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Long-Term Maintenance of Pharmacists’ Inhaler Technique Demonstration Skills
Abstract and Figures
To assess the effectiveness of a single educational intervention, followed by patient education training, in pharmacists retaining their inhaler technique skills.
A convenience sample of 31 pharmacists attended an educational workshop and their inhaler techniques were assessed. Those randomly assigned to the active group were trained to assess and teach correct Turbuhaler and Diskus inhaler techniques to patients and provided with patient education tools to use in their pharmacies during a 6-month study. Control pharmacists delivered standard care. All pharmacists were reassessed 2 years after initial training.
Thirty-one pharmacists participated in the study. At the initial assessment, few pharmacists demonstrated correct technique (Turbuhaler:13%, Diskus:6%). All pharmacists in the active group demonstrated correct technique following training. Two years later, pharmacists in the active group demonstrated significantly better inhaler technique than pharmacists in the control group (p < 0.05) for Turbuhaler and Diskus (83% vs.11%; 75% vs.11%, respectively).
Providing community pharmacists with effective patient education tools and encouraging their involvement in educating patients may contribute to pharmacists maintaining their competence in correct inhaler technique long-term.
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... This underscores the importance of workshops as a means to consolidate specific information [23]. In turn, proper training for pharmacists could enhance their ability to effectively educate patients on inhalation techniques [24]. Such consultation should not be limited to verbal communication but should also include a demonstration of the correct technique using a placebo device. ...
... The combination of written and oral instructions, along with a physical display by pharmacists, also helps reduce technical errors [55]. A similar result was observed in patients using DPI (type of DPI inhaler -turbuhaler) for asthma [24]. The combined oral explanation and demonstration by pharmacists may, therefore, be useful in improving the use of the inhaler, potentially leading to better therapeutic effectiveness [53]. ...
Background
Patients with asthma and chronic obstructive pulmonary disease could benefit from education on using inhalers provided by pharmacists. However, pharmacists may have limited competencies, indicating the necessity to implement appropriate postgraduate courses. The study aimed to evaluate an inhaler use course for pharmacists, including its impact on participants’ knowledge and satisfaction.
Methods
The study involved 261 pharmacists from community pharmacies and was conducted between September 2019 and March 2021. A pre-post analysis of their knowledge of the topic was applied. Additionally, at the beginning of the course, participants were asked about their educational needs, and at the end, they completed a satisfaction survey. The preferred learning formats indicated by participants were interactive workshops and lectures.
Results
As a result of the course, both their actual and self-assessed level of knowledge significantly increased. The percentage of correct answers in the test before the training was 24.4%, while after, it was 84.3% (p < 0.0001). Before the course, their average self-assessed level of knowledge was 52.0%, and after the training, it increased to 90.0% (p < 0.0001). Almost all respondents stated that the course met their expectations. They estimated their satisfaction at 94.0% and the usefulness of the provided information at 98.0%.
Conclusions
Improved preparation of pharmacists resulting from their participation in the course can contribute to providing more professional advice to patients, thereby positively influencing the pharmaceutical care process in community pharmacies.
... 36 This suggests that healthcare providers must be educated about inhaler techniques before we expect patient education to be effective. 37,38 In this study, we evaluated inhaler techniques based on generally accepted checklists of maneuvers that affect drug delivery and can easily be used by the busy pharmacist to assess patients' inhaler technique. Our study emphasizes the importance of the pharmacist's role and involvement in delivering patient education and counseling and improving asthma control. ...
Purpose: Asthma is a chronic condition affecting millions of people all around the world. Asthma has no cure, but disease control is essential and highly recommended. However, the available tools for asthma control assessment don't include factors such as inhaler technique and adherence. This study aimed to assess the correlation between inhaler techniques, adherence, and level of asthma control in two different healthcare settings; Jordan and Iraq. Patients and methods: A cross-sectional observational study was conducted over six months, from January to August 2018, in two public hospitals in Amman (Jordan) and Baghdad (Iraq). Asthmatic patients were interviewed to assess their inhaler technique, adherence, and asthma control. The researcher personally visited both public hospitals, conducting face-to-face interviews with patients at the hospital outpatient clinics. Validated questionnaires were used for patient assessment, including demographics, asthma history and medication use, the patient's inhaler technique, adherence, and asthma control. Results: A total of 300 patients entered the study, with a mean age of 45.54 ± 13.71. The asthma control test showed very poor asthma control for patients living in both countries (Amman n=78 (52.0%) vs. Baghdad n=106 (70.0%)). An asthma knowledge assessment showed that most asthmatic patients in both countries didn't follow their asthma medication plan (Amman n=78 (52.0%) vs. Baghdad n=93 (62.0%). Conclusion: In both Jordan and Iraq, asthma patients were found to be poorly controlled. Knowledge of patients was inadequate, probably leading to the poorly managed chronic disease. The results of this study highlight the significance of the pharmacist's role in recognizing asthmatic patients requiring assistance. Furthermore, they underscore the pharmacist's pivotal contribution to delivering patient education and counseling, ultimately resulting in enhanced asthma control.
