Misuse of Respiratory Inhalers in Hospitalized Patients
with Asthma or COPD
Valerie G. Press, MD, MPH1, Vineet M. Arora, MD, MAPP2, Lisa M. Shah, MD, MA3,
Stephanie L. Lewis, BA4, Krystal Ivy, BA4, Jeffery Charbeneau, MS4, Sameer Badlani, MD1,5,
Edward Naurekas, MD4, Antoinette Mazurek, MS4, and Jerry A. Krishnan, MD, PhD4,6
1Department of Medicine, University of Chicago, Instructor, Section of Hospital Medicine, Chicago, IL, USA;2Department of Medicine,
University of Chicago, Section of General Internal Medicine, Chicago, USA;3Avalere Health, LLC, Washington, DC, USA;4Department of
Medicine, University of Chicago, Asthma and COPD Center, Section of Pulmonary and Critical Care, Chicago, USA;5Mercy Hospital and
Medical Center, Chicago, USA;6Department of Health Studies, University of Chicago, Chicago, USA.
BACKGROUND: Patients are asked to assume greater
responsibility for care, including use of medications,
during transitions from hospital to home. Unfortunate-
ly, medications dispensed via respiratory inhalers to
patients with asthma or chronic obstructive pulmonary
disease (COPD) can be difficult to use.
OBJECTIVES: To examine rates of inhaler misuse and
to determine if patients with asthma or COPD differed
in their ability to learn how to use inhalers correctly.
DESIGN: A cross-sectional and pre/post intervention
study at two urban academic hospitals.
PARTICIPANTS: Hospitalized patients with asthma or
INTERVENTION: A subset of participants received in-
struction about the correct use of respiratory inhalers.
MAIN MEASURES: Use of metered dose inhaler (MDI)
and Diskus® devices was assessed using checklists.
Misuse and mastery of each device were defined as
<75% and 100% of steps correct, respectively. Insuffi-
cient vision was defined as worse than 20/50 in both
eyes. Less-than adequate health literacy was defined as
a score of <23/36 on The Short Test of Functional Health
Literacy in Adults (S-TOFHLA).
KEY RESULTS: One-hundred participants were enrolled
(COPD n=40; asthma n=60). Overall, misuse was com-
mon (86% MDI, 71% Diskus®), and rates of inhaler
misuse for participants with COPD versus asthma were
similar. Participants with COPD versus asthma were
twice as likely to have insufficient vision (43% vs. 20%,
p=0.02) and three-times as likely to have less-than-
adequate health literacy (61% vs. 19%, p=0.001). Parti-
cipants with insufficient vision were more likely to
misuse Diskus® devices (95% vs. 61%, p=0.004). All
participants (100%) were able to achieve mastery for
both MDI and Diskus® devices.
CONCLUSIONS: Inhaler misuse is common, but cor-
rectable in hospitalized patients with COPD or asth-
ma. Hospitals should implement a program to assess
and teach appropriate inhaler technique that can
overcome barriers to patient self-management, in-
cluding insufficient vision, during transitions from
hospital to home.
KEY WORDS: asthma; pulmonary disease; chronic disease; hospital
medicine; health literacy.
J Gen Intern Med 26(6):635–42
© Society of General Internal Medicine 2011
Transitions in care from hospitals to home are increasingly
recognized as a vulnerable period in which patients and their
caregivers are asked to assume greater responsibility for their
healthcare,1–3particularly medication management.4,5This
may be especially problematic for patients with asthma or
chronic obstructive pulmonary disease (COPD) who are com-
monly prescribed medications dispensed through respiratory
inhalers.6,7Although inhaled medications offer the advantage
of targeted delivery to the site of action (airways), they can be
difficult to use8and require multiple-steps for use.9–13More-
over, symptom control and prevention of exacerbations often
require combination therapy with two or more types of inhalers
(e.g., metered-dose-inhalers [MDI], Diskus®), requiring
patients to learn and master a different series of device-specific
instructions. At times, these instructions are in direct conflict,
causing confusion. For instance, patients should inhale slowly
when using MDIs, but inhale quickly when using Diskus®
Studies to date on inhaler use focus on patients with
asthma and use of MDI devices,
multiple risk factors for high rates of inhaler misuse, including
the use of multiple devices,11inadequate instruction,16–18and
low health literacy.9,12,19Our study is novel from two perspec-
tives. First, although COPD is as prevalent as asthma in the
United States and is associated with substantially higher
mortality than asthma, data regarding inhaler misuse in
9–11,14,15and have found
Received July 16, 2010
Revised December 8, 2010
Accepted December 15, 2010
Published online January 20, 2011
hospitalized patients with COPD are limited.20For example, it
is unclear if hospitalized patients with COPD have high rates of
inhaler misuse and what barriers may exist in the ability of
patients with COPD to learn inhaler technique. Because COPD
primarily affects older patients who are at increased risk of
poor vision21and low health literacy,22hospitalized patients
with COPD may have high rates of inhaler misuse.
