Asthma Management Handbook

Providing asthma management education for parents and children

Recommendations

Provide parents (and children, if old enough) with asthma education that includes information about asthma symptoms and signs, asthma medicines, and how to take inhaled medicines correctly.

Table. Childhood asthma education checklist

Asthma symptoms and signs

  • Explain that asthma is a long-term condition that is still there even when the child does not have current symptoms, and which involves abnormally sensitive or inflamed breathing tubes (airways) in the lungs.
  • Explain the causes of wheezing and breathlessness (narrowing of airways due to contraction of smooth muscle in airway wall, swelling of lining of airways, increased mucus secretion into airway).
  • Explain that the severity of a particular asthma flare-up (e.g. acute asthma causing a trip to the emergency department) is not the same as the severity of the child’s asthma overall.
  • Explain warning signs that mean the child needs to take reliever, needs a doctor, or needs emergency care.
  • Mention some common factors that can trigger children’s asthma (e.g. colds, exercise, allergens, tobacco smoke). Provide advice on triggers that can be avoided.

Asthma medicines

  • Explain that relievers make the abnormally narrowed breathing tubes (airways) wider so it is easier to breathe.
  • Explain that relievers should only be used when the child has symptoms, or before exercise if prescribed for exercise-induced bronchoconstriction.
  • Explain that relievers should not be used at other times ‘just in case’, and that using reliever too often is a sign that the child’s asthma is poorly controlled – the child may need regular medicine.
  • Explain that preventers (inhaled corticosteroids, montelukast, and combinations of inhaled corticosteroid and long-acting beta2 agonist) work mainly by settling down the inflammation in the airways. Combination preventers (inhaled corticosteroid plus long-acting beta2 agonist) also contain a second medicine that helps keep narrow airways open.
  • Emphasise that preventers must be taken regularly to work properly.
  • Explain the possible side effects of inhaled corticosteroids and how to minimise them (following directions closely, using a spacer, rinsing and spitting after use).
  • Explain that other medicines are used during acute asthma (‘attacks’).

Inhaler devices

  • Explain how to use a puffer and spacer or other inhaler device properly.
  • Physically demonstrate how to use the device, provide training, then watch the child or parents perform each step.
  • Explain how to clean and care for inhalers and spacers.

Written asthma action plan

  • Provide a written asthma action plan and explain how to use it
  • Provide a plan for the child’s school or childcare centre

Note: for children with difficult-to-treat asthma or comorbid conditions, provide more detailed information.

Asset ID: 30

Close
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Provide parents of wheezing preschool children with education that includes information on causes of wheeze, effective treatment options, and how to recognise warning signals.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available)

Provide training for children and parents on how to use inhaler devices correctly, including inhaler technique, care and cleaning of devices and spacers.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Provide a written asthma action plan for all children with asthma, and train parents (and older children) how to follow it.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Review the child’s written asthma action plan every 6 months, and whenever asthma control status changes significantly or medicines are changed or stopped.

Table. Checklist for reviewing a written asthma action plan

  • Ask if the person (or parent) knows where their written asthma action plan is.
  • Ask if they have used their written asthma action plan because of worsening asthma.
  • Ask if the person (or parent) has had any problems using their written asthma action plan, or has any comments about whether they find it suitable and effective.
  • Check that the medication recommendations are appropriate to the person’s current treatment.
  • Check that all action points are appropriate to the person’s level of recent asthma symptom control.
  • Check that the person (or parent) understands and is satisfied with the action points.
  • If the written asthma action plan has been used because of worsening asthma more than once in the past 12 months: review the person's usual asthma treatment, adherence, inhaler technique, and exposure to avoidable trigger factors.
  • Check that the contact details for medical care and acute care are up to date.

Asset ID: 43

Close
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Written asthma action plans for children

Every child with asthma should have their own written asthma action plan.

