document: asthma is a chronic inflammatory disease that causes airflow limitation and affects the performance of activities of daily living.1 pharmacological treatment is essential2 and is aimed at achieving and maintaining clinical asthma control.1 inhalation is the most widely used approach for the treatment of asthma because it allows drugs to reach the lungs in a selective manner , increasing drug concentration in the airways and reducing systemic adverse effects . 
   only half of all asthma patients actually use the prescribed medication and do so correctly . 
   5 low treatment adherence is related to the fact that patients do not know how to use or have difficulty in using inhaler devices correctly.3 asthma education can remedy that , being a key component of asthma management.6 
    incorrect inhaler use can lead to treatment failure by reducing drug concentration in the airways and contribute to treatment nonadherence , making clinical asthma control difficult.9 
    the frequency of incorrect use of metered dose inhalers ( mdis ) ranges from 14% to 90% , with an estimated mean of 50%,10 incorrect mdi use reducing lung drug deposition to less than 20% . in a study of patients using inhaled or oral corticosteroids , increased bronchodilator use , nebulizer use , and hospitalizations were observed in more than 50% of the patients who did not adhere to treatment.11 
    instruments ( or scoring systems ) assessing the difficulties that patients face in using inhaled drugs might be useful to reduce those difficulties . by using such instruments , health professionals can devise an educational program targeting the most common errors made by patients , thus improving treatment adherence . 
   there are some scoring systems that assess inhaler technique in patients with lung disease.12 although some assess inhaler technique errors , there is no one system that is considered the gold standard for this purpose 
   . such an instrument could play an important role in the evaluation of patients using inhalers.13 
    leal13 developed a scoring system to assess the difficulties that patients face in using mdis ; the system scores correct and incorrect mdi use , assessing the errors made during mdi use . 
   on the basis of that instrument , santos et al.3 developed scoring systems for the assessment of dry powder inhaler ( dpi ) and mdi technique . 
   although the aforementioned instruments have yet to be validated for use , they are used in our hospital in order to assess inhaler technique in patients with asthma3 and in those with copd . 
   instrument validation allows determination of the congruence between the scoring system used and the reality being measured , thus increasing the reliability of the instrument.14 the use of validated instruments in order to assess inhaler technique in asthma patients will yield results that are more reliable and will ensure data quality . 
   the objectives of the present study were to validate two scores quantifying the ability of patients to use mdis or dpis ; to identify the most common errors made during their use ; and to identify the patients in need of an educational program for the use of these devices . 
   the inclusion criteria were as follows : having been diagnosed with asthma in accordance with the global initiative for asthma criteria15 ; having been in outpatient treatment for at least two years ; being in the 15- to 65-year age bracket ; having had at least four years of schooling ; having no hearing impairment ; and agreeing to participate in the study by giving written informed consent . 
   patients who had previously participated in educational programs regarding the use of asthma medications were excluded . 
   the study was conducted in three phases : validation of the reliability of the inhaler technique scores ( phase 1 ) ; assessment of the content validity of the two scores ( phase 2 ) ; and assessment of the criterion validity and discriminant validity of the instruments ( phase 3 ) .   in phase 1 , 
   two guest pharmacists ( who were blinded to the study methodology ) simultaneously evaluated inhaler technique . 
   they used the inhaler technique scores developed by santos et al.3 in order to identify the errors made during mdi and dpi use . 
   the instruments provide step - by - step descriptions of mdi and dpi techniques . for each step that is performed correctly , 
   patients receive a score of 1 ; for each step that is performed incorrectly , they receive a score of 0 . for each serious inhaler technique error , 
   the final score determines whether a patient is able or unable to use an mdi or a dpi . 
   the pharmacists were trained in the correct use of the aforementioned scoring systems , in accordance with the guidelines established in the third brazilian consensus on asthma management.16 the following drugs were used in the evaluation : for mdis , 250 g of beclomethasone dipropionate and 100 g of albuterol ; for dpis , 200 g of budesonide and formoterol + budesonide ( 6/200 or 12/400 g ; inhalation capsules ) ; and 50 g of salmeterol xinafoate ( diskus . 
   in phase 2 , an expert panel evaluated the instruments from the previous phase in order to assess their contents . 
   the expert panel comprised three pulmonologists , two pediatric pulmonologists , and two allergists , all of whom had extensive experience in the use of inhalers . 
   the proposed changes were judged in terms of the relevance of the items assessed by the preliminary instruments , the need for additions , deletions , or changes to improve the accuracy of the modified inhaler technique scores being evaluated . 
   after the changes had been systematized by consensus , new mdi and dpi technique scores were developed .   in phase 3 , 
   a new sample of patients using dpis , mdis , or both were randomly selected to participate in the study , the eligibility criteria being the same as those used in the previous phases . 
   they were given placebo - containing inhalers and no instructions on how to use them , being asked to use them in the same manner as they did their own inhalers . 
   each patient was simultaneously evaluated by two other pharmacists , who were blinded to the changes that had been made . 
   they used the instruments derived from phases 1 and 2 and were not allowed to communicate their decisions to one another . 
   after the evaluation , all patients were instructed on how to use inhalers correctly . 
   the median and interquartile range of the scores obtained in phase 3 allowed us to establish cut - off values and divide the patients into two groups : the group of patients who were able to use inhalers and that of those who were not . 
   the latter were then enrolled in our pharmaceutical care program .   in phases 1 and 2 
   , we used a convenience sample based on previous validation studies.14 
   17 
   19 the sample size for phase 3 was calculated on the basis of the hypothesis of an association of at least 60% between the scores given by the pharmacists . considering a power of 0.95 and a type i error of 0.05 
   , we calculated that a sample size of 31 assessments was required for each inhaler type . 
   the results obtained in phases 1 and 2 were described qualitatively . in phase 3 , 
   the mean scores were compared between the observers , agreements and disagreements being evaluated individually . 
   the major errors made during inhaler use ( as assessed by the observers ) were described by frequency .   in phase 3 , descriptive analysis of the absolute values of mdi and dpi technique scores by observer 
   was performed with the statistical package for the social sciences , version 18 ( spss inc . , 
   the degree of correlation between the scores by observer was assessed by cronbach 's alpha coefficient . 