Second, to our knowledge, no studies have examined the
use of Diskus® devices in hospital settings, even though they
are routinely prescribed at hospital discharge. Incorrect use of
Diskus® devices can cause inadequate dosing or distribution
of medication.23Thus, incorrect use of Diskus® inhalers may
represent a missed-opportunity for patients to benefit from
highly efficacious therapy.24,25It is not known how common
misuse of Diskus devices is for hospitalized patients with
asthma or COPD.
Guidelines for asthma and COPD recommend assessing and
correcting inhaler technique at all healthcare encounters,
including hospitals.17,18Therefore, the objective of this study
was to extend the existing literature by examining rates of
misuse of respiratory inhalers for both rescue and controller
medications among hospitalized patients with either asthma or
COPD. The secondary objective was to determine if patients
with asthma and COPD differed in their ability to learn how to
use inhalers correctly.
The study was conducted from September 2007 to March
2009. Research staff reviewed electronic admission-logs Mon-
day through Friday to identify patients hospitalized with
asthma or COPD. Patients who met all inclusion criteria (age
of 18-years or older and hospitalized on a medical service with
a physician diagnosis of asthma or COPD) and none of the
exclusion criteria (inability to provide informed written consent
[e.g., non-English speaking, too ill to participate], or previous
participant of the study) were eligible to participate. Patients
who provided written consent and whose physicians assented
were included. The study was approved by the University of
Chicago Medical Center and Mercy Hospital and Medical
Center Institutional Review Boards.
Participants completed an interviewer-administered survey
collecting information on sociodemographics (age, sex, ethnic-
ity, race [white vs. non-white]), and smoking history (ever vs.
never). Further, participants’ utilization of several health-
services for asthma or COPD was evaluated and included 1)
whether participants had a healthcare provider who treats
their asthma or COPD (generalist [general practitioner, inter-
nist, family medicine physician, nurse practitioner]; specialist
[pulmonologist or allergist], or none); 2) number of hospitaliza-
tions for asthma or COPD in the past 12-months; and 3) near-
fatal respiratory events (intensive care unit admission or
intubation in their lifetime).
Health literacy was measured using the Short Test of
Functional Health Literacy in Adults (S-TOFHLA).26,27The
S-TOFHLA measures reading comprehension by having
participants read sentences (font-size 14) from medical
scenarios with missing key words and having them select
words from a multiple-choice list to complete the sen-
tences. Participants have up-to seven minutes to complete
the 36-item instrument and receive one point for each
correct answer. Participants were classified as having less-
than-adequate (score <23) or adequate (score ≥23-36)
health literacy.26Prior to administration of the S-TOFHLA,
vision was assessed (Snellen screening chart).25Patients
who used corrective-lenses were instructed to use them.
Vision was defined as insufficient to complete the S-
TOFHLA instrument if vision was worse than 20/50 in both
Lung function was measured using the KoKo PFT System
for spirometry (version 4.3; PDS, Louisville, Colorado). For
safety reasons, participants were excluded from spirometry
if systolic and diastolic blood pressures were higher than
180 millimeters-mercury (mmHg) and/or 100 mmHg, re-
spectively, or if trained research assistant did not consider
them to be medically stable.
