Humza Khizer

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Is Incorrect Inhaler Use Worsening Your Asthma?

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Iqra Mazhar

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Is Your Asthma Due To Your Mother’s Gestational Weight Gain?

Introduction

Gestational weight gain and high BMI (body mass index) affects a majority of pregnant women. There are various factors such as social factors, environmental factors, maternal factors, and energy balance that could contribute to weight gain <a href="https://merisehat.pk/disease/lets-talk-about-sex-during-pregnancy">during pregnancy</a>.&nbsp; 
&nbsp;

Although gestational weight gain (GWG) is a natural response to accommodate a growing fetus, GWG that is either too high or too low contributes to long-term or short-term health complications. This specifically applies for women whose BMI is greater than 25 at the time of their pregnancy. 
&nbsp;

The number of women who experience excessive gestational weight gain while they are pregnant is increasing, irrespective of their socio-economic status. Institute of Medicine, USA, has worked on identifying optimal gestational weight, so healthcare providers can advise pregnant women accordingly<a href="#accordion">[1]</a>.

&nbsp;

Understanding The Impact Of Pregnancy Weight Gain On Childhood Asthma

Extreme gestational weight gain has a significant impact on pregnant women and their health. It increases risk of birth complications, and leads to long-term maternal obesity. 
&nbsp;

Additionally, excessive gestational weight gain is harmful for the child, especially because of increased risk of childhood obesity<a href="#accordion">[2]</a>. There is also enough evidence to link maternal obesity with childhood obstructive lung diseases, e.g., asthma<a href="#accordion">[3]</a>. 
&nbsp;

<h5>GWG And Asthma&nbsp;</h5>

Obesity during pregnancy is directly related to adverse outcomes in children, e.g., higher probability of developing asthma&nbsp; 
&nbsp;

The mechanism to identify this connection is fetal programming. It describes the in-utero exposure that influences gene expression and chronic diseases during childhood. The disease originates from metabolic and psychological adaptations, which are made by the fetus in response to in-utero exposures during critically sensitive developmental phases. Moreover, environmental and genetic factors also play a role in the immune modulatory effects. 
&nbsp;

<h5>The Effects Of BMI</h5>

It&rsquo;s difficult to gauge the effects of the mother&rsquo;s and the child&rsquo;s BMI on childhood asthma. Researchers have investigated the mediating effects of BMI by adding childhood body mass index to their variable models with two or more quantities, and further describing what would reduce the risk. 
&nbsp;

Some studies concluded that birth weight of babies and BMI at the age of eight partially affected childhood asthma due to gestational weight gain. However, other studies found minimal effects on childhood BMI<a href="#accordion">[4]</a>. 
&nbsp;

Another research studied the relationship between maternal pre-pregnancy BMI, gestational diabetes, weight gain, and the risk of wheezing in preschool offspring. The focus was on the growth, infection, and atopic mechanism. 
&nbsp;

The age group of the children in the study was 1-4 years and it was observed that mothers who had a history of asthma, atopy, and pre-pregnancy obesity, had kids at risk of pre-school wheezing.&nbsp; 
&nbsp;

Moreover, whenever the standard gestational weight gain deviated, it increased the risk of preschool wheezing. The results were independent of pre-pregnancy BMI and no difference was seen in mothers with history of atopy or asthma<a href="#accordion">[5]</a>. Additionally, child growth or eczema did not change the results either. 
&nbsp;

An overall higher risk of pre-school wheezing was seen in offspring of mothers with obesity before pregnancy, history of atopy, asthma, and gestational weight gain. Neither of these could be explained by infectious or atopic mechanisms. However, further research might be able to identify what the underlying mechanisms are.

&nbsp;

Childhood asthma is one of the most common chronic respiratory diseases. Considering that the death rate of children by asthma is 0-0.7 per 100,000 around the world, it is a cause for global concern. Moreover, the annual prevalence of asthma in children is 9.5%, which is higher compared to the 7.7% seen in adults<a href="#accordion">[6]</a>. Therefore, new tools have been developed to target preventive strategies, and improve health. 
&nbsp;

Studies suggest that asthma in children is associated with maternal weight gain before and during pregnancy. Moreover, pre-pregnancy weight gain is a global issue; it jumped from 13% to 22% within a decade (1993-2003). Overall, it indicates an increase of 69%.&nbsp; 
&nbsp;

Unfortunately, numerous studies have examined the link between GWG and pre-pregnancy obesity with childhood asthma, and the results remain inconclusive.&nbsp;

&nbsp;

A healthy and balanced diet can help the baby get the required nutrients for a healthy growth. However, the question that is commonly asked is how much extra calories are even normal? Extra calories are helpful and required in some cases, but eating for two is not recommended.&nbsp; 
&nbsp;

