Improving Asthma Care - Lectures
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Lectures
Inhaler Device Selection
There are a bewildering variety of inhaler devices available to treat respiratory disease. As health professionals we are now spoilt for choice and the selection of a suitable inhaler can be daunting and difficult. Which device to chose? Which device is going to be the best for my respiratory patient? How do I know I have made the right choice?
We will concentrate here on the issues around the selection of inhaler devices for adults. Like children, they too have particular needs and as careful consideration to inhaler selection needs to be given to them as is given to selecting an inhaler device for children. The most expensive inhaler device is the one the patient can’t or won’t use!
So what do you need to think about? There are several considerations and I will split them into two groups…….devices and patients. Since medical care is about patients I will discuss patient considerations first.
Patient preference
A good starting point is to first consider what the patient would like to use. For some, this may be no inhaler at all but inhaled therapy for asthma and COPD is preferable to oral treatment, and with a little two-way discussion on the benefits of treatment, most patients can be persuaded to try it.
Previous experience
Do they have any previous experience of inhaled therapy? What have they used in the past? If they have used inhalers before then this can form the basis of a discussion about what they did, and didn’t like about that inhaler. Their views may help guide your selection of inhaler devices to show the patient.
If they have never used an inhaler they may have experience of seeing a friend or relative using one. What did they think about that one? For adolescents having the same inhaler as their peer may be particularly important.
Consider where the inhaler will be used
The next thing to consider is knowing something about a person’s lifestyle. For example, the active sportsperson may need an inhaler that fits snugly into a shorts pocket and is quick and easy to use. It is not much use to give them an inhaler that requires loading with capsules, or is too big to carry around – such as an MDI and spacer. If inhalers are going to be exposed to damp and humid conditions then some dry powder devices may not be suitable. The business traveller may also need a small, compact, portable device that does not take up much space in a suitcase, brief case or computer bag.
Spare some thought as to where the inhaler is going to need to be used. Most people want something that is discreet and attracts as little attention as possible when they use it in public. Most would prefer not to use it at all in public. How many patients have you seen using an inhaler in a dark corner and attempting to hide what they are doing under the lapels of their coat? A pill can be swallowed very discreetly. When you use an inhaler you attract attention.
Cost
Another consideration is cost. Cost may be a big issue ….and not just for the socio-economically deprived. Many people do not like having to pay for prescriptions and a simple regime, with one inhaler instead of two may be beneficial and encourage adherence to treatment. If once a month you have to collect three items the capital outlay can be a little daunting. Not all of them can afford or are willing to purchase a pre-paid prescription certificate.
So much for patient preference…but it must be stressed that inhaler selection should be, as far as possible a two-way process. Patients should be involved in the choice. It should not be imposed upon them without consultation. It is, after all the patients who have to take it.
Ability to use
What about patient ability? Metered dose inhalers require a high degree of hand/breath coordination. Not all patients can manage this. Estimates of the number of patients who can use an MDI effectively vary widely depending on which paper you read. It could be argued that for a short-acting bronchodilator this is not important…if it does not provide relief because it has not been taken properly then the patient can take another dose. But….is this cost effective and is it the best thing for the patient?
- Dexterity; some inhaler systems require a patient to load capsules into a device or are fiddly in other ways. Some people are naturally more dextrous than others, but a condition such as rheumatoid arthritis, or a stroke may make such devices difficult, if not impossible to use easily.
- Disabilities; you might need to consider other disabilities, such as partial sight or blindness which can make things difficult. Some inhaler devices have Braille markings…but not all. Generally it is better to use the same inhaler device for all the drugs the patient uses……inhaler technique only needs to be taught once and there is less potential for confusion…..but for a blind patient having different devices for different drugs may enable them to distinguish between them easily. They will then be able to take responsibility for their own treatment and are not reliant on a relative or carer to ensure that they have taken the correct inhaler
- Mental ability; what about mental ability? People with learning disabilities may have particular difficulties learning to use an inhaler that has a number of complex steps. Elderly patients may have early dementia and have lost cognitive ability. They may appear perfectly normal, but will have tremendous problems with remembering complicated sequences of events. For them, the simpler the better.
The elderly may prevent a particular problem. Not only are they more likely to have co-morbid conditions such as rheumatoid arthritis, but they may also have sight, hearing and cognition problems. If their hearing is impaired they may not be able to hear the “click” that tells them the inhaler is loaded, or has discharged.
