Poor inhalation technique might contribute to asthma morbidity. In an hospital-based assessment study, a proper technique was observed in only 62% of 71 asthmatic children.¹ Poor technique was also retained as one of the main causes of uncontrolled asthma in 7.8% of 142 patients referred to a pediatric asthma center.² In a pilot study carried out in the United Kingdom, the authors reported a deterioration in inhalation technique as early as 1 week after teaching.³ We can assume that poor inhalation technique might play a key role in persistent loss of asthma control, even in cases of good compliance. Therefore, it could be useful to assess inhalation technique during daily treatment, at home and outside a scheduled visit. To do this, we asked parents of asthmatic children to film them taking their treatment and to share the video with the physicians in charge of the study. The primary aim was to evaluate whether the quality of a video recorded at home in children receiving maintenance treatment for asthma administered by pressured meter dose inhaler (PMDI) plus dedicated spacer was sufficient to check that the treatment was being carried out correctly. The secondary aim was the assessment of the inhalation technique itself. The VIDEO-ASTHMA prospective pilot study was conducted in asthmatic children followed in Lille University Paediatric Allergy and Pulmonology department, a tertiary-care asthma center, between March 2022 and January 2023. Inclusion criteria were as follows: asthmatic children, 4–18 years old; need for daily maintenance treatment administrated by PMDI and dedicated spacer; availability of a smartphone, or any connected device to capture video clips, secondarily sent to the investigators on an external USB device. Approval was granted from an ethics committee (CPP Ile de France VII; 2021-A00057-34). Written assent was obtained from all parents/caregivers.

During a scheduled visit or hospitalization, patient (age, gender) and asthma characteristics (daily treatment, spacer brand, asthma severity, and control) were collected. Control was defined according to the asthma control test (ACT)/pediatric ACT (p-ACT) score, depending on age (well-controlled if >19). Asthma severity was assessed according to GINA guidelines. Demonstration of inhalation technique was performed and explained to the child's parents/caregivers at inclusion. At the time of the inclusion and to ensure that the video will be made in good conditions, instructions were given to the parents, which were also written on a document. An external USB device was handed over to the parents, along with ACT/p-ACT questionnaire and an envelope for sending the USB device and control questionnaire.

Four (±1) weeks after inclusion visit, the parents were asked to fulfill an ACT or pACT questionnaire, and to record a video clip of their child taking maintenance treatment, according to the instructions. The video was then downloaded onto the USB device and sent to the investigator (CeT). In cases of no response after 6 weeks, the parents were contacted by phone to remind them of their participation in the study.

The videos were read by two independent investigators (CeT and AD) and scored according to the same criteria for video clip quality and inhalation technique. Video clip quality was classified as good (all steps in the treatment administration can be assessed), acceptable (key steps assessed), insufficient (not enough to assess treatment administration), bad (no possibility of assessment). The primary endpoint was the percentage of video clips of good or acceptable quality, and the inter-observer agreement. The secondary endpoint was the quality of inhalation technique: good if there were no errors, partially good if there were some errors but no critical error, poor if there were at least one critical error.³ The relationship between asthma characteristics and the quality of inhalation technique according to the most experienced observer (AD) was evaluated.

Qualitative variables were described as numbers and percentages, quantitative variables as median and interquartile range. Inter-observer agreement was assessed using weighted kappa coefficient (95% confidence interval CI)⁴ and interpreted according to the Landis & Koch classification. Analyses were performed using SAS 9.4 software.

Thirty-four children (median age: 7 years [5–10]; male: 65%) participated in this study. Asthma was defined as moderate in 73.5% and severe in 12%, controlled in 62% at inclusion and in 84% at the time of video recording. Assessment of the quality of video clips is described in Table 1. The rate of video clips of good or acceptable quality for both observers was of 82.4% (95% CI: 65.5%–93.2%). The inter-observer agreement was high [κ = 0.61 (0.39–0.83)]. The inhalation technique was good in 35.3% (AD) and 38.2% (CeT). The inter-observer agreement was high [κ = 0.64 (0.44–0.84)]. Critical errors (AD) are listed in Table 1. There was no significant association between inhalation technique and child age [9 years (5–11) in patients with good technique, 8 (6–9) if partially good technique, and 6 (5–7) if poor technique, p = .40], asthma control (well controlled: 58% in patients with good technique, 63% if partially good technique, 60% if poor technique, p = .90) or asthma severity (GINA step 4 or 5: 50% in patients with good technique, 44% if partially good technique, 83% if poor technique, p = .34).

