Spacer devices for inhaled therapy: why use them, and how?

Environmental impact of inhalers for respiratory diseases: decreasing the carbon footprint while preserving patient-tailored treatment

Patients with asthma and Chronic Obstructive Respiratory Disease (COPD) rely on three main device classes for inhalation therapy: metered-dose inhalers (MDIs), dry powder inhalers (DPIs) and soft-mist inhalers (SMIs). The carbon footprint (CF) of these inhalers differs with MDIs having a higher impact than DPIs and SMIs due to the propellant in MDIs. However, the certified CF of specific MDI products may differ significantly. MDIs still represent an essential option for many patients. Consequently, novel approaches shall be considered to balance environmental goals with patient health and well-being while maintaining a diverse range of choices for patients and physicians.

Paediatric in vitro models showed significant variations in fluticasone proprionate output from valved holding chambers

AIM

We compared potential differences in drug delivery between different valved holding chambers (VHCs) used by asthma patients, with and without facemasks.

METHODS

An in vitro study design was created using a fluticasone propionate (FP) pressurised metered dose inhaler (pMDI) connected to a VHC. VHCs without facemasks and with sealed and unsealed facemasks were placed against face models that mimicked the features of a 1-year-old infant and a 4-year-old child. We analysed the amount of FP deposited on the filter in the face model after five breaths with a tidal volume of 75 mL.

RESULTS

Our measurements showed significant differences in the amounts of FP deposited on the filters, even without facemasks. The amount of FP delivered through the VHC and facemask combinations differed significantly, depending on the degree of the lack of facemask to face seal. All the tested VHCs showed significantly better drug output without a facemask.

CONCLUSION

The VHC and facemasks chosen had a considerable and significant impact on FP delivery. The facemask seal should be checked whenever a VHC facemask combination is used. Young children should be taught to use the VHC mouthpiece as early as possible to optimise FP delivery and achieve more effective asthma therapy.

An innovative corticosteroid/long-acting β2-agonist breath-triggered inhaler: facilitating lung delivery of fluticasone propionate/formoterol fumarate for the treatment of asthma

Introduction: Incorrect inhaler technique is one reason why the efficacies of inhaled asthma treatments in clinical trials and effectiveness in the real world differ. Inhaler technique is critical for drug delivery to the lungs; incorrect technique negatively impacts asthma control and long-term outcomes. Breath-triggered inhalers (BTIs) can simplify drug administration and are suitable for most patients, including those with reduced inspiratory flow. Until recently, no inhaled corticosteroid/long-acting β₂-agonist combination BTI was available in Europe. The flutiform® (fluticasone propionate/formoterol fumarate [FP/FORM]) k-haler® is the first combination BTI now approved in Europe for asthma maintenance treatment.Areas covered: We review studies examining the challenges posed to patients by different inhaler types and explore evidence demonstrating the clinical efficacy of FP/FORM administered via a pressurized metered-dose inhaler. We also review the pharmacokinetic/pharmacodynamic studies supporting FP/FORM k-haler use, and consider data showing high lung deposition with the device. Finally, we review patient experiences using the BTI, device characteristics, and health economic aspects.Expert opinion: Despite the availability of therapies, asthma control levels remain low, and there is a clear need for easy-to-use inhalers. Research to increase our understanding of critical errors with each inhaler and how to overcome them is important for improving care.Abbreviations: AUC_t: area under the plasma concentration-time curve from the time of dosing to the last measurable concentration; BDP: beclometasone dipropionate; BTI: breath-triggered inhaler; BUD: budesonide; CI: confidence interval; C_max: maximum observed plasma concentration; DPI: dry powder inhaler; FDC: fixed-dose combination; FEV₁: forced expiratory volume in 1 s; FORM: formoterol fumarate; FP: fluticasone propionate; HCP: health-care professional; ICS: inhaled corticosteroid; LABA: long-acting β₂-agonist; OR: odds ratio; PIL: patient information leaflet; pMDI: pressurized metered-dose inhaler; SAL: salmeterol xinafoate.

Inhalation technique practical skills and knowledge among physicians and nurses in two pediatric emergency settings

Introduction: Correct technique with a pressurized metered-dose inhaler (pMDI) equipped with a valved holding chamber (VHC) or spacer provides an important advantage for adequate control of asthma and virus-induced wheezing in young children. The aim of this study was to assess the ability and knowledge of physicians and nurses to use a pMDI with a masked VHC in two pediatric emergency units.Methods: Study design: Two-center observational study. Inhaler use technique was assessed in 50 physicians and 50 nurses using a child mannequin and a validated videotaped nine-step scoring method. The participants' knowledge was evaluated by a questionnaire.Results: The inhalation technique was perfectly mastered by 49% of the study participants and almost perfectly mastered by another 34% (mean score 8.3 ± 0.7; range 5-9). Nurses were more likely than doctors to demonstrate the technique perfectly (66% vs. 32%, p < 0.05). The two most common errors were forgetting to shake the pMDI between two consecutive puffs (38% of the participants) and putting the patient in an incorrect position (11%). About half of the participants reported that they checked each patient's inhalation technique at every opportunity and knew how to clean the VHC. A large majority did not employ a reliable method to determine the amount of medication remaining in pMDIs without a counter.Conclusion: Healthcare professionals' practical skills and knowledge on inhalation therapy were not completely mastered and could be improved with a mandatory training program.

In vitro drug delivery performance of five valved holding chambers with and without facemasks

BACKGROUND

Valved holding chambers (VHCs) are essential for efficient pulmonary delivery of inhaled medication in preschool children. The numerous devices in the market vary in material, aerodynamic characteristics, volume, valve properties, and mask design. Drug delivery is affected by the VHC characteristics as well as by the age and breathing pattern of the child.