   after assessment of data normality , the scores by observer were compared by means of the mann - whitney rank sum test , their correlation being determined by spearman 's test , with sigmastat software , version 3 ( systat software inc . , 
   the chi - square test was used in order to determine interobserver agreement in the classification of patients as being able or unable to use mdis and dpis . 
   pharmacists together identified the need for changes in the scoring systems and proposed two preliminary changes : removal of the overall score ; and removal of the suggestions section in order to reduce the number of sheets . 
   this resulted in a scoring system consisting of a single table for assessment of inhaler technique , including examples of correct / incorrect inhaler use . 
   interobserver disagreement in phase 1 was found in 19% and 25% of the dpi and mdi scores , respectively , indicating not only inhaler technique errors made by the patients but also interpretation errors made by the observers ( the pharmacists ) . 
   that level of disagreement was considered acceptable and was of relatively little significance , being clarified and resolved in the subsequent phase . 
   the expert panel suggested that two changes be made to the dpi technique score , and both suggestions were accepted : the inclusion of an item regarding patient head position ( at an angle of more than 90 or less than 90 ) , patients receiving 1 point for " an angle of less than 90 " and 0 points for " an angle of more than 90 " ; and the definition of tlc , which was included at the bottom of the page .   with regard to the mdi technique score 
   , the expert panel suggested that eight changes be made , and all of their suggestions were accepted : the item " shaking the inhaler " was changed from " 3 times " to " twice or more " ; the item " mode of use " was changed to " inhaler use " ; the score for the item " in the mouth , with a spacer " was changed to 1 because it provides a correct example of mdi use , as does the item " out of the mouth , without a spacer " ; the item " time point " was changed to " time point ( rapid inhalation ) " ; the items " upon actuation " and " immediately after actuation " have the same weight and were therefore merged ; the item " only sprays it into the mouth and does not inhale " was changed to " the device is actuated directly into the mouth , and the patient does not inhale " ; the item " not completely " was changed to " insufficient " , whereas the item " adequately " was changed to " sufficient " ; and the item " interval " was changed to " time between mdi actuations " . 
   according to all observers and experts , the resulting scoring systems were more practical ( chart 1 ) . 
   although the maximum total score remained the same ( i.e. , nine points ) for the instrument assessing mdi technique , it increased ( to six points ) for the instrument assessing dpi technique . according to the literature , a 20% variation in the total score is acceptable for a patient to be considered able to use an inhaler correctly . 
   for the present study , this means a minimum mdi technique score of 7.2 and a minimum dpi technique score of 4.8 ; however , it is not clear whether the aforementioned variation ( standard deviation ) takes into account whether a given patient received previous training in inhaler use . 
   of those patients , 39 were assessed with the mdi technique score and 50 were assessed with the dpi technique score , a total of 89 assessments being performed . 
   those assessments allowed us to identify the most common difficulties encountered / errors made during inhaler use . 
   the most relevant difficulty encountered during the use of both types of devices was the maintenance of tlc after a deep inhalation . 
   the number of errors made was higher during mdi use than during dpi use ( table 1 ) . 
   errors identified in more than 50% of all tests performed included & lt ; 60 s between mdi actuations , maintenance of tlc for & lt ; 10 s after inhalation , incorrect speed of inhalation , incorrect mdi use without a spacer , and not exhaling prior to inhalation .   among the patients who used a dpi , 
   the most common errors were maintenance of tlc for & lt ; 10 s , not exhaling prior to inhalation , and incorrect speed of inhalation ( in 75% , 62% , and 57% , respectively ) , as shown in table 2 .   of a sample of 72 patients , 60 
   did not hold their breath correctly , 58 inhaled too quickly , and 6 did not synchronize inhaler actuation with inhalation . 
   median mdi technique scores in phase 3 of the study were 4 and 5 for observers 1 and 2 , respectively ( table 3 ) . 
   median dpi technique scores were 4.5 and 5.0 for observers 1 and 2 , respectively . 
   the degree of correlation of the scores by observer was 0.97 , as assessed by cronbach 's alpha coefficient . 
   the correlation was statistically significant ( p & lt ; 0.0001 ) , as assessed by spearman 's correlation coefficient ( figure 1 ) . 
   there were no significant differences between the scores given by each observer , as assessed by the mann - whitney test . 
   all patients whose mdi and dpi technique scores were & lt ; 4 were enrolled in an educational program . 
   with regard to discriminant validity , there was good interobserver agreement in the classification of patients as being able / unable to use a dpi ( 50%/50% and 52%/58% ; p & lt ; 0.01 ) and an mdi ( 49%/51% and 54%/46% ; p & lt ; 0.05 ) . 
   the present study allowed assessment of the content validity , criterion validity , and discriminant validity of the dpi and mdi scores . 
   it also allowed identification of the major difficulties that patients encounter when using inhaler devices for the treatment of asthma . 
   finally , it allowed determination of cut - off scores to classify patients as being able or unable to use their inhalers , the latter patients being enrolled in an educational program .   to the best of our knowledge , 
   there is only one validation study of mdi technique scores ( in patients with asthma)12 and one of dpi technique scores ( in patients with copd).21 in addition , according to basheti et al.,22 although the use of device - specific checklists is the most feasible method for assessing inhaler technique , little evidence is available to assess the relative importance of different criteria . 
   divergence between the scoring systems for the same inhaler device in different studies makes direct comparison of results difficult . in our study , 
   mdi and dpi technique scores were validated in asthma patients , and the results allowed us to identify mdi and dpi technique errors and address them in a personalized manner , meaning that the instructions provided to patients were based on their own inhaler technique errors . 
   chart 1scoring systems modified and approved by an expert panel ( phase 2 ) and validated for use in brazil ( phase 3 ) . 
   evaluation criteriaerrors , % interval of & lt ; 60 s between doses ( patients are instructed to allow 60 s between doses)89maintenance of tlc for & lt ; 10 s after inhalation ( patients are instructed to hold their breath for 10 s after inhalation)83inadequate inspiratory flow rate ( patients inhaled too quickly , shallowly , or both)81incorrect mdi use without a spacer ( for patients who used a spacer)73not exhaling prior to inhalation ( patients did not exhale before using their mdis)59shaking the inhaler only once ( patients are instructed to shake their mdis at least twice)32not shaking the inhaler ( patients are instructed to shake their mdis at least twice)31incomplete inhalation ( patients did not perform a deep inhalation maneuver)18incorrect mdi position ( patients are instructed to sit down in such a way that their legs and the floor form a 90 angle)10lack of synchronization between mdi actuation and inhalation ( the device was actuated before the beginning of inhalation)8nasal breathing ( patients breathed through their nose during inhalation)5the device is actuated directly into the mouth , and patients do not inhale ( patients are instructed to place their mdis at a distance of three fingers ' breadth from their mouth and inhale after actuation)5others9.5mdi : metered dose inhaler . 
