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Clinical Investigations: ASTHMA |

Understanding and Use of Inhaler Medication by Asthmatics in Specialty Care in Trinidad*: A Study Following Development of Caribbean Guidelines for Asthma Management and Prevention FREE TO VIEW

Lexley M. Pinto Pereira, MBBS, MD; Yuri Clement, PhD; Cecil K. Da Silva, MBBS, MS; Duane McIntosh, BSc; Donald T. Simeon, PhD
Author and Funding Information

*From the Faculty of Medical Sciences (Drs. Pinto Pereira, Clement, and Simeon, and Mr. McIntosh), University of the West Indies, St. Augustine, Trinidad and Tobago; and Hackenthorpe Medical Centre (Dr. Da Silva), Sheffield, UK.

Correspondence to: Lexley M. Pinto Pereira, MBBS, MD, Pharmacology Unit, Faculty of Medical Sciences, University of the West Indies, Trinidad and Tobago; e-mail: berardo@wow.net



Chest. 2002;121(6):1833-1840. doi:10.1378/chest.121.6.1833
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Published online

Study objectives: Following the development of the Caribbean Guidelines for Asthma Care, we examined the utilization of inhaled medications in asthmatic patients in Trinidad, West Indies.

Setting: Chest Clinic, Ministry of Health, Trinidad.

Participants: Physician-diagnosed asthmatic patients who attended the Chest Clinic between July 1998 and August 2000.

Measurements and results: A consecutive sample of patients who were > 7 years of age (n = 402) was interviewed about compliance with, understanding of, and use of inhaler medication. The inhaler technique of these patients was directly observed. Inhaled steroid therapy was prescribed in 83% of patients but were prescribed the least in elderly patients (63%) and children (62%). Salbutamol was prescribed in 98% of patients, and ipratropium and sodium cromoglycate were selectively prescribed in elderly men and children, respectively. Only 33% of patients used the inhaler correctly, and children and the elderly were the least efficient in its use. The use of a spacer device was advised in 19% of patients, including only 6% of the elderly patients. Explanations for different inhaler therapies were given to 62% of patients, and 53% of patients could describe these reasons. The reported 40% noncompliance rate among patients in the sample was primarily a result of long waiting periods at the pharmacy (58%) and the personal cost incurred on purchasing the medication (52%).

Conclusions: Educating patients, with a focus on children and the elderly, in inhaler techniques and reinforcing understanding of asthma medications can improve asthma management in Trinidad. Asthma caregivers in the Caribbean should ensure the appropriate dissemination of the guidelines and should outline strategies for their implementation.

Asthma remains a disorder with increasing prevalence and significant morbidity and mortality rates despite the presence of established protocols and practice guidelines. In the Caribbean, patient admissions to accident and emergency units due to asthma increased between 19701and 1999.2The rate of asthma-related mortality continues to rise, particularly in elderly patients and children, although death is generally preventable. The mortality rate due to asthma in the general population is between < 1 and 4 persons per 100,000 population per year,3a rate that has risen in the elderly particularly. The mortality rate due to asthma increased by 24% in the United States between 1984 and 1994.4On the Caribbean island of Barbados, the death rate from asthma is reported to be as high as 10 to 12 persons per year or 4.8 persons per 100,000 population,5and in Jamaica the death rates studied between 1980 and 1989 increased with age (> 54 years) and were highest in rural areas.6

Asthma is one of the most common illnesses in children and is a major cause for hospitalization and prescribed therapy. Using the International Study of Asthma and Allergies in Children protocol,7 the self-reported prevalence of wheezing among children 12 to 15 years old in the Caribbean is among the highest in the world. Reports from Barbados show a prevalence of 18.3% in children between 6 and 7 years of age and 17.7% among those 12 to 13 years of age.7In Trinidad, 25% of school children who were 12 to 15 years of age said they had wheezed in the previous year.8

