Factors associated with quality of life impairment among asthma patients attending specialty clinics in Trinidad

Objectives: To examine factors associated with asthma related quality of life impairment (AQLI) among patient attending asthma clinics in Trinidad. Design and Methodology: A consecutive sample of 428 patients, ≥18 years, attending asthma clinics in Trinidad were recruited. Data were collected using intervieweradministered questionnaires which captured demography, comorbidities, triggers, hospital admissions and emergency department (ED) visits. AQLI was evaluated using the Juniper Mini AQL questionnaire to capture both the physical and emotional impact of the disease. The data were analysed using Chi-square test and multivariable logistic regression (SPSS Version 25). Results: Majority of patients were female (81%), ≥40 years (80.4%), of Indo-Caribbean descent (61.9%), and overweight (71.7%). The most commonly reported health conditions were gastrooesophageal reflux (53.0%), hypertension (47.2%), allergic rhinitis (45.1%), anxiety (42.8%), sleep apnoea (35.0%), and depression (32.5%). Environmental allergens (73.8%) were the most commonly reported trigger factor. The prevalence of moderate to severe AQLI was 60% and significantly associated variables were: age group (p=.0003), ethnicity (p<.0001), trigger factors (p=.013), sleep apnoea (OR=3.07, p=.001), gastrooesophageal reflux (OR=2, p=.014), depression (OR=3.59, p=.001) and anxiety (OR=2.52, p=.003), frequent (two or more) exacerbations (OR=4.07, p<.001) and having ever visited the ED (OR=4.78, p<.001) in the last 12 months. Independent predictors of AQLI were age, ethnicity, sleep apnoea and ED visits (Nagelkerke's pseudo R2=41%). Conclusion: Asthmatics demonstrate a high prevalence of moderate to severe quality of life impairment associated with demography and co-morbidities. Understanding these factors may improve doctor patient interactions, treatment and management.

Efficacy of levofloxacin loaded non-ionic surfactant vesicles (niosomes) in a Pseudomonas aeruginosa infection model in Sprague Dawley rats

Objective: To determine the efficacy of levofloxacin loaded niosomes in treating Sprague Dawley rats infected with Pseudomonas aeruginosa (ATCC 27853). Design and Methodology: Three groups of six (6) animals were infected with a known dose of the pathogen i.e. Pseudomonas aeruginosa via the intraperitoneal (ip) route. At six (6) hours post infection the infected animals were treated with drug free niosomes (control), free levofloxacin (conventional) and levofloxacin trapped in niosomes (ip). Blood was collected via tail snips at days 0,1,3,5,7 and 10 for complete blood counts and viable bacterial counts by colony forming units (CFU/µl). At day 10 the animals were sacrificed and samples from the kidney, liver and spleen were examined for bacterial counts. Results: All animals in the control group succumbed to the infection; one animal from the conventional group died. All niosome treated animals survived. The mean lymphocyte count (X109) was lower for the niosome (7.258±1.773) versus conventional (17.684±10.008) (p<0.03) treated groups at day ten (10). Neutrophil counts (X109) were lower for the niosome (2.563±1.609) versus conventional (6.2±6.548) p<0.02) treated groups. The CFUs in the bloodstream were similar for both treatment groups; the niosome treated group showed greater reduction in liver, kidney and spleen CFUs versus the conventional group (1.33±2.074) vs (5.8± 3.74) (p< 0.043), (1.5±2.35) vs (9.6±8.65) (p< 0.038) and (3.8 4.71) vs (25.6 14.66) (p<0.007) respectively. Conclusions: Further work is recommended on niosomes as a drug delivery system to treat intracellular infections.

Preparedness of healthcare facilities for a public health emergency in a Caribbean country

