Journal of General Internal Medicine

, Volume 26, Issue 6, pp 635–642 | Cite as

Misuse of Respiratory Inhalers in Hospitalized Patients with Asthma or COPD

  • Valerie G. PressEmail author
  • Vineet M. Arora
  • Lisa M. Shah
  • Stephanie L. Lewis
  • Krystal Ivy
  • Jeffery Charbeneau
  • Sameer Badlani
  • Edward Naurekas
  • Antoinette Mazurek
  • Jerry A. Krishnan
Original Research



Patients are asked to assume greater responsibility for care, including use of medications, during transitions from hospital to home. Unfortunately, medications dispensed via respiratory inhalers to patients with asthma or chronic obstructive pulmonary disease (COPD) can be difficult to use.


To examine rates of inhaler misuse and to determine if patients with asthma or COPD differed in their ability to learn how to use inhalers correctly.


A cross-sectional and pre/post intervention study at two urban academic hospitals.


Hospitalized patients with asthma or COPD.


A subset of participants received instruction about the correct use of respiratory inhalers.


Use of metered dose inhaler (MDI) and Diskus® devices was assessed using checklists. Misuse and mastery of each device were defined as <75% and 100% of steps correct, respectively. Insufficient vision was defined as worse than 20/50 in both eyes. Less-than adequate health literacy was defined as a score of <23/36 on The Short Test of Functional Health Literacy in Adults (S-TOFHLA).


One-hundred participants were enrolled (COPD n = 40; asthma n = 60). Overall, misuse was common (86% MDI, 71% Diskus®), and rates of inhaler misuse for participants with COPD versus asthma were similar. Participants with COPD versus asthma were twice as likely to have insufficient vision (43% vs. 20%, p = 0.02) and three-times as likely to have less-than- adequate health literacy (61% vs. 19%, p = 0.001). Participants with insufficient vision were more likely to misuse Diskus® devices (95% vs. 61%, p = 0.004). All participants (100%) were able to achieve mastery for both MDI and Diskus® devices.


Inhaler misuse is common, but correctable in hospitalized patients with COPD or asthma. Hospitals should implement a program to assess and teach appropriate inhaler technique that can overcome barriers to patient self-management, including insufficient vision, during transitions from hospital to home.

Key words

asthma pulmonary disease chronic disease hospital medicine health literacy 




We would like to thank The University of Chicago Asthma and COPD Center and the Department of Medicine Data Management and Statistics Core.

Prior Presentations: Prior poster presentations include the 2009 American Thoracic Society International Meeting in San Diego, the 2009 Society of Hospital Medicine Annual meeting in Chicago IL, and the 2009 and 2010 Society of General Internal Medicine Annual Meetings in Miami, Fl and Minneapolis, MN, respectively. Oral presentations include the 2009 Midwest Society of General Internal Medicine and the 2010 American Thoracic Society International Meeting in New Orleans, LA.

Conflict of Interest

Dr. Press reports receiving funding from the Institute for Translational Medicine, University of Chicago CTSA from the National Center for Research Resources (UL1RR024999) and the American Cancer Society (PSB 08-08). Dr. Arora reports receiving funding from the American Board of Internal Medicine, Agency for Healthcare Research and Quality (R03HS018278), the National Institute of Aging (K23AG033763), and the Accreditation Council of Graduate Medical Education. Dr. Krishnan reports receiving funding from the National Institutes of Health (HL101618) and the Agency for Healthcare Research and Quality (HS016967). Potential conflicts of interest exist for Dr. Shah who is employed with a for profit health care policy firm (Avalere Health, LLC); for Dr. Badlani who has received honoraria for lectures given (Merck Pharmaceuticals and PharmEd Consultants); and for Dr. Naurekas, who has provided expert testimony (once for a plaintiff on Alveolar Hemosiderosis and once for Cook County on thrombotic thrombocytopenic purpura). All other authors do not have any conflicts of interest to disclose related to employment, consultancies, honoraria, stock, expert testimony, patents, royalties or any other relationships.