Algorithms for asthma management emphasize chronic maintenance therapy over acute episodic care and stress the need for the daily use of anti-inflammatory medication. The underutilization of therapy with inhaled steroids and inadequate patient follow-up,9causing ineffective disease management, are the reasons cited for the increasing morbidity and mortality rate of patients with asthma. Data from several countries indicate that yearly death rates of patients due to asthma decreased with increased sales of inhaled corticosteroids1011 and that the use of inhaled corticosteroids significantly reduced the risk of near-fatal and fatal asthma episodes.1213 The guidelines for the management of asthma from the National Asthma Campaign (United Kingdom), the National Heart Lung and Blood Institute (United States), and the Global Initiative for Asthma (GINA) stress the use of therapy with inhaled corticosteroids for disease control. In 1997, a joint initiative of GINA and the Commonwealth Caribbean Medical Research Council brought together in Trinidad an expert committee from the Caribbean and the GINA to develop the Caribbean Guidelines for Asthma Care,14which became available in 1998. In 2000, the Ministry of Health of Trinidad invited the Michener Institute (Canada) to train health-care professionals in patient education. The report observed “a comparatively lower level of asthma care” in the country and attributed the high use of emergency departments by asthmatic patients to the insufficient use of inhaled corticosteroids.15

Inappropriate prescribing of salbutamol and inhaled corticosteroids has been reported in the Caribbean. For example, a recent study in Trinidad16reported that 98% of patients always received prescriptions for inhaled salbutamol (Ventolin; GlaxoWellcome; Research Triangle Park, NC), with the belief that it only gave them symptom relief. In a 1998 report17 of asthma drug utilization in three Eastern Caribbean countries (St. Lucia, Grenada, and St. Kitts/Nevis), oral salbutamol was the mainstay of treatment in 92% of patients, with only 6% of patients receiving therapy with inhaled corticosteroids.

Following the development of the Caribbean guidelines, the use of pharmacotherapy for the relief and control of asthma has not been examined. This study was undertaken to examine the utilization of inhaled medications for the prevention and relief of asthma in the asthma clinic in Trinidad.

The sample comprised stable patients with physician- diagnosed asthma who presented to the national Chest Clinic of the Ministry of Health in Trinidad and Tobago. The diagnosis of asthma was based on experiencing symptoms of wheezing, chest tightness, and nocturnal coughing in the past 12 months. Tests of reversible and variable airflow limitation using a peak expiratory flowmeter were not routinely conducted.

The Chest Clinic is the tertiary public health center of the Ministry of Health for respiratory diseases and operates out of two major centers at Port of Spain, the capital, and San Fernando, the country’s second largest city. Patients receive medical attention and medication without any charge but often have to wait for long periods of time for the use of these facilities. We chose the patient population attending at the Chest Clinic because the clinic is the country’s main center for the management of asthma patients and receives referrals from other health-care institutions across the country. The chest physicians who manage these patients and complete their follow-up routinely see adult and pediatric patients at the same clinic.

Using consecutive sampling, all patients aged ≥ 7 years who attended the clinic between June 1998 and July 2000 were invited to participate in the study. Following review by the specialist physician, the nurse on duty invited patients to visit an adjoining room to participate in the study and be interviewed by a trained researcher. Patients were asked to name the inhaler medications prescribed for them by the consultant physician and to describe their understanding of the use of each inhaler when more than one had been prescribed. The patient descriptions of the prescribed pressurized metered-dose inhalers (pMDIs) were checked and confirmed with their records and requests to the pharmacy. The reported compliance with the inhaler medication and the reasons for perceived noncompliance were recorded.

Records of the advice given on and demonstration of the correct use of the pMDI by a health-care professional on the first occasion that it was prescribed also were sought. Correct inhalation performance was determined by asking patients to inhale from the pMDI (either their own or a placebo) in front of the researcher. The following eight steps were evaluated for correct performance: shakes inhaler; exhales; breathes in slowly and deeply; coordinates actuation with inhaling; uses one actuation per inhalation; holds breath; breathes out slowly; and waits for 60 s before the second actuation. For participating children who were unable to answer questions appropriately, the responses of the accompanying responsible adult were recorded. For patients with recurrent hospitalizations or multiple prescription changes during the time of their managed care at the clinic, only the current prescription was considered for use in the analysis. We excluded patients who reported following hospitalization or transfer from another chronic-care institute during the study period because their outpatient medication information either was incomplete or was unavailable.