   our findings corroborate those of other studies.9 
   23 
   24 the inability to hold their breath for more than 10 s after inhalation was the major difficulty that our patients encountered during mdi and dpi use ( 83% and 75% , respectively ) . 
   manzella et al.12 assessed inhaler technique and reported that 69% of the patients studied did not hold their breath for at least 10 s. a review compiling the results of 12 studies ( including 955 patients ) identified the most common errors made by patients using inhaler devices , less than 10 s of breath - holding after inhalation having been observed in 26% . 
   a period of 10 s of breath - holding increases drug deposition in the lungs by allowing more time for the particles to settle.25 the author of the aforementioned review reported that 50% of the patients were able to hold their breath for 10 s between doses . in our study , less than 10 s of breath - holding after inhalation was the most common error made during mdi use , having been made by 89% of those who used mdis . 
   a period of 10 s of breath - holding is important to ensure that a greater quantity of drug reaches the airways.12 
   
   table 2proportion of inhaler technique errors as assessed by the dry powder inhaler score . 
   evaluation criteriaerrors , % maintenance of tlc for & lt ; 10 s after inhalation ( patients are instructed to hold their breath for 10 s after inhalation)75not exhaling prior to inhalation ( patients did not exhale before using their dpis)62inadequate inspiratory flow rate ( patients inhaled too quickly , shallowly , or both)57incomplete inhalation ( patients did not perform a deep inhalation maneuver)21incorrect dose preparation ( patients did not place the capsule inside their dpis , did not puncture the capsule before inhalation , or both)*18inhaling shallowly ( patients did not perform a deep inhalation maneuver)5exhaling into the device ( patients exhaled while their dpis were in their mouth)3nasal breathing ( patients breathed through their nose during inhalation)2inhaling irregularly ( patients were unable to inhale continuously)2dpi : dry powder inhaler . * for the dpi type used in the present study ( adaptation ) . 
   incorrect speed of inhalation was the third most common mdi technique error in our study and was reported by mcfadden as the third most common error in 12 studies , inappropriately rapid inspiratory flow rates having been observed in 19% of the total of patients . 
   this is a serious error , given that a slower inspiratory flow rate translates to higher lung drug deposition with the use of mdis.25 
    not exhaling prior to inhalation was an error made by 62% of the patients using dpis , being the second most common dpi technique error . 
   the lung volume at the beginning of inhalation interferes with drug deposition , which is why patients should exhale before inhaling.26 
   
   figure 1interobserver agreement . in a , metered dose inhaler ( mdi ) scores . in b , 
   incorrect speed of inhalation was the third most common dpi technique error ( 57% ) . in order to deliver medication , dpis depend on patient inspiratory flow . 
   if the flow rate ( volume / time ) is lower than required , the inhaled doses will be lower , and this contributes to treatment failure.8 
   27 
    sandrini et al.28 analyzed mdi use in a sample of patients , classifying inhaler technique as correct , slightly incorrect , moderately incorrect , or clearly incorrect . 
   the most common errors were placing the inhaler in the mouth ( 68.0% ) , inhaling before actuation ( 15.5% ) , inhaling too quickly ( 11.0% ) , and inhaling through the nose ( 9.0% ) . 
   although our method of evaluation differed from that used in the aforementioned study , our patients made the same errors as did those in that study . 
   dalcin et al.24 and souza et al.29 used checklists or forms in order to determine whether patients were using their inhalers correctly at work . 
   souza et al.29 found that 54.5% of the patients who used dpis did not exhale properly before inhaling the medication . 
   this finding is consistent with those of the present study , because that was the second most common error made by our patients . 
   dalcin et al.24 found that the patients who used mdis made more errors than did those who used other types of inhalers , a finding that is also consistent with those of the present study . 
   scoresdpi techniquemdi techniqueobserver 1observer 2observer 1observer 2median ( ir)4.5 ( 4.0/6.0)5.0 ( 3.0/5.0)4.0 ( 0.5/6.0)5.0 ( 1.0/6.5)minimum / maximum1/71/712/913/10dpi : dry powder inhaler ; mdi : metered dose inhaler ; and ir : interquartile range . 
   dpi : dry powder inhaler ; mdi : metered dose inhaler ; and ir : interquartile range .   in the aforementioned studies 
   , the instruments used allowed the authors to quantify and classify the errors made by patients . 
   we found no technical differences between the mdi and dpi techniques used at our institution and those described in the third brazilian consensus on asthma management6 or in the 2012 brazilian thoracic association guidelines for asthma management.1 however , in addition to providing a step - by - step description of inhaler technique , the scoring systems used in the present study are tools that health professionals can use in order to assess objectively and mathematically the errors that patients make when using inhaler devices . in addition , patients can be classified as able or unable to use their inhalers on the basis of their cut - off scores . 
   this allows health professionals to monitor improvements in inhaler technique in an objective manner . 
   our results show that the proportion of mdi technique errors was higher than that of dpi technique errors . 
   this difference might be related to the fact that the correct dpi technique is more easily understandable to patients than is the correct mdi technique . 
   the results showed that incorrect inhaler use affects drug efficacy , and the authors reported that assessment of inhaler technique is still considered irrelevant by many health professionals.21 
    in a study conducted in 2011 in the state of bahia , brazil , inhaler technique errors were assessed , and the proportion of errors was found to be low . 
   this was attributed to the fact that the patients in that study were monitored at an asthma referral center ; they periodically received instructions and refresher training on inhaler technique from a multidisciplinary team.5 
    one of the limitations of the present study is the lack of follow - up . 
   a follow - up evaluation might have allowed us to determine whether there were improvements in inhaler technique . 
