Obstructive sleep apnoea and nocturnal atrial fibrillation in patients with ischaemic heart disease.

INTRODUCTION: Arrhythmias, especially atrial fibrillation (AF) and ventricular arrhythmias, are independent risk factors of mortality in patients with ischaemic heart disease (IHD). While there is a growing body of evidence that suggests an association between obstructive sleep apnoea (OSA) and cardiac arrhythmias, evidence on this relationship in patients with IHD has been scant and inconsistent. We hypothesised that in patients with IHD, severe OSA is associated with an increased risk of nocturnal arrhythmias. METHODS: We studied 103 consecutive patients with IHD who underwent an overnight polysomnography. Exposed subjects were defined as patients who had an apnoea-hypopnoea index (AHI) ≥30/h (severe OSA), and nonexposed subjects were defined as patients who had an AHI <30/h (nonsevere OSA). All electrocardiograms (ECGs) were interpreted by the Somte ECG analysis software and confirmed by a physician blinded to the presence or absence of exposure. Arrhythmias were categorised as supraventricular and ventricular. Arrhythmia subtypes (ventricular, atrial and conduction delay) were analysed as dichotomous outcomes using multiple logistic regression models. RESULTS: Atrial fibrillation and AF/flutter (odds ratio 13.5, 95% confidence interval 1.66-109.83; P = 0.003) were found to be more common in the severe OSA group than in the nonsevere OSA group. This association remained significant after adjustment for potential confounders. There was no significant difference in the prevalence of ventricular and conduction delay arrhythmias between the two groups. CONCLUSION: In patients with IHD, there was a significant association between severe OSA and nocturnal AF/flutter. This underscores the need to evaluate for OSA in patients with IHD, as it may have important implications on clinical outcomes.

Asian Pacific Society of Cardiology Consensus Statements on the Diagnosis and Management of Obstructive Sleep Apnoea in Patients with Cardiovascular Disease.

Obstructive sleep apnoea (OSA) is strongly associated with cardiovascular disease (CVD). However, evidence supporting this association in the Asian population is scarce. Given the differences in the epidemiology of CVD and cardiovascular risk factors, as well as differences in the availability of healthcare resources between Asian and Western countries, an Asian Pacific Society of Cardiology (APSC) working group developed consensus recommendations on the management of OSA in patients with CVD in the Asia-Pacific region. The APSC expert panel reviewed and appraised the available evidence using the Grading of Recommendations Assessment, Development, and Evaluation system. Consensus recommendations were developed and put to an online vote. Consensus was reached when 80% of votes for a given recommendation were in support of 'agree' or 'neutral.' The resulting statements provide guidance on the assessment and treatment of OSA in patients with CVD in the Asia-Pacific region. The APSC hopes for these recommendations to pave the way for screening, early diagnosis and treatment of OSA in the Asia-Pacific region.

One-Bed-One-Team-Does an Integrated General Hospital Inpatient Model Improve Care Outcomes and Productivity: An Observational Study.

Introduction: With the increasing complexity of healthcare problems worldwide, the demand for better-coordinated care delivery is on the rise. However, current hospital-based practices remain largely disease-centric and specialist-driven, resulting in fragmented care. This study aimed to evaluate the effectiveness and feasibility of an integrated general hospital (IGH) inpatient care model. Methods: Retrospective analysis of medical records between June 2018 and August 2019 compared patients admitted under the IGH model and patients receiving usual care in public hospitals. The IGH model managed patients from one location with a multidisciplinary team, performing needs-based care transition utilizing acuity tagging to match the intensity of care to illness acuity. Results: 5,000 episodes of IGH care entered analysis. In the absence of care transition in intervention and control, IGH average length of stay (ALOS) was 0.7 days shorter than control. In the group with care transition in intervention but not in control, IGH acute ALOS was 2 days shorter, whereas subacute ALOS was 4.8 days longer. In the presence of care transition in intervention and control, IGH acute ALOS was 6.4 and 10.2 days shorter and subacute ALOS was 15.8 and 26.9 days shorter compared with patients under usual care at acute hospitals with and without co-located community hospitals, respectively. The 30- and 60-days readmission rates of IGH patients were marginally higher than usual care, though not clinically significant. Discussions: The IGH care model maybe associated with shorter ALOS of inpatients and optimize resource allocation and service utilization. Patients with dynamic acuity transition benefited from a seamless care transition process.

When Faculty Tell Tales: How Faculty Members' Reflective Narratives Impact Residents' Professional Identity Formation.