However it is important to note that the below caloric add-ons are applicable if a woman&rsquo;s weight is within a normal range and is moderately active. In this case, the recommended daily intake before pregnancy would be about 2,000 calories a day.&nbsp;&nbsp; 
&nbsp;

The caloric intake in pregnant women depends on the time of the pregnancy. For example, slight increase is good enough for the first trimester, which then needs to increase to an additional 300 to 350 calories per day during the second trimester. In the third trimester, an additional 450 to 500 calories per day are needed. If you&#39;re carrying multiple pregnancies, you could need an additional 300 calories per day for each baby. 
&nbsp;&nbsp;

Pregnant women need to consult their healthcare providers to know how much weight they can gain. Women who have the ideal weight according to their BMI should be able to gain 25-35 pounds during pregnancy, whereas underweight women have a margin for 28-40 pounds. Overweight women can gain only 15-25 pounds when pregnant<a href="#accordion">[7]</a>. 
&nbsp;

So, the general rule is that women can gain 2-4 pounds in their first trimester and 1 pound per week for the remaining pregnancy. Besides, women who are expecting twins can gain 35-45 pounds, which makes it an average of 1.5 pounds per week after the usual first trimester weight gain. It is very important for women with twin pregnancy to gain the right weight.&nbsp;

&nbsp;

Conclusion

It is advised that prenatal healthcare providers evaluate maternal weight at every visit. They should also monitor weight goals and provide counselling accordingly. More than 50% of women tend to exceed their weight gain goals and become overweight, which is a serious health hazard. It leads to low birth weight, failure to produce breast milk, cesarean deliveries, and postpartum weight retention. Furthermore, the offspring can also be overweight and suffer from macrosomia. 
&nbsp;

Although gestational weight gain is potentially threatening to women and the offspring, it is a modifiable risk factor. Diet and exercise during pregnancy helps in reducing the extra weight. However, these interventions have not improved neonatal outcomes significantly, and the effects on obese women are also limited. Thus, indicating that its best to achieve a healthy BMI prior to conception.

&nbsp;

[1] Rogozińska, E., Zamora, J., Marlin, N., Betrán, A.P., Astrup, A., Bogaerts, A., Cecatti, J.G., Dodd, J.M., Facchinetti, F., Geiker, N.R. and Haakstad, L.A., 2019. Gestational weight gain outside the Institute of Medicine recommendations and adverse pregnancy outcomes: analysis using individual participant data from randomised trials. BMC pregnancy and childbirth, 19(1), pp.1-12.

[2] Kominiarek, M.A. and Peaceman, A.M., 2017. Gestational weight gain. American journal of obstetrics and gynecology, 217(6), pp.642-651.

[3] Rusconi, F. and Popovic, M., 2017. Maternal obesity and childhood wheezing and asthma. Paediatric respiratory reviews, 22, pp.66-71.

[4] Harskamp-van Ginkel, M.W., London, S.J., Magnus, M.C., Gademan, M.G. and Vrijkotte, T.G., 2015. A study on mediation by offspring BMI in the association between maternal obesity and child respiratory outcomes in the amsterdam born and their development study cohort. PLoS One, 10(10), p.e0140641.

[5] Leermakers, E.T., Sonnenschein-van der Voort, A.M., Gaillard, R., Hofman, A., de Jongste, J.C., Jaddoe, V.W. and Duijts, L., 2013. Maternal weight, gestational weight gain and preschool wheezing: the Generation R Study. European Respiratory Journal, 42(5), pp.1234-1243.

[6] Liu, S., Zhou, B., Wang, Y., Wang, K., Zhang, Z. and Niu, W., 2020. Pre-pregnancy maternal weight and gestational weight gain increase the risk for childhood asthma and wheeze: an updated meta-analysis. Frontiers in pediatrics, 8, p.134.

[7] National Research Council, 2010. Weight gain during pregnancy: reexamining the guidelines.

Staff Writer

As an asthmatic, have you noticed a lack of improvement in your symptoms? Despite sticking to the doctor&#39;s advice and taking medications, do you still see your <a href="https://merisehat.pk/disease/asthma" target="_blank">asthma</a> symptoms increase in frequency? While most would blame the rise in pollution and climate change for their worsening symptoms, the blame may actually lie with your inhaler use. As per estimates, approximately 92% of asthmatics use their inhalers incorrectly<a href="#accordion">[1]</a>. Thus, affecting their quality of life.

Inhalers are usually the preferred mode of treatment for chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD) and asthma. In 2017, an estimated 545 million people worldwide suffered from a chronic respiratory disease, with COPD and asthma being the most prevalent of all<a href="#accordion">[2]</a>.

