Are children with asthma overconfident that they are using their inhalers correctly?

The Nurse's Role in Educating Pediatric Patients on Correct Inhaler Technique: An Interventional Study

The prevalence of pediatric respiratory diseases in Spain is 23%. Inhalation is the preferred route of administration but there are frequent errors in the performance of the inhalation technique leading a poor control of the disease. The aim of this research was to detect errors in the execution of the inhalation technique at a Pediatric Pulmonology Unit in a hospital of Aragón (Spain). In order to improve the administration of inhaled medication, an educational intervention for 1 year by nursing was conducted. This interventional study, including children aged 1 to 15 years with an inhalation therapy and who attended the Pediatric Pulmonology Unit, was conducted between September 2017 and September 2018. Logistic Regression models were conducted in SPSS. This study involved 393 children (61.1% boys). Before the intervention, 39.4% achieved a correct inhalation technique increasing up to 62.1% after the intervention. Those who had their first visit to the Unit, young children and girls had a higher risk of incorrect performance than those with subsequent visits, older children, and boys, respectively. The most common errors in the inhalation technique were not performing adequate apnoea after inhaling and not rinsing the mouth at the end of the procedure. The education given by nurses to pediatric patients improved the inhalation technique, achieving better control of the disease and use of the health system.

Issues on Powder Forms for Oral Solution and Suspension for Pediatric Patients in Japan: A Questionnaire-Based Observational Survey to Pediatric Pharmacists

BACKGROUND

Powders for oral solutions and suspensions (POS) are commonly used as pediatric oral medicines worldwide, except for Japan. Although global pediatric formulation development accelerates POS importation to Japan without any formulation change, oral solid multiparticulates remain to be the preferred pediatric forms in the country. This study aimed to evaluate the acceptance situation of four typical POS form products (mycophenolate mofetil, sildenafil citrate, valganciclovir hydrochloride, and voriconazole) that were recently approved in Japan.

METHODS

A questionnaire on four products was completed by pharmacists in 29 children's hospitals with more than 100 beds each, between November and December of 2019. The questionnaire has six items on (#1) type of institution, (#2) formulary status, (#3) dispensing practice, (#4) reasons why POS form(s) were not selected as hospital formulary, (#5) advantages and disadvantages of POS form, and (#6) opinions for POS form.

RESULTS

Of the 29 institutions, 7 (24%), 9 (31%), 4 (13%), and 10 (34%) institutions used POS of mycophenolate mofetil, sildenafil citrate, valganciclovir hydrochloride, and voriconazole, respectively. Reasons for not using these products were dispensed drug loss, formulation issues, and management issues in the pharmaceutical department and pediatric ward. Pharmacists preferred drug compounding such as tablet crushing and capsule opening to POS form use.

CONCLUSIONS

POS forms might be an unsuitable formulation for the current hospital settings in Japan. Thus, appropriate dosage forms that reflect the current clinical settings are necessary.

Let the Kid Speak: Dynamics of Triadic Medical Interactions Involving Pediatric Patients

Communication in healthcare represents the complex interplay between multiple individual and contextual factors unfolding over the course of the medical encounter. Despite significant improvements in patient-centered care delivery, studies of health communication typically focus exclusively on clinical interactions between adult patients and their clinicians. Much less is known about non-dyadic interactions, such as pediatric triads involving a child patient and accompanying parent. Understanding the dynamics of triadic pediatric healthcare communication is the first step toward evaluating and ultimately optimizing these healthcare interactions. Thus, we undertook a mixed-method analysis of 28 audio-recorded triadic medical interactions between healthcare providers, pediatric asthma and allergy patients, and their parents to explore the prevalence of various features of these interactions. Our findings point to mechanisms through which healthcare providers and parents may facilitate or hinder children's involvement in their own asthma and allergy care, including interruptions, unclarified technical medical language, the flow of information exchange, and the formation of dyadic conversational partnerships (coalitions) between providers and parents. Our analyses further reveal that children's participation during their medical visits was minimal (13% of the interaction). Providers in our sample elicited input directly from pediatric patients more often than from parents, though the difference was small. Taken together, these findings provide a foundation on which to develop training and communication interventions to ensure that children have a voice in their medical care.

Association between inhaler technique and confidence among hospitalized children with asthma

OBJECTIVE

Proper use of respiratory inhalers is crucial to asthma self-management and associated with improved outcomes. Previous studies conducted in outpatient and community settings show parents and children are overconfident in children's ability to use inhalers properly, which may lead healthcare providers to not teach or review inhaler technique. This study examined whether children and parents' confidence were associated with proper inhaler technique among children hospitalized with asthma.