Inhaler technique was assessed utilizing detailed check-
lists (12-steps for MDI, 10-steps for Diskus®, [Text boxes 1
and 2]). Participants were eligible for assessment of inhaler
technique if they had been prescribed the device prior to
hospitalization. There is no consensus on the most appropri-
ate threshold for defining correct versus incorrect use of
respiratory inhalers. Previous studies demonstrate a wide-
range of definitions for incorrect inhaler technique (i.e.
inhaler misuse), from anywhere less than 60% of steps
correct to less-than 100% of steps correct.9–13In the current
study, misuse of MDI or Diskus® was defined as <75% of
steps correct for each respective device (< 9 of 12 steps for
MDI; < 8 of 10 steps for Diskus®). Our threshold is a
conservative mid-point that falls within the broad-range of
definitions above. The checklists used in this study were
developed based on a review of package-inserts and the
published literature,6,9–13and modified by the research team
to explicitly identify individual inhaler steps to improve inter-
rater reliability (sample of n=10, kappa for MDI =0.94, kappa
for Diskus® =1.0).
We also evaluated whether patients differed in their
ability to learn inhaler technique by testing a standardized
educational intervention called “teach-to-goal” (TTG) using
a pre/post study design. This component of the study was
added to the initial cross-sectional study because baseline
rates of misuse were so high at the mid-study interim
analysis (May 2008). Therefore, all participants enrolled
after this interim-analysis received TTG education. TTG is
an intervention that assesses skills or knowledge at base-
line, then reassesses with patient “teachback” after an
educational intervention is performed; this cycle is contin-
ued until mastery of the skill or knowledge has been
safety, has been endorsed as a patient safety standard by
the National Quality Forum for informed consent,28and
has been successful among hospitalized with asthmatics.9
In this study, trained research assistants first screened
participants’ inhaler technique; those who did not have
mastery were provided with both verbal instructions and a
9,28The TTG technique is often used in patient
Press et al.: Misuse of Respiratory Inhalers
demonstration of proper technique. After the first-round of
the TTG teaching session, participants were asked to re-
demonstrate how to use the inhaler correctly (i.e. “teach-
back”). A second-round of teaching was provided, if the
participant did not demonstrate mastery during the parti-
Descriptive statistics used means, standard deviations, and
proportions. T-tests were used to test for differences in
means. Chi-squared or Fisher’s exact test was used to test
for bivariate associations for our primary objectives of
MDI WITH SPACER
Trained assessor to read to participant: “Please show me exactly how you use your MDI at home.”
1. Removes cap of inhaler and spacer
2. Shakes inhaler up and down
3. Attaches inhaler to back of spacer
4. Breathes OUT fully
5. When breathing out fully (step #4), does so away from spacer/MDI
6. Puts spacer mouthpiece or MDI mouthpiece (if not using spacer) into mouth,
closes lips around mouthpiece
7. Activates inhaler by pressing down on canister 1 time
8. Breathes IN SLOWLY, filling lungs with medicine. No whistle should be heard
9. Holds breath for at least 5 seconds (with or without spacer in mouth)
10. Removes spacer/MDI from mouth before breathing normally
11. Breathes normally for at least 30-60 seconds
12. Repeats sequence for second puff
Trained assessor to read to participant: “Please show me exactly how you use your Diskus® at home.”
1. Uses thumb or finger in thumb grip to open device until the mouthpiece appears
2. Keeps Diskus® horizontal prior to Step #3 & until Step #7 completed
3. Slides lever once until it clicks
4. Breathes OUT fully
5. When breathing out fully (step #4), does so away from Diskus®
6. Presses lips tightly above & below mouthpiece opening
7. Breathes IN QUICKLY, filling lungs with medicine
8. Holds breath for at least 5 seconds (with or without Diskus® in mouth)
9. Removes Diskus® before breathing normally
10. Closes Diskus® by placing thumb or finger in the thumb grip & sliding it closed
Press et al.: Misuse of Respiratory Inhalers
comparing inhaler misuse for patients with asthma com-
pared to COPD and our secondary objective of comparing
participants’ ability to learn inhaler technique for those with
COPD compared to asthma. A two-tailed p-value of less than
0.05 defined statistical significance. Computations were
performed using STATA version 10 (StataCorp).
Demographic and descriptive data (Table)
Of the 146 patients that were eligible, 100 participants
(68%) were enrolled (Fig. 1). Reasons for declining to
participate included not feeling well, not feeling as though
they needed education about inhaler use, or simply declin-
ing without further explanation. The mean age was 52 years,
and the majority of participants had asthma, were African
American, female, had been hospitalized within the past
12 months, and had a history of a near-fatal respiratory
event. Further, the majority of participants had a healthcare
provider (approximately half saw a generalist, and one-third
saw a specialist). More than one-in-four participants had
insufficient vision. Of these 29 participants, 3 (10%) were
never prescribed corrective lenses, 18 (62%) were prescribed
corrective-lenses but did not have them available in the
hospital, and 8 (28%) were wearing their corrective-lenses.
