OBJECTIVES

Health educational interventions improve health outcomes and quality of life in children with asthma. The main purpose of this study was to evaluate the effect of an education intervention for an asthma inhaler technique during hospital admission for an asthma exacerbation.

METHODS

This prospective study was conducted in a pediatric hospitalization unit of a third-level hospital. Children admitted for an asthma exacerbation were eligible for inclusion. It was developed in 2 phases: during hospital admission (T1) and 1 month after discharge (T2). In the T1 phase, caregivers completed the questionnaire to assess asthma control in children (CAN questionnaire) and performed the inhaler technique, which was evaluated with a 6-step checklist. An educational intervention was performed. In the T2 phase, caregivers completed the CAN questionnaire, and the inhaler technique was reevaluated. We hypothesized that the inhaler technique improved after the implementation of an asthma education program.

RESULTS

A total of 101 children were included, of whom 85 completed the T2 phase (84%). At baseline, 11.8% of participants performed the inhaler technique correctly. All steps of the inhaler technique upgraded in the T2 phase significantly (P < .01), except for the step “assemble the inhaler device correctly.” Former evaluation by a pediatric pneumologist was associated with a higher score in the inhaler technique in the T1 phase. The median CAN questionnaire score in the T1 phase was 8 (interquartile range 4–16), which reduced to 4 (interquartile range 1.2–6) in the T2 phase (P < .01).

CONCLUSIONS

The development of an educational intervention during admission improved inhaler technique as well as asthma knowledge.

According to the Global Burden of Diseases, Injuries, and Risk Factors 2015, asthma is the most prevalent chronic respiratory disease around the world.1  The Brussels Declaration on Asthma, published in 2008 by European Respiratory Journal, addressed the problem of the shortfalls in asthma management,2  highlighting the importance of patient education. In this study, we address asthma education in children during hospital admission.

Well-controlled asthma reduces the severity of symptoms and hospitalizations while improving lung function and quality of life.3,4  Inhalers are the most common type of medication devices used in asthma. Unfortunately, it is estimated that 60% of individuals do not use inhaled medication correctly, increasing costs as a result of uncontrolled disease.5  Besides, there are not many studies in which caregivers’ inhaler technique with a metered-dose inhaler (MDI) is assessed. These studies reveal incorrect inhalation technique in >50% of the cases, which is associated with poor knowledge about asthma, lack of inhaler training, caregivers of advanced age, and low health literacy.68 

According to The Brussels Declaration from the European Summit for Change in Asthma Management, including education for caregivers of children with asthma is one of the key elements of asthma management.3,7,9  Educational programs should include background information of the disease and teach skills and techniques to caregivers to improve a correct performance in case of acute exacerbation. There are many possible approaches, such as written information, educative sessions, or audiovisual material.5,10  Current guidelines recommend teaching and reevaluating inhaled technique in every clinic visit and before discharge11 ; therefore, hospital admission represents an opportunity to perform educational programs. However, a majority of studies regarding asthma education have been performed in outpatient scenarios, such as follow-up visits,12,13  primary care,14  or in schools,9,15  which highlights the lack of evidence regarding the effectiveness of inpatient asthma education programs.

In the current study, we report the results obtained after the implementation of an asthma educational program during admission in a pediatric hospitalization unit. The primary outcome of the current study was to assess caregivers and children’s inhaler technique skills before and after an asthma education program during admission in a pediatric hospitalization unit. Our hypothesis was that the implementation of an asthma education program during hospital admission for an asthma exacerbation would improve caregivers and children’s inhaler technique with MDI systems. The secondary outcome was to analyze which factors influence inhaler technique. We analyzed the following factors: asthma control, caregivers’ health literacy, and follow-up by pediatric pneumologists.

We enrolled pediatric inpatients between 4 months and 13 years old diagnosed with an acute episode of asthma between November 2018 and March 2019 who were admitted in the pediatric hospitalization unit. Participants were only included once during the study period. Exclusion criteria were patients admitted with bronchiolitis, those who had recently learned how to use MDIs (<4 weeks earlier), those whose caregivers were sanitary professionals and had received specific training in the use of MDIs, and idiomatic barriers.