A rounded view of your patient….not just their respiratory problem will help you to chose, with them an appropriate device.
Device considerations
What about device considerations? Inevitably there are some areas of overlap.
First of all you may need to give some thought to the drugs you are likely to want to give to this particular individual. Having gone to the trouble of finding an inhaler the patient is happy with then it is time consuming to have to go through the process again because the drug you need to give the patient is not available in that device. For example, if you are considering giving a combination of inhaled corticosteroid and a long acting bronchodilator then there are some devices that do not contain that combination of drugs.
Costs
There is tremendous pressure on prescribers to reduce prescribing costs. The cheapest inhaler is usually a metered dose inhaler. However, many people are unable to use them very effectively. So, another cheap option is to give a spacer. These devices are undoubtedly very efficient at delivering drug to the airways, but some spacers are too large, bulky and impractical for use with a short-acting bronchodilator. They are hardly pocket sized! They are also not easy or discreet to use in a public place.
What about the person with COPD? The aim of treatment is to keep these patients active and functioning socially for as long as possible. They should be encouraged to get out and about and maintain their social contacts….but they may well need to use their inhaler when they are out. Insistence on spacer use may deter them from going out.
Reliable medication delivery
How good is the inhaler at delivering the drug to my patient? Will they be able to use it when they need to? This can be a very important consideration. If the patient is going to need to use their inhaler in an emergency situation when they are acutely breathless are they going to be able to generate enough puff to use it?
Reassurance of dose taken
What about the ability to tell if they have taken a dose and being able to see when the inhaler is running out? This can be important. Many patients need the reassurance that they have taken the dose and, not knowing when your inhaler is going to run out can be a source of concern and may lead to over ordering of repeat prescriptions – just in case and that’s costly for the health service and the patient.
Green issues
Some inhalers need to be cleaned and cared for. For example, some CFC free salbutamol inhalers tend to clog and will need to be washed out regularly. For the individual with a busy or chaotic life-style this may not be done and then, when they need it most, it may not work.
Most of the currently available inhalers are disposable. There are very few that can be refilled. Some patients see this as a waste and for them, an inhaler that can be refilled may be a desirable and green option.
And so we come back again to patient preference. A complete and rounded look at all the issues; patient, inhaler, drug and situation, can help the best decision to be made. Once decisions are made, inhaler technique should be checked regularly. Is your patient still happy with their device?…..time taken in the initial choice can save time later and ensure that the patient takes and receives the treatment.
- Consider both the patient and the device carefully
- Involve the patient in the choice
- Teach and check technique
- Unable to use the device easily? Reconsider choice
- Check technique regularly.
Working with Children
Spending time with children with asthma and their families, talking about asthma and then helping them to choose and know how to use the most appropriate inhaler device for their medications can make an enormous difference.
Understanding asthma
A basic understanding of asthma is essential to allow you to reinforce what has been told to them by other health care professionals and to be able to answer basic questions that may worry the child and family. Avoiding medical ‘jargon’ or explaining very carefully what it means may help greatly. Asking them what they understand about what they have been told or have understood from various sources, is often a good start.
Knowing how devices work
In this section, we are concentrating principally on how to work with the child and their family to choose the most appropriate device for delivering the drugs that manage their asthma.
Understanding the child, and the parent
Being able to teach children and their parents how to use the chosen device and being able to recognise common mistakes associated with the use of the device is essential.
Getting the parents on side
It is important to chat to the parents and the child to find out what they understand by their asthma and their understanding of what is needed to keep their asthma under control. This allows one to assess their knowledge and help them understand the reasons for, for example, taking a bronchodilator before exercise to relieve bronchoconstriction or to ensure that they take their prophylactic inhaled steroids even when they are asymptomatic. Many people do not realise that asthma is a chronic inflammatory condition and that inflammation is often present even when there are no symptoms.
We need to understand what the child and the parents wish to gain and what they want to achieve by treating their asthma; that is, understanding their goals.
Goals vary greatly, for example, from the parents wanting their persistently wheezy child to be able to go to school each day, to a teenage athlete who is desperate not to get short of breath after exertion.
Making it fun
Making it fun is a powerful tool when one is working with children and their parents. This tends to get them to relax, talk freely and often makes them more accepting of the inhalers you want to see if they can use.