PROBLEM: Most training programs have focused on the explicit teaching of professionalism, an approach that has seen limited success, to transform trainees into physicians. It is possible that faculty members' reflective narratives, if appropriately shared with trainees, can facilitate the processes of reflection and socialization and help shift the training paradigm toward supporting professional identity formation. APPROACH: In May 2010, an online forum, where faculty could share personal reflective narratives with all residents and faculty via email, was created for the National University Health System's internal medicine residency program. By 2016, 40 letters had been written and nearly 200 residents and 30 faculty members had read these. This repository of faculty members' reflective narratives touches on a broad range of issues related to professionalism, including altruism, humanism, excellence, and accountability. In February 2017, the authors conducted semistructured focus group discussions with 20 residents to explore the impact of faculty members' reflective narratives on their professional identity development. OUTCOMES: Residents reported that narratives, if written by authors who were recognized as role models, triggered the processes of reflection and socialization; were more effective in provoking reflection if they resonated with residents' experiences; inspired them to follow how their role models reflected on and coped with challenges; and influenced the culture of the workplace, impacting the residents' daily experiences and leading to socialization and development of their professional identity. NEXT STEPS: These early observations on the role of faculty members' reflective narratives highlight the importance of credible role models, the daily work experience, and the culture of the workplace and provide information educators could use to more effectively support trainees' professional identity formation as they design curricula. Among other things, future studies should explore the role and effectiveness of faculty members' reflective narratives in different educational contexts.

Effectiveness of near-peer simulation for managing the acutely deteriorating patient among residents of an internal medicine junior residency programme.

INTRODUCTION: Near-peer teaching is gaining popularity as a teaching modality, as it improves the learner's understanding, is targeted at an appropriate level and promotes familiarisation. This study was initiated to evaluate the effectiveness of incorporating near-peer instruction into simulation-based training within a junior residency programme. METHODS: 42 first-year residents from an internal medicine junior residency programme were recruited. Participants underwent a simulation-based training programme conducted over five weeks. Each week involved either an emergency or acute clinical scenario. A structured questionnaire was administered prior to and after the course to compare participants' perceived knowledge, experience and confidence in managing the clinical scenarios. RESULTS: In our study, 83% of participants agreed/strongly agreed that the scenarios were realistic. There were improvements in perceived knowledge, experience and confidence after the course. The greatest improvement was seen for experience (post-simulation: median 7.00 [interquartile range (IQR) 6.00‒8.00] vs. pre-simulation: median 5.00 [IQR 3.00-6.25]). 65% of participants were keen to help with future training. CONCLUSION: Near-peer simulation training was found to be a viable and valuable method of instruction for first-year residents for increasing experience, instilling confidence and improving perceived knowledge. Integration of such programmes within medical education curricula shows good promise of continuity, with many first-year residents inspired to organise subsequent sessions.

Screening for Obstructive Sleep Apnea in the Assessment of Coronary Risk.

There is increasing awareness that health screening may prevent some acute coronary events. Yet, obstructive sleep apnea (OSA) is seldom screened for and its relation with coronary risk markers is not well established. Consecutive adults (n = 696) enrolled in a cardiovascular health screening program were approached to determine the feasibility of incorporating OSA screening. Screening included questionnaires and a home-based sleep study. High-sensitivity C-reactive protein was the primary coronary risk marker, and other laboratory- and exercise treadmill-based markers were also reported. Two thirds of the participants (66%) agreed to undergo OSA screening and most (78%) successfully completed the sleep study. The prevalence of OSA (apnea-hypopnea index ≥15/hour) was 38.0%. The Berlin Questionnaire (53%) and Epworth Sleepiness Scale (26%) had low sensitivity in identifying OSA. After full adjustment for age, gender, body mass index, hypertension, and diabetes mellitus, OSA remained an independent predictor of serum levels of high-sensitivity C-reactive protein (relative mean difference 1.29, 95% CI 1.03 to 1.62; p = 0.025), triglyceride (relative mean difference 1.15, 95% CI 1.03 to 1.28; p = 0.014), and exercise time (mean difference -26.4 seconds; 95% CI -51.6 to -1.2; p = 0.04). The INTERHEART Risk Score analysis suggested more participants with (31%) than without (14%, p <0.001) OSA will develop future cardiovascular events. In conclusion, based on the acceptance for OSA screening, high prevalence of OSA and independent associations between OSA and coronary risk markers, incorporation of sleep studies into cardiovascular health screening programs appears feasible.

