Asthma is a frequent chronic respiratory condition in which the airways in the lungs narrow and become inflamed with periodic attacks of wheezing, shortness of breath, chest tightness, and cough [1]. It is an important cause of impaired quality of life, emergency department attendance, hospitalization, and loss of productivity among adults and can affect people of all ages [2]. Despite the availability of effective pharmacologic therapy, it is difficult to achieve and sustain good asthma control in clinical practice. Asthma exacerbations, activity limitation, health care utilization, severe or potentially life-threatening attacks, frequent symptoms and nocturnal awakenings are all associated with poorly controlled asthma [3]. The key goals of asthma control are to minimize symptoms, avoid the complications of asthma and the side effects of treatment, and avoid worsening of the disease in the future. Therefore, it is essential that asthma control is assessed as part of patient follow-up [4].

 Control can be assessed by the number of symptoms experienced during the day and night, the number of activities that are limited, the need for a reliever medicine, and whether there are any exacerbations. Tools like the Asthma Control Test that have been validated can give a consistent measurement of disease control and can be used to pinpoint those patients needing treatment adjustments [5]. Poor control, however, does not necessarily mean that patients are not taking enough medication, as multiple factors can affect the therapeutic response, such as adherence to medication, exposure to triggers, smoking, comorbidities, and inhaler technique [6].

The use of inhaled medications is the foundation of asthma management as it is the most effective way to ensure the drug reaches the airways while avoiding systemic exposure. Correct use of the inhaler device prescribed is a major factor in the clinical effectiveness of inhaled corticosteroids, inhaled bronchodilators and inhaled combination products [7]. There are several steps to ensuring correct inhaler technique, such as device preparation, positioning, the inhalation maneuver, and breath-holding post-inhalation, which must be completed for the device [8]. Any failure at any step can significantly decrease the amount of drug delivered to the lower airway and thus the therapeutic effect, even when the drug is prescribed correctly. Common mistakes include not exhaling before inhaling, failure to coordinate the process of pressurised metered dose inhalers, inadequate inspiration during the use of a dry powder inhaler and not holding the breath after the drug has been inhaled [9].

 Many adult patients with asthma still have poor inhaler technique, which can lead to continued symptoms, apparently uncontrolled asthma, unnecessary step-up in treatment and an increased risk of asthma attack [10]. The problem may be particularly important in settings where patients have limited access to structured asthma education or regular reassessment of inhaler technique [11]. Inhaler technique is a modifiable factor, so if an incorrect technique is identified, it would be possible to intervene relatively easily, and this could have a significant impact on treatment outcomes. Thus, the clinical significance of both asthma control assessments and inhaler technique assessments exists, as they can help identify whether the poor disease control is due to treatment failure, poor inhaler technique or disease severity [12,13].

Objective

The present study is designed to assess the level of asthma control and inhaler technique among adult patients and to determine the relationship between inhaler use and asthma control, thereby identifying areas that may benefit from targeted patient education and improved clinical follow-up.

A descriptive cross-sectional study was conducted at department of Pulmonology, Hamdard University Hospital, Karachi from April 2025 to April 2026. A total of 246 bronchial asthma adult-patients were enrolled in this study. Non-probability consecutive sampling technique was used. A total of all eligible patients who appeared during the study period and met the selection criteria were approached to participate in the study until the desired number of patients was reached. Adults (18 years and over), both male and female, who had been diagnosed with bronchial asthma by a physician and who were taking at least one inhaler for their asthma were included. Inhaler therapy was used for at least one month and written informed consent was obtained from patients. Patients were excluded if they had acute severe asthma that needed to be treated in the emergency room, COPD, bronchiectasis, interstitial lung disease, had active pulmonary tuberculosis, any cognitive impairment or severe psychiatric disease to the point of not being able to fully assess inhaler technique. Informed consent was also not obtained and not obtained by patients who were not able or willing to participate. Data Collection Procedure Following the IRB approval, eligible patients in the outpatient department were recruited. Informed consent was sought prior to enrollment in writing. A structured data collection form was completed to record demographic and clinical information such as age, sex, level of education, duration of asthma, smoking status, time of inhaler use, inhaler device type, any previous asthma related hospital admissions and previous asthma exacerbations. The Asthma Control Test (ACT) was used to measure asthma control. The ACT had five questions: activity limitation, shortness of breath, nighttime symptoms, rescue medicine use and the patient's overall perception of control of asthma over the past 4 weeks. The range of the total score was 5 to 25. Asthma was grouped as well controlled (ACT 20-25), not well controlled (ACT 16-19) or very poorly controlled (ACT ≤ 15). Technique for inhaler use was evaluated by having each subject show the investigator how to use his or her prescribed inhaler. Evaluation of technique was done with a standardized checklist that is specific to the device. All the key steps were identified and marked as correct or incorrect. Specific attention was paid to critical steps that impact pulmonary drug delivery, such as device preparation, exhalation prior to inhalation, positioning of the mouthpiece, correct inspiratory maneuver, and breath-holding after inhalation (where appropriate) and coordination of actuation and inhalation. Patients who missed one or more of the critical steps were assigned to the incorrect inhaler technique group, and patients who did all the critical steps were assigned to the correct inhaler technique group. The main outcome measures were asthma control status and inhaler technique. Independent variables were age, sex, education level, length of time with asthma, length of time inhaler use, type of inhaler device, smoking status, previous inhaler training, frequency of follow-up of children, and previous asthma-related exacerbations or hospitalizations. Data Analysis The program IBM SPSS Statistics version 29.0 was used to enter and analyze the data. The Shapiro–Wilk test was used to determine normality of continuous variables (age, duration of asthma and ACT score), which were then reported as mean ± standard deviation or median with interquartile range. Frequencies and percentages were used to present categorical variables. Relationships between demographic and clinical features and asthma control and inhaler technique were also examined. Factors with clinical relevance and significance on univariate analysis were put into a multivariable logistic regression model to determine independent variables associated with poor asthma control. Odds ratios were adjusted for 95% confidence intervals. A p-value <0.05 was considered statistically significant.