A systematic review found that the use of written asthma action plans significantly reduces the rate of visits to acute care facilities, the number of school days missed and night-time waking, and improves symptoms.1 Symptom-based plans were more effective than peak flow-based plans for reducing the risk of acute care visits in children and adolescents.1

Written asthma action plans that are based on symptoms appear to be more effective than action plans based on peak expiratory flow monitoring for children and adolescents.1

A written asthma action plan should include all the following:

  • a list of the child’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
  • clear instructions on what to do in all the following situations:
    • when asthma is getting worse (e.g. when needing more reliever than usual, waking up with asthma, more symptoms than usual, asthma is interfering with usual activities)
    • when asthma symptoms get substantially worse (e.g. when needing reliever again within 3 hours, experiencing increasing difficulty breathing, waking often at night with asthma symptoms)
    • during an asthma emergency.
  • instructions on when and how to get medical care (including contact telephone numbers)
  • the name and contact details of the child’s emergency contact person (e.g. parent)
  • the name of the person writing the action plan, and the date it was issued.

Table. Checklist for reviewing a written asthma action plan

  • Ask if the person (or parent) knows where their written asthma action plan is.
  • Ask if they have used their written asthma action plan because of worsening asthma.
  • Ask if the person (or parent) has had any problems using their written asthma action plan, or has any comments about whether they find it suitable and effective.
  • Check that the medication recommendations are appropriate to the person’s current treatment.
  • Check that all action points are appropriate to the person’s level of recent asthma symptom control.
  • Check that the person (or parent) understands and is satisfied with the action points.
  • If the written asthma action plan has been used because of worsening asthma more than once in the past 12 months: review the person's usual asthma treatment, adherence, inhaler technique, and exposure to avoidable trigger factors.
  • Check that the contact details for medical care and acute care are up to date.

Asset ID: 43

Close

Templates for written asthma action plans

Templates are available from National Asthma Council Australia:

  • National Asthma Council Australia colour-coded plan, available as a printed handout that folds to wallet size and as the Asthma Buddy mobile site
  • Asthma Cycle of Care asthma action plan
  • A plan designed for patients using budesonide/formoterol combination as maintenance and reliever therapy
  • Remote Indigenous Australian Asthma Action Plan
  • Every Day Asthma Action Plan (designed for remote Indigenous Australians who do not use written English – may also be useful for others for whom written English is inappropriate)
  • Children’s written asthma action plans.

Some written asthma action plans are available in community languages.

Software for developing electronic pictorial asthma action plans23 is available online.

Close
Asthma education programs for parents and children

Asthma education for children and/or caregivers reduces the risk of emergency department visit for asthma, compared with usual care.4

However, the most effective components of education have not been clearly identified.45 There have been relatively few Australian controlled trials assessing education programs.5

There is not enough evidence to tell whether asthma education programs in the child’s home are more effective in helping control asthma than asthma education provided somewhere else or standard care,5 or to identify which types of education is more effective.

All age groups

A systematic review6 found that asthma education programs were associated with moderate improvement in lung function and with a small reduction in school absence, restriction of physical activity, and emergency department visits. The greatest effects were in children with more severe asthma.6

Another systematic review found that educational programmes for the self-management of asthma in children and adolescents improved lung function, reduced the number of school days missed and the number of days with restricted activity, reduced the rate of visits to an emergency department, and possibly reduced the number of disturbed nights.7

0-5 years

There is little evidence about the effects of education for parents of preschool-aged children with asthma or wheezing. Most studies have investigated the effects of asthma management education for older children and their parents.8 Limited evidence suggests that:

  • education for parents of preschool children (e.g. written information and review by a health professional, small-group teaching by nurses or education in the family’s home) may help improve asthma control8
  • education programs are more likely to be effective if they involve multiple sessions, each longer than 20 minutes’ duration.8

Adolescents

The school-based Adolescent Asthma Action (Triple A) program has been associated with improvement in quality of life9 and asthma knowledge.10 It is available in many Australian schools.

