American (94%), female (62%), and had asthma (68%), with a mean age of 48 years. Among those completing both pre- and post-V-TTG™ (n= 83), misuse was significantly lower post- versus pre-V-TTG™ (24% vs 83%, P < .001). Mastery and confidence both improved significantly (46% vs 7%, P < 0.001; 83% vs 67%, P < .001) post- versus pre-V-TTG™. After V-TTG™, there was greater congruence between perceived versus actual inhaler skills (P < .01). No differences were seen in subgroup analyses for age, health literacy level, or diagnosis. This study is the first to demonstrate the efficacy of adaptive V-TTG™ learning to teach the inhaler technique. V-TTG™ improved most participants' technique to an acceptable level, reached mastery for half, and also increased self-efficacy and actualized skill. V-TTG™ has potential to improve health care across care transitions.

How many instructions are required to correct inhalation errors in patients with asthma and chronic obstructive pulmonary disease?

In the treatment of asthma and chronic obstructive pulmonary disease (COPD), errors in handling and wrong techniques in using inhalation devices are associated with poor disease control. The aim of this study was to evaluate the number of instructions that are necessary to minimize errors in using pressurized metered-dose inhaler (pMDI), soft mist inhaler (SMI), and dry powder inhaler (DPI).Among 216 patients with asthma (n = 135) and COPD (n = 81), we studied 245 cases that used different types of inhalation devices. After initial guidance, 145 of 245 cases (59%) made at least one error that could affect efficacy. For every device, at least three instructions were required to achieve entirely no errors or less than 10% errors in total. The most common error on the use of pMDI was device handling, whereas that of DPI was inhalation manner. Both errors were associated with low peak flow rate. In both patients with asthma and in patients with COPD, the most common error was inhalation manner.We concluded that it is necessary to repeat at least three times of instructions to achieve effective inhalation skills in both asthma and COPD patients.

Culturally Specific Evaluation of Inhaler Techniques in Asthma.

Little work has been done on identifying the impact of educational materials developed by immigrant patients themselves, along with their caregivers and health professionals in terms of inhaler use technique. The purpose of this study was to evaluate understanding of physicians' instructions on asthma management and inhaler techniques in Punjabi and Chinese subjects using educational interventions in their native languages. Eighty-seven subjects with asthma were randomly assigned to either one of 3 experimental groups (physician-led video, subject-generated community video, or both) or a control group (educational pamphlet). Medication knowledge and inhaler skills were measured during 3 in-person interviews. Subjects in all 3 experimental groups, when compared with control subjects, demonstrated improvements in the follow-up test in terms of ability to use inhalers correctly (P < .001) and understanding of physicians' instructions (P = .008). Chinese participants showed significantly greater improvements compared with Punjabi participants for the correct use of inhalers (P < .047), and females showed greater improvements compared with male subjects (P = .04). The educational interventions developed were successful in behavioral modification and beneficial beyond usual care in terms of improving proper use of inhalers and understanding of physicians' instructions. The findings can be translated to health education practice, promoting the development of short, simple, and culturally linguistically appropriate learning materials for patients. Such interventions that draw on patients' life experiences and socio-cultural context can overcome certain limitations of conventional patient education approaches. (ClinicalTrials.gov registration NCT01474928.).

Real-world asthma management with inhaler devices in Switzerland-results of the asthma survey.

The aim of the Asthma Survey was to generate insights about the daily practice of physicians with regard to inhaler devices used for treating asthma under real-world conditions in Switzerland. A questionnaire was administered to 605 participating hospital- and practice-based Swiss physicians. Areas of interest were practical aspects of patient education, typical difficulties encountered when prescribing pressurized metered-dose inhalers (pMDI) and dry-powder inhalers (DPI), and reasons for physician preferences. Differences between the German-speaking part of Switzerland (D-CH) and French- and Italian-speaking parts of Switzerland (W-CH) linguistic regions were explored. Datasets from 529 physicians (291 D-CH and 238 W-CH) were suitable for analysis, 342 internists/general practitioners, 177 pulmonologists/allergologists, and 10 other. Approximately 90% of all participants declared being personally involved in providing inhaler device education to their patients. Practice assistants (33.0% vs. 9.2%, P<0.001) and pharmacists (6.9% vs. 19.7%, P<0.001) were more frequently involved in D-CH compared to W-CH. Patient skills with regard to inhalation technique were generally not monitored on a regular basis with only 34.0% of participants ensuring such checks at the scheduled visits. DPIs were overwhelmingly preferred over pMDI. Although the prevalence of typical handling errors was similar with both inhalers in the two regions, pMDIs were used more frequently in W-CH (P<0.001). Real-world asthma management and inhaler preferences differ between D-CH and W-CH. While the importance of patient education is widely acknowledged, inhalation skills monitoring remains suboptimal. The reasons for higher pMDI preference in W-CH compared to D-CH deserve further research.

