regarding MDI use, Guidry et al correctly point out that in most practice settings other health professionals or trained personnel will most frequently teach patients.
Timothy H. Self. Pharoi.D.~ MarkJ Rurri&k,
University of Tennessee Health Science Center; Memphis
REFERENCES 1 Guidry GG, Brown WD, Stogner SW, George RB. Incorrect use of metered dose inhalers by medical personnel. Chest 1992; 101:31-3 2 Dolovich M, Ruffin RE, Roberts R, Newhouse MT. Optimal delivery of aerosols from metered dose inhalers. Chest 1981; 80:911-15 3 Newman SP, Pavia D, Clarke SW. How should a pressurized beta adrenergic bronchodilator be inhaled? Eur J Respir Dis 1981; 62:3-21 4 Connolly CK. Method of using pressurized aerosols. BMJ 1975; 3:21 5 Lawford P, McKenzie D. Pressurized bronchodilator aerosol technique. Br J Dis Chest 1982; 76:229-33 6 U nzeitig JC, Richards W, Church JA. Administration of metereddose inhalers: comparison of open and closed mouth techniques in childhood asthmatics. Ann Allergy 1983; 51:571-73 7 Tolin-Silver J. Metaproterenol and albuterol metered dose inhalers: a comparison of inhalation technique in chronic asthma [abstract). J Allergy Clio lmmunol 1984; 73:132 8 Thompson A, Traver GA. Comparison of three methods of administering a self-propelled bronchodilator [abstract]. Am Rev Respir Dis 1982; 125:140 9 Swinburn PD, Sexton M. Inhaled bronchodilators: a comparison of different methods of inhaling [abstract]. N Z Med J 1981; 94:340 10 Rachelefsky GS, Rohr AS, W> J, Gracey V, Spector SL, Siegel SC, et al. Use of a tube spacer to improve the efficacy of a metered dose inhaler in asthmatic children. Am J Dis Child 1986; 140:1191-93 11 Mestitz H, Copland J, McDonald CF. Comparison of outpatient nebulized vs. metered dose inhaler terbutaline in chronic airflow obstruction. Chest 1989; 96:1237-40 12 Salzman GA, Pyszczynski DR. Ompharyngeal candidiasis in patients treated with beclomethasone dipropionate delivered by metered-dose inhaler alone and with Aerochamber. J Allergy Clio Immunol 1988; 81:424-28 13 Burton AJ. Asthma inhalation devices: what do we know? BMJ 1984; 288:1650-51 14 Self TH, Brooks JB, Lieberman P, Ryan MR. The value of demonstration and role of the pharmacist in teaching the correct use of pressurized bronchodilators. Can Med Assoc J 1983; 128:129-31
to accomplish the same goals as the open-mouth technique of MDI use (smaller droplets, less deposition in the mouth).• In practice, some patients, including children and working adults, will not carry spacers with them. Children, especially, are very sensitive to anything ~twill alert their peers to the presence of their disease.• Inhalation from functional residual capacity (FRC) was chosen for our study although we did not state that FRC was superior to other starting positions. More important is the rate of inspiratory Bow. However, it seems reasonable that a subject will normally inspire more rapidly from residual volume than from the end of a normal expiration. Finally, we did not include clinical pharmacists in our study because the pharmacists in our hospital are not involved in educating patients in the use of MDis. Certainly, they should participate in patient education if they are able and willing. What matters is not who educates the patients, but that they are properly educated.
Ronald B. George, M.D., F.C.C.P., and G. Gary Guidry, M.D., F.C.C.P., l..oulsiana State University Medical Center;
Shreveport REFERENCES 1 Newman SP, Pavia D, Moren F, Sheahan NF, Clarke SW. Dt>p0sition of pressurized aerosols in the human respiratory tract. Thorax 1981; 36:52-5 2 Newman SP, Moren F, Pavia D, Little F, Clarke SW. Deposition of pressurized suspension aerosols inhaled through extension devices. Am Rev Respir Dis 1981; 124:317-20 3 Dolovich M, Ruffin RE, Roberts R, Newhouse MT. Optimal delivery of aerosols from metered dose inhalers. Chest 1981; 80:911-15 4 Connolly CK. Method of using pressurized aerosols. BMJ 1975; 3:21 5 Orehek J, Gayrard P, Grimaud CH, Charpen J. Patient error in use ofbronchodilator metered aerosols. BMJ 1976; 1:76 6 Harper TB, Strunk RC. Techniques of administration of metered dose aerosolized dmgs in asthmatic children. Am J Dis Child 1981; 135:218-21 7 Unzeitig JC, Warren R, Church JA. Administration of metereddose inhalers: comparison of open- and closed-mouth techniques in childhood asthmatics. Ann Allergy 1983; 51:571-73 8 Guidry GG, George RB. Compliance with drug therapy. Pulmonary/critical care update, vol 6, lesson 1. Northbrook, Ill: American College of Chest Physicians, 1990
Pulmonary Parenchymal Perforation as a Compllcatlon of Placement of a Nasoenterlc Tube
'lb the Editor:
lb the F..ditor:
We thank Drs Self and Rumbak for their comments on our report. We are certainly aware of the article by Newman and his associates, who showed that following actuation of a metered dose inhaler
Nowadays, alimentation is an important aspect of the management of severely ill patients. Therapeutic use of nasogastric feeding dates back at least to John Hunter in the 1790s.' The development of small-diameter catheters for nasoduodenal intubation has facilitated enteral feeding. The incidence of nasotracheal intubation and subsequent pu]monary complications is poorly documented. The misplacement of a nasoenteric feeding tube into the tracheobronchial tree has been reported infrequently relative to the common use of these tubes in clinical practice. From June 1983 to December 1991, 3,875 patients were admitted to our intensive care unit. Placement of a feeding tube was attempted in 2,106 cases. In two patients, a 70-yeaM>ld woman admitted for treatment ofacute respiratory failure due to pneumonia and an 80-year-old man admitted for treatment of head trauma, a
(MDI). most of the aerosol is deposited in the mouth.' They also demonstrated the fact that placing the MDI at a distance from the mouth (using a spacer) results in improved aerosol deposition.• The method of Dolovich et al• was selected for our study because it is widely quoted and is accepted by many physicians who prescribe MDis. The open-mouth technique has been documented by several authors to be preferable to the closed-mouth technique."" Other authors report that the closed-mouth technique is equally effective,' and the FDA has accepted this technique for package inserts. Self and Rumbak state that the argument is moot, since MDls should virtually always be used with spacers. Indeed, spacers are desi~ed
CHEST/ 103 I 1 I JANUARY, 1993