   the present study was biased by the fact that the proportion of mdi technique errors was high , with median scores of 4 and 5 for observers 1 and 2 , respectively ; these scores are significantly different from the score of 7.2 suggested in the literature . given that interobserver agreement was high when a cut - off score of less than 4 was used - a finding that suggests that the mdi score has good accuracy - it can be inferred that many patients were classified as being able to use an mdi despite the fact that they did not obtain the minimum score predicted in theory , i.e. , 20% of a maximum total score of 9 . 
   this underscores the need for reassessing inhaler technique at each visit and for sequential use of the mdi score in a large population sample 
   .   the new mdi and dpi scores will allow the implementation of educational programs proposed in asthma management guidelines and strategies , which recommend that patients receive ongoing training in inhaler technique to ensure correct inhaler use . by providing pharmaceutical care 
   , pharmacists can instruct patients on how to use their inhaler devices correctly . by using our inhaler technique scores , 
   pharmacists can assess inhaler technique errors and determine whether patients are able to achieve an ideal level of technical correctness ( of 80% ) and maintain it throughout the educational program . 
   the present study showed that our inhaler technique scores can reveal exactly what it is that patients are doing incorrectly when using mdis or dpis so that the educational program during follow - up can focus on their errors rather than repeating what they already know . 
   inhalation is the most widely used approach for the treatment of asthma , and correct inhaler technique is directly related to the therapeutic efficacy of the drug . 
   therefore , correct inhaler technique is essential for the efficacy of pharmacological treatment.3 we believe that the present study is clinically relevant because it validated objective mdi and dpi technique scores that can reveal the major difficulties encountered by patients using mdis or dpis and provided cut - off scores that can be used in order to classify patients as being able or unable to use their inhalers . by using the validated scores 
   , health professionals will be able to identify and correct inhaler technique errors during visits and , as a result , improve inhaler use . 
   validar dois escores para medir a habilidade de pacientes em utilizar inaladores pressurizados ( ips ) ou inaladores de p ( ipos ) , verificar os erros mais comuns na sua utilizao e identificar os pacientes que necessitam de um programa educacional para o uso desses dispositivos . 
   este estudo foi realizado em trs etapas : validao da confiabilidade dos escores de uso dos dispositivos inalatrios ; validao do contedo dos escores utilizando - se uma amostra de convenincia ; e realizao de testes para a validao de critrio e a validao discriminante desses instrumentos em pacientes que preenchiam os critrios de incluso do estudo . 
   a amostra de convenincia foi composta por 16 pacientes , e houve discordncia interobservador em 19% e 25% para os escores de ipo e ip , respectivamente . 
   aps a anlise de expertos no assunto , os escores sofreram modificaes e foram aplicados em 72 pacientes . 
   a dificuldade mais relevante no uso de ambos os dispositivos foi a manuteno da capacidade pulmonar total aps inspirao profunda . 
   o grau de correlao dos escores por observador foi de 0,97 ( p & lt ; 0,0001 ) . 
   houve boa concordncia interobservador na classificao dos pacientes como aptos / no aptos para uso de ipo ( 50%/50% e 52%/58% ; p & lt ; 0,01 ) e de ip ( 49%/51% e 54%/46% ; p & lt ; 0,05 ) . 
   os escores validados permitem identificar e corrigir os erros da tcnica inalatria ao longo das consultas e , em consequncia , melhorar o manejo dos dispositivos para inalao . 
   a asma  uma doena crnica inflamatria que limita o fluxo areo e pode impedir que os pacientes exeram suas atividades dirias adequadamente.1 o tratamento farmacolgico  essencial2 e tem como objetivo alcanar e manter o controle clnico da doena.1 a inalao  a via mais utilizada para o tratamento da asma porque permite que os medicamentos alcancem seletivamente os pulmes , com maior concentrao do frmaco nas vias areas , reduzindo os efeitos adversos sistmicos.1 
   3 
   4 
    apenas metade dos asmticos utiliza , de fato e corretamente , a medicao prescrita.5 destaca - se que o baixo ndice de adeso est relacionado ao desconhecimento e / ou  dificuldade de administrao dos medicamentos para inalao.3 tais aspectos podem ser melhorados se a educao em asma ocorrer , sendo ela um componente estratgico para o controle da doena.6 
    a utilizao incorreta dos inaladores pode acarretar o insucesso teraputico por diminuir a concentrao do frmaco nas vias areas e contribuir para a no adeso ao tratamento , dificultando o controle clnico da asma.9 
    a frequncia de uso incorreto de inalador pressurizado ( ip ) varia entre 14% e 90% , com uma mdia estimada de 50%,10 acarretando deposio pulmonar do medicamento inferior a 20% . 
   um estudo com pacientes que faziam uso de corticoterapia inalatria ou oral apontou que mais de 50% dos pacientes que no eram aderentes ao tratamento apresentavam maior uso de broncodilatadores e nebulizaes , alm do aumento no nmero de hospitalizaes.11 
    a utilizao de instrumentos ( ou escores ) que meam e pontuem as dificuldades dos pacientes durante o uso dos seus medicamentos para inalao pode ser til para reduzi - las . 
   ao utilizar esses instrumentos , o profissional de sade pode elaborar um programa educacional direcionado para os principais erros cometidos pelo paciente , revertendo assim a baixa adeso ao tratamento . 
   existem alguns escores que avaliam o uso correto desses inaladores em portadores de molstias pulmonares.12 alguns deles avaliam os erros na utilizao desses dispositivos para inalao ; porm , no existe um escore considerado padro - ouro com essa finalidade . 
   tal instrumento poderia ser um diferencial na avaliao de pacientes que utilizam esses dispositivos.13 
    leal13 desenvolveu um escore para avaliao das dificuldades dos pacientes no uso de ips ; tal escore pontua acertos e erros na utilizao dos dispositivos , promovendo a valorao dos erros . 
   a partir daquele instrumento , santos et al.3 desenvolveram escores para a avaliao de inaladores de p ( ipo ) e ip . 
