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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 82-87

Evaluation of inhaler technique and asthma control among children in a low-resource setting

1 Department of Pediatrics, Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India
2 Department of Community Medicine, Fakir Mohan Medical College and Hospital, Balasore, Odisha, India
3 Department of Community Medicine, GITAM Medical College and Hospital, Visakhapatnam, Andhra Pradesh, India

Date of Submission25-Jan-2022
Date of Decision21-Aug-2022
Date of Acceptance30-Aug-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Dr. Sai Chandan Das
Associate Professor, Department of Community Medicine, Fakir Mohan Medical College and Hospital, Balasore - 756 019, Odisha
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijamr.ijamr_20_22

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Background: Inhalation has become the preferred route of drug administration compared to oral medication in managing Asthma due to its direct delivery to the airways, thus producing a faster onset of action and fewer systemic side effects at lower doses than would be required for other routes of administration. Aims and Objectives: This study aimed to evaluate the inhaler technique among children with asthma and its association with the level of asthma control and to identify factors associated with improper use of inhaler devices. Materials and Methods: This is a prospective cross-sectional study conducted at the Department of Pediatrics at B. P Koirala Institute of Health Science, university teaching Hospital in Nepal. The children with asthma were asked to use their inhaler device as usual and inhalational technique was assessed using inhaler device assessment tool and control of asthma level was assessed using the Childhood Asthma Control Test score. Results: One hundred and three asthmatic children of the age range of 4–11 years were enrolled in the study. The mean age of surveyed children was 6.3 ± 2.2 years and over half of the participants were boys (68.9%). Around 60% had moderate asthma. Among them, 50% had symptoms for <3 years; only 50% of children with asthma demonstrated good technique of inhaler medication. Forty-five percent of them showed optimal asthma control. Near about a quarter of the participants showed mistakes in one step and about a fifth of the children showed mistakes at more than one step. Almost 30% of children with asthma have not obtained inhaler technique education. Factors associated with poor inhaler technique and poor asthma control were younger age and irregular follow-ups. The most common errors in the proper use of inhalers were not shaking the inhaler before use (30%) and wrong breathing techniques (30%). Conclusions: Improper inhaler technique is common among children with asthma. Children with asthma should have their inhaler technique routinely checked, during visits and should be given detailed education on proper inhalation techniques. Health education programs on asthma control are recommended in countries like Nepal to improve proper asthma inhaler device use and treatment outcomes in children with asthma.

Keywords: Asthma control, health education, inhaler device, inhaler technique

How to cite this article:
Prasad H, Ghosh S, Das SC, Manasa R V. Evaluation of inhaler technique and asthma control among children in a low-resource setting. Int J Adv Med Health Res 2022;9:82-7

How to cite this URL:
Prasad H, Ghosh S, Das SC, Manasa R V. Evaluation of inhaler technique and asthma control among children in a low-resource setting. Int J Adv Med Health Res [serial online] 2022 [cited 2023 Jan 27];9:82-7. Available from: https://www.ijamhrjournal.org/text.asp?2022/9/2/82/359995

  Introduction Top

Asthma is a chronic inflammatory disease of the airways associated with bronchial hyperresponsiveness and reversible airflow obstruction.[1],[2] It causes recurrent episodes of cough, wheezing, and breathlessness, particularly at night and or early in the morning. The incidence and prevalence of asthma are 1%–18%[3] and have increased during the past 20 years, affecting 14% of the global children population. The highest percentage (>20%) was observed in Latin America and English-speaking countries of Australia, Europe, North, and South Africa.[4] The lowest prevalence (<5%) was observed in the Indian subcontinent, including Nepal.

Although the cause of asthma in children has not been identified, a combination of environmental exposures and inherent biological and genetic susceptibilities has been implicated. Managing childhood asthma is also fraught with challenges.[5] Inhalation has become the preferred route of drug administration compared to oral medications in managing asthma due to its direct delivery to the airways, thus producing a faster onset of action and fewer systemic side effects at lower doses than would be required for other routes of administration.[6]

Among the various types of inhalation devices, pressurized metered-dose inhalers (pMDIs) are the most commonly recommended and most widely used devices for pediatric patients due to their efficacy, portability, and general acceptance by asthmatic children and their caregivers.[7] Correct inhalation technique and device use is the cornerstone for optimum asthma control. Many authors have reported poor usage of devices across all ages, particularly among children. Hence, this study is planned to evaluate the inhaler technique among children with asthma, its association with the level of asthma control, and to identify factors associated with improper use of inhaler devices.

