RESPIRATORY CARE Paper in Press. Published on September 25, 2018 as DOI: 10.4187/respcare.

06302

Imperative Instruction for Pressurized Metered-Dose Inhalers:

Provider Perspectives
Daniel C Schmitz, Rebecca A Ivancie MD, Kyung E Rhee MD MSc MA, Heather C Pierce MD,
Alicia O Cantu MD, and Erin S Fisher MD

BACKGROUND: Reports show that many patients do not use their pressurized metered-dose
inhalers (pMDIs) effectively. The National Heart, Lung, and Blood Institute recommends that
health-care providers educate and assess patients’ pMDI technique at each opportunity. However,
limited data exist regarding how often pediatric primary care providers perform assessments and
which methods they use. We sought to (1) identify instructional methods used to teach pMDI use,
(2) describe how pMDI use is reassessed at follow-up visits, and (3) describe primary care provider
attitudes and barriers to in-office pMDI instruction. METHODS: A 34-item electronic survey was
distributed from August to December 2016 via E-mail to local pediatric primary care providers.
Descriptive statistics were used for analysis. RESULTS: Sixty two of 223 potential primary care
providers (28%) responded. Physicians and nurse practitioners were identified most often as the
providers of pMDI education (53%). When first prescribing a pMDI, only 10% reported having
the patient practice inhaler use in the office and receive feedback. Only 19% “always” reassessed
the technique, even for patients with poorly controlled asthma. Among those who reassessed the
technique, most (76%) did so verbally, and only 42% asked the patients to demonstrate pMDI use.
Only 32% reported that typical patient education in their setting was adequate to ensure proper
pMDI use. Commonly cited barriers included time (84%) and access to demo pMDIs (67%).
Provider solutions included video tutorials and access to demo inhalers. CONCLUSIONS: Many
pediatric primary care providers did not demonstrate or have patients practice pMDI use when
teaching or assessing pMDI technique, and the reassessment rate was low even for patients with
poorly controlled asthma. Identifying and training a consistent pMDI educator and obtaining demo
pMDIs may abate some barriers. Respiratory therapists could appropriately fulfill this educator
role. Brief, repeated pMDI practice for motor learning could promote more stable pMDI mastery.
Key words: asthma; metered-dose inhaler; education; reassessment; technique; motor learning. [Respir
Care 0;0(0):1–•. © 0 Daedalus Enterprises]

Introduction States.1 In many cases the disease is managed by using

inhaled medications dispensed via common devices such
Asthma is a common and potentially debilitating chronic as pressurized metered-dose inhalers (pMDIs). The proper
disease that affects ⬎6.2 million children in the United use of such devices is essential to effective medication
administration because up to 80% of medication may be

Mr Schmitz is affiliated with the University of California San Diego

School of Medicine, La Jolla, California. Dr Ivancie is affiliated with the University of California San Diego School of Medicine, San Diego,
Division of Hospital Medicine, Department of Pediatrics, Stanford Uni- California.
versity School of Medicine, Palo Alto, California. Dr Rhee is affiliated
with the Division of Academic General Pediatrics, Child Development, Mr Schmitz presented part of these data at the American Academy of
and Community Health, Department of Pediatrics, University of Califor- Pediatrics National Convention and Exhibition, held September 16–19,
nia San Diego School of Medicine, La Jolla, California. Drs Pierce, 2017, in Chicago, Illinois.
Cantu, and Fisher are affiliated with the Rady Children’s Hospital and
Health Centers, Division of Hospital Medicine, Department of Pediatrics, The authors have disclosed no conflicts of interest.