Of the 71 participants with sufficient vision to complete the
S-TOFHLA, approximately one-third (n=23, 32%) had less-
than-adequate health literacy.
Asthma vs. COPD
had similar characteristics Table 1. However, compared to
participants with asthma, COPD participants were older, more
likely to be an ever smoker, had worse lung function, were twice
as likely to have insufficient vision, and had less-than-adequate
health literacy (19% vs. 61%, p=0.001).
Misuse of respiratory inhalers
All enrolled participants had been previously prescribed an
MDI and/or Diskus® device. Nearly all participants with
asthma or COPD had been prescribed an MDI (100% vs.
98%, respectively) and the majority had been prescribed a
Diskus® device (75% vs. 68%, respectively).
for MDI and Diskus® were similarly high (86% and 71%,
respectively, p=0.07). For MDI devices, the majority of patients
were unable to perform the following steps: attaching the
spacer (step 3, incorrect in 83% of participants), breathing
out fully (step 4, incorrect in 77% of participants) and away from
the device (step 5, incorrect in 83% of participants). Similar
steps were misused by the majority of patients for the Diskus®
device: breathing out fully (step 4, incorrect in 77% of partici-
pants) and away from the device (step 5, incorrect in 81% of
participants). There were no significant differences in the
percent of patients with asthma vs. COPD performing any of
the MDI steps correctly (p-values: 0.09 to >0.999) or Diskus
steps correctly (p-values: 0.35 to >0.999). [Fig. 2]
Misuse of inhalers was similarly common in participants
with COPD vs. asthma (MDI, 85% vs. 86%, p>0.99; Diskus®,
81% vs. 65% p=0.18). Among participants who had been
prescribed both a MDI and a Diskus® (n=69), MDIs were more
often misused, although this difference was not statistically
significant (83% vs. 71%, p=0.07).
Participants with insufficient vision were more likely to
misuse Diskus® devices compared to those with sufficient
vision (95% vs. 61%, p=0.004). However, differences in inhaler
misuse were not significantly different between groups based
on vision for MDIs (89% vs. 84%, p=0.75). Health literacy was
not significantly associated with MDI or Diskus® misuse (MDI
misuse in patients with less-than-adequate health literacy vs.
adequate health literacy: 83% vs. 85%, p=0.74; Diskus® 63%
vs. 61%, p=0.58).
Ability to learn inhaler technique with TTG strategy
Forty-two participants were enrolled after the mid-study
analysis, and therefore participated in the TTG intervention.
Total Screened for Eligibility
Less-than 18 years of age (n=6)
Unable to consent (e.g., due to
mental status, acuity of illness
or spoke language other than
English, or unable to approach
prior to discharge) (n=139)
Physician declined assent (n=5)
(MDI n=99; Diskus® n=70)
Figure 1. Flow diagram of screening and enrollment. Participant
eligibility, enrollment, and study completion.
Press et al.: Misuse of Respiratory Inhalers
Baseline participant characteristics (age, gender, race, smok-
ing status, level of health literacy, and vision), diagnosis (COPD
vs. asthma), and rates of MDI and Diskus® misuse were
similar for those who received TTG compared to those enrolled
prior to the mid-study analysis (and therefore did not receive
TTG; data not shown).
After one-round of TTG instruction, 86% (36/42) of partici-
pants achieved MDI mastery. There was no difference in ability
to learn inhaler technique for patients with asthma compared
to those with COPD (87% vs. 84%, p=0.57), after one-round of
TTG. After a second-round of TTG, all participants (42/42,
100%) achieved MDI mastery. Participants with insufficient
vision were less-likely to achieve mastery after one-round of
TTG compared to those with sufficient vision (58% vs. 97%, p=
0.005). Level of health literacy was not associated with mastery
after one-round of teaching (less-than-adequate vs. adequate
health literacy: 92% vs. 100%, p=0.4).
As with MDIs, the majority of participants (32/41, 78%)
achieved mastery after one-round of TTG instruction. Again,
there was no difference in ability to learn inhaler technique for
patients with asthma compared to those with COPD (74% vs.
