Despite decades of experience with inhaler therapy, a variety of mistakes concerning therapy adherence, the inhalation technique, and mistakes in the handling of spacer and device were made by Dutch children. The important role of the parents in all of these aspects is highlighted in this discussion.
Therapy inconsistency
To determine therapy inconsistency we compared the reported use with the pharmacy prescription label, in our opinion the most appropriate source for comparison. The use of more than one inhaler was most frequently the reason for inappropriate use. Parents decide when and how the inhaler is to be used for most of the children, which confirms their important role in compliance with inhaler therapy. Noteworthy is that four children only used their ICS in case of symptoms, although ICS are a long-term maintenance therapy and should be administered daily.
Inhalation technique
We found that many subjects did not shake their inhaler (c.f. Kamps et al)[6]. However, despite their mistake, most subjects knew that the inhaler had to be shaken before use. On the other hand, nineteen subjects did not know that it is recommended to activate the MDI once, inhale the first dose of drug, and then activate the MDI again for a second dose [16].
Most of the parents received the instruction either at the pharmacy or the general practice, emphasizing that both organisations play an important role in educating parents about the inhalation technique.
Inhaler management
Most parents reported an incorrect method of assessing an inhaler for remaining doses. Most of them spray in the air to see whether the inhaler still contains gas. Fifteen subjects reported that they clean and dry their spacer with a towel. This is incorrect because the generated static load will prevent the drug from leaving the spacer for the first few inhalations [16]. Four subjects reported that they never cleaned their spacer.
Is every mistake a failure?
Dutch children and their parents make a variety of mistakes when using an inhaler. However, despite the mistakes made, none of the children included in this study had severe asthma symptoms. It is therefore important to further investigate the effect of both the inhalation technique and the therapy consistency on asthma control. Especially ICS have become very potent in the last decade and even with a less correct inhalation technique relief of symptoms might be achieved.
Strengths and limitations
This present study has several potential limitations. Although our strategy of using self-reports may not be ideal, no feasible alternative is available [8, 10, 12]. During the technique demonstration, some of the younger children became shy, which probably influenced their inhalation technique. The limited number of general practices and pharmacies may have affected the results. The proportion of responders, although low, is not uncommon in this setting [18]. As responders were probably more compliant, given their interest in the study, the overall compliance and inhaler technique might be even worse than our results suggest.
Strength of the present study is that the children were visited at home allowing them to demonstrate their inhalation technique in a familiar environment. We also explored knowledge on the inhalation technique and use, and combined these findings with the prescription.