–  Veena Ranaut, Sukhwinder Kaur, Sukhpal Kaur, Menu Singh

Abstract: Asthma is one of the most common respiratory disorders in children.Poor compliance with Metered Dose Inhaler (MDI) is a major problem in pediatric asthma management especially the adolescence as there is shift in responsibility for asthma management from parents to teen patients. A number of misconceptions and wrong practices regarding use of inhalers are prevalent in India. These effect the treatment seeking behavior and compliance. The present study was aimed to assess compliance with treatment, indices in past two months and mythsregarding use of MDI amongst the children suffering with asthma and their care givers. Using purposive sampling technique, 100 diagnosed patients (new and old) between ages of 3-14 years were enrolled. A semi-structured interview schedule was used to gather information regarding socio-demographic profile of the subjects, compliance with treatment and myths regarding use of the inhalers. Each subject was interviewed personally. Out of total subjects, 29% were not taking inhaler regularly. More than half (60%) were having 1- 5 or more no. of attacks of asthma and (53%) were absent from school for 1-10 days due to illness since last two months.Fifty one percent had certain myths related to inhaler like regular use of inhaler develops habit, it causes dryness of nose and throat, affects the growth of a child, children become lethargy, and affects the intelligence level etc.3% of the caregivers restricted their children to eat Rajmah, kheer, milk & milk products. It was concluded that a number of misconceptions and wrong practices regarding use of inhalers are prevalent.Various educational programmes on the management of asthma needs to be organized.

Keywords:Compliance, Indices of Asthma, Myths Metered Dose Inhaler (MDI)

Correspondence at:Mrs Veena Ranaut Clinical Instructor, Sister Nivedita Govt. College, IGMC Shimla (Himachal Pradesh)

Introduction: Asthma is the most common chronic childhood disease with one in eight children suffering from asthma.1 About 38% of these children miss school once per week and 8% miss school once per month every year.2 Inhalation therapy is the cornerstone for acute and long-term management of asthma. However, the impact of treatment on the disease morbidity and mortality dependsnto a large extent on appropriate delivery of drug to the lungs. Poor patient compliance with inhaled medication is a known cause of morbidity and mortality in asthma.3 Various factors contributing to poor compliance include the route of administration (oral therapy is preferred to inhaled medication), frequency of dosing (once- or twice-daily regimens are preferred), medication effects (a slow onset of action and long duration on discontinuance have poor adherence rates) and the risk or concern of side effects.4,5 A compliance rates of around 50% with regular preventive therapy has been reported in the studies.6,7 A number of misconceptions and myths about the inhalation therapy prevail in India, like use of inhaler is dangerous; it  damages lungs and heart, it is the last resort, costly, and habit forming; one’s ailment is exposed to all and it is difficult to use etc.8 These may affect the treatment seeking behavior and compliance. Another important cause of poor compliance may be inappropriate techniques of using inhalation devices. This may result in misuse or overdose of drugs and may lead to diminished response to therapy. The child may require repeated hospitalizations. In one of the studies only 17.4% asthmatic children who received inhalation therapy revealed good compliance with their medication regimens. No child demonstrated the correct technique of using inhaler.9 Empowering people with asthma to take an active role in the management of their condition can result in more effective treatment of the disease.10 For better control of asthma in children, parents should be actively involved in the process.There is need to explore their fears and concerns about asthma and its treatment. Majority of the deaths due to asthmatic attack are avoidable. There is a need to lay a greater emphasis on regular treatment with preventive therapy. However, patients will benefit from therapy if they take their treatment properly and regularly. The current study was carried out with the objective to assess the compliance with treatment and myths regarding use of MDI amongst the care givers of the children suffering with asthma.

