Features

Asthma's image problem

21 May 2021

Pictures used by the media and healthcare providers to illustrate asthma treatment can be misleading. But a Twitter campaign is starting to rectify the problem, explain Emily Guilmant-Farry and Sara Nelson.

A picture is worth a thousand words – but what does the wrong image say? Professionals working in healthcare have long decried the poor images used to represent illnesses in the media and sometimes within their own sector. This is particularly true of asthma inhaler use. Asthma is the most common long-term medical condition among children and young people (CYP) in the UK. One in 11 children in the UK have asthma (Asthma UK, 2021).

The image of asthma most often portrayed on screen or in print is a child spraying a blue reliever inhaler directly into their mouths from about four years of age, or a late-primary-aged child using a face mask spacer, both of which go against every medical guideline given in the UK (Global Initiative for Asthma, 2020; British Thoracic Society and Scottish Intercollegiate Guidelines Network, 2019; NICE, 2017). The concern over the type of inhaler in the images is linked to overreliance on a blue reliever rather than encouraging use of a preventer inhaler – commonly brown – and to the lack of a spacer in which to deliver it.

Medical articles and healthcare providers aren’t immune from poor asthma inhaler image use, either. A search engine or picture library hunt for ‘asthma and inhalers’ reveals various images conveying an incorrect technique and message, and a poor selection of appropriate images.

#RightInhalerImage campaign

For years, asthma professionals have been tackling the problem of poor images in isolation. But this year they joined up on Twitter to tackle the issue of the right images of inhalers and spacers available for media use. The #RightInhalerImage campaign team is supported by the clinical leads of the NHS England and Improvement Adult Respiratory Programme and Children and Young People Transformation Programme.

The campaign aims to improve the quality of information for patients, healthcare professionals and the public about the use of inhalers by promoting the publication of images of inhalers being used accurately and appropriately. The long-term goal is to have a database of clinically excellent images freely accessible to the media and professionals. It also encourages media outlets and healthcare providers to sign up and pledge to remove poor images from their own databases and to use only appropriate images.

Why imagery matters

Incorrect images contribute to poor inhaler technique and counteract medical advice. Both these effects have been seen, occasionally but becoming more frequent, in the nurse-led asthma clinic in Newham, east London, where one author works. This trend is borne out in London generally, according to the Pan-London Asthma Nurses Network. CYP attending have changed their practice of spacer use, as they saw people they followed on social media doing something different – and the people they followed had more influence than healthcare professionals.

Recommended practice

There are incorrect beliefs, among CYP and their families and also among some professionals, that blue inhalers are the ones that matter; that once CYP reach teenage years, a spacer is no longer needed; or that every child requires a face mask spacer.

So what should the images represent? Inhalers: A reliever inhaler – most commonly blue – is not the most important inhaler to have, despite popular belief. It only relieves the symptoms of asthma (cough, wheeze, breathlessness, pain or chest tightness) and doesn’t treat the underlying cause. For that, you need an inhaled corticosteroid (ICS) preventer inhaler. These are most commonly brown, orange and purple. Why, then, do we almost always see blue depicted in articles or on television?

Spacers: Only about 10% of adults can use a pressurised metered dose inhaler (pMDI) – the most common pump-action type – correctly without some kind of aid. Most people, whether old or young, benefit from using a spacer to use a pMDI. A spacer is a plastic holding tube with a one-way valve that slows down and holds the medication once depressed. This process allows normal tidal breathing to be used to get the drug contents into the lungs, rather than into the oropharynx or gastrointestinal tract – a problem that occurs in the vast majority of people not using an inhaler correctly, as they struggle to coordinate pMDI actuation with inhalation (McIvor et al, 2018). Which spacer is best, and do different types suit various ages? As a rule, children need an anatomically correct face mask spacer up to the age of three to four years, when they can transition to a mouthpiece spacer. This generalisation can vary with developmental factors and learning difficulties, but there is a device out there for everyone. Not every inhaler/asthma device needs a spacer: as well as the pMDI, there are many other types of inhaler, including breath-actuated inhalers and turbohalers. So if spacers can’t be used or are declined – for example, teenagers may not want to carry a spacer at school – there are alternatives. Community practitioners (CPs), including health visitors and nursery and school nurses, play a vital role in ensuring that everyone with asthma is receiving basic asthma care. For general advice on how asthma specialists, but also CPs, can help patients, see Checklist for good practice, left. What can we do?