OBJECTIVE: To review basic, critical elements of emergency preparedness and response capacity in the healthcare system of Trinidad and Tobago. DESIGN AND METHODS: A descriptive study involving one major hospital and one randomly selected health centre in each Regional Health Authority (RHA). Responders were chosen by purposive sampling and structured face-to-face interviews were carried out. Data collection was undertaken using modified versions of two previously validated data collection tools. RESULTS: All 5 hospitals in each RHA and 4 of 5 health centres participated. Emergency response plans existed in all healthcare facilities reviewed; however plans were not regularly tested. An investigation team can be assembled in 24 hours and a patient referral system was in place in all hospitals. There appeared to be access to stockpiles in all facilities. There was a gap in ongoing infection control measures including the absence of regular personal protective equipment (PPE) training for staff. CONCLUSIONS: There was an urgent need for systematic rather than ad hoc measures for testing existing plans and staff training in their roles and responsibilities during an acute public health event should one occur. For infectious diseases with high case fatality rates such as avian influenza and Ebola, it is critical for front line staff to be aware of infection control measures including how to properly use PPE. Governments should take the opportunity of the Ebola outbreak in West Africa to utilize public health capacity to catalyse the systematic strengthening of core capacities for alert and response to meet their International Health Regulations (IHR) 2005 obligations.

Relationship of fasting total homocysteine, high sensitivity C-reactive protein and features of the metabolic syndrome in Trinidadian subjects.

OBJECTIVES: To assess the relationship of homocysteine, hs-CRP, with known cardiovascular risk factors of the metabolic syndrome. METHOD: Cross sectional study comprised 182 diabetic outpatients (70 males and 112 females), attending endocrinology clinics in Trinidad. RESULTS: Both male and females showed significant linear relationships between high sensitive C-reactive protein (hs-CRP), blood pressure and diabetes (r = -0.2 < R or R > 0.2). In females hs-CRP showed significant linear relationship with HDL, triglyceride, blood pressure and diabetes mellitus (p < 0.0001). The inverse relationship of hs-CRP with HDL implies the strong association of hs-CRP with metabolic syndrome. The multivariate logistic regression analysis showed significant relation of hs-CRP, metabolic syndrome and diabetes mellitus. There was no significant relationship of tHCY to any of the features studied. CONCLUSION: Serum C-reactive protein is significantly related to features of the metabolic syndrome. Total plasma homocysteine, appears to be independent of both hs-CRP and features of the metabolic syndrome.

A preliminary investigation of periodontal disease and diabetes in Trinidad.

OBJECTIVES: To describe periodontal disease status in diabetic patients in Trinidad. METHOD: A cross-sectional study was conducted. Patients attending a tertiary referral centre for diabetes at an out-patient clinic were invited to undergo oral examinations. The basic periodontal examination (BPE) was used to assess periodontal disease status. RESULTS: Seventy-two patients participated in the study. Mean age was 55.7 years, 54.2% were female, with 66.7% and 22.2% being of Indo-Trinidadian and Afro-Trinidadian ethnicity respectively. There were 61.1% who had not attended for dental treatment within the last year and 56.9% only attended when in pain; 15.3% had a history of cigarette smoking and 31.9% currently wore a denture. Plaque was detectable with the use of a probe in 40.3% of the 67% that underwent a BPE assessment; 38.8% were found to have advanced periodontal disease. CONCLUSION: The prevalence of periodontal disease in this sample of diabetic patients suggests that regular dental examinations, oral health education, and collaborative patient care between medical and dental practitioners should form part of the routine management of diabetic patients in Trinidad.

Health burden of co-morbid asthma and allergic rhinitis in West Indian children.

BACKGROUND: Co-morbid allergic rhinitis (AR) and asthma has not been studied in Caribbean countries where there is a high prevalence of childhood asthma. METHODS: Using the International Primary Care Airways Group (IPAG) guidelines to determine AR, care-givers of 393 (response rate=100%) children attending asthma clinics in selected public sector health facilities in Trinidad, West Indies, were interviewed. RESULTS: Children (393) were between 2-17 years and included 239 (60.8%) boys and 154 (39.2%) girls. As many as 53.9% of children sampled (95% CI 45.9-55.8) suffered from AR. Children exposed to household smoking were nearly twice as likely to have AR (p<0.0041, OR=1.9, CI 1.22-2.88). Significantly (p<0.01) more asthmatics with AR (154, 58.6%) visited Accident and Emergency (A&E) in the past 12 months. The odds of visiting A&E at least once in the past 12 months for asthmatics with AR were 1.75 (95% CI 1.15-2.68). The average frequency of A&E visits was higher in children who also suffered from AR (1.75 vs 1.36, p<0.04). Age was negatively correlated (-0.21, p<0.005) with exacerbation frequency for asthmatics without AR suggesting A&E visits are independent of age in co-morbid disease. More children with AR (>60%) suffer day and night symptoms (p<0.001), and miss school (59.8%) (p<0.03) at least once a week (p<0.002) than asthmatics without AR (OR=1.5, 95% CI=1.03-2.30). CONCLUSIONS: AR is prevalent in 53.9% of Trinidadian children with asthma. The burden of co-morbid disease in asthmatic children is associated with increased likelihood of asthma-related A&E visits, day and night symptoms and absence from school.

