Inhalers are the mainstay of treatment for patients with asthma – but just like in adult care, inhaler technique in children is generally poor (Gillette et al, 2016; National Institute for Health and Care Excellence (NICE), 2021).
First-line treatment is to prescribe a short-acting beta 2-agonist (SABA) as a reliever therapy with newly diagnosed asthma (NICE, 2021). A low dose of an inhaled corticosteroid (IHCS) is recommended as the first-line maintenance therapy for children who are symptomatic (NICE, 2021). Despite this, many children are unable to use their inhaler devices effectively and Child (2002) suggests that many have been prescribed devices they cannot use. Some have recently had their devices changed to comply with the NHS Green Plan, swapping their medication to dry powder devices that are hydrofluorocarbon (HFC) free.
There are also many different devices, which can be confusing for patients and the health professionals who prescribe them (Alismail et al, 2016). Each inhaler device has its own set of unique characteristics relating to holding the device, its design and inhalation technology, as well as its specific advantages and disadvantages. One device may have a counter, allowing the patients to see how much medication is left in the canister, and others may not.
Inhaler education is an important aspect of the treatment of asthma. However, poor inhaler technique and poor deposition of the drug in the airways is common among children (Volerman et al, 2021). Studies have shown that only 8–22% of children with asthma use their inhalers correctly (Ferrante et al, 2021).
In a study of 530 children in general practice, 76% were inhaling asthma medication incorrectly (Hagmolen of ten Have et al, 2008). Errors mainly occurred when children used a pressurised metered-dose inhaler (MDI) without a spacer device. The errors increased the longer the child was using the device, reminding us that repeated education is important. Certainly, Capanoglu et al (2015) suggested that repetitive training in using devices contributes to improving inhaler technique. If medication must be adjusted or a new medication started, NICE (2021) recommends that they are seen again after 4–8 weeks. This is an ideal time to support repetitive training.
Gillette et al (2016) suggested that members of the healthcare team should instruct children and their caregivers on the proper use of their inhalation devices at every opportunity. This may also include correcting mistakes and ensuring effective medication delivery, and is in line with global recommendations from GINA (2020). Certainly, all members of the healthcare team should be involved in this process (Kaplan et al, 2020). Axtell et al (2017) suggested that pharmacists providing brief interventions can play a pivotal role in reducing the implications of improper inhaler use.
Leaflets instructing the patient on using the device are included in the packaging. Education can also be delivered by using short video interventions, and these can lead to immediate improvements in children's inhaler techniques (Carpenter et al, 2015). Matsuyama et al (2022) stated that only using one method of providing information (leaflet or video) was insufficient for acquiring proper inhaler techniques. They recommended a combination of two learning materials to enable patients to acquire proper inhaler techniques and subsequently improve their asthma control, although their study participants were college students not children (Matsuyama et al, 2022).
Volerman et al (2021) suggest that teaching inhaler technique should involve demonstrating each step for effective use and the cleaning procedures to ensure that the devices continue to work effectively. This must be individualised for each device, such as a metered-dose inhaler, Turbuhalers and Easyhaler devices. There are many resources to enable us to do that such as Asthma + Lung UK videos (see further information at the end of this article).
‘MDIs are considered more challenging to use than most other devices … Spacer devices are therefore helpful tools that … minimise coordination difficulties, reduce oropharyngeal deposition and increasing lung deposition.’
Metered-dose inhalers and spacer devices
MDIs are considered more challenging to use than most other devices (Lenney et al, 2000). Spacer devices are helpful tools that attach to the mouthpieces of pressurised metered-dose inhalers (pMDIs) and minimise coordination difficulties, reduce oropharyngeal deposition and increasing lung deposition (De Benedictis and Selvaggio, 2003; Newman, 2004). Volerman et al (2020) suggest that effective use of MDIs can be supported with spacers and valved holding chambers and masks.
The asthma guidelines (NICE, 2021) recommend that all patients using pMDI are prescribed a spacer device as they are more effective. Certainly, an MDI-spacer is just as effective as a nebuliser as both deliver salbutamol equally to preschool children (Hamza et al, 2022). The new digital applications on smartphones to support the use of MDIs and inspiratory flow alongside traditional verbal counselling has been shown to improve their asthma control (Behroozet al, 2020; Ferrante et al, 2021; Tony et al, 2021). Tony et al (2022), in their study comparing verbal counselling versus advanced counselling (using acoustic Flo-tone training device and its smartphone application with traditional verbal counselling), found a significant improvement in the number of inhalation technique mistakes compared to using traditional verbal counselling alone. Sportel et al (2020) suggested that it is the immediacy of the smart feedback that leads to improvement in therapy adherence and inhalation technique.