We collected clinical and epidemiological data, including age, sex, clinical features, family history of asthma, length of stay, need for PICU care during admission, pulmonary score16  in the emergency department to assess the severity of the asthma exacerbation, maintenance treatment, follow-up by the pneumology department before study inclusion, and caregivers’ sociocultural information.

A prospective analytical pre-post intervention study was conducted in a pediatric inpatient unit of a third-level hospital in Spain. The study was conducted in 2 stages: during hospitalization (T1) and 1 month after discharge (T2) (see Fig 1).

FIGURE 1

Chronogram.

Evaluation T1

During admission in the pediatric hospitalization unit (T1), 2 written tests were performed by caregivers:

  1. Questionnaire to assess asthma control in children (CAN questionnaire)17 : This 9-question questionnaire evaluates asthma control in children by analyzing the presence of asthma symptoms in the last 4 weeks. A score ranging between 0 (good control) and 36 (poor control) is obtained. A score of ≥8 was considered poorly controlled asthma. We used a modified version of this test for teenagers >10 years old.17 

  2. Health literacy test (Short Assessment of Health Literacy–Spanish [SAHL-S]).18 : This test uses paired word recognition as a clinical screening tool to evaluate health literacy. A score of ≤14 was considered low health literacy.

After completing the tests mentioned, inhaler technique with an MDI was assessed by 1 of the 3 main investigators using a 6-step checklist. All participants used an MDI device with a spacer chamber. The steps to be accomplished varied depending on the type of technique (use of spacer added [or not] to face mask), following the recommendations of the Spanish Pediatric Pneumology Association.19  It is generally accepted16  that children ranging 4–6 years old can perform inhaler technique with MDI with or without a facemask.19  To homogenize the type of technique, depending on the participant’s age, and prevent subjective clinician criteria from interfering with the type of technique to be performed, we decided that children <6 years old would perform the inhaler technique with a spacer and face mask and those >6 years old would perform the inhaler technique with only a spacer with mouthpiece. Caregivers were asked to perform the technique, allowing children >6 years to perform the technique with their caregivers’ help. Failing to perform any 1 of these 6 steps was evaluated as an inadequate technique.

Educational Intervention

Once the CAN questionnaire and the SALH-S were completed and after the inhaler technique was evaluated, the education intervention was performed. This intervention consisted of instructing caregivers and children on the correct inhaler technique, according to their age, through a theoretical and practical course. The vocabulary and methodology were adapted according to their health literacy level.

The theoretical course was imparted in ∼20 minutes by 1 of the 3 main investigators using multimedia (PowerPoint presentation). The PowerPoint presentation included basic information on the physiopathology of asthma, risk factors, how to recognize an asthma exacerbation, the course of action in case of exacerbation, and warning signs that indicate medical assistance is required. These recommendations were based on the Spanish Pediatric Pneumology Association guidelines.19  Differences between reliever and maintenance medication were also explained, highlighting the importance of treatment adherence.

Afterward, a 10-minute practical course was imparted, which consisted of explaining how to perform the inhaler technique with an MDI correctly, according to the participant’s age (<6 years old using a face mask and space chamber, >6 years old using a space chamber with mouthpiece only), following the 6-step checklist (Supplemental Table 3).20  Finally, the caregiver and older children watched a video about the correct use of the inhaler. A written asthma action plan was given before medical discharge.

Evaluation T2

The impact of the educational intervention was evaluated at T2 in an outpatient pediatric consulting room. Caregivers and teenagers completed the CAN questionnaire. Also, inhaler technique was reevaluated by using the 6-step questionnaire. We considered the educational intervention to be effective if an upgrade of 1 point in the total score of the inhaler technique was achieved at T2. Finally, caregivers fulfilled a satisfaction questionnaire.

