Asthma - refine your technique

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   I was reading the Australian Prescriber catching up with the latest advice for Doctors on controlling asthma, and was disturbed by some of the information I found there. Thankfully the number of deaths has fallen over the years and yet asthma still causes considerable health problems and impacts on the lives of many millions around the world.

Although medications haven't changed fundamentally over the years, the way they are used and the way patients should be reviewed has. But we are falling dramatically short of good and effective care partly due to poor education and partly due to poor compliance by the asthmatics themselves: " more than half of the people aged 15–34 years (who have asthma) .. (pick up their) medications only once in a year. Most patients use their inhalers incorrectly, and only 22% of patients have a written asthma action plan". These are not encouraging findings!

Picking up on the poor technique of most asthmatics, I've cut and pasted the suggestions from the Oz Prescriber so that those of you with asthma, or who have children/adolescents with asthma, can review what you are/they are doing and see if you can do it better.

                                                     Common problems with inhaler devices

• breathing out through the inhaler mouthpiece leads to condensation and clogging of the nozzle
• difficulty actuating inhaler (for patients with arthritis, an aid may be available and fitted around the inhaler to ensure easier use)
• failure to coordinate actuation with inhalation. At its worst, medication will be seen to escape from the top of the inhaler.
• too fast an inhalation
• failure to hold breath after inhalation
• multiple actuations without shaking between doses, or on the same breath
• failure to replace cap on inhaler (leaves patient at risk of inhaling foreign bodies from pocket or handbag)
• failure to use a spacer with an inhaled corticosteroid-containing medication (the spacer increases lung deposition and hence efficacy, and reduces the risk of local adverse effects)

                                              Pressurized metered dose inhaler with spacer

• failure to prepare spacer before first use, to reduce the static charge which will otherwise prevent medication reaching the airways (wash in warm detergent water, do not rinse, allow to air dry,
• reassemble; there is no need to prime with puffs of a salbutamol inhaler)
• too-frequent washing without detergent priming (regenerates the static charge)
• sticky valve (the spacer should be washed once a month as above, or if the valve sticks)
• multiple actuations of preventer inhaler into the spacer at one time
• delay between actuation and inhalation
• too-fast inhalation, without a breath-hold at the end

                                                                       Autohaler

• failing to lift the lever before inhaling
• stopping breathing in when the click is heard
• failure to hold breath

                                                                      Accuhaler

• breathing out into inhaler
• not loading dose (by pushing lever) before inhaling
• not holding breath after inhalation
• not closing inhaler cover after use

                                                                      Turbuhaler

• not holding Turbuhaler upright during priming (loading) of dose
• not twisting base both around and back (note: it does not matter whether the click is heard at the end of rotation around, or at the end of the rotation back, as long as the base is rotated in
• both directions)
• not breathing in strongly enough
• not holding breath after inhaling dose
• breathing out into inhaler

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