Positive reinforcement
Targeting the individual goals of children and their patients and explaining how the use of the inhaler and the medication may help; this should be part of any consultation. To encourage children to take their inhaler device, a positive reinforcement is a very powerful tool. Every time the child uses their inhaler well – give them praise and tell them how well they have done. The aim is eventually for the child to realise that they get the parents’ attention and praise for using the device appropriately and are somewhat ignored if they don’t use the device properly. Gradual introduction of a device to a young child is usually possible and is much better than forcing them to have it from day one.
There are a variety of ways of making the inhaler appear friendlier to a child. These can vary from using it on a favourite toy such as a teddy bear, with appropriate praise to the bear, to the use of devices that have been manufactured to look more like a friendly toy.
When children grow older, things change considerably. As we all know, by the middle of adolescence years there is often conflict between parents, as the adolescent asserts their need for independence. Again, it is important to understand what the adolescent wants from their treatment. The health professionals ‘message’ must be targeted appropriately so the child’s goals are achieved. In this age group, the choice of the device is probably most important. The child needs to choose an inhaler device that they can use and one that fits in with their lifestyle: this may help to ensure it is used, or at least most of the time!
Supervising administration
Even when young children need to take twice daily inhaled steroids, some parents still do not give the regular inhaler medicine to their child. In the older child who is given the responsibility of taking their inhalers by themselves, the number of doses they miss is likely to be considerably higher. Occasionally it may be appropriate for the administration of their inhalers to be observed by a parent or relative and to encourage the child to use their medication. This is particularly important if symptoms are becoming worse. The first thing is to always consider why the treatment is not working, before simply increasing the dose of the inhaled steroids or adding in other treatment such as a long-acting b2-agonist or a leukotriene antagonist.
Checking inhaler techniques
Being able to teach inhaler technique appropriately and then check it each time the child uses their device is essential. We know that inhaler techniques are often perfect after a teaching session in the clinic or on the ward, but are very poor when seen a few months later. Again, making sure the child and their parents understand the importance of the inhaler technique in terms of getting the drug into the lung will help. The techniques for the various inhalers are covered in the devices section.
Teaching somebody how to use an inhaler and checking the right techniques every time they are seen, are essential elements of improving asthma care. One or two common problems can occur when different devices are used and may impact on the success of the treatment.
Metered dose inhalers
Pressurised metered dose inhalers used on their own, are probably the most difficult device for the child to learn how to use correctly, and to remember how to use correctly. Many children are unable to use a metered dose inhaler until they are about 12 years of age, because of the difficulty of co-ordinating actuating the device with inspiration. How to use the metered dose correctly is covered in the section on inhalers.
The common mistakes we see are children inhaling before they actuate the device, forgetting to shake their metered dose inhaler as well as those who stop breathing as soon as the propellants hit the back of the throat. This is know as the cold Freon effect. It is thought to be caused by the rapid evaporation of the propellant, which results in a rapid cooling of the pharyngeal wall. Consequently children stop their inhalation. This cold Freon effect is much less of a problem with the CFC free propellants because the spray feels softer and warmer on actuation.
Children also inhale at different rates, some very quickly and others extremely slowly. Inhaling at a slow steady rate is probably optimal and if measured, this equates to about 30 litres/minute.
Another major problem with metered dose inhalers is the fact that very few have dose counters and so it is very difficult to predict when the device is actually empty, apart from counting the doses inhaled from the device. We suggest there is always a spare bronchodilator metered dose inhaler in case of emergency use.
Spacer devices
With spacer devices the age at which the child uses either a facemask or inhales directly by the mouthpiece, needs careful assessment. As with nebulisers, there may be a problem with inappropriate nasal inhalation where the child is breathing in and out through the nose and getting no drug from the spacer. In some cases the parents can be taught to look for the movement of the valve within the device, which suggests the child is breathing via the mouthpiece.
Two different breathing patterns are often recommended for the use of spacers. One is to get the child breathing in and out slowly and deeply on a regular basis and then actuating the metered dose inhaler once they have started this breathing pattern. Five or six breaths will be adequate to clear most spacer devices. In terms of bronchodilatation this technique has been shown to be equivalent to other techniques. The other often used technique is to actuate the medication into the spacer device and then the child take a slow deep breath attempting to clear the spacer contents. Following this, they hold their breath for 10 seconds and then repeat this procedure. This technique is suitable for the older child.
You often find that young children are taught to breathe very rapidly from the spacer device. This often results in very little drug intake and is usually obvious from the child’s breathing rate and the rapid clicking of the valve in some devices.