A total of 246 adult patients with bronchial asthma were included in the study. The mean age of the participants was 43.7 ± 13.6 years. Females constituted 142 (57.7%) of the study population, while 104 (42.3%) were males. The mean duration of asthma was 8.6 ± 6.4 years, and the mean duration of inhaler use was 6.9 ± 5.3 years. Overall, 155 (63.0%) patients demonstrated incorrect inhaler technique, while 91 (37.0%) used their inhaler correctly. Based on the Asthma Control Test, 82 (33.3%) patients had well-controlled asthma, 71 (28.9%) had not well-controlled asthma, and 93 (37.8%) had very poorly controlled asthma.

Table 1. Demographic and Clinical Characteristics of Study Participants (n = 246)

The majority of patients were female, representing 57.7% of the study population. More than half of the patients had not received formal training regarding inhaler use. Incorrect inhaler technique was observed in nearly two-thirds of the participants, while approximately 42% reported at least one asthma exacerbation during the preceding year.

Table 2. Asthma Control According to Asthma Control Test (ACT) (n = 246)

Only 82 (33.3%) patients had well-controlled asthma. In contrast, 164 (66.7%) patients had suboptimal asthma control, including 71 (28.9%) with not well-controlled asthma and 93 (37.8%) with very poorly controlled asthma. The overall mean ACT score was 16.8 ± 4.7.

Table 3. Distribution of Common Errors in Inhaler Technique (n = 246)

The most frequent error was failure to exhale adequately before inhalation, observed in 124 (50.4%) patients, followed by failure to hold the breath after inhalation in 117 (47.6%). Incorrect inhalation maneuver was noted in 96 (39.0%) patients. Overall, 155 (63.0%) patients committed at least one critical inhaler error.

Table 4. Association Between Inhaler Technique and Asthma Control (n = 246)

A statistically significant association was observed between inhaler technique and asthma control (χ² = 42.24, p<0.001). Among patients using their inhaler correctly, 57.1% had well-controlled asthma, compared with only 19.4% of patients with incorrect technique. Conversely, very poorly controlled asthma was observed in 50.3% of patients with incorrect technique compared with 16.5% of those demonstrating correct technique.

Table 5. Comparison of ACT Score According to Inhaler Technique

Patients with correct inhaler technique had a significantly higher mean ACT score compared with those using their inhaler incorrectly (20.1 ± 3.4 vs 14.8 ± 4.1, p<0.001), indicating substantially better asthma control among patients demonstrating appropriate inhaler use.