Asthma, the chronic airway inflammatory disease, affects approximately 300 million people across the world. In Pakistan, the prevalence varies between 4.3-31.6%<a href="#accordion">[3]</a>. The most common symptoms of asthma include coughing, wheezing, and shortness of breath. Poor asthma control generally leads to increased asthma attacks among people, and an increased risk of mortality. An improper inhaler technique is one of the major factors in poor asthma control. This mostly results from a lack of education among patients about their disease.

In a study conducted in Karachi, Pakistan researchers found that approximately 80% of participants using metered-dose inhalers and 61% of dry-powder inhaler users had an incorrect technique<a href="#accordion">[4]</a>. Thus, emphasizing the need for better patient education regarding the use of various inhalers.&nbsp;

&nbsp;

Understanding Advantages Of Correct Inhaler Use

In asthma, inhalers are usually used to deliver medications to the airways. This allows localized delivery of a high drug concentration without any systemic side effects. There are various types of handheld inhalers that can deliver asthma medicines. These are the two most commonly used devices for administering aerosolized asthma medications:

&nbsp;

<h5>1. Metered Dose Inhaler (MDI)</h5>

This device contains a canister for the medicine and propellant to aerosolize the medicine. Pressing the canister down releases the medicine into the mouthpiece and through your breath into the airways. It is also called a press-and-breathe inhaler. They are generally used with a spacer that attaches to the MDI and aerosolizes the medicine into smaller, easier-to-inhale particles.

&nbsp;

<h5 dir="ltr">2. Dry Powder Inhaler (DPI)</h5>

As the name suggests, the device contains medicine in the form of a dry powder. Unlike an MDI, they do not have a propellant and do not spray the medicine out. Instead, the medicine is released from the inhaler with the help of an inhale.&nbsp;

&nbsp;

Incorrect use of an inhaler means that the medicine is unable to reach your lungs fully; thus, making it harder to control your asthma. People aged 50 years and above are most likely to use an inhaler incorrectly. This is likely due to the high prevalence of health conditions such as arthritis, weakness, and poor vision that affect their inhalation technique.&nbsp;

&nbsp;

The most common errors in using an inhaler are:

<ul>
	<li>Forgetting to remove the inhaler&#39;s cap</li>
	<li>Incorrect position of the device</li>
	<li>Not positioning yourself and/or the inhaler upright</li>
	<li>Failure to shake the MDI before use or between each puff</li>
	<li>Not using a spacer with the inhaler</li>
	<li>Failure to exhale prior to placing the inhaler in the mouth</li>
	<li>Failure to hold breath after inhalation</li>
	<li>Failure to prime the inhaler</li>
	<li>Failure to insert the canister properly into the device</li>
	<li>Not giving enough pause between puffs</li>
</ul>

All these errors can reduce drug delivery into the lungs and reduce the drug&#39;s effectiveness. Moreover, during an asthma attack, an incorrect inhaler technique will fail to relieve symptoms.&nbsp;

&nbsp;

To prime the inhaler:

<ol>
	<li>Remove the cap off the MDI and give it about 10 hard shakes, for approximately 5 seconds.</li>
	<li>Spray away from your face into the air.</li>
	<li>Depending on the directions on the medicine, repeat the above step as many times as needed.</li>
</ol>

Note: Not only should MDIs be primed before first use but also if being used after a break of two weeks or more.

&nbsp;

Following are the steps to use a metered dose inhaler:

<ol>
	<li>To correctly hold the inhaler, place the thumb under the nozzle and the index finger at the base.</li>
	<li>Remove the cap and shake the inhaler.</li>
	<li>Take a slow exhale to empty out your lungs.</li>
	<li>Without breathing in, place the mouthpiece firmly in your mouth, making sure there is no space between it and your lips.</li>
	<li>While pressing the canister down, take a deep inhale.</li>
	<li>Keep&nbsp;the inhaler in place and hold your breath for 10 seconds.&nbsp;</li>
	<li>Remove the inhaler and slowly exhale.</li>
	<li>Repeat the above steps for each puff.&nbsp;</li>
</ol>

<div>
The last step of using the inhaler involves gargling the mouth to remove any residual medication from the mouth.&nbsp;

&nbsp;
</div>

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A spacer is generally used with an MDI and helps deposit more drug into the lungs. The following steps ensure correct use of a spacer: <ol><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Identify the inhaler's mouthpiece.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Shake the inhaler.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Remove the cap and place it in the spacer inhaler slot.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Slowly exhale and place the mouthpiece in the mouth, pressing firmly with the lips.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Press the inhaler, take a deep breath, and hold it for a few seconds.&nbsp;</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Repeat the above steps depending on the number of puffs you need.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">After you're done, remove the spacer from your mouth and wash it with warm water.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Gargle the mouth with warm water.</li></ol>