... Due to the wrong use of the inhaler, the amount of medicine entered into the airway is low and some of it is deposited on the tongue and back of the throat [13]. Failure to properly use inhalers by patients can lead to failure to achieve therapeutic effects, exacerbation of respiratory disease, frequent hospitalization of patients, increase in costs, and decrease in quality of life [17]. ...
Abstract
Background and Objectives Due to the high rate of inhalers’ incorrect use by the elderly, this study aims to evaluate the effect of teaching the use of inhalers to a family caregiver on its correct use by the elderly patients.
Subjects and Methods :This is a parallel-group randomized clinical trial on 80 older people with a lung disease aged >60 years who use the inhaler incorrectly and their family caregivers. Participants were randomly assigned to group A (education) and group B (control) using a block randomization method (4×4 blocks). In group A, teaching of the correct use of inhaler was provided to the caregivers of the elderly
orally and practically in one session, while in group B, training was provided only to the elderly. Three weeks later, the two groups were evaluated using a researcher-made inhaler use checklist.
Results: There was no significant difference in the use of inhaler before and after the intervention in group A (2.58±1.26) and B (2.55±1.22) (P<0.05). Pearson correlation test results showed a significant decrease in the correct use of inhaler with the increase of patients’ age (r=-0.24).
Conclusion: Further studies on the use of family members in elderly patients care, various educational programs by health care providers, and periodic evaluation of the performance of the elderly regarding
the use of inhalers are recommended.
... This may be due to a dearth of counselling by medical professionals (doctors, nurses, and chemists), and most paradoxically, the fact that many of them lack the necessary training. [11,12,13]. Hence knowledge of such delivery method is essential for all prescribers, dispensers and consumers. ...
Background: Studies in many countries revealed deficiencies in "Nurses" knowledge about the inhalation therapy in patients of Bronchial Asthma and Chronic obstructive pulmonary disease. Inhaler therapy is preferred treatment of these diseases and Metered Dose Inhaler are most commonly used in the treatment. Aim and Objectives: To determine knowledge and practice of'Nurses' regarding inhaler technique. Method: It is a cross sectional study. The questionnaire was designed which consisted of 20 questions for assessing the knowledge and practice related inhalational therapy. Results: A total of 800 respondents completed the questionnaire. 800 participants were given questionnaire for the study. Out of which, 24 questionnaires were only partially filled and were thus excluded from the data analysis. Total 776questionnaires were analysed. 576(73.8%) participants have heard the term inhalational therapy .596(76.8 %) of nurse swere of the opinion that inhalers are habit forming. According to651 (83.89 %) nurses inhaler causes weight gain and causes stunted growth. 526(67.78%) nurses responded that it is advised to start inhalation prior to pressing thecanister. According to 451(58.11%) nurses spacer should not be held between the teeth. 381(49.09%) participants knew that we should shake the Metered Dose Inhaler (MDI) before use.325(41.88%) nurses responded that dry-powder inhaler (DPI) should also be shaken before use. Conclusion: The study reveals the poor status of knowledge of MDI and DPI technique among Nurses. Special educational programmes are required to address the treatment failure due to inadequate knowledge among 'Nurses'. Keywords: Inhalational therapy, knowledge, metered dose inhaler, healthcare worker, dry powder inhaler. This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
... 5,6 Among patients with asthma, poor inhalation is a significant contributing factor toward poor control of the disease because of inadequate dosing of the prescribed medication. 7 Asthma has a great impact on the population, socially as well as economically, and when asthma is poorly controlled it may lead to considerable economic impact with frequent hospital admissions, poor QOL, and ultimately death. 8 Adherence to therapy plays an important role in the overall health of the patient. ...
