Correspondence

Misunderstandings about Inhalers

N Engl J Med 1994; 330:1690-1691June 9, 1994

Article

To the Editor:

Incorrect use of metered-dose inhalers continues to be a problem in clinical practice. Although misuse is commonly related to poor coordination between actuation and inhalation, failure to inhale slowly, or inadequate holding of breath, patients occasionally misuse their inhalers in unusual ways. The following cases are examples.

Patient 1 was a 62-year-old man with a recent diagnosis of chronic obstructive lung disease who came to our clinic reporting shortness of breath and lack of effect of his β-adrenergic-receptor agonist metered-dose inhaler. He stated that he had been given the inhaler for the first time two weeks earlier at an internist's clinic and had received only the brief oral instruction to “spray the medicine to the throat.” As a result, he had faithfully administered the beta-agonist by aiming and firing the aerosol toward his anterior neck around the thyroid cartilage four times a day for two weeks.

Patient 2, a 43-year-old woman with asthma who receives steroid therapy, also reported the ineffectiveness of her β-agonist metered-dose inhaler. She had recently increased the beta-agonist dose up to 40 puffs a day without an obvious beneficial or adverse effect. She insisted that she knew how to use the inhaler correctly and had been following the oral instructions given by a physician many years ago. When she was asked to demonstrate her skill, she fired the aerosol twice with the dust cap on, then quickly removed the cap, placed the mouthpiece between her lips, and inhaled.

These two unusual cases should remind medical personnel not, under any circumstances, to give quick oral instructions to patients without first demonstrating the correct use of an inhaler and then observing the patient's technique. In the case of patients with a long history of using metered-dose inhalers who claim to know the proper technique, it should not be assumed that they are able to use inhalers correctly. Furthermore, the absence of any effect, therapeutic or adverse, of a β-agonist metered-dose inhaler, especially in patients receiving higher doses, should alert physicians to the possibility of misuse due to inadequate instructions or demonstration.

Recent studies have shown that respiratory therapists are more successful in instructing patients in the correct use of metered-dose inhalers than are either house-staff physicians or nurses1,2. These findings support the approach of using respiratory therapists to educate patients, particularly in busy outpatient settings.

Ambrose A. Chiang, M.D.
Jin-Chuan Lee, R.R.T.
Veterans General Hospital-Kaohsiung, Kaohsiung, Taiwan 813, Republic of China

2 References

1. 1

   Guidry GG, Brown WD, Stogner SW, George RB. Incorrect use of metered dose inhalers by medical personnel. Chest 1992;101:31-33
   CrossRef | Web of Science | Medline

2. 2

   Interiano B, Guntupalli KK. Metered-dose inhalers: do health care providers know what to teach? Arch Intern Med 1993;153:81-85
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   G. Pouessel, A. Deschildre, C. Castelain, A. Sardet, S. Sagot-Bevenot, A. De Sauve-Boeuf, C. Thumerelle, C. Santos. (2006) Parental knowledge and use of epinephrine auto-injector for children with food allergy. Pediatric Allergy and Immunology 17:3, 221-226
   CrossRef

2. 2

   Shih-Wen Huang. (1998) A survey of Epi-PEN use in patients with a history of anaphylaxis. Journal of Allergy and Clinical Immunology 102:3, 525-526
   CrossRef