Opportunistic asthma education

In addition to the types of structured or formal asthma education evaluated in research trials, all health professionals who work with children with asthma and their parents can provide asthma education whenever the opportunity occurs.

Table. Childhood asthma education checklist

Asthma symptoms and signs

  • Explain that asthma is a long-term condition that is still there even when the child does not have current symptoms, and which involves abnormally sensitive or inflamed breathing tubes (airways) in the lungs.
  • Explain the causes of wheezing and breathlessness (narrowing of airways due to contraction of smooth muscle in airway wall, swelling of lining of airways, increased mucus secretion into airway).
  • Explain that the severity of a particular asthma flare-up (e.g. acute asthma causing a trip to the emergency department) is not the same as the severity of the child’s asthma overall.
  • Explain warning signs that mean the child needs to take reliever, needs a doctor, or needs emergency care.
  • Mention some common factors that can trigger children’s asthma (e.g. colds, exercise, allergens, tobacco smoke). Provide advice on triggers that can be avoided.

Asthma medicines

  • Explain that relievers make the abnormally narrowed breathing tubes (airways) wider so it is easier to breathe.
  • Explain that relievers should only be used when the child has symptoms, or before exercise if prescribed for exercise-induced bronchoconstriction.
  • Explain that relievers should not be used at other times ‘just in case’, and that using reliever too often is a sign that the child’s asthma is poorly controlled – the child may need regular medicine.
  • Explain that preventers (inhaled corticosteroids, montelukast, and combinations of inhaled corticosteroid and long-acting beta2 agonist) work mainly by settling down the inflammation in the airways. Combination preventers (inhaled corticosteroid plus long-acting beta2 agonist) also contain a second medicine that helps keep narrow airways open.
  • Emphasise that preventers must be taken regularly to work properly.
  • Explain the possible side effects of inhaled corticosteroids and how to minimise them (following directions closely, using a spacer, rinsing and spitting after use).
  • Explain that other medicines are used during acute asthma (‘attacks’).

Inhaler devices

  • Explain how to use a puffer and spacer or other inhaler device properly.
  • Physically demonstrate how to use the device, provide training, then watch the child or parents perform each step.
  • Explain how to clean and care for inhalers and spacers.

Written asthma action plan

  • Provide a written asthma action plan and explain how to use it
  • Provide a plan for the child’s school or childcare centre

Note: for children with difficult-to-treat asthma or comorbid conditions, provide more detailed information.

Asset ID: 30

Close

Resources

Education resources are available from the National Asthma Council Australia, Asthma Australia, and the Asthma Foundation in your state or territory.

Close
Administration of inhaled medicines in children: 0–5 years

To use inhaler devices correctly, parents and children need training in inhaler technique and in the care and cleaning of inhalers and spacers.

Children need careful supervision when taking their inhaled medicines (e.g. at preschool), especially when using a reliever for acute asthma symptoms. 

During acute wheezing episodes, delivery of short-acting beta2 agonist to airways is more effective with a pressurised metered-dose inhaler plus spacer than with a nebuliser.8 In older children, salbutamol has also been associated with a greater increase in heart rate when delivered by nebuliser than when delivered by pressurised metered-dose inhaler plus spacer.11

Dry-powder inhalers are usually ineffective for preschool children because they cannot generate sufficient inspiratory air flow.8

Preschool children cannot use pressurised metered-dose inhalers properly unless a spacer is attached (with mask when necessary), because it is difficult for them to coordinate inspiratory effort with firing the device.8 Note that breath-actuated pressurised metered-dose inhalers cannot be used with a spacer.

Even when using pressurised metered dose inhalers and spacers, drug delivery is very variable in young children.12 The inhaler design may improve spacer technique,12 but will not necessarily improve clinical outcomes. The amount of medicine delivered by inhaler devices to the lower airways varies from day to day in preschool children.8 This variation might explain fluctuations in effectiveness, even if the child’s parents have been trained to use the device correctly.