Material and methods:The study was conducted in the asthma clinic of Advanced Pediatric Centre (APC), Post Graduate Institute of Medical education and Research, Chandigarh. The children with various disorders are admitted in APC. The centre has a separate OPD block. Asthma clinic is held on every Tuesday on 3rd floor, D block. Using purposive sampling technique, a total of 100 diagnosed patients (new and old),were included in the study. Diagnosis was confirmed from OPD card written by the treating physician. An inclusion criterion to select the subject was children between age of 3- 14 years and their care givers of all ages who accompany the child. After reviewing the literature and with consultation of experts, a semi-structured interview schedule was developed. Tool was validated by expert in nursing and paediatrics. Information was obtained regarding socio- demographic profile of the subjects,their compliance with the treatment, myths regarding use of the inhalers and indices in the last two months. Open ended questions were used to gather the information regarding myths related to asthma and inhalation therapy and problems faced by subjects. Information regarding indices of asthma morbidity included the number of severe attacks, number of visits to emergency, number of admission to hospital, need of injections and absence from school due to illness.Ethical approval for the study was obtained from Institution Ethical Committee Informed consent was obtained from each subject. The participants were assured that the information obtained from them will be kept confidential and it will be used only for research purposes.The diagnosed patients and their caregivers were contacted personally by the investigator. They were interviewed in a separate room as per interview schedule after taking written conscent. Data was analysed using SPSS version17 . Descriptive statistics was employed.


Demographic profile of the children The mean age of the subjects was 7.7 ± 0.6 years with the range of 3-14 years. 27% of subjects were less than 5 years of age, 56% were between 5 to 10 years of age. Around three fourth (73%) subjects were male. All the children were studying in school. 46% were studng between nursery to 3rd standard and remaining 54% subjects were studying between 4th to 8th standard. 60 % subjects were suffering with asthma since last 1-5 years.

Demographic profile of the caregivers Majority (90%) of the caregivers were in the age of 24-45 years. Mean age of the caregivers were 36.2±1.9 years with the range of 24-64 years. As far as education of caregivers is concerned, 28% were under- matric, 64% were undergraduates. 42% mothers were house-maker where as 32% were professionals. 44% fathers were professionals, and 33% were unskilled and cultivators. Monthly income of around one third (37%) caregivers were ranging from Rs. >5001-10,000. Mean income of the family was Rs.13470 ±10196 with the range from Rs.2000- 40,000.

Compliance of the subjects with the use of MDI

Figure-1 depicts that out of total 100 subjects, 68% subjects were complied with the treatment whereas 29% subjects had poor compliance with the treatment.

Figure-1: Compliance of subjects with Metered dose inhaler

Problems while using MDI:Out of total subjects, one fourth (25%) subjects having problems in use of MDI. 10% were having co-ordination and actuation problem; 8% were having dry throat and dry cough during inhaling drugs and 7% subjects were feeling suffocation and irritation during using inhaler with spacer.Myths related to asthma and inhalation devices amongst the caregivers More than half (51 %) caregivers were having certain myths related to use of inhalers. 17.7% were of the opinion that using inhaler for long duration develops habit in children.15.7% thought that inhalers cause dryness of nose and throat. 13.7% caregivers had myths related to the growth of child. 13.7% had misconception that children become lethargy after taking inhalers. 11.8% were in favour that inhalers affect the intelligence of the children. 5.9% caregivers were having myths that children using inhaler could not live normal life and equal numbers restricted their children to eat Rajmah, kheer, milk & milk products as all these edible items exacerbated asthma. 7.8% were having opinion that inhalers are the last resort of treatment. (Table 1)

Table : Myths related to use of inhalers


Myths n(%)
No Yes 49


Inhaler are habit forming 9(17.7)
It causes dryness of nose and throat 8(15.7)
Inhaler affects the intelligence 6(11.8)
Inhaler and spacer should be cleaned with hot water 4(7.8)
Inhaler affects the physical activities of a child 4(7.8)
It is last resort 4(7.8)
Child becomes lethargy with the use of inhaler 4(7.8)
Child could not live normal life without it 3(5.9)
Inhaler stunt the child’s growth 3(5.9)
Asthma is exacerbated by consuming milk, cheese, butter, curd & lassi 3(5.9)
It is dangerous 3(5.9)

Indices of asthma morbidity in last two effects.4

However, to be effective, the months

Table 2 depicts that 40%subjects were having 1- 2 attacks of asthma, 20% were having 3- 5 attacks of asthma in the last two months,20 % subjects visited emergency 1- 2 times whereas 9 % were hospitalized for 1- 5 days. One- third of the subjects (33%) were absent from school for 1-4 days and 20% were absent for 5-10 days due to illness in last two months.