Introduction:
Asthma is one of the common major non-communicable respiratory diseases, and is associated with a lower health-related quality of life (QOL). Poor inhalation is a significant contributing factor to poor control of asthma. Community pharmacist has a vital role to play in assisting patients and ultimately improving their asthma conditions through the use of inhalers.
Aim:
This study aimed to assess the effectiveness of "pre" and "post" educational intervention by a community pharmacist within a community pharmacy on asthma patients' QOL, inhaler technique, and adherence to therapy during the endemic phase of COVID-19.
Methods:
A "pre" and "post" interventional study was performed at a community pharmacy in the city of Mardan, Pakistan, in 2022 during the COVID-19 pandemic. Patients were divided into two groups, ie control and pharmacist-led education groups. After assigning patients to both groups, the baseline data were collected and followed for one month to compare the reduction in errors in the use of inhalers, QOL, and adherence to therapy. A paired sample t-test was performed, keeping a p-value <0.05 as statistical significance.
Results:
A total of 60 patients were recruited, majority (58.3%) were females, and 28.3% were from the age group of 46-55 years old. A statistically significant difference was observed in the pre- and post-education QOL score among patients in the pharmacist-led education group, from a mean ± SD at pre-education of 40.23±10.03 to a mean±SD at post-education of 48.10±5.68. Similarly, a statistically significant difference was observed for the correct use of inhalers, ie MDIs and DPIs. Similarly, a statistically significant difference was observed in the adherence status between pre-education and post-education by pharmacists.
Conclusion:
The findings of the study revealed a positive impact of community pharmacist-led education on QOL, inhaler technique, and adherence to therapy among patients with asthma.
... Due to the wrong use of the inhaler, the amount of medicine entered into the airway is low and some of it is deposited on the tongue and back of the throat [13]. Failure to properly use inhalers by patients can lead to failure to achieve therapeutic effects, exacerbation of respiratory disease, frequent hospitalization of patients, increase in costs, and decrease in quality of life [17]. ...
Background and Objectives Due to the high rate of inhalers’ incorrect use by the elderly, this study aims to evaluate the effect of teaching the use of inhalers to a family caregiver on its correct use by the elderly patients. Subjects and Methods This is a parallel-group randomized clinical trial on 80 older people with a lung disease aged >60 years who use the inhaler incorrectly and their family caregivers. Participants were randomly assigned to group A (education) and group B (control) using a block randomization method (4×4 blocks). In group A, teaching of the correct use of inhaler was provided to the caregivers of the elderly orally and practically in one session, while in group B, training was provided only to the elderly. Three weeks later, the two groups were evaluated using a researcher-made inhaler use checklist. Results There was no significant difference in the use of inhaler before and after the intervention in group A (2.58±1.26) and B (2.55±1.22) (P<0.05). Pearson correlation test results showed a significant decrease in the correct use of inhaler with the increase of patients’ age (r=-0.24). Conclusion Further studies on the use of family members in elderly patients care, various educational programs by health care providers, and periodic evaluation of the performance of the elderly regarding the use of inhalers are recommended.
... It has been demonstrated that training sessions for healthcare professionals are effective. 30,31 Focussed interventions with patients teaching inhaler technique have been shown to be effective in reducing inhaler errors. Physical demonstration of how to use a specific inhaler is more effective than only providing written or verbal instructions. ...
The mainstay of the pharmacological management of asthma and chronic obstructive pulmonary disease (COPD) is the use of inhaled drugs. This route enables drugs to be delivered to the site of their action, minimising the risk of adverse effects caused by systemic absorption. Drugs that can be administered by the inhaled route include the most commonly prescribed drugs for asthma and COPD, namely short and long-acting β2 agonists and anticholinergic drugs and corticosteroids. There are two main types of inhalers: pressurised metered dose inhalers (pMDIs) and dry powder inhalers (DPIs). pMDIs were introduced in the mid-20th century. The active drug is held in suspension or solution in a canister with a propellant. Proper use of pMDIs requires the patient to apply a series of techniques correctly: i) fire the device, releasing the aerosol very shortly after the initiation of inspiration; ii) inspire slowly and deeply; and iii) hold their breath. Many patients find this procedure difficult. Modifications and add-ons include breath-activated pMDIs and spacers and valved holding chambers; these help to obviate some of the problems with pMDIs. DPIs are breath-activated devices. Following priming, which is different for each device, the aerosol is generated by the patient taking a deep, rapid inspiration. This de-aggregates the powdered drug from its carrier. A prolonged breath-hold is then required. Many studies have shown that errors that may impair the effective delivery of the drug to the lungs, including critical errors, are very common with both pMDIs and DPIs. Such inhaler misuse has been shown to be associated with poorer symptom control and more frequent emergency department attendances. Errors in the use of inhalers can be a consequence of device-related factors, patient-related factors, and health professionalrelated factors. Minimising inhaler misuse requires the prescribing physician to choose, in cooperation with the patient, the most suitable device for the individual patient. Education and training with subsequent monitoring and re-training are thereafter crucial. There remains a need for more user-friendly devices, which provide constant doses of the active agent, in addition to built-in dose counters and patient feedback.
