Time to face mask/spacer acceptance in dogs and cats

Abstract

Objective

Aerosol medications are recommended for use in dogs and cats. Perceived pet intolerance to a face mask/spacer might prevent clinicians from recommending them, and thus prevent owners from using them. Our goal was to evaluate the duration required to train a pet to accept a face mask/spacer.

Animals and procedure

Pet owners with no experience using a face mask/spacer were recruited. Pet owners applied the face mask/spacer q12h and graded each attempt on a scale of 1 to 5, with 1 = “not tolerated” and 5 = “perfect compliance.” “Compliance” was defined as the animal tolerating the face mask/spacer with minimal or no restraint for a duration of at least 10 breaths for 4 separate treatments over 2 d. Time to compliance and overall compliance were calculated.

Results

Forty-four pets were enrolled and 43 completed the study. All dogs achieved compliance with a median time of 4 d (range: 2 to 18 d). Eighteen of 20 cats achieved compliance with a median time of 6 d (range: 2 to 19 d).

Conclusion

Habituation to face masks/spacers was easily achieved in dogs and almost all cats.

Clinical relevance

Concern over pet or owner acceptance should not be an obstacle to prescribing inhaled medications. Most animals could be habituated to a face mask/spacer within 19 d.

INTRODUCTION

Various inflammatory airway diseases, such as asthma, chronic bronchitis, and bronchiectasis, occur in dogs and cats (1–4). Delivering drugs via inhalation therapy not only can provide higher doses of drugs directly to the lungs but also reduces systemic effects and their potential complications (2,3).

For inhaled medications to be effective, they must be delivered correctly, which often requires training to ensure optimal use and timing (5,6). In adult humans and older children, acceptance of inhaled medications via a metered dose inhaler is high (7), though incorrect use is also high (8). Young toddlers and infants typically have low inspiratory flow and small tidal volume and are unable to coordinate the breath and actuation of a metered dose inhaler (6,9). Similar challenges are encountered in dogs and cats as, like young children, they cannot be easily trained to use a metered dose inhaler, directly into the mouth, with the correct timing of actuation of the device with inspiration (9,10). Spacers with attached face masks have been used in small children to effectively deliver aerosols from inhaler to airway without the need for timing with inspiration (11). Use of face masks/spacers to provide effective administration of aerosol medications to dogs and cats also has been described (3,12–16).

Proper selection of and training on the use of devices commercially available for inhalation therapy, as well as acclimation of the pet, are critical to successful therapy (2). Anecdotally, veterinarians often express concern that a dog or cat will not tolerate the use of a face mask/spacer, and thus do not recommend its use to pet owners. However, there is limited information available on the time to acceptance of a face mask/spacer combination in pet dogs and cats. Therefore, the goal of this study was to evaluate pet dogs’ and cats’ acceptance of face masks/spacers applied by owners with no prior experience using them.

MATERIALS AND METHODS

We recruited dogs and cats of any age, sex, and non-brachycephalic breed belonging to veterinary students and staff of the Cummings School of Veterinary Medicine at Tufts University (North Grafton, Massachusetts, USA). Brachycephalic breeds were excluded since their conformations could prevent effective use of the face mask. Pets had to be naïve to the use of face masks and owners had to have had no prior experience treating a dog or cat with a face mask/inhaler. Owners were provided with verbal instructions on how to use the face mask/spacer. They were also given links to websites with videos (https://www.youtube.com/watch?v=r0A-7ei5Soo) but were not required to watch the videos. Owners were instructed not to struggle with their pet during the training, to avoid a negative experience, and to use positive reinforcement (treats, praise). For habituation of the pet, owners were instructed to attempt to apply the face mask/spacer (AeroKat or AeroDawg; Trudell Animal Health, London, Ontario) q12h, consistent with a typical prescription for inhaled glucocorticoids.

For the purposes of the study, neither an inhaler nor medication was used in the testing. Owners were asked to score the compliance of the pet on a scale of 1 to 5 for each attempt, with 1 being “not tolerated at all” and 5 being “perfect compliance.” “Compliance” was defined as the animal tolerating the face mask/spacer with minimal or no restraint (score of 4 or 5) for at least 10 breaths for 4 separate treatments over 2 d. Owner/pet pairs had ≤ 30 d to achieve compliance. Once compliance was achieved, the pet was defined as having completed the study. The number of days of training required to achieve compliance was recorded. After the study was completed, owners were asked about their likelihood of recommending the use of a face mask/spacer for inhaled medication administration in the future and how the training experience compared to what they had anticipated (i.e., much harder, harder, about the same, easier, much easier). For the purposes of the study, the numbers of owners who felt training and use of the face mask/spacer were easier than anticipated or much easier than anticipated were combined, since both were considered positive responses. The study was approved by our institution’s Institutional Animal Care and Use Committee and the owners provided written informed consent (protocol # G2019-104). In addition, owners were permitted to keep the face masks/spacers after completing the study.