Health literacy
Health literacy can be considered as a patient's ability to understand the basic health information and services needed to make appropriate health decisions about their care. Health literacy in children is described as the skills, commitments, and knowledge that enable a person to process health information and instigate health-promoting decisions and actions (Bröder et al, 2017). For patients with asthma, this is something we need to consider as they try to manage their disease. Certainly, we know that inadequate literacy is linked with poor health outcomes (Rosas-Salazar et al, 2012; Federman et al, 2014). Thai and George (2010) suggest that asthma educators are uniquely prepared to evaluate health literacy and to develop individualised training programmes. Despite this, Tzeng et al (2018) suggest that children's health literacy is still not completely understood and there needs to be more research in the topic.
When recommending an inhaler device, it is therefore important to identify and support children and parents or carers with low health literacy. They may have their own perceptions and preferences about certain devices, so shared decision making is therefore helpful (Muscat et al, 2021). Often, the prescribing decision about the device is made by the prescriber and is affected by local or national guidelines and cost. Hsiao et al (2022) suggest that this decision process is one way and can lead to reduced satisfaction and non-adherence. Giving children the choice as to what device they prefer will, ultimately, lead to better adherence. Kaplan and Price (2018) suggest that a shared-care approach and comprehensive patient education, including device training, can improve outcomes but that not all children are able to use their inhalers correctly. They highlight the point that some devices are unsuitable for certain patients. It is therefore important to facilitate choice but also to ensure a match between patient and device at the outset of treatment. Dijk (2017), in their doctorate thesis, suggests that there are a huge range of different inhaler devices and preferences which can be affected by the age, gender and education level of the patient. They highlight the point that it is difficult to predict which inhaler device is best suited for which child but that it should be their choice. Van Boven et al (2023) suggest that if we are being holistic about choice, then this should be about the device and the dosing regimen should be a part of the shared decision-making process. Ultimately, despite the large number of devices, there is no ideal device that fits all patients, so a personalised approach needs to be considered (Cataldo et al, 2022). This personal approach needs to be used for the education about inhaler devices.
Boise and Rotellas' (2015) systematic review of asthma training recommends that the education should be device-specific, patient-centred, and repeated at frequent intervals. They suggest that healthcare professionals must frequently reassess patient understanding and ability about their asthma inhalers, which will ultimately increase their therapeutic outcomes (Boise and Rotellas, 2015).
Conclusions
Although inhalers are the mainstay of treatment for patients with asthma, inhaler technique is generally poor (Gillette et al, 2016; NICE, 2021). Many children are unable to use their inhaler devices effectively or are even prescribed devices they cannot use (Child, 2002). There are also many different devices, which is challenging for health professionals who prescribe these (Alismail et al, 2016). Each inhaler device has its own set of unique characteristics relating to holding the device, its design and inhalation technology, as well as its specific advantages and disadvantages.
It is important to offer education that is device-specific, child-centered, and repeated at frequent intervals (Boise and Rotellas, 2015). As health professionals we need to keep up to date with new devices so we can support children with asthma and their families.
Further information
- A helpful resource for patient education about the demonstration of inhaler devices from Asthma + Lung UK: https://tinyurl.com/5n6d3pv5
- You can also register with MIMS as a health professional to access their visual inhaler guide: https://www.mims.co.uk/respiratory-visual-guide
- Also see the pocket guide to inhaler technique from the Greater and Clyde NHS Trust: https://www.nhsggc.org.uk/media/245983/respiratory-inhaler-tech-guide-final-1606.pdf
- A visual guide for optimising asthma reviews (NHS England): https://s40639.pcdn.co/wp-content/uploads/Asthma-Visual-Guide-V1.5.2.pdf
Key Points
- As many children are unable to use their inhaler devices effectively and some have recently had their devices changed to dry powder devices it is important to ensure that they are prescribed the right device and provided with adequate training.
- The variety of devices can be confusing for patients and families but also for healthcare professionals. It is therefore important that the healthcare team remains up to date and able to support training at every opportunity.
- In children using a pressurised metered-dose inhaler, fewer errors were found when they used spacer devices.
- Repeated education is important as errors would increase over time. If medication is adjusted or a new medication started it is recommended that children are seen again after 4–8 weeks.
- The use of multiple methods of providing information and training has been found to improve inhaler technique.
- A shared-care approach and comprehensive patient education, including device training, can improve outcomes. It is important to facilitate choice but also to ensure a match between patient and device at the outset of treatment to help lead to better adherence.
CPD
- Define health literacy in the context of asthma.
- How can health literacy be assessed and improved in children?
- What strategies can help improve tehcnique and adherence?