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Barnes CN, Mahler DA, Ohar JA, Lombardi DA, Crater GD. Peak Inspiratory Flows: Defining Repeatability Limits and a Predictive Equation for Different Inhalers. Chest 2020; 158:1413-1419. [PMID: 32343967 DOI: 10.1016/j.chest.2020.03.072] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/23/2020] [Accepted: 03/27/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Peak inspiratory flow (PIF) has been proposed as a measure to assess a patient's ability to use dry powder inhalers (DPIs). However, robust quality criteria to determine a repeatability limit for measuring PIF are lacking. RESEARCH QUESTIONS What are the repeatability limits for measuring PIF? What is the relationship between PIF measured using the In-Check DIAL device at Diskus (GlaxoSmithKline; PIFD) and HandiHaler (Boehringer Ingelheim; PIFHH) resistances? STUDY DESIGN AND METHODS Data from a randomized, controlled, phase 3 trial (study 0149; see Clinical Trial Registration data) were used to define repeatability limits for PIF. In addition, a model to characterize the relationship between PIF measured with the In-Check DIAL device at PIFD and PIFHH was defined using data from two randomized, controlled, phase 3 trials (studies 0128 and 0149). RESULTS In study 0128, the mean values (SD) for PIF at zero resistance and PIFHH were 84.6 (33.4) and 57.3 (26.1) L/min, respectively. In study 0149, the mean values (SD) for PIFD and PIFHH were 42.4 (11.2) and 29.0 (8.3) L/min, respectively. At the mean level, the mean difference between measurement attempts for PIFD and PIFHH was small, < 5 and < 3 L/min, respectively. The repeatability limit was determined as 10 and 5 L/min for PIFD and PIFHH, respectively. Modeling the relationship between PIFD and PIFHH, after controlling for significant covariates, demonstrated that a PIFD value of 60 L/min was approximately equivalent to PIFHH of 40 L/min. INTERPRETATIONS This analysis demonstrated that the two highest values of PIF using the In-Check DIAL device among three inspiratory efforts, met the repeatability limit. Altogether, these data provide guidance for measuring PIF against the simulated resistance of a specific DPI in clinical practice and research studies. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; Nos.: NCT02518139 (study 0128) and NCT03095456 (study 0149); URL: www.clinicaltrials.gov.
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Affiliation(s)
| | | | - Jill A Ohar
- Wake Forest University Medical Center, Winston-Salem, NC
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Prevalence and predictors of suboptimal peak inspiratory flow rate in COPD patients. Eur J Pharm Sci 2020; 147:105298. [PMID: 32151707 DOI: 10.1016/j.ejps.2020.105298] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 02/18/2020] [Accepted: 03/05/2020] [Indexed: 02/03/2023]
Abstract
The aim of this study was to determine prevalence and possible clinical predictors of suboptimal peak inspiratory flow rate (PIFR) with different dry powder inhalers. PIFR was measured across all resistance ranges of In-Check Dial® in 180 chronic obstructive pulmonary disease (COPD) subjects before hospital discharge. COPD subjects were defined as suboptimal if measured PIFR was suboptimal with any resistance representative of specific inhalers (R1-R5). Demographics and clinical data were collected, including COPD Assessment Test (CAT) and modified Medical Research Council (mMRC) scores, Global Initiative for Obstructive Lung Disease (GOLD) stage spirometry by Spirodoc® and peak flow meter measurements with portable peak inspiratory and expiratory flow meters. All were correlated with In-Check Dial PIFRs. Suboptimal PIFR was 44.44% prevalent in COPD subjects. 55% of the suboptimal cohort was female which represent 57.14% of the total female population in the study. The distribution of suboptimal PIFR included 43.75% with R1, 67.5% with R2, 100% with R3, 13.75% with R4, and 21.25% with R5. In the suboptimal cohort, CAT score was significantly higher and spirometry demonstrated significantly lower lung function results compared to the optimal cohort (p < 0.05). The only parameter to show strong and moderate correlation with In-Check Dial PIFRs was PIFR measured by peak flow meter (p < 0.001). Suboptimal PIFR is common among COPD subjects at hospital discharge. Female gender and peak flow meter PIFR was the only predictor of suboptimal PIFR. Inhaler therapy for COPD patients must be personalized based on simple routine measurement of In-Check Dial PIFRs or peak flow meter PIFR to optimize clinical benefits .
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Association between peak inspiratory flow rate and hand grip muscle strength in hospitalized patients with acute exacerbation of chronic obstructive pulmonary disease. PLoS One 2020; 15:e0227737. [PMID: 32004333 PMCID: PMC6994102 DOI: 10.1371/journal.pone.0227737] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 12/27/2019] [Indexed: 02/07/2023] Open
Abstract
Rationale Ineffective peak inspiratory flow rate (PIFR) generation in patients using inhalers results in insufficient drug delivery to the lungs and poor clinical outcomes. Low inspiratory muscle strength is associated with suboptimal PIFR. Objective To examine in a prospective study the relationship between PIFR and skeletal muscle strength using hand grip strength (HGS) as a surrogate. Methods Adult patients admitted with acute exacerbation of chronic obstructive pulmonary disease (COPD) were enrolled. PIFR was measured within 48 hours before discharge. PIFR below 60L/min was considered suboptimal. HGS was measured using a handheld dynamometer. Any readmissions and emergency department visit data were collected. The associations between PIFR, HGS, 30 and 90-day COPD and all-cause readmissions were examined, without and with adjustment for age, race and gender. Results Of the 75 enrolled patients, 56% had suboptimal PIFR; they were older (63.9±9.7 vs. 58.2±7.7 years) and had significantly lower HGS (24.2±11.1 vs. 30.9±10.9 Kg) compared to those with optimal PIFR. There were no significant differences between the two PIFR groups by gender, race, history of coronary artery disease, congestive heart failure, hypertension or functional scores. Each kilogram increase in HGS was associated with 0.50 (95%CI 0.18–0.89, p = 0.003) L/min increase in PIFR. We did not observe an association between PIFR and 30 or 90-day readmission rates. Conclusion We found a significant association between HGS and PIFR in hospitalized patients with acute exacerbations of COPD. Whether interventions aimed at increasing skeletal muscle strength also result in improvement in PIFR remains unclear and need further study.
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Gilbert I, Wada K, Burudpakdee C, Ghai C, Tan L. The Impact of a Forced Non-Medical Switch of Inhaled Respiratory Medication Among Patients with Asthma or Chronic Obstructive Pulmonary Disease: A Patient Survey on Experience with Switch, Therapy Satisfaction, and Disease Control. Patient Prefer Adherence 2020; 14:1463-1475. [PMID: 32903885 PMCID: PMC7445512 DOI: 10.2147/ppa.s242215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 06/26/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Budesonide/formoterol pressurized metered-dose inhaler (pMDI) was removed from a Medicare Part D formulary, and patients switched to fluticasone-based dry powder inhaler (DPI) therapies. This study describes the experience, satisfaction, and disease control among patients with asthma or chronic obstructive pulmonary disease (COPD) who switched due to removal from the formulary. PATIENTS AND METHODS A patient survey was conducted among adults with asthma or COPD who used budesonide/formoterol pMDI for ≥3 months prior to the formulary block and the new medication for ≥3 weeks after switching, recruited by providers in a research panel. Survey comprised both validated instruments (PASAPQ, OEQ, ACQ-6, and CAT) and stand-alone questions. Patient characteristics, switch experience, device and treatment satisfaction, onset of effect, and disease control were compared between disease (asthma and COPD) and medication (once and twice daily) cohorts. Minimal significance for group differences: P≤0.05. RESULTS Among 100 patients, 93% received communication from their doctor or nurse about the switch and 73% received training on using the new inhaler. Patients used their new treatment for an average of 7 months prior to completing the survey. Patient satisfaction with the new therapy was high (PASAPQ; mean overall satisfaction: 6.2 for asthma; 6.0 for COPD; P=0.338). However, asthma was not well controlled (ACQ-6) in 62% of patients with asthma, and 56% of patients with COPD reported high/very high impact of their illness on their lives (CAT). Sixty-eight percent and 70% of patients with asthma and COPD, respectively, required reliever medication (≥3 puffs) most days during the week prior to the survey. There were no significant differences in disease control (ACQ-6, CAT) between once-daily and twice-daily treatments (P>0.05 for both asthma and COPD). CONCLUSION Even when reporting satisfaction with their new medication, objective measures showed substantial morbidity, regardless of DPI device or dosing regimen.
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Affiliation(s)
- Ileen Gilbert
- AstraZeneca, Wilmington, DE, USA
- Correspondence: Ileen Gilbert Email
| | | | | | | | - Laren Tan
- Loma Linda University Health, Department of Medicine, Division of Pulmonary, Critical Care, Hyperbaric, Allergy and Sleep Medicine, Loma Linda, CA, USA
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Mahler DA. The role of inspiratory flow in selection and use of inhaled therapy for patients with chronic obstructive pulmonary disease. Respir Med 2019; 161:105857. [PMID: 32056720 DOI: 10.1016/j.rmed.2019.105857] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 12/11/2019] [Accepted: 12/27/2019] [Indexed: 11/26/2022]
Abstract
Inhalation therapy is the mainstay of chronic obstructive pulmonary disease management, and inhaler selection can have a profound impact on drug delivery and medication adherence, as well as on treatment outcomes. Although multiple delivery systems, such as pressurized metered-dose inhalers, dry powder inhalers, slow-mist inhalers, and nebulizers, are available, clinical benefits achieved by patients rely on effective delivery of the inhaled medication to the airways. Among several factors influencing drug deposition, inspiratory flow is one of the most important. Inspiratory flow impacts drug delivery and subsequent clinical efficacy, making it necessary to adequately train patients to ensure correct inhaler use. Peak inspiratory flow is the maximal airflow generated during a forced inspiratory maneuver. Health care professionals need to select the appropriate delivery system after carefully considering patient characteristics, including lung function, optimal inspiratory flow, manual dexterity, and cognitive function. Herein, the role of inspiratory flow in the selection and use of inhaled therapy in patients with COPD is reviewed.
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Affiliation(s)
- Donald A Mahler
- Emeritus Professor of Medicine, Geisel School of Medicine at Dartmouth, One Rope Ferry Road, Hanover, NH, 03755, USA; Valley Regional Hospital, Kane Center, 243 Elm Street, Claremont, NH, 03743, USA.
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Clark CM, Jacobs DM, Sethi S. Revefenacin for the treatment of chronic obstructive pulmonary disease. Expert Rev Respir Med 2019; 14:239-247. [PMID: 31847629 DOI: 10.1080/17476348.2020.1703676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Chronic obstructive pulmonary disease (COPD) is a progressive condition characterized by irreversible or incompletely reversible airflow limitation. Long-acting bronchodilators, including β2 agonists (LABA) and muscarinic antagonists (LAMA), serve as the standard of care for maintenance therapy in COPD. Individualizing therapy to optimize selection of delivery device has the potential to improve medication adherence and clinical outcomes among COPD patients.Areas covered: Revefenacin (Yupelri) is the only LAMA approved for once-daily administration via standard jet nebulizer for the maintenance therapy in patients with COPD. Revefenacin has a unique biphenyl carbamate tertiary amine structure, differing from the quaternary amine structure of previously approved LAMAs. Here we summarize the available clinical data for this new agent and discuss its potential place in the treatment of COPD.Expert opinion: Based on available clinical trial data, revefenacin appears to be an effective and safe option for long-term maintenance therapy of COPD. Revefenacin offers a once-daily option for LAMA therapy for patients who prefer or require nebulized drug delivery. The availability of this agent can allow patients to combine nebulized therapies that could improve clinical outcomes in appropriately selected patients with COPD.