  Materials and Methods Top

A hospital-based prospective cross-sectional study was conducted among asthmatic patients attending the pediatric respiratory clinic of B. P. Koirala Institute of Health Sciences (BPKIHS) which is located in the Eastern part of Nepal. The study area has a mixed population with families belonging to all socioeconomic strata. Children aged 4–11 years with a diagnosis of asthma based on clinical criteria and spirometry test, as per the Global Initiative National Asthma guidelines[8] and also those using MDI for a continuous period of more than a month were included in the study after taking informed consent from parents and assent from children. Those who were immunocompromised or using a device other than pMDI were excluded from the study.

The following formula was used in the calculation of sample size: N = Z2 P q/e2. Taking 5%[5] as the prevalence of asthma in children, 95% level of significance, and 80% power to estimate sample size, we got an estimate of 73, but according to the record maintained at the pediatric chest clinic, there were around 100 children with asthma in the age range of 4–11 years in 2016.

After adding 10% as nonresponsive rate we arrived at the sample size of 110. We were able to recruit 103 asthmatic children who had been on inhaled corticosteroids for more than a month and satisfied our inclusion criteria. We excluded participants whose parents did not consent, children <4 years and >11 years, immunocompromised patients and children using a device other than pMDI. A semi-structured pretested pro forma was used to collect basic demographic data of the study participants. Modified Kuppuswamy classification was used to collect the socioeconomic data. After the study was approved by the Institutional Ethical Review Committee (I. R. C) of BPKIHS, data collection was started.


Inhaler device assessment tool

This tool checks the technique of the inhaler device. Inhaler device assessment tool (IDAT) is either scored 1 or 0; no errors = 1 and error = 0 for the 5 steps. Total scores are obtained by summing the scores for each step; thus, they may range from 0 to 5.[9] IDAT assesses all the critical steps of the inhaler device, regardless of whether pMDI is used alone or together with spacer and/or mask. Children on MDI with spacer without mask were checked for five critical steps. In step 1, it was assessed whether he/she removed the cap and inserted canister into spacer correctly; if done correctly, he/she was awarded 1 point. If the metal canister of MDI was not in a plastic mouthpiece, a score of 0 was given. Other steps were assessed and scored in the same way. In the second step, it was seen if the child shook the canister and delivered only 1 spray in the chamber; if yes, he/she was awarded 1 point; if this step was done incorrectly (e.g., forgot to shake or device held incorrectly), he/she was scored 0. In the third step, we assessed whether the child exhaled completely or breathed out to the end of a normal breath before putting the apparatus in their mouth and then hears a hissing sound; if done so, 1 point was given; otherwise, we scored 0. In the fourth step, it was assessed if he/she inhaled appropriately for device, i.e., put the mouthpiece of spacer in the mouth with lips closed tightly around it, subsequently, presses the inhaler, breathe in slowly, and deeply through the mouth for about 5 s; if all this was done correctly, then he/she was given 1 point; if they showed incorrect technique such as inhaling through the nose, or heard a musical sound or whistling due to breathing in too quickly, then a score of 0 was given. In the final step, the correct technique of holding breath to a count of 10 s with lips kept closed was assessed; if this was done correctly, a score of 1 was given; else, we scored 0 for the step.

Each of the five steps for all forms of the IDAT was scored 1 or 0. A step was scored “1” if there were no errors for that step. A step was scored as “0” if it contained at least one error. Scores for all five steps were then added for a maximum possible total score of 5 and a minimum score of 0. The specific criteria to score the step as 1 or 0 were different depending on the device and age of the child, as indicated on the forms. When training nurses or other health-care providers on appropriate usage techniques for more than one device, a cumulative score of 95% to 100% should be obtained. For example, when training for the use of three devices, a score of 14/15 or 95% should be obtained (three devices ×5 maximum score = 15).