Drug utilization patterns in pregnant women: a case study at the Mount Hope Women's Hospital in Trinidad, West Indies.

OBJECTIVE: To explore drug (prescription, over-the-counter and herbal) utilization in pregnant women attending a public sector tertiary healthcare institution. METHODS: This was a cross-sectional case study in women attending antenatal clinics at the Mount Hope Women's Hospital. Women (506) who consecutively presented for routine care at the antenatal clinic were interviewed on the medication they took. Descriptive statistics and logistic regression for predictors of drug use were done using SPSS 16. RESULTS: There were 200 (39.5%) primigravidae, 306 (60.5%) multigravidae and 299 (59%) women were in the third trimester of pregnancy. Most women (69.8%) were between 20-35 years of age. Women took an average of 1.32, 1.22 and 0.94 prescribed drugs in each trimester respectively. Multivitamins (59.8%) and iron/folic acid (54.2%) were the most frequently prescribed drugs. Regardless of trimester only 20% of women took supplemental calcium. Very few women (2.4%) took herbal medications. Paracetamol was the most common over-the-counter (OTC) medication in all trimesters. Women with secondary level education were most likely to use OTC iron/folic acid (p = 0.02), paracetamol and histamine2 receptor antagonists [H2RAs] (p = 0.001). More primigravidae took non-steroidal anti-inflammatory drugs (p = 0.02) and more women in the first trimester used antiemetics (p = 0.001). Age group (p = 0.048), marital status (p = 0.001) and the trimester of pregnancy (p = 0.001) were predictors of drug utilization. CONCLUSION: Overall, women in tertiary healthcare institutions took medication as prescribed particularly multivitamins and iron/folic acid. More women with higher education took OTC paracetamol, iron/folic acid and vitamin supplements. Herbal supplements were rarely used. Research on drug utilization in primary care facilities is recommended.

Evaluation of asthma control using patient based measures and peak expiratory flow rate.

OBJECTIVE: Asthma control has not been formally evaluated in the Caribbean. This study evaluated disease control on The Asthma Control Test (ACT), The Royal College of Physicians "Three questions" for Assessing Asthma Control (RCP), peak expiratory flow rate (PEFR) and patients' self-assessment of control. SUBJECTS AND METHODS: Asthma control was examined in a cross-section of 205 asthmatics above 16 years of age using the ACT, RCP and on the PEFR % predicted. Scores below 20 and equal to or above 1 on the ACT and RCP respectively, and PEFR below 80% predicted indicated uncontrolled asthma. Patients stated whether they perceived their asthma was controlled or uncontrolled. RESULTS: Overall there were more females (63.9%, p < 0.001) than males (36.1%). Males aged between 17-30 years predominated (60.8%, p < 0.001) with gender reversal beyond 30 years of age (33.2%, p < 0.002) years. Self-assessed control was higher (69.3%, p < 0.001) than control evaluated by the ACT and RCP tests, which were comparable (p > 0.05). Fewer patients (13.2%) achieved control on PEFR > 80% predicted than on the ACT (22.4%) and RCP (18%). The Kappa statistic indicated good reproducibility of the RCP and ACT and concordance between the PEFR and RCP (0.63) and the PEFR and ACT (0.56). Higher education was associated with control on the ACT (p < 0.0005) and RCP (p < 0.002) but not on PEFR or self-assessment (p > 0.05). CONCLUSION: Approximately 80% of study asthmatics were uncontrolled, and patients tended to overestimate their disease control. The ACT and RCP instruments were comparable with the PEFR. Efforts to study their validity and formal evaluation of asthma control in Trinidad are recommended.

Evaluation of wound-healing potential of Catharanthus roseus leaf extract in rats.

Rats treated with 100 mg /kg/day of the Catharanthus roseus ethanol extract had high rate of wound contraction significantly decreased epithelization period, significant increase in dry weight and hydroxyproline content of the granulation tissue when compared with the controls. Wound contraction together with increased tensile strength and hydroxyproline content support the use of C. roseus in the management of wound healing.

