Effective Patient Education for Asthma: Inhaler Instruction & Action Plan Use (Recording)

This webinar was recorded on August 14, 2025

Enhance your patient education skills to reduce errors and improve outcomes. Studies show that up to 70% of asthma-related hospitalizations are linked to improper inhaler use—an issue that can be addressed through effective, hands-on patient education.

Join allergist and asthma expert Dr. Hogan for a focused training designed for healthcare professionals involved in asthma care. This webinar will provide evidence-based strategies for improving patient technique, adherence, and self-management.

In this session, you’ll learn how to:

• Identify and correct common inhaler technique errors
• Provide clear, consistent patient instruction that improves adherence
• Personalize and implement asthma action plans for better symptom control
• Support patients in managing their asthma confidently and effectively

Speaker:

Angela Duff Hogan, MD, FAAAAI, FACAAI, FAAP

Dr. Angela DuffHogan is the chair of the American College of Allergy, Asthma, and Immunology Asthma Committee and has developed initiatives such as the VA Asthma Action Plan for children. She is a frequent regional and national educator covering topics such as asthma management guidelines and SMART therapy. Dr. Hogan is a key healthcare provider and director for the FARE Neighborhood Initiative, providing educational resources and interventions to reduce healthcare disparities, especially in historically marginalized communities. This initiative was recently awarded to the Macon & Joan Brock Virginia Health Sciences at Old Dominion University and CHKD. Dr. Hogan is a founding member of the Coastal Food Allergy Support Group, which helps healthcare providers, schools, and families manage their food allergies. Dr. Hogan’s significant contributions to allergy and immunology were recently honored with the prestigious American Academy of Pediatrics 2023 Jerome Glaser Distinguished Service Award. Her commitment to community service and education reflects her values. She believes in healthcare equity, and her lifelong experiences with asthma and food allergies fuel her dedication to making a difference.

This Advances webinar is in partnership with the American College of Allergy, Asthma & Immunology. ACAAI offers CMEs for physicians for this webinar. If you are a member of ACAAI, you can obtain CME through the member portal for the Advances webinars.

All attendees will receive a certificate of attendance. No additional continuing education credits are available.

CME is available through ACAAI for this webinar.

Sponsored by the American College of Allergy, Asthma and Immunology

Transcript: While this transcript is believed to be accurate, errors sometimes occur. It remains your responsibility to evaluate the accuracy and completeness of the information in this transcript. This transcript is not intended to substitute for professional medical advice.

Bethany: OK, I will go ahead and get us started. Hello, everyone. Thank you for joining us today. I’m excited to welcome you to this afternoon’s webinar. Our presenter is Dr. Hogan. With her extensive knowledge, we can look over to an enlightening session. Before we begin, I would like to cover a few housekeeping details. Attendees will remain muted during the webinar to minimize distractions. We will record the session and upload it to our website later this week. You can access all of our recordings and webinars at allergyandasthmanetwork.org. Our webinar is scheduled to last one hour and will include a dedicated Q&A segment. Although we will answer questions at the end, feel free to submit them at any time using the Q&A box at the bottom of your screen. A team member will monitor the chat for questions or assistance you might need. We will do our best to address as many questions as possible before we conclude. This webinar is brought to you in collaboration with the American College of allergy and asthma immunology. You can create a free ACAAI account to earn attendance credits for webinars via the portal. I will put that in the chat. Attendees will receive a certificate of attendance. Please note that no additional continuing education credits will be provided. A few days after the webinar, you will receive an email containing supplemental information and a link to download your certificate. OK, let us get started. Today’s presentation is titled “Effective Patient Education for Asthma: Inhaler Instruction and Action Plan Use .” In this webinar, Dr. Hogan will discuss the importance of patient education in asthma management and control. She will offer practical insights and describe correct technique for common inhaler types and identify frequent patient errors. It is my letter to introduce Dr. Angela Duff Hogan. She has developed initiatives such as the EA asthma action plan for children. She is a frequent national educator covering topics such as asthma management guidelines and smart therapy. She is a key health care provider and director for their neighborhoods initiative, providing educational resources and interventions to reduce health care disparities, especially in historically marginalized communities. This initiative was recently awarded the McCone and Joan Brock Virginia health sciences award. Dr. Hogan is a founding member of the coastal food allergy support group which helps health care providers, schools, and families manage their food allergies. Dr. Hogan’s significant contribution to allergy and immunology was recently honored with the American Academy for pediatrics Jerome Glasser distinguished service award. Her commitment to community service and education reflects her values, and she believes in health care equity and her lifelong experience with asthma and food allergies fueled her dedication to making a difference. I will hand it over to you, Dr. Hogan. Thank you for being with us.