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pMDI INSTRUCTION IN PEDIATRIC PRIMARY CARE

lost due to improper technique.2 Studies have shown that

28% to 68% of subjects of all ages did not use their inhaler QUICK LOOK
effectively enough to benefit from the prescribed medica- Current knowledge
tion.3,4 In addition, poor inhalation technique has been
Proper pressurized metered-dose inhaler (pMDI) use is
associated with excess use of health-care resources, in-
essential for management of asthma symptoms, but there
cluding hospitalizations, emergency department visits, and
are reports that many patients do not use them effec-
additional courses of oral corticosteroids.5 Establishing and
tively. The National Heart, Lung, and Blood Institute
sustaining proper inhaler technique, therefore, represents a
recommends that health-care providers educate and as-
low-cost intervention vital to successful long-term asthma
sess patients’ pMDI technique at each opportunity. There
management.
are limited data about how often pediatric primary care
A variety of educational techniques have been shown to
providers perform assessments and the methods they
improve inhaler technique in the short term.6 However,
use.
skills in inhaler use deteriorate over time,6,7 which indi-
cates that a single instruction session may not be sufficient What this paper contributes to our knowledge
for patients to maintain proper technique. Previous studies
have shown that repeating instruction sessions, demon- Many pediatric primary care providers did not demon-
strating inhaler technique to patients, and having patients strate or have patients practice pMDI use when teach-
return the demonstration were all associated with higher ing or assessing pMDI technique. The reassessment rate
rates of proper technique at follow-up visits.5,8-11 These was low, even for patients with poorly controlled asthma.
aspects of effective inhaler instruction were incorporated Commonly cited challenges included time, access to
into the National Heart, Lung, and Blood Institute (NHLBI) demo pMDIs, perceived patient disinterest, and lan-
guidelines.12 These guidelines recommend that providers guage barriers.
teach and reinforce inhaler skills at every visit by demon-
strating inhaler technique, having the patient return the
demonstration, and offering feedback.
Analysis of existing data, however, indicates that health- providers do not implement NHLBI guidelines12 regarding
care providers do not consistently follow the NHLBI guide- pMDI instruction in their practices.
lines12 for inhaler instruction. In one study of 5 general These studies were limited in scope, however, because
pediatric clinics in North Carolina, providers demonstrated the former did not address reasons for suboptimal instruc-
inhaler technique to just 3.8% of children who used pM- tion, whereas the latter focused on providers in pediatric
DIs and asked only 5.4% of these children to demonstrate primary care settings that serve as residency training sites
their inhaler technique during the clinic visit.13 Many of in an urban low-income community.13,14 The goal of our
the children in this study were subsequently found to make study was to further examine how pMDI instruction takes
several errors in inhaled medication administration.13 Sim- place in a wider range of out-patient settings and what
ilarly, in a recent survey of pediatric out-patient providers challenges remain to effective instruction. We aimed to
in New York, only 5.3% of providers reported demonstrat- describe instructional methods used to teach pMDI use
ing the pMDI technique at every visit and just 13.3% and identify who performs this teaching, describe how
reported assessing patient technique at every visit.14 When pMDI use is reassessed at follow-up visits, and describe
asked to identify barriers to demonstrating and assessing provider attitudes and self-reported barriers with regard to
pMDI technique, providers cited a lack of access to pMDI in-office pMDI instruction. We hypothesized that, in these
devices, time, and knowledge of proper steps in pMDI use, out-patient settings with differing care delivery models,
and patient or parent disinterest in learning or in demon- there would not be a single common instructional method
strating the proper technique.14 Together, results of these used for pMDI instruction but that methods would include
studies13,14 indicate that, for a variety of reasons, many verbal instructions and the use of printed material, that
providers would report not assessing and providing pMDI
instruction as recommended by the NHLBI12 at follow-up
visits, and that providers would report varied barriers to
Supplementary material related to this paper is available at http:// delivering pMDI instruction.
www.rcjournal.com.

Correspondence: Erin S Fisher MD, Rady Children’s Hospital and Health Methods
Centers, Division of Hospital Medicine, Department of Pediatrics, Uni-
versity of California San Diego School of Medicine, 7960 Birmingham
Drive, San Diego, CA 92123. E-mail: estucky@rchsd.org. This cross-sectional survey-based study was conducted
in San Diego County between August and December 2016.
DOI: 10.4187/respcare.06302 Several out-patient pediatric practice types, including an

