Communications to the Editor |

Reality-Based Medicine—the Response FREE TO VIEW

Marc Noppen, MD, PhD, FCCP
Author and Funding Information

Respiratory Division, Academic Hospital Brussels, Belgium

Corrrespondence to: Marc Noppen, MD, PhD, FCCP, Interventional Endoscopy Unit, Academic Hospital AZ VUB, 101, Laarbeeklaan, B 1090 Brussels, Belgium; e-mail: noppen@az.vub.ac.be

Chest. 2001;119(3):992-993. doi:10.1378/chest.119.3.992-a
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To the Editor:

I would like to thank Dr. Chapman for his excellent editorial in CHEST (August 2000),1 concerning the often underestimated and incorrectly addressed problem of noncompliance or nonadherence to treatment prescriptions in chronic disorders (eg, metered-dose inhaler [MDI] dumping by asthmatics before scheduled visits).

In asthma (and COPD), this problem may even be worse, because most (though not all) patients typically seem to prefer pills over puffs. Furthermore, a major issue in the nonadherence of patients to MDI prescriptions, apart from a “primary” dumping phenomenon, may be the inability to use the MDIs correctly, which in turn may lead to a misconceived “ineffectiveness” of the devices, and then to“ secondary” dumping.

I tallied 50 consecutive asthmatics referred for “difficult asthma,” ie, patients who were prescribed the“ correct” inhaler drugs, but in whom treatment was unsuccessful (unpublished data, 1998). When the patients were asked the simple question, “Show me how you use your device,” the result was that 80% of patients used their MDIs incorrectly (this was only sporadically observed with use of dry powder inhalers). My first and only action was a demonstration of correct MDI use. At a control visit 2 weeks later, 80% of this group had significant or complete resolution of asthma symptoms, normalization casu quo, or improvement in lung function. In the other 20%, sinusitis, reflux disease, or Churg-Strauss syndrome were eventually diagnosed, although in a substantial number of patients no specific cause for nonresponsiveness to therapy was found.

This means that in about two thirds of asthmatics who are not responding to MDI therapy, in daily clinical practice, correct instruction of patients (which should have been done when MDI therapy was first prescribed) may suffice to obtain correct disease control! My personal “reality-based” conclusion of this little study is simple: patients do NOT leave my consultation room unless they have proven to be able to use their device correctly. Although this does not guarantee that they will adhere to the prescribed regimen, it certainly will eliminate a lot of expensive and useless supplementary diagnostic and therapeutic interventions.


Chapman, KR (2000) Reality-based medicine.Chest118,281-283




Chapman, KR (2000) Reality-based medicine.Chest118,281-283
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