Childhood Asthma Control Test

It consists of seven items and is divided into two parts. One part is to be filled in by the child having pictorial representation with four options and the second part is to be filled by the parent or caregiver and consists of three questions with six response options. The sum of all question scores yields the Childhood Asthma Control Test (C-ACT) score, ranging from 0 (poorest asthma control) to 27 (optimal asthma control). A cutoff of >19 indicates optimal asthma control, whereas a cutoff of ≤19 indicates uncontrolled asthma. A cutoff of 12 or less suggests very poorly controlled asthma.[10]

Inhaler technique assessment

A complete assessment of the inhalation technique was conducted by a team of investigators who received the required training before participating in the study. Enrolled individuals were instructed to use their inhalers as usual. All participants used their own age-appropriate medications and devices. During the performance of the test by the patient, no additional instructions were issued. However, after the test was performed and recorded, the correct technique, if applicable, was performed and demonstrated by the team members.

Scoring and interpretation of inhaler device assessment tool

Data analysis

Data were analyzed using the statistical software package for the social sciences, v 24.0 (IBM Corp, Armonk, NY, USA). For descriptive statistics, the proportions and means and standard deviations were computed. The Chi-square test for categorical data, independent t-test for normally distributed data, or Mann–Whitney test for nonparametric data were used to explore differences between proper/improper use of the inhaler. Multiple logistic regression models were used to determine independent risk factors associated with improper use of asthma inhaler devices. P < 0.05 was considered statistically significant for all analyses.

  Results Top

Among 103 asthmatic children, 73 (70.8%) had been asthmatic for <3 years and 29 (28.1%) for 3–6 years. Only 1 (0.9%) child experienced asthma for over 6 years. The children were divided into three age groups. The maximum number (n = 60, 58.2%) of children were of 4–6 years followed by 6–9 years (n = 24, 23.3%) and 9–11 years (n = 19, 18.4%). The mean age of children was 6.3 ± 2.2 years. Over half of the participants were male (n = 71, 68.9%). We found that the majority of the study participants (n = 66, 64.0%) belonged to the upper-middle socioeconomic class and 17 (16.5%) were from the lower-middle class. An almost similar proportion of the study participants belonged to the upper class and upper lower socioeconomic class.

Forty-four (42.7%) children used MDI with spacer and masks, 35 (33.9%) children used MDI with spacer, and 24 (23.3%) children used MDI alone. [Table 1] shows the association of the sociodemographic features of participants with the inhalation technique. Age (P = 0.042) and socioeconomic status (P = 0.001) were significantly associated with the inhaler technique. Children in the age group of 6–9 years (n = 18, 75%; P = 0.042) showed a good inhaler technique. Participants from lower-middle (n = 15, 88.2%); and upper-lower class socioeconomic class (n = 8, 88.9%) displayed poor technique. None of the children staying in boarding school demonstrated good inhaler technique; similar findings were noted among children born to working parents.
Table 1: Association of sociodemographic characteristics with inhaler technique

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[Table 2] illustrates the association of morbidity profile with the inhalation technique. The duration of illness had a significant relation (P = 0.004) with the method of inhalation. A higher proportion of children with the disease aged 3–6 years (n = 23, 79.3%) demonstrated good technique. This finding was found to be significant (P = 0.004).
Table 2: Association of disease morbidity characteristics and inhaler technique

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The type of device (MDI alone or with a spacer or with a spacer and mask) used by children and its relationship with the inhalation technique showed a significant association (P = 0.026). Nearly half of the children (58%) who demonstrated good technique were taught by doctors and this difference was found to be significant (P = 0.043). Children on irregular follow-up (75%) demonstrated poor technique as compared to those on regular follow-up. There was a significant association between follow-up duration and inhalation technique (P = 0.003). We identified independent risk factors associated with the inappropriate use of asthma inhalers. For this, we used multiple logistic regression with variables that emerged significant in the univariate analysis as independent variables (age, socioeconomic status, duration of illness, type of device used, and demonstration) and inappropriate use of asthma inhalers (yes/no) as the dependent variable. The results are presented in [Table 3]. We found that duration of illness and socioeconomic status such as lower, middle, and upper-lower, were found to be strongly associated, and age of child and demonstration method by doctors and nurses were also found to be significantly associated with the inhalation technique.
Table 3: Baseline independent risk factors associated with inhaler technique

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  Discussion Top

Over half of the study participants were 4–6 years old and the majority were male. These findings are well corroborated by other studies which have shown a similar male preponderance.[11] Atopy and asthma are more widespread among men but this distribution changes during puberty. The relationship between thymic stromal proliferation and lower immunoglobulin E levels in girls and the association of estrogen receptor 1 with asthma makes females more susceptible to asthma later in life.[12] Our study revealed that the technique explained or demonstrated to the children/parents were primarily by doctors and only a few by nurses. This is similar to what prior investigators have reported.[13],[14]