METHODS

Children between 5 and 10 years old hospitalized with asthma at an urban academic medical center demonstrated inhaler technique using metered dose inhalers and spacers. Technique was scored based on a validated 12-step scale. Confidence was measured using three items assessing 1. Knowledge to use inhaler, 2. Skills to use inhaler, and 3. Ability to independently use inhaler. These items were five-point scales and analyzed as binary variables. Independent t-tests were used to measure associations between confidence and number of steps performed correctly.

RESULTS

None of the confidence items, when asked to parents or children (n = 70), were associated with the number of steps performed correctly. Further, while the majority of children and parents (59-70%) were confident based on each item, the mean number of steps correctly completed was 6.4 out of 12.

CONCLUSIONS

Children and parents' confidence in children's knowledge, skills, and ability to independently use an inhaler were all poor proxies for proper inhaler technique. Inpatient healthcare professionals should objectively evaluate technique and teach proper inhaler use to all children with asthma to optimize outcomes.

An approach to the management of children with problematic severe asthma

Children with poor asthma control despite high levels of prescribed treatment are described as having problematic severe asthma. Most of these children have steroid sensitive disease which improves with adherence to daily inhaled corticosteroids and after having removed modifiable factors like poor inhalation technique, persistent adverse environmental exposures and psychosocial factors. These children are described as having “difficult-to-treat asthma” while children with persistent symptoms despite above-mentioned factors having been addressed are described as having “severe therapy-resistant asthma”. In this review, we will describe the 6-step approach to the diagnosis and management of a child with problematic severe asthma adopted by The Royal Brompton Hospital (London, UK). The role of a multidisciplinary team is crucial for identification and treatment of modifiable factors and comorbidities in order to avoid invasive examinations and useless pharmacological treatments. The current knowledge on add-on therapies will be discussed.

Use of home visits in pediatric severe asthma: randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of home visits in a group of children and adolescents with severe asthma by using the inhalation technique score and adherence rates to drug treatment.

METHOD

A 12-month randomized controlled trial involving patients aged between three and 17 years under regular follow-up treatment at a pediatric pulmonology outpatient clinic of a university hospital in southeastern Brazil. A group of patients received only outpatient consultations and the other group received home visits from nurses in addition to outpatient consultations. The differences between groups were analyzed through the outcomes of inhalation technique scores and treatment adherence rate.

RESULTS

Participation of 29 patients. In the intervention group, there was a statistically significant increase in inhalation technique scores (p<0.05) and elimination of critical errors between the first and the second evaluation, and results were maintained in the third evaluation. In the control group, there were no significant changes in inhalation technique scores. Rates of adherence to drug treatment in both groups did not rise.

CONCLUSION

Home visits were effective for improving inhalation technique scores in patients with severe asthma. Brazilian Registry of Clinical Trials: RBR-8GZWZP.

Mobile applications in surgical patient health education: an integrative review

Abstract OBJECTIVE To analyze the scientific literature produced on health education through mobile applications for surgical patients. METHOD An integrative literature review performed through consultation in the following portals and/or databases: VHL; PubMed; Web of Science; Scopus; LILACS and CINAHL. The search was guided by the question: “What is the evidence on the use of mobile applications in the health education of surgical patients?” conducted from July to September 2017, including articles published from the year 2000 to 2017. RESULTS Five articles published in international journals in English with varied methodological designs were selected. Among the studies found, 60% used an educational intervention through smartphone applications in the pre and postoperative periods, and 40% of the studies had an evidence level of 2B. CONCLUSION The studies showed that the use of smartphone applications in educating and guiding surgical patients was effective. However, there is still a gap in studies which demonstrate surgical patient education through smartphone applications.

Aerosol Therapy in Asthma-Why We Are Failing Our Patients and How We Can Do Better

In order for inhaled corticosteroids to be delivered adequately to the airways they require patients to take them regularly using an effective technique. Patients often have a poor inhaler technique, and this has been shown to result in sub-optimal asthma control. It is important for all clinicians prescribing inhaled medication to be experienced in the correct technique, and take time to train children so that they have mastered corrected inhaler technique. Using Teach to Goal or teach back methodology is a simple and effective way to provide this in the clinic setting. More than one training session is typically needed before children can master correct inhaler technique. Adherence to inhaled therapy has been shown to be sub-optimal in pediatric populations, with studies showing an average rate of around 50%. Subjective methods of measuring adherence have been shown to be inaccurate and overestimate rates. The advent of new technology has allowed adherence rates to be measured electronically, and it has been shown that regular feedback of these data can be effective at improving asthma control. New mobile apps and smart technology aim to engage patients and families with their asthma care. Effective use of these apps in collaboration with health care professionals has a vast potential to improve adherence rates and inhaler technique, resulting in improved asthma control.

