10 Common Misconceptions & Errors in Treating Asthma
Lawrence Martin, M.D., FACP, FCCP
Clinical Professor of Medicine
Case Western Reserve University School of Medicine
Cleveland, Ohio
These 10 common misconceptions & errors in treating
asthma are based on many years' experience taking care
of adult asthma patients. Note that this list includes
misconceptions & errors held by or made by patients
and doctors.
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1. Thinking a written prescription for an asthma inhaler means
the patient knows how to use it: The device itself.
There are many different kinds of asthma inhalers
on the market. (Many of these inhalers are also prescribed for COPD, or
chronic obstructive pulmonary disease; see yellow box below).
It is a mistake to write a prescription for
one unless the patient already knows how to use it or is shown
how with a demonstration. None of the inhalers is intuitive
as to how to use, in contrast to a pill or tablet which
must merely be swallowed to be effective. For each inhaler,
the patient must make some maneuver which, if not done correctly,
means the medication is not inhaled properly or in
sufficient amount.
Mis-use of inhalers is a major and well-documented
problem that occurs across the entire spectrum of patients. The problem
stems from the plethora of inhaler types (lack of standardization),
their inherent complexity (relative to swallowing a pill),
and lack of training about how to
use them among both caregivers and their patients.
If there was just one or two types of inhaler,
health care providers (and by extension, their patients)
would become very famililar with them and there would be
less confusion than currently exists. Unfortunately there
are many different types of asthma inhalers. The poster above
displays only a partial list of inhalers asthma patients may
receive. They can be broadly classified into two groups:
Pressurized metered dose inhalers (pMDIs) and dry powder inhalers (DPIs).
NOTE: Several of these inhalers are
FDA-approved for "COPD" (chronic obstructive
pulmonary disease) and not, technically, for "asthma." For example,
Spiriva is
approved for COPD (chronic bronchitis and empysema), and not
asthma. Approval is based on the population of patients
studied, as required by the FDA.
Generally, "asthmatics" are younger, have never smoked and their lung function returns
to normal with maximum treatment. Generally, "COPD patients" are
older, have a long smoking history, and their lung function does not return
to normal with maximum treatment. However, there is a lot of overlap between
"COPD" and "asthma" with many patients having features of both conditions.
As a result, patients with chronic or difficult asthma - who
may never have been labeled as having "COPD" - are often
prescribed medications approved only for COPD. It is up to the physician to decide
what medication is best for his/her patient.
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PRESSURIZED METERED DOSE INHALERS (pMDIs)
By pressing the cannister down into its plastic housing, pMDIs deliver (under pressure)
a spray of medication from the mouthpiece. You can spray the medication into the air
and see it as a fine mist, but of course the mist is supposed to be inhaled by the patient,
whose mouth should be on on the plastic mouthpiece at the time of delivery (see picture below).
The patient must inhale deeply and at the right time in order to get all of the medication
delivered into the lungs.
pMDIs are the most common type of inhaler in the US; most of the inhalers shown
on the poster above are pMDIs. Short acting bronchodilators
are typically delivered via MDIs. To use this device
you must inhale immediately after pressing the canister down
into the plastic housing, as shown. This maneuver requires
some coordination: squeezing the fingers together while
making a deep inhalation with the device held tightly
between your lips. Some people do it well,
but many others exhale when they press
down on the canister, so the medication doesn't enter the lungs.
Click here for information on how to use the pMDI
What about spacers for metered dose inhalers?
Spacers have long been used with pMDIs to make it easier for
patients to inhale the medication. Another name for spacers is
aerosol-holding chambers. Two examples are shown below: a rigid
plastic spacer on the left and a collapsible spacer.
The pMDI inserts in one part of the spacer and
the patient inhales from a chamber that holds the medication.
When the pMDI is compressed the medication aerosol
enters the spacer and the patient can breathe normally via a mouthpiece
without the need to closely coordinate inspiration with medication release.
There are many different types of spacers available.
 
Pros: Spacers makes it easier to inhale the medication, helping assure that
it enters the lungs and not the room environment or just the back of the throat.
The Asthma Society of Canada recommends that anyone using a puffer consider
a spacer.
Cons: They are bulky to carry around, and often not availble when needed
(women can put them in a purse; not so for men). The aerosol medication
can adhere to the chamber wall, lessening the amount available for treatment.
Spacers need to be cleaned or replaced, adding expense to treatment regimen.
Bottom Line: If the pMDI is used as intended, there should be no need for a spacer.
They seem to be most useful for children needing a pMDI. Only a small minority of
adults regularly use a spacer with their pMDI.