Over half of the children had an IDAT score of 5 showing good inhaler technique, about a quarter of the participants showed mistakes in one step, and about a fifth of the children showed mistakes at more than one step. More than half of the children showed a good inhalation technique. These figures are lower than that found in an earlier study of inhalation techniques among children.[15] Others have reported figures for correct use of inhalers within a range of 0% to 57%.[16],[17]

The most common error that occurred was forgetting to shake the canister. Other common mistakes were incorrect head position of children and lack of hissing sound while taking the medication through the inhalation device. Consistent with our findings, a previous study also noted that forgetting to shake the canister was a common error.[18] However, other investigators found that the most frequent error among pMDI users was forgetting to completely exhale.[19]

We found significant association between inhaler technique and duration of illness <3 years, use of MDI without spacer and mask, and also the children belonging to higher socioeconomic status; these subgroups were significantly more likely to use inhalational devices correctly. A study by Jahedi et al. has shown that the chance of wrong technique increases, particularly if no follow-up reassessment of the inhaler technique is performed. The same study highlighted the need for a follow-up assessment to maintain a good inhalation technique that, in turn, will lead to better asthma management.[20]

Similarly, a study carried out in Brazil showed that socioeconomic status was an important factor associated with poor inhalation techniques.[21] Concerning the device used by children, poor technique was more common in children using MDI with spacer and mask. This may be because these children were younger and got irritated on applying the mask for drug delivery.[22]

We found a significant association between inhaler technique and asthma control. There were 56 children who scored 5 out of 5; in other words, good inhaler skills. Of them, 55 scored >19 on C-ACT indicating optimum control. Different studies have demonstrated that patients with poorly controlled asthma are more likely to use asthma devices improperly, compared to those with partially controlled asthma.[23],[24],[25]

It has been observed in various studies that children's improper use of inhalers and other asthma medication devices can lead to poor asthma control, increased number of hospitalizations, and increased health-care costs.[5] This association can be explained as a function of device usage technique that impacts drug delivery and asthma control. For correct use of inhaler devices and better control of asthma, children need repeated education with verbal instruction and physical demonstration.

