#541 - Nasal Spray Technique, Diagnosing ADHD, Sharing Our Stories

From the Literature and a Question From a Colleague

1)  “Proper” Technique For Use of Allergy Nasal Sprays?

Question:  
“Now that ‘allergy season’ is here, I’m wondering what the evidence is regarding the proper technique for the use of intranasal sprays.  I’ve read and been taught many different things.”

Answer:  

Allergic rhinitis is quite prevalent, affecting approximately 15% of the population based on clinician diagnosis and as high as 30% based on self-reported nasal symptoms.  Intranasal corticosteroids (INS) are considered first-line treatment for allergic rhinitis.  Given the pervasiveness of use, having an evidence-based standardized technique for INS application could be of great potential benefit for optimizing treatment effectiveness and decreasing side effects.  However, there is little published information about the appropriate technique(s) for optimally using these medications. 

The most comprehensive review of nasal spray technique was published in 2004.  Among their findings was a paucity of data regarding optimal technique with notable variation among the recommendations for proper use in the package inserts for the various available medications.  Significant differences included variations in head tilt, differences in the angle the spray should be directed, whether the opposite nostril should be pressed shut while spraying, whether to use the opposite hand when spraying in each respective nostril, and whether there should be any inhalation through the nose or sniff during or immediately after spraying. 

In their conclusions, the reviewers found: “The current available data on the effects of positioning, sniffing or inhaling, and blowing the nose prior to INS administration have not conclusively demonstrated clear differences in either the effectiveness or the safety of these agents. On the basis of evidence concerning the mechanics of existing INS deposition devices, the ease with which patients can use and understand them, and the likelihood that patients will comply with recommendations for their use, the panel has developed guidelines for the use of topical INS sprays.”

Based on their review, the 7-member expert panel recommended the following as a best practice:

1. Hold head in a neutral upright position.
2. Clear nose of any thick or excessive mucus, if present, by gently blowing the nose.
3. Insert spray nozzle into the nostril.
4. Direct the spray laterally or to the side, away from the middle of the nose (septum) and toward the outer portion of the eye or the top of the ear on that side. (If possible, use the right hand to spray the left nostril and left hand to spray the right nostril, to direct the spray away from the septum.)
5. Activate the device as recommended by the manufacturer and with the number of sprays recommended by the doctor.
6. Gently breathe in or sniff during the spraying.
7. Breathe out through the nose.

Mark’s Comments:

It should be noted that the clinical resource UpToDate provides instructions on proper technique to optimize the effects of and adherence with treatment, including a Figure on “How to use a nasal spray properly,” but provides no references for these recommendations.   

My bottom line based on my review as well as clinical and personal experience is that the guidance above seems reasonable, though I do not tell my patients to gently breathe in or sniff during spraying, as I find that this likely leads to more of the medication ending up in the nasopharynx.  As I tell my patients, “If you can taste the medication, you’re not doing it right.”  I also instruct them to not blow their nose for at least 10 minutes and preferably closer to 30 minutes to optimize medication absorption. 

Reference:

·         Benninger M, et al. Techniques of Intranasal Steroid Use.  Otolaryngol Head Neck Surg.  January 2004; 130(1): 5-24.  Link

From the Literature

2)  Diagnosing ADHD in Children and Adolescents

Attention deficit and hyperactivity disorder (ADHD) has a worldwide prevalence of between 5 and 10% in children. It is certainly common in primary care practices, and, given the shortage of child/adolescent mental health services in many areas, primary care clinicians generally must be responsible for the care of these patients. The medications used, while effective, can be dangerous in terms of both side effects and potential for misuse, and the outcomes at risk are the education and socialization of children. Correct diagnosis, then, is of utmost importance.

A systematic review was published last month in the journal Pediatrics evaluating all possible tools used in the diagnosis of ADHD: “parental ratings, teacher ratings, youth self-reports, clinician tools, neuropsychological tests, biospecimen, electroencephalography (EEG), and neuroimaging.” The authors performed a comprehensive search of multiple databases, had explicit inclusion criteria (patients <18 years, a reference standard of an examination by a licensed mental health provider using the Diagnostic and Statistical Manual, version 5 (DSM-V)), and critically appraised the studies.