From this pilot study carried out in 34 patients, we observed that, in about five out of six cases, video clips taken in real-life setting, in the absence of medical supervision, were of sufficient quality to assess inhalation technique. Additionally, this method enabled us to identify errors in inhalation technique, observed in two children out of three, and potentially hindering the effectiveness of treatment. It could, therefore, be used to correct and improve remotely inhalation technique without waiting for the next scheduled visit. To our knowledge, this is one of the first studies to use home video to assess inhalation technique in children. In a Dutch study, the authors also used video clips to compare two inhalation devices (Diskus® and Autohaler®) both at home and in the hospital. The two most common errors with the Diskus® device were observed twice as often at home as in the hospital, demonstrating the value of home assessment.⁵ In another pilot study carried out in England, inhalation technique was assessed during 28 days by video clip in 22 children with severe asthma aged between 2 and 16. The children and their parents received asthma education by a trained nurse. They were asked to post twice daily video clips of their inhaler use. The investigators rated inhalation technique as “effective,” “partially effective,” or “poor” based on these videos at day 1 and 2, and then once a week. While inhalation technique was initially good in all children, it was rated “poor” in 77% after 1 week.³ Finally, the inhalation technique errors most frequently observed in our study were overall similar to those described in the literature.^{3, 6-8}

It is essential to act on all the modifiable factors to improve asthma control. Checking the correct use of inhaled treatment is a priority in cases of uncontrolled asthma. The development of communication tools such as connected devices, with the possibility for parents to easily make a video clip and share it via secured platforms, could contribute to this assessment. Remotely identifying and correcting poor technique without waiting for a scheduled visit might be a step forward in asthma management. This could be followed by a virtual or in-person visit with a physician, a nurse, or a healthcare provider to correct the technique.

Our work on a small number of children, with a single type of device (PMDI and spacer) and a single assessment, could be followed by a larger study in different levels of care settings (primary care, pediatric pulmonologist, tertiary asthma care centers) with multiple assessments over time, and evaluation of asthma treatment uptake with different devices.

不良的吸入技术可能会导致哮喘发病。在一项以医院为基础的评估研究中，71 名哮喘儿童中只有 62% 观察到了正确的技术。¹在转诊至儿科哮喘中心的 142 名患者中，有 7.8% 的患者哮喘不受控制，技术不佳也是其主要原因之一。²在英国进行的一项试点研究中，作者报告说，早在教学后 1 周，吸入技术就出现了恶化。³我们可以假设，即使在依从性良好的情况下，不良的吸入技术也可​​能在哮喘持续失控中发挥关键作用。因此，在日常治疗期间、在家中和计划外就诊时评估吸入技术可能很有用。为此，我们要求哮喘儿童的父母拍摄他们接受治疗的过程，并与负责这项研究的医生分享视频。主要目的是评估通过压力计量吸入器 (PMDI) 加专用储雾器进行哮喘维持治疗的儿童在家中录制的视频质量是否足以检查治疗是否正确进行。次要目标是评估吸入技术本身。VIDEO-ASTHMA 前瞻性试点研究于 2022 年 3 月至 2023 年 1 月期间在里尔大学儿科过敏和肺科（三级护理哮喘中心）的哮喘儿童中进行。纳入标准如下：哮喘儿童，4-18 岁; 需要PMDI和专用垫片进行日常维护处理；可用智能手机或任何连接的设备来捕获视频剪辑，然后通过外部 USB 设备发送给调查人员。获得了伦理委员会的批准（CPP Ile de France VII；2021-A00057-34）。已获得所有家长/照顾者的书面同意。

在预定的就诊或住院期间，收集患者（年龄、性别）和哮喘特征（日常治疗、间隔器品牌、哮喘严重程度和控制情况）。根据哮喘控制测试 (ACT)/儿童 ACT (p-ACT) 评分定义控制，具体取决于年龄（如果 >19 则控制良好）。根据 GINA 指南评估哮喘严重程度。进行了吸入技术演示并向孩子的父母/照顾者进行了解释。在收录时，为了确保视频在良好的条件下制作，我们向家长发出了说明，这些说明也写在文件上。我们将一个外部 USB 设备、ACT/p-ACT 问卷以及用于发送 USB 设备和控制问卷的信封交给了家长。

纳入访视后四 (±1) 周，要求家长填写 ACT 或 pACT 问卷，并根据说明录制孩子接受维持治疗的视频片段。然后视频被下载到 USB 设备上并发送给调查员 (CeT)。如果 6 周后没有回复，我们会通过电话联系家长，提醒他们参与研究。

