Authors (including presenting author) :
CE Tai (1), Karin Chow (2), Emily Leung (3), Chan LP (4), Chan SY (5), Lam WK (6), Chan HT (7), Liu KN (8), Long SY (9), So WH (10), Jacky Wong (11)
Affiliation :
(1) Nurse Consultant, Respiratory NTWC,
(2) Nurse Consultant, Stroke NTWC,
(3) Respiratory Nurse, Medicine & Geriatric, Tuen Mun Hospital,
(4) Medicine & Geriatric, Tuen Mun Hospital,
(5) Respiratory Nurse, Medicine & Geriatric, Tuen Mun Hospital,
(6) Medicine & Geriatric, Tuen Mun Hospital,
(7) Medicine & Geriatric, Tuen Mun Hospital,
(8) Respiratory Nurse, Medicine & Geriatric, Tuen Mun Hospital,
(9) Medicine & Geriatric, Tuen Mun Hospital,
(10) Medicine & Geriatric, Tuen Mun Hospital,
(11) Medicine & Geriatric, Tuen Mun Hospital.
Introduction :
Inhaled therapy is the gold standard for treatment of patients with Asthma and Chronic Obstructive Pulmonary Disease (COPD). Pressurised Metered-Dose Inhaler (pMDI) are the most widely used devices for delivering inhaled medication because of their convenience, reliable, effectiveness and low cost.
However, despite clear instruction, many patients are unable to use their pMDI correctly, with the most common error being the inability to synchronize actuation with inhalation (Levy et al., 2013). Moreover, a study reported that about 50% of pMDI users did not properly exhale before inhaling and had unsatisfactory breath-holding (less than 3 s) after inhalation; some users even inhaled through the nose during and after actuation (Melani et al., 2011).
Spacer devices were introduced in 1958 to improve medication delivery into the lungs and reduce deposition in the mouth and throat (Stein et al., 2017). The Valved Holding Chamber (VHC) was introduced later by adding a one-way inhalation valve at the exit of the spacer, which can trap aerosolized medication within the chamber until the user inhales.
The local practice of administering the pMDI is varies. Some patients are using pMDI with VHC whereas some do not. Apart from this, we also find that there are some variations in the education methods and attitude, skills and disinfection guideline. Thus we want to find out the best method, best practice and then finally but most importantly, is to make standardization in administering the pMDI.
Therefore, the Evidenced-Based Practice Project was designed to promote the good practice and standardization.
Objectives :
1. To find out the best method and best practice of administering the pMDI to Asthma/ COPD patients.
2. To promote the good practice and standardization in administering the pMDI to Asthma/ COPD patients.
Methodology :
The project was started in Jan 2020, and was evaluated in Dec 2020. The John Hopkins Nursing Evidence-Based Practice (JHNEBP) model was adopted in the project.
All Academic Journals (limited to Full Text) published from 2014 to 2019 were searched from Database CINAHL, MEDLINE, Nursing Reference Center Plus, using the keywords "Asthma/ COPD patient", "Metered-dose inhalers with spacer" and "Valved Holding Chamber". 181 articles identified through database searching, while 14 articles were included in synthesis finally after eliminating the non-English, duplicated and not relevant articles. Evidence Appraisal was done and Synthesized.
Recommendations:
All patients using pMDI to take inhaled medications should be advised to use a spacer/ VHC for both regular and emergency medication, especially for those poor at synchronizing actuation with inhalation.
Translation into Practice
Based on the evidence finding, we seek support from the stakeholders, including the managemental staffs (DOMS & WMs), all our M&G colleagues (Doctors & Nurses), and our target patients. We present our project in the TMH EBP committee meeting, M&G Nursing Management Meeting and in the respiratory team meeting. Budgets granted from Nursing Services Department (NSD) and department funding, for purchasing the single-used Valved holding chamber, and making the education leaflets.
Staff Training
Six identical training workshops were arranged for the nursing staff in our departments. Aims at promoting the concepts of EBP, introducing our project and reinforcing the education on the technique of using pMDI with VHC. Totally 156 staffs attended the workshops.
Result & Outcome :
The program was started in Jan 2020, once the patient admitted to M&G wards diagnosed with Asthma/ COPD and needed to use pMDI, they were provided with the VHC as well. Education leaflet together with a brief instruction was given to them by ward nurses.
We compared the VHC utilization rate of pre- and post- intervention . The baseline VHC utilization rate is 58 %, whereas the post- intervention rate is 96% . This is because all of the patients admitted with Asthma/ COPD needed to use pMDI are provided with the VHC with the education leaflet, together with the one-to-one education. Thus, they are willing to use as they know more about the rationale.
Apart from this, we are also promoting the projects in the IMSN COPD Nurse Clinic and advised patient to use pMDI with VHC. We also analysed the technique of using pMDI alone and together with VHC. As mentioned before, many patients are unable to use their pMDIs correctly, the mean scoring is relatively lower than those using pMDI with VHC. It is more simple when using pMDI with VHC, as it consists of only two simple steps: actuation into the chambers, followed by inhalation from the VHC mouthpiece/ mask.
Result:
Baseline (11/11/2019 – 31/12/2019)
VHC Utilization Rate: 80/138 (58%)
Received formal education: 15/ 138 (11%)
pMDI score (+/- VHC): NA
Post (1/1/2020 – 31/12/2020):
VHC Utilization Rate: 498/519 (96%)
Received formal education: 498/519 (96%)
pMDI score (+/-VHC): 10.4/ 13
Post- IMSN COPD Nurse Clinic (1/1/2020 – 31/12/2020):
VHC Utilization Rate: 668/ 772 (86%)
Received formal education: 772/ 772 (100%)
pMDI score (+/- VHC): Mean 12/13
Conclusion
Inhaled aerosol therapy remains the main treatment for Asthma and COPD. However, improper inhaler technique is the significant barrier for the treatment. Using VHC for pMDI provides patient the simple way to have the inhaled aerosol therapy. It is proved that using VHC can improve pMDI medication delivery, to reduce oropharyngeal deposition and to avoid the incoordination of actuation with inhalation, so as to improve the disease control, reduce rate of exacerbations and thus improve quality of life. However, consistently assessment and education is the essential elements to ensure the proper use of the inhaled aerosol therapy.
The project was published in the newsletter of the Hong Kong Thoracic Society in Oct 2021.
Way forward:
To standardize this best practice in all the hospitals in NTWC.
