Inhaler technique blind spot

To the Editors:

The paper by Laforest et al. 1 in a recent issue of the European Respiratory Journal is an important reminder of the poor overall management of patients with asthma. A large number of French patients were studied, but one can assume that similar results would have been found in any country in Europe. The message that this paper clearly sends to all concerned with the management of asthma is that patients under the supervision of specialists do better than those under the care of general practitioners. The main conclusion reached by Laforest et al. 1 appears to be that there is a need to improve the management of asthma in primary care. However, only 52% of the patients looked after by specialists were properly controlled in the previous 4-week period compared with 26.4% in the general practitioner group. Surely it would be complacent to accept that there is not considerable room for improvement in the management of asthma generally, and not just in those supervised in general practice?

In such a comprehensive review of asthma management, why was there no mention whatsoever of inhaler technique? This is not the first important contribution to the literature on management of asthma in Europe that has completely ignored inhaler misuse as a potential major cause of lack of disease control 2.

Many healthcare professionals involved in the management of patients with asthma and chronic obstructive pulmonary disease appear to have a blind spot as far as inhaler use is concerned, which I find very difficult to understand. There is now evidence that poor inhaler technique is associated with poor asthma control 3–5. Problems with inefficient use of the pressurised metered-dose inhaler were reported as long ago as 1976 6, 7. More recently, Cochrane et al. 8 summarised all papers describing inhaler technique and concluded that the frequency of efficient inhalation technique ranged 46–59%. It would, therefore, seem appropriate for all assessments of asthma management and control to at least include a mention of inhalation technique in the patients studied. Sadly, this is not the case and I cannot understand the reasons behind this important omission. An assessment of inhalation technique in Europe will soon be published 9, and I can only hope that this will result in clinicians and all healthcare workers concerned with the management of asthma becoming more aware of this major problem, which, in my view, may be the most important cause of poor asthma symptom control in Europe today.