Which spacer is best, and do different types suit various ages? As a rule, children need an anatomically correct face mask spacer up to the age of three to four years, when they can transition to a mouthpiece spacer. This generalisation can vary with developmental factors and learning difficulties, but there is a device out there for everyone. 

Not every inhaler/asthma device needs a spacer: as well as the pMDI, there are many other types of inhaler, including breath-actuated inhalers and turbohalers. So if spacers can’t be used or are declined – for example, teenagers may not want to carry a spacer at school – there are alternatives.

Community practitioners (CPs), including health visitors and nursery and school nurses, play a vital role in ensuring that everyone with asthma is receiving basic asthma care. For general advice on how asthma specialists, but also CPs, can help patients, see Checklist for good practice, left.

What can we do?

Healthcare practitioners should ensure that the information given is correct. Ensure images represent the care that’s been advised. Use reputable websites and social media resources (see Resources, right). And don’t be afraid to have the discussion about images that are not correct.

  • Join our campaign and follow us on Twitter #RightInhalerImage
  • Pledge to use appropriate images
  • Support us in asking the media to remove inappropriate images when asked.

Healthcare professionals have a duty to use and share images that reflect current and informed practice, and to support written information shared with patients. This practice reinforces health promotion information to ensure patients use inhalers and devices correctly, as per national guidance. Practitioners also need to be better at asking the media to replace poor images with ones that promote the right care, so that asthma care isn’t constantly represented in the media by THAT image – the blue inhaler with no spacer being used by young children.    


Checklist for good practice*  

  • Be familiar with different devices, and be confident in how to use and care for them correctly.  
  • Does the device meet the needs of the patient, and can they use it after teaching? If not, consider other devices. No one should be prescribed a device that has not been assessed/learned about.  
  • Has the GP or asthma nurse given a written personalised asthma action plan (PAAP)?  
  • Have you given good resources to back up your teaching? Asthma UK and Right Breathe have videos online demonstrating good technique with all types of device, and are user-friendly.  
  • Check inhaler technique at every available opportunity. Odd habits can creep in, and it is easy to assume, wrongly, that people will remember the correct technique.  
  • How many reliever inhalers, compared with their preventer, have patients picked up from their GP? A high salbutamol prescription rate is a high-risk factor for fatal asthma – it often corresponds with poor preventer pick-up – and highlights poor asthma symptom control. CPs can help patients understand what their medicine does.  

*Although the list applies to all staff who have an impact on asthma management in children, those staff should receive extra training.

Emily Guilmant-Farry is children’s community asthma nurse specialist (Newham), East London NHS Foundation Trust.  

Sara Nelson is deputy director of transformation for CYP, Healthy London Partnership, and London Asthma Programme lead.


Resources


References 

Asthma UK. (2021) Asthma facts and statistics. See: asthma.org.uk/about/media/facts-and-statistics (accessed 20 April 2021).

British Lung Foundation. (2021) Lung disease in the UK. See: https://statistics.blf.org.uk (accessed 26 April 2021).

British Thoracic Society/Scottish Intercollegiate Guidelines Network. (2019) British guideline on the management of asthma. See: brit-thoracic.org.uk/quality-improvement/guidelines/asthma (accessed 20 April 2021).

Global Initiative for Asthma. (2020) Global strategy for asthma management and prevention. See: ginasthma.org/gina-reports (accessed 20 April 2021).

McIvor RA, Devlin HM, Kaplan A. (2018) Optimizing the delivery of inhaled medication for respiratory patients: the role of valved holding chambers. Canadian Respiratory Journal 2018: 5076259. 

NICE. (2021) Respiratory conditions: reducing pressure on emergency hospital services. See: https://indepth.nice.org.uk/respiratory-reducing-emergency-pressure/index.html (accessed 26 April 2021) 

NICE. (2017) Asthma: diagnosis, monitoring and chronic asthma management. See: nice.org.uk/guidance/ng80 (accessed 20 April 2021).

Royal College of Physicians. (2014) Why asthma still kills: the National Review of Asthma Deaths (NRAD) confidential enquiry report. See: rcplondon.ac.uk/projects/national-review-asthma-deaths (accessed 20 April 2021).

Image Credit | Asthma UK; Shutterstock

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