To the Editor,
Asthma is a prevalent health condition (incidence rate
~7.9%) among children in India. Besides leading to
insufficient sleep, exhaustion, and steady deterioration in lung
function, poorly controlled asthma makes it extremely difficult for
these children to participate in some of the daily outdoor
activities1. Further, it is the third most common
reason for children being hospitalized and accounts for more than 10
million ‘lost school days’ annually1.
An overlap between asthma, attention-deficit/hyperactivity disorder
(ADHD), and/or autism spectrum disorder (ASD) has been reported in
children2. Kaas et al. found in a systematic review
that out of 25 asthma-ADHD studies, 17 studies revealed a significant
positive association, while one study showed a negative association.
Asthma is more common in children with ASD, reportedly 21.6% of
children with ASD were diagnosed with asthma of which 49.5% reported an
acute exacerbation of asthma over 12 months. As such comorbidities are
usually associated with complex clinical management, increased economic
burden, and complex health outcomes, the presence of ADHD/ASD with
asthma is challenging for patients and physicians. ASD is typically
characterized by severe functional impairment, poor social interaction,
and repetitive or stereotypical behavior, while ADHD is associated with
functional impairment, poor cognitive development, and
hyperactive-impulsive responses3,4. These
characteristics in either of the conditions, in addition to asthma,
present challenges to physicians in planning a treatment regimen, as it
impacts the patient’s adherence to medication.
Inhalation therapy is the key to
effective asthma management. Delivering inhaled medications directly to
the lungs has the advantage of the drug being delivered more effectively
to the airways along with reduced systemic adverse
effects.5 Use of the appropriate device(s) and patient
preference for the device are critical for patient adherence which in
turn plays an important role in controlling symptoms and thereby
improving the quality of life in such patients5.
Inhaler devices, including pressurized metered-dose inhalers (pMDIs)
with or without added spacers, and dry powder inhalers (DPIs), are
widely used to deliver medications directly to the lungs. However, these
have certain disadvantages which limit their use by physicians and
patients. Breath-actuated inhalers (BAI) have been recently introduced
which overcome some of the drawbacks of pMDIs and
DPIs.5
We evaluated the effectiveness of BAI in the management of asthma in
three such pediatric patients between the age of 10-13 years who
reported asthma exacerbations and poorly controlled symptoms. Two of
them had severe ADHD while one was a child with autistic spectrum
disorder (ASD) with ADHD. Previously, one child was treated with
budesonide (100 µg) twice a day with pMDI plus spacer, while the other
two children were treated with fluticasone (100 µg) plus salmeterol (25
µg) pMDI plus spacer, two puffs twice a day. All three patients were
referred in view of poor control of symptoms with frequent exacerbations
over 6 months with a low score on the asthma control test. While
evaluating the technique of the drug delivery, all three patients were
not cooperating sufficiently to take a minimum of six breaths with the
pMDI plus spacer. After obtaining consent from the parents, all children
were started on inhaled fluticasone (100) plus salmeterol (25) given via
BAI (Synchrobreathe®) for a period of one month with levosalbutamol BAI
(Levolin®) as a reliever. Following the use of BAI, all patients
improved on their asthma control test scores and were well controlled.
Further evaluation using a patient satisfaction questionnaire revealed
that the parents reported that BAI was easier to use, required lesser
effort for breathing, children had a better understanding of using the
device and was easier to maintain. All children followed up for 3 months
and were well controlled with no need for using reliever medication
during this period. This observation highlights the importance of
technique of inhaler use in children with special needs.
In our study, we saw the key advantages of BAI which included overcoming
the challenge of patient coordination of actuation with breathing, as
BAI detects an inhalation attempt through the actuator and mechanically
actuates the dosage in synchronization. This eliminates the need for
pressing and breathing, which thereby removes technical dependency. BAI
is compact, portable and obviates the need of a spacer. It provides the
advantage of ease of use and assurance of a consistent dosage every time
children use it, as it requires a low inspiratory flow rate for breath
actuation. Decreased oropharyngeal deposition and increased lung
deposition have also been noted with BAIs as the drug is released at a
lower velocity.5 BAIs are also easy to clean and
maintain.
In a study conducted in 51 children hospitalized with an acute
exacerbation, more number of children could activate a BAI as compared
to a DPI. Moreover, children with wheeze under 6 years of age, who were
inept at using the DPI, showed a worthwhile response to the
BAI.5
Previously a few adult studies have demonstrated the advantages of BAI.
In a prospective study, 10 stable adult patients with asthma were
administered one puff of radiolabelled (99mTC) salmeterol and
fluticasone propionate (SFC) (25/125 mcg) via either a BAI
(Synchrobreathe®) or conventional pMDI and it was found that drug
deposition in the lungs was significantly higher with
Synchrobreathe®(22.33%) as compared with the conventional pMDI
(17.32%).6
Due to the cognitive, physical, and sensory disabilities and device
disadvantages stated above, children suffering from ADHD and ASD are
likely to face difficulties in using their inhaler devices correctly,
resulting in poor disease control. More studies are needed on newer
inhalation devices in children with special needs. It is important to
map the advantages of inhaler devices in terms of patient choice,
satisfaction, and simplicity of use in addition to enhanced medication
administration, less waste, and improved adherence. Guidelines must be
established to determine patient groups that will benefit from a certain
type of device. Based on the experience with these three pediatric cases
with special health care needs, the authors recommend BAIs to be
considered in treating asthma in patients with ASD and ADHD, given the
growing number of children with these conditions.
References
- Daniel RA, Aggarwal P, Kalaivani M, Gupta SK. Prevalence of asthma
among children in India: A systematic review and meta-analysis. Lung
India 2022;39(4):357-367.
- Coghill DR, Banaschewski T, Bliss C, Robertson B, Zuddas A. Cognitive
function of children and adolescents with
attention-deficit/hyperactivity disorder in a 2-year open-label study
of lisdexamfetamine dimesylate. CNS Drugs 2018;32(1):85-95.
- Lu S, Sonney J, Kieckhefer GM. Asthma management in children with
autism spectrum disorders: pearls for a successful clinical encounter.
J Pediatr Health Care 2014;28(6):559-564.
- Kaas TH, Vinding RK, Stokholm J, Bønnelykke K, Bisgaard H, Chawes BL.
Association between childhood asthma and attention deficit
hyperactivity or autism spectrum disorders: A systematic review with
meta-analysis. Clin Exp Allergy 2021;51(2):228-252.
- Salvi S, Gogtay J, Aggarwal B. Use of breath-actuated inhalers in
patients with asthma and COPD - an advance in inhalational therapy: a
systematic review. Expert Rev Respir Med 2014;8(1):89-99.
- Gogtay J, Tambe A, Rote K, Malhotra G, Sharma BG, Bhatnagar A,et al . Improvement in the drug delivery of
salmeterol/fluticasone via a novel breath actuated pressurized metered
dose inhaler with a dose counter. Eur Respir J. Sep 2019, 54 (suppl
63) PA4222.