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the inhaler, fire one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).13 Fewer breaths may suffice; in children with asthma aged 2–7 years (not tested during an acute asthma episode), the number of tidal breaths needed to inhale salbutamol adequately from a spacer has been estimated at 2 breaths for small-volume spacers, 2 breaths for a spacer made from a 500-mL modified soft drink bottle, and 3 breaths for a large (Volumatic) spacer.14

When using a spacer with face mask (e.g. for an infant too young or uncooperative to be able to use a mouthpiece), effective delivery of medicine to the airways depends on a tight seal around the face. When masks are used for inhaled corticosteroids, there is a risk of exposure to eyes and skin if the seal over the mouth and nose is not adequate. Parents should be advised to wash the child's face after administering inhaled corticosteroids by mask.

Babies are unlikely to inhale enough medicine while crying.11 The use of a spacer and face mask for a crying infant may require patience and skill: the child can be comforted (e.g. held by a parent, in own pram, or sitting on the floor) while the mask is kept on, and the actuation carefully timed just before the next intake of breath. Most infants will tolerate the spacer and mask eventually. The child may be more likely to accept the spacer and mask if allowed to handle them first (and at other times), if the devices are personalised (e.g. with stickers), or if the mask has a scent associated with the mother (e.g. lip gloss). The use of a spacer with a coloured valve allows parents to see the valve move as the child breathes in and out.

Close
Administration of inhaled medicines in children: 6 years and over

School-aged children (depending on the child’s age, ability, and with individualised training) can correctly use a range of inhaler types,15 including manually actuated pressurised metered-dose inhalers with spacers,16 breath-actuated pressurised metered-dose inhalers (e.g. Autohaler), and dry-powder inhalers (e.g. Accuhaler, Turbuhaler).1617

A pressurised metered-dose inhaler and spacer is an appropriate first choice for most children.15

Parents and children need training to use inhaler devices correctly, including inhaler technique, and care and cleaning of inhalers and spacers.

School-aged children are unlikely to use their inhaler device correctly without careful training.18

Close
Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only approximately 10% of patients use correct technique.1920

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,21, 22, 23, 24, 25 even among regular users.26 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.27

Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.21, 28, 26, 29, 30 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.26

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.31, 32

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:27

  • failing to shake the inhaler before actuating
  • holding the inhaler in wrong position
  • failing to exhale fully before actuating the inhaler
  • actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
  • actuating the inhaler too late while inhaling
  • actuating more than once while inhaling
  • inhaling too rapidly (this can be especially difficult for chilren to overcome)
  • multiple actuations without shaking between doses.

Common errors for dry powder inhalers include:27

  • not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
  • failing to exhale fully before inhaling
  • failing to inhale completely
  • inhaling too slowly and weakly
  • exhaling into the device mouthpiece before or after inhaling
  • failing to close the inhaler after use
  • using past the expiry date or when empty.

Other common problems include:

  • difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
  • inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
  • inability to generate adequate inspiratory flow for the inhaler type
  • failure to use a spacer when appropriate
  • use of incorrect size mask
  • inappropriate use of a mask with a spacer in older children.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.27 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.33, 21, 34, 35 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.34 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).19, 32

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct technique.31, 21, 22 

Close
Preparation of new spacers before first use

Electrostatic surface charge on new standard plastic spacers (e.g. Able Spacer Universal, Breath-A-Tech, Volumatic) reduces the proportion of medicine available for delivery to the airway. This charge can be reduced by washing the plastic spacer in dishwashing liquid and allowing it to air dry or drip-dry without wiping (i.e. suds intact).8

Alternatively, priming the spacer by actuating the device several times into the spacer also overcomes the charge, but this wastes medicine. The optimal number of actuations for priming is not known and the findings of in vitro studies vary widely. One study (using older, CFC-based formulations of asthma medicines) reported that up to 40 actuations fired into a new plastic spacer overcame the effect of the electrostatic charge.36 Others have concluded that the electrostatic charge on plastic spacers does not reduce in vivo efficacy of bronchodilator therapy in children with asthma.37 The number of actuations necessary may be known when the results of recent studies become available.