Before data collection, a pilot study was conducted on 30 patients to confirm the suitability and patient understanding of the questionnaire instrument.

Statistical Analysis

In this analysis, we categorized age into the following four levels: children from 7 to 12 years of age; adolescents between 13 and 18 years of age; adults from 19 to 64 years of age; and elderly patients who were ≥ 65 years of age. Age group and gender differences were assessed using χ2 tests. The p value was set at < 0.01 for statistical significance because of the considerable numbers of tests performed. The data were analyzed using appropriate software (SPSS for Windows, version 9.0; SPSS; Chicago, IL).

During the study period, 402 patients qualified for entry, and all agreed to participate in the study. The demographic characteristics of the sample are shown in Table 1 . Adults between 19 and 64 years of age formed the largest group of patients (62.2%). There was a significant gender difference in the age distribution of patients, with more adult women and boys (p < 0.001). Most patients were of East Indian heritage (65.3%), followed in frequency by African heritage (28.7%).

Inhaled Corticosteroid Use and Knowledge

All medications were prescribed by brand name, although the Ministry of Health Formulary uses generic nomenclature (Table 2 ).

Nearly all patients studied (98%) received a prescription for salbutamol, and 333 patients (82%) received prescriptions for beclomethasone (Becotide; GlaxoWellcome) when they visited the clinic. These two inhalers were coprescribed the most frequently (82%), followed in frequency by ipratropium (Atrovent; Boehringer Ingelheim; Ridgefield, CT) with salbutamol. Salmeterol (Serevent; GlaxoWellcome) and fluticasone (Flixotide; GlaxoWellcome), which were rarely prescribed, are not on the Ministry of Health Formulary list and are not dispensed at the clinic pharmacy. More female patients (91%) received beclomethasone compared with male patients (69%), while the number of ipratropium prescriptions was higher in male patients (25%) than in female patients (3%; p < 0.0001). Twenty-seven patients (7%) received salbutamol alone for disease management. Patients received salbutamol relief medication, which was prescribed across all age groups, at each visit.

Salbutamol appeared to be the basic prescription, and patients reported that they relied on it for their asthma relief and would regularly ask for salbutamol at the pharmacy. Adults (92%) and adolescents (83%) generally received beclomethasone, but steroid prevention therapy was prescribed the least (p < 0.001) in children (62%) and the elderly (63%) [Table 3] . Cromoglycate was selectively used in pediatric patients (35%), and ipratropium was selectively used in elderly patients (35%; p < 0.0001). There were gender associations for the prescription of salbutamol plus beclomethasone and for salbutamol plus ipratropium (p < 0. 0001). The former was prescribed in 90% of female patients compared with 69% of male patients, and the latter was prescribed in 25% of male patients compared with 3% of female patients. We did not investigate for the presence of concurrent COPD in our patients.

More patients said they would discuss their medication with the doctor (with whom they always had consultation time) than with the pharmacist, who they did not associate with counseling (Table 4 ). Forty-three percent of the sample spontaneously stopped their medication when they felt they were well. Advice on the use of a spacer device (AeroChamber; Boehringer Ingelheim) was given to very few patients (19%) and was given least frequently to elderly patients (6%; p < 0.0001). The majority of patients (88%) received a demonstration of the correct pMDI technique, and 90% were confident that they were using it correctly. However, many patients (35%) said that they observed drug mist escaping when they inhaled under respiratory stress in the congested state, and some patients (11%) reported this observation every time they used the pMDI (Table 4). More children and older patients saw escaping drug every time the inhaler was used compared with other patients (p < 0.0001). Few patients (5%) could tell when the canister was reaching empty status in order to replenish it in time.

