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JAMP-2011-0895-ver9-Plaza_1P.

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JAMP-2011-0895-ver9-Plaza_1P

JOURNAL OF AEROSOL MEDICINE AND PULMONARY DRUG DELIVERY


Volume 24, Number X, 2011 Original Research
ª Mary Ann Liebert, Inc.
Pp. 1–7
DOI: 10.1089/jamp.2011.0895

Physician’s Knowledge of Inhaler Devices and Inhalation


Techniques Remain Poor in Spain

Vicente Plaza, M.D., Ph.D.,1 Joaquı́n Sanchis, M.D., Ph.D.,1 Pere Roura, M.B., M.P.H.,2 Jesús Molina, M.D.,3
Myriam Calle, Ph.D.,4 Santiago Quirce, M.D., Ph.D.,5 José Luı́s Viejo, M.D., Ph.D.,6
Fernando Caballero, Ph.D.,7 and Cristina Murio, M.D.8

Abstract

Background: Studies in many countries in the 1990s revealed deficiencies in physicians’ knowledge about
inhalation therapy. In an attempt to remedy this situation, Spanish scientific societies implemented a variety of
educational strategies. The objective of the present study was to assess changes in attitudes and knowledge
about inhalers and inhalation techniques in a sizable sample of physicians.
Methods: An 11-question multiple choice test was developed and administered throughout Spain to practicing
physicians from specialties that frequently prescribe inhaler devices. The survey collected demographic characteristics
(four items), preferences (two items), and issues related to knowledge (three items) and education (two items) about
devices and inhalation techniques. Completion of the questionnaire was voluntary, individual, and anonymous.
Results: A total of 1514 respondents completed the questionnaire. Dry powder inhalers (DPI) were preferred by
61.2% physicians, but only 46.1% identified ‘‘inhale deeply and forcefully’’ as the most significant step in the
inhalation maneuver using these devices. Only 27.7% stated that they always checked the patient’s inhalation
technique when prescribing a new inhaler. A composite variable, general inhaled therapy knowledge, which pooled
the correct answers related to knowledge, revealed that only 14.2% physicians had an adequate knowledge of
inhaled therapy. Multivariate analysis showed that this knowledge was lowest among internal medicine and
primary care physicians.
Conclusions: Prescribers’ knowledge of inhalers and inhalation techniques remains poor in Spain. The causes
should be identified in further research to allow effective educational strategies to be developed. Specific edu-
cational policies should be addressed to general practitioners.

Key words: inhaled therapy, inhalation devices, inhalation technique, pMDI, misuse of pMDI, DPI

Introduction these years, today’s devices offer substantial improvements


over their predecessors. A wide range of inhalers is now

T he development of aerosol delivery devices re-


presented a significant breakthrough in the treatment of
bronchial obstructive diseases, particularly asthma and
available, but although this means treatment can be individ-
ualized for each patient it also means physicians who prescribe
these devices must keep abreast of all their characteristics, their
chronic osbtructive pulmonary disease (COPD). It is now close potential drawbacks, and especially their inhalation technique.
to 60 years since the first device inhaler (Medihaler-EpiTM) was Inhaled drugs provide clear advantages over other routes
marketed, and with the technological advances made over of administration, but they also have some limitations. The

1
Service of Pneumology, Hospital de la Santa Creu i Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain.
2
Service of Clinical Epidemiology, Hospital General de Vic, c/ Francesc Pla, 1, Vic, Spain.
3
Health Centre France I. C/, Francia 38, Posterior, Fuenlabrada (Madrid), Spain.
4
Service of Pneumology, Hospital Clinico San Carlos, Universidad Complutense de Madrid, C/ Martin Lagos s/n, Madrid, Spain.
5
Department of Allergy, Hospital la Paz Health Research Institute (IdiPAZ), Madrid, Spain.
6
Complejo Asistencial Universitario de Burgos, Burgos, Spain.
7
School of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón (Madrid), Spain.
8
Medical Advisor of Medical Department Chiesi Spain, L’Hospitalet de Llobregat, Barcelona, Spain.

