Assessment of inhaler technique among fourth-year pharmacy students: Implications for the use of entrustable professional activities.

INTRODUCTION: It is unknown when and how often competency assessments should occur in pharmacy education. Using inhaler technique as an example competency, the study objectives were to measure the proportion of near-graduation students demonstrating correct technique approximately one year after initial training and to measure reliability between assessors. METHODS: A sample of 45 near-graduation pharmacy students with prior education on correct inhaler technique participated in this direct observation study at the University of Otago. Five trained assessors simultaneously rated each participant's inhaler technique demonstration using a checklist. RESULTS: Of 37 participants demonstrating a pressurized metered dose inhaler, 21.62% demonstrated correct technique. No participants among eight volunteers demonstrated proper use of a dry powder inhaler. On average, two steps were performed correctly for each inhaler type. Steps with the highest error rate were "hold the inhaler upright and shake well," "breath out gently, away from the inhaler," and "keep breathing in slowly and deeply". The intraclass correlation coefficient for any inhaler type was excellent (0.91), suggesting assessors had strong reliability. CONCLUSIONS: Students did not retain ability to correctly demonstrate inhaler technique one year after initial instruction. This finding supports the notion that demonstrable tasks may need to be frequently assessed to ensure the task is mastered and becomes a routine part of a student's practice. It also suggests that assessment of milestones and/or entrustable professional activities may need to occur at different time points throughout a program, rather than allowing for "signing off" prematurely.

Accurate, reproducible measurement of acetone concentration in breath using selected ion flow tube-mass spectrometry.

Using selected ion flow tube-mass spectrometry (SIFT-MS) for on-line analysis, we aimed to define the optimal single-exhalation breathing manoeuvre from which a measure of expired acetone concentration could be obtained. Using known acetone concentrations in vitro, we determined the instrument's accuracy, inter-measurement variability and dynamic response time. Further, we determined the effects of expiratory flow and volume on acetone concentration in the breath of 12 volunteers and calculated intra-individual coefficients of variation (CVs). At acetone concentrations of 600-3000 ppb on 30 days over 2 months there was an instrument measurement bias of 8% that did not change over time, inter-day and intra-day CVs were 5.6% and 0.0%, respectively, and the 10-90% response time was 500 ± 50 ms (mean ± SE). Acetone concentrations at exhalation flows of 193 ± 18 (mean ± SD) and 313 ± 32 ml s(-1) were 619 ± 1.83 (geometric mean ± logSD) and 618 ± 1.82 ppb in the fraction 70-85% by volume of exhaled vital capacity (V(70-85%)) and 636 ± 1.82 (geometric mean ± logSD) and 631 ± 1.83 ppb in V(85-100%). A difference was observed between acetone concentrations in the V(70-85%) and V(85-100%) fractions (p < 0.01), but flow had no effect. Median intra-individual CVs were 1.6-2.6%. On-line SIFT-MS measurement of acetone concentration in a single exhalation requires control of exhaled volume but not flow, and yields low intra-individual CVs and is potentially useful in approximating blood glucose and monitoring metabolic stress.

Predicting corticosteroid response in chronic obstructive pulmonary disease using exhaled nitric oxide.

RATIONALE: Predicting corticosteroid response in COPD is important but difficult. Response is more likely to occur in association with eosinophilic airway inflammation, for which the fraction of exhaled nitric oxide (Fe(NO)) is a good surrogate marker. OBJECTIVES: We aimed to establish whether Fe(NO) levels would predict the clinical response to oral corticosteroid in COPD. METHODS: We performed a double-blind, crossover trial of steroid in patients with COPD. After a 4-week washout of inhaled steroids, patients received prednisone 30 mg/d or matching placebo, in random order, with an intervening 4-week washout. The predictive values of Fe(NO) for clinically significant changes in 6-minute-walk distance (6MWD), spirometry (FEV(1)), and St. George's Respiratory Questionnaire (SGRQ) were calculated. MEASUREMENTS AND MAIN RESULTS: A total of 65 patients (mean FEV(1) = 57% predicted) were randomized. With prednisone, there was a net increase of 13 m in 6MWD (P = 0.02) and 0.06 L in postbronchodilator FEV(1) (P = 0.02) compared with placebo. The change in SGRQ was not significant. Using receiver operator characteristic analysis, the area under the curve for an increase of 0.2 L in FEV(1) was 0.69 (P = 0.04) with an optimum Fe(NO) cut-point of 50 ppb. The positive and negative predictive values were 67 and 82%, respectively. FE(NO) was not a significant predictor for changes in 6MWD or SGRQ. CONCLUSIONS: Fe(NO) is a weak predictor of short-term response to oral corticosteroid in COPD, its usefulness being limited to predicting increase in FEV(1). Clinical trial registered with www.anzctr.org.au (ACTRN12605000683639).