  1. 1.
    Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge. A review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–23.PubMedCrossRefGoogle Scholar
  2. 2.
    Coleman EA, Berenson RA. Lost in transition: challenges and opportunities for improving the quality of transitional care. Ann Intern Med. 2004;140:533–6.Google Scholar
  3. 3.
    Coleman EA, Smith JD, Frank JC, Min S-J, Ca P, Kramer AM. Preparing patients and caregivers to participate in care delivery across settings: the care transitions intervention. J Am Geriatr Soc. 2004;52:1817–25.PubMedCrossRefGoogle Scholar
  4. 4.
    Kripalani S, Henderson LE, Jacobson TA, Vaccarino V. Medication Use Among Inner-City Patients After Hospital Discharge: Patient-Reported Barriers and Solutions. Mayo Clin Proc. 2008;83(5):529–35.PubMedCrossRefGoogle Scholar
  5. 5.
    Coleman EA, Smith JD, Raha D, Min S-J. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165:1842–7.PubMedCrossRefGoogle Scholar
  6. 6.
    Rydman RJ, Sonenthal K, Tadimeti L, Butki N, McDermott MF. Evaluating the outcome of two teaching methods of breath actuated inhaler in an inner city asthma clinic. Jrnl of Med Syst. 1999;23(5):349–56.CrossRefGoogle Scholar
  7. 7.
    Celli BR, MacNee W and Committee Members. Standards for the diagnosis and treatment of patients with COPD: A Summary of the ATS/ERS Position Paper. Eur Respir J. 2004;23:932–46.PubMedCrossRefGoogle Scholar
  8. 8.
    Dolovich MB, Ahrens RC, Hess DR, et al. Device selection and outcomes of aerosol therapy. Evidence-based guidelines: American College of Chest Physicians/American College of Asthma, Allergy, and Immunology. Chest. 2005;127:335-71.Google Scholar
  9. 9.
    Paasche-Orlow MK, Riekert KA, Bilderback A, et al. Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med. 2005;172:980–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Thompson J, Irvine T, Grathwohl K, Roth B. Misuse of metered-dose inhalers in hospitalized patients. Chest. 1994;105:715–7.PubMedCrossRefGoogle Scholar
  11. 11.
    van der Palen J, Klein JJ, van Herwaarden CLA, Zielhuis GA, Seydel ER. Multiple inhalers confuse asthma patients. Eur Respir J. 1999;14:1034–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Williams MV, Baker DW, Honig EG, Lee TM, Nowlan A. Inadequate literacy is a barrier to asthma knowledge and self-care. Chest. 1998;114:1008–15.PubMedCrossRefGoogle Scholar
  13. 13.
    Dahl R, Backer V, Ollgaard B, Gerken F, Kesten S. Assessment of patient performance of the Handihaler® compared with the metered dose inhaler four weeks after instruction. Respir Med. 2003;97:1126–33.PubMedCrossRefGoogle Scholar
  14. 14.
    Apter AJ, Tor M, Feldman H. Testing the Reliability of Old and New Features of a New Electronic Monitor for Metered Dose Inhalers. Ann Allergy Asthma Immunol. 2001;86(4):421–4.PubMedCrossRefGoogle Scholar
  15. 15.
    Apter AJ, Reisine ST, Affleck G, Barrows E, ZuWallack RL. Adherence with twice-daily dosing of inhaled steroids: socioeconomic and health-belief differences. Am J Respir Crit Care Med. 1998;157:1810–7.PubMedGoogle Scholar
  16. 16.
    Melani AS. Inhalatory therapy training: a priority challenge for the physicians. Acta Biomed. 2007;78:233–45.PubMedGoogle Scholar
  17. 17.
    Guidelines for the diagnosis and management of asthma (EPR-3). Available at: Accessed December 15, 2010.
  18. 18.
    The global initiative for chronic obstructive lung disease (GOLD) guidelines: Available at: Accessed December 15, 2010.
  19. 19.
    Thai AL, George M. The effects of health literacy on asthma self-management. J Asthma Allergy Educ. 2010;1(2):50–55.CrossRefGoogle Scholar
  20. 20.
    Effing T, Monninkhof EEM, van der Valk PP, Zielhuis GGA, Walters EH, van der Palen JJ, Zwerink M. Self-management Education for Patients with Chronic Obstructive Pulmonary Disease (Review). The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Available at Accessed December 15, 2010.
