Knowledge of Oxygen Administration,Aerosol Medicine,and Chest Physiotherapy Among Pediatric Healthcare Workers in Italy

Introduction

Respiratory tract diseases are among the most frequent clinical problems in pediatrics, especially in the first years of life.^(1–3) To deal with some of these (especially hyperactive airway diseases) pediatricians, pediatric residents, and pediatric nurses need to be able to use simple devices for blood oximetry and the direct administration of drugs to the respiratory tract,^(4,5) know which topically administered drugs are the most useful for each respiratory disease,^(6,7) and know when and how chest physiotherapy should be used.^(8,9) This knowledge is clearly important when caring for hospitalized children, but becomes essential in the case of discharged patients being cared for at home by their parents. If hospital workers have a problem themselves, they can usually turn to a colleague for help; however, their lack of knowledge means that they are in no position to inform or instruct parents, which can lead to very poor control of a child's respiratory disease at home and, consequently, more frequent unscheduled ambulatory visits, more Emergency Department visits, and more hospital admissions.

Many studies of mainly adult and elderly patients have tried to verify whether the knowledge of respiratory diseases among healthcare workers negatively affected diagnosis and/or treatment and required the introduction of a specific educational program.^(10–22) A number of these have highlighted some glaring gaps in the knowledge of pulse oximetry among nurses, doctors, and allied health professionals even though all of them use this technology frequently.^(10–13) Moreover, it has been estimated that 39–67% of nurses, doctors, and respiratory therapists cannot adequately describe or perform critical steps in the use of inhalers,^(14–21) and that the ability of clinicians to use inhalers is typically 5–8 years behind the introduction of new devices.⁽²²⁾ Experience concerning different chest physiotherapy techniques has also been found to be very limited, which is particularly worrying for patients with cystic fibrosis or other chronic respiratory diseases.^(23–27)

Unfortunately, there are few published data concerning children and little is known about healthcare professionals' knowledge of oxygen administration, aerosol drugs and inhalation devices, or the use of chest physiotherapy in pediatrics. The aim of this study was to fill this gap as a preliminary step in the implementation of educational programs designed to cover all of the areas that should be known by pediatric healthcare workers involved in the management of children with respiratory disease.

Materials and Methods

Results

Of the 900 distributed questionnaires, 76.7% were completed and returned by 606 physicians (199 primary care pediatricians, 245 hospital pediatricians, and 162 pediatric residents), and 84 pediatric nurses. The group response rates were 66.3% for primary care pediatricians (p < 0.05 versus the other groups), 81.7% for hospital pediatricians, 81.0% for pediatric residents, and 84.0% for pediatric nurses.

Table 1 shows the general characteristics of the responders, most of whom were women, worked in urban setting, and cared for more than 1000 children with respiratory distress every year. The mean ages of the pediatric residents and nurses were significantly lower than those of the primary care and hospital pediatricians; there were no other significant between-group differences.

Table 2 shows the data regarding oxygen administration. Although most of the respondents knew that the administration of oxygen was the best means of treating children with cyanosis and very low blood oxygenation levels who required pulse oximetry, and that the oxygen had to be humidified, the great majority did not know the percentage of hemoglobin saturation indicating hypoxemia and the need for oxygen administration. The highest number of incorrect answers to the questions in this section was given by the primary care pediatricians.

Table 3 summarizes the data concerning aerosol treatment. Although the majority of respondents in each group knew the aerosol devices recommended in clinical practice and how to manage them, a considerable number did not have any precise idea. The highest number of incorrect answers to the questions in this section was given by the pediatric nurses.

Table 4 shows the knowledge of drugs administered by aerosol devices or inhalers. Most of the nurses admitted to overusing mucolytics and inhalatory corticosteroids, did not know the role of ipratropium bromide, were unable to indicate the first-line drug for respiratory distress, and did not know the correct dose of salbutamol. However, regardless of their role, a large number of the physicians also overused inhalatory corticosteroids. The highest number of incorrect answers to the questions in this section was again given by the pediatric nurses; among the three groups of physicians, hospital pediatricians showed the best knowledge.

Table 5 shows the data regarding chest physiotherapy. Most of the responders in all of the groups gave wrong answers. In particular, only a minority answered that chest physiotherapy was not indicated in children with bronchiolitis, pneumonia, or chronic asthma, or knew the best physiotherapy for a child with chronic respiratory disease. Only the hospital pediatricians were aware that the usefulness of chest physiotherapy has mainly been demonstrated in children with cystic fibrosis.

Table 6 shows the scores of the four groups. The nurses had the lowest score regardless of age, gender, work setting, and experience of caring for a large number of children with respiratory distress every year; among the pediatricians, the hospital pediatricians had the best score.