Dr. Hogan: Thank you very much. Thank you all for taking time out of your busy afternoon to join us. Let’s get started. The first thing we talked about is the importance of the mission of the allergy and asthma network. They did that long introduction so that you already know about you. What we do want to talk about is what our learning objectives are here. We focus on one-time medications sometimes and forget the other part of good asthma management, which involves good inhaler techniques and also involves making sure that the patients can teach themselves how to do it, show it to you back, and also, we want to make sure they have a good asthma plan, so those are what we will focus on today. It is important because if you read the recent headlines — I usually put it into perspective. This was a recent headline published this summer. The actual story was that the father was sentenced to four years for manslaughter in the death of his nine-year-old child . The little girl had gone over to a sleepover and had an asthma attack the next morning, and the parents of the girl’s friend offered to take her to the doctor, but the parents said, it’s OK, we will take her home and make sure she is OK. Later that morning, the machine was found to be having significant — later that morning, though, she was found to be having significant distress. She was taken to the emergency room and was in the ICU for seven days but did not recover. The biggest problem here was that her inhaler was empty, did not have any asthma medication whatsoever and had been empty for a month and the parents did not realize that we need to have medication with us always. There was also another recent story you probably saw the news in June. In this particular story, there was a 22-year-old named Cole. His asthma inhaler went from $70 to $500. Because of that significant increase in the cost of his inhaler, he did not purchase it, and then five days later, he had a severe asthma attack, and although he passed on, there were some mistakes made in that the parents were not notified there was going to be a formulary change and the pharmacy in their rush did not provide more options for this patient. I see lots of questions. I just want to check real — can you all hear me all right? Are there any problems?

Bethany: Yes, we can hear you just fine.

Dr. Hogan: Just wanted to make sure there are no technical issues. There are lots of stories in the news where not only do patients have difficulty getting medications, but I’m sure you have lots of patients where there’s formulary changes, and they may not get the appropriate medication, and the bigger problem with that is they may be given a different medication that they don’t have any idea how to use whatsoever. We know that asthma is a very prominent illness, the most common chronic disease of childhood. Pediatric prevalence is about 6% to 9% and adult prevalence is about 8.9%. The problem is that many patients with asthma are not well-controlled. About 50% of kids have uncontrolled asthma, and we know that uncontrolled asthma has a lot higher health care related costs in addition to increased morbidity and totality. Researchers estimate that in the next couple of decades, the cost of uncontrolled asthma alone will be about $964 billion, about $53 billion annually, and there is about 1,000,700 emergency room visits in 2020 34 asthma alone, so it really impacts the health care system. Anything we can do to help patients get better control and better understanding of their asthma is critical. I don’t need to remind you that on average, about 11 people died per day from asthma. What is really important is that we have good principles for asthma management, and those have been put forth in our national guidelines and the global initiative for asthma. They publish an update every single year. This most recent version came out on world asthma day in May. The things that really emphasizes in this particular update and that is important for the health care provider to communicate with patients effectively, make sure you listen to them and understand what their needs are, and we also need to make sure we are optimizing symptom control, minimizing whatever therapies we use for the long-term risk of exacerbations, the side effects of the medications we want to have reduced or minimized also, and ultimately, our goals are to reduce asthma mortality. In order to provide those things, we need for them to have an asthma action plan, and they need to know physically how to use their medications to get optimal asthma control. How do we know what is the best medication? Is what it takes what we do from our vision of asthma medications — we can talk about asthma medications at a population level. Those are where national formularies and national guidelines come in. We also know that asthma phenotypes are well described, and that helps us select what might be the big starting point for asthma medication, and it is important that we think about each step of the way, what is the most efficacious, what is the best effectiveness, what is the safety, and what is the patient’s access to those medications, but as you know, the best way is to bring it down to an individual level to discuss medications in the way we want to treat the asthma with the patient, and we do that through a shared decision-making process. We want to know, what are their preconceived notions about the medicines they have been described? Often times in pediatrics, there is still a significant fear.