When a new standard plastic spacer must be used immediately (e.g. for a person with asthma symptoms), patients, parents and carers should follow the manufacturer's priming instructions. In hospitals and emergency departments, a new spacer that has not been pre-treated by washing can be primed using multiple (at least 10) puffs of salbutamol. (This is an arbitrary number of actuations in the absence of evidence that would enable a precise guideline.)

Disposable cardboard spacers and antistatic polymer spacers (e.g. Able A2A, AeroChamber Plus, Breathe Eazy, La Petit E-Chamber, La Grande E-Chamber, OptiChamber Diamond) do not have this problem.8

Note: The term 'priming' is also used for the preparation process that is necessary for new pressurised metered-dose inhalers that have not been used for more than a week. This involves first actuating the inhaler into the air (away from the patient). Users should follow the manufacturer’s instructions for the particular brand of inhaler, which specify the number of actuations required.

Close
'Wheeze-detecting' devices

Some hand-held devices and smart phone applications are marketed for detecting and measuring wheeze by audio recording and analysis.

There is not enough evidence to recommend these devices and apps for use in monitoring asthma symptoms or asthma control in adults or children, or in distinguishing wheeze from other airway sounds in children.

  • Over-reliance on these devices could result in over- or under-treatment.
Close
Psychosocial factors affecting asthma self-management

Psychosocial factors can affect asthma symptoms and outcomes in children and adults. These can include biological, individual, family and community-level factors, which can have synergistic effects in an individual with asthma.38 Mechanisms may include effects of stress on the immune system38 and effects of life circumstances on patients’ and families’ ability to manage asthma.

Relationships between psychosocial and cultural factors

Important influences on asthma outcomes include the person’s asthma knowledge and beliefs, confidence in ability to self-manage, perceived barriers to healthcare, socioeconomic status, and healthcare system navigation skills, and by the quality of interaction and communication between patient and healthcare provider.39 There is a complex interrelationship between:39

  • patient factors (e.g. health literacy, health beliefs, ethnicity, educational level, social support, cultural beliefs, comorbidities, mental health)
  • healthcare provider factors (e.g. communication skills, teaching abilities, available time, educational resources and skills in working with people from different backgrounds)
  • healthcare system factors (e.g. the complexity of the system, the healthcare delivery model, the degree to which the system is oriented towards chronic disease management or acute care, and the degree to which the system is sensitive to sociocultural needs).

Health literacy

‘Health literacy’ refers to the individual’s capacity to obtain, process, and understand basic health information and services they need to make appropriate health decisions.40 A person’s level of health literacy is influenced by various factors including skills in reading, writing, numeracy, speaking, listening, cultural and conceptual knowledge.39

Inadequate health literacy is recognised as a risk factor for poorer health outcomes and less effective use of health care services.39 Poor health literacy has been associated with poor asthma control,41 poor knowledge of medications,42 and incorrect inhaler technique.42 Aspects of health literacy that have been associated with poorer asthma outcomes in adults include reading skills, listening skills, numeracy skills, and combinations of these.39 Studies assessing the association between parents’ health literacy and children’s asthma have reported inconsistent findings.39 Overall, there is not enough evidence to prove that low health literacy causes poor asthma control or inadequate self-management.39

Australian research suggests that there are probably many Australians with limited health literacy.43 It may be possible to identify some groups of patients more likely to have inadequate health literacy, such as people living in regions with low socioeconomic status, and those with low English literacy (e.g. people with limited education, members of some ethnic minorities, immigrants, and the elderly).39 However, even well-educated patients might have trouble with basic health literacy skills.39

Attempting to assess every patient’s health literacy is impractical and may be embarrassing for the person and time-consuming for the health professional.39 Instead, it may be more effective for health professionals simply to assume that all patients have limited health literacy.39 Accordingly, all self-management skills need to be explained carefully, simply and repeatedly, and all written material should be clear and easy to read. Special consideration is needed for patients from culturally and linguistically diverse communities, including Aboriginal and Torres Strait Islander people.