  Conclusions Top

There is an association between inhaler technique and level of asthma control. Children who showed good technique had an optimal level of asthma control, whereas the children who performed poorly had an uncontrolled level of asthma. A possible reason for this relationship could be inadequate delivery of drug to the desired site of action leading to suboptimal control of asthma. The most common error was that children or parents forget to shake the canister before taking the medication. This can be avoided with proper and repeated education by a qualified person about the correct technique of usage. The good inhalational technique was seen in children who used MDI with spacer without mask and children belonging to upper/upper-middle socioeconomic class. Those who were suffering from asthma for <3 years were more likely to show poor inhalational techniques. Gender, duration of medication, follow-up place, schooling of the child, and working status of parents had no significant relation with inhalational technique. Thus, we can conclude that improper asthma inhaler device use is associated with poor asthma control. We also identified many avoidable risk factors associated with improper use of inhaler devices among asthma patients. Emphasizing that the correct inhalation technique can lead to better asthma control, reduce the cost and side effects of medication, and lead to better outcomes for patients may improve motivation and adherence.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Dougherty D, Sander N, Schwartz M, Weiss ST. National asthma education and prevention program: Expert panel report 3: Guidelines for the diagnosis and management of asthma. NIH 2007;07:40-51.  Back to cited text no. 1
Turner S, Paton J, Higgins B, Douglas G, British Guidelines on the Management of Asthma. British guidelines on the management of asthma: What's new for 2011? Thorax 2011;66:1104-5.  Back to cited text no. 2
Liu AH, Covar RA, Spahn JD, Sicherer SH. Childhood Asthma. In: Kliegman, R.M., Stanton, B.F., St Geme III, J.N. and Behrman, R.E., Eds., Nelson Textbook of Paediatrics, 20th Edition, Elsevier, Philadelphia, 2016 p. 1095-115.  Back to cited text no. 3
Reddel HK, Levy ML, Global Initiative for Asthma Scientific Committee and Dissemination and Implementation Committee. The GINA asthma strategy report: What's new for primary care? NPJ Prim Care Respir Med 2015;25:15050.  Back to cited text no. 4
Richard Beasley. Worldwide variations in the prevalence of asthma symptoms: The International Study of Asthma and Allergies in Childhood (ISAAC). Eur Respir J 1998;12:315-35.  Back to cited text no. 5
Everard ML. Aerosol delivery to children. Pediatr Ann 2006;35:630-6.  Back to cited text no. 6
Laube BL, Janssens HM, de Jongh FH, Devadason SG, Dhand R, Diot P, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J 2011;37:1308-31.  Back to cited text no. 7
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention 2014. Bethesda, MD, USA: GINA; 2014. Available From: http://www.ginasthma.org. [Last accessed on 2022 Jan 10].  Back to cited text no. 8
Davies B, Danseco E, Cicutto L, Higuchi KS, McConnell H, Edwards N, et al. Nursing best practice guidelines evaluation user guide: Inhaler device assessment tool for promoting asthma control in children. IDAT Ped Asthma User Guide FINAL Nov 2006;59:53-78.  Back to cited text no. 9
Liu AH, Zeiger R, Sorkness C, Mahr T, Ostrom N, Burgess S, et al. Development and cross-sectional validation of the childhood asthma control test. J Allergy Clin Immunol 2007;119:817-25.  Back to cited text no. 10
Chan-Yeung M, Becker A. Primary prevention of childhood asthma and allergic disorders. Curr Opin Allergy Clin Immunol 2006;6:146-51.  Back to cited text no. 11
Newman SP. Principles of metered-dose inhaler design. Respir Care 2005;50:1177-90.  Back to cited text no. 12
Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med 2011;105:930-8.  Back to cited text no. 13
Bryant L, Bang C, Chew C, Baik SH, Wiseman D. Adequacy of inhaler technique used by people with asthma or chronic obstructive pulmonary disease. J Prim Health Care 2013;5:191-8.  Back to cited text no. 14
Walia M, Paul L, Satyavani A, Lodha R, Kalaivani M, Kabra SK. Assessment of inhalation technique and determinants of incorrect performance among children with asthma. Pediatr Pulmonol 2006;41:1082-7.  Back to cited text no. 15
Sleath B, Ayala GX, Gillette C, Williams D, Davis S, Tudor G, et al. Provider demonstration and assessment of child device technique during pediatric asthma visits. Pediatrics 2011;127:642-8.  Back to cited text no. 16
Sleath B, Carpenter DM, Ayala GX, Williams D, Davis S, Tudor G, et al. Communication during pediatric asthma visits and child asthma medication device technique 1 month later. J Asthma 2012;49:918-25.  Back to cited text no. 17
Uijen JH, van Uijthoven YJ, van der Wouden JC, Bindels PJ. Adequate use of asthma inhalation medication in children: More involvement of the parents seems useful. BMC Res Notes 2009;2:129.  Back to cited text no. 18
Molimard M, Raherison C, Lignot S, Depont F, Abouelfath A, Moore N. Assessment of handling of inhaler devices in real life: An observational study in 3811 patients in primary care. J Aerosol Med 2003;16:249-54.  Back to cited text no. 19
Jahedi L, Downie SR, Saini B, Chan HK, Bosnic-Anticevich S. Inhaler technique in asthma: How does it relate to patients' preferences and attitudes toward their inhalers? J Aerosol Med Pulm Drug Deliv 2017;30:42-52.  Back to cited text no. 20
Dalcin Pde T, Grutcki DM, Laporte PP, Lima PB, Menegotto SM, Pereira RP. Factors related to the incorrect use of inhalers by asthma patients. J Bras Pneumol 2014;40:13-20.  Back to cited text no. 21
Rubin BK, Fink JB. Optimizing aerosol delivery by pressurized metered-dose inhalers. Respir Care 2005;50:1191-200.  Back to cited text no. 22
Capanoglu M, Dibek Misirlioglu E, Toyran M, Civelek E, Kocabas CN. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. J Asthma 2015;52:838-45.  Back to cited text no. 23
Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002;19:246-51.  Back to cited text no. 24
Arora P, Kumar L, Vohra V, Sarin R, Jaiswal A, Puri MM, et al. Evaluating the technique of using inhalation device in COPD and bronchial asthma patients. Respir Med 2014;108:992-8.  Back to cited text no. 25


  [Table 1], [Table 2], [Table 3]


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