Assess and correct a child's inhaler technique — OSCE

Candidate brief

You have eight minutes to review a nine-year-old whose inhaled corticosteroid preventer seems to be failing. Use a structured approach: ask the child to bring every device and take a witnessed dose, run the SEAL technique check, separate a delivery problem from non-adherence and disease severity, and decide whether to escalate the dose now or to correct the technique and re-assess first. Then explain the plan to the child and her parent in plain language. [1]

Key teaching and decision objectives

Watch the dose before you change it. Ask the child to bring the preventer, the combination inhaler, the reliever, and the spacer, and to take the preventer as she normally does at home. What you see is the truth; what she describes is a kinder version. The key finding here is the admitted habit of using the pressurised inhaler without the spacer, which fires a fast aerosol cloud that deposits most of its dose in the oropharynx and delivers little to the lung. [1] [3]

Run the SEAL check. Confirm the seal of the mouthpiece, the exhalation and effort (one to two slow deep breaths with a short breath-hold per actuation), the actuation (shake the canister, fire one puff at a time into a seated spacer), and whether the lung dose is preserved (the spacer is primed and static-free, the dose counter is current, and she rinses and spits after the corticosteroid). The missing spacer and the skipped rinse are both correctable delivery problems that reduce the lung dose to a fraction of the prescribed one. [1] [3]

Separate the causes before you escalate. Decide whether the poor control is driven by delivery (the missing spacer and skipped rinse), by non-adherence, by the wrong diagnosis, or by genuine disease severity. Here the delivery problem is glaring, so the correct plan is to correct the technique — restore the spacer, the slow deep breaths, and the rinse — and to re-assess control over two to four weeks before stepping up the drug. Escalating the corticosteroid dose on top of a delivery problem over-treats a child whose real problem is technique, and it exposes her to more drug for no benefit. [3]

Protect the safety principles. Confirm she understands the difference between the preventer (taken every day, even when well) and the reliever (taken for symptoms), and that the long-acting beta-agonist in her combination inhaler must never be used without the corticosteroid component. Arrange a written asthma action plan and a review in two to four weeks. [11]

Communication to the child and family

To the child (plain language): "Your preventer medicine is good — the problem is how it's getting into your lungs. When you use it without the spacer, most of it lands in your mouth and throat instead of going down where it needs to work. Let me show you: with the spacer, you fire one puff in, take slow deep breaths, and hold for a count of five. Do that every morning and night, even when you feel well, and rinse your mouth with water afterwards and spit it out. Let's practise it together now." [3]

To the parent (plain language): "Her preventer isn't failing — it just isn't reaching her lungs because she's been using it without the spacer. The spacer slows the medicine down so it gets to where it works. I'd like us to fix the technique and check her again in two to four weeks before we think about a higher dose, because a higher dose on top of the wrong technique wouldn't help and could give her more side-effects. Here's a written plan, and please bring the spacer and every inhaler to the next visit so we can check it together." [3]

Marking domains

• Clinical reasoning (30 per cent): identifies the delivery problem (missing spacer, skipped rinse); runs the SEAL check; separates delivery from non-adherence, wrong diagnosis and severity.
• Decision-making (25 per cent): corrects the technique and re-assesses in two to four weeks before escalating; preserves the inhaled-corticosteroid safety principles; arranges a written action plan.
• Technique teaching (20 per cent): demonstrates and has the child return the spacer technique; confirms the preventer-versus-reliever distinction.
• Communication (15 per cent): explains to the child and parent in plain language why the spacer matters and why the dose is not being increased yet.
• Safety and follow-up (10 per cent): confirms the long-acting beta-agonist is never used without the corticosteroid; books a review and asks for every device to be brought back. [1] [3] [11]