Patients are worried about the word steroid. They are worried it will make their child Harry or fat or moody or short. It is important we hear what their concerns are and address those concerns. As we share in those first few stories, having medication availability is very, very important, and the medicines we give them have to be affordable. Then we need to pick a regimen where we are not asking them to do something impossible. Several years ago, we did not understand inhaled steroids very well. Sometimes we would lay her on two or three twice a day, thinking that the more and more inhaled steroids we gave them, the better control we might get and keep them from getting oral steroids, and we have learned now that probably was unnecessary or not the best way to go, but sometimes I have patients that might have been given two or three maintenance inhalers, and it becomes very cumbersome, and they just did not do it. Ultimately, whatever we pick for our treatments, we want to make sure that we optimize the environmental impact of those treatment methods for patients. Gina says basically that every time we see a patient, we should review what has been going on with patient, assess inhaler technique and adherence, and adjust those particular medications based on what they are able to manage and also evaluate if they are having side effects, and again, that the medication is getting paid for. What I would like to propose to you — sometimes having uncontrolled asthma may not be that we pick the wrong medication. It may be related to the method. There is no one perfect inhaler that every single person that every single person should have, but you can see here is a young child not using any kind of a spacer device, so you have to wonder with his hand on top of the inhaler, there are lots of issues with this approved picture of how to use your inhaler from a website. It clearly is not and we know that when you have bad technique that things can happen.

There have been recent studies that show that most patients do not use their inhaler correctly and also that most health care providers themselves may not know every single device that they prescribe, and they may not know how to do it correctly, so it is very hard to expect the patient to know how to use it if we don’t know and we don’t show them how to use it, and if you ask patients over and over again if they know how to use it, they will say yes because they have been doing it and may not recognize that they are having problems with technique. It is important for us today to review that there are lots of medicines, as you know, from the allergy and asthma network. There is our favorite chart. This is the 2025 version. You can see there are many different devices and types of asthmatic — asthma medications that are available, and they all have special, unique ways that we should be using them, so let’s review first some of the major types of asthma inhalers, and then let’s talk about how we use them. The major kinds of asthma inhalers, there is the traditional puffer that most patients refer to. This is the pressurized metered dose inhaler we have had around for about 40 years. Then there are breath actuated dose inhalers. We will go over that in a moment. Then there are also dry powder inhalers that depend on a capsule or the medicine dropping down and we sucked in with a particular force. Then there are also some inhalers we sometimes use with kids in asthma and adults, and those are disc inhalers. As I mentioned, metered dose inhalers have been around for about 40 years, and many brands of our asthma medications use this particular device. It does, however, require some coordination. You have to be able to press the top and suck in at the right time, then be able to hold your breath and take a good, deep breath in order to get the asthma medication effectively. As you know, it contains an inert gas that helps pressure and move that gas forward. It used to have things that were killing the ozone, and the new versions are supposed to be more ozone-friendly. They don’t pack as much punch, but they still are pressurized to deliver the dose, and each of the doses are importantly dispensed by pushing on the top of the inhaler, and as I mentioned, it does take a little coordination to do it correctly. Let’s review how you would do a metered dose inhaler with and without a spacer. Everybody probably would take this particular device better with the spacer, but at about the age of 12 and sometimes even younger, we get a lot of pushback from individuals who are like, no, I’m a big boy now or I’m a big girl now, I don’t need to use a spacer. If they are not going to use a spacer, there are some important things to think about. The first thing you do, you need to take off the cap. You need to make sure that space as soon as you look into the inhaler is not all dunked up with previous doses or something else. In this particular case, make sure it is clean. You want to hold the inhaler upright, and you need to shake it. I tell my families that they need to shake it up because it is like salad dressing and all the good stuff is on the bottom. Conceptually, they hear that. If it is an inhaler that has not been used for a while or is being used for the first time, you need to waste a couple of puffs, and that is called priming, so that the medicine gets all the way through the device. Then, you want them to empty their lungs so they breathe out gently so there is space to take the medicine. Then they put the mouthpiece into their mouth. Oftentimes, it is easiest to put it between their teeth, but we tell them not to buy it. They closed their lips around it to make a good seal, and they want to start to inhale slowly, but don’t take all the breath in. Then actuate it, and then finish taking the deep breath. There is that coordination where you have to push and suck at the same time. Then they hold their breath for five to 10 seconds.