1
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2 PLAZA ET AL.

most serious of these is that patients must use them appro- Table 1. Questionnaire Administered
priately for a minimal amount of a drug to reach the low to the Study Sample
airways and exert its pharmacological action successfully.
1. Age (years)
Incorrect use of inhaler devices can lead to therapeutic failure
2. Sex: Male/Female
and poor disease control.(1–3) For this reason, clinical practice 3. Medical specialty:
guidelines for asthma and COPD consider that training pa- 1.1 Internal medicine
tients to use their inhalation devices is as an essential part of 1.2 Primary care
nonpharmacological aspects of treatment.(4–6) For the same 1.3 Pneumology
reason, the European Respiratory Society (ERS) and the In- 1.4 Allergy
ternational Society for Aerosols in Medicine (ISAM) recently 1.5 Other
developed a consensus statement for the pulmonary physi- 4. Which area of Spain do you work in?:
cian that includes detailed recommendations on how to use 4.1 North (Galicia, Asturias, Cantabria, Basque Country,
inhalation devices correctly.(7) Navarra, La Rioja)
4.2 Central (Castilla-León, Castilla-La Mancha, Madrid)
Several studies have shown that most patients who use
4.3 South (Extremadura, Andalucı́a)
inhaler devices do not handle them properly.(8–13) It has also 4.4 East (Aragon, Catalonia, Valencia, Murcia, Baleares)
been observed that physicians and nurses who prescribe or 4.5 Canary Islands, Ceuta and Melilla
supervise these inhalers have poor knowledge and skills 5. Your knowledge of inhaler use comes mainly from:
regarding their use.(14–17) Results in Spain from studies per- 5.1 Attendance at meetings, courses, or workshops organized
formed in the 1990s reflected similar findings.(18–20) In view by scientific societies
of these shortcomings, scientific societies and pharmaceutical 5.2 Attendance at meetings, courses, or workshops organized
industries in Spain have since developed and launched a by pharmaceutical industries
series of educational activities (meetings, postgraduate 5.3 Reading articles or books specialized on the topic
courses, workshops, and recommendation documents sup- 5.4 Reading the leaflet included with the inhaler devices
5.5 Directly from personal clinical experience and common
ported by the scientific societies(21–22) addressed to physi-
sense
cians to improve their knowledge on inhalation therapy. To 6. Which device do you prefer?
assess physicians’ current knowledge of inhaled therapy we 6.1 TurbuhalerTM
conducted a survey in a large sample of physicians from 6.2 DiskusTM
various medical specialties that commonly prescribe inhaler 6.3 pMDI
devices. 6.4 pMDI with inhalation chamber
6.5 pMDI ModuliteTM system
7. The most important step for correct pMDI inhalation is:
Materials and Methods 7.1 Shake the device before inhalation
Study design and population 7.2 Exhale deeply before inhalation
7.3 Firing the device after beginning inspiration
The study was designed to assess the level of knowledge, 7.4 Inhale deeply and forcefully
attitudes, and preferences related to inhaled therapy among 7.5 Continue deep, slow inspiration
specialists in primary care, internal medicine, allergy, and 8. The most important step for correct DPI inhalation is:
pneumology. We developed a questionnaire consisting of 11 8.1 Shake the device before inhalation
questions. Participation in the survey was voluntary, indi- 8.2 Exhale deeply before inhalation
8.3 Firing the device after beginning inspiration
vidual, and anonymous. The questionnaires were distributed
8.4 Inhale deeply and forcefully
to physicians throughout Spain by representatives from a 8.5 Continue deep and slow inspiration
pharmaceutical industry (Chiesi). The survey was carried out 9. When you prescribe an inhaler device, which of the
between May and August 2010. following variables do you consider most important?
9.1 The disease being treated
Questionnaire 9.2 The patient’s preferences
9.3 The patient’s age
T1 c The 11-item questionnaire (Table 1) took less than 5 min to 9.4 The patient’s previous experience using a specific inhaler
answer. The first 4 questions gathered information about the 9.5 The patient’s cultural level
respondent’s age, sex, medical specialty, and geographic lo- 10. When you prescribe a new inhaler do you or another
cation. Subsequent questions were developed using a mul- healthcare worker assess the patient’s skill with its use?
tiple choice format and concerned preferences (items 5 and 10.1 Always
6), level of knowledge (items 7, 8, and 9), and patient edu- 10.2 Usually
cation activities on inhalation techniques (items 10 and 11). 10.3 Sometimes
An optical answer sheet was designed and responses on 10.4 Hardly ever
10.5 Never
questionnaires were scanned and automatically entered into
11. Who trains the patients on the inhaler device technique
a database. at your center?
The correct answers for items 7 [identification of the most 11.1 You, personally
important step in the metered-dose inhaler (pMDI) inhala- 11.2 Nurses
tion technique], 8 [identification of the most important step 11.3 Either the nurse or you, it depends
in the dry-powder inhaler (DPI) inhalation technique], 9 11.4 Nobody, but we provide written information
(most important characteristic to prescribe a specific inhaler 11.5 Nobody, and we don’t give written information
device), and 10 (assessment of the patient’s skill in the in-
pMDI, metered-dose inhaler; DPI, dry-powder inhaler.
halation technique at the time of prescription) were 7.3, 8.4,
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PHYSICIANS’ KNOWLEDGE OF INHALED THERAPY 3