   esses instrumentos ainda no esto validados e so utilizados em nosso hospital para a mensurao da qualidade da tcnica de uso dos dispositivos para inalao por pacientes asmticos3 e portadores de dpoc .   a validao de um instrumento permite verificar a congruncia entre o escore que  utilizado para realizar uma mensurao e a realidade que  medida , aumentando a confiabilidade do mesmo.14 ao se utilizar instrumentos validados para medir a tcnica de inalao de pacientes asmticos , sero obtidos resultados mais fidedignos e com maior garantia da qualidade dos dados 
   .   os objetivos do presente estudo foram validar os escores para a avaliao da tcnica de uso de ips e ipos em portugus do brasil , verificar quais erros so mais comuns durante a utilizao desses dispositivos e identificar quais pacientes necessitam de sesses de treinamento para essa utilizao . 
   trata - se de um estudo aberto e prospectivo desenvolvido em um hospital universitrio de referncia . 
   os pacientes foram selecionados de acordo com os seguintes critrios de incluso : apresentar diagnstico de asma de acordo com os critrios da global initiative for asthma,15 estar em seguimento ambulatorial por pelo menos dois anos , ter idade entre 15 e 65 anos , ter cursado no mnimo quatro anos do ensino fundamental , ter sua capacidade auditiva preservada e concordar em participar do estudo , assinando o termo de consentimento livre e esclarecido . 
   pacientes que j haviam participado de programas educacionais sobre a utilizao de medicamentos para asma foram excludos . 
   inicialmente , foi realizada a validao da confiabilidade dos escores de uso dos inaladores ( etapa 1 ) e a de seu contedo ( etapa 2 ) . 
   na etapa 3 foram realizados os testes para a validao de critrio e a validao discriminante desses novos instrumentos . 
   na etapa 1 , dois farmacuticos convidados ( cegos em relao  metodologia do estudo ) avaliaram simultaneamente a tcnica de uso dos inaladores . 
   aplicaram os escores para ipo e ip , elaborados por santos et al.,3 para elencar os erros apresentados . 
   esses escores detalham o passo a passo da tcnica para cada tipo de inalador . o paciente recebe um ponto a cada etapa executada de modo correto , e , quando a tcnica  feita de modo incorreto , o paciente no recebe pontos . 
   se o paciente comete erros graves , esses so subtrados . a pontuao determina se o paciente est apto ou no para utilizar o dispositivo para inalao 
   . os farmacuticos foram treinados quanto  correta utilizao dos escores acima referidos , seguindo as diretrizes do iii consenso brasileiro de manejo da asma.16 para essa avaliao foram utilizados os seguintes medicamentos : a ) ip : dipropionato de beclometasona 250 g e salbutamol 100 g ; b ) ipo : budesonida 200 g e formoterol + budesonida ( 6/200 ou 12/400 g ; cpsulas inalatrias ) ; e xinafoato de salmeterol 50 g ( diskus . 
   na etapa 2 , os escores oriundos da etapa anterior foram avaliados por expertos com o objetivo de mensurar o contedo desses instrumentos . o grupo de expertos foi constitudo por trs pneumologistas , dois pneumopediatras e dois alergistas , todos com slida experincia no uso de inaladores .   as modificaes propostas foram 
   julgadas quanto  pertinncia dos itens medidos pelos escores preliminares , avaliando - se a necessidade de incluses , excluses ou alteraes para melhorar a acurcia dos escores modificados . 
   depois que as alteraes foram sistematizadas por consenso , procedeu - se  elaborao de novos escores para ips e ipos . 
   na etapa 3 , novos pacientes utilizando ipo , ip ou ambos foram convidados a participar do estudo , de forma aleatria , para uma avaliao individual , obedecidos os mesmos critrios de elegibilidade das etapas anteriores . 
   foi - lhes solicitado , sem nenhuma orientao prvia , que utilizassem inaladores contendo placebo e que realizassem a mesma tcnica da sua rotina de tratamento . 
   cada paciente foi avaliado simultaneamente por outros dois farmacuticos , cegos em relao s modificaes realizadas , utilizando os escores derivados das etapas 1 e 2 , sendo vetado qualquer tipo de contato entre os avaliadores sobre os valores emitidos . 
   aps as avaliaes , todos os pacientes foram orientados sobre o modo correto do uso dos inaladores . 
   a mediana e o intervalo interquartil dos escores obtidos nessa fase permitiram a determinao dos valores de corte e a diviso dos pacientes em dois grupos : pacientes aptos e pacientes no aptos a utilizar os dispositivos para inalao . 
   os pacientes no aptos foram ento encaminhados ao programa de ateno farmacutica existente em nossa instituio . 
   para as etapas 1 e 2 foi utilizada uma amostra de convenincia baseada em estudos de validao anteriores . 
   para a etapa 3 calculamos a amostra baseados na hiptese de que a associao entre os escores pontuados pelos farmacuticos seria de pelo menos 60% . 
   considerando um poder de 0,95 e um erro tipo i de 0,05 , a amostra indicada 
   na etapa 3 , os valores mdios dos escores foram comparados entre os observadores , avaliando - se as concordncias e divergncias individualmente . 
   na etapa 3 , a anlise descritiva dos valores absolutos dos escores para cada dispositivo , por observador , foi realizada usando o programa statistical package for the social sciences , verso 18 ( spss inc . , chicago , il , eua ) . 
   os graus de correlao entre os escores e por observador foram avaliados utilizando - se o coeficiente alfa de cronbach . 
   aps a avaliao de normalidade , a comparao entre os escores por observador foi realizada atravs do teste de mann - whitney ( rank sum ) e sua correlao pelo teste de spearman , utilizando o programa sigmastat , verso 3 ( systat software inc . , san jose , ca , eua ) . 
   o teste do qui - quadrado foi utilizado para avaliar a concordncia dos grupos de pacientes ( aptos ou no aptos para utilizao dos inaladores ) entre os avaliadores . 
   farmacuticos em conjunto identificaram a necessidade de alteraes em determinados campos dos escores e propuseram duas modificaes preliminares : a retirada da pontuao geral dada ao paciente e a retirada do campo de sugestes para diminuir o nmero de folhas do escore . 
   foi criado um escore com uma nica tabela para a avaliao da tcnica do uso dos inaladores , com os acertos / erros que os pacientes poderiam cometer . a discordncia entre os avaliadores na etapa 1 ocorreu em 19% e 25% em relao aos escores para ipo e ip , respectivamente , indicando no somente erros 
   essas discordncias foram consideradas aceitveis na aplicao dos escores e proporcionalmente pouco significativas , sendo esclarecidas e dirimidas na etapa seguinte . 
