Objective: To assess asthma patients in Brazil in terms of the level of asthma control, compliance with maintenance treatment, and the use of rescue medication. Methods: We used data from a Latin American survey of a total of 400 asthma patients in four Brazilian state capitals, all of whom completed a questionnaire regarding asthma control and treatment. Results: In that sample, the prevalence of asthma was 8.8%. Among the 400 patients studied, asthma was classified, in accordance with the Global Initiative for Asthma criteria, as controlled, partially controlled, and uncontrolled in 37 (9.3%), 226 (56.5%), and 137 (34.3%), respectively. In those three groups, the proportion of patients on maintenance therapy in the past four weeks was 5.4%, 19.9%, and 41.6%, respectively. The use of rescue medication was significantly more common in the uncontrolled asthma group (86.9%; p < 0.001). Conclusions: Our findings suggest that, in accordance with the established international criteria, asthma is uncontrolled in the vast majority of asthma patients in Brazil. Maintenance medications are still underutilized in Brazil, and patients with partially controlled or uncontrolled asthma are more likely to use rescue medications and oral corticosteroids.

Keywords: Asthma/therapy; Asthma/prevention and control; Medication adherence.

Objective: To evaluate the impact of asthma on activities of daily living and on health status in patients with controlled, partially controlled, or uncontrolled asthma in Brazil. Methods: We used data related to 400 patients in four Brazilian cities (São Paulo, Rio de Janeiro, Salvador, and Curitiba), obtained in a survey conducted throughout Latin America in 2011. All study subjects were > 12 years of age and completed a standardized questionnaire in face-to-face interviews. The questions addressed asthma control, hospitalizations, emergency room visits, and school/work absenteeism, as well as the impact of asthma on the quality of life, sleep, and leisure. The level of asthma control was determined in accordance with the Global Initiative for Asthma criteria. Results: Among the 400 respondents, asthma was controlled in 37 (9.3%), partially controlled in 226 (56.5%), and uncontrolled in 137 (34.2%). The numbers of patients with uncontrolled or partially controlled asthma who visited the emergency room, who were hospitalized, and who missed school/work were higher than were those of patients with controlled asthma (p = 0.001, p = 0.05, and p = 0.01, respectively). Among those with uncontrolled asthma, the impact of the disease on activities of daily living, sleep, social activities, and normal physical exertion was greater than it was among those with controlled or partially controlled asthma (p < 0.001). Conclusions: In Brazil, asthma treatment should be monitored more closely in order to increase treatment adherence and, consequently, the level of asthma control, which can improve patient quality of life and minimize the negative impact of the disease.

Objective: To determine whether a low level of education is a risk factor for uncontrolled asthma in a population of patients who have access to pulmonologists and to treatment. Methods: This was a cross-sectional study involving outpatients > 10 years of age diagnosed with asthma who were followed by a pulmonologist for at least 3 months in the city of Jundiai, located in the state of São Paulo, Brazil. The patients completed a questionnaire specifically designed for this study, the 6-item Asthma Control Questionnaire (to assess the control of asthma symptoms), and a questionnaire designed to assess treatment adherence. Patients underwent spirometry, and patient inhaler technique was assessed. Results: 358 patients were enrolled in the study. Level of education was not considered a risk factor for uncontrolled asthma symptoms (OR = 0.99; 95% CI: 0.94-1.05), spirometry findings consistent with obstructive lung disease (OR = 1.00; 95% CI: 0.99-1.01), uncontrolled asthma (OR = 1.03; 95% CI: 0.95-1.10), or the need for moderate/high doses of inhaled medication (OR = 0.99; 95% CI: 0.94-1.06). The number of years of schooling was similar between the patients in whom treatment adherence was good and those in whom it was poor (p = 0.08), as well as between those who demonstrated proper inhaler technique and those who did not (p = 0.41). Conclusions: Among asthma patients with access to pulmonologists and to treatment, a low level of education does not appear to be a limiting factor for adequate asthma control.

Keywords: Asthma; Educational status; Spirometry; Treatment adherence and compliance.

