David P. Arpino, RRT, RPFT ALHE 4060 – Research in Allied Health Dr. Masini August 2, 2007

1. Improper Use of Metered Dose Inhalers and the Importance of Instruction Provided by Respiratory Therapists David P. Arpino, RRT, RPFT ALHE 4060 – Research in Allied Health Dr. Masini August 2, 2007

2. The Hard Facts • Several studies have shown that as many as 87% of patients are not able to properly use their MDI. • Other studies have shown that less than 40% of physicians are able to properly demonstrate how to use a MDI. • …and less than 30% of nurses are able to properly demonstrate how to use a MDI • However, 77% of Respiratory Therapists were able to demonstrate proper technique.

3. The Eight Steps for Proper MDI Use* • 1. Shake the canister • 2. Hold canister upright at mouth • 3. Begin a slow breath • 4. Actuate the MDI once • 5. Continue slow breath • 6. Inhale to lung capacity • 7. Hold breath for at least 4 seconds then exhale slowly • 8. Wait at least 30 second before next actuation • *per National Institutes of Health review committee for the treatment of asthma

4. Abstract • Metered Dose inhalers (MDI – Includes MDI and dry powder inhaler) are the mainstay of therapy for patients with chronic obstructive pulmonary disease COPD), asthma and emphysema, yet most patients are unable to properly use their MDI’s which results in sub-optimal therapy and the worsening of the patient’s lung disease. I have determined that the reason most patients do not use their inhalers properly is due to lack of proper instruction or poor instruction from health care providers. I will attempt to prove that proper instructions and demonstrations provided by Respiratory Therapists significantly improve patients use and understanding of MDI’s. • Over the course of six weeks, I directly observed approximately 100 randomly selected patients in an acute care facility use their MDI’s. Because the nature of many of the patients admission status, I was not able to do any long term observations. Further data was gathered from several similar reports published in the last 20 years. This study is limited to the initial observations of patients MDI use, instructions provided by a Respiratory Therapist (RT), and the subsequent post-instruction observations of the use of MDI’s by the patients. • Patients were first observed using their MDI’s and then questioned as to the amount of instruction they have received in the past about their inhalers. The patients were then critiqued on their use and provided written instructions and a demonstration by a Respiratory Therapist. On subsequent follow up visits by the Respiratory Therapist, the patients were evaluated on their technique and further coaching was administered if indicated. Subsequent follow up visits indicated that a significant number of patients showed measurable improvement in the use of MDI’s.

5. Conclusion • Many studies have shown that patients have a lot of difficulty using their MDI’s and that with proper instruction, that percentage does improve. However, other studies have shown that the proper skills by nurses and doctors for properly teaching MDI use are lacking. But, many studies have demonstrated that when a Respiratory Therapist teaches a patient how to properly use an MDI, the outcomes are significantly improved.