Effectiveness of Interventions to Teach Metered-Dose and Diskus Inhaler Techniques. A Randomized Trial

Abstract

Rationale: The most effective approach to teaching respiratory inhaler technique is unknown.Objectives: To evaluate the relative effects of two different educational strategies (teach-to-goal instruction vs. brief verbal instruction) in adults hospitalized with asthma or chronic obstructive pulmonary disease. Methods:We conducted a randomized clinical trial at two urban academic hospitals. Participants received teach-to-goal or brief instruction in the hospital and were followed for 90 days after discharge. Inhaler technique was assessed using standardized checklists; misuse was defined as 75% steps or less correct (<9 of 12 steps). The primary outcome was metered-dose inhaler misuse 30 days postdischarge. Secondary outcomes included Diskus technique; acute care events at 30 and 90 days; and associations with adherence, health literacy, site, and patient risk (near-fatal event). Measurements and Main Results:Of 120 participants, 73% were female and 90% were African American. Before education, metered-dose inhaler misuse was similarly common in the teach-togoal and brief intervention groups (92% vs. 84%, respectively; P = 0.2). Metered-dose inhaler misuse was not significantly less common in the teach-to-goal group than in the brief instruction group at 30 days (54% vs. 70%, respectively; P = 0.11), but it was immediately after education (11% vs. 60%, respectively; P , 0.001) and at 90 days (48% vs. 76%, respectively; P = 0.003). Similar results were found with the Diskus device. Participants did not differ across education groups with regard to rescue metered-dose inhaler use or Diskus device adherence at 30 or 90 days. Acute care events were less common among teach-to-goal participants than brief intervention participants at 30 days (17% vs. 36%, respectively; P = 0.02), but not at 90 days (34% vs. 38%, respectively; P = 0.6). Participants with low health literacy receiving teach-to-goal instruction were less likely than brief instruction participants to report acute care events within 30 days (15% vs. 70%, respectively; P = 0.008). No differences existed by site or patient risk at 30 or 90 days (P . 0.05). Conclusions:In adults hospitalized with asthma or chronic obstructive pulmonary disease, in-hospital teach-to-goal instruction in inhaler technique did not reduce inhaler misuse at 30 days, but it was associated with fewer acute care events within 30 days after discharge. Inpatient treatment-to-goal education may be an important first step toward improving self-management and health outcomes for hospitalized patients with asthma or chronic obstructive pulmonary disease, especially among patients with lower levels of health literacy.Clinical trial registered with www.clinicaltrials.gov (NCT01426581).

Patient characteristics associated with poor inhaler technique among a cohort of patients with COPD

“…Poor performance with MDIs has been found in multiple other studies, with error rates similar to those found in our study. [20, 31] In our analysis of individual steps, the most errors for both MDIs and Advair were errors of breathing—breath holding, appropriate rate of inhalation, full exhalation, etc. Careful coordination of breathing and breath holding may be difficult for subjects with cough or dyspnea, and is a much more subjective maneuver for a patient to perform in comparison to steps such as twisting the device or pressing to actuate.…”

“…A recent study examining methods of inhaler instruction for hospitalized patients with asthma and COPD found that subjects with low health literacy responded well to the intervention. [31] This suggests that while low educational attainment and health literacy may predict worse technique, they are not a barrier to improvement. Lack of knowledge about inhalers on the part of providers is a significant issue [32] that must be separately addressed.…”

“…Our primary outcome was poor inhaler technique, defined as the odds of making an error in 20% or more of the steps (≥2/11 steps for MDIs, ≥2/10 steps for Diskus, ≥3/14 steps for Spiriva) for 1) any inhaler used by an individual patient and 2) each individual inhaler. The 20% error cutoff was selected both as being similar to other studies of inhaler technique [24, 31] and more likely to be clinically relevant. Given the variability in steps between devices, as well as the fact that some steps are critical to receiving medication (ex: removing the cap), we were interested in whether individual steps or devices were particularly prone to error.…”

Developing a Virtual Teach-To-Goal™ Inhaler Technique Learning Module: A Mixed Methods Approach

“…11,21–22 However, we have also shown that the improved inhaler technique initially obtained through TTG wanes within 30 days post-discharge. 22 Since providing in-person inhaler teaching post-discharge is often impractical, but reinforced teaching is necessary, a need exists for an effective, portable education strategy that remains accessible to patients both in-hospital and post-discharge.…”

Design of a pragmatic trial in minority children presenting to the emergency department with uncontrolled asthma: The CHICAGO Plan

“…In addition, the CHICAGO Plan ED Coordinator, a member of the study team, provides all participants two metered dose inhaler (MDI) spacers free-of-charge and uses teach-to-goal methodology (repeated rounds of education and evaluation until the child achieves mastery) to educate the child and the caregiver about appropriate inhaler technique for a MDI. (13,14) Patient education regarding the MDI device was selected because it is commonly used for quick-relief medications and is also the device for many inhaled controller medications. Stakeholders identified the need for all participants to benefit as a central aspect of the study design to ensure adequate support of the CHICAGO Plan by clinical staff and caregivers.…”