Objective: To evaluate the use of inhaler devices by patients with severe asthma treated via the Programa para o Controle da Asma e Rinite Alérgica na Bahia (ProAR, Bahia State Asthma and Allergic Rhinitis Control Program), recording the frequency of their errors in performing key steps and the relationship between such errors and the lack of asthma control. Methods: A cross-sectional study involving 467 patients enrolled in the ProAR in the city of Salvador, Brazil. The devices evaluated were metered dose inhalers (MDIs), with or without a spacer, and dry powder inhalers (DPIs; Pulvinal® or Aerolizer®). For the assessment of the inhalation technique, a checklist was used; the patients were asked to demonstrate the technique so that an interviewer could observe all of the steps performed. For the assessment of asthma control, we used the 6-item asthma control questionnaire. Results: Most of the patients showed appropriate inhalation techniques when using the devices. When using an MDI, few patients made mistakes in the key step of "coordinating activation and inhalation" (5.2% and 9.1% with and without the use of a spacer, respectively). During Pulvinal® use, 39% of the patients did not inhale quickly and deeply, compared with only 5.8% during Aerolizer® use. Of the patients that made use of Aerolizer® alone, 71.3% appropriately performed all of the essential steps, and their asthma was controlled. Conclusions: Most of the patients in this sample, all of whom had been submitted to periodic checks of their inhalation technique (as part of the program), used the devices appropriately. Proper inhalation technique is associated with asthma symptom control.

Keywords: Asthma; Administration, inhalation; Metered dose inhalers; Dry powdered inhalers.

Objective: To investigate the level of agreement between the GINA questionnaire and the Asthma Control Test (ACT) in children and adolescents with asthma, as well as to compare the clinical, laboratory, and spirometric characteristics of patients with controlled and uncontrolled asthma as assessed by the two questionnaires. Methods: Children and adolescents with asthma had their level of asthma control cross-sectionally assessed by the GINA questionnaire and the ACT, the Childhood ACT (C-ACT) being used for the children in the sample. The participating patients also underwent spirometry, clinical assessment (for passive smoking, asthma severity, medication use, and type of inhaler device used), and laboratory measurements of vitamin D levels, blood eosinophils, and total IgE. Results: A total of 76 patients were assessed. Of those, 62% were male, and the mean age was 10 [9-12] years. In addition, 42% and 20% were classified as having uncontrolled asthma by the GINA questionnaire and the C-ACT/ACT, respectively. There was moderate agreement between the two questionnaires regarding identification of controlled and uncontrolled asthma (? = 0.505; p < 0,0001). The patients classified as having uncontrolled asthma by the GINA questionnaire had worse results in terms of daily inhaled corticosteroid dose, asthma severity, passive smoking, and spirometric parameters (FVC, FEV1, and FEF25-75%). However, there was no significant difference between patients classified as having controlled or uncontrolled asthma by the C-ACT/ACT. Conclusions: In children and adolescents with asthma, the level of agreement between the GINA questionnaire and the C-ACT/ACT appears to be moderate. The GINA questionnaire appears to have a stronger association with functional parameters, indicating better clinical assessment with less underreporting of uncontrolled asthma.

Keywords: Asthma; Pediatrics; Surveys and questionnaires; Therapeutics.

Objective: To determine the proportion of asthma patients with poor perception of asthma control and to evaluate the characteristics of this subgroup. Methods: A cross-sectional study in which consecutive outpatients (over the age of 12) with mild, moderate, or severe asthma were selected. The patients underwent clinical examination, and pulmonary function tests, as well as being assessed for depression and perception of asthma control. The degree of concordance between patients and physicians regarding the perception of asthma control was determined. Patients with good perception of asthma control were compared, in terms of characteristics, with those presenting poor perception. Results: The degree of concordance between patients and physicians regarding the perception of asthma control was low (kappa index = 0.5). Of the 289 patients included, 66 (23%) presented poor perception of asthma control. The preliminary univariate analysis revealed that the patients with poor perception of asthma control were older, had a lower income, and presented a lower degree of asthma severity. Those factors did not change in the multivariate analysis. There were no differences between the groups in terms of gender, frequency of having literate patients, duration of asthma symptoms, having been diagnosed with rhinitis, frequency of depression, pulmonary function, or treatment compliance. Conclusions: The incidence of poor perception of asthma control in asthma patients is high, especially in elderly patients with lower income and a lower degree of asthma severity.

Keywords: Asthma; Signs and symptoms; Asthma/therapy.