Another thing to avoid is the practice of putting multiple actuations of medication into the spacer device and then inhaling. By putting five actuations into the spacer, the child may only get the equivalent of one actuation, as the spray coming into the spacer device forces the existing particles on to the wall of the spacer. Only one actuation should be put into the spacer at a time.
Static charge on spacers and its effect on drug output have received a lot of attention. Plastic and polycarbonate devices usually carry very high static charges and can markedly reduce the output from the spacer. If the spacer is used intermittently, then washing the spacer device in soapy water or in a household detergent and letting it dry without rinsing results in the largest initial output of drug. If the device is used on a daily basis for inhaled steroids, the drug is deposited on the spacer walls over the first week and also increases drug output. Research has shown that the anti-static effects of washing the spacer in detergent and drip drying it, last for 3-4 weeks. Some spacers are made of metal or antistatic material which gets rid of this problem.
It is important to check that the spacer valves are actually moving as occasionally, depending on the device, they can become stuck with a build up of drug and moisture.
The last thing to remember with spacers is, as with metered dose inhalers, you always need to shake them immediately before use otherwise the actuated drug dose may be significantly reduced.
Breath activated inhalers
Breath activated inhalers help with the coordination problems that a number of children have with ordinary pressurised metered dose inhalers. Firing of the aerosol is triggered by inhalation. Again, occasionally the cold Freon effect can make the child halt their breathing suddenly, although this is now less of a problem as we have already mentioned. Breath activated devices are often preferred to using a pressurised metered dose inhaler on their own. Again, a dose counter would be useful on these devices.
Dry powder inhalers
Dry powder inhalers have become very popular over the last decade. Inspiratory effort varies between each inhaler device and this is dealt with in the section on specific inhaler devices. It is important for most of these inhaler devices that the patient does not breathe out into the device before inhaling. Breathing out into the device puts very humid air near the drug particles that can rapidly absorb it potentially reducing the drug output.
Nebulisers
There are also a number of problems associated with nebuliser use. It is important to ensure that the child is actually breathing in and out from the nebuliser via the mouthpiece. This may sound obvious, but children frequently put the nebuliser in their mouth and breathe through their nose without actually knowing that the drug isn’t getting into their lungs. This is known as inappropriate nasal inhalation. If suspected, either a nose clip or facemask is indicated.
For the majority of nebulisers, most if not all of the available drug for inhalation comes out within the first five minutes. If child and their parents are advised that is only necessary to nebulise for five minutes, this may help to improve adherence with inhaled treatment. It is important that during this shorter time period, parents encourage their child to breath in and out appropriately from the device.
Another practice that is commonly observed, and should be avoided, is holding a facemask away from a child’s face or simply waving the pot of a nebuliser under the child’s nose or mouth. This practice means there is a decrease of between 50 and 80% of available drug for the child to inhale. If a facemask is used, there should be a snug fit around the nose and mouth.
Looking after inhalers is covered in the specific section on inhaler devices. Here I am just going to mention one or two points.
It is always important with any inhaler to check that no foreign body such as a pebble or a small piece of Lego has managed to get into the mouthpiece. This will prevent inhaling it into the lungs.
Nebulisers
The care of nebulisers varies depending on the advice given via the manufacturer. Some devices may be put in a dishwasher while others would be washed in household detergent, rinsed and allowed to air dry. The process of air drying is hoped to reduce bacterial contamination.
Nebulisers require checking on a regular basis to ensure that their output is appropriate. This is routinely done by checking the output from the compressor, to ensure flow from the nebuliser is appropriate. Local hospitals usually have a technical service that will provide for this care checking the nebuliser twice a year; however manufacturers instructions should always be followed.
Spacers
We have already discussed spacer devices briefly in terms of the washing regimen that is needed for plastic and polycarbonate devices. In years to come, all spacers may have anti-static properties which would reduce the concern raised by drug variability due to static charge.
Parents and children have to take on board a lot of information about their asthma, the drugs prescribed and how to use the chosen drug delivery devices. Regular review to reinforce knowledge and inhaler techniques are of immense help. Never loose the opportunity to check what the family and child understand and always check how they use their device. We all need encouragement – give them plenty.
- Reinforcement
- Parent education
- Child education.
Inhaler Devices for Children
There are currently a huge number of aerosol drug delivery devices available for the delivery of anti-asthma therapy.