Many resources say 10 seconds. While they are holding their breath, many times it is good to pull it out of your mouth so you don’t have that space in between the corners of your lips where the medicine can go out. Breathe out gently away from the inhaler because you don’t want to get extra moisture inside the mouth of the inhaler. If another dose is needed, you shake it up again and repeat those and replace the cap. What you will notice here on the side is a video link that you can go ahead and look to see if that video will help you teach that inhaler a little bit better. The next thing we talk about is the mistakes people make with metered dose inhalers. The first thing is they forgot to shake it, which is something that — or they do not shake it very well. We want to make sure they hold the inhaler in the correct position, not upside down or some other way. We want to make sure they exhale so they can get a good deep breath. We do not want them to exhale into the inhaler, and that coordination part, they do not actuate the inhaler deeply enough, and because they do not actuate the inhaler quickly enough, they may not get the good, deep breath and timing. What we know is that if you do not time it right, you do not get the full dose. Sometimes they suck in just way too fast and they don’t get the full dose, either. In multiple actuations, you should repeat the dose, do the priming — or not the priming but the shake and then do the puff. We do not want to do puff, puff, then sucked in. The other thing is what happens when the inhaler is empty. Probably all of you all know that many of them have dose counters on them. Sometimes people do not understand that that dose counter is there for a reason and the inhaler is empty. It really is empty. Let’s talk about what would be the correct technique if you were using the inhaler with a spacer. Again, there is a video link on the side of the screen if you would like to go out and watch an actual video. What we know again is you need to shake the inhaler and prime it has not been used in a little while. You put on the little rubber ring at the end of the spacer device. Many times, we tell kids not to slouch, set up tall or stand up, and we tell them to breathe out completely and empty their lungs again, put the mouthpiece in their mouth, close it around it. We want to time the pump, but they get a little extra time by having the spacer device so they do not have to be quite as coordinated. Some of these devices squeak or make a noise if you breathe in too fast, so we tell individuals, it it makes a noise, you did it too fast and you need to repeat it, and again, when it is done, put a cap back on the inhaler, and that is an effective way. What I want to remind you is that zero really does mean zero, and I had to tell my patients that lots of times because I have seen sometimes that patients say about 60 puffs still come out of my inhaler in in spite of the fact that it is on zero, and that means that is still just a propellant and is not actual medication still coming out of it, so it is not a bonus. Fortunately, some of the devices mechanically lock down, so once it is on zero, you cannot get any extra puffs out of it, and you can see those listed here in the table, the ones that do lock down, but you need to remind them that zero actually does mean zero. What about a spacer holding chamber?

Spacer holding chambers are helpful in individuals that are younger that may not be able to coordinate using a spacer with the mouthpiece. What we know with — or elderly individuals, too. Don’t let me forget that. There is a QR code here that will take you to a video from the American lung Association that will show you how to use this device. We know chambers reduce oropharyngeal deposits of the medication. It also allows more time for the patients to inhale, and it limits some of the need for the hand/breath coordination. It is important in very young individuals who cannot seal their mouth very well around the mouthpiece that we get good coverage of the nose and mouth with these particular devices, and they can be very, very helpful when we are doing it. The way we would use this particular device is, again, we would shake the inhaler. We would take the caps off of it and put the rubber end in, we would cover the mouth and nose, and then we would push the puff. Inside of these usually is a flat that will move and let you see the breath, and most people say that you want to see them take six regular breaths, and then we get the medication into our lungs, and at the end of it, we want to clean the device. Sometimes in kids, we do see because of this particular device a Perry oral dermatitis. Those are red bumps we see sometimes around the mouth when the inhaled steroid gets deposited on the face, so sometimes we recommend that you wipe the face with a cloth or washcloth after they have their dose, and that can sometimes reduce the risk for Perry oral dermatitis. Probably the easiest thing is to put it in warm water and dishwashing soap. We recommend not to rinse it because if you leave that soap film in, it can be helpful in keeping the particles from sticking to the side as much. We usually recommend that you let it air dry and reassemble it. Some spacers say to put it through the dishwasher, and that can be helpful also. Then we will move onto the next kind of an inhaler, which is a breath actuated inhaler. Breath actuated inhalers are breath actuated MDI’s, so they still have a propellant-based aerosol in the, but they do not really start until you actually actuate it with your breath. There are two main forms on the market. There is an albuterol form, and there’s also a form that uses this particular device, and this device is good for patients struggling with timing and they still do get the additional benefit of an aerosolized medication, though, and they don’t have to have quite as much effort as you need when you use a dry powdered inhaler, so this would be helpful for people who cannot generate a strong and rapid lung volume in order to get their inhaler. There is a high reproducibility. The same amount of medication is delivered with this particular device, and these devices do not need to have priming, and they don’t need to have any shaking done before you use them, either, so those are additional points to remember for these inhalers. Then we will move on to dry powdered inhalers. Again, there is a visual here that you can see how to use these particular ones. These are breath actuated devices. The person needs to take a quick, deep breath in order to create enough turbulence to transform the powder into more smaller particles and are able to get it into the lungs. These inhalers, you don’t want to exhale into the device because you will add extra moisture, and you might make device less effective, and you want to make sure you close them because they are very sensitive to moisture. And keep them in a dry place. The effective way for doing this particular inhalers are making sure you do not shake the device and that you keep it in the proper device order. If it is an upright device, you do not have it tilting left and right. If it is the one we talk about holding like a hamburger, you want to make sure you keep it level. Again, we want them to exhale. We want them to suck in and hold their breath, and we want them to take a good, forceful breath so they can get the medicine where it needs to go. And again, we want to discard it and it is empty and we also want to discard it when it is past the expiration date. Again, there are multiple links and QR codes to videos that will help if you need to demonstrate it to your patients. The other device that is complicated for a lot of kids is if you have advice that actually makes a mist. These particular devices, you have to put them together first, and once you have them locked in place, you put the cartridge in, and once you have the cartridge put in place, which does take a little bit of force — we usually recommend that you put the cartridge in, use a hard, firm surface, and push the cartridge all the way up, and when these devices are ready to be used, we recommend that you hold them upright. We move the arrows until we hear a