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pMDI INSTRUCTION IN PEDIATRIC PRIMARY CARE

academic center (1 group), large pediatric group practices providers were also asked about the frequency of pMDI
(5 groups), federally qualified health centers (1 group), technique reassessment both when a patient’s asthma is
and private practices (6 groups), were included. Leaders and is not well controlled and about the mode used to
within each of these groups were asked to distribute the evaluate technique.
survey link via E-mail to pediatric physicians, nurse prac- To assess attitudes about pMDI education, the providers
titioners, and physician assistants (N ⫽ 223) within their rated their level of agreement with several statements, such
group by using the E-mail addresses in active use for their as “proper inhaler technique plays a significant role in
respective providers. The survey was distributed 4 times asthma control,” and “given my current time and resources,
within a 4-month period to increase response rates. No I am able to regularly assess patients’ inhaler technique in
incentive was provided for participation. This study (Ap- standard office visits.” The 5-point Likert scale answer
proval Project 160646) was approved by the University of choices ranged from 1 [strongly disagree] to 5 [strongly
California San Diego Human Research Protections Pro- agree].
gram. To assess potential barriers to pMDI education, the pro-
viders were asked to identify the most significant barriers
Survey to regular assessment of patient’s inhaler technique. An-
swer choices included time, access to inhaler devices, health
A 34-item survey was developed to assess pMDI in- providers’ knowledge of proper inhaler technique, lan-
structional practices and provider attitudes, and perceived guage differences between the provider and patients, the
barriers to pMDI instruction. Because there were no pre- lack of interest of patients in proper inhaler technique, no
viously validated instruments on this topic, questions were significant barriers, and a free-response option. The pro-
generated based on peer-reviewed literature13,14 and clin- viders were queried on how they learned the proper steps
ical experience. Questions were reviewed and revised by in inhaler use and how they learned to teach these steps to
us. Items included multiple choice, Likert scale, and free- patients. Answer choices consisted of personal experience,
response formats. The survey included questions regarding personal research, training during medical or nursing
the following: type of medication delivery device prescribed school, training during residency, a resource (eg, pam-
and prescribing habits, form and frequency of pMDI ed- phlet, video) at their practice, another health-care provider,
ucation and reassessment, attitudes toward inhaler educa- an organized training, “I have not learned,” or “other,”
tion, perceived barriers to inhaler education, personal ed- with an option for free response. The providers were also
ucational experiences regarding how to use an inhaler and asked to rate their confidence in their ability to teach the
how to teach these steps to patients, confidence in and proper technique and their perception of the effectiveness
perceived effectiveness of their instruction, and methods of their instruction. The 5 answer options ranged from “not
or resources that the providers thought would be most at all confident/effective” to “completely confident/effec-
effective to teach proper technique (for survey questions, tive.” We included a final free-response question that asked
see the supplementary materials at http://www.rcjournal. providers to identify, assuming no barriers, what methods
com). The survey was formatted for distribution within an or resources would be most effective to teach patients the
online platform (SoGoSurvey, Herndon, Virginia, https:// proper inhaler technique.
www.sogosurvey.com/). Demographic information consisted of sex, type of med-
To assess who delivers asthma and pMDI education, the ical training (Doctor of Medicine [MD], Doctor of Osteo-
providers were asked how often they deliver such educa- pathic Medicine [DO], Nurse Practitioner [NP], Regis-
tion themselves and who else besides them provides pMDI tered Nurse [RN], Physician Assistant [PA], Medical
education in their practice. The responses to these 2 ques- Assistant [MA], or Licensed Vocational Nurse [LVN]),
tions were pooled and categorized into 5 groups: physician years in practice (0 – 4, 5–9, 10 –14, or ⱖ15), and the
or nurse practitioner; medical assistant, physician assis- providers’ personal experience with asthma, including
tant, registered nurse, licensed vocational nurse, or asthma whether they have active asthma or have a child with
educator; other; no one; and unsure. active asthma and whether they or their child uses an
To assess inhaled medication prescribing habits, the pro- inhaler with a spacer. The providers were asked to identify
viders were asked about the device they most often pre- their practice setting (independent private practice, large
scribe and how often they prescribe spacers to several age single- or multiple-specialty group private practice, Kaiser
groups (0 –3, 3– 6, 6 –12, and ⬎12 y). To assess educa- Permanente associated, university associated, federally
tional methods, the providers were asked to select all ed- qualified health center, military associated, or other) and
ucation modes used for initial pMDI instruction, including to describe their patient population (percentages with
verbal, provider demonstration; patient practice of pMDI asthma, speak Spanish, or receive Medicaid insurance).
use with provider feedback; and provision of printed ma- Use of a Spanish translator was also queried (1 [never] to
terials, a training video, or a computer-based tutorial. The 5 [always]).