Table 2 : Indices of asthma morbidity (in last two months)





Indices of asthma mordibity N
1. Numbers of attack
1-2 40
3-5 20
No attack 40
2. Emergency visits(in days)
1-2 20
No visit 80
3. Hospitalization(in days)
1-5 9
No Hospitalization 91
4. Absence from school (in days)
1-4 33
5-10 20
Not absent 47

inhalation devices should be used properly and regularly as prescribed. In the present study out of 100 subjects, 68% subjects were taking prescribed drugs regularly whereas 29% subjects were having poor compliance with inhaler therapy. As per the responses from the caregivers, the causes for poor compliance were the problems in the form of coughing, suffocation and irritation while using inhalers without spacer. The use of spacers helps overcome the problem of coordinating inspiration with actuation. Cramer et al11had reported that only 15% of patients were receiving inhaled treatment regularly. In India, a number of misconceptions and wrong practices regarding use of inhalers’ are prevalent. These affect the treatment seeking behavior and compliance. In the current study, around half of the subjects (51%) had certain myths regarding use of MDI like regular use of inhaler develops habit, it causes dryness of nose and throat, affects the growth of child, children become lethargy, affects the intelligence level, cleanliness of inhaler and spacer with hot water, affects the daily activities of child and the child could not live normal life. Three percent of the caregivers restricted their children to eat Rajmah, kheer, milk & milk products as all these edible items exacerbated asthma. Certain myths as per

Discussion:Management of asthma through inhalation route is the mainstay of treatment. The various advantages over the other route of drug therapy include rapid action of the drugs, less dose and no systemic side Bosley  et  el12     were  asthma  medicine   is addictive, long use of inhaler will lose effectiveness and won’t work when the child is really sick, the steroids used to treat asthma are the same as the steroids used by athletes to get bigger and stronger, child can stop taking medicine when he/ she feel good and don’t have any symptoms or problems breathing, If child has asthma, he or she should not be allowed to play like other kids and shouldn’t take gym class or play sports etc. It is important that one should take inhalation medications regularly but utmost important that the technique to take inhaler should be proper. If the patient do not take their inhaler properly, their disease could get worsen. However it has been observed that patients have lack of skill in using MDI. Inhalers if not taken regularly may result in misuse, overdose, or diminished response of the administered therapeutic drugs, or may even result in unnecessary and repeated hospitalization. Inappropriate inhalation technique is hazardous to the safety of children with asthma and unnecessarily increases costs resulting from unnecessary re-hospitalizations. The ISAYA13 study confirmed that the inappropriate use of drugs is mainly responsible for failure to control asthma. This study found that 47% of persistent asthmatics that participated in the survey in Italy were using combination therapy that was inadequate for the severity level (too low a dosage of corticosteroids and/or inappropriate treatment), and that 64% of asthmatics were on an irregular treatment that should have been taken daily. The study confirmed that for each degree of severity, regularity of treatment was associated with better control of symptoms. As per the indices of asthma morbidity, in the present study, 40% subjects were having 1- 2 attacks of asthma where as 20% were having 3- 5 attacks of asthma in the last two months, 20 % subjects visited emergency 1-2 times and 9 % were hospitalized for 1-5 days. One- third of the subjects (33%) were absent from school for 1-4 days and 20% were absent for 5-10 days due to illness in last two months. The study conducted by Ray14 revealed that the increase in morbidity of asthma is reflected in days lost from school, worsening quality of life, increased hospitalization rates, increased intensive care admission and increased emergency department visits. It has been suggested that the rise in cases of asthma indicates a tendency to over-diagnosed childhood asthma; how ever a study conducted by Clark et al15 suggested that there is under treatment of asthma. It is found that risk of misusing inhalers is particularly high in children and more debilitated patients and brief verbal instruction on correct technique, with a physical demonstration, is effective when repeated over time and can improve clinical outcomes.As there are a lot of misconception and misinformation in general public regarding use of inhaler and cause of bronchial asthma, they keep on avoiding dietary and other items which in fact have no role to play in either the causation or management of bronchial asthma. The most likely cause may be lack of training programmes regarding use of the inhalers, poor compliance and lack of knowledge. There is need for continue reinforcement and supplement asthma management programme at short interval. This will help the children and their caregivers in relieving and decreasing myths.


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