Once the T2 evaluation had been performed, those participants with a CAN questionnaire score > 8 in the T1 phase who had not been assessed by a pneumologist before study inclusion were referred to the pneumology department. Pneumologist evaluation did not interfere with results in the T2 phase because children were referred to this department only once they had performed the technique at T2.

Statistical analysis was performed with statistical program SPSS version 25.0 (IBM SPSS Statistics, IBM Corporation, Armonk, NY), GraphPad Prism version 8, and R Statistical Software version 3.5.3. Quantitative variables were expressed as mean and SD or median and interquartile range (IQR). Qualitative variables were expressed as percentages. The sample size estimated was 101 participants for an α error of .05 and 80% statistical power to detect a difference of 0.5 points in the inhaler technique evaluation, assuming a variance of 1 point in the results and a 15% participant loss to follow-up.

We performed a statistical analysis of before and after paired data with χ2, Mann–Whitney U, Kruskal-Wallis, and Friedman tests. Correlation between quantitative variables was analyzed by using the Spearman test.

We performed multivariable lineal regression with the dependent variable “improvement of punctuation in inhalation technique.” The variables that had a value of P < .2 in the bivariate analyzes were entered into the model as independent variables, including age, severity of episode (pulmonary score), CAN questionnaire score at T1, the caregiver’s level of education attained, and assessment by a pneumologist before study inclusion.

Also, we performed a 2-way analysis of variance with the dependent variable “improvement of punctuation in inhalation technique” and the following independent variables: baseline treatment, severity, previous assessment by a pneumologist, and their interactions. Results were expressed as t and β coefficients. Assumption of no multicollinearity was evaluated in all models. Two-sided tests were performed, and P < .05 was considered statistically significant.

The study was approved by the hospital’s institutional review board. Legal guardians provided written informed consent to participate in the study.

A total of 101 children were eligible for inclusion before the educational intervention, of whom 85 completed the T2 phase (84%) (Fig 2). Seventy-four children (73%) were <6 years old. The median age was 3.3 years (IQR 1.9–5.9), and 58.4% of the patients were male. The median number of days of hospitalization was 3 (IQR 2–4), and 4% of the patients had been admitted at first in the PICU. The median pulmonary score at admission was 6 (IQR 5–7). A total of 16 participants, whose median age was 3.29 years (IQR 1.48–5.20), were lost during follow-up; 87.5% (14) were male. Twenty-five percent of them had been evaluated by a pneumologist before admission, and 31% had baseline asthma treatment. Regarding health literacy, the median SAHL-S score was 17 (IQR 16–18). The median number of days of hospitalization was 3 (IQR 2–4), and 68.7% (11) were admitted for a moderate asthma exacerbation (Table 1).

FIGURE 2

Study flow diagram of enrollment and follow-up.

FIGURE 2

Study flow diagram of enrollment and follow-up.