9.2, and 10.1 (see Table 1), respectively. The correct answers fer?’’), DPIs (TurbuhalerTM and DiskusTM) were selected by
chosen for items 7, 8, and 10 were based on the current 61.2% of the physicians and a significant proportion of pri-
recommendations for inhalation therapies,(7–23) where the mary care physicians (24.3%) preferred the pMDI Mod-
critical step for each inhaled maneuver and educational as- uliteTM system than other specialty groups. Results for item 7
pects to train the patients were emphasized. Regarding the (‘‘The most important step for correct pMDI inhalation is’’)
correct answer for the item 9, undoubtedly, there were sev- showed that a high proportion of participants (72.3%) chose
eral aspects that physician’s had to consider when prescrib- the correct answer (‘‘Firing the device after beginning in-
ing an inhaler, such as age, skill, previous experience, and a spiration’’), but primary care physicians (5.9%), more than
patient’s cultural level.(24,25) Patient opinion though, is con- any other group, stated incorrectly ‘‘shake the device before
sidered to play a critical role, because including patients in inhalation.’’ In the Item 8 (‘‘The most important step for
the decision making improves disease outcomes and treat- correct DPI inhalation is’’) only 46.1% of the physicians
ment compliance. (26,27) sample identified ‘‘inhale deeply and forcefully’’ as the cor-
The level of knowledge about inhalation therapy was as- rect answer. Results for item 9 (‘‘When you prescribe an in-
sessed by using the sum of correct answers to items 7, 8, 9, haler device, which of the following variables do you
and 10. Each correct answer was assigned one point. Total consider most important?’’) revealed that only 12.3% of the
scores therefore ranged from zero to four. This score gener- physicians selected the ‘‘patient’s preferences,’’ and between
ated a new variable, general inhaled therapy knowledge, from specialty groups, pneumologists significantly chose more
which we arbitrarily stratified the sample into two groups: frequently this option than any other group. Item 10 asked
poor (0, 1, or 2 points) and adequate (3 or 4 points) inhaled about educational aspects (‘‘When you prescribe a new in-
therapy knowledge. This analysis was only done on pneu- haler do you or another healthcare worker assess the pa-
mologists, allergists, primary care, and internal medicine tient’s skill with its use?’’) where only 27.7% of the sample
physicians), after excluding other specialties. stated that they ‘‘always’’ checked the patient’s skill and by
groups, pneumologists and allergists had significantly higher
Statistical analysis response rates (32.4 and 30%, respectively) in this answer
option than other analyzed groups. Finally, for item 11
Double data entry was performed to verify data entry
(‘‘Who trains the patients in the device inhaler technique in
accuracy; the sample size was calculated to identify less than
your centre?’’) the internal medicine group showed a lower
5% of errors. No errors were identified in the quality as-
involvement to train patients in the inhalation techniques.
sessment of automated data management. Descriptive sta-
The composite variable generated, general inhaled therapy
tistics were compiled for the entire population sample.
knowledge, showed an average score of 1.53 points (95% CI:
Results for each item were expressed as percentages and
