Critical Errors in Inhaler Technique among Children Hospitalized with Asthma
Past studies have not evaluated inhaler use in hospitalized children with asthma. The objectives of this study were to evaluate inhaler technique in hospitalized pediatric patients with asthma and identify risk factors for improper use. We conducted a prospective cross-sectional study in a tertiary children’s hospital for children 2-16 years of age admitted for an asthma exacerbation, and inhaler technique demonstrations were analyzed. Of 113 participants enrolled, 55% had uncontrolled asthma, and 42% missed a critical step in inhaler technique. More patients missed a critical step when they used a spacer with mouthpiece instead of a spacer with mask (75% [51%-90%] vs 36% [27%-46%]) and were older (7.8 [6.7-8.9] vs 5.8 [5.1-6.5] years). Patients using the spacer with mouthpiece remained significantly more likely to miss a critical step when adjusting for other clinical covariates (odds ratio 6.95 [1.71-28.23], P = .007). Hospital-based education may provide teachable moments to address poor proficiency, especially for older children using a mouthpiece.
© 2019 Society of Hospital Medicine
RESULTS
Participants
From October 2016 to June 2017, 380 participants were assessed for participation; 215 were excluded for not having a parent available (59%), not speaking English (27%), not having an asthma diagnosis (ie, viral wheezing; 14%), and 52 (14%) declined to participate. Therefore, a total of 113 participants were enrolled, with demonstrations provided by 100 caregivers and 13 children. The mean age of the patients overall was 6.6 ± 3.4 years and over half (55%) of the participants had uncontrolled asthma (NHLBI criteria1).
Errors in Inhaler Technique
The mean asthma checklist score was 6.7 (maximum score of 10 for SM and 12 for SMP). A third (35%) scored <7 on the asthma checklist and 42% of participants missed at least one critical step. Overall, children who missed a critical step were significantly older (7.8 [6.7-8.9] vs 5.8 [5.1-6.5] years; P = .002). More participants missed a critical step with the SMP than the SM (75% [51%-90%] vs 36% [27%-46%]; P = .003), and this was the most prominent factor for missing a critical step in the adjusted regression analysis (OR 6.95 [1.71-28.23], P = .007). The most commonly missed steps were breathing normally for 30 seconds for SM, and for SMP, it was breathing out fully and breathing away from the spacer (Table 1). Twenty participants (18%) did not use a spacer device; these patients were older than those who did use a spacer (mean age 8.5 [6.7-10.4] vs 6.2 [5.6-6.9] years; P = .005); however, no other significant differences were identified.
Demographic, Medical History, and Socioeconomic Characteristics
Overall, race, ethnicity, and insurance status did not vary significantly based on asthma checklist score ≥7 or missing a critical step. Patients in the SM group who 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 were less likely to miss a critical step (Table 2). Parental education level varied, with 33% having a high school degree or less, but was not associated with asthma checklist score or missing critical steps. Parental BHLS and parental confidence (PAMSE) were not significantly associated with inhaler proficiency. However, transportation-related barriers were more common in patients with checklist scores <7 and more missed critical steps (OR 1.62 [1.06-2.46]; P = .02).
Nearly half of the participants in this study missed at least one critical step in inhaler use. In addition, 18% did not use a spacer when demonstrating their inhaler technique. Despite robust studies demonstrating how asthma education can improve both asthma skills and clinical outcomes,13 our study demonstrates that a large gap remains in proper inhaler technique among asthmatic patients presenting for inpatient care. Specifically, in the mouthpiece group, steps related to breathing technique were the most commonly missed. 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. Adolescents may be a high-impact population on which to focus inpatient asthma education. Additionally, we found that a previous PICU admission and previous inpatient asthma education were associated with missing fewer critical steps in inhaler technique. This finding is consistent with those of another study that evaluated inhaler technique in the emergency department and found that previous hospitalization for asthma was inversely related to improper inhaler use (RR 0.55, 95% CI 0.36-0.84).14 This supports that when provided, inpatient education can increase inhaler administration skills.