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DRY POWDERED INHALERS (DPIs)
With DPIs the patient's breath (rather than hand action) actuates delivery of the
medication. You cannot see the spray because the only way to get the medication is to
inhale it from the mouthpiece. Within the DPI category, there are two broad types:
DPI Type 1): the medication is contained within the inhaler device at all times,
until inhaled, or
DPI Type 2): the medication comes in a separate capsule that must be placed
into the inhaler device at the time of use.
One study that received wide publicity showed that up to 1/3 of patients use
DPIs incorrectly. The error rate increased with patient's age, and
correlated with lack of instruction to the patient.
DPI Type 1. Medication is contained within the device
- Turbuhaler (also known as Flexhaler).
Several medications are
delivered via the tubuhaler, including the steroid
Pulmicort
(shown below; the manufacturer, Astra Zeneca calls their device a "Flexhaler,"
just another name for turbuhaler). The turbuhaler requires you to
twist the dark cap shown at the bottom in order to activate the
next inhalation. The turbuhaler (flexhaler)
eliminates the type of coordinated effort needed for
traditional MDIs, since once activated all you have to do
is inhale from the mouthpiece. However, the bottom cap can twist
both right and left, and it's not obvious which
way activates the flexhaler. Thus some patients twist
it so as to close the chamber, preventing delivery
of medication when they inhale. For instructions on how to use
the turbuhaler/flexhaler, see:
National Jewish Hospitals web site
Asthma Society of Canada web site
- Twisthaler is another plastic device that contains dry powdered medication.
Like the turbuhaler, the bottom cap (in this case pink; see picture below) must
be twisted to prepare the medication for delivery by breath inhalation.
Asmanex, an inhaled steroid, is delivered via a twisthaler (see below). When
you inhale (after twisting the cap), the twisthaler automatically releases the medication.
As with the other DPIs, when inhaled correctly the medication is delivered
properly. For instructions on how to use the twisthaler, see
National Jewish Hospital web site
- Diskus inhaler (see below).
Advair and
Serevent come in
this 'flying saucer' inhaler. The Diskus inhaler
requires sliding two different levers on the side, one to
activate the medicine for delivery and the other
to open the channel so the medication can be inhaled.
Each lever is accompanied by a 'click' and the patient
is suppose to make sure there are "two clicks" each time
they prepare to use the inhaler. However,
many patients only do one click,which means
the inhaler may actually be closed when they breathe
in, so no medicine is delivered. For instructions on
how to use the diskus inhaler, see:
National Jewish Hospital web site
Asthma Society of Canada web site
- Diskhaler (see below).
The diskhaler is not available in the United States, but is used in
Canada, England and other countries.
Serevent
is one of the medications that comes in a diskhaler.
The diskhaler is somewhat of a hybrid between the two types of DPI,
in that the medication comes prepackaged on a disk, with
each disk containing 8 separate doses. The disk
is inserted into the inhaler, and only needs replacement after the 8
doses are used up. The patient need never touch the medication itself.
For instructions on how to use the diskus inhaler, see:
Asthma Society of Canada web site
DPI Type 2.
Medication is separate from the inhaler, in a capsule
- Handihaler (see below). The widely used drug
Spiriva
(tiotropium bromide) is delivered in this device. (Technically Spiriva
is for chronic obstructive pulmonary disease, not asthma. However, many patients
with"asthma" also have chronic lung disease and are prescribed Spiriva.)
With the handihaler (as with the aerosolizer, below), the
actual medication resides apart from the device,
in capsules that are individually packaged.
The patient must: retrieve the capsule from its
wrapping, place it into the chamber of the handihaler,
close the chamber with a cap, then pierce the capsule by
pushing hard on a lever to the side of the handihaler. It's
a lot of steps! Furthermore, there are anecdotal reports of patients
who swallow the capsule instead of putting into the
chamber for puncture. The drug works well IF the patient is
instructed how to use the device and can perform the
required maneuvers. Without adequate instruction,
proper use is unlikely.For instructions on how to use the handihaler, see
National Jewish Hospital web site.
- Aerolizer. Like the handihaler (discussed
above), the aerolizer consists of a plastic device to
inhale medication. A capsule of powdered medication is placed
in the device and its delivery is breath activated.
Foradil,
a long acting bronchodilator, comes in this device (shown below).
For instructions on how to use
the aerolizer, see
National Jewish Hospital web site.