Objective: To evaluate the association between degree of asthma control and health-related quality of life in patients with moderate or severe asthma. Methods: This was a descriptive observational study involving 59 outpatients with moderate or severe asthma under treatment at the Asthma Outpatient Clinic of the Federal University of Ceará Walter Cantídio University Hospital, in the city of Fortaleza, Brazil. The patients were evaluated regarding sociodemographic and clinical characteristics, as well as spirometric parameters. The asthma control status was assessed using the asthma control test (ACT), and quality of life was assessed using the Saint George's Respiratory Questionnaire (SGRQ). Results: The mean age of the patients was 55.0 ± 12.4 years, and 76.3% were female. The ACT score showed statistically significant negative correlations with all SGRQ scores: total (r = −0.72); symptoms (r = −0.78); activity (r = −0.67); and impact (r = −0.68). Multiple regression analysis showed that the most robust predictive variables for SGRQ total score were ACT score (coefficient = −3.18; 95% CI: −4.14 to −2.23) and duration of disease (coefficient = −0.29; 95% CI: −0.54 to −0.03). The ACT score also explained the linear variation of the SGRQ domains: symptoms (coefficient = −3.41; 95% CI: −4.45 to −2.37); activity (coefficient = −3.07; 95% CI: −4.57 to −1.57); and impact (coefficient = −2.68; 95% CI: −3.71 to −1.65). Conclusions: The degree of asthma control appears to have a significant impact on health-related quality of life.

Keywords: Asthma/prevention and control; Quality of life; Questionnaires.

Asthma is characterized by variable airflow obstruction, hyperresponsiveness of airways to endogenous or exogenous stimuli and inflammation. Inadequacy of the techniques to use different inhalation devices is a cause of no response to treatment. The main purpose of this study was to evaluate how 20 medical students, 36 resident physicians on Internal Medicine/Pediatrics, and 40 asthma patients used three devices for inhalation therapy containing placebo. All patients were followed at the Pulmonary Outpatient Service of Botucatu Medical School and had been using inhaled medication during the last six months. The following devices were evaluated: metered dose inhalers (MDI), dry powder inhalers (DPI), and MDI attached to a spacer device. A single observer applied a protocol containing the main steps necessary to obtain a good inhaler technique to follow and grade the use of different devices. Health care professionals tested all three devices and patients tested only the device being used on their management. MDI was the device best known by doctors and patients. MDI use was associated with errors related to the coordination between inspiration and device activation. Failure do exhale completely before inhalation of the powder was the more frequent error observed with DPI use. In summary, patients have not been receiving repeated instruction on how to use inhaled medication and health care professionals are not well prepared to adequately teach their patients.

Background: Hypersensitivity to dust mites, mold and pet dander found in the home is common among patients with asthma. Home environmental control to reduce exposure to allergens is one of various therapeutic measures that can be taken. Objectives: To determine the prevalence of adequate home environmental control among a study population monitored by the Family Health Program and to identify any possible correlation with the exacerbation of asthma among children between the ages of 5 and 14 in the city of Camaragibe, located in the state of Pernambuco, Brazil. Method: A transversal study was carried out involving 210 mothers/guardians of children, to whom International Study of Asthma and Allergies in Children questionnaires were administered in order to characterize the exacerbation of asthma attacks. The Environment Assessment Guide of Allergic Patients was used to assess the bedrooms and living rooms in the home. Results: Among the 210 asthmatic children and adolescents evaluated in 2001, adequate home environmental control was observed in 141 (67.1%), and no correlation was observed between the degree of environmental control and fewer (< 3) asthma attacks (p = 0.39). Regarding the rooms where the asthmatic patients sleep, inappropriate furnishings were found in the homes of 93 patients (44.3%), including rag curtains in 84 cases (40.2%). Passive smoking was reported in 77 cases (36.7%). Conclusion: The level of home environmental control was satisfactory in the great majority of the residences, which may have contributed to the fact that no correlation was found between home environmental control and lower frequency of acute asthma attacks among the population studied.

Keywords: Key Words: Asthma. Environment Control. Frequency of Attacks.

