Does inhaler technique align with confidence among African-American children and their parents?

Appropriate inhaler use in children with asthma: barriers and opportunities through the lens of the socio-ecological model

Objective: Proper use of inhaled medications is essential for management of asthma, as inhaled therapies are recommended as first-line for both prevention and treatment of asthma symptoms. Optimizing adherence requires identifying and understanding multiple layers of systemic complexity to obtaining and using these therapies and offering specific solutions to address these barriers. Bronfenbrenner's socio-ecological model provides a framework for examining multilevel systems - both internal and external - that contribute to the management of childhood asthma. The four levels in this model consist of factors related to the individual, interpersonal relationships, organizational entities, and societal structures and rules. This narrative review identifies influences and factors related to asthma inhaler adherence by each level and offers evidence-based solutions to each obstacle.Data Sources: We conducted PubMed searches to identify relevant articles for barriers and solutions impacting asthma control at each level of the socio-ecological model.Study Selection: Common barriers to asthma control at each model level were identified. Pertinent studies for each barrier were identified and reviewed by the writing group for inclusion into the narrative review.Results: For each level of the socio-ecological model, three primary issues were identified based on the literature review. Approaches for addressing each issue in an evidence-based, systematic fashion are presented.Conclusion: Understanding the obstacles and potential interventions to achieve proper use of inhaled medications is a critical step necessary to develop and implement systematic solutions aimed at improving asthma control and morbidity for the more than 6 million affected children in the United States.

Strategies for Improving Inhalation Technique in Children: A Narrative Review

Inhaled medicines are commonly utilized by children for various respiratory conditions and must be used effectively for the medication to reach the airways. Poor inhaler technique contributes to poorly controlled asthma with significant associated morbidity. Given the significant consequences of improper inhaler use in children, the goal of this review is to comprehensively describe existing and potential solutions to improve inhaler technique. Because children move through various settings, including clinical practices, schools, pharmacies, and homes, in their daily routine, there is great opportunity to teach and reinforce proper inhaler technique across settings. Within each setting, in-person and technology-based interventions have shown promise to improve technique. These solutions need to be more broadly adopted to deliver tailored education with support for provider training, team-based care, communication structures, and reimbursement. Such solutions hold the potential to improve inhaler use among children, with potential for decreasing morbidity and costs.

Association between inhaler technique and confidence among hospitalized children with asthma

OBJECTIVE

Proper use of respiratory inhalers is crucial to asthma self-management and associated with improved outcomes. Previous studies conducted in outpatient and community settings show parents and children are overconfident in children's ability to use inhalers properly, which may lead healthcare providers to not teach or review inhaler technique. This study examined whether children and parents' confidence were associated with proper inhaler technique among children hospitalized with asthma.

METHODS

Children between 5 and 10 years old hospitalized with asthma at an urban academic medical center demonstrated inhaler technique using metered dose inhalers and spacers. Technique was scored based on a validated 12-step scale. Confidence was measured using three items assessing 1. Knowledge to use inhaler, 2. Skills to use inhaler, and 3. Ability to independently use inhaler. These items were five-point scales and analyzed as binary variables. Independent t-tests were used to measure associations between confidence and number of steps performed correctly.

RESULTS

None of the confidence items, when asked to parents or children (n = 70), were associated with the number of steps performed correctly. Further, while the majority of children and parents (59-70%) were confident based on each item, the mean number of steps correctly completed was 6.4 out of 12.

CONCLUSIONS

Children and parents' confidence in children's knowledge, skills, and ability to independently use an inhaler were all poor proxies for proper inhaler technique. Inpatient healthcare professionals should objectively evaluate technique and teach proper inhaler use to all children with asthma to optimize outcomes.

What can be done to impact respiratory inhaler misuse: exploring the problem, reasons, and solutions

INTRODUCTION

Respiratory inhalers, when used correctly, provide critical treatments for managing pulmonary conditions. However, many patients misuse inhalers, negatively affecting disease control, quality of life, healthcare utilization, and costs. Numerous factors are associated with misuse and are nested within four levels of influence: individual, interpersonal, organizational/institutional, and policy.

AREAS COVERED

This review analyzed published literature and identified the most salient factors at each socio-ecological framework level. English language articles from any year were identified from PubMed, Google Scholar, and Embase databases. Misuse exists across clinical settings, patient populations, and device types. Several potential solutions are highlighted. Published interventions to improve inhaler technique have utilized handouts, in-person, virtual, and biofeedback approaches both inside and outside of healthcare settings with varied effectiveness. However, some interventions have superior effectiveness for improving technique and reducing acute care utilization.

EXPERT OPINION

To robustly address inhaler misuse, future solutions should focus on multi-level approaches to account for the myriad of factors contributing to inhaler misuse. Solutions should also streamline inhaler equipment, identify innovative technology-based solutions, support collaborations across healthcare and non-healthcare settings, and ensure reimbursement to healthcare professionals for inhaler education. Rigorous research studies must be funded and supported to identify and disseminate solutions.

Aerosol Therapy in Asthma-Why We Are Failing Our Patients and How We Can Do Better

In order for inhaled corticosteroids to be delivered adequately to the airways they require patients to take them regularly using an effective technique. Patients often have a poor inhaler technique, and this has been shown to result in sub-optimal asthma control. It is important for all clinicians prescribing inhaled medication to be experienced in the correct technique, and take time to train children so that they have mastered corrected inhaler technique. Using Teach to Goal or teach back methodology is a simple and effective way to provide this in the clinic setting. More than one training session is typically needed before children can master correct inhaler technique. Adherence to inhaled therapy has been shown to be sub-optimal in pediatric populations, with studies showing an average rate of around 50%. Subjective methods of measuring adherence have been shown to be inaccurate and overestimate rates. The advent of new technology has allowed adherence rates to be measured electronically, and it has been shown that regular feedback of these data can be effective at improving asthma control. New mobile apps and smart technology aim to engage patients and families with their asthma care. Effective use of these apps in collaboration with health care professionals has a vast potential to improve adherence rates and inhaler technique, resulting in improved asthma control.

Transition for Adolescents and Young Adults With Asthma

Asthma is a complex, heterogenous medical condition which is very common in children and adults. The transition process from pediatric to adult health care services can be a challenge for young people with chronic medical conditions. The significant changes in physical and mental health during this time, as well as the many unique developmental and psychosocial challenges that occur during adolescence can complicate and impede transition if not adequately addressed and managed. The transition period can also be a challenging time for health professionals to assess readiness for transition and manage some of the complications which are particularly common during this time, including poor adherence to therapy, smoking, drug use, and emerging mental health conditions. The natural history, presentation, symptoms, and management of asthma is often significantly different when comparing pediatric and adult practice. In addition, management in infants, toddlers, school aged children, and adolescents differs significantly, offering an additional challenge to pediatric physicians managing asthmatic children and young people. Despite these challenges, if the transition process for young people with asthma is planned and performed in a formalized manner, many of these issues can be addressed, allowing the transition to occur smoothly despite changes that may occur in medical and psychosocial domains.