NOTE: When these inhalers -- both pMDIs and DPIs -- are tested in drug
studies there is virtually unlimited support and follow up to assure
the study patients use them correctly. This support is funded
by the drug companies, who obviously want to know if the medication
is effective, so they spend whatever it takes to make sure the enrolled patients
are properly instructed and know how to use the inhalers. That level of
education and support for inhaler use is seldom available
in clinical practice, resulting in discrepancy between the
effectiveness of the drug in published studies versus the real world.
The medication itself may be good but the delivery system is complicated and prone
to mis-use; as a result, improperly-used inhalers are often the
'weak link' in treating the patient's lung disease.
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2. Thinking a written prescription for an asthma inhaler means
the patient knows when to use it: The drug's purpose.
For treatment purposes all asthma inhalers fall into one of
two broad categories:
a) to provide quick relief ('rescue inhalers') and
b) to improve chronic symptoms and prevent flareups ('maintenance inhalers').
Examples of rescue inhalers are albuterol (brand names Proventil HFA,
ProAir HFA, Ventolin HFA) and ipratropium bromide (brand name Atrovent). Combivent
contains a combination of albuterol and ipratropium bromide.
Maintenance inhalers include any inhaled steroid (IS),
either alone (brand names Azmacort, Qvar, Pulmicort, etc.)
or in combination with a 'long acting bronchodilator' (LABD;
brand names Symbicort, Advair).
PROBLEM: The SAME type of delivery device (size, shape,
mechanism of action) is commonly used for both
rescue and maintenance inhalers. For example, as shown below,
ProAir HFA (a rescue inhaler, on left) and
Symbicort (a maintenance inhaler, on
right) both come packaged as pressurized metered dose inhalers, and
both are deep red in color. There is nothing intuitive about this.
For a patient who may have both inhalers (quite common), and who
becomes short of breath, it is all too easy to forget which is which.
This confusing situation happens often, even when the
rescue and maintenance inhalers are of
different color. The root problem is lack of standardization
among inhalers, with unclear labeling to distinguish between
rescue and maintenance inhalers. A contributing cause is
lack of proper education for both the caregivers and their patients.
All too often proper instructions were not given
when the drug was first prescribed. And even when they are provided,
patients sometimes don't really understand, or they forget.
Either way, having similar inhalers for different purposes
is an invitation to error. (This was less likely to be a problem
when the drug was studied
by the drug companies; see NOTE above, under 'DPI Type 2'.)
The problem is compounded when patients are on multiple
inhalers, eg, Proventil for rescue, Advair and Spiriva for
maintenance. That's 3 separate devices with two different
purposes -- easy for the patient to get confused. (Pills and
capsules come in many colors and sizes, but they are all
swallowed the same way.) What's needed is a universal delivery
device for all inhalers, with perhaps just two colors:
red for rescue drugs and green for maintenance drugs.
Anyone with clinical interest in the inhaler problems discussed above
(Errors 1 & 2) should definitely read
Problems With Inhaler Use: A Call for Improved Clinician and Patient Education,
by James B. Fink and Bruck K. Rubin (Respiratory Care, Sept 2005, Vol 50, No. 10,
pages 1360-75).
3. Not checking some objective measurement of
the patient's air flow obstruction.
Every patient should have a breathing test to ascertain the degree of
impairment caused by the asthma. The most frequently performed
test is 'spirometry', which takes just a few minutes and requires the
patient to exhale forcefully thru a testing device (shown below).
Measuring air flow is analagous to checking a patient's
blood sugar to monitor diabetes - a measurement
to determine how bad (or good) the condition is.
Spirometry need not be done often (frequency depending on
severity and chronicity of symptoms), but should be obtained
at least once in the course of management.
4. Missing the diagnosis of asthma because of
"clear lung fields" on exam.
A patient can have clear lungs if the exam is done
only during quiet breathing. The examiner places the
stethoscope over the lungs and pronounces them 'clear -
no wheezing.' In fact wheezing may be heard, but only after
a deep breath followed by a forceful exhalation.
Here the problem is simply an inexperienced care giver
(physician, nurse practioner or other health aide).
Many asthmatics with 'clear lung fields' on exam in
fact have bad lungs, with wheezes heard only at
the end of a forced exhalation.
5. Smoking while suffering from asthma.
I see many patients who continue to smoke while complaining
of cough or shortness of breath. Sure, they admit to
being addicted, or "I just can't stop", but there is still no
excuse. Smoking could either be the direct cause of wheezing
and shortness of breath (when we generally use the term
'acute bronchitis'). Also, smoking greatly retards
recovery, since cigarette smoke impairs clearing of mucus from
the lungs. I tell my patients it's like complaining of
a headache while banging your head with a hammer. Duh!