Relationship between severity of obstructive sleep apnea and adverse cardiac outcomes in non-diabetic patients presenting with myocardial infarction.

Previous studies that have reported an association between obstructive sleep apnea and adverse cardiac events were confounded by a high prevalence of diabetes mellitus. We investigated the relationship between obstructive sleep apnea and the occurrence of major adverse cardiac events in non-diabetic patients who presented with ST-segment elevation myocardial infarction. A total of 41 patients who underwent overnight sleep screening within 5 days after admission for myocardial infarction from January 2007 to December 2008 were identified. Major adverse cardiac events-defined as a composite of cardiac death, non-fatal myocardial infarction, hospitalization for angina and congestive heart failure at 5-year follow-up-were determined. The patients were divided into two groups: those who experienced major adverse cardiac events and those who did not. In the overall cohort, the prevalence of obesity was 4.9 %. A total of 13 (31.7 %) patients had major adverse cardiac events. The mean apnea-hypopnea index was 25.4 ± 20.3. The group that experienced major adverse cardiac events had a higher apnea-hypopnea index than the group that did not (36.1 ± 21.0 vs 20.4 ± 18.2; P = 0.016). After adjusting for the resolution of ST-segment elevation and the use of a glycoprotein IIb/IIIa inhibitor, logistic regression analysis revealed that the apnea-hypopnea index remained an independent predictor of major adverse cardiac events (odds ratio 1.044; 95 % confidence interval 1.003-1.086; P = 0.033). In non-diabetic patients, the severity of obstructive sleep apnea was associated with the occurrence of major adverse cardiac events at 5-year follow-up after ST-segment elevation myocardial infarction.

When traditional model meets competencies in Singapore: beyond conflict resolution.

INTRODUCTION: The implementation of competency-based internal medicine (IM) residency programme that focused on the assurance of a set of 6 Accreditation Council for Graduate Medical Education (ACGME) core competencies in Singapore marked a dramatic departure from the traditional process-based curriculum. The transition ignited debates within the local IM community about the relative merits of the traditional versus competency-based models of medical education, as well as the feasibility of locally implementing a training structure that originated from a very different healthcare landscape. At the same time, it provided a setting for a natural experiment on how a rapid integration of 2 different training models could be achieved. MATERIALS AND METHODS: Our department reconciled the conflicts by systematically examining the existing training structure and critically evaluating the 2 educational models to develop a new training curriculum aligned with institutional mission values, national healthcare priorities and ACGME-International (ACGME-I) requirements. RESULTS: Graduate outcomes were conceptualised as competencies that were grouped into 3 broad areas: personal attributes, interaction with practice environment, and integration. These became the blueprint to guide curricular design and achieve alignment between outcomes, learning activities and assessments. The result was a novel competency-based IM residency programme that retained the strengths of the traditional training model and integrated the competencies with institutional values and the unique local practice environment. CONCLUSION: We had learned from this unique experience that when 2 very different models of medical education clashed, the outcome may not be mere conflict resolution but also effective consolidation and transformation.

Exploring new healthcare professionals' roles through interprofessional education.

This article presents findings from a simulation-based interprofessional education (IPE) program involving trainee advanced practice nurses (APNs) and internal medicine residents (IMRs) based in Singapore. Trainee APNs and IMRs participated in a semester-long series of high-fidelity simulations of medical emergencies. Learners' attitudes toward the IPE intervention were assessed using validated Likert scaled surveys and written comments. Overall satisfaction was high among learners, with strongly positive attitudes toward teamwork, collaboration and patient centredness. Of most interest, written comments highlight the utility of IPE in defining the professional scope and boundaries of APNs. Comments from both professions observed that participation in the IPE scenarios greatly aided their understanding of the scope and role of APN's practice within the health care team. This aspect of IPE may find further application in other similarly novel roles in healthcare.

OSA and coronary plaque characteristics.

