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-to-goal 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).

Keywords: asthma; chronic obstructive pulmonary disease; patient education as topic; self-care.

Figure 1.

Intervention. *Disease education served as an attention control. BI = brief intervention; RA = research assessor; RE = research educator; TTG = teach-to-goal.

Figure 2.

Participant flow from initial assessment through primary outcome analysis. BI = brief intervention; HP1 = hospital 1; HP2 = hospital 2; MDI = metered-dose inhaler; TTG = teach-to-goal.

Figure 3.

(A) Proportion of participants misusing either (a) metered-dose inhaler or (b) Diskus inhaler. (B) Proportion of participants who misused metered-dose inhaler with (a) adequate literacy, (b) low literacy, and (c) insufficient vision. BI = brief intervention; MDI = metered-dose inhaler; TTG = teach-to-goal. *Significant association at the P < 0.05 level.

Figure 4.

Postdischarge acute care visits. A total of 107 participants (89%) returned at 30 days postdischarge (TTG, 54 of 62; brief intervention, 53 of 58), and a total of 103 (86%) returned at 90 days (TTG, n = 52 of 62; brief intervention, n = 51 of 58). There were fewer acute care visits (emergency department visits and/or hospitalizations) among teach-to-goal participants than among brief intervention participants (9 [17%] of 54 vs. 19 [36%] of 53, respectively; P = 0.03) at 30 days, but not at 90 days (21 [40%] of 52 vs. 22 [43%] of 51, respectively; P = 0.64) after hospital discharge. BI = brief intervention; ED = emergency department; TTG = teach-to-goal.