Discussion

This is the first study globally evaluating the problems related to the use of pulse oximetry, aerosol therapy, and chest physiotherapy in pediatrics. It consequently provides an overall evaluation of the level of knowledge of these subjects among healthcare workers caring for children with respiratory disorders, which can be used to suggest how to implement educational programmes.

The results show that the knowledge of primary care pediatricians, hospital pediatricians, and pediatric nurses in Italy concerning the use of pulse oximetry, aerosol devices and drugs, and chest physiotherapy is far from satisfactory, and that the lack of knowledge seems to be significantly more important among pediatric nurses. This finding is clinically relevant because nursing staff are not only responsible for administering therapy to hospitalized children but, in many hospital wards and Emergency Departments, they are also responsible for instructing parents in the correct use of respiratory devices for discharged children. However, a considerable number of pediatricians also gave wrong answers to the questions regarding the use of aerosol devices and drugs, which could be particularly important in the community where children may be registered with a physician who cannot explain how and when to use a device.

The data relating to oxygen and aerosol administration in this article are quite similar to those previously collected in different geographic areas among healthcare workers looking after adult and elderly patients,^(10–22) but provide new information concerning the overall knowledge of pediatric healthcare professionals. Moreover, there are few published studies of the knowledge of drugs usually administered by means of aerosol devices or inhalers with spacers.

In this regard, our results indicate that most of the nurses knew little about when and how to use any of the usually prescribed inhaled drugs. The knowledge of the pediatricians was significantly better, but not completely satisfactory because, although they correctly answered all of the questions regarding ipratropium bromide and salbutamol, most of them failed to indicate the correct use of inhalatory corticosteroids. The nurses' lack of knowledge of the pharmacological approach to respiratory diseases is of relative importance because they often only have to administer drugs mainly prescribed by physicians. However, the pediatricins lack of knowledge of the use of corticosteroids is clinically highly important is because it can lead to drug abuse or misuse. This finding could have been expected because it is well known that, although the official guidelines do not suggest administering corticosteroids to treat bronchiolitis or infectious wheezing, they are widely prescribed for infants and young children with these diseases throughout the world.^{(28,28,35,36)} Furthermore, a recent survey found that 93% of the responding pediatricians considered inhaled corticosteroids very safe for asthmatics and tended to make extensive use of them.⁽³⁷⁾

Finally, our data indicate that most of the responders did not know when and how chest physiotherapy should be used. This may explain why most healthcare workers routinely prescribe airway clearance techniques for acute respiratory diseases in infants and children (although it has been clearly demonstrated that they do not play a significant role in disease outcomes)^(26,27) and misuse them in children with chronic disease.^(23–25) These findings clearly suggest that educational programmes concerning rational approaches to respiratory diseases should include the use and real value of chest physiotherapy.

One of the limitations of this study is that, although the general characteristics of the pediatric healthcare workers registered at the Annual Congress of the Italian Society of Pediatrics and of those who completed the questionnaire were similar to those of Italian pediatric healthcare workers as a whole,^(38–40) it is possible that those who were more interested in the subject were more willing to participate in the survey. In this case, we may have overestimated the general level of healthcare workers' knowledge. Moreover, the survey was not designed to detect geographical differences and a larger sample size may have allowed such a comparison. Furthermore, it describes the Italian situation among pediatric healthcare workers and results from other countries as well as other categories of healthcare workers could be different. However, in our previous experiences using questionnaires for obtaining indications for education, results were useful for several other countries and permitted to fill gap in knowledge in different settings.^{(38,39,41,42)}

Global evaluation of all of the data collected with this study indicates that educational programs covering oxygen administration, the use of aerosol devices and drugs, and the use of chest physiotherapy in infants and children with respiratory diseases should be planned for pediatric nurses and pediatricians, but more urgently for the former. The programs should cover all of the subjects analyzed in this survey, but particular attention should be given to the use of inhalation devices and chest physiotherapy for nurses, and the use of aerosol drugs and chest physiotherapy for pediatricians and pediatric residents. On the other hand, it is reasonable to conjecture that inappropriate treatment is associated with increased risk to the patient and extensive additional procedures to deal with mistreated patient.

Finally, regardless of their targets, it must be remembered that although educational programs can be highly effective,⁽⁴³⁾ their effects may be limited in time.⁽⁴⁴⁾ It has been shown that the impact of a single teaching session on the use of a metered dose inhaler lasted for two months after training,⁽⁴⁴⁾ and so educational programs need to be repeated, especially when new devices are marketed. It is only by improving these programs that we can be more confident that pediatric healthcare workers can adequately administer oxygen, aerosol therapy, and chest physiotherapy, and correctly care for children with respiratory disease.