BACKGROUND: Virtual histology intravascular ultrasound (VH-IVUS) is an intravascular imaging technique that enables the characterization of coronary plaques. We sought to determine the association between OSA and coronary plaque characteristics in patients presenting with coronary artery disease. METHODS: We prospectively recruited patients with angiographically proven coronary artery disease for a VH-IVUS examination and home-based sleep study. The total atheroma volume of the entire target coronary artery and the incidence of thin cap fibroatheroma of patients with no to mild and moderate to severe OSA were compared. RESULTS: One hundred eighteen patients were recruited from two university-affiliated centers. Among the 93 patients who completed the study, 32 (34.4%) had newly diagnosed moderate to severe OSA (apnea-hypopnea index > 15). Compared with patients with no to mild OSA, those with moderate to severe OSA had a larger total atheroma volume (461.3 ± 250.4 mm³ vs 299.2 ± 135.6 mm³, P < .001), and the association remained after adjustment for age, BMI, hypertension, diabetes mellitus, smoking, and hyperlipidemia (relative mean difference, 1.73; 95% CI, 1.38-2.15). In contrast, there were no significant differences between the patients with moderate to severe OSA and no to mild OSA regarding the prevalence of thin cap fibroatheroma in the culprit lesion (53.1% vs 54.2%, P = .919). CONCLUSIONS: In patients presenting with coronary artery disease, moderate to severe OSA was independently associated with a larger total atheroma volume in the target coronary artery. Further studies on the effects of CPAP on total atheroma volume are warranted. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01306526; URL: www.clinicaltrials.gov.

The influence of timing of polysomnography on diagnosis of obstructive sleep apnea in patients presenting with acute myocardial infarction and stable coronary artery disease.

BACKGROUND: We aimed to determine if timing of polysomnography (PSG) influences the diagnosis of obstructive sleep apnea (OSA) in acute myocardial infarction (AMI) or stable coronary artery disease (CAD). METHODS: A total of 160 patients admitted with AMI or stable CAD were consecutively recruited for either in-hospital (n=80) or postdischarge (n=80) PSG. RESULTS: The median time from admission to PSG for the in-hospital and postdischarge groups was 1 day and 17 days, respectively (P<.001). Overall, 59 patients (36.9%) were diagnosed with OSA (apnea-hypopnea index [AHI] > or = 15), and they were more likely to have diabetes mellitus (DM), hypertension, hyperlipidemia, chronic renal failure, and a greater body mass index (BMI) (P<.05 for all). The diagnosis of OSA was significantly higher (P=.037) in patients who had a PSG performed as an inpatient than those who had a PSG as an outpatient. There was a significant interaction between clinical presentation and the effect of PSG timing on the diagnosis of OSA (P=.003). For the patients presenting with AMI but not those with stable CAD, in-hospital PSG was an independent predictor of OSA (adjusted odds ratio, 3.84 [95% confidence interval, 1.42-10.41]; P=.008). CONCLUSION: The timing of PSG influenced the diagnosis of OSA in patients who presented with AMI but not in those who presented with stable CAD.

Relationship between apnoea-hypopnoea index and angiographiccoronary disease phenotypes in patients presenting with acutemyocardial infarction.

BACKGROUND: Relationship between obstructive sleep apnoea and atherosclerosis has not been confirmed using coronary angiography. We sought to investigate the relationships between the apnoea-hypopnoea index (AHI) and angiographic coronary disease phenotypes.
 METHODS: SYNTAX score, lesion complexity, and thrombus burden grade were determined in 125 patients presenting with acute myocardial infarction and had undergone a screening sleep study. Severe OSA was defined as AHI ≥ 30.
 RESULTS: Most of the recruited patients were male (97.6%). Severe obstructive sleep apnoea was diagnosed in 37% of the patients. The severe obstructive sleep apnoea group (n = 46) was older (P = 0.039) and more obese (P = 0.003) than the non-severe group (n = 79). There was no evidence of difference between the severe and non-severe obstructive sleep apnoea groups with regard to SYNTAX score (P = 0.871), number of complex lesions (P = 0.241), and thrombus burden grade (P = 0.433). Multivariate analysis adjusting for difference in age and body mass index did not change the findings. CONCLUSION: Using the three angiographic scoring systems, we found no association between AHI and angiographic coronary disease phenotypes, suggesting a limited effect of obstructive sleep apnoea on the amount and distribution of coronary plaques in patients presenting with acute myocardial infarction.

The successful, rapid transition to a new model of graduate medical education in Singapore.

Graduate medical education (GME) in Singapore recently underwent major reform (2009-2012), leading to accreditation of residency programs by the Accreditation Council for Graduate Medical Education-International (ACGME-I) within two years of the initial commitment to change. The main aims of the reforms were to implement best practices in GME, to provide better support structures for program administration, and to bring all specialty training under one administrative umbrella. The authors outline the historic development of GME in Singapore, the complexities of the model in place immediately prior to ACGME-I accreditation, and the difficulties addressed by the proposed changes, leading to a description of implementation efforts at the National University Hospital of Singapore, a university-affiliated academic medical center. The authors describe the institutional factors uniting hospital leaders in support of reform, the recruitment of a team to manage change within the institution, the inauguration of a new office for GME, and the faculty development initiatives needed to educate faculty leading the change process. The preparation and execution of specific initiatives designed to improve GME and the communication strategies needed to coordinate and publicize change efforts are outlined, as well as strategies for sustaining improvements and building them into the culture of the institution. The authors demonstrate that external accreditation can be a powerful driver of educational reform and summarize key lessons derived from Kotter principles, a current model of change management.