Table 6. Factors Associated with Poor Asthma Control on Multivariable Logistic Regression

The authors of the present study evaluated asthma control and inhaler technique in 246 bronchial asthma adult patients. The results indicated both poor asthma control and poor inhaler technique were very common. A minority of participants (33.3%) were classified as having well controlled asthma, 28.9% were classified as having not well controlled asthma and 37.8% were classified as having very poorly controlled asthma. Additionally, at least one critical inhaler technique error was shown by 63.0% of the participants. These results indicate that suboptimal inhaler use may play a significant role in the lack of asthma control in the real-world setting. The relative high number of patients with uncontrolled asthma seen in this study is clinically relevant. Even with the availability of effective inhaled asthma medications, asthma control may not be optimal if treatment is not administered to the lower airways. Previous studies have also shown that many adults with asthma are poorly controlled despite their use of maintenance inhaler therapy [14]. This could be due to disease-related factors, lack of adherence, environmental exposures, comorbidities, smoking, poor follow-up, and poor inhaler technique. The average ACT score among the present study population of 16.8 ± 4.7 further supports that there was a high prevalence of poor symptom control. Fifteen-five (63.0%) patients had incorrect inhaler technique. This is in line with other studies that have found that inhaler use errors continue to be prevalent amongst people with chronic respiratory conditions. Inhaler devices require a series of coordinated steps and if one or more steps at critical points are not completed properly, the inhalation of the drug can reduce significantly the drug deposition in the lungs [15]. The most common mistakes in the present study were missing a proper exhalation before inhalation, missing a proper breath-hold after inhalation, and a wrong inhalation manoeuvre. These steps have been shown in previous studies to be steps that are frequently not followed when taking inhalers. These errors can lead to less drug delivered to the airways (by inhaled drugs) and therefore decrease the effectiveness of the treatment. One of the most significant results of the current study was the correlation between inhaler use and asthma control [16]. Of all those who used the inhaler correctly, 57.1% had well controlled asthma, whereas only 19.4% of those who used it incorrectly had well controlled asthma. Patients who had incorrect technique had much higher rates of very poorly controlled asthma (50.3% vs. 16.5%). This difference was significant at the 0.05 level. These findings have been echoed in previous studies, which have shown that patients who make critical errors with their inhalers are more likely to report poor asthma control, exacerbations, frequent use of relievers and persistent symptoms [17]. The data presented here confirm the notion that assessment of inhaler technique should be viewed as a necessary follow-up measure and not only as an educational step during the first time prescribing. ACT scores also varied significantly based on inhaler technique. The mean ACT score for patients who demonstrated correct technique was 20.1 ± 3.4, while the mean ACT score for patients who demonstrated incorrect technique was 14.8 ± 4.1. This clinically significant difference is also statistically significant, which further strengthens the clinical link between the delivery of the correct drug and the control of the asthma. Structured inhaler education and correcting the common errors have been shown to lead to similar gains in symptom control in previous publications [18]. This is particularly important, as sometimes, inadequate control of asthma can cause clinicians to unnecessarily prescribe high doses of medications or even extra treatments when the real issue is the use of the inhaler. From the present study it was also found that previous inhaler training was an important factor. Over half of participants had no formal training and no previous training was independently associated with poor asthma control. Previous studies have shown that giving patients repeated demonstrations of the inhaler technique are more successful in achieving correct use of the inhaler than repeating verbal instructions. Technique, however, can become faulty over time and so it is important to reassess during later clinic visits. So, it is important for health care providers to not assume that a long-term inhaler use is being conducted in the right way [19,20]. There were several limitations in the present study. First, because of its cross-sectional design, it was not possible to draw a causal conclusion between asthma control and inhaler technique. Second, the study had been performed in one tertiary care centre, thus possibly restricting the generalisability of the results to patients receiving care in primary-care clinics or other health-care facilities. Third, the control of asthma was evaluated by the Asthma Control Test and this is partly based on patients' symptoms, where recall bias and subjective perception may play a role. Fourth, this was a one-time demonstration of inhaler technique, which may have been different than usual because the patient knew they were being examined for technique. Furthermore, treatment adherence, allergen exposure in the environment, socioeconomic factors, the type and dosage of medication and relevant comorbidities were not evaluated in detail and could have affected the control of asthma symptoms. Lastly, parameters of pulmonary function (spirometry) were not included in the primary assessment, restricting the objective assessment of airflow limitation. Further large prospective studies with multiple assessments of inhaler technique, adherence, lung function, and clinical outcomes are suggested to confirm these conclusions.

It is concluded that the poorly controlled asthma and improper inhaler technique were frequent among adult patients with bronchial asthma. Many patients had significant problems with inhaler technique, including inadequate exhalation before inhalation, use of the inhalation maneuver, and inability to hold the breath after inhalation. There is a significant difference between asthma control and ACT scores between patients using inhalers correctly and those who use them incorrectly. Poor asthma control was related to incorrect inhaler technique, absence of inhaler training, smoking, longer duration of asthma and recent history of exacerbation. The results underpin the need to routinely evaluate inhaler technique in clinical settings and to offer repeated, structured, inhaler education to enhance treatment efficacy and asthma control.

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