METHODS

We measured the drug delivery efficacy of five VHCs widely available in the market, evaluated the effect of facemasks and tested the differences between manufacturing lots. A breathing simulator was used to mimic normal (respiratory rate [RR] 25/minute and tidal volume (V_T ) 200 mL) and obstructive (RR 50/minute and V_T 50 mL) breathing of infants and toddlers.

RESULTS

Salbutamol output was significantly higher with a normal breathing pattern compared to the obstructive breathing pattern in most VHCs. Without masks, the differences in the median in vitro filter doses of salbutamol were mainly from 2 to 10-fold among different types of VHCs. With masks, there was a greater than 20-fold difference in drug delivery capacity between the most and least effective devices. Most VHCs had a notable variation of performance between individual devices from different lots within the same brand.

CONCLUSIONS

There was an extreme variation in the salbutamol delivery performance among different types of VHCs for both normal and obstructive pediatric breathing patterns with and without masks. This magnitude of performance variability can have significant and unpredictable clinical implications.

Inhalation technique and asthma outcomes with different corticosteroid-containing inhaler devices

Objective: Inhaler devices must be used correctly to ensure the effectiveness of the asthma treatment. This study evaluated inhalation technique across different types of corticosteroid-containing inhaler devices as well as health outcomes in patients with asthma. Methods: In a cross-sectional study, we evaluated inhaler technique by observing patients' handling of the inhaler devices and using checklists for four inhaler types, namely Diskus (n = 52), pressure metered dose inhalers (pMDIs; n = 41), Turbuhaler (n = 36) and Twisthaler (n = 16). We also collected data on patients' characteristics, asthma therapy, exacerbations, medication adherence (8-item Morisky Medication Adherence Scale), asthma control (Asthma Control Test) and quality of life (Saint George Respiratory Questionnaire). Results: In total, we included 145 patients. The mean (SD) age of the patients was 54.5 (18.9) years and 57% were female. The majority of the patients (70%) made at least one error in their inhalation technique. Patients using Turbuhaler performed the highest number of elements correctly, followed by pMDIs, Twisthaler and Diskus. Patients with Diskus or Twisthaler had better adherence compared with patients using pMDIs or Turbuhaler. Patients using Twisthaler had better asthma outcomes than patients using the other device types. Conclusions: Most patients with asthma made mistakes when handling their inhaler devices, especially those using Diskus. However, in addition to the device type being used, patients' characteristics, asthma therapy and medication adherence also played an important role in achieving good health outcomes.

Valved holding chamber drug delivery is dependent on breathing pattern and device design

Small children with airway obstruction breathe with very low tidal volumes (V_T) and high respiratory rates (RRs). These extreme respiratory patterns affect drug delivery unpredictably through valved holding chambers (VHCs).

We compared in an in vitro study the effectiveness of two VHCs, one small (140 mL, Optichamber Diamond) and one large (350 mL, Babyhaler) without facemasks, to deliver salbutamol to filters positioned between the VHC mouthpieces and a breathing simulator. Different tidal volumes (from 30 mL to 200 mL) and RRs (25·min^-1 and 50·min^-1) were applied through a breathing simulator.

The amount of salbutamol delivered increased with increasing V_T in both VHCs for both RRs (ρ>0.87 and p<0.001 for both devices at both rates). The effect of RR was not as evident, but drug delivery tended to be higher at the higher rate. Drug delivery was significantly higher through the Optichamber Diamond as compared with the Babyhaler at every combination of RR and V_T up to a 12-fold difference.

We found marked differences in salbutamol delivery between the Babyhaler and Optichamber Diamond VHCs. The delivered dose of salbutamol increased with increasing V_T and RR with both VHCs but with differences related to valve dead spaces. Instead of considering all VHCs equal in clinical paediatric practice, each device should be tested in vitro with respiratory patterns relevant to small children with respiratory difficulties.

Children with respiratory problems are treated with inhaled drugs given via valved holding chambers (VHCs). Efficacy can vary up to 12-fold between devices. The effectiveness of VHCs should be tested in all age groups with different respiratory patterns.http://ow.ly/2Aca30mT2Pa

It takes a village - asthma networks utilized by parents when managing childhood asthma medications

Objective: We are yet to understand how widely parents seek asthma medication management information for their children, how they are used for health information, how parents engage with them and their influence on parent's decision-making. This study aimed to gauge the current level of asthma knowledge and skills of parents of children with asthma and gain insight into who and what influences their child's asthma medication management decisions. Method: Social network theory was used to map parents' asthma networks and identify the level of influence of each individual/resource nominated. Parents of children with asthma (aged 4-18 years) were interviewed, completed an asthma network map, questionnaires and an inhaler technique assessment. Results: Twenty-six parents participated and had significant gaps in asthma knowledge and inhaler technique skills. The asthma networks of participants ranged from two to ten individuals/resources, with an average number of five. The most commonly nominated individual/resource was general practitioners followed by family members and the internet. Professional connections represented 44% of individuals/resources in networks, personal connections 42% and impersonal connections 14%. When parents were asked about how influential individuals/resources were, professional connections represented 53% of parents influences, personal connections 36% and impersonal connections 11%. Conclusion: This study highlights the priority and co-influence of non-medical sources of information/support on parent's behaviors and decision-making with regards to their child's asthma medicine taking. In further understanding the complexities surrounding these connections and relationships, HCPs are better positioned to assist parents in addressing their needs and better supporting them in the management of their child's asthma.