Preparing for transition: The effects of a structured transition program on adolescent heart transplant patients' adherence and transplant knowledge

Transition to adult health care has become a mainstream focus in pediatric health care as a higher percentage of patients are surviving into adulthood. This study investigated the success of a structured educational transition program in improving pediatric heart transplant patients' overall medical knowledge, medication adherence, readiness to transition, as well as parental perceptions of their child's readiness to transition to aid in the successful transition to an adult heart transplant program. Patients underwent a structured transition program over 2 years that included a total of seven 2-hour educational sessions hosted quarterly. This study comprised of a retrospective review of 12 heart transplant patients between the ages of 16-22 years. Test results indicated a statistically significant increase in overall medical knowledge scores from presession assessment compared to post-session assessment. Participants remained confident in their ability to transition throughout the program. Further, a statistically significant decrease in participant non-adherence was observed, as percentage of calcineurin inhibitor levels determined to be out of range decreased over the course of the program. Results suggest that a structured transition program is effective in improving overall patient medical knowledge in relation to their heart transplant and enhancing patient medication adherence. To effectively facilitate transition, pediatric providers, caregivers, and patients must communicate to provide a purposeful planned transition experience from pediatric to adult health care.

Do Urban Minority Parents and Children Agree on Asthma Symptoms with Exercise, Worries, and Confidence in Disease Management?

OBJECTIVE

Providers commonly rely on parent reports of a child's asthma symptoms; however, children as young as 7 years can report on their own health. Our study compared parent and child reports of asthma symptoms with exercise, worries about developing an asthma attack, and confidence in disease management.

METHODS

We recruited children ages 7 to 10 years with asthma from 4 Bronx, NY, schools, as well as their parents. The parents and children completed interview surveys with parallel questions regarding perceived asthma symptoms, asthma-related worries, and confidence in disease management. We used McNemar tests for paired data to compare parent and child responses.

RESULTS

We analyzed data for 105 parent-child pairs. Mean child age was 8.5 years (standard deviation, 0.99); 53% were male, and 82% were Hispanic. Children were more likely than their parents to report ever having an exercise-induced asthma attack (85% vs 48%; P < .001) and that they "worry a lot" about developing an asthma attack during exercise (63% vs 45%; P = .01). Children felt more confident about using an inhaler correctly (76% of the children were "very sure" vs 60% of the parents; P = .009) and were more likely to report having an inhaler available in case of an attack (38% of the children were "very sure" vs 20% of the parents; P = .003).

CONCLUSIONS

In this school-based sample of urban children with asthma, we found disagreement between parent and child reports of symptoms with exercise, worry about developing an attack, and confidence in medication use. These findings suggest that including child reports during history taking could help providers identify children in need of enhanced asthma management.

Adolescent ownership of asthma health: A concept analysis

AIM

This concept analysis was developed to produce a working definition regarding ownership of health in advanced practice nursing.

BACKGROUND

Ownership of health is a new concept developed in nursing. Adolescence is a time of learning identity and needed life skills for a chronic illness. Nurses can utilize this concept for improvement of outcomes for their adolescent patients.

DESIGN/METHOD

This concept analysis is based on Walker and Avant.

DATA SOURCE AND REVIEW OF LITERATURE

As ownership of health is new in nursing, a literature search was based on elements of Donnelley's Functional Mastery of Health Ownership nursing model.

RESULTS

Attributes (responsibility, self-efficacy, mastery/control, and self-image), model/contrary case, antecedents (awareness, willingness, desire, and acceptance), consequences, and empirical referents are discussed.

CONCLUSIONS

The definition of ownership is critical to both nursing and the advanced practice nurse. Adolescents are a special population of patients; learning how to both be independent and to care for their health. By employing a framework of ownership, adolescents can be more likely to thrive versus merely survive with asthma and the impact will go beyond the patients to their families and impact health outcomes as well.

Asthma 101: Teaching children to use metered dose inhalers

Providers across the spectrum of healthcare must be aware of their patients' inhaler use. This article addresses common errors and the proper use of pressurized metered-dose inhalers in pediatric patients.

Smartphones for Real-time Assessment of Adherence Behavior and Symptom Exacerbation for High-Risk Youth with Asthma: Pilot Study

BACKGROUND

Youth with asthma who have poor medication adherence, have limited access to care, and are frequently seen in the acute care setting are often termed "high risk."