Two hundred fifty patients (62%) said that they had received explanations of the benefits of using different inhaler treatments, and 212 patients (53%) provided the accurate reasons (Table 5 ). Compared with other age groups, fewer elderly patients received these explanations and could relate the correct reasons for the use of their inhalers for asthma relief and prevention (p < 0.001). More female than male patients could explain the need for relief and prevention therapy (57% vs 46%, respectively), although the difference failed to reach statistical significance (p = 0.04).

pMDI Technique

Although 90% of the patients in the sample were confident that they had used the correct inhaler technique, and although at least 70% were proficient in individual steps, only 33% of patients (134) demonstrated using all the steps correctly (Table 6 ). There were significant gender-related and age- related associations for correct performance. More female than male patients performed all steps of inhalation correctly (38% vs 26%, respectively) [p < 0.01], and fewer pediatric patients (24%) and elderly patients (24%) were able to use the inhaler correctly (p < 0.003). Almost half the patients in the sample proceeded with the second actuation without waiting the prescribed 60 s following the previous actuation. In addition, more children (30%) and elderly patients (37%) failed to hold their breath after inhaling (p < 0.0001), and more elderly patients (51%) immediately actuated the inhaler on the second occasion when compared with the other patient groups (p < 0.01).

Compliance With pMDI

Two hundred forty-one patients (60%) reported that they had been compliant with the prescribed treatments and had not missed any doses. On further questioning, 175 patients (43%) said that they had stopped using their medications when they felt well, highlighting the necessity of probing into patient impressions and beliefs. Female patients were more likely to stop their medication when they felt well compared with male patients (p < 0.0001). Only 63 patients (16%) received their medication regularly at the clinic pharmacy, and more children (35%) than other patients got their prescriptions filled (p < 0.004). Patients had to wait in long queues to get their prescriptions filled at the clinic pharmacy, and 58% of patients said that they could not afford to “wait and waste” that time. Often, the pharmacy was unable to dispense pMDI medications, not having received supplies, mandating patients to purchase their medication at private pharmacies. Patients who have to buy their own medication are not reimbursed, and, because of the cost of private purchase, 52% of them were unable to comply with treatment.

This study was prompted by the need to review the use of medications for the relief and prevention of asthma following the development and dissemination of use asthma guidelines for the Caribbean. The data provided an insight into the prescribing trends for patients with asthma in Trinidad, which is the largest country in the southern Caribbean, and is the second largest country among English-speaking countries in the Caribbean. The results reflect the regular use of inhaled salbutamol rather than inhaled corticosteroids in the management of asthma. These findings were disturbing, especially since the study was conducted not long after a joint expert committee from the region and the GINA met to formulate guidelines for the management and prevention of asthma in the Caribbean. The study is limited in that the diagnosis of asthma was not validated by specific tests for reversible airway obstruction, and it does not represent the conditions of the management of asthma in the community setting. In addition, although we attempted to study the use of oral medications that had been prescribed in the chest clinic (beclomethasone, salbutamol, and theophylline), the data were not recorded in a consistent manner to allow for proper analysis.

Therapy with inhaled β2-agonist agents was prescribed for 98% of patients. It was very encouraging to observe that 83% of the patients in the sample had received prescriptions for inhaled steroids, but age remained an important predictor for the utilization of inhaled steroids. The lowest utilization of inhaled steroid therapy was observed in patients < 13 years of age and in those aged > 65 years. The underuse of inhaled corticosteroids has been reported in patients treated by primary-care providers, among whom only 30% of asthmatic patients who were ≥ 65 years18and just 46% of children in managed care received prescriptions for inhaled steroids.19We think that our patients received a high level of asthma care from attending specialist physicians, which is reflected in the comparatively high rate of prescription of inhaled steroids. This finding, which is supported by the results of other reports,2021 is demonstrated in the changing trends of drug prescriptions made by US physicians over a period of > 28 years.22 However, physician concerns about the safety of inhaled steroid therapy in elderly and young patients, patient expectations directing physician behavior to provide medication for symptom relief, and patient perceptions of the lack of immediate response from inhaled steroids21 are plausible explanations for the significant age-related underutilization of inhaled steroids in our patients.