Psychosocial support and improving health literacy

Psychosocial interventions that include asthma education may improve health-related quality of life for children and adolescents with asthma and their families.44 However, simply providing education might not improve a person’s health literacy, since it also depends on other factors like socioeconomic status, social support, and is influence by the provider and the healthcare system.39

Asthma Australia provides personal support and information for people with asthma and parents of children with asthma through the Asthma Australia Information line by telephone on 1800 Asthma (1800 278 462) or online.

Close

References

  1. Zemek RL, Bhogal S, Ducharme FM. Systematic Review of Randomized Controlled Trials Examining Written Action Plans in Children - What Is the Plan?. Arch Pediatr Adolesc Med. 2008; 162: 157-63. Available from: http://archpedi.jamanetwork.com/article.aspx?articleid=379087#tab1
  2. Roberts NJ, Mohamed Z, Wong PS, et al. The development and comprehensibility of a pictorial asthma action plan. Patient Educ Couns. 2009; 74: 12-18. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18789626
  3. Roberts NJ, Evans G, Blenkhorn P, Partridge M. Development of an electronic pictorial asthma action plan and its use in primary care. Patient Educ Couns. 2010; 80: 141-146. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19879092
  4. Coffman JM, Cabana MD, Halpin HA, Yelin EH. Effects of asthma education on children's use of acute care services: a meta-analysis. Pediatrics. 2008; 121: 575-86. Available from: http://pediatrics.aappublications.org/content/121/3/575.long
  5. Welsh EJ, Hasan M, Li P. Home-based educational interventions for children with asthma. Cochrane Database Syst Rev. 2011; Issue 10: CD008469. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008469.pub2/full
  6. Wolf F, Guevara JP, Grum CM, et al. Educational interventions for asthma in children. Cochrane Database Syst Rev. 2002; Issue 4: CD000326. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000326/full
  7. Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003; 326: 1308-1309. Available from: http://www.bmj.com/content/326/7402/1308
  8. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from: http://erj.ersjournals.com/content/32/4/1096.full
  9. Smita S, Jennifer KP, Evalynn JM, et al. Effect of peer led programme for asthma education in adolescents: cluster randomised controlled trial. BMJ. 2001; 322: 583-585. Available from: http://www.bmj.com/content/322/7286/583
  10. Gibson PG, Shah S, Mamoon HA. Peer-led asthma education for adolescents: impact evaluation. J Adolesc Health. 1998; 22: 66-72. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9436069
  11. Schuh, S., Johnson, D. W., Stephens, D., et al. Comparison of albuterol delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma. The Journal of pediatrics. 1999; 135: 22-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10393599
  12. Schultz A, Sly PD, Zhang G, et al. Incentive device improves spacer technique but not clinical outcome in preschool children with asthma. J Paediatr Child Health. 2012; 48: 52-6. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2011.02190.x/full
  13. National Asthma Council Australia. Kids' First Aid for Asthma. National Asthma Council Australia, Melbourne, 2011. Available from: http://www.nationalasthma.org.au/first-aid
  14. Schultz A, Le Souëf TJ, Venter A, et al. Aerosol inhalation from spacers and valved holding chambers requires few tidal breaths for children. Pediatrics. 2010; 126: e1493-8. Available from: http://pediatrics.aappublications.org/content/126/6/e1493.long
  15. Ram FS, Brocklebank DD, White J, et al. Pressurised metered dose inhalers versus all other hand-held inhaler devices to deliver beta-2 agonist bronchodilators for non-acute asthma. Cochrane Database Syst Rev. 2002; Issue 2: CD002158. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002158/full
  16. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
  17. Nikander K, Turpeinen M, Pelkonen AS, et al. True adherence with the Turbuhaler in young children with asthma. Arch Dis Child. 2011; 96: 168-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21097795