6. Fear of prescribing oral steroids.
Doctors are often reluctant to
prescribe oral steroid medication (prednisone, methylprednisolone),
yet many times it is the only drug that will effectively treat the patient's asthma. Instead,
all too often physicians prescribe the latest inhaled steroid or long acting bronchodilator
or combination IS+LABD. These drugs (non-generic and all
expensive) have a definite role in asthma maintenance,
but not in treating the patient whose symptoms are acute,
progressive or interfering with daily activity.
7. Over-using antibiotics to treat asthma.
In adults, bacterial infections are almost never the cause
of asthma exacerbations, and antibiotics are rarely needed. The
most common triggers of an asthma attack in adults are
viral infection, allergens (pollen, animal fur, etc.),
and irritants (fumes, dusts, etc.), none of which respond to
an antibiotic. An antibiotic may be needed if the
patient has sinusitis or smoking-related chronic bronchitis.
8. Not looking for other causes or precipitants of
wheezing and shortness of breath when asthma medication
is ineffective.
Asthma starts in the lungs and almost always leads to wheezing.
However, not all wheezing starts in the lungs or is 'asthma';
The problem may arise elsewhere in the body. Examples:
- Congestive heart failure is fluid buildup in the lungs from heart disease,
which can then cause wheezing. Diagnosis is usually not
difficult, and starts with a detailed history, physical exam and
chest x-ray. Treatment of so-called 'cardiac asthma' is different
than traditional asthma, and must be directed to the heart problem
- Sinusitis is often present in many chronic asthmatic
conditions, and requires treatment before the asthma can
be improved; the best test to uncover sinusitis is a sinus
CT scan. The figure below illustrates chronic sinusitis, which
can lead to asthma.
- Acid reflux can cause wheezing by spilling over of acid
from the stomach into the lungs. In addition to treating the asthma
medication is used to help control the acid (eg, proton
pump inhibitors). In the most severe cases the patient may
need a surgical procedure to prevent the acid reflux
- Upper airway obstruction can cause wheezing. Here the
problem is in the neck area (trachea, voice box),
not the lungs. Tumors, vocal cord disease and other conditions
in the upper airway can causes wheezes that sound like they are
coming from the lungs; treatment with asthma medications usually
has no benefit.
9. Not considering environmental factors in managing
asthma.
Occupational asthma
is a common problem, and should always
be considered when evaluating an adult with asthma.
The home environment (plants, animals, molds)
may also trigger an asthma attack, either thru
direct irritation or via an allergy mechanism. While
treatment is usually the same regardless of
precipitating causes, if triggers can be identified it
is of paramount importance to avoid them. This may be
difficult if one's livelihood is causing asthma, or even one's pets.
(I have been more successful in getting patients to change
offending jobs than in getting rid of offending pets.)
10. Letting the asthma attack continue
without getting proper treatment.
In fact, many patients suffer too long before seeking medical
treatment. The longer the asthma attack continues the more
refractory it becomes. Patients have died because they didn't
seek medical attention for symptoms that lasted days.
After seeing a physician for treatment,
patients must be encouraged to either call if they are
not responding or go to an urgent care center or
emergency department if they are getting worse.
Books About Asthma and Sinusitis
(With links to Amazon.com. Books listed in reverse
order of publication)
The Allergy and Asthma Cure: A
Complete 8-Step Nutritional Program, Fred Pescatore, MD, Wiley,
2008.
Asthma-free naturally,
Patrick McKeown, Conari Press, 2008.
The Asthma Sourcebook, 3rd ed.,
Francis V.Adams, MD, McGraw Hill Books, 2007.
The Sinus Cure: 7 Simple Steps to Relieve
Sinusitis and Other Ear, Nose and Throat Conditions,
Debra Fulghum Bruce PhD and Murray Grossan, MD, Ballantine
Books, 2007.
Sinus Relief Now: The Groundbreaking 5-Step
Program for Sinus, Allergy and Asthma Sufferers, Jordan S. Josephson, MD,
Perigee Trade, 2006.
Asthma for Dummies, William
E. Berger, MD, For Dummies, 2004.
The Children's Hospital Guide to Asthma,
Julian Lewis Allen, editor. Wiley, 2004.
The Harvard Medical School Guide to Healing
Your Sinuses, Ralph B. Metson, MD, and Steven Mardon,
McGraw Hill, 2004.
The Harvard medical School Guide to Taking Control
of Asthma, Christopher H. Fanta, Lynda M. Cristiano, Kenan
Hayer, Free Press, 2003.
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Forward any comments to:
Lawrence Martin, M.D., FACP, FCCP
Copyright © Lawrence Martin, M.D.
Posted December 2008; Revised April 30, 2009