Close modal
TABLE 1

Demographic Characteristics of Patients and Caregivers

CharacteristicsNo. Participants (n = 101)
Child sex, n (%)  
 Male 59 (58.4) 
Child background, n (%)  
 Prematurity 25 (24.8) 
 Previous pneumologist assessment 44 (43.6) 
 Asthma maintenance treatment 35 (34.7) 
 Caregiver smoking 31 (32) 
 Family history of asthma (first relatives) 53 (52.5) 
Race and/or ethnicity, n (%)  
 White 68 (67.3) 
 Latino 26 (25.7) 
 Gypsy 5 (5) 
 Arabic 2 (2) 
Caregiver relationship, n (%)  
 Mother 72 (71.3) 
Caregiver age, y, n (%)  
 <30 15 (14.9) 
 30–40 59 (58.4) 
 >40 27 (26.7) 
Caregiver education  
 SAHL-S test score, median (IQR) 17 (16–18) 
 Health literacy score <14, n (%) 11 (4.1) 
 University degree, n (%) 37 (36.6) 
Characteristics of the episode  
 Median days of hospitalization (IQR) 3 (2–4) 
 Median result in pulmonary score (IQR) 6 (5–7) 
 PICU admission, % 
CharacteristicsNo. Participants (n = 101)
Child sex, n (%)  
 Male 59 (58.4) 
Child background, n (%)  
 Prematurity 25 (24.8) 
 Previous pneumologist assessment 44 (43.6) 
 Asthma maintenance treatment 35 (34.7) 
 Caregiver smoking 31 (32) 
 Family history of asthma (first relatives) 53 (52.5) 
Race and/or ethnicity, n (%)  
 White 68 (67.3) 
 Latino 26 (25.7) 
 Gypsy 5 (5) 
 Arabic 2 (2) 
Caregiver relationship, n (%)  
 Mother 72 (71.3) 
Caregiver age, y, n (%)  
 <30 15 (14.9) 
 30–40 59 (58.4) 
 >40 27 (26.7) 
Caregiver education  
 SAHL-S test score, median (IQR) 17 (16–18) 
 Health literacy score <14, n (%) 11 (4.1) 
 University degree, n (%) 37 (36.6) 
Characteristics of the episode  
 Median days of hospitalization (IQR) 3 (2–4) 
 Median result in pulmonary score (IQR) 6 (5–7) 
 PICU admission, % 

Before the educational intervention, only 12 caregivers (12%) performed all 6 steps correctly. Two of the 6 steps were the most challenging at the T1 evaluation: “waiting at least 30 to 60 seconds to repeat second puff” followed by “shake the inhaler before the next inhalation” (Table 2).

TABLE 2

Percentage of Patients Who Performed the Steps Correctly in T1 and T2

T1 (n = 101), n (%)T2 (n = 85), n (%)P
Adequate inhaler device set-up 98.9 (98) 85 (100) .87 
Shake MDI before administration 69.9 (69.3) 82 (96.5) <.01 
Correct sealing technique 61 (60.4) 78 (91.8) <.01 
Await 5–10 s after pressing the inhaler canister 77.9 (77.2) 69 (81.2) .03 
Await 30–60 s between inhalations 37.9 (37.6) 74.9 (88.2) .01 
Shake the inhaler before the next inhalation 54 (53.5) 77 (90.6) <.01 
T1 (n = 101), n (%)T2 (n = 85), n (%)P
Adequate inhaler device set-up 98.9 (98) 85 (100) .87 
Shake MDI before administration 69.9 (69.3) 82 (96.5) <.01 
Correct sealing technique 61 (60.4) 78 (91.8) <.01 
Await 5–10 s after pressing the inhaler canister 77.9 (77.2) 69 (81.2) .03 
Await 30–60 s between inhalations 37.9 (37.6) 74.9 (88.2) .01 
Shake the inhaler before the next inhalation 54 (53.5) 77 (90.6) <.01 

We observed that the upgrade in the global score in the practical technique evaluation in the T2 phase was associated with a higher health literacy score (P = .01). The number of participants who correctly performed each step of the inhaled technique increased significantly in the T2 phase (P < .01), except for the step “assemble the inhaler device correctly.”

The median CAN questionnaire score in the T1 phase was 8 (IQR 4–16), implying a low symptom control. Also, the median MDI technique score in the T1 phase was 4 (IQR 3–5) out of a total score of 6. In the T2 phase, both results improved (P < .01): the median CAN questionnaire score was 4 (IQR 1.2–6), and the median score in the practical evaluation of the inhaled technique was 6 points (IQR 5–6) (Fig 3).

FIGURE 3

Improvement of CAN questionnaire score and global inhaled technique after educational intervention.

FIGURE 3

Improvement of CAN questionnaire score and global inhaled technique after educational intervention.

Close modal

A multivariant analysis of lineal regression revealed that the only factor that was associated with a higher score in the practical evaluation of the inhaler technique in the T1 phase was a previous evaluation by a pneumologist (P = .04). Bifactorial analysis of variance revealed that the interactions between baseline treatment, previous evaluation by a pneumologist, and a more severe asthma episode were associated with a higher global score in the practical inhaler technique evaluation in the T1 phase (P < .01).