这些视频由两名独立研究人员（CeT 和 AD）阅读，并根据视频剪辑质量和吸入技术的相同标准进行评分。视频剪辑质量被分类为良好（可以评估治疗管理中的所有步骤）、可接受（评估关键步骤）、不足（不足以评估治疗管理）、差（无法评估）。主要终点是质量良好或可接受的视频片段的百分比以及观察者间的一致性。次要终点是吸入技术的质量：如果没有错误，则为良好；如果有一些错误但没有严重错误，则部分良好；如果至少有一个严重错误，则为较差。³根据最有经验的观察者 (AD) 评估哮喘特征与吸入技术质量之间的关系。

定性变量被描述为数字和百分比，定量变量被描述为中位数和四分位数范围。使用加权 kappa 系数（95% 置信区间 CI）⁴评估观察者间的一致性，并根据 Landis & Koch 分类进行解释。使用 SAS 9.4 软件进行分析。

34 名儿童（中位年龄：7 岁 [5-10]；男性：65%）参与了这项研究。73.5% 的哮喘被定义为中度，12% 的哮喘被定义为重度，纳入时的哮喘控制率为 62%，视频录制时的哮喘控制率为 84%。视频剪辑质量的评估如表 1 所示。两位观察者认为视频剪辑质量良好或可接受的比率为 82.4%（95% CI：65.5%–93.2%）。观察者间的一致性很高 [ κ  = 0.61 (0.39–0.83)]。吸入技术良好，有 35.3% (AD) 和 38.2% (CeT)。观察者间的一致性很高 [ κ  = 0.64 (0.44–0.84)]。表 1 列出了严重错误 (AD)。吸入技术与儿童年龄之间没有显着相关性 [技术良好的患者为 9 岁 (5-11)，技术部分良好的患者为 8 (6-9)，如果技术部分良好，则为 6 (6)。 5-7) 如果技术差，p  = .40]，哮喘控制（控制良好：技术好的患者为 58%，如果技术部分好则为 63%，如果技术差则为 60%，p  = .90）或哮喘严重程度（ GINA 步骤 4 或 5：技术良好的患者为 50%，技术部分良好的患者为 44%，技术差的患者为 83%，p  = .34）。

从这项对 34 名患者进行的试点研究中，我们观察到，在六分之五的病例中，在没有医疗监督的情况下在现实生活中拍摄的视频剪辑的质量足以评估吸入技术。此外，这种方法使我们能够识别在三分之二的儿童中观察到的吸入技术错误，这些错误可能会阻碍治疗的有效性。因此，它可以用于纠正和改进远程吸入技术，而无需等待下一次预定的访问。据我们所知，这是首批使用家庭视频评估儿童吸入技术的研究之一。在荷兰的一项研究中，作者还使用视频剪辑来比较在家中和医院中使用的两种吸入装置（Diskus® 和 Autohaler®）。Diskus® 设备的两个最常见错误在家中观察到的频率是在医院中的两倍，这证明了家庭评估的价值。⁵在英国进行的另一项试点研究中，通过视频剪辑对 22 名 2 至 16 岁之间患有严重哮喘的儿童进行了 28 天的吸入技术评估。这些儿童及其父母接受了经过培训的护士的哮喘教育。他们被要求每天发布两次有关吸入器使用的视频片段。研究人员根据第一天和第二天的这些视频，然后每周一次，将吸入技术评为“有效”、“部分有效”或“差”。虽然所有儿童的吸入技术最初都良好，但 1 周后 77% 的儿童被评为“差”。³最后，我们研究中最常见的吸入技术错误总体上与文献中描述的相似。^3、6-8

必须对所有可改变的因素采取行动以改善哮喘控制。对于哮喘未受控制的情况，检查吸入治疗的正确使用是首要任务。联网设备等通信工具的发展，以及父母可以轻松制作视频剪辑并通过安全平台分享的可能性，可能有助于这一评估。无需等待预定就诊即可远程识别和纠正不良技术可能是哮喘管理的一个进步。随后可以与医生、护士或医疗保健提供者进行虚拟或亲自拜访以纠正该技术。

我们对少数儿童进行的工作，使用单一类型的设备（PMDI 和垫片）和单一的评估，随后可以在不同级别的护理机构（初级护理、儿科肺科医生、三级哮喘护理中心）进行更大规模的研究随着时间的推移进行多次评估，并评估不同设备的哮喘治疗效果。