Improving treatment of asthma attacks in childrenBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5763 (Published 29 December 2017) Cite this as: BMJ 2017;359:j5763
All rapid responses
People in the general population have difficulties using devices related to their asthma (1). Adults and children who have intellectual/learning disabilities may have coexisting vision, hearing, dexterity, cognition and memory difficulties that will impact on their understanding of their asthma and the devices necessary to treat the condition. The health literacy level of the person and/or their formal or informal carer will impact on treatment.
The lack of information about medication that people with intellectual/learning disabilities have been prescribed has been highlighted as an area of concern (2). Several people with intellectual/learning disabilities said that they did not understand patient information produced to raise awareness of health problems. “ What’s the use of having a leaflet that is full of writing for someone that can’t understand it? I’ve got a booklet on asthma at home, but it’s not very accessible. My carers have to sit down and explain the leaflets to me.”
Clinicians including doctors and pharmacists often underestimate the complexity of the task that must be undertaken by people with intellectual disabilities and/ or their carers. Common errors in technique made by patients (3) include the following:
• Not shaking the aerosol inhaler before use
• Not priming the aerosol inhaler before first use
• Failing to detect an empty inhaler before use
• Failing to breathe out fully before inhaling
• Incorrect coordination of MDI and pMDI actuation with inspiration
• Incorrect inspiration flow rate (breathing in too fast or too slow)
• Failing to hold breath after inhalation.
A large, systematic review identified a high frequency of poor and/or sub optimal inhaler use for all types of devices (4), illustrating the complexity of the task of administering medication via an inhaler. It is recommended that healthcare professionals promote use of spacers and written asthma action plans as well as counsel people with intellectual disability about how to recognise and minimise side-effects of asthma medications (5). Recommended strategies include careful instruction, observation of inhalation technique, and individual matching of inhaler and patient (4).
1. Mayor, Susan. Most people use adrenaline autoinjectors and asthma inhalers incorrectly, study warns. BMJ 2014;349:g7738
2. National Patient Safety Agency , Understanding the patient safety issues © National Patient Safety Agency 2004 for people with learning disabilities.
3. Murphy, Anna , 2016. How to help patients optimise their inhaler technique. The Pharmaceutical Journal, July 27 2016.
4. Systematic Review of Errors in Inhaler Use Sanchis, Joaquin et al. CHEST , Volume 150 , Issue 2 , 394 - 406
5. Davis S, Durvasula S, Merhi D, et al. Knowledge that people with intellectual disabilities have of their inhaled asthma medications: messages for pharmacists. Int J Clin Pharm 2015; 38: 135–143.
Competing interests: No competing interests
Professors Bush and Griffiths are right to draw attention to the continuing evidence for suboptimal management of exacerbations of asthma in children in the UK and the associated continuing mortality. They also remind us of the evidence for equivalent or superior performance of metered dose inhaler with spacer over nebuliser - in all but the most severe exacerbations - for administering the necessary higher doses of beta agonists when asthma gets worse.
The advantages of the metered dose inhaler / spacer combination for increasing the lung deposition and clinical effectiveness of inhaled treatments during exacerbations of asthma have been well established for many years (1) , but this simple technology remains undervalued and under used. Every person with asthma, whatever their age, should have metered dose inhalers and a spacer, and they or their caregivers should know how to use them to temporarily increase the dosage of both beta agonist and inhaled corticosteroid inhalers when symptoms significantly worsen This should be the case even when, in older children and adults, their regular treatment is given using other types of inhaler.
Knowing exactly how to do this should form part of the personal asthma action plan of all people with asthma - and all health professionals need to know how to give this advice. Plans must also include clear advice on the need for urgently seeking medical attention if symptoms are worsening despite increased inhaler use, and the need for oral corticosteroid treatment of severe exacerbations. Health professionals need to know the vital importance of careful clinical assessment of exacerbations and the need for oral corticosteroids, pulse oximetry and oxygen for severe episodes.
Given the key role of the metered dose inhaler and spacer combination for the treatment of mild to moderate exacerbations it is essential to ensure the continued availability of metered dose inhalers while solutions are found to the continuing issues and concerns over the environmental impact of MDI propellants.
Dr Duncan Keeley
Thame OX9 3JF
The author is executive committee policy lead for the Primary Care Respiratory Society UK. This response us written in a personal capacity. The author is executive committee policy lead for the Primary Care Respiratory Society UK
Large volume plastic spacers in asthma. Keeley D.
BMJ 1992; 305 doi: https://doi.org/10.1136/bmj.305.6854.598 (Published 12 September 1992)
Cite this as: BMJ 1992;305:598
Competing interests: No competing interests