Selection Flawed Paradigms Drive Aerosol Device

Flawed Paradigms Drive Aerosol Device Selection James B. Fink Chest 1997;112;1447-1449 DOI 10.1378/chest.112.6.1447-a The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/112/6/1447.1.citation

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CHEST

editorials VOLUME 112 /NUMBER 6/DECEMBER, 1997

www.journal? Revisited 1997 issue of CHEST,1 I asked for from our readers about the prospect of publishing the journal electronically. Many of you responded, often by email. Several respondents sug¬ the table of gested that we electronically publishabstracts to be contents of each issue and allow the read by clicking on the title of the paper. This was a surprising suggestion since we already provide this service on the ACCP home page (http://www.chestnet. org), as I mentioned in the June editorial. We also provide full text of editorials and a search engine to allow the user to compile lists of articles about a subject of their choice. Perhaps we have not adequately pub¬ licized these features of the home page. I have selected several representative Communi¬ cations to the Editor to publish in this issue which express various opinions about electronic publishing. I perceive that there are three camps in which readers have pitched their tents. First, there are those who would love to read everything on their computer and want to interconnect to the Index Medicus and read the references too. Second, there are those with Internet capability who would rather sit in a chair by a roaring fire and read a paper there are many with no Internet journal. Third,claim who they would not read CHEST on capability the web. I pitch my tent in the second camp, although one rarely needs a fire inweFlorida. What is the solution? For now, will continue to electronically publish on paper. We will continue to and editorials post the table of contents, abstracts, each month on the ACCP home page. In addition, every 6-month volume of CHEST will be available on CD-ROM for storage. If you want to discard or recycle the paper, the contents ofthe journal will still be available on your computer. In the future, "if we build it, they will come." The future of publishing clearly resides in some elec¬ tronic process. But most ofthe readers oi CHEST do not have current Internet access. Despite Dr. String¬ er's advice (see page 1711), we must not assume that everyone has the capabilities nor the desires that we ourselves have. I would predict that by the year 2000,

T n the

June

-*- comments

will have solved many practical problems noted in June editorial on this subject. If computers still keep accurate time in the next millennium, we will probably publish CHEST in toto both on paper and on the Internet.

we

the

A.

Jay Block, MD, FCCP Gainesville, Florida

Editor-in-Chief, CHEST; Professor of Medicine and Anesthesi¬

ology, University of Florida; Chief, Pulmonary Section, Veteran's Administration Medical Center. Reprint requests: A. Jay Block, MD, FCCP, 408 West Ave, Suite 408, Gainesville, FL 32610

University

Reference 1 Block AJ.

www.journal [editorial]? Chest 1997; 111:1477

Flawed Paradigms Drive Aerosol Device Selection we respond when a patient with Howasthmashouldor COPD presents to the emergency department (ED), dyspneic with severe broncho¬ spasm, complaining that they have been using their metered-dose inhaler (MDI) all day and that the hasn't helped? Selection of an appropriate "puffer" aerosol device in the ED has implications that extend well beyond the efficacy of the treatment, reflecting a paradigm of health care that the clinician adopts. A of considerations the clinician's variety

impact

selection of an aerosol device.1 The unadorned MDI is not a fool-proof device, and its proper use requires education and the ability of the patient to follow instructions and coordinate their breathing with actuation of the device.23 As simple as the MDI seems, many physicians, nurses, and (alas) respira¬ tory care practitioners have been shown to be unable to demonstrate its proper use.4 Even when the health-care team has the knowledge of how to use the device, current economic con¬ properly reduce the likelihood that physicians (or straints other clinic and office staff) will have the time or resources to properly instruct, demonstrate, and

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1447

solicit return demonstrations for use of the MDI, as should be done with both initial order and follow-up

visits.