83%, p=0.37) after one-round of TTG. Similar to MDI, after a
second-round of TTG, all participants (100%) achieved mastery
for the Diskus® device. Additionally, participants with insuffi-
cient vision were less-likely to achieve mastery of Diskus® after
one-round of TTG compared to those with sufficient vision,
though statistical significance was not demonstrated (83% vs.
67%, p=0.41). While health literacy was also not associated
with mastery of Diskus® after one-round of teaching, results
approached statistical significance (less-than-adequate vs.
adequate health literacy: 64% vs. 94%, p=0.05).
Our study demonstrates that rates of respiratory inhaler
misuse are high among hospitalized patients with asthma
and COPD. This is interesting since patients with COPD have
higher rates of potential risk factors including insufficient
vision and less-than-adequate health literacy. Although great-
er than one-in-four participants had insufficient vision, and
these participants were twice-as-likely to misuse Diskus®
devices, we also found that all participants, regardless of
diagnosis, were able to learn and master both MDI and
Our findings extend the results of previous studies mainly
done in outpatient and emergency room settings, that found
Table 1. Participant characteristics (total n=100; asthma (n=60); COPD†(n=40))*
Age, years (mean [sd‡])
Hispanic or Latino
Less-than adequate health literacy¶
Healthcare provider (asthma/COPD care)
Hospitalized in the last 12 months
Near-fatal respiratory event††
FEV1/FVC (mean [sd])
FEV1, % predicted (mean [sd])
*All data are presented as n (%) unless otherwise indicated
†COPD: chronic obstructive pulmonary disease (COPD)
‡sd: standard deviation
§Nonwhite: Black, American Indian, Alaska native, native Hawaiian or other Pacific Island
‖Insufficient vision: worse than 20/50 vision in both eyes
¶Less-than adequate health literacy: health literacy was assessed in 71 participants; asthma (n=48); COPD (n=23); remaining subjects had insufficient
vision to complete assessment; less-than adequate health literacy was defined as score of <23/36 on Short Test of Functional Health Literacy (S-TOFHLA)
#Generalist: family practice, internist, general practitioner, nurse practitioner
**Specialist: pulmonologist or allergist
††Near-fatal respiratory event: intensive care unit admission or intubation for asthma or COPD in their lifetime.
‡‡Lung function: assessed in 81 participants; asthma (n=51); COPD (n=30); for safety reasons, participants were eligible for spirometry if blood pressure
was lower than 180/100 millimeters-mercury and could tolerate the procedure; FEV1 =Forced expiratory volume in one second; FVC = forced vital
Press et al.: Misuse of Respiratory Inhalers
high rates of inhaler misuse (from 32%-100% of patients).9–
13,29,30Further, our study is unique in that it examines the
use of respiratory inhalers for both rescue (e.g., MDIs) and
controller medications (e.g., MDI and Diskus® devices) in
hospitalized patients with asthma or COPD, two of the most
common lung conditions, accounting for more than 50 million
individuals in the United States.31Our results suggest that
providing hospital-based instruction can overcome barriers to
self-management, such as insufficient vision.
One unexpected finding was the high prevalence (more
than one–in-four participants) of insufficient vision in our
study population. The majority of participants with insuffi-
cient vision did not have their corrective-lenses with them in
the hospital; the remainder either had corrective-lenses that
were not adequate or had not previously been prescribed
corrective-lenses. Vision in the range of 20/50 to 20/100 is
considered “disabling” in occupations that require work with
numbers or extensive reading, thereby making sufficient
vision essential to one’s ability to perform certain vocations
or tasks.32Similarly, this concept can be applied to an
individual’s ability to manage chronic diseases on a daily
basis. For instance, insufficient vision may serve as a
barrier to self-management of asthma or COPD, including
the use of medications (e.g., respiratory inhalers). For
example, one study reported that poor vision is related to
the inability of patients to open medication containers.33
Our study demonstrates that insufficient vision is a newly
identified barrier to appropriate inhaler use. This finding is
not surprising since patient education is heavily weighted with
written materials that are not only too complex for patients with
to be legible for patients with insufficient vision.34For example,
font-sizes on package-inserts for MDI and Diskus® devices are
well below the size 14-font used with the S-TOFHLA, instru-
ment,35,36presenting a potential challenge for patients with
However, insufficient vision does not appear to fully
explain inhaler misuse. For instance, although COPD
patients had higher rates of insufficient vision, they had
similar rates of misuse compared to patients with asthma.