>> — until we hear a click, and that missed will happen and able to go into your lungs, and when the spray stops, you are done with it. We usually recommend you hold your breath for a few seconds, and then you have another dose to take, you take it, and ultimately, you close the cap. Again, there are videos available that show. In pediatrics, we do not use this device very often, but certainly, at a patients to use this device. Things I want you to remember for how we should think about inhaler devices is we want to choose correctly. She the most appropriate inhaler that we think the patients will be able to use, either based on age — we want to think about if we need a space or for that particular individual, and if we do need a spacer or chamber-holding device, do we need to use a mask so they can get the medicine most effectively? And then what we want to do is try to avoid using different devices that they have to learn all the different techniques for those particular devices because that becomes very confusing, and they very quickly forget how to use which one, especially if they are not very good about taking their medication. Then what I would challenge you to do is that every time you see them, you want to make sure that you review their inhaler technique, and it does not necessarily have to be you. Perhaps you have a nurse in your office or maybe you have MA’s particularly knowledgeable about how to use the devices, but this is an opportunity to make sure they are optimizing their asthma therapy, so we should review the device. We don’t want to just show them. The most helpful thing is to ask them how they use the device, let them show us, and you can identify specific errors or problems or things you can change like, be sure to shake it up before you do it, and we will find the payoff in the long run will be very important. And it is important that as we teach these devices, do pay attention to where the problems are and the steps that we know and have seen other patients have problems with so we can repeat that teaching as necessary. As soon as for to six weeks, people can develop poor technique for using the inhalers, so we want to review it every time we see them and have an opportunity. We know that the clinician should be able to demonstrate the correct technique. We want to make sure that somebody shows them along the way. There was a recent Australian study that showed 75% of patients using an inhaler for two to three years would tell you, oh, yeah, got that down, but actually only 10% — 10% were actually using their inhaler correctly. Here is a prime example of a video that I like very much. It is from “House,” and I think we will watch it just a second. Here we go.

>> My asthma. They said they fixed it, but it did not make any difference at all.

>> well, sometimes doctors make mistakes. Are you using your inhaler?

>> All the time. Go through one a week.

>> Are you sure you’re using it right? Quick story look like an idiot?

>> No. Why don’t you show me how your inhaler works?

>> What was that all about?

