Investigating the validity and reliability of the traditional checklist for assessment of specific inhalation techniques with pressurized metered-dose inhalers using the Aerosol Inhalation Monitor

Abstract

Background: Correct inhalation techniques are essential for optimum delivery of drugs to the airways for patients with asthma and chronic obstructive pulmonary disorder. Checklists often are used to assess the techniques, but the validity of checklists is unknown and few studies have been conducted to date. We investigated the validity and reliability of checklists.Methods: A prospective, observational study was conducted at a tertiary care teaching hospital in Taiwan using an objective tool, the aerosol inhalation monitor (AIM). Inhalation techniques using pressurized metered-dose inhalers (pMDIs) were assessed by checklist and AIM. The κ coefficient and prevalence and bias-adjusted κ (PABAK) were calculated to determine the consistency between the checklist and AIM in four specific techniques, including actuation, inspiratory flow, inhalation time, and breath hold time. Sensitivity and specificity were used to evaluate the validity of the checklist using these techniques.Results: The κ and PABAK values were −0.023 and −0.176 for actuation, 0.43 and 0.529 for inspiratory flow, −0.046 and −0.412 for inhalation time, and 0.12 and 0.686 for breath hold time, respectively. Sensitivity and specificity for the four individual steps were 0.706 versus 0.265, 0.833 versus 0.600, 1 versus 0.1, and 0.955 versus 0.143, respectively.Conclusion: Our results invalidate use of the checklist alone as a reliable tool to assess inhalation techniques. The low specificity indicates that the checklist tends to overestimate the accuracy of inhalation techniques. AIM can be added as an objective tool to assess and quantify specific steps for MDIs.