1.48–1.57) in the sample of the four specialties (pneumology,
compared between specialty groups using the chi-square or
allergy, primary care, and internal medicine) analyzed
analysis of variance (ANOVA) tests. Statistical significance
(1495). Fourteen respondents (0.9%) achieved the highest
was set at a p-value of less than 0.05. Bonferroni’s correction
possible score (four points) and 170 (11.4%), the lowest
was used when required. Logistic regression was used to
possible score (zero points). Pneumologists [1.66 (95% CI:
define a profile of the physician with adequate inhaled
1.59–1.73)] and allergists [1.65 (95% CI: 1.54–1.75)] achieved a
therapy knowledge. Independent variables were included in
significantly higher mean score than primary care [1.36 (95%
the model only if they were significant in the bivariate
CI: 1.27–1.46)] and internal medicine physicians [1.28 (95%
analysis. Analyses were carried out with IBM SPSS Statistics
CI: 1.17–1.38)] ( p < 0.05). According to the stratification es-
version 19 (SPSS for Windows, Chicago, IL).
tablished, 1283 (85.8%) respondents were classified into the
poor inhaled therapy knowledge group and 212 (14.2%)
Results
were classified into the adequate group. Table 3 shows the b T3
A total of 1514 respondents completed the questionnaire. differences between specialties: the proportion of pneumol-
The mean age of the sample was 44.5 [confidence interval ogists and allergists in the adequate group was significantly
(CI) 95%: 44–45] years and 830 (55%) were men. Regarding higher than that of primary care and internal medicine
medical specialty, 652 (43%) were pneumologists, 307 physicians. Neither gender nor age was significantly associ-
(20.2%) were primary care physicians, 270 (17.8%) were al- ated with general inhaled therapy knowledge score. Multivariate
lergists, 266 (17.6%) were internal medicine physicians, and analysis to predict adequate general inhaled therapy knowledge
19 (1.2%) were from other specialties. Respondents came revealed (Table 4) that pneumologists and allergists doubled b T4
from the following areas of Spain: 493 (32.6%) were from the odds ratio (2.33 and 1.98, respectively) of primary care
eastern regions, 451 (29.8%) were from the central area, 291 and internal medicine physicians.
(19.2%) were from the south, 218 (14.4%) were from the
north, and 34 (2.2%) were from the Canary Islands or Ceuta-
Discussion
Melilla.
T2 c Table 2 displays the results for the whole sample inter- A very high proportion of physicians who frequently
viewed for items 5, 6, 7, 8, 9, 10, and 11, and compares the prescribed inhaler devices lacked adequate knowledge con-
results observed by specialty group. For the item 5 (‘‘Your cerning inhaled therapy and related educational aspects. The
knowledge of inhaler use comes mainly from’’) responses composite variable, general inhaled therapy knowledge, which
showed no clear origin of learning, but when groups of pooled the answers of the four related items on the ques-
specialty were compared significantly more pneumologists tionnaire, identified only 14.2% of the sample as having ad-
(34%) chose the option ’’reading articles or books specialized equate knowledge of inhaled therapy. Several studies have
on the topic’’. For the item 6 (‘‘Which device do you pre- consistently shown poor asthma control,(28–30) and it has
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4 PLAZA ET AL.