The authors evaluated over 23,000 studies and selected the reports of 231 studies that met criteria. The strength of evidence was overall low-moderate and the supporting evidence for each set of diagnostic tools varied in its strength. For results, each category of assessment had associated ranges of sensitivity and specificity, but it is more expedient to report the “area under the curve” (AUC) for these tests. AUC is a commonly used statistic in diagnostic testing that reflects the best balance (therefore the most clinical utility) between sensitivity and specificity in a diagnostic test. The AUC ranges for each group (0.5 is useless, 1.0 is perfect) were:

• Parent rating:  0.55 to 0.95
  • Child behavior checklist (CBCL) only:  0.83 to 0.84
• Teaching rating:  0.65 to 0.84
• Combined rating (parents and teachers):  0.86
  • With machine learning (ML):  0.98
• Self-rating:  0.56 to 0.85
• Other testing (interview guides, activity trackers, etc.):  0.75 to 0.9996
• Neuropsychologic testing:  0.59 to 0.93
• Biospecimen:  0.68 to 1.00
• EEG:  0.63 to 1.00
• Neuroimaging (MRI, fMRI, aided by ML):  0.58 to over 0.99

The sensitivities of these tools varied widely by setting; they were lower in primary care compared with behavioral health settings. The specificities were much more consistent between settings. These tests were better at distinguishing ADHD from a “neurotypical” population than they were at distinguishing ADHD from other behavioral disorders. There was general inconsistency in parent vs. teacher rating scales, which could indicate either different behavior in each setting or poor instrument performance between settings. Neuropsychological testing, frequently assumed to be more “diagnostic,” performed no better than the rating scales.

John’s Comments: 

Examining the numbers in the AUC column above tells me that research in this area has not settled. The CBCL seems to be the most consistently good symptom checklist. Combining parent and teacher ratings is not necessarily better than parent rating alone but may be useful to get a full picture of behavior across settings. In addition, there doesn’t seem to be much benefit from routine use of neuropsychiatric testing, imaging, or other advanced testing over just symptom scores. Thoughtful use of readily available tools in primary care is frequently all that is needed.

In the introduction, the authors note that, based on rigid diagnostic criteria, the prevalence of ADHD is 5%, but based on clinical diagnosis, it reaches up to 10%. One explanation for this may be symptoms that are impairing but don’t reach the rigid thresholds for diagnosis. But another explanation has been shown to be cultural bias; ADHD is diagnosed more in boys, in poor families, and in whites. It is important to use standard diagnostic tools like rating scales and to work against this potential for bias when interpreting the ratings.

Reference:

·         Peterson BS, Trampush J, Brown M, et al. Tools for the Diagnosis of ADHD in Children and Adolescents: A Systematic Review. Pediatrics. Published online March 25, 2024:e2024065854. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Helping Each Other Carry the Weight of Our Professional Burdens

“Owning our story and loving ourselves through that process is perhaps the bravest thing we will ever do.”  Brené Brown

Imagine eleven physicians sitting in a circle, devoting an hour together to process their “collective stories” of professional challenges.  While for some that may be hard to imagine, that is exactly what I did with 10 other colleagues last week.  After a brief introduction, we each read a short, prepared vignette we had been given about a professional struggle that had been experienced by a colleague.  While none had been written by the group, each one read sounded eerily familiar.

“One of my colleagues appears completely burned out and I worry about them but am hesitant to say anything because I don’t want to make them defensive or appear to think that I know what’s best for them.  And I feeling pretty crispy myself!” read the first.  Then after a brief moment of silence and already some knowing nods, the next was read.  “By the time I get home after a day at work I am often so exhausted that I can’t even pretend I’m excited to see my partner and children.  And our sex life has tanked and sadly, I’m not sure I really care,” read the next with more nods and a few fleeting grimaces of recognition.  

And so we continued around the circle.  After some time for quiet reflection, we then shared what spoke to us, what we identified with, and how these stories related to our own experience and the professional burdens we carried.  Similar to the many other “Burdens and Blessings” workshops I have co-facilitated for medical students, residents, and practicing physicians across numerous specialties, our burdens were plentiful.  Likewise, with our sharing, we were also comforted in our realization that we were not alone in our experience of them. 

As often happens, one of the group reminded us that these challenges were part of “what we signed up for.”  Certainly our professional training and socialization would have us believe this.  If this is true, then where do our “human selves” go to share and begin to process all our stories of the tragedy, despair, powerlessness, woundedness, pain and loss we see daily in our work?  For too many of us, the answer is ”nowhere and with no one,” as most have had no modeling for doing so, and often no encouragement.  Instead, we carry these burdens by ourselves, concluding that since others appear to be adeptly handling these challenges, we must be weak or flawed because we are finding them overwhelming.  And so we struggle in silence and too often are left feeling isolated and alone.

The work we do is good and important work, and yes, we knew it would be hard, but that in no way justifies our allowing it to break us.  The PeerRxMed process was created to help dismantle the many barriers the culture of medicine has created which interfere with our fundamental human need to connect with and support each other on our professional journey.  With my PeerRx partners, I’ve found a safe space where we can share our stories – stories of grief, of burdens, of loss, and also of the many blessings of our work.  Please don’t keep the stories you carry bottled up inside.  We need to share our stories with each other.  No one should carry their professional burdens alone. 

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org