Dr. Hogan: I love that video clip because it does show that clearly, she’s been doing it wrong for a long time and that’s why her inhaler is not working. As you know, she is probably not alone. There are lots of people who are not appropriately or effectively using their inhaler, so I made a chart that may be able to help you think about what kinds of inhalers are helpful for different populations and if what some of the common errors are and what kinds of things you need to take into account. For example, if we focus on infants and toddlers, those individuals will probably be best with the traditional puffer. They will need to have a spacer that has a mask, and because they are just breathing and do not follow instructions very well, it is important that we get a good seal around the mouth and nose, and it is important we do clean that particular spacer. In this particular chart, you can refer back to, but it refused different things that might help the select. Again, I think the most important thing is whatever inhaler you use the most that you feel comfortable being able to demonstrate it to support staff so they can teach it correctly or that you are teaching it correctly. I want to touch a second on particle size. That was all the rage 10 or 15 years ago. It was all about the particle size, where does the particle go, and smaller particle sizes are super important to deliver medicine effectively. I want to review particle size. We know if the particle is too small, it will be exhaled or quickly absorbed into the systemic circulation. We think of the particle is too big, it will get left in the mouth or nose before you breathe it into the lung. We know there has recently been a systematic review and meta-analysis that says particle size really is not that important. Gina 2025 says there is currently insufficient good quality evidence to support the use of extra fine and hailed cortical aerosols over time and that that is really not that advantageous, so it put that, at least in my mind, to rest. That is sort of out of mode. Everybody is not talking so much about particle size. What is important is that particles get into your lungs, and that is probably a much bigger issue than worrying about particle size. Gina says the key to self-management involved three things — patients need to have self-monitoring for their symptoms. They need to have a written asthma action plan, and then there needs to be regular review for their control and treatment by their health care providers. I think this is super important, that if we simply implement self-management in 20 patients, then we prevent one hospitalization. For you, it might be a single day of clinic. You understand how to self monitor. They have an asthma action plan, that you review it and make sure they know how to take their medicines, you have prevented one person from being hospitalized. That in and of itself is a huge impact we can make. There are actual studies that show a significant reduction in hospitalizations, emergency room visits, and they have many fewer symptoms if we can simply implement these particular self-management tools. In addition, one of the things that is very important is that patients need to have an asthma action plan. If you ask Gina how many different times in 2025, they talk about asthma action plans, it is 103 separate times in the guidelines do they talk about how important an asthma action plan is. I think it is important that we talk about asthma action plans, and they need to be written in a language that people can understand. If they needed to be printed or digital or pictures for some people that have lower literacy, it is important they understand their action plan. Many EMR systems, you can type in edits and get a very personalized action plan, and that is probably even more actionable, but we are going to take a walk through the electronic world, what is available online. We know the importance of asthma action plans is that it is guided step-by-step management for the individuals and what they need to know about their asthma and it also gives you an opportunity to improve communication. I always go over my asthma action plan in the room with the family, so it gives them an opportunity to ask questions and make sure they understand. Again, this is our opportunity to reduce utilization of the health care system so they are getting early recognition of symptoms and also feeling empowered that they are able to manage their asthma. It is important we have those available in school and community settings also. I am a big advocate of asthma action plans. I have several asthma action plans available for you. There are QR codes that will take you to those. There are a few procedures I think are important. This particular plan is from the asthma and allergy foundation of America. An important first part of the action plan identifies the patient and also identifies who is the doctor that needs to be consulted if asthma is not going well, and also emergency contact information is available. That is usually the first part of the asthma action plan. This particular asthma action plan demonstrates well what a Green Zone is. A Green Zone is the important plan we share with the patient about what you do when things are going well. It outlines baseline control medications, how often they should take them, and particular dosing. One puff, two puffs, and it also tells them, how do you know you are doing well? The patient says there’s things like no cough, no wheezing, or chest tightness. You can also identify known triggers for their asthma. This is usually part of the action plan where it talks about what do you do if a particular individual goes to school and has symptoms, and we make sure they know how to pretreat for exercise or how to post treat if they have symptoms during exercise. The yellow zone is usually what happens when things start to get a little out of control. This is where we step up therapy. We tell them how many rescue puffs to take or if there is someone we want to accelerate their number of controller medication puffs, that will also be included. Sometimes there will be parameters they monitor. Those numbers would be there to say, you dropped to this, the you may not be under very good control. The yellow zone is usually the time we deal with early intervention and hopefully pull them back up to their Green Zone, and the red zone is recognition of severe symptoms. We