  21. 21.
    Nikolaus T, Kruse W, Bach M, Specht-Leible N, Oster P, Schlierf G. Elderly patients’ problems with medication: an in hospital and follow-up study. Eur J Clin Pharmacol. 1996;49:255–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med. 2007;167(14):1502–9.CrossRefGoogle Scholar
  23. 23.
    Duerden M, Price D. Training issues in the use of inhalers. Dis Manage Health Outcomes. 2001;9(2):75–87.CrossRefGoogle Scholar
  24. 24.
    Hanania NA, Darken P, Horstman D, et al. The efficacy and safety of fluticasone propionate (250 ug)/salmeterol (50ug) combined in the diskus inhaler for the treatment of COPD. Chest. 2003;124:834–43.PubMedCrossRefGoogle Scholar
  25. 25.
    Celli BR, Thomas NE, Anderson JA, et al. Effect of pharmacotherapy on rate of decline of lung function in chronic obstructive pulmonary disease. Results from the TORCH study. Am J Respir Crit Care Med. 2008;178:332–8.PubMedCrossRefGoogle Scholar
  26. 26.
    Nurss JR, Parker RM, Williams MV, Baker, DW. Short Test of Functional Health Literacy in Adults (STOFHLA). Hartford: Peppercorn Books & Press; 2001.Google Scholar
  27. 27.
    Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38:33–42.PubMedCrossRefGoogle Scholar
  28. 28.
    Wu HW, Nishimi RY, Page-Loez CM, Kizer KW. Improving patient safety through informed consent for patients with limited health literacy. An implementation report. National Quality Forum. 2005. Available at: Accessed December 15, 2010.
  29. 29.
    Van der Palen J, Klein JJ, Kerkhoff AHM, van Herwaarden CLA, Seydel ER. Evaluation of the long-term effectiveness of three instruction modes for inhaling medicines. Patient Educ Couns. 1997;32:S87–S95.PubMedCrossRefGoogle Scholar
  30. 30.
    Shrestha M, Parupia MFH, Andrews B, et al. Metered-dose inhaler technique of patients in an urban ED: prevalence of incorrect technique and attempt at education. Am J of Emerg Med. 1996;14(4):380–4.CrossRefGoogle Scholar
  31. 31.
    Morbidity and Mortality: 2009 Chart Book on Cardiovascular, Lung, and Blood Disease. National Institutes of Health National Heart, Lung and Blood Institute. October 2009. Available at: Accessed December 15, 2010.
  32. 32.
    University of Illinois Eye & Ear Infirmary, Chicago, IL. The eye digest. Available at: Accessed December 15, 2010.
  33. 33.
    Beckman A, Bernstein C, Parker MG, Thorslund M.Fastbom J. The difficulty of openingmedicines containers in old age: a population based study. Pharm World Sci. 2005;27:393–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Fuchs J, Hippius M. Inappropriate dosage instructions in package inserts. Patient Educ Couns. 2007;67:157–68.PubMedCrossRefGoogle Scholar
  35. 35.
    Ventolin HFA® Package Insert. Available at: Accessed December 15, 2010.
  36. 36.
    Advair Diskus® Package Insert. Available at: Accessed December 15, 2010.

Copyright information

© Society of General Internal Medicine 2011

Authors and Affiliations

  • Valerie G. Press
    • 1
    Email author
  • Vineet M. Arora
    • 2
  • Lisa M. Shah
    • 3
  • Stephanie L. Lewis
    • 4
  • Krystal Ivy
    • 4
  • Jeffery Charbeneau
    • 4
  • Sameer Badlani
    • 1
    • 5
  • Edward Naurekas
    • 4
  • Antoinette Mazurek
    • 4
  • Jerry A. Krishnan
    • 4
    • 6
  1. 1.Department of MedicineUniversity of Chicago, Instructor, Section of Hospital MedicineChicagoUSA
  2. 2.Department of MedicineUniversity of Chicago, Section of General Internal MedicineChicagoUSA
  3. 3.Avalere Health, LLCWashingtonUSA
  4. 4.Department of MedicineUniversity of Chicago, Asthma and COPD Center, Section of Pulmonary and Critical CareChicagoUSA
  5. 5.Mercy Hospital and Medical CenterChicagoUSA
  6. 6.Department of Health StudiesUniversity of ChicagoChicagoUSA

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