Allercy and Asthma Health
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Spring 2007

Hey! Keep it Clean in There

New Guidelines Will Help You Breathe Easy

Pharmacology and Delivery Devices: What Works Best for Your Patient?

Asthma Management: Barriers to Care

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The Official Publication of AAN - MA

Pharmacology and Delivery Devices: What Works Best for Your Patient?

By Thomas J. Kallstrom

“Respiratory therapists are recognized as patient advocates and educators. One of the greatest challenges therapists face is how to appropriately pair the drug and the aerosol delivery device to the patient.

Respiratory therapists work hard to determine that the medication, the aerosol device, and the patient's understanding of the correct and proper usage of both match up. This article in their professional magazine, AARC Times, talks about the RT's role in helping you better understand how to use and administer your asthma medication.

The greatest struggle that we face in patient care as it relates to delivery of aerosolized medications is to appropriately pair up the drug and the device to the patient. There are a multitude of reasons why that is so important, and I will try to explore some of them.

Looking for the perfect match
One of the reasons that we stumble is because we may not have all of the device or drug information or enough background information about the patient. Hence, we may not be educating at the patient’s level of need. Along with this, it is important to keep in mind that literacy levels may differ between patients as well. And, of course, there is the need to have an educated educator. Another barrier often seen is a mismatch between patient and device. There needs to be some level of thought that takes place when a particular device is prescribed. Finally and most important, we need to understand that the device and adherence to a prescription go hand in hand. Simply put: If the patient cannot operate the device, it takes too long for a treatment, there are multiple devices, or the patient cannot afford the device, adherence will greatly suffer.

Today there are approximately 10 different aerosol delivery devices on the market for the administration of about 17 different aerosolized medications. Is there any wonder that patients have varying levels of confusion when it comes to self-administration? Given the choices, and with little aforethought, the patient could end up with a multitude of devices. And that is exactly what often happens. When I asked one particular patient whom I followed in his home to show me his devices, he proudly produced a half dozen different aerosol delivery devices. Was he adherent to the instructions that he received from his physician? Absolutely not. In fact he was only able to adequately demonstrate proper use of three of them. The rest were either improperly used or not used at all. Therein lies the dilemma.

In a perfect world, patients would not be allowed to leave the hospital clinic or emergency department until the instructor is assured that the patient can properly use the device. I will never forget the mother who, when I visited her and her child and asked the mother how she dispensed the albuterol, proceeded to reach for a multi-dose albuterol container, drew up 3 mL’s of the drug, and put it in the nebulizer cup. After I caught my breath and tried to cover up a perplexed look, she explained this was how she thought the drug should be administered. On further investigation, I discovered that the pharmacist did not educate her nor did the hospital-based RT. Instead, she assumed that since the hospital-based RT did not mix the medication (unit dose was used instead), that’s how she was to do it at home as well.

The take-home point is that the clinician must keep a critical eye on the device and patient match. This can be accomplished by asking, and taking the time to observe the patient’s preparation and administration technique. Unfortunately, this type of scenario may not be all that infrequent in the home—or the hospital as well. In fact, albuterol, which is the most commonly administered aerosolized respiratory medication, is second only to insulin as the most common drug implicated in health system medication errors.1

Correcting the errors
E. Regis McFadden has researched patient education extensively and has uncovered common errors seen with metereddose inhaler (MDI) administration.2 They include:
• Failure to coordinate MDI to inhalation
• Too rapid of an inspiratory rate
• Not shaking the device before using
• Exhaling during inhalation
• Putting the wrong end of the inhaler into the mouth
• Holding the canister in the wrong position
• Failing to remove cap prior to use.

These errors are surprising but do illustrate the importance of proper education and follow-up with the patient, whether they are just starting to use the device or have been using it for some time. Probably no one would argue the fact that the device needs to be tailored to the patient. Arecent evidence-based analysis published in Chest found that when the patient uses the device correctly, the efficacy is equivalent.3 However, to me the take-home point from this study was that we must make the following considerations when prescribing aerosol medication and the devices that will deliver the medicine. They include:
• In what device is the desired drug available?
• What device is the patient likely to use correctly, given age and setting?
• What is reimbursement, and is it cost effective?
• Can all or most of medications be applied with the same type of device?
• Which device is more convenient to use?
• How portable is it?
• How durable is the device?
• Does the clinician or patient have a preference?
• What is the treatment time?

Once all of these questions are answered, the clinician should have a better basis for deciding which device is best suited for the patient.

The thing to remember is that patient adherence is directly related to perceived ease or difficulty in using a particular device. We need to work to assure that our patients are given the appropriate device, and we must continue to keep ourselves current on the newer devices being prescribed today. •

References
1. Hicks, R.W., Santell, J.P., Cousins, D.D., & Williams, R.L. (2004). Medmarx 5th anniversary data report: A chartbook of 2003 findings and trends 1999–2003. Rockville, MD: USP Center for the Advancement of Patient Safety.
2. McFadden, E.R., Jr. (1995). Improper patient techniques with metered dose inhalers: Clinical consequences and solutions to misuse. The Journal of Allergy and Clinical Immunology, 96(2), 278-283.
3. Dolovich, M.B., Ahrens, R.C., Hess, D.R., et al. (2005). Device selection and outcomes of aerosol therapy: Evidencebased guidelines. Chest, 127(1), 335-371.

Upcoming Resource
A new AARC education paper, “A Guide to Aerosol Delivery Devices for Respiratory Therapists,” will be released in early 2007. Its primary goal will be to increase the knowledge level of all respiratory therapists and will provide detailed and comprehensive information on MDI, DPI, and nebulizer aerosol devices. The AARC encourages all RTs to increase their knowledge and skill levels relating to these devices. With the increasing number of devices available on the market today and our critical role in administration and patient education, this will be a document you will want to have.

About the author
Thomas J. Kallstrom is associate executive director and chief operating officer of the AARC. He is also a member of the NAEPP Coordinating Committee and is a certified asthma educator.

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