Device Matters: Looking Beyond the Drug

Prof Helen Reddel opened the symposium by discussing the need to examine the modifiable nonpharmacological factors in the treatment of asthma and chronic obstructive pulmonary disease (COPD) that can be addressed to improve clinical outcomes. Dr Kai-Michael Beeh set the scene and discussed the need to review patient behaviour and drug delivery mechanisms to improve outcomes for patients with asthma and COPD. Dr John Haughney then discussed how patient preferences for inhalers can impact real-world outcomes. Prof Sinthia Bosnic-Anticevich outlined the challenges in learning and maintaining correct inhaler technique, while Prof Henry Chrystyn highlighted how inhaler design can help minimise the impact of inhaler errors on clinical outcomes. Prof Helen Reddel closed the session by bridging the gap between guidelines and clinical care, describing ways to incorporate regular checking and training of inhaler skills into a range of settings. The meeting objectives were to look beyond drugs to the role of devices in optimising asthma and COPD management, to understand the impact of inhaler technique on treatment efficacy, to review how patient perspectives about their inhaler can impact on clinical outcomes, and to discuss how to implement current clinical guidelines on inhaler technique in day-to-day clinical care.

Salmeterolio ir flutikazono derinio efektyvumas gydant astmą

Astma yra plačiai paplitusi kvėpavimo takų uždegimo liga, kuri tinkamai nekontroliuojama blogina paciento gyvenimo kokybę ir didina išlaidas, skirtas sveikatos paslaugoms. Astmos gydymo tikslai yra gera simptomų kontrolė, normalus kasdienis paciento aktyvumas, maža rizika ir normali plaučių funkcija. Norint juos įgyvendinti, reikia laiku diagnozuoti ligą, parinkti tinkamą gydymą, ingaliatorių, suteikti pacientui informacijos, mokyti jį taisyklingos vaisto įkvėpimo technikos.

The effect of pharmacist-led education on inhaler use skills in hospitalised patients with chronic obstructive pulmonary disease

ObjectiveTo assess patient inhalation skills and the effect of pharmacist-led education on these skills in chronic obstructive pulmonary disease (COPD) patients using inhalers in a hospital setting.MethodsPre- and 1 month...

Inhaler technique training and health-care professionals: effective long-term solution for a current problem.

The aims of this study were (1) to assess the ability of a range of health-care professionals (HCPs: specialists [physicians specializing in management of airways disease], general practitioners, pharmacists, pharmacist assistants, nurses, and respiratory therapists) in Jordan to demonstrate the correct use of some commonly used inhalers using standardized checklists, with highest scores indicating optimal use, and (2) to evaluate the short-term and long-term effectiveness of a single educational intervention on the HCPs' skills in using inhalers. HCPs' inhaler technique was assessed at baseline. All HCPs were then invited to attend a workshop on asthma management with particular reference to inhaler use. At the workshop, HCP skills in inhaler technique were optimized. Inhaler technique was assessed before and after training. All participants were assessed on their inhaler technique at follow-up (after 4 months). Two hundred HCPs (10 specialists, 46 general practitioners, 79 pharmacists, 15 pharmacist assistants, 40 nurses, and 10 respiratory therapists) participated in the study. Specialists scored highest on baseline inhaler technique demonstration skills. All HCPs scored poorly in demonstrating the correct use of the dry powder inhalers when compared with pressurized metered-dose inhalers (MDIs) (range of mean scores ± SD: MDI, 7.24 ± 0.97 to 8.70 ± 0.67; Diskus, 4.83 ± 0.51 to 6.30 ± 1.7; Turbuhaler, 4.90 ± 0.32 to 6.40 ± 1.7). Participants attending the workshop showed improved inhaler skills (mean scores before and after training: MDI, 4.77 ± 1.60 vs 8.77 ± 0.52; Diskus, 4.40 ± 2.60 vs 8.85 ± 0.41; Turbuhaler, 4.96 ± 2.05 vs 8.63 ± 0.67). Four months after the workshop, the inhaler technique of 129 participants was again assessed. Those who had attended the workshop (n = 48) scored significantly higher mean scores for all devices (score = 7.64) than nonattendees (n = 81, score = 5.99, P < .001), by one-way analysis of covariance. With the exception of specialists, HCPs in Jordan need to be updated on their inhaler technique skills, specifically the newer dry powder inhalers. A single effective educational workshop on inhaler technique can significantly improve HCPs' long-term ability to demonstrate these skills.

