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Mehta V, Sayedy N, Fogel J, Lam E, Upadrista P, Okoro B, Tahir H, Akella J. Pulmonologist Education of the Teach-to-Goal Inhaler Technique for Those With Asthma and COPD. Respir Care 2024; 69:975-981. [PMID: 38688545 PMCID: PMC11298224 DOI: 10.4187/respcare.11478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Inhaler education for patients with asthma and patients with COPD is typically provided by non-pulmonologists. We studied inhaler education by pulmonologists to determine changes in clinical outcomes and inhaler use. METHODS This was a retrospective study of 296 subjects diagnosed with asthma, COPD, or both that evaluated use of inhaler technique education and its impact on (1) inhaler/dosage change consisting of dosage change in the same class of inhaler and/or change in number of inhalers, (2) forced expiratory volume in one second/forced vital capacity (FEV1/FVC%), (3) disease symptom control, (4) out-patient visits, (5) urgent care visits (6) emergency department visits, and (7) hospital admissions. One group received inhaler technique education by a pulmonologist while the other group did not. RESULTS The pulmonologist inhaler technique-educated group had significantly decreased relative risk for inhaler/dosage increase (relative risk 0.57 [95% CI 0.34-0.96], P = .03) and significantly increased odds for symptom control (odds ratio 2.15 [95% CI 1.24-3.74], P = .01) at 1-y follow-up as compared to the no education group. No differences occurred for FEV1/FVC%, out-patient visits, urgent care visits, emergency department visits, and hospital admissions. CONCLUSIONS Pulmonologist education of inhaler technique for patients with asthma and patients with COPD was associated with decreased relative risk for inhaler/dosage increase and increased odds for symptom control. We recommend pulmonologists provide education of inhaler technique to patients with asthma and patients with COPD and not rely on non-pulmonologist education alone. Prospective research is needed to confirm the importance of proper inhaler techniques.
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Affiliation(s)
- Vaishali Mehta
- Division of Pulmonary Medicine and Critical Care, Department of Medicine, Nassau University Medical Center, East Meadow, New York
| | - Najia Sayedy
- Division of Pulmonary Medicine and Critical Care, Department of Medicine, Nassau University Medical Center, East Meadow, New York
| | - Joshua Fogel
- Department of Business Management, Brooklyn College, Brooklyn, New York
| | - Eric Lam
- Department of Medicine, Nassau University Medical Center, East Meadow, New York
| | - Pratap Upadrista
- Department of Medicine, Nassau University Medical Center, East Meadow, New York
| | - Bruno Okoro
- Department of Medicine, Nassau University Medical Center, East Meadow, New York
| | - Hira Tahir
- Department of Medicine, Nassau University Medical Center, East Meadow, New York
| | - Jagadish Akella
- Division of Pulmonary Medicine and Critical Care, Department of Medicine, Nassau University Medical Center, East Meadow, New York
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Erdoğan EG, Örsal Ö. The effect of web-designed education on medication adherence, asthma control and fatigue in patients with asthma: A randomized controlled trial. Int J Nurs Pract 2024:e13288. [PMID: 39031297 DOI: 10.1111/ijn.13288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 06/30/2024] [Accepted: 07/09/2024] [Indexed: 07/22/2024]
Abstract
AIMS This study aimed to determine the effect of web-designed education developed for asthma patients on drug adherence, asthma control and fatigue. METHODS This randomized controlled trial was conducted between August 2021 and January 2022 with 200 individuals suffering from poor asthma control who participated in web-designed education. After the intervention, the asthma patients were followed up for 6 weeks to measure Medication Adherence Report Scale (MARS), Chronic Obstructive Pulmonary Disease and Asthma Fatigue Scale (CAFS), Asthma Control Test (ACT) and Inhalation Devices Usage Techniques Knowledge Test (IDUSTKT). Data were analysed in the Statistical Package for the Social Sciences program using the Chi-square test, Independent t-test, Man-Whitney U test, Wilcoxon test, Paired t-test, Greenhouse-Geisser (F) test and Linear regression. RESULTS The web-designed education had a statistically significant effect on the total scores of CAFS, ACT and IDUSTKT for individuals with asthma (p < 0.001). This intervention decreased fatigue levels, improved asthma control and enhanced knowledge of inhalation device usage techniques. Although there was an improvement in medication adherence, this difference was not statistically significant. CONCLUSION These results suggest that web-based educational programs can be an effective tool in asthma management and may improve patients' quality of life. Future research should examine the long-term effects of such educational programs and their effectiveness across different demographic groups in more detail.
