Correct Aerosol MedicationUse
and the HealthProfessions
Who Will Teachthe Teachers?
pproximately 80 million metered-dose
inhalers
(MDIs) are sold each year in the United States.
It has been estimated that if the National Asthma
Education Program's therapy guidelines' were adopted
for all eligible patients, the number of inhalers sold
per year would exceed 190 million. Although the vast
majority of these inhalers are prescribed for the
ambulatory patient, many are now advocating the use
of MDIs with spacer devices as a cost-saving alterna
tive for emergency department and inhospital ther
apy.2'3
Unfortunately, it has also been apparent over the
past 20 years that the proper use of these devices is
not as intuitively obvious to patients as taking tablets
or capsules by mouth. Surveys have indicated that
fewer than half of adult patients with MDIs4 or even
as few as 10 percents will achieve optimal benefit as a
result of inefficient technique. Giving written and oral
instructions alone is little better, resulting in 50
percent of patients using an MDI effectively.@ Dem
onstration of appropriate technique and patient obser
vation by health professionals is the most effective
means of teaching appropriate inhaler use,5 although
up to 30 percent of patients (particularly young chil
dren and the elderly) may not be able to use MDIs
effectively even with repeated instruction.5
The latter problem has been an impetus for the
development of add-on spacer devices for MDIs and
breath-activated
inhalers such as the Turbuhaler,
which has been available in Europe and Canada and
is undergoing clinical trials in the United States, and
the Rotahaler, which is currently available in the
United States. Although spacer devices improve MDI
efficacy and patients more easily become proficient
with breath-activated inhalers, recent evidence shows
that these devices also require instruction by demon
stration.6
How are we going to provide this instruction to the
millions of patients who obviously need it? Respiratory
therapists, nurses, and pharmacists trained in patient
education can instruct the hospitalized patient. Most,
if not all, specialists who care for respiratory patients
(pulmonologists and allergists) either have trained
personnel to provide instruction or provide it them
selves. Unfortunately, only 30 percent of asthmatic
patients are seen by specialists; the majority receive
their care from primary-care practitioners.7 Studies
have shown that very few of these practitioners know
how to use inhalation devices correctly, and this has
recently been translated into significantly fewer of
their patients being able to use MDIs effectively
compared with patients from specialty practices.8
In this issue (see page 1737), Kesten and coworkers
explore the utility of a heretofore undervalued re
source for providing the necessary patient instruction,
the retail pharmacist. Pharmacists are in the unique
position of having patient contact at the time the
patients actually receive their medication, when spe
cific education about medications may have the great
est impact. In addition, the pharmacist often has more
frequent contact with the patients as they come in for
prescription refills. Finally, it is the pharmacist's pro
fessional duty to ensure the safe and effective use of
medications by patients.
While numerous studies have indicated that phar
macist counseling and instruction can significantly
improve inhaler use and patient outcomes,56'9' ‘¿o
Mickle
et al―recently found that only 13 percent of 52
randomly selected community pharmacists offered to
provide instruction on MDI use when presented with
a prescription, only 46 percent offered education when
requested by the patient, and only 1 pharmacist
provided a demonstration. As reported in the Kesten
et al study, a number of the required steps were
omitted during instruction. While it is tempting to
dismiss this as another example of overly busy primary
care health professionals doing an inadequate job,
both studies provide valuable insight into a crucial
barrier: “¿You
can't teach what you don't know―
Unknown to many physicians, the practice of phar
macy in the United States is undergoing a major
transformation. The Omnibus Reconciliation Act of
1990 legislated mandatory patient counseling by phar
macists for all Medicaid prescriptions, to be defined
by local state pharmacy boards and to become effective
by January 1, 1993. To their credit, most state regu
lations are mandating patient counseling on all patient
prescriptions, as well as proactive utilization review
monitoring. However, legislation of professional prac
tice does not provide the pharmacists with the tools
to provide appropriate education. Kesten et al point
out that professional schools' programs have affected
only a small percentage of pharmacists, but this is
changing, as therapeutics and communication skills
are integral parts of most pharmacy school curricula.
How do we help the existing practitioners? Kesten
et al suggest a role for pharmaceutical industry
representatives, and this is an appropriate resource.
The pharmaceutical industry has been very suppor
tive, with many providing videotape and live contin
uing education programs on inhaler use. One hopes
that the recent restrictions on industry involvement
in medical education will not adversely affect that
support. The problem is acute, and we need all the
resources we can get. Finally, the recent inclusion of
pharmacy representation on the coordinating commit
tee of the National Heart, Lung, and Blood Institute
National Asthma Education Program is a positive step
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Editorials
in recognizing
a valuable resource.
H. William Kelly, Pharm.D., F.C.C.P
Albuquerque
Professor of Pharmacy; College of Pharmacy, and Associate Professor
of Pediatrics, School of Medicine, University of New Mexico.