Further, while insufficient vision was significantly associat-
ed with Diskus® misuse and the inability to learn MDI
technique, we did not find significant associations between
insufficient vision and MDI misuse, nor did we find signif-
icant associations between insufficient vision and ability to
learn Diskus® technique. One potential reason is the
relatively modest sample size for some of the tests of
associations. It is also possible that unmeasured patient
confounders such as cognitive status or hearing, among
others, play a role in inhaler misuse and ability to learn
inhaler technique. There could also be device-specific factors
that increase risk for misuse that need to be better
evaluated in future studies. These potential unmeasured
patient-specific factors may also explain why, even though
patients with COPD have higher rates of inadequate health
literacy and insufficient vision, patients with asthma are
just as likely to misuse inhalers. Larger prospective studies
should evaluate the role of insufficient vision, along with
other important patient factors, in inhaler misuse and
ability to learn inhaler technique.
It was encouraging that the TTG intervention was able to
overcome potential barriers, such as insufficient vision, for
learning inhaler technique. Our findings suggest that com-
parative studies to evaluate the relative effectiveness of
intensive approaches (e.g., TTG), compared to less-intensive
approaches to inhaler instruction, are needed.
Unlike earlier studies, we did not detect an association
between health literacy and inhaler misuse.9,12Although
rates of mastery after instruction were larger for patients
with less-than-adequate health literacy (compared to ade-
quate health literacy), differences between the groups were
not statistically significant. Because we could not measure
health literacy for all study participants, we were inadequate-
ly powered to detect a statistically significant association
between lower-levels of health literacy and inhaler mastery.
Our study has some limitations. Because we enrolled a
predominately minority population with frequent exacerba-
tions and hospitalizations, it is not clear if our findings
would be generalizable to all hospitalized patients with
COPD or asthma. We did not include a control group when
evaluating the effectiveness of TTG; thus we cannot provide
information about the relative effectiveness of intensive
versus less-intensive approaches. TTG employed trained
research assistants to provide the intervention, as opposed
to clinicians; additional studies are needed to determine
whether TTG is effective and feasible when delivered by
clinicians. Although TTG was successful at teaching patients
while hospitalized, we have no long-term follow-up data from
Figure 2. Figure 2a: MDI. Percentage of participants demonstrating
correct inhaler technique for each of the 12 MDI steps. Data for all
participants(All),participants with asthma(Asthma), and participants
with chronic obstructive pulmonary disease (COPD) are presented
above. There were no statistically significant differences in percent-
the steps when comparing patients with asthma to those with COPD.
See Table 1 for the description of each MDI step. Figure 2b: Diskus®.
Percentage of participants demonstrating correct inhaler technique
for each of the 10 Diskus steps. Data for all participants (All),
participants with asthma (Asthma), and participants with chronic
obstructive pulmonary disease (COPD) are presented above. There
were no statistically significant differences in percentage of partici-
pants demonstrating correct inhaler technique for any of the steps
when comparing patient with asthmato those with COPD. See Table 1
for the description of each Diskus step.
Press et al.: Misuse of Respiratory Inhalers
this study to determine its effectiveness post-hospital dis-
charge (retention), or the cost-effectiveness of TTG. Finally,
this was a modest-sized study conducted at two urban
academic healthcare centers. Larger multi-center studies
are need to confirm our findings and more fully examine
vision, health literacy, inhaler technique, and ability to learn
inhaler technique during transitions in care.
In conclusion, most patients hospitalized with asthma or
COPD were unable to use inhalers correctly, and poor vision is a
surmountable barrier to inhaler misuse. Comparative effective-
ness studies are needed to examine different approaches to
assessing and improving inhaler technique in this high-risk
population during transitions from hospital to home.
Contributors: We would like to thank The University of Chicago
Asthma and COPD Center and the Department of Medicine Data
Management and Statistics Core. Prior Presentations: Prior poster
presentations include the 2009 American Thoracic Society Interna-
tional Meeting in San Diego, the 2009 Society of Hospital Medicine
Annual meeting in Chicago IL, and the 2009 and 2010 Society of
General Internal Medicine Annual Meetings in Miami, Fl and
Minneapolis, MN, respectively. Oral presentations include the 2009
Midwest Society of General Internal Medicine and the 2010 American
Thoracic Society International Meeting in New Orleans, LA.