Device selection between MDIs and nebulizers is

often premised on the ability of the patient to take a deep breath and to hold that breath for inat least 4 seconds. This myth has been perpetuated several consensus documents,5-6 which offer as "expert opin¬ ion" (rather than evidence-based fact), that the to take a deep breath and hold it should be inability used as exclusion criteria for the use of an MDI, in favor of a nebulizer. While evidence and common sense support the premise that deep breaths with breath holding improves aerosol deposition,7 it has not been shown that the advantage of these maneu¬ vers is unique to an MDI. A breathing pattern of shallow, rapid breaths without breath hold reduces deposition of aerosol inhaled from both pulmonary an MDI and a nebulizer, and a rational alternative increase the dose of the p-agonists might betheto dose to effect) rather than to change to (titrating another device with no proven clinical advantage. The valved holding chamber has emerged as the "great equalizer" in allowing patients with subopti¬ mal breathing patterns and poor hand/breath coor¬ dination to experience comparable clinical benefits to those derived with a nebulizer. In this issue of CHEST, Mandelberg and colleagues (see page 1501) further confirmation that the administration provide of ^-agonists via an MDI with holding chamber in the ED yields comparable results to those experi¬ enced with use of a nebulizer. These findings sup¬ port the growing body of evidence that administra¬ tion of an MDI with a valved holding chamber is clinically equivalent to a nebulizer, at lower cost, in a wide variety of patient populations presenting with dyspnea and moderate to severe airflow obstruction in the ED.8-10 If clinical efficacy is similar between an MDI with valved holding chamber and a nebulizer, what, then, should guide our selection of an aerosol device? it depends on which paradigm of health care Perhaps embrace. you A long-standing paradigm offers that once the patient enters the ED, the role of the health-care team is to treat the patient, with the patient as a passive recipient of care. For our patient in the above scenario, this paradigm has us take away the seem¬ ingly ineffective "puffer" and replace it with the nebulizer. As the patient's symptoms are ultimately

relieved, the nebulizer is discontinued, and the patient is discharged from the ED or hospital with one or more

MDIs reordered for home

use.

This

approach teaches patients that when they get into trouble with their breathing they cannot rely on their "puffer" and must come to the ED or Urgent Care 1448

they can be treated with a nebulizer and the "real" medication that will make them feel

Center where

better. What patients typically do not learn is how to get the desired therapeutic effect from that same medication in their MDI (or nebulizer) when outside the hospital, which is precisely where they need it most.

emerging paradigm incorporates patients as participants in the health-care team. This involves teaching patients to treat themselves and work with the health-care team to control their disease, minimize symptoms, and integrate thera¬ peutic options into their management, which is consistent in the ED, clinic, and home settings. This paradigm allows that the failure of the patients to get The

active

relief from their "puffers" may extend beyond the efficacy of the device and include the possibility of improper technique or an inability to coordinate the actuation ofthe MDI with their dyspneic breathing pattern. Rather than discard and replace the puffer, adding a holding chamber to the MDI creates an opportunity to demonstrate to patients how proper use of the device can alleviate their symptoms. Key to this approach is integrating a continuity of devices, instruction, and treatment plan methodologies to patients at all access points within their health-care continuum. Using the same teaching materials and devices in the ED, hospital, and the clinics ensures that each review of tools and techniques given to the patient is complementary to and reinforces previous

instruction.

Neither the ED nor doctor's office provides the ideal environment for patient There is often little time available to a wide range of services and instruction to patients, and this is

learning. provide complicated by often their distracted disease and patients being by stress, resulting in less than optimal learning. A more important topic than MDI or nebulizer selection is how we can find teaching time with the patient, when the health-care providers are less rushed, and the patient is not too ill to effectively learn. Two options are in the hospital, after the acute exacerbation has subsided, prior to discharge, and in the clinic or office with follow-up visits. In both settings, the role of the respi¬ ratory

care

practitioner (or other allied health

team

member) as educator is of tremendous value. The integration of an MDI with valved holding chamber allows us to provide consistency of treatment and

educational message throughout the continuum: from ED to acute care to home. An MDI with holding chamber is clearly not the answer for all patients in all situations. No matter which device you reach for, consider the need to provide patients with education support to optimize


Editorials

their care before they go home, and to reduce their need to return to the ED.

James B. Fink, BRT Hines, Illinois

Division of Pulmonar)7 and Critical Care

Hines, Jr.

Hospital.

Medicine, The Edward

References 1 AARC Clinical Practice Guidelines: selection of aerosol de¬ liver)7 device. Respir Care 1992; 37:891-97 2 Crompton GK. Problems patients have using aerosol inhalers. Eur J Respir Dis 1982; 3 Goodman DE, Israel E, M, et al. The influence of

Rosenberg

pressurized 119(suppl):101-04

age, diagnosis and gender on proper use of metered-dose inhalers. Am J Respir Crit Care Med 1994; 150:1256-61 4 Guidry GG, Brown WD, Stogner SW, et al. Incorrect use of metered dose inhalers by medical personnel. Chest 1992;

101:31-33 5 O'Donohue

WJ, and the NAMDRC Consensus Group. Guidelines for the use of nebulizers in the home and at domiciliary sites: report of a consensus conference. Chest 1996; 109:814-20