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pMDI INSTRUCTION IN PEDIATRIC PRIMARY CARE

Table 1. Provider Demographics practitioners provided pMDI education most often (53%),
followed by physician assistants, medical assistants, nurses,
Demographics n (%)
and asthma educators (27%). Several providers (11%) were
Sex unsure if anyone other than themselves provided inhaler
Women 48 (77) education. Nearly all the respondents, 95% (59/62), agreed
Men 14 (23) that proper inhaler technique plays a significant role in
Practice setting asthma control, and 97% (60/62) agreed that patients should
Private practice: large single- or multi-specialty group 38 (61)
receive formal instruction in inhaler use when first pre-
Federally qualified health center 12 (19)
scribed a new inhaler. When instructing a patient in pMDI
Private practice: independent 6 (10)
University associated 6 (10)
use for the first time, 81% (50/62) reported giving a verbal
Medical training description of proper technique and 52% (32/62) demon-
Doctor of medicine 52 (84) strated the use of the inhaler. Only 10% (6/62) reported
Nurse practitioner 7 (11) having the patient practice the use of the inhaler in the
Doctor of osteopathic medicine 2 (3) office and receive feedback (Fig. 1). Overall, 65% (40/62)
Physician assistant 1 (2) reported that they were mostly or completely confident in
In practice their ability to teach the pMDI technique, and 48% (30/62)
0–4 y 12 (19) thought their instruction was mostly or completely effec-
5–9 y 15 (24) tive.
10–14 y 5 (8)
ⱖ15 y 30 (48)
Repeated Instruction

Data Analysis Most providers, 85% (53/62), agreed that patients re-
quire periodic reassessment of their inhaler technique to
Standard summary statistics (means and frequencies) ensure maintenance of pMDI skill over time. However,
were used to describe patient and provider demographics, only 19% of the respondents (12/62) reported “always”
and provider practices and attitudes about pMDI educa- reassessing pMDI technique when a patient’s asthma is
tion. Five-point Likert scale responses were categorized not well controlled. When reassessing technique at fol-
into 3 groups, combining groups “1 and 2” and “4 and 5” low-up visits, 76% (47/62) reported asking patients for a
to create a 3-point scale. Free-response answers were re- verbal description of how they used their inhaler, and 42%
viewed and summarized into recurrent themes. We (DS, (26/62) reported asking the patient to demonstrate the use
KER, ESF) reviewed the responses and achieved consen- of his or her inhaler (Fig. 2).
sus on categorizations and themes.
Barriers and Solutions
Results
Overall, only 32% of the respondents (20/62) thought
The response rate was 28% (62/223); 54 physicians and
that the typical patient education in their setting was ade-
8 nurse practitioner/physician assistants participated. Pro-
quate to ensure proper inhaler use. Just 23% (14/62) agreed
vider demographics are shown in Table 1. The majority of
that they were regularly able to assess patients’ technique
the responding providers, 71% (44/62), were associated
in standard office visits. Commonly cited barriers to in-
with private practice groups of varying sizes, whereas 19%
haler education included time, access to a demo inhaler,
(12/62) were from federally qualified health centers, and
lack of patient interest, and language differences between
10% (6/62) were from university-associated practices. All
providers and patients (Fig. 3). Frequently identified so-
the respondents identified at least a 5% prevalence of asthma
lutions included providing physicians access to demo in-
in their practice, and 35% (22/62) estimated that ⱖ15% of
halers and creating computer tutorials to assist patients in
their own patients had asthma. More than one third of the
learning proper pMDI technique.
providers reported either having active asthma themselves
or a child with active asthma. The majority of the provid-
Discussion
ers, 58% (36/62), reported prescribing pMDIs to patients
with asthma ages 0 –3 y, whereas ⬎93% prescribed pMDIs
In our survey of 62 pediatric out-patient providers in
to patients with asthma in each of the remaining age groups.
San Diego County, we found a notable disparity between
Initial Instruction provider attitudes and actual practices pertaining to pMDI
technique instruction and assessment. Almost all the pro-
Approximately a third of respondents reported “always” viders agreed that formal pMDI instruction was important
delivering education about inhaler use. Physicians and nurse for asthma control. However, most providers in our study

