Asthma Advice

Vol. 20 •Issue 11 • Page 28
Asthma Advice

Association of Asthma Educators Calls for Improved Inhalation Instructions

There’s compelling evidence that inhalation instructions by health care professionals have not met the needs of people who take medications intended for deposition into the lungs.1,2

Studies examining procedural steps performed by individuals using inhaled medications have consistently demonstrated low levels of proficiency, with rates ranging from 7-55 percent among children who showed their technique with metered dose inhalers (MDI).3-6

More recently, studies that used objective assessments of inspiratory flow rate and inhalation time demonstrated inappropriate air stream characteristics among many adults and children.7 Studies that reviewed prescription filling patterns for inhaled corticosteroids have shown a very low rate of adherence.8

Epidemiological studies of asthma and disability suggest the advent of potent, efficacious inhaled medications has not resulted in the expected reduction of disease burden. In fact, during the past two decades, when oral medications like theophylline and prednisone were largely replaced with inhaled medications, disability due to asthma among children skyrocketed 232 percent.9

The link between inadequate inhalation instructions and increasing asthma disability has not been widely recognized. However, the relationship between poor inhalation technique and inadequate disease control is both empirical and intuitive.10,11

Implications of Studies

This understanding should change clinical practice. Consider for a moment implications of published studies. It is instructive to estimate the likelihood that three factors required for effective delivery of an inhaled medication actually will occur.

I will use data related to asthma for this illustration; however, the same principles apply to other disease states that involve inhaled medications.

Researchers have reported low levels of competency based on performance of required psychomotor tasks among people using inhaled medications such as shaking the MDI, exhaling fully, timing inhalation to occur immediately after actuation and holding breath for five to ten seconds after filling the lungs.

These data point to a high rate of procedural errors among individuals using inhaled medications.6 However, when a person performs the correct procedural steps, inadequate lung deposition still can occur if the inspiratory flow is too fast, too slow or too brief.11

Researchers who objectively evaluated inspiratory flow rate and inhalation time concluded many individuals do not generate an air stream that is appropriate for the resistance imposed by specific inhalation devices and for the aerodynamic properties of drugs delivered by both metered dose and dry powder inhalers.12

The likelihood of an air stream mismatch varies by user age, state of health, device type and other factors.7

The implication is clear. Instruction that does not incorporate objective assessment of inspiratory flow rate and time fails to control a second type of error (air stream mismatch).

Few Pick Up Drugs

Lastly, only a fraction of people actually pick up and consume their prescribed dose of inhaled corticosteroid at the correct frequency.8 Whether the reason for low pharmacy fill rate is lack of understanding or motivation, financial burden or other factors, the net effect is the same: a reduction in dose and in therapeutic benefit.

It’s reasonable to view procedural errors, air stream mismatch and poor adherence as exerting a compounded, adverse effect on inhalation therapy outcome.2 If this logic is applied arithmetically, there is an obvious link to the trend of worsening asthma disability.

Consider the net impact of the following rates: Fewer than 50 percent of people demonstrate adequate proficiency in the procedural steps required to correctly actuate a dose in several studies; as few as 20 percent generate an air stream with an acceptable inspiratory flow rate for MDIs; and fewer than 40 percent fill their inhaled corticosteroids at the prescribed rate.8

Whereas the percentages listed are approximate, it is possible to estimate the potential impact on populations who use inhaled medications such as children who have asthma. If we consider 100 children who have asthma and who have a prescribed daily dose of inhaled steroids, the percentages cited above can be applied.

Out of 100 children, only about 50 would likely enjoy the benefits of correct technique by either their parent or self-administered.3,4,13,14

Of these 50 children, 10 (20 percent adequate air stream rate) are likely to inhale at a correct speed and for an adequate time if using an MDI. Of the remaining children, fewer than 40 percent are likely to receive the recommended daily supply of medication.

Therefore, the compounded effect of the three cited reasons for inadequate deposition of medications into an individual’s lungs might mean only four in 100 people would actually achieve appropriate levels of medication in the lungs. This degree of therapeutic failure would contribute readily to a trend toward increasing disease and disability.

Worst-Case Scenarios

These calculations represent a worse-case scenario, so efforts must be made to heighten awareness of barriers to effective inhalation therapy. Opting to abandon efforts to provide effective support for inhalation therapy in preference for oral medications poses substantial risks for the person with asthma.15

There’s actually reason to be encouraged. We have effective approaches to address and overcome each of these barriers. In the clinical setting, educators, clinicians and therapists can raise the level of proficiency among individuals taking inhaled medications by using face-to-face time to address these concerns systematically.12,16

First, it is possible to improve inhalation technique by evaluating and correcting procedural steps. Requesting the client to “please show me your day-to-day routine for using this medication” can quickly reveal the need for education and training.