Table 2. Results from the Questionnaire for the Whole Sample and Each Specialty
(Excluding Other Specialties)

Total Primary Internal p (between


sample Pneumology Allergy care medicine specialty
(n = 1514) (n = 652) (n = 270) (n = 307) (n = 266) groups)

Demographic Characteristics
Age, mean (SD) 44.5 (9.7) 44.2 (10.2) 42.8 (8.8) 46.5 (8.7) 44.6 (9.9) < 0.001
Men/Women, % 55/45 56/44 43/57 55/45 67/33 < 0.001
Preferences
ITEM 5. Your knowledge of inhaler use comes mainly from: (valid surveys, n = 1,321)
- Meetings by scientific societies 386 (29.2) 164 (28.9) 81 (33.9) 76 (27.0) 65 (27.9)
- Meetings by industries 233 (17.6) 75 (13.2) 36 (15.1) 86 (30.5) 36 (15.5)
- Reading scientific articles 364 (27.6) 193 (34.0) 60 (25.1) 53 (18.8) 58 (24.9)
- Reading the leaflet drug 25 (1.9) 6 (1.1) 5 (2.1) 7 (2.5) 7 (3.0)
- Personal experience 313 (23.7) 129 (22.8) 57 (23.8) 60 (21.3) 67 (28.8)
0.001
ITEM 6: Which device do you prefer?: (valid surveys, n = 1360)
- TurbuhalerTM 493 (36.3) 224 (38.6) 103 (42.4) 94 (32.2) 72 (29.5)
- DiskusTM 338 (24.9) 140 (24.1) 54 (22.2) 58 (19.9) 86 (35.2)
- pMDI 121 (8.9) 49 (8.4) 22 (9.1) 29 (9.9) 21 (8.6)
- pMDI with inhaler chamber 218 (16.0) 113 (19.4) 33 (13.6) 40 (13.7) 32 (13.1)
- pMDI ModuliteTM system 190 (14.0) 55 (9.5) 31 (12.8) 71 (24.3) 33 (13.5)
< 0.001
Issues Related to the Knowledge of Inhalation Techniques and Prescription
ITEM 7: The most important step for correct pMDI inhalation is: (valid surveys, n = 1435)
- Shake the device before inhalation 33 (2.3) 4 (0.6) 4 (1.5) 18 (5.9) 7 (2.8)
- Exhale deeply before inhalation 125 (8.7) 44 (7.1) 21 (8.0) 38 (12.5) 22 (8.9)
- Firing the device after beginning inspirationa 1,038 (72.3) 481 (77.2) 200 (76.6) 185 (61.1) 172 (69.4)
- Inhale deeply and forcefully 93 (6.5) 35 (5.6) 14 (5.4) 27 (8.9) 17 (6.9)
- Continue deep, slow inspiration 146 (10.2) 59 (9.5) 22 (8.4) 35 (11.6) 30 (12.1)
< 0.001
ITEM 8: The most important step for correct DPI inhalation is: (valid surveys, n = 1451)
- Shake the device before inhalation 22 (1.5) 2 (0.3) 1 (0.4) 7 (2.3) 12 (4.7)
- Exhale deeply before inhalation 175 (12.1) 82 (13.0) 35 (13.4) 35 (11.5) 23 (9.1)
- Firing the device after beginning inspiration 205 (14.1) 80 (12.7) 20 (7.6) 55 (18.0) 50 (19.7)
- Inhale deeply and forcefullya 667 (46.1) 297 (47.1) 134 (51.1) 131 (43.0) 105 (41.3)
- Continue deep, slow inspiration 382 (26.3) 169 (26.8) 72 (27.5) 77 (25.2) 64 (25.2)
ns
ITEM 9: When you prescribe an inhaler device, which of the following variables do you consider most important?:
(valid surveys, n = 1401)
- Disease to treat 360 (25.7) 126 (20.8) 66 (26.5) 86 (29.2) 82 (32.5)
- Patient’s preferencesa 172 (12.3) 95 (15.7) 31 (12.4) 30 (10.2) 16 (6.3)
- Patient’s age 247 (17.6) 88 (14.5) 53 (21.3) 61 (20.7) 45 (17.9)
- Patient’s experience with device 544 (38.8) 259 (42.8) 91 (36.5) 99 (33.6) 95 (37.7)
- Patient’s cultural level 78 (5.6) 37 (6.1) 8 (3.2) 19 (6.4) 14 (5.6)
< 0.001
Issues Related to Education in Device Inhalation Techniques
ITEM 10: When you prescribe a new inhaler do you or another healthcare worker assess the patient’s skill in its use?
(valid surveys, n = 1495)
- Alwaysa 414 (27.7) 211 (32.4) 81 (30.0) 74 (24.1) 48 (18.0)
- Usually 613 (41.0) 304 (46.6) 128 (47.4) 104 (33.9) 77 (28.9)
- Sometimes 371 (24.8) 124 (19.0) 51 (18.9) 91 (29.6) 105 (39.5)
- Hardly ever 80 (5.4) 11 (1.7) 8 (3.0) 29 (9.4) 32 (12.0)
- Never 17 (1.1) 2 (0.3) 2 (0.7) 9 (2.9) 4 (1.5)
< 0.001
ITEM 11: Who trains the patients on the inhaler device technique at your center? (valid surveys, n = 1493)
- Physicians 516 (34.6) 212 (32.5) 122 (45.2) 103 (33.8) 79 (29.7)
- Nurses 335 (22.4) 134 (20.6) 39 (14.4) 67 (22.0) 95 (35.7)
- Either nurses or physicians 579 (38.8) 293 (44.9) 101 (37.4) 115 (37.7) 70 (26.3)
- Nobody, but written information is provided 34 (2.3) 11 (1.7) 4 (1.5) 12 (3.9) 7 (2.6)
- Nobody, and written information is not provided 29 (1.9) 2 (0.3) 4 (1.5) 8 (2.6) 15 (5.6) < 0.001
Values are shown as the mean with percentages in brackets.
SD, standard deviation; pMDI, metered-dose inhaler; DPI, dry-powder inhaler; ns, not significant.
a
Correct answers for items 7, 8, 9, and 10 used to generate the composite variable general inhaled therapy knowledge.