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Affiliation(s)
- Eylül Gülnur Erdoğan
- Department of Public Health Nursing, Faculty of Health Science, Bilecik Seyh Edebali University, Bilecik, Turkey
| | - Özlem Örsal
- Department of Public Health Nursing, Faculty of Health Science, Eskisehir Osmangazi University, Eskisehir, Turkey
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Bhattarai A, Shakya R, Bista D. Impact of Pharmacist-Led Intervention on Adherence to Inhalers, Inhalation Technique, and Disease Control Among Asthma/COPD Patients in a Resource Limited Center: An Interventional Study. Patient Prefer Adherence 2024; 18:1395-1408. [PMID: 38974680 PMCID: PMC11226859 DOI: 10.2147/ppa.s460810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 06/19/2024] [Indexed: 07/09/2024] Open
Abstract
Background Asthma and Chronic obstructive pulmonary disease (COPD) are chronic respiratory conditions characterized by airflow obstruction and respiratory symptoms. Adherence to prescribed inhaler therapy and correct inhalation technique are essential for effective disease management and optimal disease control. However, non-adherence and incorrect inhalation technique are common challenges faced by patients with asthma and COPD, leading to suboptimal treatment outcomes and increased healthcare burden. Purpose To study the impact of a pharmacist-led intervention on inhaler adherence, inhalation technique, and disease control among patients with asthma and COPD. Patients and Methods A pre-post interventional design assessed the effects of pharmacist-led intervention on inhaler adherence, inhalation techniques, and disease control in asthma and COPD patients at Dhulikhel Hospital in Nepal. Inclusion criteria: adult patient clinically diagnosed with asthma or COPD patients of all genders. The intervention comprised counseling patients with aids like videos, and informational leaflets. Impact was measured using checklist method for inhalation technique, the Test of Adherence to Inhaler (TAI) questionnaire for adherence to inhaler, and "Asthma Control Test (ACT)" or "COPD Assessment Test (CAT)" for disease control. Results The pharmacist-led intervention significantly increased adherence to inhalers, evidenced by a notable rise in the proportion of patients with good adherence (P<0.001). Sporadic, deliberate, and unwitting noncompliance pattern also improved significantly after the intervention (P<0.001, P<0.001 and P=0.001). Inhalation technique exhibited substantial improvement after intervention (P<0.001). The analysis indicated significant moderate negative correlations between "TIA" and "CAT" [ρ=-0.31; P=0.01], and between "inhalation technique score" and "CAT score" [ρ=-0.31; P=0.01] suggesting that as adherence to inhaler usage and inhalation technique improve, CAT scores tend to decrease, indicating reduced disease impact on the patient. Conclusion This study shows the potential efficacy of pharmacist-led intervention in enhancing adherence to inhaler, inhalation technique, and disease control in respiratory conditions such as asthma and COPD.
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Affiliation(s)
- Aashish Bhattarai
- Department of Pharmacy, School of Science, Kathmandu University, Dhulikhel, Nepal
| | - Rajani Shakya
- Department of Pharmacy, School of Science, Kathmandu University, Dhulikhel, Nepal
| | - Durga Bista
- Department of Pharmacy, School of Science, Kathmandu University, Dhulikhel, Nepal
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Abbas MA, Tariq O, Bin Zafar S, Jamil MI, Hamid K, Iqbal A, Ahmed A, Naeem I. Improvement in Inhaler Techniques After Training and Counseling in Patients With Chronic Obstructive Pulmonary Disease or Asthma. Cureus 2024; 16:e62255. [PMID: 39006564 PMCID: PMC11245178 DOI: 10.7759/cureus.62255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2024] [Indexed: 07/16/2024] Open
Abstract
Background Chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD) and asthma significantly impair quality of life and impose a substantial burden on healthcare systems. Proper inhalation technique is important for effective management of these diseases, yet remains poorly performed by many patients. This study evaluated the impact of structured counseling and training sessions on inhaler use among patients with COPD and asthma, aiming to enhance technique correctness and disease control. Methodology This cross-sectional study analyzed 150 patients with asthma and COPD who fulfilled the inclusion criteria for inhalation techniques. Patients were counseled regarding the proper seven-step inhalation technique for each inhaler type [metered-dose inhaler (MDI), MDI with spacer, and dry powder inhaler (DPI)] through practical demonstration at baseline visits. Correct use of inhalers was assessed by a predefined checklist for each inhaler device at the baseline visit and after three months. The correctness of the inhalation technique was evaluated by scoring each of the seven steps. The disease control assessment