Objective: The translation and cross-cultural adaptation of a specific scoring instrument for the comprehensive control of asthma, the Asthma Control Scoring System (ACSS), for use in Brazil. Methods: The protocol included ten steps: acquisition of written permission from the author of the ACSS; translation of the instrument to Brazilian Portuguese, carried out by three separate translators; analysis and comparison of the three versions by a review committee; literal back-translation to English; review and harmonization of the back-translation; acquisition of the approval of the original author; review of the translation by specialists; cognitive debriefing: test of clarity to, understanding by, and acceptance of the target population (evaluation of the translation by 10 health care workers); second cognitive debriefing: review of the revised version by a second group of health care workers; and reconciliation and preparation of the final version by the review committee. Results: The Brazilian Portuguese-language version of the ACSS showed clarity, understandability, and acceptability. The instrument was considered to be comprehensive because it includes the clinical manifestations of asthma, as well as the functional and inflammatory aspects of the disease. Conclusions: With the use of this careful methodology in the translation and cross-cultural adaptation of the ACSS, we have ensured its cultural adequacy for Brazil. The use of this instrument could facilitate future studies on asthma control.

Keywords: Asthma/classification; Asthma/prevention & control; Questionnaires.

Objective: To evaluate whether the Portuguese version of the Asthma Control Questionnaire (ACQ) is a valid instrument to measure asthma control in adult outpatients in Brazil. Methods: We selected 278 outpatients diagnosed with asthma. All of the patients completed the questionnaire, underwent spirometry and were clinically evaluated by a physician in order to characterize the control of the disease in the first visit. The questionnaire was evaluated in three versions, with 5, 6 and 7 questions, respectively, and scores of 0.75 and 1.50 were used as cut-off points. Results: Of the 278 patients, 77 (27.7%) had intermittent asthma, 39 (14.0%) had mild persistent asthma, 40 (14.4%) had moderate persistent asthma and 122 (43.9%) had severe persistent asthma. The sensitivity of ACQ to identify uncontrolled asthma ranged from 77% to 99%, and the specificity ranged from 36% to 84%. The positive predictive value ranged from 73% to 90%, and the negative predictive value ranged from 67% to 95%. The positive likelihood ratio ranged from 1.55 to 4.81, and the negative likelihood ratio ranged from 0.03 to 0.27. In the 5- and 6-question versions of the ACQ, the intraclass correlation coefficient was 0.92. These two versions were both responsive to clinical changes in the patients. Conclusions: All three versions of the ACQ satisfactorily discriminated between patients with uncontrolled asthma and those with controlled asthma. The 5- and 6-question versions also presented good reliability and responsiveness. Therefore, the ACQ is a valid tool for evaluating asthma control in adult outpatients in Brazil.

Keywords: Asthma; Therapeutics; Diagnosis; Questionnaires; Reproducibility of results.

Objective: To develop and validate a Portuguese-language version of the Asthma Control Test (ACT) for use in Brazil. Methods: The study comprised 290 asthma outpatients over 12 years of age. The patients completed the ACT questionnaire and had an appointment with a pulmonologist in order to assess asthma control in two visits. In the first visit, the patients also underwent spirometry. The second visit took place at least four weeks later. Results: We found that a cut-off score of 18 points-to differentiate between subjects with controlled asthma and those with uncontrolled asthma-had a sensitivity of 93%, a specificity of 74%, a negative predictive value of 86% and a positive predictive value of 85%. The positive and negative likelihood ratios were 3.58 and 0.09, respectively. The questionnaire has an outstanding capacity to differentiate uncontrolled asthma from controlled asthma, with an area under the ROC curve of 0.904. The patients whose symptoms remained stable between the two visits had similar scores, demonstrating good test-retest reproducibility, with an intraclass correlation coefficient of 0.93. The patients whose symptoms improved in the second visit had significantly higher scores, demonstrating good responsiveness of the questionnaire in the identification of changes in disease control. Conclusions: The Portuguese-language version of the ACT showed good test-retest reproducibility and was capable of discriminating the levels of asthma control and detecting changes in asthma control in a population of patients with a low level of education and low family income at a public health facility in Brazil.

Keywords: Asthma; Questionnaires; Validation studies; Signs and symptoms.