been suggested that one cause could be the inappropriate use care resource use and poor clinical control with an inap-
of inhalers.(1–3) In a recent prospective study involving 1664 propriate use of their inhaler devices. Fortuna et al.(32) found
(COPD and asthma) patients Melani et al.(31) observed a that although 76% of 1363 patients with asthma were treated
strong association between increased unscheduled health- with a combination of inhaled corticosteroid plus a long-
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PHYSICIANS’ KNOWLEDGE OF INHALED THERAPY 5

Table 3. Classification in ‘‘Poor’’ or ‘‘Adequate’’ Inhaled Therapy Knowledge for the Sample
After Excluding Other Specialties and Each Specialty

Sample of specialty Pneumology Allergy Primary care Internal medicine p (between


physicians (n = 1,495) (n = 652) (n = 270) (n = 307) (n = 266) specialty groups)

Poor ( £ 2 points) 1,283 (85.8) 533 (81.7) 227 (84.1) 281 (91.5) 242 (91.0)
Adequate ( ‡ 3 points) 212 (14.2) 119 (18.3) 43 (15.9) 26 (8.5) 24 (9.0) < 0.05
Stratification was made after correct answers were pooled for items 7, 8, 9, and 10 [1 point for each correct answer (marked with an asterisk
in Table 2)] in a new composite variable (general inhaled therapy knowledge). Values are shown the as mean with percentages in brackets.

acting beta agonist, 44% of the total sample had suffered a tries.(16,17) Two studies conducted in Spain 15 years ago to
moderate to severe asthma exacerbation in the previous year. evaluate healthcare professionals’ skills in the use of inhalation
As the pharmacologic treatment prescribed follows present devices asked participants to give a practical demonstration
guidelines, issues such as incorrect inhalation techniques with a placebo inhaler.(19,20) One of these studies showed that
could be involved in these unexpectedly low results. only 28% of 428 physicians managed the pMDI correctly,(19)
Item 5 was related to the source of inhaled therapy and the other showed that only 27% of 118 physicians and
knowledge and responses showed no clear origin of learning. nurses used the TurbuhalerTM DPI correctly.(19) Our present
This could therefore be another aspect to take into account in results may therefore imply an improvement compared to the
the future to improve physicians’ knowledge of inhaled above-mentioned studies,(19,20) but the different methods used
therapy. Perhaps this topic should be included in the aca- must be taken into account when interpreting the findings. The
demic curriculum at medical school, where, at least in our use of multiple choice questions to assess self-referred knowl-
country, it is not given proper attention. edge, not dexterity, on the inhalation technique has been suc-
Item 6 explored physicians’ choice concerning the type of cessfully used by several investigators.(34,35) However, it is
inhaler. The TurbuhalerTM and DiskusTM DPI devices were more challenging and exacting to achieve optimum scores
the preferred inhalers by 61.2% of physicians who completed when a practical demonstration with a placebo device is re-
the questionnaire. This finding contradicts recent sale figures quested, as in our former studies,(19,20) than when participants
indicating that pMDI is the most widely sold device in are only asked to identify the critical maneuver from a multiple
Spain.(33) However, these differences observed between our choice list. Moreover, this improvement in knowledge about
results and the sale rates could be related to the fact that the the pMDI inhalation technique could have been favored by the
number of pneumologists interviewed (43%) was higher fact that the same phrasing was used in answers to items 7 and
than the number of primary care physicians (20.2%) inter- 8 (the most important steps for correct pMDIs and DPI’s in-
viewed. The proportion of preferences for DPI was higher in halation techniques, respectively). This could have made it
pneumologists and allergists than in primary care and in- easier to identify the right answer for the correct inhalation
ternal medicine physicians. An alternative explanation could technique (item 7).
be related to the higher drugs available in DPI, particularly The survey noted two main deficiencies related to inhaler
combinations of inhaled corticosteroid plus a long-acting training for patients. The first of these was related to item 9,
beta agonist, than pMDI in Spain. Another finding that de- which asked physicians to identify the most relevant char-
serves comment is that although DPI was the preferred de- acteristic to take into account when prescribing a device.
vice by 61.2% of physicians, only 46.1% correctly identified Only 12.3% chose ‘‘patient’s preferences.’’ The second defi-
‘‘inhale deeply and forcefully’’ as the most important step for ciency related to inhaler training concerned item 10 where
the DPI inhalation maneuver (see Table 2). This inconsis- only 27.7% of physicians responded that they ‘‘always’’
tency adds to the general deficiencies identified in knowl- checked patient skill in using the device at the moment of
edge of inhalation therapy in the sample surveyed. prescription, and 5.4% and 1.1% ticked the ‘‘hardly ever’’ or
Seventy-two percent of our sample successfully identified ‘‘never’’ boxes, respectively. These findings are those of most
the critical step for the pMDI and 46.1% identified that for the concern in our study and they are consistent with the re-
DPI, results that were similar to studies from other coun- sponses to item 9. The score for general inhaled therapy
knowledge was weighed down by the poor results observed in
items 9 and 10, emphasizing the need to specifically address
Table 4. Results of Multivariate Analysis these educational aspects in future educational programs.
to Predict Adequate General Inhaled
As in the studies mentioned earlier,(20) when our results
Therapy Knowledge Showing the Significant
Variables Included in the Model were compared between specialty groups, pneumologists
and allergists showed significantly better scores than pri-
‘‘Odds ratio’’ 95% CI p mary care and internal medicine physicians for all items and
also, therefore, in the combined variable generated (general
Specialty inhaled therapy knowledge). In the multivariate analysis,
Internal medicine 1 pneumology and allergy specialists, doubled the ‘‘odds ra-
Primary care 0.93 0.52–1.70 > 0.05
tio’’ (2.33 and 1.98, respectively) for ‘‘adequate knowledge’’
Pneumology 2.33 1.45–3.75 < 0.05
Allergy 1.98 1.15–3.41 < 0.05 in inhaled therapy in comparison with other groups. This
finding is of particular clinical relevance given the large
CI, confidence interval. volume of chronic respiratory patients (asthma and COPD)
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6 PLAZA ET AL.