... The choice of tools and involved professionals often depends on local availability and organisation. It is also of utmost importance to educate professionals properly in the first place 44 and then repeat training regularly. ...
Inhalation therapy remains the cornerstone of treatment for bronchial diseases. Despite being pharmacologically efficacious, currently available inhaled drugs can have decreased real-life effectiveness due to a variety of factors, including poor inhalation technique. Each device type has its own specifications regarding the optimal way to use it, in terms of device handling and characteristics of the inhalation manoeuvre. Poor inhalation technique is associated with decreased treatment effectiveness. Choosing the optimal device, together with proper education, improves inhalation technique, adherence and outcomes or effectiveness, but has to be performed regularly and rigorously, including visual checking of the patient’s ability to use the inhaler. Some testing devices are also available, as well as various training materials. All healthcare professionals caring for the patient can be involved provided that they have also been properly trained. To optimise treatment effectiveness, healthcare providers should prescribe inhalation device(s) optimised to the patient, accounting for the specific characteristics of each individual, his/her disease, and involved healthcare professionals.
... Research shows that trained pharmacists get practical skills and broaden their knowledge, which has a huge impact on improving asthma and COPD control in patients. Without speci c training, they will not have the required skills to provide an effective consultation to patients [7,30]. ...
Background: Following the example of other countries, it is very important to educate patients on the correct use of inhalers by properly trained healthcare professionals, including pharmacists.
Objectives: The aim of the study was to assess the quality and comprehensiveness of professional advice given by pharmacists on the use of inhalers, which was determined by the pharmacists’ level of training.
Methods: The study was conducted from June 2019 to March 2020. 150 pharmacists from Poznan and Warsaw (Poland) were involved. Before the study began, the professional education of 240 pharmacists was conducted in Warsaw to implement standard operating procedures. The study used the model of a mystery patient.
Results: The conversation with a trained pharmacist lasted on average 5.5 minutes, with an untrained one - 3.0 minutes. Placebo inhalers were used more often by trained pharmacists during patients’ education. 10.3% of untrained pharmacists did not provide any education. Additionally, untrained employees quality of advice were assessed on an average of 3.5 points, while trained ones - 7.6 points.
Conclusions: This study has shown that there is a need for professional training among pharmacists in Poland, which translates into better patient education in the field of inhalation techniques.
... Inappropriate asthmatic inhalation device use had been linked to poor asthma management and more visits to the emergency department [31].Poor inhalation performance is a key issue in asthma management since individual doesn't really obtain the recommended dose of medication, resulting in decreased treatment effects and poor disease control [32][33]. The pressurized metered-dose inhalers are the most common inhaler devices and this may be responsible for better handling by the patients compared to the dry powder inhalers [34]. ...
The proper use of inhaler devices can improve medication efficacy while decreasing dose and adverse effects. The main objective of this study was to investigate the effect of pharmacist-led asthma education interventions on inhaler techniques. This study was a controlled, randomized, prospective intervention, in Wad Medani Teaching Hospital outpatient clinic, between March and June 2021.Structured questionnaire with validated checklists of inhaler techniques were used to collect data, from patients at baseline and at three months of follow-up, for both intervention and control groups. Paired and independent t-tests were used to monitor the effectiveness of the interventions. A total of 130 asthmatic patients were enrolled in this study. The intervention group contains 70 patients (53.8%), while the control group contains 60 patients (46.2%). The mean score for the inhaler techniques of Pressurized metered-dose inhalers(PMDIs) was (3.50±1.43) for the intervention group at baseline and increased after the intervention to (6.78±0.515), this result was significant at the (P = 0.05) level, and the mean score of the dry powder inhaler technique at the initial of this study in the intervention group was (4.72 ±1.50) this means were improved after the intervention to (6.83± 0.44) this result was statistically significant. There was no significant difference between the control group before and after intervention (P=0.321).This study has shown that the pharmacist-led educational intervention improved the inhalation technique of asthmatic patients. It is important to consider these programs as routine health care to enhance inhaler techniques.