tell them when and how to take their rescue medication, and, hopefully, there are clear directions that tell them when they need to activate emergency medical services and proceed on to the emergency room. A good action plan may be labeled differently, but the standard way now is looking at a Green Zone, yellow zone, and red zone. Here is an example of the action plan which is what the American Academy of pediatrics reflects as their asthma action plan. There are some additional things on the second page for this, and it does discuss peak flow monitoring. Peak flow monitoring is a little bit for me controversial. I do not routinely do it with most children unless they are very motivated. It is something you can clearly not do a very good job if you want to get out of a biology test. In some populations, it can be useful, but in children, there’s the opportunity to not perform it well or to manipulate results. We get better results I think with motivated adults. Lots of action plans do not have peak flow monitoring on them at all. These particular action plans when they are being used for schools, we want to have a place where school staff can sign off, that they have reviewed the action plan, they know the medication the child has, and in general, we think that children remaining for afterschool activities like a sport or chess club or something else when the school nurse may very well go home, that they should have an inhaler available, not locked up with — not locked up in the office when the office locks. Usually, these plans will also talk about self-administering. Most of the other action plans are focused on albuterol or have multiple lines you can fill in. This particular plan available on the Allergy and Asthma Network was developed for people on smart or marked or air — smart or mart or air. As you can see, there is what you do when you’re well, and if you start to have unraveling , and — you have an element added. As you know, it uses for moral and we do that differently than traditionally with albuterol. I will share with you another one that is a college website. Again, has ways to fill in, a lot of opportunities and space to fill in medications and describe how you would like to use it, and I’m going to share with you the action plan we developed for the state of Virginia. In the state of Virginia, we do not have access as readily to the same EMR system for everyone across the state. There are a lot of health-care providers on different systems, so we try to develop paper copies that incorporated both traditional usage of albuterol and also smart, mart, or air. If you look at the particular plan we are currently using, there are two separate yellow zones, one that uses traditional albuterol, and one that tells what to do if you are on smart therapy. This particular action plan is used across the state and available for all of our public schools. I think it is important we start to merge both kinds of active plans and try to give schools guidance on when to use medications and how to use them, and following along with guidelines for the number of puffs and also what to do when asthma starts getting out of control. The question that always comes up for me has to do with what you do when you have exceeded your eight or 12 puffs and now you’re on the way to the emergency room. It is OK to give additional puffs if you are in route to an emergency room. Our action plan says you can have up to six additional puffs. I think these are things that action plans need to address and we need to get practical, helpful points to families that have asthma. This is from the Allergy and Asthma Network. It is an advertisement or a cute little picture that says to families, if you don’t have an asthma action plan, you should ask for one. Potentially take a picture of it and keep it on your own so if you’re like, it’s back at home on the refrigerator or I don’t remember where I put it, I try to remind patients to have it in a place like their phone that is very visible so they can refer to it even though they may have mild asthma and think they will never need it. 27% of mortalities are in patients who have mild asthma. You never know when you will have a bad attack. And I always say bring it to your appointments so we can review it and also make sure that if we need to update it for the school year, we can see when it expired. Ideally that will be standard, but that does not always happen. As time moves on and we get more systems that are able to adjust and ideally having the patient be able to go in and print their asthma action plan will be very important. Again, I think it is important to tailor these with different literacy levels and that we make sure that potentially in addition to making sure that they have their medicine, that we also address other departments that affect how well our asthma symptoms are managed. We want to make sure that everyone who cares for these individuals has access to these action plans. What I would like for you to take home from this is that even the right medicine, if we don’t know how to use it correctly and we don’t have it actually can set us up for failure. Again, I want to remind you that if we review the asthma action plan and make sure they have the medicine and know how to do it for 20 patients, one patient will have been prevented from hospital intervention if we actually do that for our patients, and I think it is important that to educate, we should check inhaler technique every time and make sure there is an asthma action plan available at each visit that we see the patient, and there are some additional resources. There’s a QR code that reviews how to correctly use your devices and allergy and asthma foundation of America and also, if you go to the Allergy and Asthma Network, there are a slew of action plans available there that you can probably find that will suit your practice and help you be able to give patients the right action plan. I think I did it with a minute left before my 10 minutes for questions were up. I do want to tell you that the Allergy and Asthma Network does have another webinar if you enjoyed this one coming up in September. It is diagnosis and management of options for mass cell disorders, which many of us find difficult to manage and that is on September 10. I appreciate the opportunity to talk very fast you all, and I look forward to seeing you all around and about and answering some questions.