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Affiliation(s)
- Collin M Clark
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA.,Department of Family Medicine, Primary Care Research Institute, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - David M Jacobs
- Department of Pharmacy Practice, School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Sanjay Sethi
- Department of Medicine, Clinical and Translational Research Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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Donohue JF, Mahler DA, Sethi S. Revefenacin: A Once-Daily, Long-Acting Bronchodilator For Nebulized Treatment Of COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:2947-2958. [PMID: 31908443 PMCID: PMC6927563 DOI: 10.2147/copd.s157654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 09/23/2019] [Indexed: 01/17/2023] Open
Abstract
Bronchodilation with muscarinic antagonists, β2-agonists, and inhaled corticosteroids remains the foundation of pharmaceutical treatment for patients with stable COPD. These drugs are delivered from a variety of devices, including dry powder inhalers, pressurized metered-dose inhalers, soft-mist inhalers, or nebulizers. Nebulized delivery is often preferable in patients who are elderly, are cognitively impaired, are unable to generate sufficient inspiratory force to use their inhaler, have difficulty coordinating hand-breath activity, are too dyspneic to hold their breath for a sufficient time, and/or may be acutely ill. Revefenacin, a once-daily long-acting muscarinic antagonist for nebulization recently approved by the US FDA for the treatment of patients with COPD, was discovered and developed using "duration and lung selectivity-by-design." This strategy selected a molecule with a high lung-selective index to maximize bronchodilation and limit systemic anti-muscarinic side effects. In early-phase clinical studies, revefenacin for nebulization led to a rapid onset of bronchodilation that was sustained for 24 hrs in patients with moderate to severe COPD. Revefenacin also demonstrated minimal systemic exposure and good tolerability in these studies. Statistically and clinically significant improvements in lung function (ie, peak and/or trough FEV1) relative to placebo were observed with revefenacin in Phase III clinical trials of up to 3 months in patients with moderate to very severe COPD. Revefenacin was well tolerated in Phase III clinical trials with a low incidence of systemic antimuscarinic adverse events, which is consistent with its lung-selective design. There was no evidence of an increased risk of major cardiovascular events. Patient-reported outcome data from clinical trials indicated statistically significant improvements in several disease-specific measures. Revefenacin 175 μg for nebulization provides an effective once-daily treatment option for patients with moderate to very severe COPD who require or prefer nebulized therapy.
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Affiliation(s)
- James F Donohue
- Pulmonary Medicine, UNC School of Medicine, Chapel Hill, NC, USA
| | - Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Director of Respiratory Services, Valley Regional Hospital, Claremont, NH, USA
| | - Sanjay Sethi
- University at Buffalo, State University of New York, Buffalo, NY, USA
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Clark AR, Weers JG, Dhand R. The Confusing World of Dry Powder Inhalers: It Is All About Inspiratory Pressures, Not Inspiratory Flow Rates. J Aerosol Med Pulm Drug Deliv 2019; 33:1-11. [PMID: 31613682 PMCID: PMC7041319 DOI: 10.1089/jamp.2019.1556] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Dry powder inhalers (DPIs) all have the ability to aerosolize dry powders, but they each offer different operating mechanisms and resistances to inhaled airflow. This variety has resulted in both clinician and patient confusion concerning DPI performance, use, and effectiveness. Particularly, there is a growing misconception that a single peak inspiratory flow rate (PIFR) can determine a patient's ability to use a DPI effectively, regardless of its design or airflow resistance. For this review article, we have sifted through the relevant literature concerning DPIs, inspiratory pressures, and inspiratory flow rates to provide a comprehensive and concise discussion and recommendations for DPI use. We ultimately clarify that the controlling parameter for DPI performance is not the PIFR but the negative pressure generated by the patient's inspiratory effort. A pressure drop ∼≥1 kPa (∼10 cm H2O) with any DPI is a reasonable threshold above which a patient should receive an adequate lung dose. Overall, we explore the underlying factors controlling inspiratory pressures, flow rates and dispensing, and dispersion characteristics of the various DPIs to clarify that inspiratory pressures, not flow rates, limit and control a patient's ability to generate sufficient flow for effective DPI use.
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Affiliation(s)
| | | | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee
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Establishment of relationships between native and inhalation device specific spirometric parameters as a step towards patient tailored inhalation device selection. Respir Med 2019; 154:133-140. [DOI: 10.1016/j.rmed.2019.06.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 05/31/2019] [Accepted: 06/21/2019] [Indexed: 11/24/2022]
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Dolovich MB, Kuttler A, Dimke TJ, Usmani OS. Biophysical model to predict lung delivery from a dual bronchodilator dry-powder inhaler. INTERNATIONAL JOURNAL OF PHARMACEUTICS-X 2019; 1:100018. [PMID: 31517283 PMCID: PMC6733285 DOI: 10.1016/j.ijpx.2019.100018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 05/24/2019] [Accepted: 05/27/2019] [Indexed: 11/30/2022]
Abstract
A biophysical lung model was designed to predict inhaled drug deposition in patients with obstructive airway disease, and quantitatively investigate sources of deposition variability. Different mouth-throat anatomies at varying simulated inhalation flows were used to calculate the lung dose of indacaterol/glycopyrronium [IND/GLY] 110/50 µg (QVA149) from the dry-powder inhaler Breezhaler®. Sources of variability in lung dose were studied using computational fluid dynamics, supported by aerosol particle sizing measurements, particle image velocimetry and computed tomography. Anatomical differences in mouth-throat geometries were identified as a major source of inter-subject variability in lung deposition. Lung dose was similar across inhalation flows of 30–120 L/min with a slight drop in calculated delivery at high inspiratory flows. Delivery was relatively unaffected by inhaler inclination angle. The delivered lung dose of the fixed-dose combination IND/GLY matched well with corresponding monotherapy doses. This biophysical model indicates low extra-thoracic drug loss and consistent lung delivery of IND/GLY, independent of inhalation flows. This is an important finding for patients across various ages and lung disease severities. The model provides a quantitative, mechanistic simulation of inhaled therapies that could provide a test system for estimating drug delivery to the lung and complement traditional clinical studies.
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Key Words
- AIT, Alberta idealised throat
- APSD, aerodynamic particle size distribution
- CFD, computational fluid dynamics
- COPD, chronic obstructive pulmonary disease
- CT, computed tomography
- Chronic obstructive pulmonary disease
- Computational fluid dynamics
- DPI, dry powder inhaler
- Dry powder inhaler
- FDC, fixed-dose combination
- GLY, glycopyrronium
- HRCT, high-resolution computed tomography
- IFR, inspiratory flow rate
- IND, indacaterol
- Inhaler devices
- Lung deposition
- MMAD, mass median aerodynamic diameter
- NGI, Next Generation Impactor
- PIV, particle image velocimetry
- USP/Ph. Eur, European Union Pharmacopoeias
- pMDI, pressurised metered dose inhaler
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Affiliation(s)
- Myrna B Dolovich
- Department of Medicine, Division of Respirology, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London, London, UK
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Balamurugan S, Apte K, Singh BP, Deb AK, Deshmukh C, Modi K, Godse A, Dhar R, Lahiri KR, Singh V, Pandya H, Rajan S, Vaidya A, Gaur V, Gogtay J. Device-handling study of a novel breath-actuated inhaler, Synchrobreathe®, versus a pMDI. Respir Med 2019; 161:105707. [PMID: 32056719 DOI: 10.1016/j.rmed.2019.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/06/2019] [Accepted: 05/22/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Synchrobreathe®, a new-generation, novel breath-actuated inhaler (BAI) can address the key issues arising during the use of both pressurised metered dose inhalers ([pMDIs]; hand-breath coordination) and dry powder inhalers ([DPIs]; high inspiratory flow required) with respect to optimal drug deposition. MATERIALS AND METHODS This was an open-label, prospective, 2-week, multicentre study that assessed device handling, ease of use, errors and participant perception regarding the use of Synchrobreathe® versus a pMDI in patients with chronic obstructive pulmonary disease (COPD) (n = 162) or asthma (n = 239) and inhaler-naïve healthy volunteers (n = 59). Ability to use the device without errors at the first attempt, total number of errors before and after training, time taken to use the device correctly and total number of training sessions, and number of attempts to perform the correct technique on Day 1 and Day 14 were evaluated. Device handling and preference questionnaires were also administered on Day 14. RESULTS Of 460 participants, 421 completed the study. The number of participants using Synchrobreathe without any error after reading the patient information leaflet (PIL) was significantly low (p < 0.05) on Day 1. On Day 14, significantly more number of participants used Synchrobreathe without any error (p < 0.001). The total number of errors before and after training with Synchrobreathe was significantly less (p < 0.001). The average time required to perform the inhalation technique correctly (p < 0.01) and the total number of attempts (P < 0.001) with Synchrobreathe were significantly lower. The average number of attempts to inhale correctly was significantly (p < 0.001) less with Synchrobreathe on Day1 and Day 14. Most participants rated Synchrobreathe as their choice of inhaler. CONCLUSION Synchrobreathe is an easy-to-use and easy-to-handle device with significantly less number of errors, which may have positive implications for disease control in asthma and COPD.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Keya Rani Lahiri
- Padmashree Dr. D. Y. Patil Medical College, Hospital & Research Centre, Navi Mumbai, India
| | | | - Hiren Pandya
- Ratandeep Multispecialty Hospital, Ahmedabad, India
| | | | | | - Vaibhav Gaur
- Medical Affairs Department, Cipla Ltd, Mumbai, India
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Crim C, Watkins ML, Bateman ED, Feldman GJ, Schenkenberger I, Kerwin EM, Crawford C, Pudi K, Ho S, Baidoo C, Castro-Santamaria R. Randomized dose-finding study of batefenterol via dry powder inhaler in patients with COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:615-629. [PMID: 30880951 PMCID: PMC6413745 DOI: 10.2147/copd.s190603] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background Batefenterol is a novel bifunctional muscarinic antagonist β2-agonist in development for COPD. The primary objective of this randomized, double-blind, placebo-controlled, active comparator, Phase IIb study was to model the dose–response of batefenterol and select a dose for Phase III development. Patients and methods Patients aged ≥40 years with COPD and FEV1 ≥30% and ≤70% predicted normal were randomized equally to batefenterol 37.5, 75, 150, 300, or 600 µg, placebo, or umeclidinium/vilanterol (UMEC/VI) 62.5/25 µg once daily. The primary and secondary endpoints were weighted-mean FEV1 over 0–6 hours post-dose and trough FEV1, analyzed by Bayesian and maximum likelihood estimation Emax of dose–response modeling, respectively, on day 42. Results In the intent-to-treat population (N=323), all batefenterol doses demonstrated statistically and clinically significant improvements from baseline vs placebo in the primary and secondary endpoints (191.1–292.8 and 182.2–244.8 mL, respectively), with a relatively flat dose–response. In the subgroup reversible to salbutamol, there were greater differences between batefenterol doses. Lung function improvements with batefenterol ≥150 µg were comparable with those with UMEC/VI. Batefenterol was well tolerated and no new safety signals were observed. Conclusion Batefenterol 300 µg may represent the optimal dose for Phase III studies.
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Affiliation(s)
- Courtney Crim
- GSK, Research and Development, Research Triangle Park, NC, USA,
| | | | - Eric D Bateman
- Division of Pulmonology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - Edward M Kerwin
- Clinical Trials Division, Crisor LLC, Clinical Research Institute, Medford OR, USA
| | | | - Krishna Pudi
- Upstate Pharmaceutical Research, Greenville, SC, USA
| | - Shuyen Ho
- PAREXEL International, Durham, NC, USA
| | - Charlotte Baidoo
- GSK, Clinical Statistics, Stockley Park, Uxbridge, Middlesex, UK
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Ghosh S, Pleasants RA, Ohar JA, Donohue JF, Drummond MB. Prevalence and factors associated with suboptimal peak inspiratory flow rates in COPD. Int J Chron Obstruct Pulmon Dis 2019; 14:585-595. [PMID: 30880948 PMCID: PMC6402615 DOI: 10.2147/copd.s195438] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Adequate peak inspiratory flow rate (PIFR) is required for drug dispersion with dry powder inhalers (DPIs). Prevalence of PIFR discordance (suboptimal PIFR with prescribed inhalers) and factors influencing device-specific PIFR are unclear in COPD. The objective of this study was to determine the prevalence of PIFR discordance and associated clinical factors in a stable COPD population. Patients and methods An observational, single-center, cohort study was conducted including 66 outpatients with COPD. PIFR was measured using the In-Check™ Dial with applied resistance of prescribed inhalers. Participants were defined as discordant if measured PIFR was <30 L/min and <60 L/min for high and low–medium resistance devices, respectively, using an inspiratory effort the participant normally used with their prescribed DPI. Results The median age of the COPD participants was 69.4 years, 92% were white and 47% were female. A total of 48% were using low–medium resistance DPIs (Diskus®/Ellipta®) and 76% used high-resistance DPI (Handihaler®). A total of 40% of COPD participants were discordant to prescribed inhalers. Female gender was the only factor consistently associated with lower PIFR. Shorter height was associated with reduced PIFR for low–medium resistance (r=0.44; P=0.01), but not high resistance (r=0.20; P=0.16). There was no correlation between PIFR by In-Check™ dial and PIFR measured by standard spirometer. Conclusion PIFR is reduced in stable COPD patients, with female gender being the only factor consistently associated with reduced PIFR. Discordance with prescribed inhalers was seen in 40% of COPD patients, suggesting that many COPD patients do not generate adequate inspiratory force to overcome prescribed DPIs resistance in the course of normal use.
