The Respiratory Report
Section 1: Introduction -- The Inhaler Nobody Is Using Correctly
A 48-year-old woman in Castries, St. Lucia has been on salbutamol MDI for seven years. She uses it every day, sometimes four or five times. She has never been taught how to use it. She takes a short sharp puff as she begins to inhale, holds the inhaler vertically, and breathes in rapidly. She estimates her asthma is "not well controlled" but assumes this is simply how asthma is.
She has never received an inhaled corticosteroid. She has never had her inhaler technique assessed. She has never been stepped up on the asthma treatment ladder.
Poor inhaler technique is the single most common reason for treatment failure across all inhaled respiratory medicines. Studies consistently show that 70-80% of patients using MDI inhalers make at least one critical error. In the Caribbean, where device training is infrequently done and pharmacy counselling time is limited, the proportion is likely higher.
Caribbean respiratory practice has four specific challenges this report addresses: over-reliance on short-acting beta-2 agonists; under-use of inhaled corticosteroids; diagnostic confusion between asthma and COPD; and drug interactions in respiratory prescribing.
1.1 The SABA overuse problem
Salbutamol is widely available, inexpensive, and fast-acting. It is the drug patients reach for at every symptom. It is also, when used more than twice weekly for symptoms, a marker of uncontrolled asthma requiring step-up rather than continued SABA monotherapy. The GINA 2019 revision removed SABA monotherapy from all treatment steps.
1.2 Steroid fear and ICS under-use
Steroid phobia -- fear of "steroids" from patients who conflate inhaled corticosteroids with systemic steroids -- is common in Caribbean communities. Clinicians sometimes reinforce this by not explaining the difference. ICS at standard doses have negligible systemic absorption and are the cornerstone of asthma maintenance.
Section 2: Asthma -- Diagnosis, Classification, and the Treatment Ladder
2.1 Confirming the diagnosis
Asthma is characterised by variable, reversible airflow obstruction. The hallmark is variability -- symptoms that come and go, worse at night or in the morning, triggered by exercise, cold air, allergens, or irritants, and improved with bronchodilators.
Spirometry confirming reversible obstruction (improvement in FEV1 of at least 12% and 200 mL after bronchodilator) is the diagnostic gold standard. Where spirometry is unavailable, a documented trial of inhaled salbutamol with symptomatic improvement supports the diagnosis.
Features favouring asthma over COPD: onset in childhood or early adulthood, atopic history, family history of asthma, symptoms fully resolving between episodes, significant diurnal variability, and good bronchodilator response.
2.2 The GINA treatment ladder
| Step | Controller | Reliever |
|---|---|---|
| Step 1 (mild intermittent) | Low-dose ICS whenever SABA taken | As-needed SABA or low-dose ICS-formoterol |
| Step 2 (mild persistent) | Daily low-dose ICS | As-needed SABA |
| Step 3 (moderate persistent) | Low-dose ICS + LABA | As-needed SABA or ICS-formoterol |
| Step 4 (severe persistent) | Medium-dose ICS + LABA | As-needed SABA or ICS-formoterol |
| Step 5 (very severe) | High-dose ICS + LABA; add tiotropium, biologics, or oral corticosteroids | As-needed SABA |
A patient using salbutamol for symptoms more than twice per week is at minimum Step 2 and requires daily ICS. A patient using salbutamol daily is at minimum Step 3.
2.3 When to step up
Step up when: SABA used for symptoms more than twice per week, nocturnal symptoms more than twice per month, any activity limitation from asthma, or any oral corticosteroid course in the past year. Before stepping up, confirm that inhaler technique is correct, adherence is adequate, and triggers have been addressed.
Section 3: Inhaled Corticosteroids -- The Evidence and the Steroid Fear
3.1 Why ICS is essential
Asthma is an inflammatory condition. Bronchodilators treat the bronchoconstriction but not the underlying inflammation. ICS reduce airway inflammation, reduce exacerbations, reduce hospitalisation, and reduce asthma mortality. They are the most evidence-supported maintenance treatment in asthma.
The dose of steroid reaching the systemic circulation from standard-dose ICS is substantially lower than from a single course of oral prednisolone. The lung is the target organ, and first-pass hepatic metabolism of swallowed drug further reduces systemic exposure.
Documented local adverse effects at standard ICS doses: oropharyngeal candidiasis (prevented by rinsing the mouth with water after each dose) and dysphonia. Systemic adverse effects at standard doses are not clinically significant for most patients.