Chronic obstructive pulmonary disease is missed in asthmatics in specialty care in Trinidad, West Indies.

SETTING: Underdiagnosis of chronic obstructive pulmonary disease (COPD) in asthmatics attending specialty care in Trinidad, West Indies. OBJECTIVE: To determine the prevalence of COPD in diagnosed asthmatics receiving specialty respiratory care. DESIGN: In a cross-sectional study, 258 asthmatics were screened for lung function measures to examine forced expiratory volume after 1 second (FEV1), forced vital capacity (FVC) and post-bronchodilator FEV1/FVC (COPD was defined as FEV1/FVC < 70%). RESULTS: Of 165 patients evaluated (response rate 64.0%), 53 (32.1%, 95%CI 25.0-39.2) had a study diagnosis of COPD and a mean FEV1/FVC of 60.12 +/- 1.2. Proportionally, more males had COPD (50.9%) than asthma (24.1%, P < 0.001). Patients with COPD were 10 years older than asthmatics (P < 0.001). Persons with asthma who smoked were more likely to have COPD (56.0%) (OR 3.26, 95%CI 1.36-7.80, P = 0.006). In both sexes, FEV1/FVC was lower among older people (P < 0.001), with a greater effect (OR 2.75, 95%CI 1.00-7.56, P < 0.01) seen among men in this cross-sectional study. CONCLUSIONS: One third of diagnosed asthmatics in specialty care also have COPD. Lung function was lower among older persons. Early spirometric evaluation of elderly asthmatics who smoke can determine the presence of COPD and facilitate appropriate management.

Aspirin for everyone over 50? Avoid the harm

Editor—The recommendation that everyone over 50 should take aspirin ignores the issue of dose with its ratio of benefit to risk, given that a person still has at least a third of life span remaining and that older hypertensive patients are susceptible to haemorrhagic stroke.1 The debate about what is a low dose has gone on long enough, with no definite answer beyond 75 mg to over four times its multiple at 325 mg for secondary prevention of cardiovascular and cerebrovascular thrombotic disease. Aspirin across the board for primary prevention may be considered in patients with a 10 percent risk of coronary heart disease, and the risk-benefit balance between the number of myocardial infarctions that can be prevented and the risk of haemorrhagic stroke and gastrointestinal bleeds must be taken into account.

Assessment of risk for type 2 diabetes mellitus in a Caribbean population with high diabetes-related morbidity

Diabetes mellitus is a major cause of morbidity in Trinidad and Tobago. Screening programmes are not incorporated in the health sector and the population at risk remains unaware of the benefits of screening. We investigated the risk of developing Type 2 diabetes mellitus in office workers with one risk factor. Participants were randomly selected from the urban corporate sector in Port of Spain. Fasting capillary blood glucose and the American Diabetes Association (ADA) questionnaire for major diabetes risk factors were used to assess risk. Student pharmacists approached 482 persons, of whom 317 consented to participate (66 response rate). There were 101 (32) men and 216 (68) women, 37 (39) were of African ancestry and 28 each were of East Indian and mixed ancestry. Family history was positive in 54. Thirty per cent (95) of the volunteers were at risk of developing Type 2 diabetes mellitus (41 men; 54 women). Based on the ADA questionnaire, 82 (78) of volunteers were at high risk for developing Type 2 diabetes mellitus. The ADA risk test and Impaired Fasting Glucose were both positive in 13 (14) volunteers. In subjects at risk, Body Mass Index (BMI) was > 25 kg/m2 in 74 (78) and the waist/hip ratio was 0.85. Approximately 30 of office staff was at risk of developing diabetes mellitus. The ADA questionnaire is a useful non-invasive measure which pharmacists can use to assess risk for Type 2 diabetes mellitus. The glucometer can be used for risk assessment providing that it is associated with a quality assurance programme and that diagnosis is confirmed with laboratory testing

Community pharmacists' knowledge and dispensing recommendations for treatment of acute diarrhoea in Trinidad, West Indies.

