Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma

Ann Emerg Med. 2008 Jan;51(1):70-7. doi: 10.1016/j.annemergmed.2007.04.008. Epub 2007 Jun 7.


Study objective: We explore perceptions surrounding use of portable inhalers and holding chambers (spacers) for delivery of beta-agonist respiratory medications to children in the emergency department (ED) and factors influencing practice change.

Methods: This was a qualitative study guided by principles of grounded theory. Data were collected through focus groups and individual interviews at 2 sites in eastern Canada: Hospital A, where inhalers and holding chambers are used routinely; and Hospital B, where prevailing practice is the use of nebulization. Participant encounters were transcribed verbatim and analyzed for emerging themes.

Results: At Hospital A, 6 physicians and 7 nurses participated in separate focus groups. Four interviews were conducted with physician, nurse, respiratory therapy, and pharmacy leaders. At Hospital B, 4 physicians and 3 nurses participated in focus groups, and 6 leaders were interviewed. Perceptions negatively influencing the adoption of inhalers and holding chambers included increased workload, increased equipment costs, myths about the superiority of nebulization, and interprofessional conflict. Health professionals reported that their most prominent concern about administering medications with inhalers and holding chambers was the time demand. Nurses especially seemed to think this way, tipping the balance in favor of nebulization despite knowledge of evidence to the contrary and affecting physician decisionmaking as well. Professional territorialism appeared to hinder efforts to ameliorate workload issues through the use of respiratory therapists in the ED.

Conclusion: Findings from this study could be used to inform a change program to close the gap between evidence and practice with respect to use of inhalers and holding chambers in the ED.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adrenergic beta-Agonists / administration & dosage*
  • Asthma / drug therapy*
  • Attitude of Health Personnel*
  • Canada
  • Education, Professional
  • Emergency Service, Hospital / organization & administration*
  • Focus Groups
  • Humans
  • Length of Stay
  • Medical Staff, Hospital
  • Metered Dose Inhalers / economics
  • Metered Dose Inhalers / statistics & numerical data*
  • Nebulizers and Vaporizers / economics
  • Nebulizers and Vaporizers / statistics & numerical data*
  • Nursing Staff, Hospital
  • Organizational Innovation
  • Patient Education as Topic
  • Qualitative Research
  • Workforce


  • Adrenergic beta-Agonists