Impact of an Asthma Education Program During Admission

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).

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.

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.

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).

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).

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).

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 studies^23,24  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.^28–30 

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.^10,31–33  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.