REFERENCES
1 National Heart, Lung, and Blood Institute National Asthma
Education Program. Expert panel report: guideliines for the
diagnosis and management of asthma. Bethesda, Md: US
Department of Health and Human Services publication No, 913042, 1991
2 Bowton DL, Goldsmith WM, Haponik EF. Substitution of
metered-dose inhalers for hand-held nebulizers: success and
cost savings in a large, acute-care hospital. Chest 1992; 101:30508
3 Fuller HD, Dolovich MB, Posmituck G, Pack WW, Newhouse
MT Pressurized aerosol versus jet aerosol delivery to mechani
cally ventilated patients: comparison of dose to the lungs. Am
Rev Respir Dis 1990; 141:440-44
4 Crompton GK. The adult patient's difficulties with inhalers.
Lung 1990; suppl:658-62
5 Self TH, Brooks JB, Lieberman P. Ryan MR. The value of
demonstration and the role of the pharmacist in teaching the
correct use of pressurized bronchodilators. Can Med Assoc J
1983; 128:129-31
6 Nimmo CJ, Chen DNM, Martinusen SM, Ustad TL, Ostrow
DN. Assessment of patient acceptance and inhalation technique
of a pressurized aerosol inhaler and two breath-actuated devices.
Ann Pharmacother (in press)
7 Weiss KB, Gergen PJ, Hodgson TA. An economic evaluation of
asthma in the United States. N Engi J Med 1992; 326:862-66
8 Interiano B, Cuntupalli KK. Metered-dose inhalers: do health
care providers know what to teach? Arch Intern Med 1993;
153:81-5
9 Roberts RJ, Robinson JD, Doering PL, Dallmar, JJ, Steeves BA.
A comparison of various types of patient instruction in the
proper administration of metered inhalers. DICP 1982; 16:53-9
10 Im JH, Hartman TC Jr. Evaluation of a role for clinical
pharmacists in asthma and ambulatory care. Presented at the
First National Conference on Asthma Management, Arlington,
Va, Oct 11-13, 1992
11 Mickle TR, Self TH, Farr GE, Bess DT, Tsiu SJ, Caldwell FL.
Evaluation of pharmacists' practice in patient education when
dispensing a metered-dose inhaler. DICP/Ann Pharmacother
1990; 24:927-30
Corticosteroidsand Respiratory
Muscles
Does It Matter?
orticosteroids
in high doses and for prolonged
periods are frequently used in the treatment of
many diseases, including chronic respiratory disor
ders.―2Unfortunately, steroids have a potential to
cause several major side effects, including myopathy.3
Typically, steroids affect muscles that are less active,
that are proximal, and that contain a predominance of
type IIb, or fast glycolytic, fibers—characteristics not
found in respiratory muscles, particularly the dia
phragm.@ Nevertheless, steroid-induced myopathy of
the respiratory muscles has been suggested, although
its prevalence and clinical importance remain contro
versial.
In several animal models, corticosteroids have been
shown to produce a myopathy of the respiratory
muscles, which impacts on their function.@'@However,
extension of this information to humans is fraught with
problems due to interspecies differences in steroid
sensitivity and steroid metabolism and the excessive
dosing typically used in animal models. In humans,
various case reports have suggested that corticoste
roids can produce an acute myopathy in the respiratory
muscles,6 can cause prolonged respiratory
muscle
dysfunction following simultaneous administration
with paralytic agents,7 and may induce respiratory
muscle dysfunction in respiratory patients undergoing
chronic steroid therapy.8 On the other hand, the results
of clinical trials specifically designed to examine the
impact of prolonged steroid use on respiratory muscle
function have, in general, been negative.9
Unfortunately, several potential problems limit in
terpretation of the findings from the case reports and
even the clinical trials. In most instances, respiratory
muscle pathology was not assessed, with conclusions
regarding the presence of a myopathy inferred from
tests of respiratory muscle function. In addition,
patients had underlying pulmonary diseases, which
may have altered respiratory muscle function, inde
pendent of any effect of steroid therapy. Furthermore,
most studies looked solely at respiratory muscle
strength, without measuring muscle endurance or
other aspects of respiratory muscle function. Finally,
low doses of corticosteroids were typically used in the
clinical trials.
In an attempt to address some of these issues,
Weiner et al in this issue of Chest (see page 1788)
report the effect of oral corticosteroids on respiratory
muscle strength and endurance.
Although not a
blinded, controlled trial, the sole intervention likely
to have impacted on respiratory muscle function in
these patients was the corticosteroid therapy. It is
noteworthy that they used corticosteroid doses pre
scribed for many acute and even chronic conditions
and studied patients with no underlying pulmonary or
neuromuscular disease and normal baseline respira
tory muscle function, eliminating some of the problems
described above. They observed moderate reductions
in strength and striking reductions in endurance,
which took several months to reverse following discon
tinuation of steroids. Of interest, they found that
respiratory muscle endurance was affected earlier and
more severely than strength, a finding that has been
noted in in vivo animal experiments'0 and that suggests
that factors other than muscle atrophy with secondary
CHEST / 104 / 6 / DECEMBER,1993
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