Assessment of Inhalation Technique in Children in General Practice: Increased Risk of Incorrect Performance With New Device
Authors: Leo Harvey L. 
Published: October 2008

Hagmolen of ten Have W, Van de Berg WN, Bindels PJ, Van Aalderen WM, Van der Palen J. J Asthma. 2008;45(1):67–71
PURPOSE OF THE STUDY. To assess the inhalation technique of asthmatic children with varying inhalation devices over time.
STUDY POPULATION. The study included children between the ages of 6 and 7 years who were prescribed at least 2 β agonists or controller medications by a general practitioner during 2000–2003 in the Netherlands.
METHODS. Inhalation technique was evaluated twice by using a standardized checklist first at enrollment in the study (n = 530) and 1 year later (n = 362). If children used &gt;1 device, they were asked to demonstrate (with a placebo) their inhalation technique for the different inhalers. The study was observational, and no inhalation instructions were given. At enrollment, parents were questioned on previous inhalation instructions.
RESULTS. A total of 131 (24%) children made ≥1 essential error with their inhaler devices initially. Children with a longer duration of asthma showed significantly more frequent incorrect inhaler performance. Incorrectly performing children with a metered-dose inhaler (MDI) with a spacer received less inhalation instruction by a health care worker as reported by the child or parent. The poor performance in children with a pressurized MDI was only slightly and not significantly better if they had received inhalation instruction (P = .2). Children who kept the same device more often demonstrated correct technique compared with the year before. This was irrespective of the type of inhaler and only significant for children with an MDI (without spacer). Despite this improvement after 1 year, children with an MDI again performed worse compared with all of the other inhaler types. Moreover, Discus and other dry-powder–inhalation devices were more often demonstrated correctly compared with MDIs with or without a spacer. Of the children who were prescribed a new device, 21% (24 of 114) demonstrated an incorrect technique compared with 11% (26 of 241) of the children who kept the same device (P = .01). Furthermore, 41% (37 of 91) of incorrect performances appeared to be correct 1 year later. Conversely, 4% (11 of 300) of the correct performances were incorrect at the end of the study. The MDI was still significantly and strongly associated with incorrect technique.
CONCLUSIONS. Children are prone to use inhalation devices incorrectly if they are not monitored closely in correct use. Pressurized MDIs with and without a spacer were more prone to errors compared with dry-power inhalers. Children prescribed a new device were more prone to usage errors.
REVIEWER COMMENTS. Although MDIs and dry-power–inhaler devices offer convenient and effective means of controller- and rescue-medication delivery, proper instruction and reinforcement of technique is essential to ensure proper use. Understanding the limitations of medication device delivery can assist the pediatrician in avoiding medication errors in asthmatic children. Device training for both children and their parents are an essential part of asthma education.