AE-C common mistakes
AE-C · Understand the traps and how to avoid them.
Charts only the post-bronchodilator spirometry printout and reports the FEV1/FVC ratio from that tracing as the patient's baseline, skipping the pre-bronchodilator values entirely.
In busy clinics the post-bronchodilator maneuver is the last one performed, so it is the freshest number in the chart, and staff may not realize the diagnosis of obstruction and the reversibility criterion both depend on the pre-bronchodilator values.
What to do instead
Document pre- and post-bronchodilator FEV1, FVC and FEV1/FVC side by side. Confirm obstruction with a pre-bronchodilator ratio below 0.70 (or below the lower limit of normal), and call reversibility only when FEV1 improves by at least 12% AND at least 200 mL from the pre-bronchodilator value.
Labels the patient 'mild persistent' or 'moderate persistent' based on how they look at today's visit, and uses severity terms interchangeably with control when scoring a validated questionnaire.
Severity and control sound like the same idea, and the visit snapshot feels representative; candidates also apply severity categories to a patient already on controller therapy.
What to do instead
Reserve severity classification for the patient before treatment. For a patient on treatment, assess control over the tool's stated recall period (for example the 4-week ACT/C-ACT window) at the stated cut points, and pair the score with risk markers (exacerbations, urgent care use, lung function, SABA use) before deciding whether therapy should step up, stay, or step down.
Demonstrates the inhaler once, hands it back, and asks 'Do you have any questions?' without ever watching the patient use the device.
Demonstration feels like teaching, and a patient nodding 'yes' is read as competence; there is also time pressure and discomfort with making an adult 'perform'.
What to do instead
Use return demonstration every visit: the patient (or caregiver) shows the full sequence while you score it against a checklist, you correct the specific step that failed, and they repeat it until correct. Confirm competence on the device they actually use, including spacer or valved holding chamber assembly.
Gives the patient a printed handout and three new instructions at a single visit, with no check of reading level, numeracy, or what the family already believes about the inhaler.
Written material feels like a permanent, transferable intervention, and it is easier to hand over a brochure than to negotiate a shared plan; literacy and health beliefs are rarely asked about directly.
What to do instead
Limit each visit to one or two priority behaviors, use plain language at roughly a 5th-6th grade level with pictures, confirm understanding by teach-back ('Show me how you would tell your sister when to use this'), and elicit the family's existing beliefs and barriers before correcting them.
Applies MDI rules to a dry powder inhaler: tells the patient to shake the device, attach a spacer, and inhale slowly and deeply.
MDI technique is taught first and most often, so the checklist gets reused for every device; patients are also switched between devices without device-specific retraining.
What to do instead
Match instruction to the actual device. DPI: do not shake unless the label says so, no spacer, quick and forceful inhalation, keep the device level, close lips tightly and exhale away from the mouthpiece. MDI: shake, coordinate actuation with a slow deep breath, wait the labeled interval between puffs, and use a valved holding chamber when coordination is poor. Reteach whenever the device changes.
Omits the mouth-rinse instruction after inhaled corticosteroid and never quantifies rescue inhaler use, so thrush, dysphonia, and SABA overuse (two or more canisters a year) go unrecognized.
The controller and reliever discussion gets compressed into 'use the purple one every day and the blue one when you need it', and canister counts are not something patients volunteer.
What to do instead
Instruct rinse-and-spit after every ICS dose and check for oral thrush and hoarseness. Explicitly separate controller from reliever by name, color, and purpose. Ask how many reliever canisters the patient fills per year and how many days per week they use it, and treat increasing SABA reliance as a risk marker that triggers reassessment of control and technique.
Recommends blanket trigger removal ('get rid of the carpet, the cat, and the stuffed animals, and keep the house clean') without knowing what the patient is sensitized to or exposed to.
Generic environmental advice is widely circulated and feels safe; allergy testing results are often not in the chart at the time of counseling.
What to do instead
Target interventions to documented sensitization plus confirmed exposure, and bundle them: allergen-impermeable mattress and pillow encasements and bedding washing for dust mite sensitization, pest management for cockroach, and removal or exclusion of the animal for pet sensitization. Always address secondhand smoke and vaping exposure, and advise against ozone generators and humidifiers as asthma interventions.
Tells the patient with exercise-induced symptoms to cut back on physical activity or gym class.
Exercise appears on every trigger list, and restricting activity seems like the simplest way to prevent an attack.
What to do instead
Keep activity and prescribe around it: pre-treat with a short-acting beta-agonist about 5-20 minutes before exercise (or use the controller strategy the clinician has chosen, such as a leukotriene modifier), ensure the controller regimen is adequate, and provide a school or coach copy of the action plan so symptoms are treated rather than activity being withdrawn.
Provides an action plan that says 'call your doctor if you get worse' or 'use your inhaler more', with no green/yellow/red criteria, no specific drug names and doses, and no copy given to school or caregivers.
The plan gets written at the end of a visit from memory, and vague wording feels safer than committing to numbers that might be wrong.
What to do instead
Write the plan with explicit zones: green (well, with controller doses listed), yellow (specific symptoms or a peak flow percentage of personal best, with exact reliever dose and frequency and when to call), red (specific numbers and symptoms, with instructions to call 911 or go to the ED). Include drug names, strengths, and number of puffs, date and review date, and give copies to school, caregivers, and the patient's pharmacy or chart.
Closes the encounter without booking a follow-up, particularly after an ED visit or hospitalization for asthma or after a controller step-up, and then does not recheck technique and adherence at the return visit.
The acute problem feels resolved at discharge, and follow-up is assumed to be the primary care clinician's responsibility or the family's initiative.
What to do instead
Schedule the follow-up before the patient leaves (typically within 2-7 days after an ED visit or hospitalization and within 2-6 weeks after starting or stepping up controller therapy), document who is responsible, confirm transportation and language needs, and at that visit reassess symptoms and control, inspect inhaler technique, check adherence and refill history, and confirm the action plan still matches the prescription.