Concerning asthma control, follow-up by pediatric pneumologists before study inclusion (odds ratio 4.5; P = .04) was the only factor associated with better asthma control in the T2 phase.

Lastly, 86% (73) of caregivers rated the educational intervention 5 out of a total score of 5 points. Up to 92% (78) of the caregivers found the information provided and the educational intervention to be useful.

The main purpose of this study was to assess the inhaler technique skills among caregivers and children before and after an asthma education program during hospital admission. At baseline, only 11.8% of the participants demonstrated correct technique. Inhaler misuse has been frequently described in asthma literature. In line with our results, studies reveal that 50% to 80% of the patients are unable to use their inhaler correctly.21  Gillette et al22  reported that between 1% and 58% of children using MDI devices had a good inhaler technique. After the educational intervention, the scores of the inhaler technique improved globally. The rate of adequate technique in previous studies23,24  is wide, ranging from 1.2% to 75.9%. Similarly, 68.1% of the participants assessed by Capanoglu et al12  used their MDI correctly. In contrast with some studies in which the most mistaken steps were “slowly breathe in from the spacer 5 to 6 times (10 seconds)” followed by “shake the puffer for 5 seconds (5–6 times),”9,14,25  we obtained that the most challenging items were “await 30 to 60 seconds between inhalations” followed by “shake the inhaler before the next inhalation.” Our results were consistent with those obtained by Gillette et al.22  This may be due to the difference between the inhaler technique steps considered in each study and the different steps considered depending on the participant’s age. To establish the type of technique to be performed (space chamber added to the mask or not) we followed the Spanish Pediatric Pneumology Association recommendations.19 

In our study the inhaler technique scores improved after the educational intervention, proving that the intervention was effective. It is well known that education plays an important role in the management of chronic diseases, such as asthma.22  Different education strategies have been used to the date, including the use of informative videos.13  Health care professionals must educate both patients and caregivers on inhaler technique to ensure a proper use of inhalers.9,12  However, it should be repeated regularly and incorporated into daily clinical management. In our study, 43.6% of the participants had been previously assessed by a pediatric pneumologist, which was the only factor associated with a higher numerical score in the evaluation of the inhaler technique in T1. Neither sex, age, severity of the episode, nor caregivers’ health literacy level was associated with a higher score, as reported previously by Capanoglu et al.12 

Asthma control was assessed with the CAN questionnaire before the educational intervention and 1 month after hospitalization, which has proved to be a sensitive score to measure changes in asthma control.17  The CAN questionnaire measures asthma symptoms in the previous 4 weeks, which, in our study, included an asthma exacerbation that had led to hospital admission. This influences the fact that CAN questionnaire scores during admission were higher than those after the educational intervention, with median scores of 8 and 4, respectively. Both follow-up by pediatric pneumologists and the CAN questionnaire score in the T1 phase were associated with a better asthma control in the T2 phase, which once more highlights the importance of education in patients with asthma.

Regarding the impact of caregivers’ health literacy, no association was observed between the SAHL-S score and caregivers’ educational level with respect to asthma control and inhaler technique. These results could be due to the following: underrepresentation of caregivers with low health literacy scores in our sample (only 4.1% had a score of <14 points on the SAHL-S) and the high percentage of caregivers with higher education. In consequence, these factors could interfere in the capacity of our study to detect differences in asthma control and inhaler technique regarding health literacy and educational level. In contrast, previous studies point out that parental education level is a significant predictor of asthma knowledge.26,27  Caregivers’ motivation levels and the type of education strategy have a high impact on asthma control results.2830 

It is well known that teaching self-management strategies to children with chronic diseases improves health outcomes, knowledge, and life quality. These strategies should be focused on providing information and teaching skills and techniques as well as reinforcing health behaviors in the appropriate level of complexity.10,3133  In this matter, we adapted the content of the educational intervention to the participants’ ages and to the caregivers’ educational levels, guided by the score obtained on the SALH-S.18  In addition, we provided structured information that included basic information about asthma and a care plan.