Asthma advice giving by community pharmacists

Abstract Objective To investigate the frequency and type of asthma-related advice provided by community pharmacists to customers, and pharmacist attitudes to advice giving and training needs. Method Postal questionnaire surveying the provision of advice to asthma patients in the previous month. Responses were discussed in a focus group of 13 pharmacists representing different types of community pharmacy and stratified by age and sex. Setting All community pharmacists in the Grampian health board area, in North East Scotland. Key findings Of an estimated 180 community pharmacists, 125 responded. Respondents had dispensed a median of 70 asthma medications per week to approximately 40 customers. Most had given advice no more than twice a week. In the previous month, half had checked inhaler technique and most (75 per cent) had “loaned” relief inhalers on an emergency basis. The most common areas where patients sought advice were problems with inhalers, concerns about side effects of asthma medications and using peak flow meters. In the focus group, pharmacists expressed concerns about their training in advice giving for inhaler skills and peak flow meter use and self-management plans. The 69 pharmacists who had undertaken additional training were significantly more likely to feel confident in giving asthma-related advice and to give advice more often. Sixty-one per cent of pharmacists wanted more training in advice giving. Conclusion At present, asthma-related advice is given infrequently. Reasons for missed opportunities for giving such advice are limited facilities in premises, lack of pharmacist knowledge of some aspects of asthma management and patient attitudes (ie, lack of awareness that pharmacists can fulfil this role).

Evaluation of the Standardized MDI-Spacer Checklist on Pediatric Asthma Management

A metered-dose inhaler (MDI) with spacer allows for the delivery of maintenance therapy for childhood asthma. In this study, the authors aimed to assess the possible effects of inhalation skills in the use of an MDI with a small-volume spacer on asthma outcome in asthmatic children. The study group consisted of 66 asthmatic children between 7 and 11 years of age (mean ± SD, 8.2 ± 1.7 years) and a control group that consisted of 54 asthmatic children between 7 and 12 years of age (mean ± SD, 7.7 ± 0.9 years). All subjects were prescribed fluticasone propionate 125 µg 1 puff by an MDI with a small-volume Aerochamber spacer twice daily for 12 weeks. Inhalation skill scoring was made using the standardized MDI spacer checklist. Spirometric measurements and Health-related qualify-of-life measures were performed before and at the end of the 12-week treatment. There was no significant correlation between asthma outcome measures and MDI spacer checklist scores in children with asthma ( r = 1.76, P &gt; .05). Moreover, the MDI spacer checklist scores were not statistically different between the study and control groups ( P &gt; .05). This finding suggests that the standardized MDI spacer checklist scale scores have no significant impact on asthma outcome in children with asthma.

Inhaler technique in older people in the community.

Good inhaler technique and medication concordance is important for symptom and disease control in chronic airways disease. Establish the prevalence of inhaler use; the main inhaler devices used by older people at home; their ability to use the inhalers they have been prescribed; and the relationship between perceived ease of use and actual performance. Cross-sectional population based study. Subjects aged 70 years and over living at home. 500 subjects were randomly selected from 5002 subjects aged 70 years and over living at home. Inhalers used over the previous 24 hours were identified by a nurse on home visit. Those with cognitive impairment were excluded. Inhaler system was assessed and graded by a doctor as acceptable (perfect or minor errors) or unacceptable (major errors), using previously published criteria. Perceived ease of use of the device was rated as easy, moderate or difficult. 423 subjects participated in the study. The population prevalence of inhaler use was 15.8% (12.0, 19.7). Of the 91 inhaler devices used, 39 (42.8%) were metered dose inhalers, 34 (37.4%) were metered dose inhalers with large volume spacers, and 18 (19.8%) were breath-actuated devices. Thirty-two subjects (82.1%) using metered dose inhalers had an acceptable technique compared with 33 (97.1%) of those using metered dose inhalers with large volume spacers and 13 (72.2%) of those using breath-actuated devices (P < 0.05). Up to three quarters of inhalers were considered easy to use but 12% of subjects who rated their inhaler device as being easy to use made major errors. Metered dose inhaler was the most frequently prescribed inhaler and was used correctly by most subjects especially in combination with large volume spacers. Major errors were more common with breath-actuated devices. Inhaler technique should be checked as patients' perception of their inhaler skills correlates poorly with actual performance.