   na avaliao dos escores pelos expertos , foram sugeridas e acatadas duas modificaes no escore para ipo : acrescentar um campo sobre a posio da cabea do paciente ( ngulo maior ou menor que 90 ) , sendo atribudo um ponto para " ngulo menor que 90 " e zero para " ngulo maior que 90 " ; e o significado da sigla cpt , adicionado ao final do escore . 
   em relao ao escore para ip , os especialistas fizeram oito sugestes de modificaes que foram acatadas : o item " agitao do dispositivo " foi alterado de " 3 vezes " para " 2 vezes ou mais " ; o campo " modo " foi alterado para " modo de uso " ; a pontuao do item " dentro da boca com espaador " foi alterada para um ponto por ser to correto quanto  forma de utilizao do inalador no item " fora da boca sem espaador " ; no campo " momento " , foi adicionado o item " inspirao rpida " ; os itens " junto ao acionamento " e " logo depois do acionamento " possuem o mesmo peso e foram unificados ; o item " s jogar na boca ou no inspirar " foi alterado para " acionamento direto na boca e no inspirar " ; no campo " profundidade " o item " no completamente " foi modificado para " insuficiente " , enquanto o item " adequadamente " foi alterado para " suficiente " ; e o campo " intervalo " foi alterado para " intervalo entre os acionamentos " . 
   os escores resultantes foram considerados mais prticos por avaliadores e expertos ( quadro 1 ) . o novo escore para ip manteve a pontuao total mxima ( nove pontos ) , mas houve um aumento na pontuao do escore novo para ipo ( seis pontos ) . 
   de acordo com a literatura , para se considerar que um paciente conhece e domina a utilizao correta do tipo de inalador , o escore obtido por ele pode apresentar uma variao aceitvel de 20% . 
   isso significa uma pontuao mnima de 7,2 e de 4,8 para os escores para ip e ipo , respectivamente ; entretanto , no est definido se essa variao ( desvio - padro ) leva em considerao se o paciente foi treinado anteriormente para o uso do inalador . 
   participaram da etapa 3 do estudo 72 pacientes , com mdia de idade de 41 anos , sendo 82% do sexo feminino . 
   esses pacientes geraram 89 avaliaes , sendo 39 pacientes avaliados com o escore para a tcnica de uso de ip e 50 pacientes com o escore para a de ipo . 
   essas avaliaes permitiram elencar as principais dificuldades / erros dos pacientes no uso de dispositivos para inalao . 
   o erro mais relevante entre os pacientes avaliados quanto ao uso de ambos os tipos de inaladores foi a falta de manuteno da cpt aps a inspirao profunda . 
   observou - se um maior nmero de erros entre os pacientes com o uso do ip ( tabela 1 ) . 
   o intervalo entre as doses & lt ; 60 s , a manuteno da cpt & lt ; 10 s aps a inalao , a velocidade da inspirao inadequada , o uso inadequado do ip sem espaador e a ausncia de realizao de expirao antes da inalao foram erros cometidos em mais de 50% dos testes realizados . 
   entre os pacientes que utilizaram ipo , os erros mais comuns foram a manuteno da cpt & lt ; 10 s , a ausncia de expirao antes da inalao e a velocidade inadequada da inspirao ( em 75% , 62% e 57% , respectivamente ) , conforme demonstrado na tabela 2 
   . de uma amostra de 72 pacientes , 60 pacientes no realizaram a pausa inspiratria de maneira correta ; 58 pacientes realizaram a inspirao muito rpida ; e 6 pacientes no sincronizaram o incio da inspirao com o acionamento do dispositivo . 
   nas mensuraes para o escore para ip realizadas na etapa 3 , os valores encontrados por avaliador , em mediana , foram 4 e 5 pontos para os observadores 1 e 2 , respectivamente , conforme mostrado na tabela 3 . 
   o grau de correlao entre os escores avaliados por observador , utilizando - se o coeficiente alfa de cronbach , foi de 0,97 . 
   essa correlao foi estatisticamente significativa usando - se a correlao de spearman ( p & lt ; 0,0001 ) , como se observa na figura 1 . 
   o teste de mann - whitney confirmou que os valores atribudos aos escores pelos dois avaliadores no foram estatisticamente diferentes . 
   foram encaminhados ao programa de educao pacientes com valor de escore & lt ; 4 pontos tanto para os escores para ip quanto para ipo . 
   esse foi o menor valor inteiro da mediana de avaliao concordante entre os dois observadores . 
   para a validao discriminante , encontrou - se uma concordncia entre os grupos de pacientes aptos e de no aptos ( necessitando de um programa de educao ) indicados pelo observador 1 e pelo observador 2 , tanto para o escore para ipo ( 50%/50% e 52%/58% ; p & lt ; 0,01 ) quanto para o escore para ip ( 49%/51% e 54%/46% ; p & lt ; 0,05 ) . 
   o presente estudo possibilitou a validao de contedo , de critrio e de discriminante dos escores para ipo e ip , permitindo tambm elencar as maiores dificuldades encontradas pelos pacientes no uso dos dispositivos para inalao no tratamento da asma , alm de determinar uma nota de corte , classificando os pacientes como aptos a utilizar seus inaladores ou identificar aqueles que necessitavam ser encaminhados para um programa educacional . 
   no melhor do nosso conhecimento atual , encontramos na literatura pesquisada um estudo que validou escores para ip para pacientes asmticos12 e , no caso de escores para ipo , somente um estudo com pacientes com dpoc.21 alm disso , segundo basheti et al.22 apesar de o uso de check - lists para um inalador especifico ser o mtodo mais vivel de avaliao , existem poucas evidncias para avaliar a importncia relativa dos diferentes critrios . as divergncias dos sistemas de pontuao para o mesmo dispositivo para inalao em diferentes estudos dificultam a comparao direta dos resultados . 
   considerando que o nosso estudo validou escores tanto para ip quanto para ipo para pacientes asmticos , os resultados obtidos nos permitiram pontuar erros em ambos e trat - los de forma personalizada , de modo que todos os pacientes puderam ser orientados sobre o modo correto de utilizao desses dispositivos com base em seus erros de execuo da tcnica . 
