Best Practices in Asthma: From MDI Missteps to Monitoring Adherence

Charles P. Vega, MD; Sandra G. Adams, MD, MS


May 01, 2017

Charles P. Vega, MD: Welcome to Critical Issues in Pulmonary Medicine. I am Chuck Vega, a clinical professor of family medicine at the University of California at Irvine.

Today we are going to discuss the use of inhaled medications for asthma. To help me with this effort is Dr Sandra Adams, a professor of medicine and pulmonary and critical care specialist at University of Texas Health in San Antonio. Sandra, thanks very much for joining me.

Sandra G. Adams, MD, MS: Thank you.

Optimal Use of Devices for Asthma: 'We Have Lots of Work to Do"

Dr Vega: We just discussed asthma diagnosis, but left treatment to the side because we wanted to talk about the use of inhaled medications for asthma in this segment—what is going well, and what could be better. Sandra, not only do you have a strong expertise in delivery systems for asthma medications, but I know you are "evangelical" about teaching clinicians and patients how to use these devices appropriately. The evidence certainly supports you in that effort.

In a study[1] of children between the ages of 2 and 18 years, 45% of the cohort demonstrated improper use of a metered-dose inhaler (MDI). Adding in a spacer did not increase the appropriate use of the MDI. You figure, kids will be kids. They do not necessarily understand how to use these devices, and they will improve over time, right?

But a study[2] of 450 adults who presented in the emergency department with asthma symptoms demonstrated the exact same rate of improper MDI use of 45%. There really was no improvement whatsoever. In that study, a lack of education about asthma and their medications, as well as lack of routine outpatient follow-up, were associated with higher rates of improper MDI use.

We have lots of work to do and, Sandra, I know you are up to the task. Your website provides a great resource for exploring the different delivery systems associated with asthma medications as well as easy to follow videos on how to use them. Could you take us through some top tips and pearls in asthma treatment, including the application of newer delivery devices?

Common Mistakes With Devices

Not Enough 'Buy-in'

Dr Vega: What are the most common mistakes patients make when using inhalers for asthma?

Dr Adams: Probably the most common mistake is that patients do not buy in to the fact that they need them. They get their short-acting beta-agonist, which makes many of them feel a little better. They get their inhaled steroid but do not feel anything, so they junk it in the trash, and only use their beta-agonist.

We know that scheduled short-acting beta-agonists are not useful. We talked in the last segment about patients who overuse beta-agonists by taking them on a regular basis. However, when these patients need the rescue medicine, it does not work as well. No matter which device you use, you need patients to buy in to the fact that they need controller agents to help stop and block the inflammation from asthma and the inflammatory disease.

Not Holding Breath Long Enough

Dr Adams: I commonly see that 10 seconds is a long time to hold your breath after inhaling the medicine. You really do need to count "1-Mississippi..." or set a timer on your watch or your phone to count 10 seconds. In younger people and young adults, 10 seconds should not be that hard unless they are having an exacerbation. The breath hold is really important.

Not Using Dosage Forms Correctly

Dr Adams: Another common mistake is not knowing the difference in inhalational technique required for the different types of inhalers: MDIs, dry powder inhalers (DPIs), and soft mist inhalers (SMIs). Most people have seen the MDIs.

Figure 1. MDI with valved holding chamber.

You really need to shake the MDI for at least 5 seconds before you take the medication. You can put the MDI directly to the mouth, but it is hard for many patients to start inhaling, depress, and keep inhaling. Therefore, a valved holding chamber (spacer device) may be very useful (Figure 1).

We also have a lot of DPIs, many of them multidose (Figure 2). Some you twist; some you just open; some look like an MDI. One DPI, you just open and inhale. All of these should be inhaled using a very quick and deep breath, whereas the MDI should be used with a very slow breath over 2-3 seconds.

Figure 2. (A) Multidose dry powder inhaler. (B) Single-dose dry powder twist inhaler.

Other DPIs [require use of a capsule]. Common mistakes I see are patients who put the capsule in a pill box, which exposes the medicine to air (which allows moisture to get into the powder and results in clumping and inadequate delivery to the lungs), or they swallow it. This does not hurt the stomach or anything, but it sure does not help the lungs. You have to ask patients, "How often do you take your medicine?" Expand on the question when you hear, "I take it twice a day with my other meds." Ask them, "How do you take it? Do you inhale it, or are you swallowing it?" I have many patients who have swallowed it.