Conflict of Interest: Dr. Press reports receiving funding from the
Institute for Translational Medicine, University of Chicago CTSA
from the National Center for Research Resources (UL1RR024999)
and the American Cancer Society (PSB 08-08). Dr. Arora reports
receiving funding from the American Board of Internal Medicine,
Agency for Healthcare Research and Quality (R03HS018278), the
National Institute of Aging (K23AG033763), and the Accreditation
Council of Graduate Medical Education. Dr. Krishnan reports
receiving funding from the National Institutes of Health (HL101618)
and the Agency for Healthcare Research and Quality (HS016967).
Potential conflicts of interest exist for Dr. Shah who is employed with
a for profit health care policy firm (Avalere Health, LLC); for Dr.
Badlani who has received honoraria for lectures given (Merck
Pharmaceuticals and PharmEd Consultants); and for Dr. Naurekas,
who has provided expert testimony (once for a plaintiff on Alveolar
Hemosiderosis and once for Cook County on thrombotic thrombocy-
topenic purpura). All other authors do not have any conflicts of
interest to disclose related to employment, consultancies, honoraria,
stock, expert testimony, patents, royalties or any other relationships.
Corresponding Author: Valerie G. Press, MD, MPH; Department of
Medicine, University of Chicago, Instructor, Section of Hospital
Medicine, Chicago, IL 60637, USA (e-mail: firstname.lastname@example.org.
1. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting
effective transitions of care at hospital discharge. A review of key issues
for hospitalists. J Hosp Med. 2007;2(5):314–23.
2. Coleman EA, Berenson RA. Lost in transition: challenges and opportu-
nities for improving the quality of transitional care. Ann Intern Med.
3. Coleman EA, Smith JD, Frank JC, Min S-J, Ca P, Kramer AM.
care transitions intervention. J Am Geriatr Soc. 2004;52:1817–25.
4. Kripalani S, Henderson LE, Jacobson TA, Vaccarino V. Medication Use
Among Inner-City Patients After Hospital Discharge: Patient-Reported
Barriers and Solutions. Mayo Clin Proc. 2008;83(5):529–35.
5. Coleman EA, Smith JD, Raha D, Min S-J. Posthospital medication
discrepancies: prevalence and contributing factors. Arch Intern Med.
6. Rydman RJ, Sonenthal K, Tadimeti L, Butki N, McDermott MF.
an inner city asthma clinic. Jrnl of Med Syst. 1999;23(5):349–56.
7. Celli BR, MacNee W and Committee Members. Standards for the
diagnosis and treatment of patients with COPD: A Summary of the
ATS/ERS Position Paper. Eur Respir J. 2004;23:932–46.
8. Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and
outcomes of aerosol therapy. Evidence-based guidelines: American
College of Chest Physicians/American College of Asthma, Allergy, and
Immunology. Chest. 2005;127:335-71.
9. Paasche-Orlow MK, Riekert KA, Bilderback A, et al. Tailored educa-
tion may reduce health literacy disparities in asthma self-management.
Am J Respir Crit Care Med. 2005;172:980–6.
10. Thompson J, Irvine T, Grathwohl K, Roth B. Misuse of metered-dose
inhalers in hospitalized patients. Chest. 1994;105:715–7.
11. van der Palen J, Klein JJ, van Herwaarden CLA, Zielhuis GA, Seydel
ER. Multiple inhalers confuse asthma patients. Eur Respir J.
12. Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate
literacy is a barrier to asthma knowledge and self-care. Chest.
13. Dahl R, Backer V, Ollgaard B, Gerken F, Kesten S. Assessment of
patient performance of the Handihaler® compared with the metered dose
inhaler four weeks after instruction. Respir Med. 2003;97:1126–33.
14. Apter AJ, Tor M, Feldman H. Testing the Reliability of Old and New
Features of a New Electronic Monitor for Metered Dose Inhalers. Ann
Allergy Asthma Immunol. 2001;86(4):421–4.
15. Apter AJ, Reisine ST, Affleck G, Barrows E, ZuWallack RL. Adherence
with twice-daily dosing of inhaled steroids: socioeconomic and health-
belief differences. Am J Respir Crit Care Med. 1998;157:1810–7.
