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
Previous studies conducted in the outpatient setting have demonstrated variable rates of inhaler skill, from 0% to approximately 89% of children performing all steps of inhalation correctly.8 This wide range may be related to variations in the number and definition of critical steps between the different studies. 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. While past studies did evaluate both MDIs and discuss the devices, our study is the first to report difference in problems with technique between SM and SMP. As asthma educational interventions are developed and/or implemented, it is important to stress that different steps in inhaler technique are being missed in those using a mask versus mouthpiece.
The limitations of this study include that it was at a single center with a primarily urban and English-speaking population; however, this study population reflects the racial diversity of pediatric asthma patients. Further studies may explore the reproducibility of these findings at multiple centers and with non-English-speaking families. This study included younger patients than in some previous publications investigating asthma; however, all patients met the criteria for asthma diagnosis and this age range is reflective of patients presenting for inpatient asthma care. Furthermore, because of our daytime research hours, 59% of patients were excluded because a primary caregiver was not available. It is possible that these families have decreased access to inpatient asthma educators as well and may be another target group for future studies. Finally, a large proportion of parents had a college education or greater in our sample. However, there was no association within our analysis between parental education level and inhaler proficiency.
The findings from this study indicate that continued efforts are needed to establish that inhaler technique is adequate for all families regardless of their educational status or socioeconomic background, especially for adolescents and in the setting of poor asthma control. Furthermore, our findings support that inhaler technique education may be beneficial in the inpatient setting and that acute care settings can provide a valuable “teachable moment.”14,15
CONCLUSION
Errors in inhaler technique are prevalent in pediatric inpatients with asthma, primarily those using a mouthpiece device. Educational efforts in both inpatient and outpatient settings have the potential to improve drug delivery and therefore asthma control. Inpatient hospitalization may serve as a platform for further studies to investigate innovative educational interventions.
Acknowledgments
The authors thank Tina Carter for her assistance in the recruitment and data collection and Ashley Hull and Susannah Butters for training the study staff on the use of the asthma checklist.
Disclosures
Dr. Gupta receives research grant support from the National Institutes of Health and the United Healthcare Group. Dr. Gupta serves as a consultant for DBV Technology, Aimmune Therapeutics, Kaleo & BEFORE Brands. Dr. Gupta has received lecture fees/honorariums from the Allergy Asthma Network & the American College of Asthma, Allergy & Immunology. Dr. Press reports research support from the Chicago Center for Diabetes Translation Research Pilot and Feasibility Grant, the Bucksbaum Institute for Clinical Excellence Pilot Grant Program, the Academy of Distinguished Medical Educators, the Development of Novel Hospital-initiated Care Bundle in Adults Hospitalized for Acute Asthma: the 41st Multicenter Airway Research Collaboration (MARC-41) Study, UCM’s Innovation Grant Program, the University of Chicago-Chapin Hall Join Research Fund, the NIH/NHLBI Loan Repayment Program, 1 K23 HL118151 01, NIH NLBHI R03 (RFA-HL-18-025), the George and Carol Abramson Pilot Awards, the COPD Foundation Green Shoots Grant, the University of Chicago Women’s Board Grant, NIH NHLBI UG1 (RFA-HL-17-009), and the CTSA Pilot Award, outside the submitted work. These disclosures have been reported to Dr. Press’ institutional IRB board. Additionally, a management plan is on file that details how to address conflicts such as these which are sources of research support but do not directly support the work at hand. The remaining authors have no conflicts of interest relevant to the article to disclose.