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pMDI INSTRUCTION IN PEDIATRIC PRIMARY CARE

100

Proportion of providers (%)

80

60

40

20

0
Verbal Provider demo Print Practice-feedback Other

Fig. 1. Methods of initial pressurized metered-dose (pMDI) inhaler use instruction. Verbal ⫽ verbal instruction; provider demo ⫽ health provider
demonstrates pMDI use; print ⫽ printed material provided; practice-feedback ⫽ patient practices pMDI use and receives feedback.

80
Proportion of providers (%)

60

40

20

0
Verbal Patient demonstrates Ask about None Other
confidence
Fig. 2. Methods of pressurized metered-dose inhaler (pMDI) technique reassessment. Verbal ⫽ provider asks the patient for a verbal
description of pMDI technique; patient demonstrates ⫽ provider asks the patient to demonstrate pMDI use; ask about confidence ⫽
provider asks the patient about the patient’s confidence in pMDI use; none ⫽ provider does not regularly reassess pMDI technique.

did not adhere to the NHLBI guidelines12 that recommend latory pediatric practices is not new, it is most often re-
demonstrating inhaler technique and having patients prac- ported in subspecialty clinic settings.15,16 Respiratory ther-
tice and receive feedback. Previous studies show that sub- apists may not have been a consideration by respondents
jects who were taught in this manner were more likely due to a lack of exposure to this kind of integrated care
than others to demonstrate proper technique at follow-up team model in the primary care setting. Extending respi-
visits.8,9,11 In our study, just over half of the providers ratory therapists’ expertise to the general ambulatory pe-
reported demonstrating inhaler use to patients when first diatric sites could also improve the quality of instruction
prescribing pMDIs, and only 10% reported having patients of medication administration.
practice pMDI use and receive feedback. This suboptimal The providers also did not adhere to NHLBI guide-
initial education may contribute to the elevated rate of lines12 regarding assessment of inhaler technique at fol-
inadequate pMDI technique that has been identified pre- low-up visits. Despite agreement that periodic reassess-
viously.3 Respiratory therapists could help fill this educa- ment is needed to ensure the proper pMDI technique, ⬍20%
tion gap because they have been successful in assessing of the providers reported always reassessing the technique
and teaching this technique to patients and families.15-17 even when asthma was poorly controlled. When they did
Although involvement of respiratory therapists in ambu- reassess technique, fewer than half reported having the

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pMDI INSTRUCTION IN PEDIATRIC PRIMARY CARE

100

Proportion of providers (%)

80

60

40

20

0
Time No demo MDI Patient Language Provider None Other
disinterest differences knowledge

Fig. 3. Barriers to assessment of pressurized metered-dose inhaler (pMDI) technique. No demo pMDI ⫽ lack of access to a pMDI for
demonstration; patient disinterest ⫽ lack of patient interest in learning proper inhaler technique; language differences ⫽ language differ-
ences between provider and patient; provider knowledge ⫽ lack of provider knowledge of pMDI technique.