Severe obstructive sleep apnea and outcomes following myocardial infarction.

STUDY OBJECTIVE: We sought to determine the effect of severe obstructive sleep apnea (OSA) on long-term outcomes after myocardial infarction. We hypothesized that severe OSA was associated with lower event-free survival rate after ST-segment elevation myocardial infarction (STEMI). METHODS: A total of 120 patients underwent an overnight sleep study during index admission for STEMI. Severe OSA was defined as apnea hypopnea index (AHI) ≥ 30, and non-severe OSA defined as AHI < 30. RESULTS: Among the 105 patients who completed the study, 44 (42%) had severe OSA and 61 (58%) non-severe OSA. The median creatine kinase level and mean left ventricular systolic function were similar between the 2 groups. None of the 105 study patients had received treatments for OSA. Between 1- and 18-month follow-up, the severe OSA group incurred 1 death, 2 reinfarctions, 1 stroke, 6 unplanned target vessel revascularizations, and 1 heart failure hospitalization. In contrast, there were only 2 unplanned target vessel revascularizations in the non-severe OSA group. The incidence of major adverse events was significantly higher in the severe OSA group (15.9% versus 3.3%, adjusted hazard ratios: 5.36, 95% CI: 1.01 to 28.53, p = 0.049). Kaplan-Meier event-free survival curves showed the event-free survival rates in the severe OSA group was significantly worse than that in the non-severe OSA group (p = 0.021, log-rank test). CONCLUSION: 42% of the patients admitted with STEMI have undiagnosed severe OSA. Severe OSA carries a negative prognostic impact for this group of patients. It is associated with a lower event-free survival rate at 18-month follow-up.

Diagnostic characteristics of clinical prediction models for obstructive sleep apnea in different clinic populations.

PURPOSE: As predictive factors and their diagnostic values are affected by the characteristics of the population studied, clinical prediction model for obstructive sleep apnea (OSA) may exhibit different diagnostic characteristics in different populations. We aimed to compare the diagnostic characteristics of clinical prediction models developed in two different populations. METHODS: One hundred seventeen consecutive clinic patients (group 1) were evaluated to develop a clinical prediction model for OSA (local model). The diagnostic characteristics of this local model were compared with those of a foreign model by applying both models to another group of 52 patients who were referred to the same clinic (group 2). All patients underwent overnight polysomnography. RESULTS: The local model had an area under receiver operator characteristics curve of 79%. A cutoff of 0.6 was associated with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 77.9%, 72.5%, 84.5%, and 63.0%, respectively. The overall diagnostic accuracy, sensitivity, specificity, PPV, and NPV of the local model using data from patients in group 2 were 69.0%, 78.1%, 45.0%, 69.4%, and 56.3%, respectively. The foreign model had an overall diagnostic accuracy of 64.0% when applied to data from patients in group 2. At the optimal cutoff of 17, the foreign model was associated with sensitivity of 38.2%, specificity of 83.3%, NPV of 41.7% and PPV of 81.3%. CONCLUSIONS: Clinical prediction model for OSA derived from a foreign population exhibits markedly different diagnostic characteristics from one that is developed locally, even though the overall accuracy is similar. Our findings challenge the predictive usefulness and the external validity of clinical prediction models.

The relative impact of obstructive sleep apnea and hypertension on the structural and functional changes of the thoracic aorta.