attended to by primary care physicians and internal medi- 2. Giraud V, and Roche N: Misuse of corticosteroid metered-
cine physicians in routine care and the emergency room dose inhaler is associated with decreased asthma stability.
when patients present exacerbations. Specific educational Eur Respir J. 2002;19:246–265.
policies should be addressed to both these medical groups. 3. Barnes PJ: Achieving asthma control. Curr Med Res Opin.
Given our failure to improve general inhalation therapy 2005;21(Suppl 4):S5–S9.
knowledge with traditional educational methods, different 4. GINA. Global Initiative for Asthma. Global Strategy for
strategies should be devised. These should include inhalation Asthma Management and Prevention NHLBI/WHO Work-
therapy topics to be addressed during residency training and shop Report. 2009. Available from: http://www.ginasthma
in recertification programs. .com.
5. GOLD: NHLBI/WHO: Gobal Initiative for Chronic Ob-
One of the potential weaknesses of this study could be
structive Lung Disease. NHLBI/WHO workshop report.
related to the method used. The data are based solely on the
National Institutes of Health, National Heart, Lung and
results of a survey on self-perceived knowledge and may not
Blood Institute. Publication Number 2701. 2010. Available
reflect respondents’ behavior in actual clinical practice. from: http://www.goldcopd.com.
To conclude, physicians who manage respiratory patients 6. GEMA: Spanish Guideline on the Management of Asthma.
in Spain continue to have a poor knowledge of inhaler de- Arch Bronconeumol. 2009;45(Supl. 7):2–35. Available from
vices and inhalation techniques. Despite the educational ac- http://www.gemasma.com.
tivities developed in the past 20 years, information on the use 7. Laube BL, Janssens HM, de Jongh FH, Devadason SG, Dhand
of aerosols does not appear to have improved substantially. R, Diot P, Everard ML, Horvath I, Navalesi P, Voshaar T, and
Further studies are needed to identify the causes of this Chrystyn H: ERS/ISAM TASK FORCE REPORT: what the
continued deficiency. New educational programs should be pulmonary specialist should know about the new inhalation
developed, and general practitioners should be specifically therapies. Eur Respir J. 2011;37:1308–1331.
addressed. 8. De Blaquiere P, Christensen DB, Carter WB, and Martin TR:
Use and misuse of metered-dose inhalers by patients with
Acknowledgments chronic lung disease. Am Rev Respir Dis. 1989;140:910–916.
9. Thompson J, Irvine T, Grathwohl K, and Roth B: Misuse of
The authors would like to thank Carolyn Newey and metered-dose inhalers in hospitalized patients. Chest.
Nadia Brienza for editorial assistance. The study was sup- 1994;105:715–717.
ported in part by an unrestricted grant from Chiesi (Spain). 10. Goodman DE, Israel E, Rosenberg M, Johnson R, Weiss ST,
and Drazen JM: The influence of age, diagnosis, and gender
Author Disclosure Statement on proper use of metered-dose inhalers. Am J Respir Crit
Vicente PLAZA received honoraria for speaking at spon- Care Med. 1994;150:1256–1261.