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Affiliation(s)
- Sohini Ghosh
- Division of Pulmonary Diseases and Critical Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
| | | | - Jill A Ohar
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy, and Immunology, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - James F Donohue
- Division of Pulmonary Diseases and Critical Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
| | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA,
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Mannan H, Foo SW, Cochrane B. Does device matter for inhaled therapies in advanced chronic obstructive pulmonary disease (COPD)? A comparative trial of two devices. BMC Res Notes 2019; 12:94. [PMID: 30786914 PMCID: PMC6383223 DOI: 10.1186/s13104-019-4123-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 02/09/2019] [Indexed: 11/26/2022] Open
Abstract
Objective COPD patients have challenges for effective use of inhalers due to advanced age, fixed airflow obstruction and comorbid medical conditions. Published clinical trials investigate drug efficacy but rarely consider the inhaler device. This trial investigates device efficacy, comparing clinical outcomes for the same medication via two different devices. Our intention was to communicate the results and to critically appraise the study protocol to inform planning of future device comparison research. Subjects with spirometry confirming at least moderate COPD were randomly assigned to inhaler sequence; starting with Accuhaler or metered dose inhaler and spacer (MDI/s). After baseline testing, subjects were assigned to fluticasone propionate/salmeterol xinafoate (SFC) 500/50 mcg twice daily via the first device for 6 weeks’ duration, then changed to the alternate device for the following 6 weeks. Subjects were reassessed in terms of health-related quality of life (HRQL), exercise endurance and lung function after each exposure period. Results The recruitment target was not achieved due to unanticipated developments within the pharmaceutical industry, potentially compromising the study’s power. Study outcomes did not differ significantly according to the allocated inhaler device even after adjusting for baseline lung function or inhaler technique. Recommendations for future device comparison protocols are offered. Trial registration Australia and New Zealand Clinical Trials Registry, Current Controlled Trials ACTRN12618000075280, date of registration: 18.01.2018. Retrospectively registered Electronic supplementary material The online version of this article (10.1186/s13104-019-4123-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Haider Mannan
- Translational Health Research Institute, Western Sydney University, Campbelltown, NSW, Australia.
| | - Soo Wei Foo
- School of Medicine, Western Sydney University, Campbelltown, NSW, Australia.,Department of Respiratory and Sleep Medicine, Campbelltown and Camden Hospitals, Campbelltown, NSW, Australia
| | - Belinda Cochrane
- School of Medicine, Western Sydney University, Campbelltown, NSW, Australia.,Department of Respiratory and Sleep Medicine, Campbelltown and Camden Hospitals, Campbelltown, NSW, Australia
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65
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Mahler DA, Ohar JA, Barnes CN, Moran EJ, Pendyala S, Crater GD. Nebulized Versus Dry Powder Long-Acting Muscarinic Antagonist Bronchodilators in Patients With COPD and Suboptimal Peak Inspiratory Flow Rate. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2019; 6. [PMID: 31647854 DOI: 10.15326/jcopdf.6.4.2019.0137] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Patients with chronic obstructive pulmonary disease (COPD) and suboptimal peak inspiratory flow rate (sPIFR) may not benefit optimally from dry powder inhalers (DPI) because of inadequate inspiratory flow. Nebulized bronchodilators may provide a better alternative. We compared bronchodilation with the long-acting muscarinic antagonist (LAMA) revefenacin for nebulization versus the DPI LAMA tiotropium, in patients with COPD and sPIFR (< 60 L/min against the resistance of Diskus®). Methods This was a randomized, double-blind, double-dummy, 28-day Phase 3b study in patients with COPD enrolled based on sPIFR. The primary endpoint was trough forced expiratory volume in 1 second (FEV1) on Day 29 for revefenacin for nebulization versus tiotropium HandiHaler® DPI. Results We enrolled 206 patients with mean (standard deviation) age, 65 (8) years; percent predicted FEV1, 37 (16)%; PIFR, 45 (12) L/min. In the intent-to-treat (ITT) population, revefenacin improved trough FEV1 from baseline; however, the difference versus tiotropium was not significant (least squares [LS] mean difference [standard error], 17.0 [22.4] mL, P=0.4461). In a prespecified analysis of patients with FEV1 < 50% predicted, revefenacin produced an LS mean difference (95% confidence interval [CI]), 49.1 (6.3-91.9) mL in trough FEV1 and 103.5 (7.7-199.3) mL in forced vital capacity versus tiotropium. Revefenacin produced >100 mL increase in FEV1 in 41.6% versus 34.4% of patients with tiotropium in ITT and 41.4% versus 25.7% of patients in FEV1 < 50% predicted populations. Conclusions Revefenacin did not produce significant improvements in FEV1 versus tiotropium in the ITT population, but increased trough FEV1 in patients with FEV1 < 50% predicted and sPIFR. Clinical Trial Registration (www.Clinicaltrials.gov): Study 0149 (NCT03095456).
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Affiliation(s)
- Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire and Respiratory Services, Valley Regional Hospital, Claremont, New Hampshire
| | - Jill A Ohar
- Wake Forest University Medical Center, Winston-Salem, North Carolina
| | - Chris N Barnes
- Theravance Biopharma US, Inc., South San Francisco, California
| | - Edmund J Moran
- Theravance Biopharma US, Inc., South San Francisco, California
| | | | - Glenn D Crater
- Theravance Biopharma US, Inc., South San Francisco, California
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66
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Duarte AG, Tung L, Zhang W, Hsu ES, Kuo YF, Sharma G. Spirometry Measurement of Peak Inspiratory Flow Identifies Suboptimal Use of Dry Powder Inhalers in Ambulatory Patients with COPD. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2019; 6:246-255. [PMID: 31189057 DOI: 10.15326/jcopdf.6.3.2018.0163] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objectives Determine the prevalence of suboptimal peak inspiratory flow rate (PIFR) and associated patient characteristics and compare PIFR measurements obtained with spirometry and In-Check DIAL® device in ambulatory patients with COPD. Methods Patients underwent PIFR measurement with In-Check DIAL® device and pulmonary function testing with calibrated equipment. Group characteristics and lung function were compared for patients with suboptimal (≤ 60 L/min) and optimal (> 60 L/min) PIFR. Receiver operating curve analysis determined the best maximal forced inspiratory flow (FIF max) value in identifying optimal PIFR by gender and height. Results From July 1, 2016 to January 31, 2018, a total of 303 patients with chronic obstructive pulmonary disease (COPD) had PIFR and pulmonary function measurements. Group mean age was 65.5 ± 11.3 years with equal gender distribution. Suboptimal PIFR was observed in 61 (20.1%) patients. A significant correlation was observed between PIFR and FIF max, inspiratory capacity and residual volume (RV) to total lung capacity (TLC) ratio. In the suboptimal PIFR group, mean FIF max measured by spirometry was significantly less compared with the optimal PIFR group; 178.5 ± 56.9 L/min and 263.4 ± 89.9 L/min, respectively (p<0.0001). Receiver operator curve analysis of FIF max to identify an optimal PIFR yielded an area under the curve of 0.79. Males < 65 inches had a suboptimal PIFR in 16.7 % of the male cohort, while females < 65 inches had a suboptimal PIFR in 27.4 % of the women. Conclusions Suboptimal PIFR was present in 1 in 5 stable patients with COPD and was more frequent in short statured females. Spirometry determined FIF max was associated with PIFR based on gender and height.
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Affiliation(s)
- Alexander G Duarte
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Leon Tung
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Wei Zhang
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - En Shuo Hsu
- Office of Biostatistics, University of Texas Medical Branch, Galveston
| | - Yong-Fang Kuo
- Office of Biostatistics, University of Texas Medical Branch, Galveston.,Sealy Center of Aging, University of Texas Medical Branch, Galveston
| | - Gulshan Sharma
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Texas Medical Branch, Galveston.,Sealy Center of Aging, University of Texas Medical Branch, Galveston
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67
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Price DB, Yang S, Ming SWY, Hardjojo A, Cabrera C, Papaioannou AI, Loukides S, Kritikos V, Bosnic-Anticevich SZ, Carter V, Dorinsky PM. Physiological predictors Of peak inspiRatory flow using Observed lung function resultS (POROS): evaluation at discharge among patients hospitalized for a COPD exacerbation. Int J Chron Obstruct Pulmon Dis 2018; 13:3937-3946. [PMID: 30587952 PMCID: PMC6296178 DOI: 10.2147/copd.s174371] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Peak inspiratory flow (PIF) as generated through the resistance of a dry powder inhaler (DPI) device is a critical patient-dependent maneuver impacting the success of DPI medication delivery. Despite its importance, it is not routinely measured in clinical practice. Little is currently known about the relationship, if any, between PIF through DPI devices, routine spirometry and disease outcomes. Aim The aim of this study was to identify potential predictors of PIF for different DPIs from spirometric parameters and patient characteristics and explore the association between PIF and follow-up events. Patients and methods A retrospective observational study at discharge among patients hospitalized for a COPD exacerbation at Attikon hospital, Athens, Greece. Spirometry was performed using an Easy on-PC™ spirometer. PIF was measured through four DPI resistances using the In-Check™ DIAL. Regression analyses were used to investigate the association between PIF through resistances and spirometric parameters obtained at discharge, comorbidities and demographic parameters. Results Forty-seven COPD patients (mean [±SD], age 71 [±9] years, 72% males, 51% current smokers) were included in this study. Overall, 85% and 15% were classified as GOLD (2017) groups D and C, respectively. Most prevalent comorbidities were hypertension (70%) and cardiovascular disease (53%). In the final regression model, higher PIF was significantly associated with the following: higher FEV1 and % predicted peak expiratory flow (PEF) for Turbohaler® (R-squared value 0.374); higher FEV1 and diagnosis of gastroesophageal reflux disease (GERD) for Aerolizer® (R-squared value 0.209) and higher FEV1, younger age and diagnosis of ischemic heart disease (IHD) for Diskus® (R-squared value 0.350). However, R-squared values for all three devices were weak (<0.4). Conclusion The study did not provide evidence to support the use of surrogate measurements for PIF through device resistance, which could assist in determining the appropriateness of inhaler device type. Although PIF measurement is feasible in patients at discharge and could be a valuable addition to the standard of care in COPD management, it needs to be measured directly.