OBJECTIVE

This study aimed to design and test the feasibility of using smartphone technology to assess contextual factors that may impact changes in daily medication adherence and to identify new symptom episodes among high-risk youth with asthma in their home environment.

METHODS

Youth aged 8-17 years with high-risk asthma from 2 children's hospitals were eligible for the 2-month study. An app was downloaded on participants' phones at enrollment. Daily text message (short message service) reminders were sent to complete ecological momentary assessment of asthma symptoms and other contextual factors such as emotional state using the app. Bluetooth inhaler devices were used to record timestamps of inhaler use with the ability to review and manually enter data. The acceptability was assessed with surveys, key informant interviews (KII), and frequency of days with asthma data. KII data were used in an iterative design approach to identify challenges, strengths, and suggestions for maximizing use. Generalized linear mixed modeling was used to preliminarily explore contextual factors associated with changes in daily adherence.

RESULTS

We enrolled 14 children aged 8-16 years (13/14, 93% were African Americans). Over the 2-month study period, participants reported coughing (42/110, 38%), wheezing (8/111, 7%), chest tightness (9/109, 8%), boredom (57/109, 52%), and 10 new asthma symptom episodes. The controller medication adherence was 30%, which increased significantly on days with asthma symptoms or boredom. Data were received on 89% (606/681) of study days. Surveys and KIIs suggest acceptability among youth and their caregivers. Challenges reported during the study included lost or damaged phones and available memory.

CONCLUSIONS

Youth and their caregivers reported the acceptability of using smartphones for real-time asthma monitoring. Overall, the controller medication adherence was low but increased significantly on days with reported asthma symptoms or boredom, suggesting that daily contextual factors may be associated with a change in the adherence behavior.

Cognitive factors predict medication adherence and asthma control in urban adolescents with asthma

PURPOSE

Adolescents with asthma often report poor medication adherence and asthma control. Cognitive factors embedded in the social cognitive theory including self-efficacy, outcome expectations, and barrier perceptions may explain poor asthma outcomes in this population. This study was performed to examine the extent to which these cognitive factors are intercorrelated and explain medication adherence and asthma control in urban adolescents.

PATIENTS AND METHODS

A total of 373 urban adolescents (12-20 years) with asthma completed questionnaires measuring asthma-related self-efficacy, outcome expectations, barrier perceptions, medication adherence, and asthma control. Multiple linear regression was conducted to examine the extent to which the three cognitive factors predicted medication adherence and asthma control after controlling for covariates including age, sex, household income, and age at diagnosis.

RESULTS

Participants' ages were on average 14.68 (±1.94) years; 50% were female, and most (78.6%) were African American. Higher self-efficacy associated with lower barrier perceptions and higher outcome expectations (r=0.50, p<0.001; r=-0.26, p<0.001, respectively). Self-efficacy predicted better asthma control (B=-0.098, p=0.004) and adherence (B=0.426, p=0.011), whereas barrier perceptions predicted poorer asthma control (B=0.13, p<0.001) and adherence (B=-0.568, p<0.001). Self-efficacy independently predicted fewer missed doses (B=-0.621, p=0.006), and barrier perception independently predicted asthma control (B=0.12, p<0.001) and adherence (B=-0.519, p<0.001).

CONCLUSION

Improving medication adherence and asthma control among adolescents may require a multifaceted approach. Interventions focused on increasing self-efficacy and addressing barriers, actual or potential, to medication adherence could ameliorate asthma disparities in urban adolescents.

Urban-Rural Differences in School Nurses' Asthma Training Needs and Access to Asthma Resources

PURPOSE

Few studies have examined school nurses preferences' for asthma training. Our purpose was to: 1) assess school nurses' perceived asthma training needs, 2) describe nurses' access to asthma educational resources, and 3) identify urban-rural differences in training needs and access to resources in southern states.

DESIGN AND METHODS

A convenience sample of school nurses (n=162) from seven counties (two urban and five rural) in North Carolina and South Carolina completed an online, anonymous survey. Chi-square tests were used to examine urban-rural differences.

RESULTS

Although most nurses (64%) had received asthma training within the last five years, urban nurses were more likely to have had asthma training than rural nurses (χ2=10.84, p=0.001). A majority of nurses (87%) indicated they would like to receive additional asthma training. Approximately half (45%) of nurses reported access to age-appropriate asthma education materials, but only 16% reported that their schools implemented asthma education programs. Urban nurses were more likely than rural nurses to have access to asthma education programs (χ2=4.10, p=0.04) and age-appropriate asthma education materials (χ2=8.86, p=0.003).

