Journal of Asthma, 44:403–405, 2007Copyright C© 2007 Informa HealthcareISSN: 0277-0903 print / 1532-4303 onlineDOI: 10.1080/02770900701364312

MDI Inhalers: Do Nursing Home Support Staff Have Correct Technique?

LEAH M. SCHAMMEL,1 OMSIV AND AMY R. ELLINGSON, M.D.2,∗

1Kirksville College of Osteopathic Medicine, A.T. Still University2 Allergy and Asthma Specialty Clinic, Willmar, Minnesota

Many elderly patients in nursing homes in the United States use metered-dose inhaler (MDI) medications for a variety of lung diseases. Wewondered how much the nursing support staff knew about correct MDI inhaler technique. Thirty-eight nursing home support staff were asked todemonstrate correct use of a placebo MDI inhaler on themselves. The staff completed an average of 6.9 steps out of 8 correctly. The most commonerror demonstrated was the staff did not hold their breath for 10 seconds at full inspiration after inhaling the medication. The results suggest that thesupport staff have incorrect MDI inhaler technique.

Keywords metered dose inhaler techinique, nursing

INTRODUCTION

Metered dose-inhalers (MDIs) are the most widely usedmethod of delivery of β-adrenergic agonists, and the mostfrequently used inhaler device amongst elderly people in thecommunity (1, 2). They provide a rapid, cost-effective, andsafe method of delivering medication to the lungs.

According to Allen et al. (3), only 60% of older people haveadequate MDI technique. However, poor technique is not lim-ited to patients themselves, but medical personnel responsi-ble for assisting and educating patients. Hanania et al. (4)reported that many medical personnel responsible for mon-itoring and instructing patients in optimal inhaler use lackrudimentary skills. They also reported that physicians andnurses seldom receive formal training in the use of inhalingdevices.

In the nursing home setting, physicians are often not whoassists and instructs patients, but nurses and medical assis-tants who are involved in daily patient care. It is reasonableto assume that if nursing home support staff cannot use MDIinhalers correctly, they would have difficulty educating theirpatients on how to use them. Clearly, medical personal whotrain patients to use MDI inhalers must themselves be able touse the device correctly.

To our knowledge, no reported study has looked at thetechnical ability of nursing home support staff to use MDIinhalers. This study was designed to compare MDI techniqueamong nursing home support staff involved in treating andeducating patients with lung diseases.

METHODS

Thirty-eight nursing home support staff working in 4community-based nursing homes in Willmar, MN were ran-domly selected to be tested. Of the 38 staff; 12 were regis-tered nurses, 17 were licensed practical nurses, and 9 weretrained medical assistants. This study was approved by theKirksville College of Osteopathic Medicine investigational

∗Corresponding author: Amy R. Ellingson, 1037 19th Avenue, Willmar,MN 56201; E-mail: allergy@en-tel.net.

review board and carried out during the month of December2006 over a 7-day period.

All participants were surveyed by a 4th-year medical stu-dent, trained on correct MDI inhaler technique by a boardcertified allergy and asthma physician. The participants weregiven a placebo MDI inhaler and were asked to use the in-haler in the same manner they would want their patients touse the inhaler. The participants underwent a standardized as-sessment of MDI technique, based on the National Instituteof Health’s Expert Panel Report 3, Guidelines for the Diagno-sis and Management of Asthma (5). Without being allowedto refer to MDI inhaler package inserts or other instructions,each staff member was asked to demonstrate correct MDItechnique, consisting of 8 steps:

1. Remove cap and hold inhaler upright.2. Shake inhaler.3. Breathe out slowly and fully.4. Place inhaler 1–2 inches away from mouth or in mouth.5. Start to breath in slowly and press down inhaler.6. Breath in slowly over 3–5 seconds.7. Hold breath at full inhalation for 10 seconds.8. Exhale. Repeat puff as directed, waiting 1 minute between

puffs.

For each step, the medical student marked on the scoringsheet whether the staff member completed the step correctlyor incorrectly. If the step was completed correctly, they weregiven 1 point, and if done incorrectly or not completed, 0points. Because there were 8 steps, each step or point ac-counted for 12.5% of the total test score, and a score of 100%meant that all 8 steps were performed correctly. The staffmember’s final score was the percentage of steps performedcorrectly.

The participants were also asked to complete a question-naire on previous MDI inhaler training, frequency of admin-istration of MDI inhalers, and personal history of educatingpatients on correct MDI technique.

Each participant’s MDI technique was tested with themalone in a conference type room and the testing was

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404 L. M. SCHAMMEL AND A. R. ELLINGSON

TABLE 1.—MDI inhaler technique-steps completed correctly.

# of Steps RN (%) LPN (%) TMA (%) Total (%)

Performed (n = 12) (n = 17) (n = 9) (n = 38)Correctly (%)

8/8 (100%) 4(33.3) 6(35.3) 4(44.4) 14(36.8)7/8 (87.5%) 3(25) 6(35.3) 3(33.3) 12(31.6)6/8 (75%) 3(25) 2(11.8) 2(22.2) 7(18.4)5/8 (62.5%) 2(16.7) 3(17.6) 0(0) 5(13.2)<4/8 (50%) 0(0) 0(0) 0(0) 0(0)

completed without interruption. An effort was made to ensurethat the atmosphere was relaxed, and it was clearly stated toeach participant that their participation in the research projectwas in no way a job performance review and that all resultswould remain confidential.