Inhaled salbutamol, the use of which is advised only for symptom relief, was routinely prescribed at every visit in all age groups of the population. This finding invites concern. Wheezing may provoke well-intentioned physicians to focus on quick, dramatic relief with the regular and even long-term use of inhaled β-agonist agents, which is a behavior that is associated with death23and deleterious effects in the lungs.24Patients felt that this treatment was more important in managing their asthma, and it ensured that they regularly took it rather than a medication that would control their asthma. This attitude is reflected in their requests for the pharmacy to keep them regularly supplied with salbutamol. Clearly, there is a need for constant education about inhaler medications because although many patients indicated correct knowledge about medication for asthma prevention and relief, we found a separation between the recommended and actual use of these medications by patients. A failure to instruct patients about different inhalers and about how to use the inhaler and to reinforce these instructions decreases compliance and inhaler efficacy.25

The effectiveness of inhaled steroid therapy is consequent to patient compliance, inhalation technique (ie, adequate drug deposition in the lung), and the use of a spacer device. Noncompliance among our patients was mainly consequent to the pharmacoeconomics of personal purchase and the failure to get the drug from having to wait a long time at the pharmacy to receive free supplies. The Ministry of Health in Trinidad and Tobago must outline strategies to ensure the adequate supply and distribution of inhaled steroids for use in therapy with which to manage the condition of patients with asthma, thereby preempting emergency hospital admissions. This is important because the cost of emergency hospital admissions exceeds many times that of medication. It may also be opportune to consider a concern voiced by the clinic physicians for focused attention on pediatric and adult patients in separate clinics.

Poor pMDI technique in our patients is a significant finding that is supported by just 33% of them inhaling correctly. Elderly patients were advised least often to use a spacer. Their poorer performance was particularly evident at crucial steps with immediate actuation of the inhaler on the second occasion and (along with children) at the breath-hold stage. Previously, we reported that these two age groups should be targeted for intensive patient education to maximize medication benefit and participation in disease management.16 Other work supports our findings of suboptimal inhaler technique,26the presence of many patients who did not have knowledge about the action of their drugs,2728 and few elderly patients receiving inhaled steroids20 or having an understanding of the roles of different asthma medications.16 We also found a void between reality and patient beliefs about good compliance with the widespread cessation of prevention therapy when they were feeling well. Our findings draw attention to the prevailing paradigm that information dissemination must include verbal instructions, demonstrations, and practice sessions and that these must be checked periodically to ensure that patient skills have not been eroded,29enhancing the gains from practice-based education. The latter include reduced patient suffering and increased cost-efficacy, as described by the World Asthma Meeting Education and Delivery of Care Working Group.30 We recommend that this education for patients specifically addresses the role of relief and control medications, the correct technique for pMDI and spacer use, and even the need for physicians to know, teach, and check patient inhaler techniques. Programs to improve compliance and inhaler techniques should become an integral component of asthma management in the Caribbean.

The significant female to male adult prevalence of asthma (60% vs 40%, respectively) among our patients is similar to that in other published reports.29,31The higher rate of use of inhaled steroid preparations among female patients may reflect their greater concern for health matters, their ready seeking of medical care, and their taking better care of themselves,32as evidenced by more women who correctly explained the rationale for their therapies and inhaled correctly. In a 10-year retrospective study of admitted high-risk asthmatic patients, female patients outnumbered male patients by two to one, tended to have longer hospital stays, but were less hypercapneic than were high-risk male patients.33 Research on gender-related differences in ventilatory responses to airflow obstruction or hypercapnia in our population might prove interesting.