Previous studies have shown that a significant proportion of patients and physicians have difficulty using metered dose inhaler (MDI) delivery systems. It has been suggested that paramedical personnel such as pharmacists could address this problem by serving as patient educators. Few studies have assessed a pharmacist's knowledge of and ability to use inhaled devices, including not only the conventional MDI but newer devices such as an add-on spacing chamber (Aerochamber) and a multidose dry powder inhaler (Turbuhaler). We therefore approached all pharmacists in a predefined geographic area of a large city in order to evaluate their knowledge of and ability to use inhaled medications. Of 62 pharmacists approached, 45 (73 percent) agreed to participate. Ability to use the conventional MDI, Aerochamber (A), and Turbuhaler (T) was graded by a trained observer using a checklist of 11 essential steps. The percentage of pharmacists performing greater than 6, 8, and 10 steps correctly for each device was MDI = 96 percent, 87 percent, 62 percent; MDI + A = 80 percent, 76 percent, 47 percent; T = 67 percent, 64 percent, 29 percent. The most common problems with the MDI were forgetting to shake prior to use and coordinating inspiration with actuation. The most common problems with the MDI + A were forgetting to shake prior to use, remembering to inspire after actuation, and breath holding after inspiration. The most common difficulty with the T was total unfamiliarity with the device with 33 percent of pharmacists achieving less than 2 steps correctly. The observer subsequently administered a questionnaire of 11 clinically relevant questions for each of the devices tested. The mean score was 50 percent with only 21 percent of pharmacists scoring above 70 percent. Thirty-three percent of respondents had no instruction in device use beyond reading the packing insert; 40 percent had received instruction from a pharmaceutical representative; only 24 percent had received instructions from professional school. We conclude that a pharmacist's knowledge of inhaling devices is roughly proportional to the length of time the device has been available and that pharmacists form another group of health care professionals who require further teaching regarding inhaled medication delivery systems.
Current treatment strategies for asthma and chronic obstructive pulmonary disease (COPD) emphasize the inhalation route, yet patients often misuse metered-dose inhalers (MDI). To address this problem, patient education by medical personnel has been recommended and a variety of alternate inhaler devices have been developed.
We surveyed medical personnel to assess their knowledge of and ability to use three widely used inhaler devices; MDI, MDI with a spacing chamber (Aerochamber, Trudell Medical, Canada), and a breath-actuated multidose dry powder inhaler (Turbuhaler, Astra Pharmacy, Inc., Conada). Thirty respiratory therapists (RT), 30 registered nurses (RN), and 30 medical house staff physicians (MD) were asked to demonstrate the use of each device using placebo inhalers and to answer 11 clinically relevant questions related to the use and maintenance of the tested devices.
The RT's percent mean knowledge score (67 +/- 5 percent) was significantly higher than those achieved by either the RNs (39 +/- 7 percent) or the MDs (48 +/- 7 percent) (for all p < 0.0001). Similarly, percent mean demonstration scores for each device were significantly higher for RTs than either RN or MD groups; for MDI, 97 +/- 3 percent versus 82 +/- 13 percent and 69 +/- 24 percent, respectively (p < 0.0001); for the Aerochamber, 98 +/- 2 percent versus 78 +/- 20 percent and 57 +/- 31 percent (p < 0.0001); and for the Turbuhaler, 60 +/- 30 percent versus 12 +/- 23 percent and 21 +/- 30 percent (p < 0.0001). Knowledge of and practical skills with the devices were roughly proportional to the length of time the device had been in clinical use, Turbuhaler demonstration scores being lower than either MDI or Aerochamber scores (p = 0.05 and p = 0.09, respectively). More RTs (77 percent) had received formal instruction on the use of devices at school than either RNs (30 percent) or MDS (43 percent) (p < 0.05).
We conclude that (1) many medical personnel responsible for monitoring and instructing patients in optimal inhaler use lack rudimentary skills with these devices, (2) nurses and physicians seldom receive formal training in the use of inhaling devices, and (3) newer inhaling devices designed to obviate problems of technique are at present less likely to be used well by medical personnel soon after their introduction.