3.2 ICS in Caribbean practice
| Drug | Notes |
|---|---|
| Beclometasone dipropionate 50, 100, 200 mcg MDI | Widely available on Caribbean formularies |
| Budesonide DPI / nebuliser solution | Preferred in pregnancy |
| Fluticasone propionate MDI / Accuhaler | Higher potency per mcg than beclometasone |
| Fluticasone/salmeterol (combined ICS/LABA) | Step 3+ |
| Budesonide/formoterol (combined ICS/LABA) | Can be used as MART reliever |
Section 4: Inhaler Technique -- The Intervention With the Highest Return
4.1 MDI technique -- critical errors
| Step | Correct | Common error |
|---|---|---|
| Preparation | Shake; remove cap; breathe out fully | Not shaking; not exhaling first |
| Positioning | Hold horizontally; mouthpiece to lips, tongue flat | Holding vertically; tongue blocking mouthpiece |
| Actuation | Press canister at START of a slow, deep inhalation | Pressing before or after inhalation begins |
| Inhalation speed | Slow and deep (3-5 seconds) | Rapid forceful inhalation -- drug deposits in throat |
| Breath hold | 10 seconds | Not holding breath |
| Multiple puffs | Wait 30-60 seconds between puffs | Rapid successive puffs |
A spacer device eliminates the coordination requirement. All patients on MDI should be offered a spacer. Spacers are particularly important for children, elderly patients, and anyone making coordination errors.
4.2 DPI technique
DPIs (Turbuhaler, Accuhaler) are breath-actuated -- no coordination required. However: - Load the dose as per device instructions - Exhale fully -- but NOT into the device (moisture clumps the powder) - Inhale FORCEFULLY and DEEPLY (opposite to MDI technique) - Hold breath 10 seconds
Most common error: inhaling too slowly (MDI habit carried over).
4.3 Assessment principle
Ask the patient to demonstrate technique -- do not ask them to describe it. Most patients believe their technique is correct. Observation reveals the errors. Assess at every prescribing and every dispensing encounter.
Section 5: COPD -- Different Disease, Different Treatment
5.1 Diagnosis
COPD is defined by persistent airflow limitation confirmed by post-bronchodilator FEV1/FVC below 0.70 on spirometry.
| Feature | Asthma | COPD |
|---|---|---|
| Age of onset | Usually under 35 | Usually over 40 |
| Smoking / occupational exposure | Not required | Usually present |
| Symptom variability | Marked | Progressive, less variable |
| Reversibility | Significant | Incomplete |
| Sputum | Usually clear | Mucoid or purulent in exacerbations |
5.2 COPD treatment principles
ICS are not first-line in COPD. Long-acting bronchodilators are the backbone of maintenance treatment.
| Severity | First-line | Second-line |
|---|---|---|
| Mild (FEV1 above 80%) | SABA as needed | LAMA or LABA daily |
| Moderate (FEV1 50-80%) | LAMA daily | LAMA + LABA |
| Severe (FEV1 30-50%) | LAMA + LABA | Add ICS if exacerbations or eosinophilia |
| Very severe (FEV1 below 30%) | LAMA + LABA + ICS | Consider roflumilast, oxygen therapy |
5.3 COPD exacerbations
Nebulised salbutamol + ipratropium, oral prednisolone 30-40 mg for 5 days, and antibiotic (doxycycline or amoxicillin) if sputum is purulent. Hospitalise if severe.
Section 6: Drug Interactions in Respiratory Prescribing
6.1 Beta-blockers and asthma
Beta-blockers can provoke severe bronchospasm in asthma -- a potentially life-threatening interaction. Contraindicated in asthma. Cardioselective beta-blockers may be used with caution in COPD when the cardiac indication is compelling. Topical timolol eye drops (used for glaucoma) can cause systemic beta-blockade and precipitate bronchospasm -- ask about ophthalmic preparations.
6.2 NSAIDs and aspirin-sensitive asthma
Approximately 10% of adults with asthma have aspirin-exacerbated respiratory disease (AERD). In these patients, aspirin and non-selective NSAIDs trigger acute bronchoconstriction through COX-1 inhibition. Suspect AERD in patients with asthma, chronic rhinosinusitis, and nasal polyps. Selective COX-2 inhibitors are generally tolerated.