Guidelines for the management of asthma have proliferated across countries, but current practices indicate poor adherence to national3435 and international27 guidelines. The introduction of such guidelines into the Caribbean region signals an awareness for the need for better asthma control in the region. Based on the ratio of the use of β2-agonist to anti-inflammatory agents and of inhaled therapy vs oral therapy and nebulized medication, Barbadian doctors were reported to have good adherence to guidelines. However, that study was conducted with the index points of 1987 and 1996, prior to the development of the regional guidelines.,36 Although a large percentage of our patients was prescribed prevention therapy by specialist physicians, when compared with other surveys, the regular use of inhaled salbutamol remains disturbing. We think that our study may have been conducted too early, before the full impact of the guidelines was appreciated, and that perhaps the dissemination of the guidelines was inadequate. While local adaptation of the guidelines may be practical, they are unlikely to be effective without a defined strategy for their implementation27 and dissemination. Guidelines present an effective mechanism to alter physician behavior and to encourage patient response, but they remain written dogmas unless they are associated with proactive administrative changes and educational strategies to improve patient outcomes.

This study stresses the need for the administrative authorities and asthma caregivers in Trinidad, and perhaps in the wider Caribbean region, to plan strategies to disseminate and implement the guidelines to optimize therapy and compliance with the use of inhaled steroids and to reduce asthma morbidity, particularly in young and elderly patients. The data direct attention to instituting protocols to diagnose, assess, follow-up, and educate patients about their disease. There is no structured pathway in Trinidad, or to our knowledge in the Caribbean region for the management of asthma. Now perhaps is the time to initiate the process. The study identifies deficiencies in patient knowledge and inhaler technique, and a reliance on prescribed relief therapy, indicating a need to institute a plan of action for patient self-management and for strategies to address the lack of response to therapy by health administrators. Studies in other Caribbean territories will determine how well the guidelines have been implemented and the level of patient compliance with them, and will identify barriers, if any exist, to the appropriate management of asthma to prevent a lack of response to asthma therapy.

Abbreviations: GINA = Global Initiative for Asthma; pMDI = pressurized metered-dose inhaler

Table Graphic Jump Location
Table 1. Demographic Characteristics of the Sample
Table Graphic Jump Location
Table 2. Patients for Whom Inhaler Medications Were Prescribed
Table Graphic Jump Location
Table 3. pMDI Drugs Prescribed by Age in Asthmatic Patients in Trinidad*
* 

Values given as No. (%), unless otherwise indicated. NS = not significant.

Table Graphic Jump Location
Table 4. pMDI Use, Knowledge, and Technique in Patients
Table Graphic Jump Location
Table 5. Understanding of Inhaler Use by Age Group*
* 

Values given as No. (%).

 

p < 0.0001.

Table Graphic Jump Location
Table 6. Patients Correctly Performing Steps of Inhalation

The authors thank Dr. Martyn R. Partridge, Whipps Cross Hospital (London, UK), for guiding us in our focus on patient education and self-management of asthma. Drs. Albert Persaud and Dottin Ramoutar gave us permission to study patients in the clinic. Professors Amanda McCrae and Peter Knott critically reviewed the manuscript.

Pearson, RS (1973) Asthma in Barbados.Clin Allergy3,289-297. [PubMed] [CrossRef]
 
Naidu, RP Use of the log book in a quality assurance exercise in the hospital emergency department in Barbados [abstract]. West Indian Med J. 1990;;39(suppl) ,.:44
 
Sears, MR Descriptive epidemiology of asthma.Lancet1997;350(suppl),1-4
 
Mannino, DM, Homa, DM, Pertowski, CA, et al Surveillance for asthma: United States, 1960–1995.MMWR Morb Mortal Wkly Rep1998;47,1-27. [PubMed]
 
Howitt, ME Asthma management in the Caribbean: an update.Postgrad Doctor Caribbean2000;16,86-104
 