The efficacy of delivering medicines by metered-dose inhaler (MDI) is well established, and the patient's technique with MDIs is related directly to achieving the desired clinical outcome. The present study was designed to assess and improve MDI technique by using a Vitalograph Aerosol Inhalation Monitor (VAIM) in an airways disease education programme. Baseline measurements were made immediately prior to educational intervention incorporating feedback from a VAIM unit. At 6 weeks' follow-up, MDI technique was found to have regressed to the sub-optimal measures recorded at baseline prior to educational intervention. However, patients reported a significant improvement in physical function between baseline and follow-up as measured by the Rand 36-Item Health Survey (SF-36), Version 1.0. The results reinforce the need for a longitudinal educational programme for patients prescribed medications delivered by MDI. The VAIM unit provided health educators and patients with both a visual and a quantitative assessment of patients' MDI technique, and was thus of positive value as part of the intervention process.
We administered a questionnaire and observed usage of a placebo metered dose inhaler (MDI) among 35 physicians, 14 nurses, and 12 respiratory therapists. Ninety-two percent of the respiratory therapists performed at least four of seven steps correctly, compared with 65 percent of house staff physicians, 57 percent of nurses, and 50 percent of nonpulmonary faculty. Most participants followed package insert instructions, while only 18 percent followed recent recommendations for proper MDI use. We conclude that (1) medical personnel should have additional instruction in proper MDI usage and (2) respiratory therapists and nurses can play a prominent role in instructing patients in their proper use.
(Chest 1992; 101:31-33)
This how-to guide and resource book is designed to help in planning educational and training programs for adults in settings from the corporate sector to educational organizations. Chapters 1-3 lay the groundwork for the rest of the guide by introducing the 12-component Interactive Model of Program Planning. Chapter 1 describes adult programs and discusses planners, sponsors, purposes, outcomes, and program planning models. Chapter 2 presents an overview of the model, basic assumptions on which it rests, its sources, and users. Chapter 3 addresses using the model: identifying personal beliefs about program planning, developing upfront parameters, determining which model components and tasks to use, and using technology in program planning. Chapters 4 through 15 each explain one model component and give practical tips and ideas related to concrete tasks within the component. These are the model components: discern the context; build a solid base of support; identify program ideas; sort and prioritize program ideas; develop program objectives; design instructional plans; devise transfer-of-learning plans; formulate evaluation plans; make recommendations and communicate results; select formats, schedules, and staff needs; prepare budgets and marketing plans; and coordinate facilities and on-site events. Each chapter concludes with highlights and application exercises. Chapter 16 revisits the model. Appendixes include 301 references and an index. Contains 9 figures, 40 exercises, and 73 exhibits.) (YLB)
We administered a questionnaire and observed usage of a placebo metered dose inhaler (MDI) among 35 physicians, 14 nurses, and 12 respiratory therapists. Ninety-two percent of the respiratory therapists performed at least four of seven steps correctly, compared with 65 percent of house staff physicians, 57 percent of nurses, and 50 percent of nonpulmonary faculty. Most participants followed package insert instructions, while only 18 percent followed recent recommendations for proper MDI use. We conclude that (1) medical personnel should have additional instruction in proper MDI usage and (2) respiratory therapists and nurses can play a prominent role in instructing patients in their proper use.
Improper inhalation technique with beta-agonist metered-dose inhalers (MDIs) decreases efficacy of the bronchodilator. The success of demonstrating the correct technique and the pharmacist's role in patient education has been reported. To obtain information regarding the routine patient education practice of pharmacists when dispensing a beta-agonist MDI (albuterol), the following study was performed. Fifty-two prescriptions for an albuterol MDI were presented to 52 randomly chosen community pharmacists in three Tennessee cities. Twenty-six independent and 26 chain pharmacies wer evaluated. Pharmacists' practice with regard to patient education, instruction, and demonstration of the correct usage of the MDI was observed and recorded. Overall, 13 percent of the pharmacists initially offered to educate the patient-investigator (PI) regarding the correct usage of the MDI without being asked for information. Fifty-three percent of pharmacists offered information only upon being asked specifically how to use the MDI. Of the pharmacists who offered to educate the PI, 71 percent discussed less than half of the eight steps correctly. Only 1 of the 52 pharmacists actually demonstrated MDI inhalation technique, and this in response to a request. No pharmacist asked the PI to perform the technique while he/she observed. No pharmacist offered information on delivery enhancement devices. Our results demonstrate that few pharmacists educate patients on the correct usage of an MDI, and that many pharmacists are not aware of the correct technique.
