Inhaler technique in at-risk adults with uncontrolled asthma
Published online: June 4, 2019
Uncontrolled asthma has high morbidity and disproportionately affects minority, low-income, and inner-city patients. Uncontrolled asthma is a multifaceted problem. Asthma phenotype, atopy, genetics, environmental factors, comorbidities, inhaler technique, and medication nonadherence may contribute to uncontrolled disease. Previous research has shown that inhaler technique, an important modifiable risk factor for uncontrolled asthma, is suboptimal in most patients. However, the relative importance of inhaler technique on disease control is unknown.
In an article recently published in The Journal of Allergy and Clinical Immunology: In Practice, Gleeson and colleagues examined inhaler technique in low-income, inner-city adults in Philadelphia, all with uncontrolled asthma by currently accepted criteria. Inhaler technique, for both metered dose inhalers and dry powder inhalers, was rated by research coordinators using steps derived from commonly accepted checklists. Incorrect steps were then corrected to benefit the users.
Obesity and other medical comorbidities were over-represented in this group. Most patients were current or former smokers, and about half were on Medicaid. Most had an Emergency Room visit or hospitalization for asthma in the previous one year. Surprisingly, about sixty percent of patients achieved adequate visually-assessed inhaler technique, a number higher than typically seen in the general asthma population. There was no difference in inhaler scores based on healthcare literacy.
The dissociation between asthma control and inhaler technique was counterintuitive, and may be partially explained by baseline patient characteristics, such as obesity, that confer a risk of uncontrolled asthma. Suboptimal living conditions may have also contributed to uncontrolled disease. The authors’ study population was exceptional, including adults with the highest morbidity. While incorrect technique is common and must be addressed as part of routine asthma care, other factors contribute to poor asthma outcomes and must be explored.
The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.