sored meetings from Amgen, AstraZeneca, Chiesi, Esteve 11. Van der Palen J, Klein JJ, Kerkhoff AHM, and Van der
Herwaarden CLA: Evaluation of the effectiveness of four
Laboratories, GlaxoSmithKline, Merck, and Novartis, and as
different inhalers in patients with chronic obstructive pul-
a consultant for Almirall. He received help assistance for
monary disease. Thorax. 1995;50:1183:7.
travel from AstraZeneca and Merck, and he received fund-
12. Van Beerendonk I, Mesters I, Mudde AN, and Tan TD: As-
ing/grant support for research projects from a variety of sessment of the inhalation technique in outpatients with asthma
Government agencies and not-for-profit foundations, as well or chronic obstructive pulmonary disease using a metered-dose
as AstraZeneca, Chiesi and Merck. Joaquı́n SANCHIS re- inhaler or dry powder device. J Asthma. 1998;35:273–279.
ceived honoraria for speaking at sponsored meetings from 13. Molimard M, Raherison C, Lignot S, Depont F, Abouelfath
Medeva and Chiesi. Pere ROURA received grant support for A, and Moore N: Assessment of handling of inhaler devices
research projects from a variety of Government agencies and in real life: an observational study in 3811 patients in pri-
not-for-profit foundations as well as GlaxoSmithKline and mary care. J Aeorsol Med. 2003;16:249–254.
Chiesi. For Jesús MOLINA, no conflicts of interest exist. 14. Kelling JS, Strhol KP, Smith RL, and Altose MD: Physician
Myriam CALLE received honoraria for speaking at spon- knowledge in the use of canister nebulizers. Chest. 1983;83:
sored meetings from AstraZeneca, Chiesi, Esteve Labora- 612–614.
tories, GlaxoSmithKline, Merck, Nicomed, and Novartis. 15. Hanania NA, Wittman R, Kesten S, and Chapman KR:
Santiago QUIRCE has been on advisory boards for and has Medical personnel’s knowledge of and ability to use inhal-
received speaker’s honoraria from AstraZeneca, Glax- ing devices. Chest. 1994;105:111–116.
oSmithKline, MSD, Novartis, Almirall, Altana, Chiesi, and 16. Self TH, Arnold LB, Czosnowski LM, Swanson JM, and
Pfizer. José Luı́s VIEJO recieved honoraria for speaking at Swanson H: Inadequate skill of healthcare professionals in
sponsored meetings from Chiesi, Pfizer, Boehringer, Esteve, using asthma inhalation devices. J Asthma. 2007;44:593–598.
GlaxoSmithKline, Merck, Meda, Novartis, Almirall, and 17. Kim SH, Kwak HJ, Kim TB Chang YS, Jeong JW, Kim CW,
Nycomed. Fernando CABALLERO received funding/grant Yoon HJ, and Jee YK: Inappropriate techniques used by in-
ternal medicine residents with three kinds of inhalers (a
support for research projects from Spaniard Government
metered dose inhaler, Diskus, and Turbuhaler): changes af-
Agencies, Scientific Associations, and Universities. Cristina
ter a single teaching session. J Asthma. 2009;46:944–950.
MURIO received a stipend as a Medical Advisor from Chiesi.
18. Felez MA, Gonzalez Clemente JM, Cardona Q, Montserrat
JM, and Picado C: Destreza en el manejo de los aerosoles por
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