Early in my pediatrics rotation, I learned that I should get used to admitting children for asthma exacerbations. And so, during each intake, one question quickly became routine: “Do you use a spacer and mask with your inhaler at home?” More often than not, the answer was a no, often followed by, “What is that?”
That gap in knowledge has significant clinical consequences. Proper inhaler use entails a choreograph of multiple coordinated steps: attaching a spacer and mask, timing actuation appropriately, inhaling with the right technique, positioning the inhaler appropriately, cleaning it properly, etc. For any child, this is a labyrinth of steps to navigate. And research reflects this, observational studies consistently report proper pediatric inhaler use rates of less than 20 percent and as low as 8.1 percent. Take just one step: using a spacer and mask. Without it, only a limited amount of the inhaled medication reaches the bronchi and lungs; the rest laying bare in the oropharynx with minimal therapeutic benefit. And so, when multiple steps are not performed, drug delivery becomes markedly subtherapeutic. Given this, it is unsurprising that 42 percent of pediatric hospitalizations for asthma exacerbations in one study revealed improper inhaler use.
The educational gap in pediatric asthma
The problem begins with education. Across clinical settings, children are not taught or asked to demonstrate correct inhaler technique. One study found that only 3.8 percent of children were shown how to use an inhaler correctly, and just 5.4 percent were asked to demonstrate proper technique. So, what can be done?
The most obvious solution is implementing consistent, standardized inhaler teaching protocols at the time of inhaler prescription and during hospitalizations. Simply reading proper inhaler steps aloud to hospitalized children with asthma reduced inhaler misuse from 92 percent to 69 percent and structured checklists coupled with the teach-back method markedly reduce asthma instruction misunderstanding. And, importantly, better inhaler use actually translates to fewer exacerbations. It has been shown that comprehensive asthma education confers a hospitalization risk reduction of 54 percent and an emergency department (ED) visit risk reduction of 31 percent.
Of course, time for education and teach-back is a major limitation for providers and staff already constrained by back-to-back appointments, so electronic medical record (EMR) embedding of asthma education checklists at the time of prescription may hasten and improve the scalability of this approach. Another possible solution is to encourage the use of “smart” inhalers, devices equipped with real-time feedback technology that tracks inhaler use, technique, and provides real-time biofeedback guidance. While the adherence burden for some of these devices may preclude universal adoption, they may be a good option for high-risk patients with repeat exacerbations.
Leveraging video modeling and technology
The most scalable and cost-effective solution, in my opinion, is video modeling delivered at the point of care, during clinic visits, in schools by nursing staff, or during hospitalizations. Short instructional videos increase proper inhaler technique more than written instruction alone and improve correct technique by 70 percent. Of course, this approach has the added benefit of being cost-effective and being of minimal time burden to staff and providers.
The economic impact of proper inhaler use
These approaches would not only reduce hospitalizations and improve clinical outcomes but would reduce significant unnecessary health care expenditure in the United States (U.S.). Asthma affects about 4.5 million children in America. An analysis of the 2022 Kids’ Inpatient Database found that the 64,393 pediatric asthma exacerbations that year generated $480 million in hospital charges. And 629,000 ED visits for asthma exacerbations in 2010 amounted to $404 million (in 2026 dollars).
No study has been done to estimate the total cost, but as a baseline estimate, if only accounting for these two facets of asthma exacerbations, the cost of pediatric asthma exacerbations annually in the U.S. is more than $884 million, of which a large portion can be attributed to improper inhaler use. And this figure excludes the additional costs of exacerbations such as outpatient follow-up, medication regimen changes post-hospitalization, 10 to 13 million missed school days annually, and caregiver productivity losses. Clearly, this is an issue of vast scale.
Ultimately, it is not one intervention but likely a combined strategy of video modeling at point of care, EMR-embedded asthma education checklists, and targeted use of smart inhalers that is most likely to effectively reduce pediatric asthma exacerbations on a national level.
Piyush Pillarisetti is a medical student.