Reassessment and retraining are required for achieving and maintaining optimal proficiency.17 Many people use more than one type of inhaler, so it is necessary to address each type.

Next, it is important to acknowledge that performance of the correct manual steps does not ensure a resultant air stream that is appropriate for the device and drug.

Use of a hand-held, low-range inspiratory flow measurement device for training has been shown to result in optimal air stream characteristics for most clients.7

If both administration technique and air stream characteristics are appropriate yet the patient is not demonstrating an appropriate response to inhalation therapy, further steps are indicated.18 Data suggest direct communications with their pharmacists often will reveal inadequate prescription fill rates.8

For most patients, this can be easily accomplished by simply saying: “We would like to check your pharmacy records to try to better understand why you are not doing well on your current medications. Where do you fill your prescriptions?”

Adherence problems can be identified and addressed also during regular encounters with patients by asking, “Please tell me what problems keep you from taking your medication daily.”

Finally, evidence suggests that clinicians tend to overestimate asthma control.19 An appropriate clinical history can uncover disability due to respiratory conditions like asthma. Ask, “How is asthma limiting your daily life?” or “How does asthma make your life different?”

Be alert for evidence that lifestyle changes have occurred to accommodate poorly controlled disease.

For References, see our Web site at

Ben Francisco is an assistant professor at the University of Missouri, Columbia, and president of the Association of Asthma Educators.

Inhalation Instruction Guidelines for Educators and Clinicians

Metered Dose Inhaler

Use a spacer (good idea for bronchodilators; essential for inhaled corticosteroids).

Insert MDI into the valved holding chamber and shake the medication gently several times.

A common error is excessive inspiratory flow rate (IFR) with very brief inspiratory time (results in oropharyngeal deposition).

Valved Holding Chamber

Might require cleaning in diluted dish detergent once a month to block static build-up (look for a static-free designation on the label).

Might have a flow signal that sounds off if IFR exceeds 60 Lpm; (Reminder: Ask the patient, “If you hear a whistle, what does that mean?” Answer: “Slow down. Keep breathing, but slow down.”)

Valved Holding Chamber with Mask

Infants are going to be passive participants. The goal is to have the parent observe the exhalation valve (nose valve). If this is a device feature, be sure the infant takes six breaths after each actuation of the MDI. Otherwise, the rise and fall of the chest/abdomen will be the indicator for breaths. Toddlers usually will respond with patience if the parent counts out loud for the required six breaths. (One, two, three, four, five, six – clap and applaud now.)

Preschool children usually will respond to the following instructions after the mask is in place: “OK. Blow out all your air like you’re blowing out the candles on a cake (or similar instructions).” Now, actuate the medication. Then say: “Take a big breath and hold it. Hold it Hold it. Hold it. Good work!” If the effort is not great, just keep the mask in place and repeat.

Dry Powder Inhaler

Common errors: either insufficient IFR (leading to settling of the drug in the mouth and upper airway–aerosol sedimentation) or excessive IFR with short inspiratory time leading to over-acceleration of drug, keeping it from making the many turns required to arrive in the lower airways–aerosol impaction).

Coach for mid-range IFR with two to four seconds inspiratory time; use correct resistance setting on the inspiratory flow measurement device.

Some patients don’t like the feel of the lactose on the back of their throat. Recommend they take a sip of water first to moisten the throat.

Recommend “rinse and spit, then brush your teeth” after inhaled corticosteroids (ICS). For infants, toddlers, and others unable to perform good oral care, recommend eating or drinking after ICS doses to remove drug from oropharynx.

Nebulizer with Mask

Without a mask, 90 percent of the intended dose of nebulized medication will be lost (when blow-by technique is used for infants and young children; sucking on a mouth piece doesn’t deliver medication to the lungs, air passes through the nose, and drug is deposited in the mouth).

Reminder: Ask the parent, “Will your child leave the mask in place for the treatments?” Also ask, “Is the time and effort required for these treatments doable for your household?” and “Can you afford this medication?” If not, consider MDI by valved holding chamber with mask. This approach cuts drug administration time from 10 minutes several times a day to one minute and eliminates the need for a machine. This might make the family more portable and adherent to the ICS dosing plan.

–Ben Francisco PhD, PNP, AE-C