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Affiliation(s)
- David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore, .,Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK,
| | - Sen Yang
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore,
| | - Simon Wan Yau Ming
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore,
| | - Antony Hardjojo
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore,
| | - Claudia Cabrera
- Global Medical Affairs, AstraZeneca R and D, Mölndal, Sweden.,Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Andriana I Papaioannou
- 2nd Respiratory Medicine Department, Medical School, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece
| | - Stelios Loukides
- 2nd Respiratory Medicine Department, Medical School, National and Kapodistrian University of Athens, Attikon General Hospital, Athens, Greece
| | - Vicky Kritikos
- Woolcock Institute of Medical Research, Quality Use of Respiratory Medicines Group, School of Medical Sciences, University of Sydney, Glebe, Australia
| | - Sinthia Z Bosnic-Anticevich
- Woolcock Institute of Medical Research, Quality Use of Respiratory Medicines Group, School of Medical Sciences, University of Sydney, Glebe, Australia
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68
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Loukil M, Mejri I, Khalfallah I, Ghrairi H. [Evaluation of inhaler techniques in patients with asthma and chronic obstructive disease]. REVUE DE PNEUMOLOGIE CLINIQUE 2018; 74:226-234. [PMID: 30031594 DOI: 10.1016/j.pneumo.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/04/2018] [Accepted: 04/11/2018] [Indexed: 06/08/2023]
Abstract
INTRODUCTION The correct method for using inhalation devices (DI) is essential to optimize treatment efficacy. OBJECTIVE To evaluate the method of inhalation technique, study the correlations with patient characteristics, disease, treatment and measure the impact of direct and individual educational method, centered on the use of technical DI, on improving this technique and control of the disease. METHOD Prospective study of 54 patients. The therapeutic education program included 3 levels of action: identifying errors in the inhalation technique, demonstrating the inhalation technique and evaluation of therapeutic education. RESULT The most used DI was metered-dose inhalers (AD) (66.67%). The average error was 4.63 errors/patient for AD and 5.11 for dry powder inhalers. The main factors related to the misuse of DI were lower advanced level of education and age. The therapeutic education has significantly improved the number of errors/patient with improved asthma control (P<0.05) and COPD assessment test (CAT) in the case of COPD. CONCLUSION Our study confirms the important role of therapeutic education focused on inhalation techniques in improving the use of DI technology and the evolution of asthma and COPD.
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Affiliation(s)
- M Loukil
- Service de pneumologie, hôpital Mohamed Tahar Maamouri, 8000 Nabeul, Tunisie; Faculté de médecine de Tunis, Tunis, Tunisie.
| | - I Mejri
- Service de pneumologie, hôpital Mohamed Tahar Maamouri, 8000 Nabeul, Tunisie; Faculté de médecine de Tunis, Tunis, Tunisie
| | - I Khalfallah
- Service de pneumologie, hôpital Mohamed Tahar Maamouri, 8000 Nabeul, Tunisie; Faculté de médecine de Tunis, Tunis, Tunisie
| | - H Ghrairi
- Service de pneumologie, hôpital Mohamed Tahar Maamouri, 8000 Nabeul, Tunisie; Faculté de médecine de Tunis, Tunis, Tunisie
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69
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Pohlmann G, Hohlfeld JM, Haidl P, Pankalla J, Cloes RM. Assessment of the Power Required for Optimal Use of Current Inhalation Devices. J Aerosol Med Pulm Drug Deliv 2018; 31:339-346. [PMID: 29791260 DOI: 10.1089/jamp.2017.1376] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Inhalation of medications is the cornerstone in the treatment of patients with lung diseases. A variety of inhalation devices exists and each device has specific requirements to achieve optimum inhalation of the drug. The goal of this study was to establish a clear overview on performance requirements of standard inhalation devices that should be met by the patient's breathing power and to develop a new method to measure the individual performance data. Materials and Methods: An optimum and still acceptable required breathing power (P in watts) was calculated for each device with the aid of individual device flow rates (determined by a literature search) and the flow resistances (by measuring the pressure drop over the different inhalation devices). For the in vivo part of the study, peak inspiratory flow and peak inspiratory pressure drop were measured in 21 adult patients with asthma or chronic obstructive pulmonary disease and healthy volunteers and the peak inspiratory power (PIPO in watts) was calculated. Results: Nearly no power is needed to achieve optimum results when using pressurized metered dose inhalers. For dry powder inhalers, the required power depends on the specific inhalation device. Conclusions: Inhalation devices impose differing demands on the inspiratory breathing power of patients. To ensure adequate use of the different devices, a cheap and simple assessment of patients' PIPO may be one option.
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Affiliation(s)
- Gerhard Pohlmann
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
| | - Jens M Hohlfeld
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany.,Member of the German Center for Lung Research (BREATH), Hannover, Germany
| | - Peter Haidl
- Hospital Kloster Grafschaft, Schmallenberg, Germany
| | - Jelena Pankalla
- Fraunhofer Institute for Toxicology and Experimental Medicine, Hannover, Germany
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70
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Suboptimal Inspiratory Flow Rates Are Associated with Chronic Obstructive Pulmonary Disease and All-Cause Readmissions. Ann Am Thorac Soc 2018; 14:1305-1311. [PMID: 28406710 DOI: 10.1513/annalsats.201611-903oc] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Dry powder inhalers (DPIs) are prescribed after hospitalization for acute exacerbation of COPD (AECOPD). Peak inspiratory flow (PIF) affects DPI delivery. OBJECTIVES To study the impact of PIF on readmission after hospitalization for AECOPD. METHODS A retrospective analysis of hospitalized patients, enrolled in an AECOPD care plan, was performed. Data analyzed included PIF, age, sex, length of stay, Charlson Comorbidity Index, COPD Assessment Test score, modified Medical Research Council score, percent predicted FEV1, FVC, and inspiratory capacity. A PIF equal to and less than 60 L/min was defined as suboptimal (sPIF). Outcome measures included 30- and 90-day COPD and all-cause readmissions, and days to next COPD and all-cause readmissions. RESULTS Of the 123 subjects, 52% (n = 64) had sPIF. They had greater COPD Assessment Test scores (29.1 ± 5.9 vs. 25.3 ± 8.7; P = 0.0073), rates of 90-day COPD readmissions (28.1 vs. 13.6%; P = 0.048), fewer median days to COPD (63.5 [interquartile range (IQR), 21-89.8] vs. 144 [IQR, 66-218]; P = 0.002) and all-cause readmissions (65.5 [IQR, 24.3-107.3] vs. 101 [IQR, 54.5-205.5]; P = 0.009). PIF was the only variable (P = 0.041) that predicted days to COPD readmission in a multivariate model incorporating age, sex, percent predicted FEV1, Charlson Comorbidity Index, and inspiratory flow group. In a group of patients with sPIF (n = 22), all-cause and COPD 30- and 90-day readmission rates were significantly lower for those discharged with nebulizer compared with DPI therapy. CONCLUSIONS sPIF is common during AECOPD and predicts all-cause and COPD readmissions. Patients with sPIF may benefit from nebulized therapies. We recommend checking PIF in patients hospitalized for AECOPD for selection of delivery devices.
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71
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Hejduk A, Urbańska A, Osiński A, Łukaszewicz P, Domański M, Sosnowski TR. Technical challenges in obtaining an optimized powder/DPI combination for inhalation delivery of a bi-component generic drug. J Drug Deliv Sci Technol 2018. [DOI: 10.1016/j.jddst.2018.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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72
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Kappeler D, Sommerer K, Kietzig C, Huber B, Woodward J, Lomax M, Dalvi P. Pulmonary deposition of fluticasone propionate/formoterol in healthy volunteers, asthmatics and COPD patients with a novel breath-triggered inhaler. Respir Med 2018; 138:107-114. [PMID: 29724381 DOI: 10.1016/j.rmed.2018.03.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 02/08/2018] [Accepted: 03/28/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION A combination of fluticasone propionate/formoterol fumarate (FP/FORM) has been incorporated within a novel, breath-triggered device, named K-haler®. This low resistance device requires a gentle inspiratory effort to actuate it, triggering at an inspiratory flow rate of approximately 30 L/min; thus avoiding the need for coordination of inhalation with manual canister depression. The aim of the study was to evaluate total and regional pulmonary deposition of FP/FORM when administered via the K-haler device. MATERIALS AND METHODS Twelve healthy subjects, 12 asthmatics, and 12 COPD patients each received a single dose of 2 puffs 99mtechnetium-labelled FP/FORM 125/5 μg. A gamma camera was used to obtain anterior and posterior two-dimensional images of drug deposition. Prior transmission scans (using a99mtechnetium flood source) allowed the definition of regions of interest and calculation of attenuation correction factors. Image analysis was performed per standardised methods. RESULTS Of 36 subjects, 35 provided evaluable post-dose scintigraphic data. Mean subject ages were 35.7 (healthy), 44.5 (asthma) and 61.7 years (COPD); mean FEV1% predicted values were 109.8%, 77.4% and 43.2%, respectively. Mean pulmonary deposition was 26.6% (healthy), 44.7% (asthma), 39.0% (COPD) of the delivered dose. The respective mean penetration indices (peripheral:central ratio normalised to a transmission lung scan) were 0.44, 0.31 and 0.30. CONCLUSION FP/FORM administration via the K-haler device resulted in high lung deposition in patients with obstructive lung disease but somewhat lesser deposition in healthy subjects. Regional deposition data demonstrated drug deposition in both the central and peripheral regions in all subject populations. EUDRACT NUMBER 2015-000744-42.
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Affiliation(s)
| | - Knut Sommerer
- Inamed GmbH, Robert-Koch-Allee 29, Gauting, Germany.
| | | | - Bärbel Huber
- Inamed GmbH, Robert-Koch-Allee 29, Gauting, Germany.
| | - Jo Woodward
- Mundipharma Research Limited, Cambridge Science Park, Milton Road, Cambridge, CB4 0AB, UK.
| | - Mark Lomax
- Mundipharma Research Limited, Cambridge Science Park, Milton Road, Cambridge, CB4 0AB, UK.
| | - Prashant Dalvi
- Mundipharma Research Limited, Cambridge Science Park, Milton Road, Cambridge, CB4 0AB, UK.
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Doty A, Schroeder J, Vang K, Sommerville M, Taylor M, Flynn B, Lechuga-Ballesteros D, Mack P. Drug Delivery from an Innovative LAMA/LABA Co-suspension Delivery Technology Fixed-Dose Combination MDI: Evidence of Consistency, Robustness, and Reliability. AAPS PharmSciTech 2018; 19:837-844. [PMID: 29019170 DOI: 10.1208/s12249-017-0891-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 09/24/2017] [Indexed: 11/30/2022] Open
Abstract
To ensure consistency of clinical outcomes, orally inhaled therapies must exhibit consistent delivered dose and aerosol properties at the time of manufacturing, throughout storage, and during various patient-use conditions. Achieving consistency across these scenarios has presented a significant challenge, especially for combination products that contain more than one drug. This study characterized the delivered dose and aerosol properties of glycopyrrolate/formoterol fumarate metered dose inhaler (GFF MDI; Bevespi Aerosphere™). GFF MDI, a fixed-dose combination (FDC) of a long-acting muscarinic antagonist, glycopyrrolate (18 μg, equivalent to glycopyrronium 14.4 μg), and a long-acting β2-agonist, formoterol fumarate (9.6 μg; equivalent to formoterol fumarate dihydrate 10 μg), is formulated using innovative co-suspension delivery technology, which suspends micronized drug crystals with spray-dried phospholipid porous particles in hydrofluoroalkane propellant. In this study, delivered dose uniformity was assessed through the labeled number of doses, and aerosol properties, such as percent fine particle fraction (FPF) and mass median aerodynamic diameter, were determined by cascade impaction. GFF MDI achieved reproducible dose delivery and an FPF greater than 55%, whether formulated and delivered as a monocomponent or dual FDC. The performance of GFF MDI was maintained across various manufacturing batches, under extended storage, and with variations in flow rate. Furthermore, unlike a GFF drug crystal-only suspension, drug delivery remained consistent for GFF MDI when simulated patient-handling errors were applied, such as reduced shake energy and delays between shaking and actuation. These results demonstrate that co-suspension delivery technology overcomes well-known sources of variability in MDI drug delivery.
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74
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Barbara S, Kritikos V, Bosnic-Anticevich S. Inhaler technique: does age matter? A systematic review. Eur Respir Rev 2017; 26:26/146/170055. [PMID: 29212836 DOI: 10.1183/16000617.0055-2017] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/27/2017] [Indexed: 11/05/2022] Open
Abstract
Poor inhaler technique and inferior asthma outcomes are evident in older adults. Reviews comparing metered dose inhaler (MDI) and dry powder inhaler (DPI) techniques across older adults and younger cohorts are scarce. This systematic review aimed to determine whether differences exist between such cohorts with regards to the number and type of MDI and DPI errors made. A systematic literature search was conducted in Embase, Medline and PubMed from July 1 to December 31, 2016. Studies were selected in accordance with preset inclusion criteria, relevant data were extracted, and quality was assessed with validated checklists. 14 studies were identified. Evidence suggests a negative correlation between advancing age and correct technique across MDI and varying DPI devices when examined collectively. Differences appear to exist between older adult and younger cohorts prescribed MDIs in error types. There is evidence of age-associated differences in the number and type of inhaler technique errors. Further research is required to assess outcomes in individual DPIs, reproducibility and the effects of confounders.