Kaur, B, Anderson, HR, Austin, J, et al Prevalence of asthma symptoms, diagnosis, and treatment in 12–14 year old children across Great Britain (International Study of Asthma and Allergies in Childhood, ISAAC, UK)BMJ1998;316,118-124. [PubMed]
 
Howitt, ME, Roach, TC, Naidu, R Prevalence of childhood asthma and allergy in Barbados: the Barbados National Asthma and Allergy Study [abstract]. Am J Respir Crit Care Med. 1997;;157 ,.:A642
 
Tam Tam, HB, Deva Taka, M, Ganganaidu, K, et al Prevalence of asthma related symptoms in school children in Port of Spain, Trinidad [abstract]. West Indian Med J. 1998;;47(suppl) ,.:22
 
Mellis, CM, Peat, JK, Woolcock, AJ The cost of asthma: can it be reduced?Pharmacoeconomics1993;3,205-219. [PubMed]
 
Devoy, MAB, Fuller, RW, Palmer, JBD Asthma mortality and β-agonists.Chest1995;108,1116-1124
 
Suissa, S, Ernst, P Optical illusions from visual data analysis: example of the New Zealand asthma mortality epidemic.J Clin Epidemiol1997;50,1079-1088. [PubMed]
 
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Figures

Tables

Table Graphic Jump Location
Table 1. Demographic Characteristics of the Sample
Table Graphic Jump Location
Table 2. Patients for Whom Inhaler Medications Were Prescribed
Table Graphic Jump Location
Table 3. pMDI Drugs Prescribed by Age in Asthmatic Patients in Trinidad*
* 

Values given as No. (%), unless otherwise indicated. NS = not significant.

Table Graphic Jump Location
Table 4. pMDI Use, Knowledge, and Technique in Patients
Table Graphic Jump Location
Table 5. Understanding of Inhaler Use by Age Group*
* 

Values given as No. (%).

 

p < 0.0001.

Table Graphic Jump Location
Table 6. Patients Correctly Performing Steps of Inhalation

References

Pearson, RS (1973) Asthma in Barbados.Clin Allergy3,289-297. [PubMed] [CrossRef]
 
Naidu, RP Use of the log book in a quality assurance exercise in the hospital emergency department in Barbados [abstract]. West Indian Med J. 1990;;39(suppl) ,.:44
 
Sears, MR Descriptive epidemiology of asthma.Lancet1997;350(suppl),1-4
 
Mannino, DM, Homa, DM, Pertowski, CA, et al Surveillance for asthma: United States, 1960–1995.MMWR Morb Mortal Wkly Rep1998;47,1-27. [PubMed]
 
Howitt, ME Asthma management in the Caribbean: an update.Postgrad Doctor Caribbean2000;16,86-104
 
Kaur, B, Anderson, HR, Austin, J, et al Prevalence of asthma symptoms, diagnosis, and treatment in 12–14 year old children across Great Britain (International Study of Asthma and Allergies in Childhood, ISAAC, UK)BMJ1998;316,118-124. [PubMed]
 
Howitt, ME, Roach, TC, Naidu, R Prevalence of childhood asthma and allergy in Barbados: the Barbados National Asthma and Allergy Study [abstract]. Am J Respir Crit Care Med. 1997;;157 ,.:A642
 
Tam Tam, HB, Deva Taka, M, Ganganaidu, K, et al Prevalence of asthma related symptoms in school children in Port of Spain, Trinidad [abstract]. West Indian Med J. 1998;;47(suppl) ,.:22
 
Mellis, CM, Peat, JK, Woolcock, AJ The cost of asthma: can it be reduced?Pharmacoeconomics1993;3,205-219. [PubMed]
 
Devoy, MAB, Fuller, RW, Palmer, JBD Asthma mortality and β-agonists.Chest1995;108,1116-1124
 
Suissa, S, Ernst, P Optical illusions from visual data analysis: example of the New Zealand asthma mortality epidemic.J Clin Epidemiol1997;50,1079-1088. [PubMed]
 
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