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On demonstrating her inhaler technique, she uses a quick and deep inhalation with her pressurised metered dose inhaler and does not use her spacer device. Asthma is one of the most common non-communicable diseases and carries a substantial morbidity and mortality burden worldwide.1 A cross-sectional study from 17 countries carried out by the Global Asthma Network in 2022 found that about 7% of adults were affected by asthma symptoms that were not well controlled, resulting in a high burden of preventable symptoms, restrictions on activity, and an increased risk of asthma attacks.2 Sub-optimally …" /> <meta name="DC.Contributor" content="Aarti Bansal" /> <meta name="DC.Contributor" content="Lauren Franklin" /> <meta name="DC.Contributor" content="Helen Twohig" /> <meta name="article:published_time" content="2024-09-20" /> <meta name="article:section" content="Practice" /> <meta name="citation_title" content="Optimising inhaled therapy for patients with asthma" /> <meta name="citation_journal_title" content="BMJ" /> <meta name="citation_publisher" content="British Medical Journal Publishing Group" /> <meta name="citation_publication_date" content="2024/09/20" /> <meta name="citation_mjid" content="bmj;386/sep20_3/e080353" /> <meta name="citation_id" content="386/sep20_3/e080353" /> <meta name="citation_public_url" content="https://www.bmj.com/content/386/bmj-2024-080353" /> <meta name="citation_abstract_html_url" content="https://www.bmj.com/content/386/bmj-2024-080353.abstract" /> <meta name="citation_full_html_url" content="https://www.bmj.com/content/386/bmj-2024-080353.full" /> <meta name="citation_pdf_url" content="https://www.bmj.com/content/bmj/386/bmj-2024-080353.full.pdf" /> <meta name="citation_issn" content="1756-1833" /> <meta name="citation_journal_abbrev" content="BMJ" /> <meta name="citation_doi" content="10.1136/bmj-2024-080353" /> <meta name="citation_pmid" content="39304315" /> <meta name="citation_volume" content="386" /> <meta name="citation_article_type" content="Other" /> <meta name="citation_section" content="Practice" /> <meta name="citation_author" content="Aarti Bansal" /> <meta name="citation_author_institution" content="Humber and North Yorkshire Integrated Care Board, Willerby HU10 6DT, UK" /> <meta name="citation_author" content="Lauren Franklin" /> <meta name="citation_author_institution" content="School of Medicine, Keele University, Keele ST5 5BG, UK" /> <meta name="citation_author" content="Helen Twohig" /> <meta name="citation_author_institution" content="School of Medicine, Keele University, Keele ST5 5BG, UK" /> <meta name="citation_reference" content="Global Asthma Network. 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Leese;citation_title=Healthcare costs associated with short-acting β2-agonists in asthma: observational UK SABINA study;citation_volume=7;citation_year=2023;citation_pmid=36759020;citation_doi=10.3399/BJGPO.2023.0015" /> <meta name="citation_reference" content="citation_title=Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report.;citation_year=2014" /> <meta name="citation_reference" content="Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2024. www.ginasthma.org." /> <meta name="citation_reference" content="citation_journal_title=Adv Ther;citation_author=CI. Bloom;citation_author=C. Cabrera;citation_author=S. Arnetorp;citation_title=Asthma-related health outcomes associated with short-acting β2-agonist inhaler use: an observational UK study as part of the SABINA Global Program;citation_pages=4190-208;citation_volume=37;citation_year=2020;citation_pmid=http://www.n;citation_doi=10.1007/s12325-020-01444-5" /> <meta name="citation_reference" content="citation_journal_title=Adv Ther;citation_author=C. Janson;citation_author=A. Menzies-Gow;citation_author=C. Nan;citation_title=SABINA: an overview of short-acting β2-agonist use in asthma in European countries;citation_pages=1124-35;citation_volume=37;citation_year=2020;citation_pmid=http://www.n;citation_doi=10.1007/s12325-020-01233-0" /> <meta name="citation_reference" content="citation_author=. Asthma Control Test" /> <meta name="citation_reference" content="citation_journal_title=Chest;citation_journal_abbrev=Chest;citation_author=R. Horne;citation_title=Compliance, Adherence, and Concordance: Implications for Asthma Treatment;citation_pages=65S-72S;citation_volume=130;citation_year=2006;citation_issue=1_suppl;citation_pmid=16840369;citation_doi=10.1378/chest.130.1_suppl.65S" /> <meta name="citation_reference" content="British Thoracic Society. SIGN158 British guideline on the management of asthma, a national clinical guideline. British Thoracic Society. 