What are the consequences of a pediatric asthmatic patient with a history of recurrent Emergency Room (ER) visits for asthma exacerbations, prescribed Inhaled Corticosteroids (ICS) and salbutamol, not using their inhalers correctly due to lack of education?

Consequences of Improper Inhaler Technique in Pediatric Asthma

The failure to educate this pediatric patient on proper inhaler technique will result in continued recurrent ER visits and hospitalizations, not a decrease in hospitalizations, making option B incorrect. The correct answer is that this situation leads to increased adverse outcomes including persistent exacerbations, poor asthma control, and higher healthcare costs—the opposite of options B and D.

Why Proper Inhaler Education Matters

Improper inhaler technique directly causes treatment failure, even when appropriate medications are prescribed. The efficacy of aerosol treatment depends substantially less on the device itself than on the patient's skill in using it—using an inhaler is a skill that must be learned through coaching and experience, just like riding a bicycle 1.

Direct Consequences of Poor Technique

• Uncontrolled asthma and frequent ED visits: Improper inhaler device use is associated with uncontrolled asthma (ACT score ≤15) and three or more ED visits per year 2.
• Treatment failure despite correct prescriptions: Only 8.1% of children perform all metered dose inhaler steps correctly without proper instruction, and even with spacers, technique errors are common 3.
• Poor medication delivery: Critical errors in technique substantially affect drug delivery to the lungs, meaning the patient receives inadequate doses of both ICS and salbutamol despite using them regularly 4.

The Specific Problem in This Case

This scenario describes a systems failure where the physician prescribed appropriate medications (ICS and salbutamol) but failed to ensure proper education on inhaler technique. This is a well-documented barrier to asthma control 1.

What Actually Happens Without Education

• Persistent exacerbations continue: Poor education about asthma and medication use is directly associated with unnecessary and frequent ED visits 5.
• Lack of disease control: Patients without asthma education are more likely to have inadequately controlled asthma (60.3% in one study) 5.
• Medication non-compliance: Patients educated about asthma are less likely to inappropriately stop corticosteroid therapy when symptoms improve (OR: 0.55; 95% CI: 0.3-0.9) 5.

Why Each Answer Option is Wrong or Right

Option A (Increased Self-Efficacy) - INCORRECT

Self-efficacy decreases without proper education. Patients and families need to feel they are active participants in their care, which requires education about asthma as a chronic inflammatory disease 1. Without instruction, patients lack confidence and competence in managing their condition.

Option B (Decreased Hospitalization) - INCORRECT

This is the opposite of what occurs. Improper inhaler technique is associated with poor asthma control and frequent ED visits 2. Guidelines emphasize that aggressive asthma self-management education programs substantially improve outcomes and lead to fewer ED visits and hospitalizations 1.

Option C (Increased Adverse Effects) - PARTIALLY CORRECT

While not the primary consequence, there is potential for increased adverse effects from:

• Overuse of salbutamol: Patients may use excessive rescue medication when controller therapy fails due to poor technique, and fatalities have been reported with excessive use of inhaled sympathomimetic drugs 6.
• Systemic effects from improper ICS technique: Though ICS are generally safe, improper technique may lead to increased oropharyngeal deposition and systemic absorption 1.

Option D (Low Cost) - INCORRECT

The opposite is true. Poor education and medication compliance have a major adverse impact on healthcare costs 1. Frequent ED visits are far more expensive than proper outpatient management with education.

What Should Have Been Done

The National Asthma Education and Prevention Program explicitly recommends that patients must be educated on correct inhaler use before discharge and provided with written discharge plans 7.

Essential Education Components

• Demonstrate proper technique: Providers should demonstrate all steps of inhaler use and have the patient demonstrate back to ensure competence 7.
• Repeated instruction sessions: Repetition of instructions is significantly associated with correct technique (OR 8.2; 95% CI 3.2-21.5) 8.
• Written action plans: Creation of individualized written action plans is essential, though it places demands on physician time 1.
• Follow-up scheduling: Scheduling outpatient follow-up before discharge increases adherence to treatment plans 7.

Device-Specific Considerations

• For young children: Use nebulizer or MDI with valved holding chamber (spacer) and face mask, as children under 4-5 years cannot coordinate standard MDI technique 9, 10.
• Proper spacer technique: The mouthpiece must be kept clean and thoroughly air-dried to prevent medication buildup and blockage 6.

Common Pitfalls to Avoid

• Assuming patients can use inhalers without instruction: Physicians should not assume all patients can use an inhaler—it requires specific teaching 1.
• Single instruction session: A single form of instructional material (leaflet or video alone) is insufficient; combination approaches are more effective 4.
• Not assessing technique: The majority of providers do not demonstrate or assess child use of devices during visits, despite guideline recommendations 3.
• Discharging without written plans: Verbal instructions alone are insufficient 7.