   quadro 1escores modificados e aprovados pelos expertos ( etapa 2 ) e validados para uso em portugus do brasil ( etapa 3 ) . 
   tabela 1proporo de erros realizados pelos pacientes na avaliao do escore da tcnica do inalador pressurizado.critrios avaliadoserros , % intervalo entre as doses & lt ; 60 s ( paciente orientado a aguardar 60 s entre uma dose e outra)89manuteno da cpt & lt ; 10 s aps a inalao ( paciente orientado a prender a respirao por 10 s aps a inalao)83fluxo inspiratrio inadequado ( inspirao rpida e / ou curta)81uso inadequado do ip sem o espaador ( para os pacientes que utilizavam o espaador)73ausncia de expirao antes da inalao ( no expirar antes do uso do ip)59agitao do inalador apenas uma vez ( paciente orientado a agitar o ip no mnimo 2 vezes)32no agitar o inalador ( paciente orientado a agitar o ip no mnimo 2 vezes)31manobra inspiratria incompleta ( paciente no realiza uma inspirao profunda)18posio do ip inadequada ( paciente orientado a sentar - se de modo que suas pernas formem um ngulo de 90 com o cho)10ausncia de sincronizao entre o acionamento do ip e incio da inspirao ( paciente no sincroniza o disparo do ip com o incio da inspirao)8respirao nasal ( paciente realiza a respirao nasal durante a inalao)5acionamento do inalador direto na boca e ausncia de inspirao ( paciente orientado a distanciar o ip trs dedos da boca e realizar a inspirao aps o acionamento)5outros9,5ip : inalador pressurizado 
   
   tabela 2proporo de erros realizados pelos pacientes na avaliao do escore da tcnica do inalador de p.critrios avaliadoserros , % manuteno da cpt & lt;10 s ( paciente orientado a prender a respirao por 10 s aps a inalao)75ausncia de expirao antes da inalao ( no expirar antes do uso do ipo)62fluxo inspiratrio inadequado ( inspirao rpida e / ou curta)57profundidade incompleta ( paciente no realiza uma inspirao profunda)21preparo da dose incorreta ( paciente no coloca a cpsula dentro do ipo e / ou no fura a cpsula antes de realizar a inalao)*18inspirar levemente ( paciente no realiza uma inspirao profunda)5expirar dentro do ipo ( paciente realiza a expirao com o ipo na boca)3respirao nasal ( paciente realiza a respirao nasal durante a inalao)2inspirar irregularmente ( paciente no consegue realizar a inspirao de modo contnuo)2ipo : inalador de p . * relativo ao tipo de ipo utilizado no estudo ( adaptao ) . 
   a capacidade de prender a respirao por mais de 10 s aps a inalao foi a dificuldade mais importante entre os pacientes do nosso estudo , tanto para ip como para ipo ( 83% e 75% , respectivamente ) . 
   manzella et al.12 avaliaram a tcnica inalatria e relataram que 69% dos pacientes avaliados no prendiam a respirao por no mnimo 10 s. uma reviso que compilou resultados de 12 estudos ( 955 pacientes includos ) classificou os erros mais cometidos pelos pacientes , sendo que a dificuldade de prender a respirao por 10 s aps a inalao ocorria em 26% da populao . 
   esse tempo determinado de prender a respirao  importante para que ocorra uma maior sedimentao das partculas do medicamento nos pulmes.25 
    o autor da reviso tambm relatou que 50% dos pacientes faziam a pausa de tempo necessria entre as doses . 
   no nosso estudo , esse foi o erro mais frequentemente ( 89% ) encontrado em relao ao escore para ip . 
   esse passo da tcnica  importante para garantir que uma maior quantidade do medicamento alcance as vias areas.12 
   
   tabela 3valores dos escores encontrados por instrumento de acordo com o observador.valoresipoipavaliador 1avaliador 2avaliador 1avaliador 2mediana ( ii)4,5 ( 4,0/6,0)5,0 ( 3,0/5,0)4,0 ( 0,5/6,0)5,0 ( 1,0/6,5)mnimo / mximo1/71/712/913/10ipo : inalador de p ; ip : inalador pressurizado ; e ii : intervalo interquartil . 
   ipo : inalador de p ; ip : inalador pressurizado ; e ii : intervalo interquartil . 
   a velocidade de inalao inadequada , terceira dificuldade mais comumente encontrada em nosso estudo para ip , foi igualmente relatada por mcfadden como a terceira dificuldade mais frequentemente observada em 12 estudos , sendo que , no total , 19% dos pacientes realizavam a inalao de forma muito rpida . 
   esse erro  grave , pois quanto mais devagar  a taxa de medicamento inalado , maior ser a deposio pulmonar desse medicamento com o uso de ip.25 
    em relao ao ipo , a ausncia de expirao antes da inalao foi verificada em 62% dos casos , sendo a segunda dificuldade mais frequente para esse tipo de inalador . 
   o volume pulmonar existente no incio da inspirao interfere na deposio da droga e  por isso que se recomenda a realizao da expirao antes do incio da inalao.26 
    a velocidade de inspirao inadequada foi o terceiro erro mais comumente encontrado ( 57% ) no uso de ipo . 
   no caso desses dispositivos para inalao , a sada do medicamento  decorrente do fluxo inspiratrio que o paciente realiza . 
   se o fluxo ( volume / tempo ) for menor que o necessrio , as doses inaladas sero reduzidas , e esse  um fator importante para o insucesso teraputico . 
   sandrini et al.28 analisaram o uso de ip em uma amostra de pacientes , classificando a tcnica de inalao em correta , pouco errada , com erro intermedirio e muito errada . 
   os autores classificaram a tcnica de 48% dos pacientes como no correta . os erros mais encontrados foram colocao do inalador dentro da boca ( 68,0% ) ; inspirao antes de acionar o jato ( 15,5% ) ; inspirao rpida ( 11,0% ) ; e inspirao pelo nariz ( 9,0% ) . 
   esses erros tambm foram encontrados em nossos pacientes , mesmo com o modo de avaliao diferente do utilizado naquele estudo . 
   dalcin et al.24 e souza et al.29 utilizaram listas ou fichas de controle para verificar a utilizao adequada dos inaladores pelos pacientes em seus trabalhos . 