2019. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/." /> <meta name="citation_reference" content="citation_journal_title=Patient Prefer Adherence;citation_author=S. Amin;citation_author=M. Soliman;citation_author=A. McIvor;citation_author=A. Cave;citation_author=C. Cabrera;citation_title=Understanding patient perspectives on medication adherence in asthma: a targeted review of qualitative studies;citation_pages=541-51;citation_volume=14;citation_year=2020;citation_pmid=http://www.n;citation_doi=10.2147/PPA.S234651" /> <meta name="citation_reference" content="citation_journal_title=Eur Respir J;citation_author=M. Engelkes;citation_author=HM. Janssens;citation_author=JC. de Jongste;citation_author=MC. Sturkenboom;citation_author=KM. Verhamme;citation_title=Medication adherence and the risk of severe asthma exacerbations: a systematic review;citation_volume=45;citation_year=2015;citation_pmid=25323234;citation_doi=10.1183/09031936.00075614" /> <meta name="citation_reference" content="citation_journal_title=Clin Immunol;citation_author=W. Shang;citation_author=G. Wang;citation_author=Y. Wang;citation_author=D. 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Nguyen;citation_title=Association of Inhaled Corticosteroids and Long-Acting β-Agonists as Controller and Quick Relief Therapy With Exacerbations and Symptom Control in Persistent Asthma: A Systematic Review and Meta-analysis;citation_pages=1485-96;citation_volume=319;citation_year=2018;citation_pmid=http://www.n;citation_doi=10.1001/jama.2018.2769" /> <meta name="citation_reference" content="citation_journal_title=ERJ Open Res;citation_author=L. Hatter;citation_author=P. Bruce;citation_author=I. Braithwaite;citation_title=ICS-formoterol reliever versus ICS and short-acting β2-agonist reliever in asthma: a systematic review and meta-analysis;citation_pages=00701-02020;citation_volume=7;citation_year=2021;citation_pmid=33532465;citation_doi=10.1183/23120541.00701-2020" /> <meta name="citation_reference" content="citation_journal_title=J Prim Health Care;citation_author=L. Bryant;citation_author=C. Bang;citation_author=C. Chew;citation_author=SH. Baik;citation_author=D. Wiseman;citation_title=Adequacy of inhaler technique used by people with asthma or chronic obstructive pulmonary disease;citation_pages=191-8;citation_volume=5;citation_year=2013;citation_pmid=23998169;citation_doi=10.1071/HC13191" /> <meta name="citation_reference" content="citation_journal_title=Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology;citation_journal_abbrev=Ann Allergy Asthma Immunol;citation_author=N. Sander;citation_author=SJ. Fusco-Walkert;citation_author=JM. Harder;citation_author=BE. Chipps;citation_title=Dose counting and the use of pressurized metered-dose inhalers: running on empty.;citation_pages=34-38;citation_volume=97;citation_year=2006;citation_issue=1;citation_pmid=16892778;citation_doi=10.1016/S1081-1206(10)61366-X" /> <meta name="citation_reference" content="citation_journal_title=European Respiratory Journal;citation_journal_abbrev=Eur Respir J;citation_author=A. 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She says her asthma is well controlled, but she has been issued two inhaled corticosteroid (ICS) preventer inhalers and six short acting beta agonist (SABA) reliever inhalers in the past year. On further questioning, she says that she limits her exercise because this brings on her asthma symptoms, and she experiences occasional night-time waking with cough. She describes irregular use of her ICS preventer inhaler, especially during the summer months, and almost daily use of her SABA reliever inhaler. On demonstrating her inhaler technique, she uses a quick and deep inhalation with her pressurised metered dose inhaler and does not use her spacer device. Asthma is one of the most common non-communicable diseases and carries a substantial morbidity and mortality