Objective: There is evidence that asthma is associated with an increase in psychiatric symptoms and mental disorders. This association can make it difficult to achieve asthma control. The purpose of this study was to determine whether the level of asthma control is associated with anxiety and depression. Methods: A cross-sectional study involving 78 patients with confirmed moderate or severe asthma and under regular treatment at the Asthma Outpatient Clinic of the Federal University of São Paulo Hospital São Paulo, in the city of São Paulo, Brazil. The patients were divided into two groups by asthma control status, as assessed by the asthma control test, and were subsequently compared in terms of demographic, clinical, and spirometric data, as well as scores for asthma quality of life and hospital anxiety/depression. Results: The sample was predominantly female. Of the 78 patients, 49 (63%) were classified as having uncontrolled asthma. The prevalence of anxiety and of anxiety+depression was significantly higher among patients with uncontrolled asthma than among those with controlled asthma (78% and 100%; p = 0.04 and p = 0.02, respectively), whereas there were no differences between the two groups in terms of the prevalence of depression, spirometry results, or quality of life score. Conclusions: In this sample, the prevalence of anxiety symptoms was higher in the patients with uncontrolled asthma than in those with controlled asthma.In the evaluation of asthma patients, the negative impact of mood states ought to be taken into consideration when asthma control strategies are being outlined.

Keywords: Asthma; Anxiety; Depression; Cross-sectional studies.

Objective: To determine whether the quality of life of adolescents with asthma correlates with parameters obtained prior to and after the six-minute step test (6MST); spirometric results after the 6MST; and level of physical activity. Methods: Nineteen adolescents with asthma, ranging from 11-15 years of age, were assessed with spirometry, 6MST, the International Physical Activity Questionnaire (IPAQ), the Pediatric Asthma Quality of Life Questionnaire (PAQLQ), and the 10-point Borg category-ratio scale. Results: Sensation of dyspnea correlated negatively with the total PAQLQ score (r = −0.54) and with the scores of its activity limitation (AL) and symptoms domains (r = −0.64 and r = −0.63, respectively), leg fatigue also correlating negatively with those same domains (r = −0.49 and r = −0.56, respectively). The total IPAQ score correlated with the total PAQLQ score (r = 0.47) and with the PAQLQ AL domain (r = 0.51); IPAQ time spent walking correlated with the PAQLQ symptoms domain (r = 0.45); and IPAQ time spent in vigorous activity correlated with the AL domain (r = 0.50). In the regression analysis, only sensation of dyspnea remained significantly correlated with the total PAQLQ score and the PAQLQ AL domain; leg fatigue remained significantly correlated with the symptoms domain. Conclusions: Higher levels of physical activity indicate better quality of life, as do lower perception of dyspnea and less leg fatigue. The 6MST proved to be a viable option for evaluating exercise capacity in adolescents with asthma, because it reflects the discomfort that asthma causes during activities of daily living.

Objective: To determine the risk factors for ER visits due to asthma exacerbations in patients monitored at a referral center. Methods: Prospective cohort study of 253 outpatients (children and adults) with asthma who were monitored for 12 months at the Referral Center of the Program for the Control of Asthma and Allergic Rhinitis in the city of Feira de Santana, Brazil. Results: Exacerbations were common, and 36.5% of the patients sought ER treatment within the twelve-month period. The risk factors for asthma exacerbations were being over 20 years of age (OR = 1.34: (95% CI: 1.06-1.70), residing in an urban area (OR = 1.19; 95% CI: 1.06-1.33); having a low level of education (OR = 1.53: 95% CI: 1.00-2.39); having severe asthma (OR = 1.65; 95% CI: 1.24-2.18); and having chronic rhinitis (OR = 2.20; 95% CI: 1.00-4.80). Conclusions: In this cohort, having chronic rhinitis, having asthma that is more severe and having a low level of education were the main risk factors for ER visits due to asthma exacerbations. These results are similar to those reported for asthma patients who are receiving no regular treatment.

Keywords: Asthma/etiology; Health services; Program evaluation.

Objective: To translate the Pediatric Asthma Control and Communication Instrument (PACCI) to Portuguese and adapt it for use in Brazil, ensuring the cultural validity of the content and semantic equivalence of the target version. Methods: The Brazilian Portuguese-language version of the PACCI was developed according to the most commonly used methodology, which included the following steps: translation; synthesis of the translation; review by the author of the original questionnaire; back-translation; synthesis of the back-translation; review by a native external researcher who is a native speaker of English; approval of the author of the original questionnaire; review by a specialist in Portuguese; review by a multidisciplinary committee of experts to determine the agreement of the items, considering the clarity of each and its appropriateness in the cultural context; cognitive debriefing; and development of the final version. The cognitive debriefing involved 31 parents/legal guardians of children 1-21 years of age with a clinical diagnosis of asthma, as defined by the Global Initiative for Asthma, with the objective of determining the comprehensibility and clarity of the items for the target population. Results: The multidisciplinary committee of experts indicated that the items on the questionnaire were clear and comprehensible, with kappa values above 0.61, indicating substantial agreement. In the cognitive debriefing, the parents/legal guardians presented no difficulties in understanding any of the items (agreement > 0.90); therefore, no further changes were needed.Conclusions: The translation and cross-cultural adaptation of the PACCI for use in Brazil were successful.