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Affiliation(s)
- Sarah Barbara
- Woolcock Institute of Medical Research, Sydney, Australia .,University of Sydney, Sydney, Australia
| | - Vicky Kritikos
- Woolcock Institute of Medical Research, Sydney, Australia
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Yawn BP, Han MK. Practical Considerations for the Diagnosis and Management of Asthma in Older Adults. Mayo Clin Proc 2017; 92:1697-1705. [PMID: 29101938 DOI: 10.1016/j.mayocp.2017.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 08/08/2017] [Accepted: 08/08/2017] [Indexed: 11/29/2022]
Abstract
Although often considered a disease of childhood, the prevalence of asthma in US adults aged 65 years or older is similar to that in children, with the number of older patients needing care for asthma likely to continue to increase. As with most chronic diseases, there are challenges associated with the diagnosis and management of asthma in an older population. This review discusses these challenges, suggesting practical management strategies for primary care physicians and their teams. Asthma comprises a spectrum of phenotypes, some associated with adult onset. The symptoms and characteristics of patients with late-onset asthma can differ from those of patients with early-onset disease. Furthermore, older patients may fail to recognize respiratory symptoms as abnormal and have other comorbidities, complicating the differential diagnosis of asthma. Once diagnosed, the long-term goals of asthma management are no different in older adults than in anyone with asthma, with inhaled corticosteroids being the cornerstone of therapy. Comorbid conditions become more common with age and have a direct impact on a patient's respiratory symptoms and potential adverse effects of therapy, thereby influencing the choice of therapies and delivery systems and potentially increasing the likelihood of complex polypharmacy. In conclusion, asthma, although traditionally considered a disease of the young, should be considered as a potential diagnosis in older adults with respiratory symptoms, even without a history of asthma or allergies. As with all patients, the primary goals of asthma management in older adults are symptom control and exacerbation reduction.
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Affiliation(s)
- Barbara P Yawn
- Department of Family Medicine and Community Health, University of Minnesota, Blaine, MN.
| | - MeiLan K Han
- Women's Respiratory Clinic, Division of Pulmonary and Critical Care Medicine, University of Michigan Health System, Ann Arbor, MI
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76
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Ferguson GT, Hickey AJ, Dwivedi S. Co-suspension delivery technology in pressurized metered-dose inhalers for multi-drug dosing in the treatment of respiratory diseases. Respir Med 2017; 134:16-23. [PMID: 29413503 DOI: 10.1016/j.rmed.2017.09.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/29/2017] [Accepted: 09/23/2017] [Indexed: 10/18/2022]
Abstract
Technologies for long-term delivery of aerosol medications in asthma and chronic obstructive pulmonary disease have improved over the past 2 decades with advancements in our understanding of the physical chemistry of aerosol formulations, device engineering, aerosol physics, and pulmonary biology. However, substantial challenges remain when a patient is required to use multiple inhaler types, multiple medications, and/or combinations of medications. Combining multiple drugs into a single inhaler while retaining appropriate dosing of the individual agents in the combination may enhance patient adherence to therapy and reduce device errors that occur when patients are using multiple inhalers. Pressurized metered-dose inhaler (pMDI) devices are widely used by patients for acute symptom relief as well as maintenance treatment, so the pMDI may be a suitable option with which to explore medication combinations. However, optimizing drug formulation remains a key challenge for pMDI delivery systems. This article introduces a new pMDI formulation approach: co-suspension delivery technology, which uses drug crystals with porous, low-density phospholipid particles engineered to deliver combinations of drugs to the airways with accurate and consistent dosing via pMDIs, independent of medication types and combinations. We describe the key characteristics of pMDIs, and discuss the rationale for the co-suspension delivery technology platform based on the limitations associated with traditional formulations. Finally, we discuss the clinical implications of co-suspension delivery technology for developing combination drug therapies administered by pMDIs.
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Affiliation(s)
- Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI 48336, USA.
| | | | - Sarvajna Dwivedi
- Pearl Therapeutics, Inc., 200 Cardinal Way, Redwood City, CA 94063, USA
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77
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Ghosh S, Ohar JA, Drummond MB. Peak Inspiratory Flow Rate in Chronic Obstructive Pulmonary Disease: Implications for Dry Powder Inhalers. J Aerosol Med Pulm Drug Deliv 2017; 30:381-387. [PMID: 28933581 DOI: 10.1089/jamp.2017.1416] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States with a significant economic burden related to hospital admissions for exacerbations. One of the primary treatment modalities for COPD is medications delivered through breath-actuated dry powdered inhalers (DPIs). For users to successfully receive inhaled medication, they must inhale with enough flow to overcome the internal resistance of the device, leading to deaggregation of the medication powder. Peak inspiratory flow rate (PIFR) is the maximal flow rate obtained during an inspiratory maneuver. PIFR measurement can be impacted by the internal resistance of the device, which varies with device design. Many devices require a PIFR >60 L/min for adequate medication dispersal, while others appear to have adequate drug deaggregation with a PIFR >30 L/min. Studies have shown PIFRs are reduced among females and decrease with age, without a clear correlation between forced expiratory volume in 1 second and PIFR. PIFR can be reduced at the time of COPD exacerbation. Recent data suggest that reduced PIFR may be associated with worse COPD-related symptom burden, increased odds of COPD-related hospital readmissions, and improved responsiveness to nebulized therapy. This review article aims to examine the physiology and clinical correlations of PIFR, as well as review published studies related to PIFR with DPIs used to treat COPD.
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Affiliation(s)
- Sohini Ghosh
- 1 Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
| | - Jill A Ohar
- 2 Section of Pulmonary, Critical Care, Allergy, and Immunology, School of Medicine, Wake Forest University , Winston-Salem, North Carolina
| | - M Bradley Drummond
- 1 Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill , Chapel Hill, North Carolina
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Jones R, Martin J, Thomas V, Skinner D, Marshall J, Stagno d'Alcontres M, Price D. The comparative effectiveness of initiating fluticasone/salmeterol combination therapy via pMDI versus DPI in reducing exacerbations and treatment escalation in COPD: a UK database study. Int J Chron Obstruct Pulmon Dis 2017; 12:2445-2454. [PMID: 28860739 PMCID: PMC5566416 DOI: 10.2147/copd.s141409] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD), a complex progressive disease, is currently the third leading cause of death worldwide. One recommended treatment option is fixed-dose combination therapy of an inhaled corticosteroid (ICS)/long-acting β-agonist. Clinical trials suggest pressurized metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs) show similar efficacy and safety profiles in COPD. Real-world observational studies have shown that combination therapy has significantly greater odds of achieving asthma control when delivered via pMDIs. Our aim was to compare effectiveness, in terms of moderate/severe COPD exacerbations and long-acting muscarinic antagonist (LAMA) prescriptions, for COPD patients initiating fluticasone propionate (FP)/salmeterol xinafoate (SAL) via pMDI versus DPI at two doses of FP (500 and 1,000 μg/d) using a real-life, historical matched cohort study. COPD patients with ≥2 years continuous practice data, ≥2 prescriptions for FP/SAL via pMDI/DPI, and no prescription for ICS were selected from the Optimum Patient Care Research Database. Patients were matched 1:1. Rate of moderate/severe COPD exacerbations and odds of LAMA prescription were analyzed using conditional Poisson and logistic regression, respectively. Of 472 patients on 500 μg/d, we observed fewer moderate/severe exacerbations in patients using pMDI (99 [42%]) versus DPI (115 [49%]) (adjusted rate ratio: 0.71; 95% confidence interval: 0.54, 0.93), an important result since the pMDI is not licensed for COPD in the UK, USA, or China. At 1,000 μg/d, we observed lower LAMA prescription for pMDI (adjusted odds ratio: 0.71; 95% confidence interval: 0.55, 0.91), but no difference in exacerbation rates, potentially due to higher dose of ICS overcoming low lung delivery from the DPI.
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Affiliation(s)
- Rupert Jones
- Clinical Trials and Health Research, Institute of Translational and Stratified Medicine, Plymouth University Peninsula School of Medicine and Dentistry, Plymouth, UK
| | - Jessica Martin
- Observational and Pragmatic Research Institute, Singapore
| | | | | | | | | | - David Price
- Observational and Pragmatic Research Institute, Singapore.,Centre for Academic Primary Care, University of Aberdeen, Aberdeen, UK
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Sharma G, Mahler DA, Mayorga VM, Deering KL, Harshaw O, Ganapathy V. Prevalence of Low Peak Inspiratory Flow Rate at Discharge in Patients Hospitalized for COPD Exacerbation. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2017; 4:217-224. [PMID: 28848933 DOI: 10.15326/jcopdf.4.3.2017.0183] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: Low peak inspiratory flow rate (PIFR) (<60 L/min) among patients with chronic obstructive pulmonary disease (COPD) may result in ineffective medication inhalation, leading to poor bronchodilation. Objective: The objectives of this analysis were to evaluate the prevalence of low PIFR at the time of discharge from a COPD-related hospitalization and to examine the real-world treatment patterns and rehospitalizations by PIFR. Methods: Patients at 7 sites in the United States were screened for enrollment at hospital discharge. PIFR was measured using the InCheckTM DIAL to simulate resistance of the DISKUS® dry powder inhaler (DPI). An equal number of patients were enrolled into low PIFR (<60 L/min) or normal PIFR (≥60 L/min) cohorts. Demographics, COPD-related clinical characteristics, health status, treatment and rehospitalization data were collected. Results: Mean PIFR was 71±22.12 L/min among 268 screened patients; 31.7% (n=85) of patients had low PIFR. Among all enrolled patients (n=170), the low PIFR cohort was older (66.2±10.04 years versus 62.1±9.41 years, p=0.006) and more likely to be female (61.2% versus 42.4%, p=0.014). There was an increase in DPI use at discharge, compared with admission, in the low PIFR cohort (62.4% versus 70.6%, p=0.020). The incidences of all-cause rehospitalization up to 180 days were similar between the low and normal PIFR cohorts. Conclusions: At discharge following hospitalization for an exacerbation of COPD, approximately one-third of patients had a PIFR <60 L/min. More patients with a low PIFR were discharged with a DPI medication compared with use at admission. There was no difference in the rehospitalization rates by PIFR.
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Affiliation(s)
| | - Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire and Valley Regional Hospital, Claremont, New Hampshire
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80
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Loh CH, Ohar JA. Personalization of Device Therapy - Prime Time for Peak Inspiratory Flow Rate. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2017; 4:172-176. [PMID: 28848928 DOI: 10.15326/jcopdf.4.3.2017.0155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Chee H Loh
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
| | - Jill A Ohar
- Section of Pulmonary, Critical Care, Allergy and Immunology, School of Medicine, Wake Forest University, Winston-Salem, North Carolina
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81
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Bell D, Mansfield L, Lomax M. A Randomized, Crossover Trial Evaluating Patient Handling, Preference, and Ease of Use of the Fluticasone Propionate/Formoterol Breath-Triggered Inhaler. J Aerosol Med Pulm Drug Deliv 2017; 30:425-434. [PMID: 28683212 DOI: 10.1089/jamp.2017.1385] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Appropriate inhaler selection is of fundamental importance in obstructive lung disease management. Key factors in device selection include a patient's capacity to operate a particular device and their preference for it. METHODS This randomized, open-label, two-period, crossover study (NCT01739387) compared the ability of adolescent and adult patients with obstructive lung disease to correctly handle the fluticasone propionate/formoterol fumarate (FP/FORM; Flutiform®) pressurized metered-dose inhaler (pMDI) and FP/FORM K-haler®, a novel breath-triggered inhaler (BTI), following a simple, standardized training regimen. The primary endpoint was the ability to perform all steps correctly at the first attempt. Secondary endpoints included the ability to perform all critical steps correctly at the first attempt, the requisite number of attempts to successfully use the inhaler, the ability to be trained within 15 minutes, and the ability to trigger the K-haler BTI to actuate at the first attempt. Ease of device use and device preference versus patients' usual maintenance inhalers were also assessed. RESULTS AND CONCLUSIONS At the first attempt, an identical proportion (77.2% [95% confidence interval [CI]: 72.1, 81.8]) of 307 patients performed all pMDI and K-haler BTI handling steps correctly, whereas the corresponding proportions performing all critical steps correctly were 82.4% (95% CIs: 77.7, 86.5) and 87.0% (95% CI: 82.7, 90.5), respectively. For both devices, >90% of patients required only two attempts to master device usage; >99% of patients could be trained to correctly use each device within 15 minutes. Virtually all patients (99.0% [95% CIs: 97.2, 99.8]) were able to successfully trigger the K-haler BTI's dose-release mechanism at first attempt. Ease of use and preference data for FP/FORM pMDI challenged the perceived wisdom that dry powder inhalers are necessarily simpler to use, whereas the corresponding data for FP/FORM K-haler strongly favored this novel BTI over the Turbuhaler®, Accuhaler®, and other pMDIs.
