Inhaler Errors Common Among Kids Hospitalized for Asthma

Tara Haelle

April 25, 2019

Two of every five children hospitalized with asthma exacerbation make an error when using their inhaler, a prospective cross-sectional study shows. Missing a critical step, such as incorrect breathing technique, was particularly common among those using a spacer with a mouthpiece compared with those using a spacer with a mask.

"Despite robust studies demonstrating how asthma education can improve both asthma skills and clinical outcomes, our study demonstrates that a large gap remains in proper inhaler technique among asthmatic patients presenting for inpatient care," write Waheeda Samady, MD, of Ann & Robert H. Lurie Children's Hospital and Northwestern University Feinberg School of Medicine in Chicago, and associates.

The researchers published the results of their single-center study April 8 in the Journal of Hospital Medicine.

Samady and colleagues report that children were less likely to miss a critical step when using their inhaler if they "had received inpatient asthma education during a previous admission, had a history of pediatric intensive care unit (PICU) admission, and had been prescribed a daily controller." Those associations match up with past research that has found lower risk of improper inhaler use among patients with a previous hospitalization for asthma. "This supports that when provided, inpatient education can increase inhaler administration skills," the authors write.

The researchers analyzed inhaler technique among a convenience sample of 113 children, ages 2-16 years with a diagnosis of asthma, prospectively enrolled in the study while receiving inpatient treatment for asthma exacerbation at Lurie Children's Hospital. Patients were not eligible if they had a separate respiratory disease, cardiac disease, or sickle cell anemia. Just over half the children (55%) had uncontrolled asthma.

At the investigators' request, the children (n = 13) or their caregivers (n = 100) demonstrated how they use their usual home inhaler with a spacer and mask, with a spacer and mouthpiece, and with no spacer. The researchers used an asthma checklist to assess the child's inhaler technique and deemed four steps critical: removing the cap, attaching to a spacer, taking six breaths (for using a spacer with mask), and holding breath for 5 seconds (for using a spacer with a mouthpiece.

"In our study, we highlighted removing the cap, attaching a spacer and adequate breathing technique as critical steps because failure to complete them would significantly reduce lung deposition of medication," the authors explain.

Caregivers filled out questionnaires about their health literacy, confidence, and barriers to managing their child's asthma.

On a scale of 1 to 10, the average checklist score for participants' use of the inhaler was 6.7, with 35% of participants scoring less than 7 (they skipped three or more steps in their technique). Overall, 42% of participants' missed a critical step.

"The most commonly missed steps were breathing normally for 30 seconds for spacer with mask, and for spacer with mouthpiece, it was breathing out fully and breathing away from the spacer," the authors report.

Just over a third of patients (36%) missed a critical step in technique when they used a spacer with a mask, but more than twice as many (75%) missed a critical step while using a spacer with a mouthpiece (P = .007). Meanwhile, 18% of participants did not use a spacer.

Even after accounting for other clinical covariates, patients were nearly 7 times more likely to miss a critical step in their use of their inhaler when using a spacer with a mouthpiece (odds ratio [OR], 6.95; P < .007). Checklist score was not associated with patients' race, ethnicity, or insurance status, or with parents' education level, health literacy, or confidence, though patients with scores below 7 tended to have more transportation-related barriers to care (OR, 1.62; P = .02).

Older children were more likely to miss a critical step than younger children, the researchers found: the average age of those who missed a critical step was 7.8 years, compared with an average of 5.8 years among those who didn't (P = .002).

"Our results also show that inhaler technique errors were most prominent in the adolescent population, possibly coinciding with the process of transitioning to a mouthpiece and more independence in medication administration," the researchers write. "Adolescents may be a high-impact population on which to focus inpatient asthma education."

The research was funded by internal grants at Lurie Children's Hospital. Gupta disclosed research grants from United Healthcare Group and consulting for DBV Technology, Aimmune Therapeutics, Kaleo, and BEFORE Brands. The remaining authors have disclosed no relevant financial relationships.

J Hosp Med. Published online April 8, 2019. Abstract

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