The child
It is important to choose an appropriate device for the age and ability of the child and also to have an understanding of how to approach the child and encourage them to accept the device. An understanding by the parents and by the child (if they are old enough) of what asthma is and why they need the medication prescribed is essential to encourage appropriate use of their medications.
The age
First of all we will go through what are now considered to be the most appropriate inhaler devices to use for different age groups. Understanding some basic child psychology and how this relates to the acceptance of inhaler devices will then be addressed followed by some thoughts on the very important issue of compliance and adherence to therapy.
Asthma: Children under 3 years
First choice - spacer device + face mask
There is now reasonably good consensus about the type of drug delivery device that is chosen for children of various ages. For children under 3 years of age the first choice is very much the spacer device with a facemask attachment. This may be used to deliver bronchodilators for acute symptoms, inhaled steroids or other medications.
The advantages of such devices are the excellent clinical responses seen, the ease of use of these devices, their portability and very short treatment times. The main requirement for their use is that the child will tolerate the facemask being placed on their face. It is essential for the mask to make a seal around their nose and mouth, otherwise room air is breathed in instead of drug aerosol. Fortunately, virtually all children can be encouraged to do this in a short period of time. I will mention strategies that may help to achieve this later on.
Second choice - nebuliser
Nebulisers are very much second choice but occasionally do need to be used. They are relegated to second place due to their expense, the time it takes to give a treatment, their portability and the fact that there is no evidence of any superiority during the treatment of acute exacerbations or in the delivery of prophylactic anti-asthma medications.
First choice - spacer device
In children from three to five years of age, the spacer device is still first choice. In this age group the question is: can the child use the spacer device without a mask, breathing in and out of the mouthpiece? This can be difficult to judge at times because ‘inappropriate nasal inhalation’ is a common problem in children using spacers or nebulisers. That is, the child has the device in their mouth but is simply breathing in and out through their nose without anybody realising it.
Second choice - spacer + face mask
If there is any doubt, the use of a spacer with a facemask attachment and ensuring a good seal with the face is appropriate.
Third choice - nebuliser
The back up device is again the nebuliser with or without a mouthpiece depending on the child’s ability. Again, with a nebuliser, one must remember that just because the child puts the device in their mouth, it does not mean that they are inhaling through the device.
It is also important that the facemask of a nebuliser is positioned against the face. Simply by holding the facemask a couple of centimetres away from the face, so as not to upset the child, may result in the child receiving between 50-80% less drug.
Spacer device + metered dose inhaler
Over the age of five years spacers are still recommended for prophylactic drugs such as inhaled steroids. They result in a marked reduction in oropharyngeal deposition of drug. This may reduce local side effects such as thrush, and for drugs that are absorbed via the gastro-intestinal tract, the amount of drug reaching the systemic circulation will also be reduced. Drug absorbed in this way merely contributes to systemic side effects with no added clinical benefit.
Breath activated inhaler & dry powder inhaler
For daily use and ease of portability, a breath actuated inhaler or a dry powder inhaler are suitable for the delivery of bronchodilators. Allowing choice at this stage for older children may help. These devices are preferred to a metered dose inhaler alone as the correct technique is very difficult to achieve on a regular basis for many children and in fact adults as well.
Children may be given a metered dose bronchodilator inhaler and spacer device to use in case of an acute attack of asthma. In an acute attack of asthma, inhaling one puff of bronchodilator from a spacer and then repeating this on five, and if necessary on ten occasions, has been shown to be just as good as a nebuliser. This may prevent an acute asthma attack progressing as well as give extra time to enable medical attention to be sought.
Having an understanding of basic child psychology is helpful when relating to children and their inhaler devices.
Positive reinforcement
Young children like attention of a parent or a helper and regard this as a reward. It is always best to give attention or reward for good behaviour and this is then reinforced. However, all too often, children who misbehave are focussed on by their parents who spend time with them explaining what they have done wrong or telling them off. Unfortunately the child may consider this extra time as a reward even if the parents are upset with them. What often happens is that when the child starts to behave well, the parents or carers often leave the child to get on with what they are doing, and use it as an opportunity to have a break. The child is ignored and feels that this better behaviour isn’t rewarded by getting more of their parents attention
By simply misbehaving again, they regain their parents’ attention. To change this behaviour pattern, one needs to positively reward their good behaviour and attempt to ignore them when they are misbehaving. Applying this basic psychology can give one an advantage especially when attempting to get young children to accept and use inhaler devices. For example, if the parents spend a lot of time coaxing the child to use their inhaler device and the child realises that they get lots of attention from the parents, by struggling or playing around instead of inhaling, this behaviour will often persist or get worse.