According to our results, physicians and other members of the health care team should take every possible opportunity to instruct and enhance correct inhalation technique among children and caregivers, such as during hospital admission. Along with previous evidence,31  our results confirm that the implementation of an educational interventional is an effective strategy to improve patients and caregivers’ inhaler technique with MDI in the short-term. All the participants included in our study received the same basic concepts about asthma and inhaler technique, which were based on the Spanish Pediatric Pneumology Association guidelines.19  To our knowledge, this is the first study published in Spain that reflects the effectiveness and impact over time of an educational intervention in pediatric patients admitted for an acute asthma episode.

This study should be considered in light of its limitations. Caregivers’ asthma knowledge and inhaler technique depend on the information provided in previous occasions, which depends on the health care professionals’ asthma knowledge and the guidelines used in each center. In addition, guidelines are in constant change, and professionals should update frequently. The impact of the educational intervention we propose is limited because of the characteristics of the study because it is a unicentric study. This study could be extended to other centers and bolster a national asthma education program. We used the CAN questionnaire to measure asthma control in children, which is a reliable and valid questionnaire for evaluating asthma control in Spanish-speaking children. However, it is only validated in outpatient settings and in children between 2 and 14 years old. No control group was included; therefore, we could not evaluate and compare CAN questionnaire scores and inhaler technique after discharge in participants who had not received the education program. Additionally, there was 15% attrition during follow-up. We excluded patients who had recently learned how to use an MDI because we considered recent education would bias results. However, the sample would have been more heterogeneous if these patients had been included. Our study included young children with viral-induced wheezing, who could have been misclassified as having asthma. This fact may have overestimated the impact of the education intervention concerning asthma control because those children are less likely to have chronic disease symptoms. Because of the small proportion of teenagers in our sample, no conclusions could be drawn from the evaluation of CAN questionnaire scores in the T1 phase or from the impact of the education intervention on inhaler technique in this subgroup of patients.

Finally, the impact of the educational intervention is restricted to the short-term because we measured its impact only a month after admission. Long-term studies should be conducted to measure patients’ inhaler technique knowledge later on (eg, 6–12 months). Future research is needed to discover if the educational intervention during hospitalization improves disease control and symptom-free days as well as if it reduces emergency visits and hospital admissions.

Education plays an important role in the management of chronic diseases, such as asthma; therefore, it must be part of an effective pediatric asthma treatment. The development of an educational intervention during admission improved inhaler technique. This ensures sufficient inhaler medication disposition in the distal airways, optimizing the medical treatment. However, this information must be repeated during follow-up visits. More studies must be conducted in the long-term to evaluate its effectiveness.

FUNDING: No external funding.

Drs Jové Blanco and González Roca contributed to the literature search, study design, data collection, and manuscript preparation; Dr Corredor Andrés contributed to the literature search, data collection, study design, analysis of data, review of the manuscript; Drs Bellón Alonso and Rodríguez Cimadevilla contributed to the literature search, data collection, review of the manuscript; Dr Rodríguez-Fernández contributed to the study design, analysis of data, and review of the manuscript; and all authors approved the final manuscript as submitted.