At the completion of the study, all participants were shownthe correct recommendations on proper MDI technique andany questions they had on allergy, asthma, chronic lungdisease, and administration of other inhaler devices wereanswered.

RESULTS

Study PopulationThirty-eight nursing home support staff working in 4

community-based nursing homes in Willmar, MN were ran-domly approached, and 38 participants completed the study.Of the 38 participants, 12 were registered nurses, 17 werelicensed practical nurses, and 9 were trained medical assis-tants.

MDI Technique DemonstrationThe mean number of correct steps performed in demon-

strating MDI technique was 6.9, and the median was 7, out ofa maximum of 8 (Table 1). The most common errors in MDIuse were not breathing out slowly and fully (correct in 71%,27 out of 38), and not holding breath at full inhalation for 10seconds or more (correct in 50%, 19 out of 38)(Figures 1 and2). Of the remaining participants, 10.5% (4 out of 38) heldtheir breath at full inhalation less than 10 seconds but greaterthan 5 seconds, and 39.5% (15 out of 38) held their breath atfull inhalation for less than 5 seconds.

FIGURE 1.—Number of nursing home support staff correctly performing indi-vidual steps of MDI inhaler technique.

FIGURE 2.—Percentage of nursing home support staff correctly performing in-dividual steps of MDI inhaler technique.

ExperienceOf interest is that 60.5% of the nursing home staff re-

ported teaching their patients correct MDI technique in thepast. However, only 55.2% reported being taught correct MDItechnique in their past training. At least 50% of the nursinghome support staff stated that they administered MDI inhalerson a daily basis. Another 15.8% reported they administeredMDIs weekly, and 26.3% said they never administered MDIs.Of note, 10.5% of the study participants either had asthmapersonally, or routinely used MDI inhalers in the care of fam-ily members who did (Table 2).

DISCUSSION

The National Heart, Lung, and Blood Institute’s Guidelinesfor Asthma Management, have stressed the importance of re-peatedly educating patients on MDI technique (5). Recently,Fink and Rubin estimated that 28–68% of patients do not usetheir MDIs well enough to benefit from the prescribed drug(6). Considering that even with the best inhalation technique,only 10% to 15% of the aerosol actually reaches the lung,makes proper usage of MDI inhalers imperative (7, 8) Theyalso pointed out that improper inhaler use results in $7–15.7billion wasted, with no benefit to the patient (6).

It has been estimated that it takes 10 to 28 minutes toinstruct a patient properly in the use of MDI (9). Realizing

TABLE 2.—Questionaire answers.

Question # of Support Staff (%)

Have you ever received MDI training in the past?YES 21(55.2)NO 17(44.7)

Do you teach your patients correct MDI technique?YES 23(60.5)NO 15(39.5)

How often do you administer MDI inhalers?DAILY 19(50)WEEKLY 6(15.8)MONTHLY 3(7.9)NEVER 10(26.3)

Do you personally have asthma, or routinelycare for a family member who does?YES 4(10.5)NO 34(89.4)

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NURSING HOME STAFF CAPABILITY OF USING MDI INHALERS 405

this, proponents of MDI education need to realize that longamounts of time spent with patients in the nursing home is notfeasible. Roberts et al. have shown that patients demonstratebetter MDI technique when given both verbal instructions anddemonstration with a placebo inhaler than when given onlyan MDI-technique instruction leaflet (10). Thus, educatingnursing home support staff on repeated instruction each timean MDI inhaler is administered, will improve patient care.

This study reinforces what has been shown from previousstudies, that education on correct MDI technique is not onlynecessary but underestimated, especially among physiciansand nurses. Havania et al. (4) found that many house staff ina hospital setting lacked rudimentary skills with inhalationdevices. Kelling et al. looked at MDI use in house staff andattending physicians. They reported that 40% of participantscould perform more than 4 of 7 steps with correct technique.Another study reported 65% of house officers, and 50% ofnon-pulmonary physicians performed at least 4 of 7 stepscorrectly, while nurses and respiratory therapists had superiorperformance (11).

The research participants in our study completed an aver-age of 6.9 steps out of 8 correct, but failed to complete themost critical steps to improve optimal aerosol drug place-ment in the lungs. Thus, nursing home staff needs continuededucation, repeated instruction, and monitoring to improvemedication administration to elderly patients.

Many elderly patients have limited cognitive ability to un-derstand MDI inhaler technique, and also have limited handstrength and coordination to complete the medication admin-istration themselves. Thus, they rely on the nursing home staffto help them, stressing the importance of staff awareness ofcorrect MDI technique.

Variables of this study include a limited geographical areaof study, because the research was based in a rural communityin Minnesota of 18,000 people. Another limitation of thestudy was that the statistical power was low; because therewere only 38 support staff that completed the study. We alsodid not test the theoretic knowledge of MDI inhalers of thestudy participants, limiting our study only to MDI inhalertechnique.

In conclusion, we determined that nursing home supportstaff responsible for monitoring and instructing patients inoptimal MDI inhaler technique lack rudimentary skills. Theyalso seldom receive formal training in the use of MDI inhalerdevices, even though most administer MDI inhalers on a dailybasis.

In the future, further studies could extend on our researchto incorporate a larger study population, including both nurs-ing home patients and nursing home support staff. Studyingdry-powder inhalation medication administration is also an-other area of concern. Many elderly people use mediationssuch as Advair R©, Pulmicort R©, and Spiriva R©, along with MDI

inhaler mediations. Lack of knowledge on proper techniquemay extend to these medications as well.

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