This is a breath activated inhaler that delivers the medicine to the lungs on a deep inhale. Here are the steps to use a dry powder inhaler:

<ol><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Remove the cap and load the capsule into the device.&nbsp;</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Slowly exhale to empty the lungs, but not into the device.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Place the mouthpiece of the inhaler between the front teeth and wrap the lips around it, forming a seal.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Take a deep and quick inhale through the mouth for over 2 to 3 seconds.</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Remove the inhaler from your mouth and hold your breath for 10 seconds.&nbsp;</li><li style="line-height: 1.2; margin-top: 0pt; margin-bottom: 0pt;">Slowly exhale.&nbsp;</li></ol>

Proper storage technique ensures that the medicine inside the inhaler does not degrade quickly and stays effective.&nbsp;

&nbsp;

<ul dir="ltr">
	<li>Protect The Canister - Since the canister is under pressure, care should be taken so that it does not puncture or burst. If you&#39;re placing the inhaler in your bag, make sure it is protected with the help of a smaller bag and not free to bump into various objects present in the bag.</li>
</ul>

&nbsp;

<ul>
	<li>Store In&nbsp;A&nbsp;Secure, Cool, Dry Place - Extreme temperatures can degrade the medicine; therefore, it is advised to keep the inhaler in a cool and dry place with a temperature of 15-30 degrees Celsius. Moreover, after use, the cap should be placed back to protect the canister from damage.</li>
</ul>

&nbsp;

The increasing urbanization means that the prevalence of asthma in Pakistan will continue to rise among both adults and children. Therefore, there is a need for developing effective public health policies that can control and prevent asthma among the population.&nbsp;

Despite the high prevalence of asthma and the wide use of inhalers among people, there is a lack of awareness among patients regarding the disease and its treatment. Although patients are taught the proper inhaler use at the start of the treatment, doctors note the persistence of incorrect inhalation techniques. This leads to poor treatment compliance and poor asthma control, especially in case of a severe asthma attack. Thus, increasing mortality and morbidity associated with asthma.&nbsp;

An important step in addressing improper inhaler technique is improving patients&#39; knowledge about the disease and the various treatment options available to them. Along with leaflets, patients should be shown video tutorials to demonstrate the correct usage of various inhalers. It is important to note that a huge majority of people in Pakistan belong to low socioeconomic conditions and have a low literacy rate. Therefore, in such cases, it is important to ensure understanding of instructions by repeated follow-up checks on their inhaler technique. Moreover, follow-up checks can also help determine whether the patient is finding the prescribed device easy to use and staying compliant with medications.

&nbsp;

Key Points

<ul>
</ul>

<ul>
	<li>Asthma is a chronic inflammatory condition of the airways characterized most commonly by coughing, wheezing, and shortness of breath. Inhalers are the preferred mode of treatment for asthma medications.</li>
	<li>Approximately 92% of asthmatics use their inhaler incorrectly, leading to poor asthma control and increased mortality and morbidity.</li>
	<li>While there are various inhalation devices available for asthma, metered dose inhalers and dry powder inhalers are the two most commonly prescribed devices in Pakistan.</li>
	<li>The most common errors associated with inhaler use include incorrect positioning of the device, forgetting to shake MDI before use, failure to empty lungs prior to placing inhaler in mouth, failure to hold breath afterward, and forgetting to remove the inhaler&#39;s cap.</li>
	<li>Improper inhaler techniques decrease the amount of drug delivered to the lungs; thus, reducing the drug&#39;s effectiveness in controlling symptoms of an asthma attack.</li>
	<li>Increasing patient knowledge is key to reducing the incidence of incorrect inhaler techniques among the masses.&nbsp;</li>
</ul>

&nbsp;

[1] Soriano, J. B. et al., 2020. Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Respiratory Medicine, 8(6), pp. 585-596

[2] Bonds, R. S., Asawa, A. & Ghazi, A. I., 2015. Misuse of medical devices: a persistent problem in self-management of asthma and allergic disease. Annals of Allergy, Asthma & Immunology, 114(1), pp. 74-76.

[3] Masoli, M., Fabian, D., Holt, S. & Beasley, R., 2004. The global burden of asthma: executive summary of the GINA Dissemination Committee report. Allergy, May.pp. 469-78.

[4] Razzaq, S. et al., 2018. Epidemiology of asthma and associated factors in an urban Pakistani population: adult asthma study-Karachi. BMC Pulmonary Medicine, p. 184.

[5] Farooq, M. Z. et al., 2016. Assessment of inhalation technique among patients of chronic respiratory disorders in Civil Hospital Karachi: A cross sectional study. Journal of the Pakistan Medical Association, 66(11).