|Year : 2019 | Volume
| Issue : 1 | Page : 12-18
Use of inhaler devices in the asthma clinic of Alexandria University Children’s Hospital
Maged M Eissa, Ghada M El-Deriny, Fares A Koretam
Department of Pediatrics, Faculty of Medicine, Alexandria University, Egypt
|Date of Submission||01-Aug-2019|
|Date of Acceptance||02-Sep-2019|
|Date of Web Publication||9-Sep-2019|
Ghada M El-Deriny
Department of Pediatrics, Faculty of Medicine, Alexandria University, Alexandria
Source of Support: None, Conflict of Interest: None
Background Asthma is the most common chronic noncommunicable disease among children. High rates of incorrect inhaler use among children with asthma have been reported and are associated with worse outcomes.
Aim This study was designed to state the types of inhaler devices and to evaluate inhalation techniques and their relation to control of asthma
Patients and methods The study was conducted on 130 asthmatic children on inhaled corticosteroids at the age between 1 and 14 years attending the asthma clinic of Alexandria University Children’s Hospital, Egypt. The cases were subjected to detailed history. A preprepared questionnaire about the type of inhaler device and their correct use by the caregivers or older children was conducted. Correlation between inhaler techniques and asthma control according to Global Initiative for Asthma guidelines was done.
Results The number of patients who used meter dose inhaler (MDI)-spacer, turbuhaler, and aerolizer was 115, 8, and 7, respectively. The percentage of children having wrong inhalational techniques was 21.74, 25, and 14.28% for MDI-spacer, turbuhaler, and aerolizer, respectively.Wrong technique has a significant relation with asthma control in the three devices (P<0.05).There was a significant relation between the control of asthma and all MDI-spacer parameters except for the spacer type. Presence of cracks, absence of valves, wrong method of cleaning of spacer, and not counting doses are all associated with poor asthma control (P<0.05) while the type of spacer has no effect on control of asthma.
Conclusion Poor inhalational technique is associated with poor asthma control and regular assessment of inhalational technique in asthmatic children is recommended.
Keywords: asthma, asthma control, inhaler devices, inhaler techniques
|How to cite this article:|
Eissa MM, El-Deriny GM, Koretam FA. Use of inhaler devices in the asthma clinic of Alexandria University Children’s Hospital. Alex J Pediatr 2019;32:12-8
|How to cite this URL:|
Eissa MM, El-Deriny GM, Koretam FA. Use of inhaler devices in the asthma clinic of Alexandria University Children’s Hospital. Alex J Pediatr [serial online] 2019 [cited 2020 Jan 20];32:12-8. Available from: http://www.ajp.eg.net/text.asp?2019/32/1/12/266404
| Introduction|| |
Asthma is the most common chronic noncommunicable disease among children .
It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness, and cough that vary over time and in intensity, together with variable expiratory airflow limitation .
The diagnosis of asthma requires a careful review of child’s current and past medical history, family history, physical examination, and sometimes specialized testing like spirometry .
The goals for successful management of asthma include: achievement and maintaining control of asthma symptoms, maintaining normal activity levels, including exercise, maintaining pulmonary function as close to normal as possible, preventing asthma exacerbations, avoiding adverse effects from asthma medications and preventing asthma mortality. The National Institutes of Health guidelines recommend daily inhaled corticosteroids (ICS) therapy as the treatment of choice for all patients with persistent asthma .
Inhaler devices include a metered dose inhaler (MDI) with spacer in infants and young children and dry powder inhaler (DPI) in children older than 6 years .
High rates of incorrect inhaler use among children with asthma have been reported , even among regular users . Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instructions, including a physical demonstration, and have their inhaler technique checked regularly .
It has been reported that poor inhaler technique is associated with worse outcomes in asthma. It can lead to poor asthma symptom control and overuse of relievers and preventers ,. Correcting the patients’ inhaler technique has been shown to improve asthma control, asthma-related quality of life, and lung function ,.