burden worldwide.1 A cross-sectional study from 17 countries carried out by the Global Asthma Network in 2022 found that about 7% of adults were affected by asthma symptoms that were not well controlled, resulting in a high burden of preventable symptoms, restrictions on activity, and an increased risk of asthma attacks.2 Sub-optimally …" /> <meta name="og-title" property="og:title" content="Optimising inhaled therapy for patients with asthma" /> <meta name="og-url" property="og:url" content="https://www.bmj.com/content/386/bmj-2024-080353" /> <meta name="og-site-name" property="og:site_name" content="The BMJ" /> <meta name="og-description" property="og:description" content="### What you need to know A 30 year old woman attends her general practice for her annual asthma review. She says her asthma is well controlled, but she has been issued two inhaled corticosteroid (ICS) preventer inhalers and six short acting beta agonist (SABA) reliever inhalers in the past year. On further questioning, she says that she limits her exercise because this brings on her asthma symptoms, and she experiences occasional night-time waking with cough. She describes irregular use of her ICS preventer inhaler, especially during the summer months, and almost daily use of her SABA reliever inhaler. On demonstrating her inhaler technique, she uses a quick and deep inhalation with her pressurised metered dose inhaler and does not use her spacer device. Asthma is one of the most common non-communicable diseases and carries a substantial morbidity and mortality burden worldwide.1 A cross-sectional study from 17 countries carried out by the Global Asthma Network in 2022 found that about 7% of adults were affected by asthma symptoms that were not well controlled, resulting in a high burden of preventable symptoms, restrictions on activity, and an increased risk of asthma attacks.2 Sub-optimally …" /> <meta name="og-type" property="og:type" content="article" /> <meta name="og:image" property="og:image" content="https://www.bmj.com/sites/default/files/highwire/bmj/388/8457.cover-source.jpg"/> <meta name="twitter:card" content="summary_large_image"><meta name="twitter:image" property="twitter:image" content="https://www.bmj.com/sites/default/files/sites/defautl/files/attachments/bmj-article/2024/09/asthma_inhaler_2.jpg"><meta name="twitter:title" content="Optimising inhaled therapy for patients with asthma" /><meta name="generator" content="Drupal 7 (http://drupal.org)" /> <link rel="canonical" href="https://www.bmj.com/content/386/bmj-2024-080353" /> <link rel="shortlink" href="https://www.bmj.com/node/1101129" /> <meta name="twitter:card" content="summary" /> <meta name="twitter:url" content="https://www.bmj.com/content/386/bmj-2024-080353" /> <meta name="twitter:title" content="Optimising inhaled therapy for patients with asthma" /> <title>Optimising inhaled therapy for patients with asthma | The BMJ</title>   <link type="text/css" rel="stylesheet" href="https://www.bmj.com/sites/default/files/advagg_css/css__h_i3RBVEfBUfld4W97DMhFjEFQ891KrwB-1j-MMZobo__cO76IPg_gacgOBnuSoED_1LgmEn81XWVnZjiqE_vslc__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.css" media="all" /> <link type="text/css" rel="stylesheet" href="https://www.bmj.com/sites/default/files/advagg_css/css__hcEfBsSfdZ2na-rT9Jhk7K2mHyy5KBdPKm6ia_F7MYU__4716zpuGoj4DfVIEENbeOWgAOX_pf_t16EI4fvJGo7A__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.css" media="print" /> <link type="text/css" rel="stylesheet" href="https://www.bmj.com/sites/default/files/advagg_css/css__b-tWEqg3_twqP_ufdNXyA5V14StJgBdiIxG1UIi0LYc__3z5eyFP7TvyPE6DkwNj3xM94b3mZNfr4lSWEChDxsvU__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.css" media="screen" /> <link type="text/css" rel="stylesheet" href="https://www.bmj.com/sites/default/files/advagg_css/css__-BkZ71IF4pBXmZfP4vYyswWdIhuaKktrUUQ4i2vtUVo__0i_0YcYkMECNn0z7FdhNoJ8gLWleqnTtjnHRAmLijvc__a7Jq5VSqcMKMeR_gboGw1x4AC4g6SRpO1Geb_4xJjYc.css" media="all" /> <link href="/sites/default/themes/bmj/the_bmj/css/fonts.css" rel="stylesheet" media="all" type="text/css"> <style media="screen" type="text/css"> .page-news #latest-blogs h2.pane-title, .bootstrap-threecol-4-4-4 #latest-blogs h2.pane-title { width: 153px !important; 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