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Am Fam Physician. 2000;61(2):517-518

Asthma is a leading cause of morbidity among American children. In urban areas, poor control of asthma is often linked to improper or noncompliance with prescribed medical therapies. The beta-agonist, albuterol, is a first-line therapy for acute asthma exacerbations and also plays a role in chronic treatment. The proper administration of albuterol in its various formulations is critical to efficacy. Simon performed a study to evaluate the ability of caregivers to properly deliver albuterol to children for whom they were caring.

The study took place at two inner-city pediatric emergency departments. Families of children younger than 18 years of age were eligible if at the time of triage, albuterol was noted to be one of the child's prescribed medications. Caregivers were first asked 20 questions about demographics, medical history and access to care followed by 12 questions about their child's use of albuterol. After the interview, caregivers were given a mock scenario in which they were asked to determine the correct dose, scheduling and method of administration of albuterol. A correct response was considered to be within 20 percent of the appropriate dose.

Forty-one caregivers participated in the study. Thirty-nine of their children had come to the emergency department with a respiratory illness. The mean age of the children was 6.3 ± 4.1 years and the mean age of the caregivers was 33 ± 8.5 years. Approximately three fourths of the caregivers were black and one fourth were white. Ninety percent were one of the child's parents. Thirty-six (88 percent) of the 41 caregivers had completed at least high school and 39 (95 percent) were able to identify a primary care physician or clinic where their child normally received health care.

Sixty-three percent of the caregivers were out of medication at the time of the emergency department visit. In addition, only 54 percent stated they received the last prescription from the primary care physician, 44 percent received the prescription from the emergency department and 2 percent were unsure. Regarding how they normally based the dosing of albuterol, 80 percent reported “just knowing it,” 15 percent said they “rely on the doctor,” and 5 percent said they “rely on the bottle.” When questioned specifically about dosing, 17 percent gave an incorrect dose, 44 percent gave an incorrect frequency of dosing, 24 percent gave an inadequate duration of albuterol use and 17 percent read the instructions each time.

For the mock scenario, albuterol liquid was chosen by 36.5 percent, nebulizers by 36.5 percent and metered-dosing inhalers by 27 percent. Nine of the doses (22 percent) were improperly measured; the dose intended to be given was inaccurately measured by 17 percent. The greatest number of errors was made with a calibrated device or a teaspoon to measure the liquid formulation of albuterol. Interestingly, there were no errors among those selecting the nebulizer with premixed or standard dosing. Collectively, 83 percent of caregivers were able to state a proper dose of medication, and 78 percent were able to actually give the correct dose.

The author concludes that the overall ability of caregivers to administer albuterol is considerably better than in the previous study that had used over-the-counter acetaminophen. In this early trial, only 30 percent were able to properly state and deliver the correct dose. Nonetheless, patient and caregiver education in regard to correct dosing, the use of measuring devices and the frequency of administration is still lacking. Also worrisome is that 63 percent of patients had run out of medication.

editor's note: I believe the message here is straightforward—that patient/parental education is critically important and should be repeated at each visit. Some offices may also want to evaluate how medication refills are handled, as this seems to have a direct relationship to emergency department visits.

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