   souza et al.29 encontraram que 54,5% dos pacientes avaliados que faziam uso de ipo no realizavam a expirao antes da inalao de forma adequada . 
   esse achado corrobora o nosso , pois esse foi o segundo erro mais comumente encontrado na avaliao de nossos pacientes . 
   j dalcin et al.24 encontraram um maior nmero de erros nos pacientes que utilizavam ip quando comparados aos que usavam outros inaladores , sendo esse achado tambm igual ao nosso . 
   fato que , nos trabalhos acima citados , os instrumentos utilizados permitiram aos autores quantificar e classificar os erros cometidos pelos pacientes . 
   comparando as tcnicas de inalao para o uso de ip e ipo publicadas no iii consenso de asma16 e nas diretrizes para o manejo de asma de 2012,1 verifica - se que as orientaes no diferem tecnicamente das utilizadas em nossa instituio . 
   entretanto , verificamos que os escores utilizados no presente estudo , alm de especificarem o passo a passo da tcnica de inalao , so uma ferramenta para que o profissional de sade possa mensurar , de forma objetiva e matemtica , os erros cometidos pelos pacientes . 
   alm disso , eles possibilitam verificar se o paciente est apto ou no a utilizar seu inalador atravs da especificao de uma nota de corte . 
   isso tambm permite que o profissional de sade acompanhe objetivamente a evoluo do paciente quanto a sua tcnica de inalao . 
   nossos resultados demonstram que a proporo de erros no escore para ip foi maior do que no para ipo . 
   essa diferena na proporo de erro entre os dispositivos pode estar associada  maior facilidade na compreenso da tcnica de uso de ipo em detrimento quela de ip por parte dos pacientes . 
   destacamos que lavorini et al.21 realizaram uma reviso da literatura com 47 artigos que analisavam a tcnica do uso do ipo . 
   os resultados demonstram que o uso incorreto de inaladores influencia a eficcia da droga , e os autores destacam que a avaliao do uso correto dos inaladores ainda  considerada irrelevante por muitos profissionais de sade.21 
    em um estudo realizado em 2011 na bahia , foram avaliados os erros que os pacientes cometiam ao utilizar os seus inaladores ; encontrou - se baixa proporo de erros na tcnica inalatria . 
   tais resultados foram associados ao acompanhamento em um centro de referncia em asma que os pacientes daquele estudo recebiam ; eles participavam de peridicas orientaes e revises acerca da tcnica inalatria , realizadas por uma equipe multiprofissional.5 
    como limitao do estudo , pode - se indicar a falta de seguimento dos pacientes avaliados aps o mesmo . 
   tal acompanhamento poderia permitir que se determinasse a evoluo da tcnica do uso dos inaladores pelos pacientes . 
   um vis do presente estudo ocorreu porque os pacientes apresentaram um alto ndice de erros ao utilizarem ip ( mediana de 4 e 5 pontos para os avaliadores 1 e 2 , respectivamente ) , distantes dos valores tericos de 7,2 pontos sugeridos pela literatura . 
   como os resultados obtidos pelos dois avaliadores foram altamente concordantes usando uma nota de corte menor que 4 pontos , sugerindo boa acurcia do escore , pode - se inferir que os observadores classificaram muitos pacientes como aptos para o uso do ip apesar de no terem atingido a pontuao mnima prevista em teoria ( 20% de 9 pontos mximos ) . 
   isso refora a necessidade de reavaliao do uso do inalador a cada consulta e a utilizao sequencial desse escore em uma grande amostra populacional . 
   estes novos escores permitiro a execuo de programas educacionais , propostos em diretrizes e estratgias para o tratamento da asma . 
   segundo esses documentos , os pacientes precisam receber treinamento contnuo sobre a tcnica de inalao para que se possa garantir a utilizao correta do inalador . o farmacutico , por meio da ateno farmacutica , pode 
   orientar o paciente quanto ao manejo dos dispositivos para inalao e , ao utilizar nossos escores , pode quantificar os acertos / erros e mensurar se o paciente alcana e mantm o ideal de 80% de correo na tcnica ao longo do programa de educao . os escores no presente estudo demonstraram ser capazes de especificar em qual passo os pacientes esto errando , permitindo direcionar o programa educativo durante o acompanhamento sem repetir o que paciente j sabe . 
   a inalao  a via mais utilizada para o tratamento da asma , e a realizao de uma tcnica correta na utilizao dos dispositivos est diretamente relacionada  eficcia teraputica do medicamento . 
   sendo assim , a execuo correta da tcnica de inalao  essencial para que o tratamento farmacolgico seja eficaz.3 acreditamos que o presente estudo , ao validar escores objetivos para o uso de ip e de ipo que especificam as maiores dificuldades encontradas pelos pacientes no uso dos dispositivos e uma nota de corte , assim como classifica os pacientes como aptos a utilizar seus inaladores ou no , pode ser de relevncia clnica . 
   o profissional de sade ser capaz , por meio desses escores validados , de identificar e corrigir os erros do paciente ao longo das consultas e , consequentemente , melhorar o manejo dos inaladores .
summary: abstractobjective : to validate two scores quantifying the ability of patients to use metered dose inhalers ( mdis ) or dry powder inhalers ( dpis ) ; to identify the most common errors made during their use ; and to identify the patients in need of an educational program for the use of these devices . 
   methods : this study was conducted in three phases : validation of the reliability of the inhaler technique scores ; validation of the contents of the two scores using a convenience sample ; and testing for criterion validation and discriminant validation of these instruments in patients who met the inclusion criteria . 
   results : the convenience sample comprised 16 patients . 
   interobserver disagreement was found in 19% and 25% of the dpi and mdi scores , respectively . 
   after expert analysis on the subject , the scores were modified and were applied in 72 patients . 
   the most relevant difficulty encountered during the use of both types of devices was the maintenance of total lung capacity after a deep inhalation . 
   the degree of correlation of the scores by observer was 0.97 ( p & lt ; 0.0001 ) . 
   there was good interobserver agreement in the classification of patients as able / not able to use a dpi ( 50%/50% and 52%/58% ; p & lt ; 0.01 ) and an mdi ( 49%/51% and 54%/46% ; p & lt ; 0.05 ) . 
   conclusions : the validated scores allow the identification and correction of inhaler technique errors during consultations and , as a result , improvement in the management of inhalation devices .