Teaching the use of respiratory inhalers to hospitalized patients with asthma or COPD: a randomized trial

Abstract

Background: Hospitalized patients frequently misuse their respiratory inhalers, yet it is unclear what the most effective hospital-based educational intervention is for this population.

Objective: To compare two strategies for teaching inhaler use to hospitalized patients with asthma or chronic obstructive pulmonary disease (COPD).

Design: A Phase-II randomized controlled clinical trial enrolled hospitalized adults with physician diagnosed asthma or COPD.

Participants: Hospitalized adults (age 18 years or older) with asthma or COPD.

Interventions: Participants were randomized to brief intervention [BI]: single-set of verbal and written step-by-step instructions, or, teach-to-goal [TTG]: BI plus repeated demonstrations of inhaler use and participant comprehension assessments (teach-back).

Main measures: The primary outcome was metered-dose inhaler (MDI) misuse post-intervention (<75% steps correct). Secondary outcomes included Diskus® misuse, self-reported inhaler technique confidence and prevalence of 30-day health-related events.

Key results: Of 80 eligible participants, fifty (63%) were enrolled (BI n=26, TTG n=24). While the majority of participants reported being confident with their inhaler technique (MDI 70%, Diskus® 94%), most misused their inhalers pre-intervention (MDI 62%, Diskus® 78%). Post-intervention MDI misuse was significantly lower after TTG vs. BI (12.5 vs. 46%, p=0.01). The results for Diskus® were similar and approached significance (25 vs. 80%, p=0.05). Participants with 30-day acute health-related events were less common in the group receiving TTG vs. BI (1 vs. 8, p=0.02).

Conclusions: TTG appears to be more effective compared with BI. Patients over-estimate their inhaler technique, emphasizing the need for hospital-based interventions to correct inhaler misuse. Although TTG was associated with fewer post-hospitalization health-related events, larger, multi-centered studies are needed to evaluate the durability and clinical outcomes associated with this hospital-based education.

Figure 1.

Schematic of in-hospital baseline assessment, randomization, and education (comparing BI with TTG). [BI: brief intervention; TTG: teach-to-goal].

Figure 2.

Flow diagram of screening and enrollment. Participant eligibility, enrollment, and study completion.

Figure 3.

a) Percentage of patients demonstrating incorrect use of metered-dose inhaler (MDI) before and after either a brief intervention (BI) or TTG intervention (TTG). b) Percentage of patients demonstrating incorrect use of Diskus inhaler before and after either a brief intervention (BI) or TTG intervention (TTG).