6.3 Theophylline interactions
Theophylline has a narrow therapeutic index (target 10-20 mg/L) with significant CYP1A2 interactions:
| Precipitant | Effect on theophylline | Action |
|---|---|---|
| Ciprofloxacin | Levels rise (CYP1A2 inhibition) | Reduce dose 30-50%; check level at 48 hours |
| Erythromycin / clarithromycin | Levels rise | Monitor; reduce dose if needed |
| Smoking | Levels fall (CYP1A2 induction) | Higher doses required |
| Smoking cessation | Levels rise (enzyme de-induction) | Reduce dose at 1-2 weeks after stopping |
| Rifampicin / carbamazepine | Levels fall | Increase dose; monitor level |
6.4 Oral corticosteroids
Short courses (5-7 days) carry low systemic risk. In patients on concurrent drugs: prednisolone raises blood glucose (monitor in diabetics), can affect INR (monitor in warfarin patients -- Report 15), causes hypokalaemia (relevant with diuretics -- Report 13 context), and combined with NSAIDs increases GI risk.
6.5 Ipratropium and tiotropium
Additive anticholinergic effects with tricyclics, antihistamines, oxybutynin, and procyclidine. Check cumulative ACB in elderly patients (Report 1). Avoid tiotropium in patients with narrow-angle glaucoma and use with caution in severe benign prostatic hyperplasia.
Section 7: The Respiratory Prescribing Checklist
| Scenario | Key question | Action |
|---|---|---|
| Patient on SABA alone | How often is SABA used? | More than 2x/week = add ICS; step up |
| Patient refusing ICS | Steroid fear? | Explain inhaled vs systemic; teach mouth rinse |
| Prescribing a beta-blocker | Does patient have asthma? | Contraindicated in asthma |
| NSAID in respiratory patient | NSAID-triggered wheeze? | Ask about AERD; substitute paracetamol |
| Ciprofloxacin + theophylline | Theophylline level safe? | Reduce theophylline dose; level at 48 hours |
| Patient stopping smoking on theophylline | Rising theophylline? | Monitor level; reduce dose at 1-2 weeks |
| Prednisolone course | Diabetic? On warfarin? | Monitor glucose; monitor INR |
| COPD exacerbation antibiotic | Purulent sputum? | Doxycycline or amoxicillin |
| Any inhaler prescription | Technique assessed? | Demonstrate; observe; offer spacer for MDI |
| Tiotropium in elderly | Other anticholinergic drugs? | Check ACB; caution in BPH and glaucoma |
Section 8: About ElesRx
ElesRx flags beta-blocker prescriptions in patients with documented asthma, theophylline drug interactions (CYP1A2 inhibitors and inducers including smoking cessation), additive anticholinergic burden from ipratropium or tiotropium in combination with other anticholinergic drugs, and oral corticosteroid interactions with warfarin and antidiabetics.
The tool is available at elesrx.com. ElesRx is a product of PIPPS Smart Apps, a division of J.C. Epiphany Limited (Jamaica, est. 1998).
Section 9: Methodology and References
9.1 Data sources
Respiratory prescribing data is drawn from the ElesRx clinical database, DailyMed, the Global Initiative for Asthma (GINA) 2024 guidelines, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2024 guidelines, and the European Medicines Agency.
9.2 Limitations
Specialist-level management -- severe refractory asthma, biologic therapy (mepolizumab, dupilumab), non-invasive ventilation in COPD -- is beyond this report's scope.
9.3 Author and conflict of interest disclosure
This report was authored by Juliet Duncan, BPharm, founder of J.C. Epiphany Limited and developer of ElesRx. The author has a commercial interest in ElesRx. This report is published without an access gate as a contribution to Caribbean clinical education. No external funding was received.
9.4 Citation
Duncan J. The Respiratory Report: Asthma, COPD, and the Inhaler Problem in Caribbean Practice. ElesRx Clinical Reports, Report 19. Prepared June 2026. Published 2027 at elesrx.com/reports/respiratory-report/. J.C. Epiphany Limited, Jamaica.
References
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Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. GINA; 2024. ginasthma.org
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Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Prevention, Diagnosis and Management of COPD. GOLD; 2024. goldcopd.org
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Sanchis J, Gich I, Pedersen S. Systematic review of errors in inhaler use. Chest. 2016;150(2):394-406. doi:10.1016/j.chest.2016.03.041
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Virchow JC, Crompton GK, Dal Negro R, et al. Importance of inhaler devices in the management of airway disease. Respir Med. 2008;102(1):10-19. doi:10.1016/j.rmed.2007.07.031
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Pavord ID, Beasley R, Agusti A, et al. After asthma: redefining airways diseases. Lancet. 2018;391(10118):350-400. doi:10.1016/S0140-6736(17)30879-6