Plastic bottles as inhaler spacers: improving the effectiveness of healthcare using clinical skills

There are more than half a million refugees in the DRC. Healthcare in refugee camps is overseen by the UNHCR, with whom PCI is working in a number of countries to develop care for NCDs. That’s why, in September 2018, PCI’s French-speaking clinical team headed to Kinshasa to train doctors and nurses working with refugees from the Central African Republic. Read on to hear how the training went and what we hope can be achieved.

“How well could you use an asthma inhaler? How well could you teach someone else to use one? They’re tricky. Don’t forget to shake it first. Hold it the right way up. Seal your lips around it: people seem to find that hard. Then — this is the really tricky bit — co-ordinate releasing the dose of medication as you inhale, so it’s carried down into your lungs and doesn’t end up on the back of your throat, or wafting out into the atmosphere. After that, hold your breath for a few seconds. And then repeat. I find it hard. It can be almost impossible for smaller children, or if you’re not very co-ordinated, or if when stressed because you’re finding it hard to breathe.

It’s lots easier, and more effective, if you use a spacer — a chamber (with a mask, for small children) into which the medication is released, making it less important to co-ordinate your breathing just so. People often think of spacers as being for children, but I suggest to all my own patients that they use a spacer whenever they can. Spacers can be hard to find in low- and middle-income countries. But you can make a perfectly good one for free from something that otherwise litters the environment everywhere: a small, empty, plastic drinking-water bottle.

So I found myself with a group of doctors and nurses working in refugee camps in the north-west of DRC, discovering that none of us was very good at using an inhaler. ‘I never knew this was so difficult’, laughed one: we could all see the clouds of placebo medication from demonstration inhalers drifting uselessly from the mouths of these experienced and committed clinicians. ‘I’ve been prescribing these for years, but I’ve only ever seen them in the pharmacy — never tried to use one.’ Asthma and COPD disable and kill — but the main treatments, inhalers, don’t work if they aren’t used right. Reviewing what people had learnt from the course, ‘how to teach patients to use inhalers effectively’ kept on coming up.

It’s a nice example of improving the effectiveness of healthcare using nothing more than clinical skills — skills that we can teach colleagues, who can teach their own colleagues.

During our visit to DRC, as with most of our projects, we were developing participants’ ability to manage patients with NCD-related problems. But we were also working with them to develop their NCD services — the structured care, review systems, records, registers and clinical supplies that are needed to reduce the risk that people develop complications from their diabetes, that those with hypertension are identified and helped to reduce chance that they will go on to develop heart disease, stroke, or kidney problems. And we were training them to train their colleagues — to help build something sustainable. We’ll be continuing to support them over the coming months. And we hope to return to the DRC to work with refugees in the east of the country — and to the other countries that form a part of PCI’s fruitful and effective working relationship with UNHCR.”

(Note that the accompanying photo is taken from a different training – but illustrates the point about using plastic water bottles as spacers)