1.
GBD 2015 Chronic Respiratory Disease Collaborators
.
Global, regional, and national deaths, prevalence, disability-adjusted life years, and years lived with disability for chronic obstructive pulmonary disease and asthma, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015
.
Lancet Respir Med
.
2017
;
5
(
9
):
691
706
2.
Holgate
S
,
Bisgaard
H
,
Bjermer
L
, et al
.
The Brussels Declaration: the need for change in asthma management
.
Eur Respir J
.
2008
;
32
(
6
):
1433
1442
3.
Kneale
D
,
Harris
K
,
McDonald
VM
,
Thomas
J
,
Grigg
J
.
Effectiveness of school-based self-management interventions for asthma among children and adolescents: findings from a Cochrane systematic review and meta-analysis
.
Thorax
.
2019
;
74
(
5
):
432
438
4.
Franken
MMA
,
Veenstra-van Schie
MTM
,
Ahmad
YI
,
Koopman
HM
,
Versteegh
FGA
.
The presentation of a short adapted questionnaire to measure asthma knowledge of parents
.
BMC Pediatr
.
2018
;
18
(
1
):
14
5.
Thomas
RM
,
Locke
ER
,
Woo
DM
, et al
.
Inhaler training delivered by internet-based home videoconferencing improves technique and quality of life
.
Respir Care
.
2017
;
62
(
11
):
1412
1422
6.
Al-Jahdali
H
,
Ahmed
A
,
Al-Harbi
A
, et al
.
Improper inhaler technique is associated with poor asthma control and frequent emergency department visits
.
Allergy Asthma Clin Immunol
.
2013
;
9
(
1
):
8
7.
Boulet
LP
.
Asthma education: an essential component in asthma management
.
Eur Respir J
.
2015
;
46
(
5
):
1262
1264
8.
Axtell
S
,
Haines
S
,
Fairclough
J
.
Effectiveness of various methods of teaching proper inhaler technique
.
J Pharm Pract
.
2017
;
30
(
2
):
195
201
9.
Topal
E
,
Celiksoy
MH
,
Catal
F
, et al
.
Assessment of skills using a spacer device for a metered-dose inhaler and related independent predictive factors in caregivers of asthmatic preschool children
.
Int Forum Allergy Rhinol
.
2016
;
6
(
2
):
130
134
10.
Saxby
N
,
Beggs
S
,
Battersby
M
,
Lawn
S
.
What are the components of effective chronic condition self-management education interventions for children with asthma, cystic fibrosis, and diabetes? A systematic review
.
Patient Educ Couns
.
2019
;
102
(
4
):
607
622
11.
Comité Ejecutivo de la GEMA
.
Guía española para el manejo del asma
.
2019
.
Available at: www.gemasma.com. Accessed January 28, 2019
12.
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
(
8
):
838
845
13.
Carpenter
DM
,
Lee
C
,
Blalock
SJ
, et al
.
Using videos to teach children inhaler technique: a pilot randomized controlled trial
.
J Asthma
.
2015
;
52
(
1
):
81
87
14.
Aziz
NA
,
Norzila
MZ
,
Hamid
MZ
,
Noorlaili
MT
.
Skills amongst parents of children with asthma: a pilot interventional study in primary care setting
.
Med J Malaysia
.
2006
;
61
(
5
):
534
539
15.
Harris
K
,
Kneale
D
,
Lasserson
TJ
,
McDonald
VM
,
Grigg
J
,
Thomas
J
.
School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review
.
Cochrane Database Syst Rev
.
2019
;(
1
):
CD011651
16.
Smith
SR
,
Baty
JD
,
Hodge
D
 III
.
Validation of the pulmonary score: an asthma severity score for children
.
Acad Emerg Med
.
2002
;
9
(
2
):
99
104
17.
Pérez-Yarza
EG
,
Badía
X
,
Badiola
C
, et al
;
CAN Investigator Group
.
Development and validation of a questionnaire to assess asthma control in pediatrics
.
Pediatr Pulmonol
.
2009
;
44
(
1
):
54