  18. Sleath B, Ayala GX, Gillette C, et al. Provider demonstration and assessment of child device technique during pediatric asthma visits. Pediatrics. 2011; 127: 642-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21444594
  19. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
  20. Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  21. Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23098685
  22. Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  23. Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18083019
  24. Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24779482
  25. Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ primary care respiratory medicine. 2014; 24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
  26. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
  27. National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
  28. Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762
  29. Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415
  30. Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
  31. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol. 2007; 119: 1537-8. Available from: http://www.jacionline.org/article/S0091-6749(07)00439-3/fulltext
  32. Giraud, V., Allaert, F. A., Roche, N.. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respiratory medicine. 2011; 105: 1815-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21802271
  33. Basheti, I. A., Reddel, H. K., Armour, C. L., Bosnic-Anticevich, S. Z.. Counseling about turbuhaler technique: needs assessment and effective strategies for community pharmacists. Respiratory care. 2005; 50: 617-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15871755
  34. Lavorini, F.. Inhaled drug delivery in the hands of the patient. Journal of aerosol medicine and pulmonary drug delivery. 2014; 27: 414-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25238005
  35. Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert opinion on drug delivery. 2014; 11: 365-78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24386924
  36. Berg E. In vitro properties of pressurized metered dose inhalers with and without spacer devices. J Aerosol Med. 1995; 8 Suppl 3: S3-10; discussion S11. Available from: http://www.ncbi.nlm.nih.gov/pubmed/10157897
  37. Dompeling E, Oudesluys-Murphy AM, Janssens HM, et al. Randomised controlled study of clinical efficacy of spacer therapy in asthma with regard to electrostatic charge. Arch Dis Child. 2001; 84: 178-182. Available from: http://adc.bmj.com/content/84/2/178.full
  38. Yonas MA, Lange NE, Celedon JC. Psychosocial stress and asthma morbidity. Curr Opin Allergy Clin Immunol. 2012; 12: 202-10. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3320729/
  39. Rosas-Salazar C, Apter AJ, Canino G, Celedon JC. Health literacy and asthma. J Allergy Clin Immunol. 2012; 129: 935-42. Available from: http://www.jacionline.org/article/S0091-6749(12)00128-5/fulltext
  40. Ratzan S, Parker R. Introduction. In: Selden C, Zorn M, Ratzan S, Parker R, editors. National Library of Medicine Current Bibliographies in Medicine: Health Literacy. National Institutes of Health, US Department of Health and Human Services, Bethesda, Maryland, USA, 2000; v-vi. Available from: http://www.nlm.nih.gov/archive//20061214/pubs/cbm/hliteracy.html
  41. Adams RJ, Appleton SL, Hill CL, et al. Inadequate health literacy is associated with increased asthma morbidity in a population sample. J Allergy Clin Immunol. 2009; 124: 601-603. Available from: http://www.jacionline.org/article/S0091-6749(09)00859-8/fulltext
  42. Paasche-Orlow MK, Riekert KA, Bilderback A, et al. Tailored education may reduce health literacy disparities in asthma self-management. Am J Respir Crit Care Med. 2005; 172: 980-6. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2718412/
  43. Adams RJ, Appleton SL, Hill CL, et al. Risks associated with low functional health literacy in an Australian population. Med J Aust. 2009; 191: 530-4. Available from: https://www.mja.com.au/journal/2009/191/10/risks-associated-low-functional-health-literacy-australian-population
  44. Clarke SA, Calam R. The effectiveness of psychosocial interventions designed to improve health-related quality of life (HRQOL) amongst asthmatic children and their families: a systematic review. Qual Life Res. 2012; 21: 747-64. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21901377