Using a hypothetical case presentation of a patient with acute diarrhoea, community pharmacists in Trinidad were asked about their knowledge and dispensing recommendations to manage acute diarrhoea. Oral rehydration salts (ORS) were recommended by 86% (79), but more pharmacists would recommend ORS as the first choice therapy alone, for children (70%) than adults (33%) (p < 0.01). Antimotility agents as a first choice therapy alone or with ORS would be given to more adults (60%) than children (10%) (p < 0.01), and more adults (59%) than children (33%) would receive cotrimoxazole. Pharmacists (93%) would counsel on preparation, storage and treatment schedule for ORS, but not on discontinuing (32%) or continuing ORS (4%). Despite 51 pharmacists knowing the WHO guidelines to treat acute diarrhoea, only 23 dispensed in accordance. Educational re-enforcement to manage acute diarrhoea and dispensing practices of medications are necessary for pharmacists who are the first patient contact in Trinidad.

Assessment of risk for type 2 diabetes mellitus in a Caribbean population with high diabetes-related morbidity.

Diabetes mellitus is a major cause of morbidity in Trinidad and Tobago. Screening programmes are not incorporated in the health sector and the population at risk remains unaware of the benefits of screening. We investigated the risk of developing Type 2 diabetes mellitus in office workers with one risk factor. Participants were randomly selected from the urban corporate sector in Port of Spain. Fasting capillary blood glucose and the American Diabetes Association (ADA) questionnaire for major diabetes risk factors were used to assess risk. Student pharmacists approached 482 persons, of whom 317 consented to participate (66% response rate). There were 101 (32%) men and 216 (68%) women, 37 (39%) were of African ancestry and 28% each were of East Indian and mixed ancestry. Family history was positive in 54%. Thirty per cent (95) of the volunteers were at risk of developing Type 2 diabetes mellitus (41 men; 54 women). Based on the ADA questionnaire, 82% (78) of volunteers were at high risk for developing Type 2 diabetes mellitus. The ADA risk test and Impaired Fasting Glucose were both positive in 13 (14%) volunteers. In subjects at risk, Body Mass Index (BMI) was > 25 kg/m2 in 74% (78) and the waist/hip ratio was 0.85. Approximately 30% of office staff was at risk of developing diabetes mellitus. The ADA questionnaire is a useful non-invasive measure which pharmacists can use to assess risk for Type 2 diabetes mellitus. The glucometer can be used for risk assessment providing that it is associated with a quality assurance programme and that diagnosis is confirmed with laboratory testing.

Extended-spectrum beta-lactamase producing enterobacteriaceae in a tertiary care hospital in Trinidad and Tobago.

Extended-spectrum beta-lactamase (ESBL) mediated resistance to third generation cephalosporins, amongst the family Enterobacteriaceae, is emerging worldwide. This is the Caribbean's first survey on ESBL production, and was conducted during two six-month periods in 1998 and 2001, in a tertiary health institution in Trinidad and Tobago. Consecutive ampicillin resistant isolates of the family Enterobacteriaceae from in-patients were screened for resistance to third generation cephalosporins, and for ESBL production. The proportion of isolates found to be ESBL producers was similar in both samples (40 of 560 and 23 of 361). Overall, ESBL production was more frequent in enterobacter, citrobacter and proteus (and related organisms) than in Klebsiella and Escherichia (11.2% and 4.6%, respectively, p < 0.001). In the 1998 sample, this proportion (9.8% versus 5.8%) was significant (p < 0.05), but the difference was more marked in the 2001 sample (13.6% versus 2.9%, p < 0.001). Continued distribution of these resistant bacterial strains is of concern. In the Caribbean region, more laboratory surveillance and increased infection control vigilance are recommended, with focus on specific genera in the family.

Extended-spectrum beta-lactamase producing enterobacteriaceae in a tertiary care hospital in Trinidad and Tobago

Extended-spectrum beta-lactamase (ESBL) mediated resistance to third generation cephalosporins, amongst the family Enterobacteriaceae, is emerging worldwide. This is the Caribbean's first survey on ESBL production, and was conducted during two six-month periods in 1998 and 2001, in a tertiary health institution in Trinidad and Tobago. Consecutive ampicillin resistant isolates of the family Enterobacteriaceae from in-patients were screened for resistance to third generation cephalosporins, and for ESBL production. The proportion of isolates found to be ESBL producers was similar in both samples (40 of 560 and 23 of 361). Overall, ESBL production was more frequent in enterobacter, citrobacter and proteus (and related organisms) than in Klebsiella and Escherichia (11.2 and 4.6, respectively, p < 0.001). In the 1998 sample, this proportion (9.8 versus 5.8) was significant (p < 0.05), but the difference was more marked in the 2001 sample (13.6 versus 2.9, p < 0.001). Continued distribution of these resistant bacterial strains is of concern. In the Caribbean region, more laboratory surveillance and increased infection control vigilance are recommended, with focus on specific genera in the family

Salmeterol decreases eosinophilic cationic protein and rescue medication in patients inhaling beclomethasone dipropionate: preliminary study in mild and moderate asthma in Trinidad, West Indies.