6

Mclntyre NR (chair), Faculty and Working Group. American Association for Respiratory Care Aerosol Consensus Confer¬ ence Statement.1991. Respir Care 1991; 36:916-21

7 Dolovich M, Ruffin RE, Roberts R, et al.

Optimal delivery of 80(suppl):

aerosols from metered dose inhalers. Chest 1981; 911-15 8 Levitt MA, Gambrioli EF, Fink

JB. Comparative trial of metered-dose inhaler in the bronchospasm. Ann Emerg Med 1995;

continuous nebulization treatment of acute

26:273-77

versus

9 Idris AH, McDermott

department

MF, Raucci JC, et al. Emergency of severe asthma: metered-dose in¬ chamber is equivalent in effectiveness to

treatment

haler plus holding nebulizer. Chest 1993; 103:665-72 10 Newhouse MT, Chapman KR, McCallum AL, et al. Cardio¬ vascular safety7 of high doses of inhaled fenoterol and albu¬ terol in acute severe asthma. Chest 1996; 110:595-603

only 17 cases of this syndrome involving interatrial right-to-left shunting had been described in the medical literature.1 The additional two cases re¬ ported in this issue of CHEST make a total of 19 cases. The rate of incidence of the syndrome not associated with intracardiac shunting is not known, but presumably is very low. These reports provide an opportunity to review the medical history of the platypnea-orthodeoxia syndrome. In this review, our goal is threefold: (1) to provide a clinical and physiologic perspective; (2) to indicate the application of the disordered physiology to a more common, current problem, diffuse endocardial disease; and (3) to suggest a "new," previously untried form of therapy. History

The original description of patients with platypneaorthodeoxia dates back to 1949 when Burchell et al2 described a patient with an atrial septal defect manifesting platypnea-orthodeoxia and subsequently described the reversal of both following closure of a patent foramen ovale. "Platypnea" and "orthodeoxia" were not used to describe the manifestations of this syndrome until they became commonly accepted in 1969 and 1976, respectively. In 1956, two patients with upright dyspnea and oxygen desaturation were described. Each had the combination of an atrial septal defect and unilateral pneumonectomy.3 However, the term "platypnea" was not used. The upright desaturation was called "orthostatic cyanosis." These workers speculated on the mechanism of the two phenomena, suggesting that the dyspnea was caused by the orthostatic

cyanosis.

An Analysis of PlatypneaOrthodeoxia Syndrome Including a "New" Therapeutic

Approach

(see pages 1681 and 1682) -*¦ contains two separate case reports, each describ¬

HThis issue of CHEST

ing a patient with a patent foramen ovale, and each patient manifesting platypnea (increased dyspnea in the erect position relieved by assuming a recumbent and orthodeoxia (accentuated hypoxemia in position) the erect position, improved by assuming a recum¬ bent position). In each patient, closure of the fora¬ men

oxia.

ovale led

to

a

remission of platypnea-orthode-

The platypnea-orthodeoxia syndrome appears to be exceedingly rare. By 1994, it was estimated that

The term "platypnea" was introduced by our group in 1969.4 A patient with severe COPD was noted to develop severe dyspnea in the sitting posi¬ tion relieved by assuming a prone position. An autopsy documented severe obstructive lung disease. There was no interatrial communication. There was a significant fall in Pa02 in the upright vs the prone position, but we did not connect the hypoxia with the platypnea. We also overlooked the prior case reports mentioned above. Medical history is not an exact

discipline. Seven years later we reported three patients with significant, accentuated arterial hypoxemiaAllin the upright compared to the supine position. three manifested platypnea.5 We coined the term "orth¬ odeoxia" to describe the phenomenon. None of the three patients had significant intrinsic pulmonary disease. Two ofthe patients had chronic liver disease (lung spiders) and one had multiple congenital arte-

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Flawed Paradigms Drive Aerosol Device Selection James B. Fink Chest 1997;112; 1447-1449 DOI 10.1378/chest.112.6.1447-a This information is current as of July 14, 2011 Updated Information & Services Updated Information and services can be found at: http://chestjournal.chestpubs.org/content/112/6/1447.1.citation Permissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.chestpubs.org/site/misc/reprints.xhtml Reprints Information about ordering reprints can be found online: http://www.chestpubs.org/site/misc/reprints.xhtml Citation Alerts Receive free e-mail alerts when new articles cite this article. To sign up, select the "Services" link to the right of the online article. Images in PowerPoint format Figures that appear in CHEST articles can be downloaded for teaching purposes in PowerPoint slide format. See any online figure for directions.