The aim of this study was to state the types of inhaler devices and evaluate inhalation techniques and their relation to control of asthma in asthmatic children attending the asthma clinic of Alexandria University Children’s Hospital.
| Patients and methods|| |
An observational study approach was conducted on 130 children with diagnosis of persistent asthma attending Alexandria University Children’s Hospital who were maintained on ICS and are still maintained on it. The age of the children ranged from 1 to 14 years. The study was conducted during the period starting from July 2017 to April 2018.The study was approved by the Local Ethics Committee of Scientific Research, Faculty of Medicine, Alexandria University. Verbal consent was taken from the caregivers of the participants and verbal assent was taken from the children older than 7 years. The study methods and aims were explained to the children and their caregivers.
The cases were subjected to detailed history including: personal data, disease course, number of asthmatic attacks, and previous hospital admission. A preprepared questionnaire about the type of inhaler device and their correct use by the caregivers or older children was conducted. Correlation between inhaler techniques and asthma control according to Global Initiative for Asthma  guidelines was done.
Data were collected and entered into a computer using the statistical package for the social sciences program for statistical analysis (version 21, IBM Corp, Armonk, NY) . Data were entered as numerical or categorical, as appropriate. Kolmogorov–Smirnov test of normality was carried out, and according to its significance parametric or nonparametric statistics were adopted . An α level was set to 5% with a significance level of 95%, and a β error accepted up to 20% with a power of study of 80%.
| Results|| |
The number of patients who used MDI-spacer, turbuhaler, and aerolizer in our study was 115, 8, and 7, respectively.
The mean age for patients with well-controlled, partially controlled, and noncontrolled asthma was 8.21, 6.61, and 7.46 years, respectively. Older children have better control of asthma ([Table 1]).
The relation between the type of device and control of asthma was significant. Patients using a DPI have better asthma control than those using MDI ([Table 2]).
The percentage of children with wrong MDI-spacer technique who had well-controlled, partially controlled, and noncontrolled asthma was 4, 48, and 48%, respectively, whereas the percentage of both children with wrong turbuhaler and aerolizer techniques who had well-controlled, partially controlled, and noncontrolled asthma was 0, 0, 100%, respectively. There was a significant relation between the wrong techniques and poor asthma control ([Table 3],[Table 4],[Table 5] and [Figure 1]).
|Table 3 Relation between meter dose inhaler-spacer technique and control of asthma|
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|Figure 1 Clustered bar chart showing control of asthma in patients with wrong technique.|
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There was a significant relation between the control of asthma and all MDI-spacer parameters except for the type of spacer ([Table 6] and [Figure 2]).
|Table 6 Relation between meter dose inhaler with spacer parameters and control of asthma|
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|Figure 2 Clustered bar chart showing control of asthma in patients with bad meter dose inhaler with spacer parameters.|
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| Discussion|| |
The anatomy and physiology of the lungs change during development, making drug delivery to young children already a challenge; the results of inadequate inhalation technique, such as decreased asthma control, are intensified in children because of this reason .
In this study, the mean age for patients with well-controlled, partially controlled, and noncontrolled asthma was 8.21, 6.61, and 7.46 years, respectively. Older children had better control of asthma. This may be a logical finding as older children may have better inhalational technique and as a consequence better control of their asthma. Older children are able to understand the steps of the techniques better than younger ones. They are also able to cooperate with their parents better during receiving treatment. In accordance to our results, Alangari and Schneider  found that young ages of the patients and the parents were associated with improper use. Cicutto et al.  also suggested a relation between age and control of the disease.
In this study, the number of patients who used MDI-spacer, turbuhaler, and aerolizer was 115, 8, and 7, respectively. Discus device was not included as it was not available for patients at the asthma clinic of Alexandria University. The percentage of children having wrong inhalational techniques was 21.74, 25, and 14.28% for MDI-spacer, turbuhaler, and aerolizer, respectively. These percentages of wrong techniques may be attributed to the absence of repeated education during follow-up visits. Turbuhaler had the highest frequency of errors but not significant statistically as a small number of patients were using it in our study. The most common errors in MDI with spacer was not taking at least six deep slow breaths and not waiting at least 30 s to repeat the second puff. Errors in turbuhaler include not rotating the grip counterclockwise and then back until a click is heard and not holding breath for 5 s after inhalation. Errors in aerolizer include not piercing the capsule and not holding breath for 5 s after inhalation.