To assess inhalation technique in patients after written instruction alone, written and verbal instruction, and clinical use of two new inhalation devices.
Randomized, crossover evaluation of the albuterol Diskhaler and the terbutaline Turbuhaler.
Canadian tertiary-care hospital.
Twenty hospitalized adults with asthma or chronic obstructive pulmonary disease currently using an albuterol metered-dose inhaler (MDI). Nineteen patients received Diskhaler, 16 received Turbuhaler, 15 received both inhalers, and 10 patients used both inhalers for three days each.
Patients were randomized to receive either Diskhaler or Turbuhaler for three days. Inhaler technique was assessed after written instruction, written plus verbal instruction, at the first scheduled dose after instruction, and after three days of clinical use. Patients remaining in the hospital after three days crossed over to the other study inhaler and the same protocol was followed.
Patient inhalation technique was assessed and compared for the MDI, Diskhaler, and Turbuhaler.
Assessment of MDI technique revealed that 35 percent of patients used their MDI correctly on the first puff, and 42 percent used it correctly on the second puff. Following written instruction alone, correct technique was demonstrated by 32 percent of patients with Diskhaler and 6 percent with Turbuhaler. Technique significantly improved following verbal instruction, although 40 percent of the patients required up to three attempts to demonstrate correct technique on at least one of the study inhalers. After three days of clinical use, correct technique was demonstrated in only 54 percent of the Diskhaler and 64 percent of the Turbuhaler assessments. Performance at this assessment was, however, significantly better on the Turbuhaler than on the MDI (p = 0.01). Performance on the Diskhaler was not significantly different from the performance on the other inhalers.
Written instruction alone is inadequate in teaching correct inhalation technique. Verbal instruction and technique assessment are essential for patients to achieve proper technique. Patients may perform better on the Turbuhaler than on other inhalation devices.
It is known that many housestaff physicians are unable to demonstrate perfect metered dose inhaler (MDI) technique.
This study assessed whether a single teaching session for house staff physicians would significantly improve their MDI technique.
Thirty-eight pediatric house staff physicians were asked to demonstrate MDI technique with a placebo MDI. The physicians were evaluated on the following seven steps: (1) shaking the MDI and removing the cap, (2) exhaling prior to MDI use, (3) holding the MDI upright, (4) proper timing of actuation, (5) a slow inspiratory effort, (6) one MDI actuation per breath, and (7) holding the breath > or = 5 seconds. A 20-minute teaching session and demonstration of proper MDI technique was then given. At the end of this session all residents were eventually able to demonstrate proper technique. Two months following this educational session the same house staff physicians were re-evaluated on their MDI technique.
Initially, ten participants (26%) demonstrated perfect technique. Two months postinstruction the same number of physicians (ten) demonstrated perfect technique. Only six physicians demonstrated perfect technique at both evaluations. Three of the seven steps showed enough change from the first evaluation to the second to permit statistical analysis. Step 4 (timing of actuation) had 11 Physicians' performances improve while three worsened (P=.03). Step 5 (a slow inspiratory effort) had nine physicians' performances improve while three worsened (P=.073). For step 7 (holding the breath > or = 5 seconds), 11 physicians improved while 2 worsened (P=.006). Comparing global performance, there were 17 physicians that improved, 8 that worsened, and 13 with no change (P=.054).
This study confirmed that many housestaff physicians do not demonstrate optimal MDI technique. While one educational session may somewhat improve their future performance, it is not sufficient to guarantee perfect technique. This suggests that repeated education needs to be given to housestaff physicians.
Pharmacists must ensure that patients know how to make the best use of their medication. An education programme was initiated in the southernmost part of Sweden during 1990 in order to improve the communication skills of pharmacy staff and the information given to customers. Customers with prescriptions for Turbuhaler were asked to 'show-and-tell' how they used their inhalers, and the results were documented. In April 1992, 53% of patients handled their Turbuhaler correctly. One year later a significantly higher proportion of the patients (67%) used their inhalers correctly. If patients are asked to 'show-and-tell' how they use their medication and how they interpret the information given, then errors in their handling of the medicines can be revealed. If advice on the proper use of drugs is given to individual patients, then mishandling is reduced. The study used an open design, so the conclusions drawn can only be tentative. However, the magnitude of the change observed suggests that the conclusions are valid.