Keywords: Surveys and questionnaires; Translating; Asthma; Child; Adolescent.

Objective: To determine whether serum total IgE levels and total eosinophil counts have any relationship with the response to routine pharmacological treatment in patients with acute asthma. Methods: A cross-sectional study involving 162 patients with acute asthma. Serum total IgE levels, peripheral blood cell counts and eosinophil counts were determined. The treatment was adjusted for each patient according to the severity of asthma. Spirometry was performed at baseline and two weeks after the treatment. The patients were divided into two groups: high IgE (≥100 IU/mL) and low IgE (<100 IU/mL). We compared the two groups in terms of the relationships between baseline values and final values (percentage change) for the following parameters: FEV1, FVC, FEF25-75%, peripheral white blood cell counts and eosinophil counts. Results: There were no significant differences between the groups regarding the percentage changes of the studied parameters. Nor were there significant differences between the groups regarding FEV1, FVC, and FEF25-75% (% of the predicted values) at baseline. Conclusions: On the basis of these findings, we conclude that serum total IgE levels, peripheral white blood cell counts and eosinophil counts cannot predict the response to the pharmacological treatment of patients with acute asthma.

Keywords: Asthma/drug therapy; Eosinophils; Immunoglobulin E

Objective: To quantify the use of health care resources among patients enrolled in the Bahia State Asthma and Allergic Rhinitis Control Program. Methods: As of January of 2006, 1405 patients had enrolled in the program, which is carried out in four referral centers in the city of Salvador. These patients formed the basis of this retrospective/prospective, observational cohort study. The preliminary analysis involved 269 consecutive patients, all above the age of 12 and diagnosed with severe asthma. After being seen by pulmonologists, nurses, pharmacologists and psychologists, the patients received inhaled asthma medications. Based on patient interviews and charts, the year preceding enrollment in the program was compared with the first year enrolled in the program in terms of the following quantifiable parameters: hospital admissions; emergency room visits; courses of oral corticosteroids; and days of school/work missed due to asthma attacks. Results: In this sample of patients with severe asthma, enrollment in the program resulted in significant reductions in the number of emergency room visits and hospital admissions (of 85% and 90%, respectively). There were also reductions in the number of school/work days missed due to asthma attacks and in the number of courses of oral corticosteroids (of 86% and 67%, respectively). Conclusion: A program designed to control severe asthma in referral outpatient clinics and including pharmacological services at no charge can lead to a pronounced reduction in the demand for Unified Health Care System resources.

Keywords: Asthma/therapy; Asthma/prevention  control; Hospitalization; National Health System (BR)

To evaluate the characteristics of users of inhalers and the frequency of inhaler use among adolescents and adults with self-reported physician-diagnosed asthma, bronchitis, or emphysema. Methods: A population-based study conducted in the city of Pelotas, Brazil, involving 3,670 subjects ≥ 10 years of age, evaluated with a questionnaire. Results: Approximately 10% of the sample reported at least one of the respiratory diseases studied. Among those individuals, 59% reported respiratory symptoms in the last year, and, of those, only half reported using inhalers. The use of inhalers differed significantly by socioeconomic status (39% and 61% for the lowest and the highest, respectively, p = 0.01). The frequency of inhaler use did not differ by gender or age. Among the individuals reporting emphysema and inhaler use, the use of the bronchodilator-corticosteroid combination was more common than was that of a bronchodilator alone. Only among the individuals reporting physician-diagnosed asthma and current symptoms was the proportion of inhaler users higher than 50%. Conclusions: In our sample, inhalers were underutilized, and the type of medication used by the individuals who reported emphysema does not seem to be in accordance with the consensus recommendations.

Keywords: Metered dose inhalers; Asthma; Pulmonary disease, chronic obstructive; Bronchitis; Emphysema; Dry powder inhalers.