Does introduction of new “easy to use” inhalational devices improve medical personnel's knowledge of their proper use?

Lack of basic inhaler skills by medical personnel has been documented by numerous studies. Consequently, training of patients in correct inhalational technique suffers. Newer dry powder inhalers such as Turbuhaler (budesonide, Astra USA, Westborough, MA) and Diskus (salmeterol, GlaxoSmithKline, Research Triangle Park, NC) have some advantages over conventional metereddose inhalers (MDIs) including easier technique of usage. They have been recently marketed with the hope of overcoming this problem. To determine whether introduction of newer "easy to use" dry powder inhalers such as budesonide (Turbuhaler) and salmeterol (Diskus) would result in improvement in medical personnel's knowledge of their proper use. In and around a community-based teaching hospital, interviews were conducted in March 2000 of 50 assorted randomly selected medical personnel. They included 10 respiratory therapists, 10 registered nurses, 10 medical residents, 10 primary care physicians, and 10 pharmacists. Objective evaluation was made of their skills demonstration and knowledge scores for usage of MDIs, budesonide, and salmeterol. Mean percentage demonstration scores of different medical personnel for all three devices taken together: respiratory therapist (81.6%), primary care physicians (77.7%), pharmacists (57.7%), registered nurses (54.4%), and medical residents (53.8%). Mean percentage demonstration scores of different inhalers for all medical personnel taken together: MDI (80.9%), salmeterol (64.2%), budesonide (49.9%). Mean percentage knowledge score of all three inhalational devices taken together for respiratory therapist was the best at 76.6%. Registered nurses performed the worst with a score of 52.0%. Mean percentage knowledge scores: MDI (78%), salmeterol (63.2%), and budesonide (52.4%). A repeated measures two-way analysis of variance demonstrated that differences in both demonstration and knowledge scores between inhaler types and between medical personnel were all highly statistically significant (P < 0.0001). Demonstration skills and knowledge scores for use of both budedsonide and salmeterol were substantially lower than that for MDI for all medical personnel. Medical personnel responsible for teaching the correct use of inhalational devices are lacking in basic knowledge and user skills. This likely contributes to patient's poor technique when using these devices.

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.

Meta-analysis of the effects of psychoeducational care in adults with chronic obstructive pulmonary disease

Meta-analysis, a quantitative research review, was conducted on 65 studies of the effect of education, exercise and/or psychosocial support (hereafter called psychoeducational care) in adults with chronic obstructive pulmonary disease (COPD). Studies ranged in publication date from 1954 to 1994. Only 34% of studies had subjects that were randomly assigned to treatment condition, and only 15% of studies had a placebo-type control group. Analyses by type of treatment showed that pulmonary rehabilitation (large muscle exercise and education plus a variety of psychosocial or behavioral interventions) had statistically significant beneficial effects on psychological well-being ( d + = 0.58, n = 13), endurance ( d + = 0.77, n = 13), functional status ( d + = 0.63, n = 8), VO 2 ( d + = 0.56, n = 5), dyspnea ( d + = 0.71, n = 10), and adherence ( d + = 1.76, n = 2). A statistically significant beneficial effect of pulmonary rehabilitation was not found on Forced Expiratory Volume at 1 s. Across 7 outcomes examined, treatments including education-alone had significant beneficial effect only on the accuracy of performing inhaler skills ( d + = 1.27, n = 7). Based on a very small sample of studies, a non-significant but small or medium sized effect of education-alone was evident on health care utilization ( d + = 0.26, n = 3) and on adherence to treatment regimen ( d + = 0.50, n = 2). Such results are inconclusive, suggesting that further research may be indicated. Relaxationalone had statistically significant beneficial effects on both dyspnea ( d + = 0.91, n = 3) and psychological well-being ( d + = 0.39, n = 6). The research base has methodological weaknesses that should be rectified in future research. Nonetheless, based on the best evidence available to date, identified types of psychoeducational care have been shown to improve the functioning and well-being of adults with COPD.