CONCLUSIONS

Few schools are implementing asthma education programs. Rural nurses may be disadvantaged in terms of receiving asthma training and having access to asthma education programs and materials.

PRACTICE IMPLICATIONS

Schools are an ideal setting for delivering age-appropriate asthma education. By providing school nurses with access to age-appropriate asthma education resources and additional asthma training, we can help them overcome several of the barriers that impede their ability to deliver asthma care to their students.

Communication Predicts Medication Self-Efficacy in Glaucoma Patients

PURPOSE

Medication self-efficacy, or patients' confidence that they can perform medication-related behaviors, is associated with better glaucoma medication adherence. Little is known about how to enhance glaucoma patients' medication self-efficacy. Our purpose is to examine whether patient-provider communication increases glaucoma patients' medication self-efficacy.

METHODS

During an 8-month cohort study of 279 glaucoma patients and 15 providers, two office visits were videotape-recorded, transcribed, and coded for six patient-provider communication behaviors. A validated scale was used at baseline and 8-month follow-up to assess patients' confidence in overcoming adherence barriers (adherence barriers self-efficacy) and carrying out tasks to use eye drops correctly (eye drop task self-efficacy). We ran two generalized estimating equations to examine whether more frequent patient-provider communication during office visits predicted increased patient adherence barriers self-efficacy and eye drop task self-efficacy at 8-month follow-up.

RESULTS

For each additional topic providers educated about, patients reported an average increase of 0.35 in self-efficacy in overcoming adherence barriers (p < 0.001). Patients also reported an average increase of 1.01 points in eye drop task self-efficacy when providers asked about patients' views of glaucoma and its treatment versus not (p < 0.001). Patients who asked more medication questions (p < 0.001) and African-American patients (p < 0.05) reported lower adherence barriers self-efficacy by 0.30 and 2.15 points, respectively. Women had a 0.63 lower eye drop task self-efficacy than men (p < 0.05).

CONCLUSIONS

When providers educate glaucoma patients and assess patient views about glaucoma and its treatment, patients report higher medication self-efficacy. Providers should be aware that patients who ask more medication questions may have less confidence in their ability to overcome barriers to adherence.

Managing the pediatric patient with refractory asthma: a multidisciplinary approach

Children with asthma that is refractory to high levels of prescribed treatment are described as having problematic severe asthma. Those in whom persistent symptoms result from a failure of basic asthma management are described as having "difficult asthma", while those who remain symptomatic despite these factors having been addressed are described as having "severe therapy-resistant asthma" (STRA). The majority of children have difficult asthma; asthma that is poorly controlled because of a failure to get the basics of asthma management right. Modifiable factors including nonadherence to medication, persistent adverse environmental exposures, and psychosocial factors often contribute to poor control in these patients. As our skill in identifying and addressing modifiable factors has improved, we have found that a progressively smaller proportion of our clinic patients is categorized as having true STRA, resulting in an infrequent resort to escalation of treatment. Many of the modifiable factors associated with the diagnosis of difficult asthma can be identified in a general pediatric clinic. Characterization of more complex factors, however, requires the time, skill, and expertise of multiple health care professionals within the asthma multidisciplinary team. In this review, we will describe the structured approach adopted by The Royal Brompton Hospital in the management of the child with problematic severe asthma. We highlight the roles of members of the multidisciplinary team at various stages of assessment and focus on prominent themes in the identification and treatment of modifiable factors.

How to manage a child with difficult asthma?

INTRODUCTION

Children with difficult asthma have significant morbidity and fail to achieve asthma control despite being prescribed high dose maintenance treatment. If control remains poor after diagnostic confirmation, detailed assessments of the reasons for asthma being difficult-to-control are needed. Underlying modifiable factors including non-adherence to medication, persistent environmental exposures that trigger asthma symptoms and psychosocial factors contribute to poor control in these patients.

AREAS COVERED

The focus of this review is to provide a practical approach to the diagnosis and management of difficult asthma including an overview of long term assessments to identify potential progression to true, severe asthma. A multi-disciplinary team is critical to enable modifiable factors to be identified and addressed. Significant resources are required to manage paediatric difficult asthma optimally and only specialist centres should be tasked with the assessment of these patients. Although this may have an impact on healthcare resources, long term benefits for lung health are significant. Expert commentary: The management of paediatric difficult asthma is not simple and involves numerous professionals with varied expertise. However, if it is not undertaken with the appropriate skills, there is a significant risk of children receiving inappropriate invasive investigations and therapies that will have no impact on morbidity.