Bethany: Thank you so much for that extremely informative presentation. I have a couple bastions for you today. The first is — at what age is it OK to switch from a spacer with a mask to a spacer with a mouthpiece?

Dr. Hogan: Part of that is dependent on the child. If we have a special needs child, we will end up doing a mask for many years. I tend to switch over right around — and this is totally just my clinical experience — I tend to change over around age nine or 10 if I have a very good child who is able to coordinate it, but I watch first and sometimes go in with both mouthpiece and mask and make sure they can do the mail spacer device well first. Again, not even encourage high school kids, even though they could technically not use a spacer, to still use a spacer because I think it more effectively since the medicine where it needs to be, but around the age of nine or so, and that is pretty arbitrary, but that is about when I start to think about it. Eight or nine.

Bethany: Thank you. The next question is — if there is a noise heard using a holding chamber, are they breathing in too fast with that one as well?

Dr. Hogan: In general, neither one should make a noise. I don’t really think you can hear the flap. If you have really supersonic sonic hearing and you can hear the flap, maybe that is OK, but if you hear a whistle or a noise, then to the technique is not correct. In general, the biggest noise we here are the ones that have the mouth these, and they will whistle. Clearly if they whistle, I will say, you’ve got to do it again.

Bethany: Thank you. Where would a person get an asthma peak flow monitor?

Dr.: — Dr. Hogan: Usually, peak flow monitors are provided by your physician at the office if they have one. They can write a prescription. They are available I think on Amazon, and I think there is also — don’t quote me on this, but there used to be a link at Allergy and Asthma Network that you could get a peak flow. They are not necessarily a prescription. You can get them over the counter, but you need someone to set it for you, so you need to know what you’re correct numbers are. It is based on your height, and it is also based on how well you breathe. In the old days, we used to take it in the room. We used to have them blow in for or five times, average for their best, and we would say, this is your best. They can be helpful, but they can be manipulated, so we really do not rely on them as much as we used to. We really more ask questions about how you are doing clinically, are you coughing, are you having problems when you exercise, are you having problems when you wake up? We focused more on symptoms than necessarily peak flow monitoring. There are some select patients we use it in.

Bethany: Thank you. Another question we just got in the chat was, if it whistles and does not count and you have to do it again, does that mean another of the inhaler?

Dr. Hogan: Yes.

Bethany: All right. And question — have you seen kids continuing to use a spacer and mask into teenage years? I think you touched on that just a moment ago.

Dr. Hogan: Absolutely. My daughter is 25 who has asthma. She uses a spacer and she’s like, I feel better. I get it better. If you’re in the throes of a significant asthma attack, it is hard to generate enough force to use your inhaler correctly. Certainly in those individuals that have frequent exacerbation, you absolutely want to make sure that they get the medicine where it needs to be, and they may not be able to type it correctly without a spacer, so in general, if they can afford a spacer, I think spacers are the best way to go.

Bethany: Thank you. If there was a myth to bust, what would be a mythposter you would like to talk about.

Dr. Hogan: I think I covered most of my myths, but I think probably would just basically be if I were a provider that this patient has had asthma for a really long time and I’m certain they know how to use their spacer and inhaler and that I don’t need to review it. People forget, and it is so critical to review it, and again, it is so important. Gina says over and over again, they need to have action plans and need to know how to use their devices. My myth would be don’t trust anybody to say, yes, you really do know how to use it without reviewing it with them again.

Bethany: That was great. Thank you so much. We will end here. We really appreciate your time today, Dr. Hogan. Dr. Hogan: Thank you, everybody, for coming.

Bethany: Yes, thank you. In a few days, zoom will email you additional resources. On the screen, this information about our next webinar focusing on the clinical manifestation and diagnostic challenges and differential diagnosis for mast cell disorders. He will share the latest advancements in biological marker medication, diagnostic testing and therapeutic approaches including, — pharmacological treatments and lifestyle changes. We have a webinar later this month on understanding and managing contact dermatitis, and we will be joined by allergist and pediatric expert Dr. Alexis for focused training designed for clinicians involved in allergy and dermatology care. This webinar will involve evidence-based approaches to improve patient communication, adherence, and personal treatment. Patients and physicians are welcome to attend, and that is the end of our webinar today. Thank you all. You will receive a closed webinar email shortly. Have a great day. Thank you.