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Affiliation(s)
- David Bell
- 1 BioKinetic Europe Limited , Belfast, Northern Ireland
| | | | - Mark Lomax
- 2 Mundipharma Research Limited , Cambridge, United Kingdom
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82
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Lavorini F, Pistolesi M, Usmani OS. Recent advances in capsule-based dry powder inhaler technology. Multidiscip Respir Med 2017; 12:11. [PMID: 28536654 PMCID: PMC5439154 DOI: 10.1186/s40248-017-0092-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 04/12/2017] [Indexed: 11/26/2022] Open
Abstract
Pulmonary drug delivery is currently the focus of accelerated research and development because of the potential to produce maximum therapeutic benefit to patients by directly targeting drug to the site of pathology in the lungs. Among the available delivery options, the dry powder inhaler (DPI) is the preferred device for the treatment of an increasingly diverse range of diseases. However, because drug delivery from a DPI involves a complex interaction between the device and the patient, the engineering development of this medical technology is proving to be a great challenge. Development of DPI systems that target the delivery of fine drug particles to the deeper airways in the lungs using a combination of improved drug formulations and enhanced delivery device technologies means that each of these factors contributes to overall performance of the aerosol system. There are a large range of devices that are currently available, or under development, for clinical use, however no individual device shows superior clinical efficacy. A major concern that is very relevant in day-to-day clinical practice is the inter- and intra-patient variability of the drug dosage delivered to the deep lungs from the inhalation devices, where the extent of variability depends on the drug formulation, the device design, and the patient’s inhalation profile. This variability may result in under-dosing of drug to the patient and potential loss of pharmacological efficacy. This article reviews recent advances in capsule-based DPI technology and the introduction of the ‘disposable’ DPI device.
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Affiliation(s)
- Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Massimo Pistolesi
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London& Royal Brompton Hospital, London, UK
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83
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Kawamatawong T, Khiawwan S, Pornsuriyasak P. Peak inspiratory flow rate measurement by using In-Check DIAL for the different inhaler devices in elderly with obstructive airway diseases. J Asthma Allergy 2017; 10:17-21. [PMID: 28260934 PMCID: PMC5328129 DOI: 10.2147/jaa.s127580] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Inhaler device technique is a common cause of treatment failure in patients with asthma and chronic obstructive pulmonary disease. Dry powder inhaler (DPI) requires optimal peak inspiratory flow rate (PIFR) for drug delivery. Low PIFR generation is common in the elderly. Patient lung function and intrinsic inhaler resistance are factors for determining generated PIFR and drug delivery from DPI. Objectives We aimed to identify the PIFR of the older (aged >60 years) and the younger (aged ≤60 years) patients with obstructive airway diseases for the different inhaler devices (Turbuhaler® and Accuhaler). Patients and methods A cross-sectional study was conducted from January to December 2014. Patients with obstructive airway diseases were recruited. Spirometry was performed. PIFR was measured by using an In-Check DIAL device. Individual PIFR values for each inhaler device were obtained for three consecutive measurements and then averaged. Results A total of 139 patients diagnosed with obstructive lung diseases (asthma, n = 109; chronic obstructive pulmonary disease, n = 30) were recruited. Of these, 71 patients (51%) were >60 years. The PIFR generated by the patients who were ≤60 years for nonresistance mode was not different from that generated by those aged >60 years (115.0 ± 15.2 L/min vs 115.4 ± 13.3 L/min, p = 0.86). Regarding the DPI, PIFR generated from the older group was significantly lower than that generated from the younger group for Turbuhaler (72.5 ± 18.8 L/min vs 82.4 ± 21.1 L/min, p = 0.01), but the PIFR generated was not significantly different between the older and the younger groups for the Accuhaler (93.8 ± 22.9 L/min vs 99.4 ± 24.2 L/min, p = 0.86). The low peak expiratory flow rate and PIFR from spirometry were associated with the suboptimal PIFR measured by using In-Check DIAL. Discussion Optimal PIFR is critical for DPI use in the elderly; appropriate DPI selection is essential for management. In-Check DIAL may be useful for detecting inhaler device problem among the elderly. Conclusion Lower PIFR generated from Turbuhaler was noted in patients with airway diseases who were older than 60 years, when compared to the younger patients.
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Affiliation(s)
- Theerasuk Kawamatawong
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Supattra Khiawwan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Prapaporn Pornsuriyasak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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84
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Wise RA, Acevedo RA, Anzueto AR, Hanania NA, Martinez FJ, Ohar JA, Tashkin DP. Guiding Principles for the Use of Nebulized Long-Acting Beta2-Agonists in Patients with COPD: An Expert Panel Consensus. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2016; 4:7-20. [PMID: 28848907 DOI: 10.15326/jcopdf.4.1.2016.0141] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Determining which patients with COPD may benefit from a nebulized long-acting beta2-agonist (LABA) is a challenge in current practice. In the absence of strong clinical guidelines addressing this issue, an expert panel convened to develop guiding principles for the use of nebulized LABA therapy in patients with COPD. This article summarizes these guiding principles and other practical issues discussed during a roundtable meeting.
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Affiliation(s)
- Robert A Wise
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Antonio R Anzueto
- University of Texas Health Science Center, and South Texas Veterans Health Care System, San Antonio, Texas
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Jill A Ohar
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Donald P Tashkin
- David Geffen School of Medicine at the University of California, Los Angeles
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85
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Haynes A, Geller D, Weers J, Ament B, Pavkov R, Malcolmson R, Debonnett L, Mastoridis P, Yadao A, Heuerding S. Inhalation of tobramycin using simulated cystic fibrosis patient profiles. Pediatr Pulmonol 2016; 51:1159-1167. [PMID: 27133552 DOI: 10.1002/ppul.23451] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 04/14/2016] [Accepted: 04/18/2016] [Indexed: 11/11/2022]
Abstract
INTRODUCTION TOBI® Podhaler™ is a capsule-based drug-device combination (tobramycin inhalation powder [TIP] 28 mg capsules via unit-dose dry powder T-326 Inhaler [Podhaler™]) developed for treatment of Pseudomonas aeruginosa infection in cystic fibrosis (CF). We explored how inspiratory flow profiles and mouth-throat geometries affect drug delivery with the T-326 Inhaler. METHODS Inspiratory flow profiles were recorded from 38 subjects aged 6-71 who had CF and varying degrees of lung function impairment. Ten of the inspiratory flow profiles were simulated in the laboratory using a custom breath simulator to determine delivered dose (DD) from the T-326 Inhaler. In vitro total lung dose (TLDin vitro ) was measured using four anatomical throat models, ranging from a child to a large adult. RESULTS Aerosol performance was assessed across a range of inspiratory flow profiles. Mean DD ranged from 88.8% to 97.0% of declared capsule content. TLDin vitro ranged from 54.8% to 72.4% of capsule content between the flow profile/throat options tested, and the mean TLDin vitro across the range of flow profiles and anatomical throats tested was 63 ± 5%. CONCLUSIONS Our findings indicate that the T-326 Inhaler provides reliable drug delivery at flow rates likely to be achieved by a broad spectrum of patients with CF. Importantly, forceful inhalation was not required to achieve a robust TLDin vitro . Pediatr Pulmonol. 2016;51:1159-1167. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Alfred Haynes
- Novartis Pharmaceuticals Corporation, San Carlos, California
| | - David Geller
- Florida State University College of Medicine, Orlando, Florida
| | - Jeffry Weers
- Novartis Pharmaceuticals Corporation, San Carlos, California.
| | - Brian Ament
- Novartis Pharmaceuticals Corporation, San Carlos, California
| | - Richard Pavkov
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | | | - Paul Mastoridis
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Anthony Yadao
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
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86
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Farkas Á, Jókay Á, Balásházy I, Füri P, Müller V, Tomisa G, Horváth A. Numerical simulation of emitted particle characteristics and airway deposition distribution of Symbicort(®) Turbuhaler(®) dry powder fixed combination aerosol drug. Eur J Pharm Sci 2016; 93:371-9. [PMID: 27552906 DOI: 10.1016/j.ejps.2016.08.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 08/18/2016] [Accepted: 08/19/2016] [Indexed: 01/27/2023]
Abstract
One of the most widespread dry powder fixed combinations used in asthma and chronic obstructive pulmonary disease (COPD) management is Symbicort(®) Turbuhaler(®). The aim of this study was to simulate the deposition distribution of both components of this drug within the airways based on realistic airflow measurements. Breathing parameters of 25 healthy adults (11 females and 14 males) were acquired while inhaling through Turbuhaler(®). Individual specific emitted doses and particle size distributions of Symbicort(®) Turbuhaler(®) were determined. A self-developed particle deposition model was adapted and validated to simulate the deposition of budesonide (inhaled corticosteroid; ICS) and formoterol (long acting β2 agonist; LABA) in the upper airways and lungs of the healthy volunteers. Based on current simulations the emitted doses varied between 50.4% and 92.5% of the metered dose for the ICS, and between 38% and 96.1% in case of LABA component depending on the individual inhalation flow rate. This variability induced a notable inter-individual spread of the deposited lung doses (mean: 33.6%, range: 20.4%-48.8% for budesonide and mean: 29.8%, range: 16.4%-42.9% for formoterol). Significant inter-gender differences were also observed. Average lung dose of budesonide was 29.2% of the metered dose for females and 37% for males, while formoterol deposited with 26.4% efficiency for females and 32.5% for males. Present results also highlighted the importance of breath-holding after inhalation of the drug. About a half of the total lung deposition occurred during breath-hold at 9.6s average breath-hold time. Calculated depositions confirmed appropriate lung deposition of Symbicort(®) Turbuhaler(®) for both genders, however more effort for optimal inhalation technique is advised for persons with low vital capacity. This study demonstrated the possibility of personalized prediction of airway deposition of aerosol drugs by numerical simulations. The methodology developed in this study will be applicable also to other marketed drugs in the future.