Activated eosinophils play a critical role in asthma pathogenesis, and eosinophil cationic protein (ECP) is a useful indicator of inflammation. Inhaled corticosteroids and long-acting beta2-agonists (LABA) effectively control asthma symptoms and improve airway function. Salmeterol's anti-inflammatory efficacy as add-on therapy to inhaled corticosteroids has not been evaluated in Caribbean populations. We investigated nine non-smoking subjects (three men and six women; mean age: +/- SE, 50.7 +/- 3.82 years) with stable mild and moderate persistent asthma who were inhaling > or = 500 microg beclomethasone dipropionate (BDP) daily. This was a with-in-patient controlled laboratory blind study performed over 8 weeks. Patients received BDP for 2 weeks, add-on salmeterol 100 microg in weeks 3-6 and BDP alone in weeks 7-8. Patients recorded daily morning and night symptoms. Morning peak expiratory flow rate was measured on entry to the study and with sputum ECP at the end of weeks 2, 4, 6 and 8. Salmeterol together with BDP decreased sputum ECP from a pretreatment median value of 897.84 microg/l to 628.38 microg/l after 4 weeks, and ECP continued to decrease even after salmeterol withdrawal. Both drugs decreased the frequency of rescue medication use by approximately 50% and increased the median number of days per week without rescue salbutamol from 0 to 3 days. Salmeterol's bronchoprotective effect was maximal after 4 weeks and was sustained after its withdrawal. In conclusion, this study, performed in Trinidadian asthmatics, used ECP as a surrogate marker of bronchial inflammation and supports the recent Salmeterol Multi-center Asthma Research Trial (SMART) data recommending add-on salmeterol therapy to adequate anti-inflammatory medication such as inhaled corticosteroids for optimal asthma management. Further studies are required to evaluate the anti-inflammatory efficacy and possible tolerance to salmeterol in Caribbean patients.

Problem-based compared with traditional methods at the Faculty of Medical Sciences, University of the West Indies: a model study.

The University of the West Indies (UWI) comprises three campuses located on three different islands. Two of the Campuses, Mona in Jamaica and St Augustine in Trinidad & Tobago offer full medical programmes, i.e. both basic sciences and clinical training. At Cave Hill, where basic sciences courses are not offered, students are drawn from the traditional school at Mona or the Problem Based Learning (PBL) school at St Augustine to follow a common clinical programme. After 24 months of clinical training consisting of a minimum of 12 clerkships these students take identical examinations in Medicine & Therapeutics, Surgery and Obstetrics & Gynaecology. In this paper the results of the final clinical examinations at Cave Hill for the five-year period 1995-99 have been analysed, comparing the performances of students drawn from Mona with those from St Augustine. We found that, except for a few isolated cases, there were no significant differences in the performance of the two groups of students. These results suggest that the delivery of a significant component of a basic sciences programme by a well-planned PBL system is unlikely to produce substandard students at the end of their clinical training.

Educational intervention for correct pressurised metered dose inhaler technique in Trinidadian patients with asthma.

Correct pressurised metered dose inhalers (pMDI) usage is reportedly sub-optimal in patients and data for Caribbean populations is not available. We studied proficiency of inhaler use in Trinidadian patients, and determined sub-groups to be targeted for educational interventions. Inhaler use by 331 consecutive stable patients with airway disease (over 7 years) was observed and marked on a standard checklist. From direct observation only 41% of patients correctly inhaled, though 92% were confident of accurate technique. Few elderly patients (6%) received appropriate instructions on inhaler technique and only 35% (n = 23/66) understood the rationale for two different inhaler therapies (P < 0.001). More children (33%) and elderly patients (21%) reported escaping drug with use. Multiple regression analysis indicated the independent predictors of correct pMDI were age (P < 0.01) and correct understanding of different inhalers. Intensive patient education in Trinidadian children and elderly patients with airway disorders can enable active participation in disease management and maximal benefit from medication.