patient demonstrate the proper use of his or her inhaler. from a skilled provider. Supplying clinics with demo pMDIs
This low rate of reassessment represents a missed oppor- would support the ability to regularly perform pMDI in-
tunity to improve patients’ inhaler use skills because re- struction. Further studies are needed to explore the impact
peated instruction and patient demonstration of inhaler use of perceived patient disinterest and language differences
have both been associated with improved technique.5,9-11 on pMDI use education.
Without reassessing patient skills, many providers may not The above-mentioned interventions could also facilitate
recognize how pMDI use may play into their patients’ a complementary approach to pMDI education supported
adherence to medication regimens. Although further study by theories of motor learning. Proper use of a pMDI in-
is needed to assess the impact of improved inhaler tech- volves motor skills that require coordinating several move-
nique on clinical outcomes,18 interventions to enhance ment tasks with an appropriate order and timing. Although
pMDI instruction and skill reassessment have the potential motor skills can be mastered effectively during brief ses-
to facilitate better disease management through improved sions spaced over days,19,20 ongoing skill use and training
pMDI use. are needed to maintain proficiency over time.6,7 Therefore,
Most providers in this study recognized that patient ed- pMDI use could be most efficiently learned through brief
ucation in their setting was inadequate to ensure proper but consistent practice in the days after initial instruction until
inhaler use. Barriers to assessing patient technique included the skill is mastered, coupled with reassessment and retrain-
time, access to demonstration inhalers, patient disinterest, ing to assure that the skill is retained. An up-front investment
and language differences between patients and providers. in the time and resources for this strategy could have long-
The providers suggested solutions, including access to sam- term implications for improved asthma management.
ple pMDIs and computer tutorials. Analysis of these data Despite our key findings of areas for improvement in
supports the work of Reznik et al14 that similarly identified the teaching and assessment of pMDI use, there were a
time and access to sample pMDIs in the clinic as signifi- few limitations to consider. Our responses were obtained
cant challenges. Providers in that study, as well as ours, via an online survey. Although this method was chosen to
suggested that having a nurse or health educator deliver decrease participant burden and increase the response rate
asthma education could alleviate time constraints.14 A log- across a range of practice settings, it may instead have
ical extension of this idea would be to embrace a true resulted in fewer respondents. Survey methodology can
interdisciplinary practice or collaborative care model in also limit the range of responses that are captured. Tele-
which respiratory therapists perform this educator role. phone surveys, key informant interviews, or focus groups
Using computer tutorials could similarly streamline pMDI would have allowed for a greater range of responses and
use education and would be useful in addition to or inte- exploration of barriers about pMDI instruction. Survey
grated with in-person education. Such tutorials used in research has limitations, such as data entry errors, reliance
isolation, however, could not accomplish the key step of on memory, and dependence on respondents’ correct in-
having patients practice pMDI use and receive feedback terpretation of the questions. There may also have been a

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pMDI INSTRUCTION IN PEDIATRIC PRIMARY CARE

response bias because the participants who have a vested Has Patient Technique Improved Over Time? Chest 2016;150(2):
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vey. The self-report design also raised the possibility of
Gruppo Educazionale Associazione Italiana Pneumologi Ospedalieri.
discrepancies between provider perceptions and actual prac- Inhaler mishandling remains common in real life and is associated with
tices within the clinics. Unfortunately, we were unable to reduced disease control. Respir Med 2011;105(6):930-938.
objectively assess the competency of the providers in their 6. Klijn SL, Hiligsmann M, Evers SMAA, Román-Rodríguez M, van der
pMDI technique. Also, the relatively small sample size Molen T, van Boven JFM. Effectiveness and success factors of educa-
and low response rate limited the generalizability of our tional inhaler technique interventions in asthma & COPD patients: a
systematic review. NPJ Prim Care Respir Med 2017;27(1):24.
data and precluded potential subgroup analysis, including
7. Munzenberger PJ, Thomas R, Bahrainwala A. Retention by children of
variation in pMDI use education by practice type. For this device technique for inhaled asthma drugs between visits. J Asthma
reason, a subgroup analysis that could show potential dif- 2007;44(9):769-773.
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256.
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9. Kamps AW, Brand PL, Roorda RJ. Determinants of correct inhala-
fered a greater variety of potential solutions that could tion technique in children attending a hospital-based asthma clinic.
improve the effectiveness of pMDI use instruction in the Acta Paediatr 2002;91(2):159-163.
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Conclusions Pediatr Pulmonol 2000;29(1):39-42.
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et al. Communication during pediatric asthma visits and child asthma
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supported previous studies’ descriptions of guideline-to- 918-925.
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https://www.nhlbi.nih.gov/health-topics/guidelines-for-diagnosis-
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