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Affiliation(s)
- Árpád Farkas
- Centre for Energy Research, Hungarian Academy of Sciences, Konkoly-Thege Miklós út 29-33, 1121 Budapest, Hungary.
| | - Ágnes Jókay
- Centre for Energy Research, Hungarian Academy of Sciences, Konkoly-Thege Miklós út 29-33, 1121 Budapest, Hungary
| | - Imre Balásházy
- Centre for Energy Research, Hungarian Academy of Sciences, Konkoly-Thege Miklós út 29-33, 1121 Budapest, Hungary
| | - Péter Füri
- Centre for Energy Research, Hungarian Academy of Sciences, Konkoly-Thege Miklós út 29-33, 1121 Budapest, Hungary
| | - Veronika Müller
- Department of Pulmonology, Semmelweis University, Diós árok 1/C, 1125 Budapest, Hungary
| | - Gábor Tomisa
- Department of Pulmonology, Semmelweis University, Diós árok 1/C, 1125 Budapest, Hungary; Chiesi Hungary Kft., Dunavirág u. 2, 1138 Budapest, Hungary
| | - Alpár Horváth
- Department of Pulmonology, Semmelweis University, Diós árok 1/C, 1125 Budapest, Hungary; Chiesi Hungary Kft., Dunavirág u. 2, 1138 Budapest, Hungary
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87
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Ramadan WH, Kabbara WK, Abilmona RM. Olodaterol for the treatment of chronic obstructive pulmonary disease. Am J Health Syst Pharm 2016; 73:1135-43. [PMID: 27354040 DOI: 10.2146/ajhp150364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
PURPOSE Published data on the pharmacology, pharmacokinetics, efficacy, and safety of the once-daily, long-acting β2-agonist (LABA) olodaterol are reviewed. SUMMARY Olodaterol (Striverdi Respimat, Boehringer Ingelheim), a LABA with high selectivity for β2-adrenergic receptors, is indicated for the treatment of chronic obstructive pulmonary disease (COPD); the recommended dose is 5 μg, to be delivered once daily via the Respimat inhaler. In 48- and 6-week Phase III clinical trials of olodaterol evaluating various lung function and symptomatic outcomes in patients with moderate to very severe COPD, olodaterol use was associated with significant improvements in spirometry outcomes, such as postbronchodilator forced expiratory volume in one second (FEV1), as well as dyspnea severity and quality-of-life measures. Other clinical trials demonstrated that olodaterol produced beneficial effects on FEV1 measures throughout the 24-hour dosing interval. A meta-analysis of data from 20 published research reports indicated that olodaterol's efficacy was comparable to that of the once-daily LABA indacaterol and that the combination of olodaterol and tiotropium provided improvements in lung function greater than those provided by tiotropium alone. Analysis of pooled data from four long-term trials showed that olodaterol's safety profile was comparable to that of formoterol; the most frequently reported adverse effects associated with olodaterol use were bronchitis, nasopharyngitis, and upper respiratory tract infection. CONCLUSION Once-daily olodaterol 5 μg is an effective therapy in improving lung function and symptomatic outcomes in patients with moderate to very severe COPD receiving other maintenance therapy, with a satisfactory safety profile.
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Affiliation(s)
- Wijdan H Ramadan
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, Byblos, Lebanon.
| | - Wissam K Kabbara
- Department of Pharmacy Practice, School of Pharmacy, Lebanese American University, Byblos, Lebanon
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88
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Price D, Chrystyn H. Concept review of dry powder inhalers: correct interpretation of published data. Multidiscip Respir Med 2015; 10:36. [PMID: 26634121 PMCID: PMC4667462 DOI: 10.1186/s40248-015-0033-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 10/30/2015] [Indexed: 11/17/2022] Open
Abstract
Dry powder inhalers (DPIs) are widely used in the clinical practice for delivering therapeutics to patients with lung diseases, such as chronic obstructive pulmonary disease. An overview of current DPIs available on the market from high resistance to low resistance has been reported in a recent review article. We assessed this concept review article and believe this letter provides important additional information regarding the correct interpretation of the data on low resistance DPIs.
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Affiliation(s)
- David Price
- Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, AB25 2ZD UK ; Research in Real Life (RiRL), 2 Changi Business Park Avenue 1, Singapore, 486015 Singapore
| | - Henry Chrystyn
- Research in Real Life Limited, Cambridge, CB24 3BA UK ; Talmedica Ltd, St Crispin House, St Crispin Way, Haslingden, Rossendale BB4 4PW UK
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Prime D, de Backer W, Hamilton M, Cahn A, Preece A, Kelleher D, Baines A, Moore A, Brealey N, Moynihan J. Effect of Disease Severity in Asthma and Chronic Obstructive Pulmonary Disease on Inhaler-Specific Inhalation Profiles Through the ELLIPTA® Dry Powder Inhaler. J Aerosol Med Pulm Drug Deliv 2015; 28:486-97. [PMID: 26372467 PMCID: PMC4685483 DOI: 10.1089/jamp.2015.1224] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Two studies were undertaken to characterize the maximal effort inhalation profiles of healthy subjects and patients with asthma or chronic obstructive pulmonary disease (COPD) through a moderate-resistance dry powder inhaler (DPI). Correlations between inhaler-specific inhalation characteristics and inhaler-independent lung function parameters were investigated. METHODS Healthy subjects (n = 15), patients with mild, moderate, or severe asthma (n = 45), and patients with mild, moderate, severe, or very-severe COPD (n = 60) were included in the studies. Inhalation pressure drop versus time profiles were recorded using an instrumented ELLIPTA® DPI or bespoke resistor component with equivalent resistivity. Inhaler-independent lung function assessments included pharyngometry, spirometry, plethysmography, and diffusion. RESULTS For the inhaler-specific inhalation profiles, the mean maximal effort peak inspiratory flow rates (PIFRs) varied across the subgroups from 65.8-110.6 L/min (range: 41.6-142.9). Peak pressure drop, PIFR, inhaled volume, and average inhalation flow rate (primary endpoints) did not differ markedly between healthy subjects and patients with asthma or mild COPD. Moderate, severe, and very-severe COPD patients demonstrated lower mean peak pressure drops, PIFRs and inhaled volumes, which tended to decrease with increasing COPD severity. Severe and very-severe COPD patients demonstrated shorter mean inhalation times compared with all other participants. Inhaler-independent lung function parameters were consistent with disease severity, and statistically significant (p < 0.05) strong correlations (R > 0.7) with components of the inhaler-specific inhalation profiles were observed in the COPD cohort; correlations in the asthma cohort tended to be weaker. CONCLUSIONS All participants achieved a maximal effort PIFR ≥ 41.6 L/min through the moderate resistance of the ELLIPTA inhaler. Patients with asthma achieved similar inhalation profiles to healthy subjects, but increasing COPD severity tended to reduce a patient's inhalation capability. Correlation analyses suggest that some lung function parameters may be a useful indicator of ability to inhale efficiently through a moderate-resistance DPI, such as the ELLIPTA inhaler.
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Affiliation(s)
- David Prime
- 1 GSK Research and Development Ltd., Ware, Hertfordshire, United Kingdom
| | - Wilfried de Backer
- 2 Department of Pulmonary Medicine, University Hospital and University of Antwerp , Belgium
| | - Melanie Hamilton
- 1 GSK Research and Development Ltd., Ware, Hertfordshire, United Kingdom
| | - Anthony Cahn
- 3 Medicines Discovery and Development, GSK , Stevenage, Hertfordshire, United Kingdom
| | - Andrew Preece
- 4 Respiratory Therapy Area Unit, GSK , Stockley Park West, Middlesex, United Kingdom
| | | | - Amanda Baines
- 3 Medicines Discovery and Development, GSK , Stevenage, Hertfordshire, United Kingdom
| | - Alison Moore
- 4 Respiratory Therapy Area Unit, GSK , Stockley Park West, Middlesex, United Kingdom
| | - Noushin Brealey
- 4 Respiratory Therapy Area Unit, GSK , Stockley Park West, Middlesex, United Kingdom
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90
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Holmes MS, Seheult J, Geraghty C, D'Arcy S, Costello RW, Reilly RB. Using acoustics to estimate inspiratory flow rate and drug removed from a dry powder inhaler. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2013:6866-9. [PMID: 24111322 DOI: 10.1109/embc.2013.6611135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Morbidity and mortality rates of chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) are rising. There is a strong requirement for more effective management of these chronic diseases. Dry powder inhalers (DPIs) are one kind of devices currently employed to deliver medication aimed at controlling asthma and COPD symptoms. Despite their proven effectiveness when used correctly, some patients are unable to reach the inspiratory flow rate required to remove medication from the breath actuated devices and as a result, the medication does not reach the airways. This study employs an acoustic recording device, attached to a common DPI to record the audio signals of simulated inhalations. A rotameter was used to measure the flow rate through the inhaler while a milligram weighing scale was used to measure the amount of drug removed from each simulated inhalation. It was found that a strong correlation existed (R(2)>0.96) when average power, median amplitude, root mean square and mean absolute deviation were used to predict peak inspiratory flow rate. At a flow of 30 L/Min (mean absolute deviation=0.0049), it was found that 77% of the total emitted dose was removed from the inhaler. Results indicate that acoustic measurements may be used in the prediction of inspiratory flow rate and quantity of medication removed from an inhaler.
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91
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Pritchard JN. Industry guidance for the selection of a delivery system for the development of novel respiratory products. Expert Opin Drug Deliv 2015; 12:1755-65. [PMID: 26067581 DOI: 10.1517/17425247.2015.1056148] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Respiratory diseases remain a target for improved forms of inhalation therapy. However, there are neither regulatory preferences for one type of device over another, nor well-recognized guidelines. This guidance describes factors that should be considered to optimize the choice of delivery system. AREAS COVERED This article summarizes the different types of delivery systems with key technical and commercial considerations for selection. It highlights current market trends and opportunities for the future, based on the author's experience of more than 20 years in this field. EXPERT OPINION For a generic drug, low device cost favors a capsule dry powder inhaler (DPI) or a propellant-based metered-dose inhaler (pMDI). Novel particle engineering approaches may allow close matching to the innovator product performance. For novel drugs, most companies favor a bespoke DPI, adding patent protection and aiding brand recognition, despite being expensive to develop. Device features may add differentiation, but "no outcome, no income." Patient technique and adherence remain problematic, compounded by age, although accessories, including monitors, can help. There are few modern medicines available in nebulized form, so there is value in fast-tracking the nebulized formulations from Phase I studies through to market in parallel to the chosen inhaler.
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Affiliation(s)
- John N Pritchard
- a Respironics Respiratory Drug Delivery (UK) Ltd, a Business of Philips Electronics UK Limited , Chichester, West Sussex, UK +44 0 870 42 31370 ; +44 0 870 42 31471 ;
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92
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Murphy L, Rennard S, Donohue J, Molimard M, Dahl R, Beeh KM, Dederichs J, Fülle HJ, Higgins M, Young D. Turning a molecule into a medicine: the development of indacaterol as a novel once-daily bronchodilator treatment for patients with COPD. Drugs 2015; 74:1635-57. [PMID: 25212789 DOI: 10.1007/s40265-014-0284-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Indacaterol is the first once-daily, long-acting β2-adrenergic agonist (LABA) approved for the treatment of chronic obstructive pulmonary disease (COPD). Indacaterol was developed using a combination of informed drug design and molecular chemistry to generate a β2-adrenergic agonist with a fast onset and long duration of action, enabling once-daily dosing with an acceptable safety profile. Early preclinical studies with indacaterol demonstrated these characteristics, and this promising molecule was taken into clinical development, originally for asthma treatment. Subsequent safety concerns over LABA monotherapy in patients with asthma redirected indacaterol's development to centre on COPD, where a good evidence base and guideline recommendations for bronchodilator monotherapy existed. Clinical development was initially complicated by different inhaler devices and differing doses of indacaterol. Using a phase III innovative adaptive-design clinical trial (INHANCE), indacaterol 150 and 300 μg once-daily doses were selected to be taken forward into the phase III INERGIZE programme. This programme delivered placebo-controlled and active-comparator data, including comparisons with formoterol, tiotropium and salmeterol/fluticasone, as well as the use of indacaterol in combination with tiotropium. Together, these studies provided a comprehensive assessment of the benefit-risk profile of indacaterol, allowing for regulatory submission. Indacaterol was first approved at once-daily doses of 150 and 300 μg in the European Union in 2009, followed by 150 µg in Japan (2011) and China (2012), and 75 μg in the United States (2011). To date, indacaterol is approved and marketed in more than 100 countries worldwide for once-daily maintenance treatment of COPD.