Data are reported as frequency (percentage) for categorical data and median (range) for continuous data, since variables were not normally distributed. The difference in compliance rates between cats and dogs was compared using a Fisher exact test and the difference in time to compliance in cats versus dogs was compared using a Mann-Whitney U test. Animals that did not achieve compliance [recorded as a binary (yes/no) variable] were included in the analysis for compliance rate but not in the analysis for time to compliance. Data analysis used commercial statistical software (SPSS 28.0; IBM Corporation, Armonk, New York, USA). A P-value < 0.05 was considered statistically significant.

RESULTS

Forty-four pets (24 dogs and 20 cats) belonging to 28 separate individuals with no prior experience were enrolled in the study. One dog experienced a seizure on Day 3 and was subsequently identified as having idiopathic epilepsy; the owner elected to not continue the study. The other 23 dogs (96%) completed the study, and all 23 (100%) achieved compliance. The median time to compliance for dogs was 4 d (range: 2 to 18 d).

All 20 cats completed the study, with 18/20 cats (90%) achieving compliance. Two of the 20 cats (10%) did not achieve compliance by Day 30. The median time to compliance for the 18 cats that achieved compliance was 6 d (range: 2 to 19 d).

There was no difference in the overall percentages of cats and dogs that achieved compliance (P = 0.21) nor in the median times to compliance for cats and dogs (P = 0.19). All (100%) of the 28 owners responded that they would definitely (24/28, 86%) or probably (4/28, 14%) recommend a face mask/spacer for inhaled medication administration to future clients. Fourteen of the 28 owners (50%) responded that training their pet to accept the face mask/spacer was easier or much easier than they had anticipated. The other 14 of the 28 owners (50%) responded that training was about the same as they had anticipated.

DISCUSSION

In this study, dogs and cats with no prior experience with a face mask/spacer were generally able to learn to accept the equipment within a short time frame, and even owners with no prior experience felt the training was straightforward. Long-term therapy with oral glucocorticoids in dogs and cats can be associated with systemic complications, such as diabetes mellitus or congestive heart failure (12,17). Use of inhaled glucocorticoids helps to limit their systemic absorption and could reduce complications associated with systemic glucocorticoids (12,13,17). In dogs and cats with asthma, chronic bronchitis, and eosinophilic bronchopneumonia, the use of inhaled medication has been well described (3,12–16).

Some animals (mostly cats) may not readily accept these apparatuses and may require longer training periods, different methods, use of treats, or other strategies. Further research in cats is recommended to assess different types of training methods and determine which are most effective at achieving compliance and reducing time to acceptance. Ninety-six percent of animals in the current study achieved compliance with the face mask/spacer and the median time to compliance was short (4 d in dogs, 6 d in cats). However, the range of times to compliance was relatively wide (2 to 19 d), suggesting there is individual variability of owners, pets, or the combination that must be considered. In humans, the Global Initiative for Asthma recommends checking inhaler technique by direct observation (rather than relying on a description of how it is used by the patient), identifying errors, physically demonstrating correct use, and frequently rechecking for correct inhaler use (18). Similarly, pet owners should be counseled with tips for training, be encouraged to have patience, have their techniques evaluated, and provided with support if the training is not immediately successful. Counseling might be accomplished with telehealth visits to help improve compliance and ease of device use.

Another limitation was that this study tested only the face mask/spacer and did not test the combination of the face mask/spacer with an inhaler. Although the authors’ experience is that most animals that accept the face mask/spacer will tolerate the introduction of the inhaler, the noise, taste, and smell may surprise some animals and may require additional training for compliance. Some medications can have an odor or taste that is unpleasant to animals, which could negatively affect compliance. All the animals in this study were healthy, and compliance might differ in animals with respiratory disease. Future research is needed to evaluate an affected population. We did not assess owner compliance with daily testing and so could not determine whether owners “skipped” any testing days. As this was a relatively small study, testing in a large study of dogs and cats would be useful. Some owners enrolled multiple pets in the study (44 pets from 28 owners), so some pets were handled by the same owner. Pets with the same owner might have demonstrated similar responses, which could have affected the results. Addressing this issue of pseudoreplication would be important in future studies (e.g., allowing enrollment of only 1 pet per owner). Last, all owners participating in the current study were veterinary students, veterinary technicians, or other hospital staff. Although these participants had no prior experience with face mask/spacers, they may have had more training in animal handling than the average pet owner. Therefore, it would be valuable to repeat this study with owners unaffiliated with a veterinary hospital.

Despite these limitations, most dogs and cats in this study were successfully and relatively quickly trained by their owners to accept a face mask/spacer, mimicking treatment with aerosol medications. Concern about pets’ acceptance of these devices to effectively administer aerosol medications should not influence medical recommendations in animals with respiratory disease. Having veterinary healthcare team members use these devices with their own pets might encourage more widespread use, since 100% of owners responded that they would definitely or probably recommend a face mask/spacer/inhaler to future clients after using it with their own pets. CVJ

Funding Statement

Funding and face masks/spacers were provided by Trudell Animal Health, 725 Baransway Drive, London, Ontario N5V 5G4.