So the question is how do we build in positive reinforcement? There are a variety of ways. It is important, for example, when starting with a spacer device with a facemask to reward the child with praise and attention if they make any attempt to use the device properly when it is first given to them. If you think the child is about to refuse or play up, then you should put the device away and say well done for trying. The device is put away from the child and the child given no further attention at that time. By repeating this approach, the child realises that attention and reward comes only with the correct use of the device. When undertaking an approach such as this, it is important that the approach is shared and agreed on by everyone looking after the child. Consistency is essential.
Young children
There are other tricks that may help to get a young child to use a device. For example, this may include having a game where the inhaler device is used with a favourite teddy bear or doll. The teddy bear or doll then gets lots of praise for ‘using the inhaler’. Alternatively, the parents may also pretend to use the inhaler device and receive praise for using it. This approach requires a short period of time to work. A few days winning the child over may be seen as a very good investment especially when regular treatment is needed.
If a child is only having bronchodilator therapy it is important to occasionally practice using the spacer device, as it may be needed in an emergency situation when things are tenser. You can practice using the spacer device without using the bronchodilator inhaler so when the child does need it, they will be more likely to tolerate the device.
Older children
Positive reinforcement is also necessary for older children and in fact, it is a very good strategy for all of us. Older children may be left to take their own medication but, as we know, they often don’t do this on a regular basis. Parents often have unrealistic expectations that their child will remember to take their inhaler without any support or reminder from themselves and then express surprise or tell their child off when they discover the inhaler has not been used! Monitoring the use of the inhalers directly, by parents or carers, may be the only way to be sure medication is taken. It’s worth considering this, if the child is experiencing symptoms, despite being on what is thought to be an appropriate dose of medication. Adherence to treatment should be checked before increasing the dose of inhaled steroids or adding in extra medication such as long acting b2-agonists or leukotriene antagonists.
Many children do not take all of or sometimes any of the prescribed medication. Understanding the terminology relating to this very important aspect of treatment success, is important.
An understanding of how children behave at various ages and how this is affected by interaction with their parents will help when choosing an appropriate drug delivery device. Making sure that the parents and child understand what asthma is the effect it has and the best way to treat it is needed.
What is non-compliance?
It may be helpful to go through a number of terms that are used in relation to a child who is using their medication on a long-term basis. When one talks about drug therapy, the term compliance with medication is often used. Compliance however implies that the individual is very passive and follows exactly what the health professional says. In the case of children, this is usually dependent not only on the child but also their parents or carers.
What is adherence?
The term adherence has been suggested as a way of avoiding the implication that the patient is very passive and submissive: that is, they are adhering to their therapy and understand why.
Other terms such as concordance, therapeutic alliance or therapeutic contract have also been proposed as a way of showing that a child’s action or self-management plan, is in some way negotiated between the health professional and the child, parent/ carer.
What is intelligent non-compliance?
There is another great term ‘intelligent non compliance’. This is used to describe the situation where non-compliance is a result of a reasoned decision. This decision may not always be inappropriate! For example, it may be appropriate that by changing a medication regime slightly, there is improved asthma control. However, at other times, non-adherence may be dangerous and inappropriate; for example if prophylactic therapy such as inhaled steroids are stopped because there are no asthma symptoms for a short period of time, or the inhaler device is considered to be too much of a nuisance.
There are a number of things to bear in mind. Occasionally children may feel they are forced to comply against their wishes. This may lead to dissatisfaction and the risk of future non-adherence. The child may indicate their dissatisfaction with what they are advised, while others will outwardly agree and then do something completely different! This leads to a dishonest relationship between the child, parents and the health professional.
Currently we do not have ready access to devices that will tell us if the child has taken all of their medication. Appreciating that adherence to therapy is a problem and trying to understand the reasoning behind the way medications are taken, may allow for more open discussions. If the concerns and confusions are addressed and understanding subsequently improves, this may be a more successful approach. Hopefully this will lead to the development of a therapeutic alliance that the child, parents or carers are happier with. This process will take time.
Education by health professionals trained in asthma and medication delivery device technique can make a huge difference.
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