16. Melani AS. Inhalatory therapy training: a priority challenge for the
physicians. Acta Biomed. 2007;78:233–45.
17. Guidelines for the diagnosis and management of asthma (EPR-3).
Available at: http://www.nhlbi.nih.gov/guidelines/asthma/. Accessed
December 15, 2010.
18. The global initiative for chronic obstructive lung disease (GOLD) guide-
lines: Available at: http://www.goldcopd.com/. Accessed December 15,
19. Thai AL, George M. The effects of health literacy on asthma self-
management. J Asthma Allergy Educ. 2010;1(2):50–55.
20. Effing T, Monninkhof EEM, van der Valk PP, Zielhuis GGA, Walters
EH, van der Palen JJ, Zwerink M. Self-management Education for
Patients with Chronic Obstructive Pulmonary Disease (Review). The
Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Available
at http://www2.cochrane.org/reviews/en/ab002990.html. Accessed
December 15, 2010.
21. Nikolaus T, Kruse W, Bach M, Specht-Leible N, Oster P, Schlierf G.
Elderly patients’ problems with medication: an in hospital and follow-up
study. Eur J Clin Pharmacol. 1996;49:255–9.
22. Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA,
Huang J. Health literacy and mortality among elderly persons. Arch
Intern Med. 2007;167(14):1502–9.
23. Duerden M, Price D. Training issues in the use of inhalers. Dis Manage
Health Outcomes. 2001;9(2):75–87.
24. Hanania NA, Darken P, Horstman D, et al. The efficacy and safety of
fluticasone propionate (250 ug)/salmeterol (50ug) combined in the
diskus inhaler for the treatment of COPD. Chest. 2003;124:834–43.
25. Celli BR, Thomas NE, Anderson JA, et al. Effect of pharmacotherapy
on rate of decline of lung function in chronic obstructive pulmonary
disease. Results from the TORCH study. Am J Respir Crit Care Med.
26. Nurss JR, Parker RM, Williams MV, Baker, DW. Short Test of
Functional Health Literacy in Adults (STOFHLA). Hartford: Peppercorn
Books & Press; 2001.
27. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J.
Development of a brief test to measure functional health literacy. Patient
Educ Couns. 1999;38:33–42.
28. Wu HW, Nishimi RY, Page-Loez CM, Kizer KW. Improving patient safety
through informed consent for patients with limited health literacy. An
implementation report. National Quality Forum. 2005. Available at: http://
aspx. Accessed December 15, 2010.
29. Van der Palen J, Klein JJ, Kerkhoff AHM, van Herwaarden CLA,
Seydel ER. Evaluation of the long-term effectiveness of three
instruction modes for inhaling medicines. Patient Educ Couns.
30. Shrestha M, Parupia MFH, Andrews B, et al. Metered-dose inhaler
technique of patients in an urban ED: prevalence of incorrect
Press et al.: Misuse of Respiratory Inhalers
technique and attempt at education. Am J of Emerg Med. 1996;14
31. Morbidity and Mortality: 2009 Chart Book on Cardiovascular, Lung, and
Blood Disease. National Institutes of Health National Heart, Lung and
Blood Institute. October 2009. Available at: http://www.nhlbi.nih.gov/
resources/docs/2009_ChartBook.pdf. Accessed December 15, 2010.
32. University of Illinois Eye & Ear Infirmary, Chicago, IL. The eye digest.
Available at: http://www.agingeye.net/visionbasics/healthyvision.php.
Accessed December 15, 2010.
33. Beckman A, Bernstein C, Parker MG, Thorslund M. Fastbom J. The
difficulty of openingmedicines containers in old age: a population based
study. Pharm World Sci. 2005;27:393–8.
34. Fuchs J, Hippius M. Inappropriate dosage instructions in package
inserts. Patient Educ Couns. 2007;67:157–68.
35. Ventolin HFA® Package Insert. Available at: http://us.gsk.com/products/
assets/us_ventolin_hfa.pdf. Accessed December 15, 2010.
36. Advair Diskus® Package Insert.Available at: http://us.gsk.com/products/
assets/us_advair.pdf. Accessed December 15, 2010.
Press et al.: Misuse of Respiratory Inhalers