Similarly Reznic  in a surprising study conducted on 169 patients for the evaluation of MDI-spacer utilization and technique in caregivers of urban minority, children with persistent asthma found that only one caregiver correctly demonstrated all 10 steps of the MDI-spacer technique.
Other studies also found high rates of poor techniques. Wong et al.  found that only 55.9% of the studied children demonstrated the correct technique in using their inhalation devices. In children using MDI, the most common incorrect performance was the step of breathing in slowly at the same time with actuation. They demonstrated that among those who used MDI-spacer, all medication was given by their caregivers and the most common error was the step of waiting for 30 s prior to the next MDI actuation. Another study found that only 12% of the studied patients were able to perform all steps for MDI administration correctly .
Alangari and Schneider  found that about 45% of patients demonstrated multiple steps improperly. Another study showed that the devices were used correctly by 68.1% of patients using MDI and 34.6% of patients using DPI. The most common improper step was ‘breathe in from the spacer five to six times or 10 s’ for MDI (24.4%) and ‘exhale to a residual volume’ for DPI (51.9%) .
In a review of 21 studies looking at the misuse of MDI, poor technique was estimated to be prevalent in 14–90% (with an average of 50%) of cases . It is perhaps not surprising that patients often use their device incorrectly since healthcare professionals’ understanding of the correct use of these devices is also poor. In a study of medical interns, only 5% were found to be able to use an MDI device correctly . The wide range of reported frequency in studies may be the result of the differences in the definition of ‘incorrect use’ and the differences between the characteristics of the study population.
Our study showed that control of asthma was better with DPIs than MDI with spacers. Percentages of well-controlled children were as follows: 85.7, 75, and 41.7% for aerolizer, turbuhaler, and MDI with spacer, respectively.
Other main finding in this study is the significant relation between poor inhalation technique and poor control of asthma which we observed in the whole three devices. As regards the parameters in using MDI with spacer, all parameters were significantly related to poor control of asthma except for the type of the spacer. The parameters that significantly correlated with poor asthma control were spacer cracks, wrong method of cleaning, no valves, and not counting doses. These bad parameters were common in our study and this may explain why asthma control was better with DPI than MDI in our study. Poor technique or defects in devices especially MDI with spacer which constitute the major part of our study will decrease the delivery of the required dose of ICS to the lung and finally poor asthma control. This was consistent with the previous study of Capanoglu et al.  which aimed to address the problems about correct use of inhaler devices, adherence to inhaler corticosteroid treatment, and the effects of these problems on the control of asthma. Agreeing to our results, they suggested that asthma was controlled more frequently among correct users. But in contrast to the results of this study, MDI technique was better than DPI. Cicutto et al.  also agreed to our results as they found children with poor inhalational technique were more likely to have poor control of asthma.
The current results were also in accordance to Ammari et al.  who aimed to evaluate a school-based, multifaceted asthma program that targeted students with asthma and the broader school community. They found a significant link between poor control of asthma and poor inhalational technique. Moreover, they provided some evidence that improving the techniques of using inhalational devices will lead to improve asthma control and enhance quality of life of children with asthma. Counseling children on the correct inhaler technique was associated with improved technique and control of asthma in multiple studies ,.
As the patients were told to perform the inhaler technique and that they would be observed whether they were doing it correctly or not, there is a possibility that they might had done it inappropriately under the pressure of being observed, so there may be over-reporting of the faulty techniques in this study. However, the incorrect inhaler use has been found to be high in this study. Another limitation is the distribution of the cases in different groups; using the inhaler devices this could be explained by a wide range of age included in the study (1–14 years) which affect the choice of the suitable inhaler.
| Conclusion|| |
Many patients use their inhaler devices incorrectly. Wrong inhaler techniques and defects in inhaler devices lead to poor asthma control. Our recommendation is to repeat education of correct inhaler techniques to patients during follow-up visits. We also recommend that patients should bring their spacers with them during follow-up visits and the treating physicians should check these spacers for any defects in its components and revise the correct method of dealing with them with patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]