63
18.
Lee
SYD
,
Stucky
BD
,
Lee
JY
,
Rozier
RG
,
Bender
DE
.
Short Assessment of Health Literacy-Spanish and English: a comparable test of health literacy for Spanish and English speakers
.
Health Serv Res
.
2010
;
45
(
4
):
1105
1120
19.
Spanish Pediatric Pneumology Association
.
Action plan: asthma treatment
.
2020
.
Available at: http://fr.zone-secure.net/84369/805660/#page=1. Accessed January 28, 2019
20.
Salcedo
A
,
Cimadevilla
JL
.
Sistemas de inhalación
. In:
Casado Flores
J
,
Serrano González
A
, eds.
Urgencias y Tratamiento del Niño Grave. Síntomas Guía, Técnicas y Cuidados Intensivos
. 3rd ed.
Madrid, Spain
:
Majadahonda
;
2015
21.
Volerman
A
,
Carpenter
D
,
Press
V
.
What can be done to impact respiratory inhaler misuse: exploring the problem, reasons, and solutions
.
Expert Rev Respir Med
.
2020
;
14
(
8
):
791
805
22.
Gillette
C
,
Rockich-Winston
N
,
Kuhn
JA
,
Flesher
S
,
Shepherd
M
.
Inhaler technique in children with asthma: a systematic review
.
Acad Pediatr
.
2016
;
16
(
7
):
605
615
23.
Marguet
C
,
Couderc
L
,
Le Roux
P
,
Jeannot
E
,
Lefay
V
,
Mallet
E
.
Inhalation treatment: errors in application and difficulties in acceptance of the devices are frequent in wheezy infants and young children
.
Pediatr Allergy Immunol
.
2001
;
12
(
4
):
224
230
24.
Kamps
AW
,
Brand
PL
,
Roorda
RJ
.
Determinants of correct inhalation technique in children attending a hospital-based asthma clinic
.
Acta Paediatr
.
2002
;
91
(
2
):
159
163
25.
Reznik
M
,
Silver
EJ
,
Cao
Y
.
Evaluation of MDI-spacer utilization and technique in caregivers of urban minority children with persistent asthma
.
J Asthma
.
2014
;
51
(
2
):
149
154
26.
Ho
J
,
Bender
BG
,
Gavin
LA
,
O’Connor
SL
,
Wamboldt
MZ
,
Wamboldt
FS
.
Relations among asthma knowledge, treatment adherence, and outcome
.
J Allergy Clin Immunol
.
2003
;
111
(
3
):
498
502
27.
Koster
ES
,
Wijga
AH
,
Koppelman
GH
, et al
.
Uncontrolled asthma at age 8: the importance of parental perception towards medication
.
Pediatr Allergy Immunol
.
2011
;
22
(
5
):
462
468
28.
Radic
SD
,
Milenkovic
BA
,
Gvozdenovic
BS
,
Zivkovic
ZM
,
Pesic
IM
,
Babic
DD
.
The correlation between parental education and their knowledge of asthma
.
Allergol Immunopathol (Madr)
.
2014
;
42
(
6
):
518
526
29.
Belice
PJ
,
Mosnaim
G
,
Galant
S
, et al
.
The impact of caregiver health literacy on healthcare outcomes for low income minority children with asthma
.
J Asthma
.
2020
;
57
(
12
):
1316
1322
30.
Morrison
AK
,
Glick
A
,
Yin
HS
.
Health literacy: implications for child health
.
Pediatr Rev
.
2019
;
40
(
6
):
263
277
31.
Klijn
SL
,
Hiligsmann
M
,
Evers
SMAA
,
Román-Rodríguez
M
,
van der Molen
T
,
van Boven
JFM
.
Effectiveness and success factors of educational inhaler technique interventions in asthma & COPD patients: a systematic review
.
NPJ Prim Care Respir Med
.
2017
;
27
(
1
):
24
32.
Morton
RW
,
Elphick
HE
,
Craven
V
,
Shields
MD
,
Kennedy
L
.
Aerosol therapy in asthma-why we are failing our patients and how we can do better
.
Front Pediatr
.
2020
;
8
:
305
33.
Plaza
V
,
Giner
J
,
Rodrigo
GJ
,
Dolovich
MB
,
Sanchis
J
.
Errors in the use of inhalers by health care professionals: a systematic review
.
J Allergy Clin Immunol Pract
.
2018
;
6
(
3
):
987
995

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.