The last type of inhaler is the SMI—there is one on the market approved for use in asthma. (Figure 3). This also requires a very slow inhalation, over 2 to 3-4 seconds.

Figure 3. Soft mist inhaler.

Technique is a key point in all these different devices. Many clinicians, even pulmonologists, do not know the intricacies of how to take these medicines. If you do not know, it is really hard for our patients to know.

Best Practices for Patient Education and Evaluation

Dr Vega: I demonstrate use of these devices to patients who literally do not know how to use their inhalers or what their inhalers may be for. What are your best practices for educating patients and empowering them to use these devices correctly?


Dr Adams: One of the best things that we can do is repetition. Teach the patient, and then have them do a return demonstration or teach back. Teaching back is really important. Go through everything with them. Asthma educators, a medical assistant, nurse, or somebody else can do this training. It is really important that someone is identified in every practice to do this. There are lots of different inhalers and it is hard to keep up with the new ones that keep coming out. We can bill as clinicians for teaching proper inhaler technique, even if our medical assistant does the education, at least in the United States.

Here is a quick story. We taught a patient how to use a MDI with spacer. She went to do spirometry and came back, I taught her again. She did it with us. Then I asked her to show me how to use her inhaler. She proceeded to shake the MDI, push the button down, and blow into the device. She seemed to understand; she is a very bright lady. But if we had sent her out without asking her to show us how she will use her inhaler, she would have not gotten any medicine until her next appointment.

Dr Vega: Repetition is important. Even if patients have a team, which is a great privilege and luxury, it is not just about teaching them once, but rechecking their performance. Having the patient bring in the inhaler and show us how to use it is actually recommended now at every visit for asthma. It does make a difference, because people forget over time or the devices may change, particularly when you are changing prescriptions around.

Checking a few times a year is very reasonable. If they are coming in every few weeks because they are having difficulty with control, certainly I would consider it more often, but I do not think they need to be checked every single time.

Once you get the patient out of an exacerbation, they are more at a stable level. How do you follow patients for their control of asthma and make sure that the treatment is still appropriate? Any tips in terms of the chronic management of asthma?


Dr Adams: We know that adherence is really a problem, not only in asthma but in all obstructive lung diseases.[3] Asthma is so episodic that many patients think, "I am doing okay, and so I will just stop using the controller." Then suddenly, they are waking up at night coughing. They do not necessarily remember that it is their asthma and that they are not on their controllers. It is critical to not only look at all the environmental things in their house (eg, dust mites, mattress covers, curtains), but to ask [about adherence]. I do not ask, "How many times do you take your inhaler?" Basically, I say, "Most people end up missing a few doses—even I do when trying to take medicine. On average, how many doses would you say you miss in a week?" That seems a little more nonjudgmental than saying, "How often do you not take your meds?"

Symptom Assessment

Dr Vega: Right; there is a big social bias there. People want to be good patients and take their medications even when they are not using their medications at all. You are an advocate for using a more formal way of screening for symptoms, such as a checklist, as opposed to just saying, "Hey, how you doing?" and kind of moving forward. Do you think that is a bit of a trap?

Dr Adams: That is very important because, as you said, patients want to please us. If you ask, "How are you doing?" and they say, "I am doing great. I used to use my short-acting beta-agonist seven times a day, and now I am just using it once a day," as clinicians, we know that still is not well-controlled.

There are many standardized questionnaires out there. The Asthma Control Test™, which is available on line in multiple languages, is five questions and is very well-validated[4] to help step up and even step down therapy as we were talking about in the prior segment. It is very important to be able to step down therapy and get the patient off medicines they do not need.

Dr Vega: Absolutely. It is about giving them what they need, but not too much of a good thing, because we know that there are some significant effects associated with the use and overuse of such drugs as short-acting beta-agonists and higher doses of inhaled steroids.

Sandra, this was a great conversation. Thanks again for enlightening us on the subject of asthma. Readers can visit for more information. I wish you well and hope to see you soon.


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