BACKGROUND: Recent studies suggest that obstructive sleep apnea (OSA) causes thoracic aortic dilatation; but it is well accepted that hypertension can cause aortic dilatation, and hypertension is a common finding in patients with OSA. We aimed to investigate the relative impact of OSA and hypertension on the structural and functional changes of the thoracic aorta. METHODS: This was an echocardiography substudy of our prospective OSA study in patients with acute myocardial infarction (AMI). Ninety-four male patients who completed both echocardiography and polysomnography were recruited. OSA was defined as an apnea-hypopnea index (AHI) > or = 15/hour. RESULTS: The patients' mean age was 53 +/- 10 years, and mean body mass index (BMI) was 24.6 +/- 3 kg/m2. Sixty-four (68.1%) patients had OSA; of these, 39 (41.5%) had severe OSA. Thirty-three (52.6%) of the OSA cohort had hypertension. There was no correlation between any of the echocardiographic parameters and thoracic aortic size. Stepwise multivariate regression showed that BMI (P = 0.024), older age (P = 0.044), and hypertension (P = 0.025) were the only determinants. There was no significant independent relationship between OSA/AHI and thoracic aortic size. Systolic blood pressure but notAHI correlated significantly with aortic distensibility and compliance (r = -0.40 and -0.26, P < 0.001 and 0.022, respectively). CONCLUSIONS: Hypertension is a common finding in male AMI patients with OSA. In these patients, increased afterload from systemic hypertension rather than mechanical stress on the aortic wall determines the thoracic aortic size and abnormalities in aortic functional indices. BMI and age were also independent predictors of thoracic aortic dilatation.

Obstructive sleep apnea in patients admitted for acute myocardial infarction. Prevalence, predictors, and effect on microvascular perfusion.

BACKGROUND: We investigated the prevalence and predictors of obstructive sleep apnea (OSA) in patients admitted to the hospital for acute myocardial infarction and whether OSA has any association with microvascular perfusion after primary percutaneous coronary intervention (PCI). METHODS: Recruited patients were scheduled to undergo an overnight sleep study between 2 and 5 days after primary PCI. An apnea-hypopnea index (AHI) of > or = 15 was considered diagnostic of OSA. Impaired microvascular perfusion after primary PCI was defined as an ST-segment resolution of < or = 70%, myocardial blush grade 0 or 1, or a corrected Thrombolysis in Myocardial Infarction (TIMI) [antegrade flow scale] frame count > 28. RESULTS: Sleep study was performed in 120 patients and completed in 105 patients (study cohort, mean age 53 +/- 10 years, male 98%) with uncomplicated myocardial infarction. An AHI was > or = 15 in 69 patients (OSA-positive), giving a prevalence of 65.7%. Diabetes mellitus was found to be a significant risk factor for OSA (odds ratio, 2.86; 95% confidence interval, 1.06 to 8.24; p = 0.033). There were no differences between OSA-positive and OSA-negative groups with regard to the percentage of patients with < or = 70% ST-segment resolution (73% vs 64%, respectively; p = 0.411), myocardial blush grade 0 or 1 (39.1% vs 38.9%, respectively; p = 1.000), or corrected TIMI frame count > 28 (21.7% vs 25.0%, respectively; p = 0.807). CONCLUSIONS: We found a high prevalence of previously undiagnosed OSA in patients admitted with acute myocardial infarction. Diabetes mellitus was independently associated with OSA. No evidence indicated that OSA is associated with impaired microvascular perfusion after primary PCI.

Metered-dose inhaler with spacer instead of nebulizer during the outbreak of severe acute respiratory syndrome in Singapore.

BACKGROUND: The use of metered-dose inhaler (MDI) with spacer instead of nebulizer may be important during an outbreak of an airborne infection. However, there is a paucity of data on patients' and nurses' abilities and perspectives on MDI with spacer for the treatment of acute airway obstruction during such an outbreak. METHODS: We evaluated 50 consecutive MDI-with-spacer treatments administered in the respiratory wards of the National University Hospital of Singapore, and interviewed the patients after each treatment during the outbreak of severe acute respiratory syndrome (SARS). We also conducted interviews with 50 nurses who had experience in administering bronchodilators via both nebulizer and MDI with spacer. RESULTS: Forty-six patients (92%) were able to use MDI with spacer effectively. Sixteen percent of the patients preferred nebulizer over MDI with spacer. Fifty-eight percent of the patients thought MDI with spacer was easier to use than nebulizer, and 34% thought MDI was as easy to use as nebulizer. Sixteen percent of the patients thought that nebulizer was more effective than MDI with spacer in relieving their symptoms. Ninety-six percent of the nurses preferred nebulizer over MDI with spacer. Forty-two nurses (84%) thought that nebulizer was more effective for treating acute airflow obstruction in the hospital. CONCLUSIONS: In the in-patient setting during an outbreak of an airborne infection, for treatment of acute airflow obstruction, MDI with spacer was acceptable and preferred by a high percentage of patients. However, a high percentage of nurses had misconceptions regarding the efficacy of and patients' ability to use MDI with spacer.