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Affiliation(s)
- Lorraine Murphy
- Novartis Horsham Research Centre, Novartis Pharmaceuticals UK Limited, Wimblehurst Road, Horsham, West Sussex, RH12 5AB, UK,
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93
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Hassoun M, Ho S, Muddle J, Buttini F, Parry M, Hammond M, Forbes B. Formulating powder-device combinations for salmeterol xinafoate dry powder inhalers. Int J Pharm 2015; 490:360-7. [PMID: 25987210 DOI: 10.1016/j.ijpharm.2015.05.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/08/2015] [Accepted: 05/11/2015] [Indexed: 10/23/2022]
Abstract
Using salmeterol xinafoate (SX) as an active pharmaceutical ingredient, the effects of carrier lactose particle type, total lactose fines content and device resistance on dry powder inhaler performance were investigated in vitro. To mimic drug levels in commercial preparations, interactive mixtures containing 0.58% w/w SX were prepared by low shear tumble mixing. Three types of milled inhalation grade lactose were used (Lactohale(®) LH 200, Respitose(®) ML006 and ML001) and the concentration of fine lactose (Lactohale(®) 300) added was varied. The in vitro deposition of each mixture was studied using a next generation impactor and inhaler devices exhibiting different resistances, Rotahaler(®)<Aerolizer(®)<Handihaler(®). Aerosol performance was evaluated based on the emitted dose (ED), mass median aerodynamic diameter (MMAD) ± geometric standard deviation (GSD) and fine particle fraction (FPF). Increases of up to eight-fold in FPF were observed with increasing intrinsic fine lactose content. The addition of extra fine lactose increased the FPF further, although the effect diminished as more fines were added. The Aerolizer produced the best aerosol performance with any given powder blend, although suitable formulations were identified for each device as defined by the a priori success criteria: >80% ED and MMAD ± GSD between 1-5 μm. The results confirmed the factors under investigation to be important determinants of product performance, but demonstrated using realistic conditions how individual factor impact may be enhanced or mitigated by inter-dependency.
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Affiliation(s)
- Mireille Hassoun
- Department of Pharmacy, King's College London, 150 Stamford Street, London SE1 9NH, UK
| | - Shirlene Ho
- Department of Pharmacy, King's College London, 150 Stamford Street, London SE1 9NH, UK
| | - Joanna Muddle
- Department of Pharmacy, King's College London, 150 Stamford Street, London SE1 9NH, UK
| | - Francesca Buttini
- Department of Pharmacy, King's College London, 150 Stamford Street, London SE1 9NH, UK; Department of Pharmacy, University of Parma, Parco Area delle Scienze 27/a, Parma 43124, Italy
| | - Mark Parry
- Intertek-Melbourn Scientific Limited, Saxon Way, Melbourn SG8 6DN, UK
| | - Mark Hammond
- Intertek-Melbourn Scientific Limited, Saxon Way, Melbourn SG8 6DN, UK
| | - Ben Forbes
- Department of Pharmacy, King's College London, 150 Stamford Street, London SE1 9NH, UK.
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94
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Widagdo IS, Nyfort-Hansen K, Kowalski SR. Prevalence of Potentially Inappropriate Medication Use in Elderly Hospitalised Patients. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2015. [DOI: 10.1002/j.2055-2335.2011.tb00678.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Imaina S Widagdo
- School of Pharmacy and Medical Sciences; University of South Australia
| | | | - Stefan R Kowalski
- School of Pharmacy and Medical Sciences; University of South Australia; Adelaide South Australia
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95
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Dal Negro RW. Dry powder inhalers and the right things to remember: a concept review. Multidiscip Respir Med 2015; 10:13. [PMID: 25878791 PMCID: PMC4397837 DOI: 10.1186/s40248-015-0012-5] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 03/18/2015] [Indexed: 11/10/2022] Open
Abstract
Dry powder inhalers (DPIs) are widely and increasingly used in clinical practice because they represent a substantial advancement in inhalation technology. The effectiveness of a powdered drug to inhale depends on the inspiratory flow rate generated by the patient and on the turbulence produced by the intrinsic resistance of the DPI. While the inspiratory flow is variable with the patient's ability and conditions, the turbulence is differently sized within each device because depending of its technical design. There are higher - medium-, and low-resistance devices. With low-resistance DPIs, the disaggregation and the microdispersion of the drug highly depend on the patient's inhalation airflow rate, because the role of the resistance-induced turbulence is obviously negligible in these cases. This flow-rate dependency is minimized in the presence of a sufficient regimen of turbulence as in the case of medium-resistance DPIs. Both the disaggregation and the micro-dispersion of the powdered drug are optimized in these circumstances even in the absence of a maximal inspiratory flow rate. The low resistance DPIs should not be regarded as the best performer DPIs because their intrinsic low-resistance regimen requires a higher inspiratory airflow rate and effort, which frequently cannot be achieved by subjects suffering from a disease-induced airflow limitation. Only when the ratio between the inhalation flow rate and the DPI intrinsic resistance is balanced, the speed of the particulate, the distribution of the drug within the lung, and the variability of the effective inhaled dose are optimized.
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Affiliation(s)
- Roberto W Dal Negro
- National Center for Respiratory Pharmacoeconomics and Pharmacoepidemiology - CESFAR, Verona, Italy ; Research & Clinical Governance, Verona, Italy
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96
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Fromer L, Goodwin E, Walsh J. Customizing Inhaled Therapy to Meet the Needs of COPD Patients. Postgrad Med 2015; 122:83-93. [DOI: 10.3810/pgm.2010.03.2125] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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97
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Muralidharan P, Hayes D, Mansour HM. Dry powder inhalers in COPD, lung inflammation and pulmonary infections. Expert Opin Drug Deliv 2014; 12:947-62. [PMID: 25388926 DOI: 10.1517/17425247.2015.977783] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The number of pulmonary diseases that are effectively treated by aerosolized medicine continues to grow. AREAS COVERED These diseases include chronic obstructive pulmonary disease (COPD), lung inflammatory diseases (e.g., asthma) and pulmonary infections. Dry powder inhalers (DPIs) exhibit many unique advantages that have contributed to the incredible growth in the number of DPI pharmaceutical products. To improve the performance, there are a relatively large number of DPI devices available for different inhalable powder formulations. The relationship between formulation and inhaler device features on performance of the drug-device combination product is critical. Aerosol medicine products are drug-device combination products. Device design and compatibility with the formulation are key drug-device combination product aspects in delivering drugs to the lungs as inhaled powders. In addition to discussing pulmonary diseases, this review discusses DPI devices, respirable powder formulation and their interactions in the context of currently marketed DPI products used in the treatment of COPD, asthma and pulmonary infections. EXPERT OPINION There is a growing line of product options available for patients in choosing inhalers for treatment of respiratory diseases. Looking ahead, combining nanotechnology with optimized DPI formulation and enhancing device design presents a promising future for DPI development.
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Affiliation(s)
- Priya Muralidharan
- The University of Arizona, College of Pharmacy, Skaggs Pharmaceutical Sciences Center , 1703 E. Mabel St, Tucson, AZ 85721 , USA +1 520 626 2768 ; +1 520 6262 7355 ;
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98
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Pulmonary drug delivery by powder aerosols. J Control Release 2014; 193:228-40. [DOI: 10.1016/j.jconrel.2014.04.055] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Revised: 04/27/2014] [Accepted: 04/29/2014] [Indexed: 12/24/2022]
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99
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Malmberg LP, Everard ML, Haikarainen J, Lähelmä S. Evaluation of in vitro and in vivo flow rate dependency of budesonide/formoterol Easyhaler(®). J Aerosol Med Pulm Drug Deliv 2014; 27:329-40. [PMID: 24978441 PMCID: PMC4175975 DOI: 10.1089/jamp.2013.1099] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 05/20/2014] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The Easyhaler(®) (EH) device-metered dry powder inhaler containing budesonide and formoterol is being developed for asthma and chronic obstructive pulmonary disease (COPD). As a part of product optimization, a series of in vitro and in vivo studies on flow rate dependency were carried out. METHODS Inspiratory flow parameters via EH and Symbicort(®) Turbuhaler(®) (TH) inhalers were evaluated in 187 patients with asthma and COPD. The 10(th), 50(th), and 90(th) percentile flow rates achieved by patients were utilized to study in vitro flow rate dependency of budesonide/formoterol EH and Symbicort TH. In addition, an exploratory pharmacokinetic study on pulmonary deposition of active substances for budesonide/formoterol EH in healthy volunteers was performed. RESULTS Mean inspiratory flow rates through EH were 64 and 56 L/min in asthmatics and COPD patients, and through TH 79 and 72 L/min, respectively. Children with asthma had marginally lower PIF values than the adults. The inspiratory volumes were similar in all groups between the inhalers. Using weighted 10(th), 50(th), and 90(th) percentile flows the in vitro delivered doses (DDs) and fine particle doses (FPDs) for EH were rather independent of flow as 98% of the median flow DDs and 89%-93% of FPDs were delivered already at 10(th) percentile air flow. Using±15% limits, EH and TH had similar flow rate dependency profiles between 10(th) and 90(th) percentile flows. The pharmacokinetic study with budesonide/formoterol EH in healthy subjects (n=16) revealed a trend for a flow-dependent increase in lung deposition for both budesonide and formoterol. CONCLUSIONS Comparable in vitro flow rate dependency between budesonide/formoterol EH and Symbicort TH was found using the range of clinically relevant flow rates. The results of the pharmacokinetic study were in accordance with the in vitro results showing only a trend of flow rate-dependant increase in lung deposition of active substances with EH.
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Affiliation(s)
- L. Pekka Malmberg
- Department of Allergy, Helsinki University Central Hospital, Helsinki, Finland
| | - Mark L. Everard
- Department of Respiratory Medicine, Sheffield Children's Hospital, Sheffield, United Kingdom
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100
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Seheult JN, Costello S, Tee KC, Bholah T, Al Bannai H, Sulaiman I, Costello RW. Investigating the relationship between peak inspiratory flow rate and volume of inhalation from a Diskus™ Inhaler and baseline spirometric parameters: a cross-sectional study. SPRINGERPLUS 2014; 3:496. [PMID: 25279290 PMCID: PMC4164676 DOI: 10.1186/2193-1801-3-496] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 08/18/2014] [Indexed: 11/18/2022]
Abstract
Drug delivery from a Dry Powder Inhaler (DPI) is dependent on the peak inspiratory flow rate (PIFR) generated. Currently available methods for estimating PIFR from most DPIs are limited and mainly rely on subjective assessment. We aim to show that spirometric and Diskus™ PIFR and Inspiratory Vital Capacity (IVC) are related to the underlying respiratory condition and that spirometric PIFR can be used to assess whether Diskus™ PIFR will be adequate when using this DPI. Healthy volunteers and patients with asthma, COPD, neuromuscular disease and non-respiratory disorders were recruited (n = 85). Demographics and baseline lung function by spirometry were recorded. Flow and volume readings were taken while patients used a Diskus™ DPI, housed in an airtight container connected to a spirometer. T-tests were performed to compare mean spirometric and Diskus™ PIFR/ IVC between groups. Stepwise regression analysis of Diskus™ PIFR versus spirometric PIFR, spirometric IVC, age, gender, condition, BMI, FEV1 and FVC was performed. The Diskus™ PIFR for the COPD and Neuromuscular Disease group was more than 10 L/min lower than the Healthy or Asthma groups (p < 0.05). The mean spirometric and Diskus™ IVC of the Healthy group was significantly (>0.75 L) higher than the mean for the other three groups (p < 0.05). Diskus™ PIFR was moderately correlated with spirometric PIFR and age (Adjusted R2 = 0.58, p < 0.0001). PIFR generated using a Diskus™ DPI is dependent on the underlying disease and age. A spirometric PIFR of less than 196 L/min should prompt further investigation into the suitability of a patient for a Diskus™ DPI, with possible consideration of alternate devices.
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Affiliation(s)
- Jansen N Seheult
- Department of Medicine Respiratory Research Division, RCSI-Beaumont Hospital, Beaumont Road, Dublin, Ireland
| | - Simon Costello
- School of Mathematics, Trinity College Dublin, Dublin, Ireland
| | - Kee Chun Tee
- Department of Medicine Respiratory Research Division, RCSI-Beaumont Hospital, Beaumont Road, Dublin, Ireland
| | - Tariq Bholah
- Department of Medicine Respiratory Research Division, RCSI-Beaumont Hospital, Beaumont Road, Dublin, Ireland
| | - Hasan Al Bannai
- Department of Medicine Respiratory Research Division, RCSI-Beaumont Hospital, Beaumont Road, Dublin, Ireland
| | - Imran Sulaiman
- Department of Medicine Respiratory Research Division, RCSI-Beaumont Hospital, Beaumont Road, Dublin, Ireland
| | - Richard W Costello
- Department of Medicine Respiratory Research Division, RCSI-Beaumont Hospital, Beaumont Road, Dublin, Ireland
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