was done using the COPD assessment test (CAT) and asthma control test (ACT) at the baseline visit and after three months. Results In this study of 150 patients, there were 97 (64.7%) males and 53 (35.3%) females. In total, 67 (44.7%) were diagnosed with asthma and 83 (55.3%) with COPD. The mean age was 45.33 ± 12.62 years. Post-counseling improvements in inhaler technique were marked, with MDI users enhancing their technique score from an average of 4.4 to 6.1, MDI with spacer from 4.56 to 6.26, and DPI from 4.92 to 6.24 (p < 0.001 for all). Disease control also showed significant gains; CAT scores decreased for MDI users from 23.4 to 20.5, MDI with spacer from 23.92 to 20.96, and DPI from 24.89 to 21.96. Concurrently, ACT scores increased for MDI users from 16.4 to 18.0 (p = 0.002), MDI with spacer from 17.29 to 19.04, and DPI from 16.42 to 18.37 (p < 0.001 for both), reflecting substantive advances in managing COPD and asthma symptoms. Furthermore, patients with primary education exhibited a significant boost in technique mastery post-counseling (p < 0.001), underscoring the potential of well-crafted counseling to transcend educational barriers in promoting effective inhaler use. Conclusions Post-counseling, inhaler technique improved significantly across all types, with MDI with spacer users demonstrating the most progress. Technique scores increased notably (p < 0.001), and disease control scores for COPD and asthma, measured by CAT and ACT, also showed significant improvements (p < 0.001). Remarkably, primary education level participants exhibited substantial technique gains post-intervention, emphasizing the effectiveness of counseling irrespective of initial educational status in enhancing inhaler use and disease management.
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Affiliation(s)
| | - Owais Tariq
- Gastroenterology, Lahore General Hospital, Lahore, PAK
- Medicine, Milvik Bima Pakistan, Lahore, PAK
| | - Saad Bin Zafar
- Internal Medicine, King Edward Medical University, Lahore, PAK
| | | | - Khizra Hamid
- Internal Medicine, Evercare Hospital Lahore, Lahore, PAK
| | - Aqsa Iqbal
- Pulmonology, Lahore General Hospital, Lahore, PAK
| | - Adeel Ahmed
- Medicine, Lahore General Hospital, Lahore, PAK
| | - Iqra Naeem
- Psychiatry and Behavioral Sciences, Lahore General Hospital, Lahore, PAK
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Tibble H, Sheikh A, Tsanas A. Estimating medication adherence from Electronic Health Records: comparing methods for mining and processing asthma treatment prescriptions. BMC Med Res Methodol 2023; 23:167. [PMID: 37438684 PMCID: PMC10337150 DOI: 10.1186/s12874-023-01935-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 04/26/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND Medication adherence is usually defined as the extent of the agreement between the medication regimen agreed to by patients with their healthcare provider and the real-world implementation. Proactive identification of those with poor adherence may be useful to identify those with poor disease control and offers the opportunity for ameliorative action. Adherence can be estimated from Electronic Health Records (EHRs) by comparing medication dispensing records to the prescribed regimen. Several methods have been developed in the literature to infer adherence from EHRs, however there is no clear consensus on what should be considered the gold standard in each use case. Our objectives were to critically evaluate different measures of medication adherence in a large longitudinal Scottish EHR dataset. We used asthma, a chronic condition with high prevalence and high rates of non-adherence, as a case study. METHODS Over 1.6 million asthma controllers were prescribed for our cohort of 91,334 individuals, between January 2009 and March 2017. Eight adherence measures were calculated, and different approaches to estimating the amount of medication supply available at any time were compared. RESULTS Estimates from different measures of adherence varied substantially. Three of the main drivers of the differences between adherence measures were the expected duration (if taken as in accordance with the dose directions), whether there was overlapping supply between prescriptions, and whether treatment had been discontinued. However, there are also wider, study-related, factors which are crucial to consider when comparing the adherence measures. CONCLUSIONS We evaluated the limitations of various medication adherence measures, and highlight key considerations about the underlying data, condition, and population to guide researchers choose appropriate adherence measures. This guidance will enable researchers to make more informed decisions about the methodology they employ, ensuring that adherence is captured in the most meaningful way for their particular application needs.
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Affiliation(s)
- Holly Tibble
- Usher Institute, University of Edinburgh, Edinburgh, Scotland.
- Asthma UK Centre for Applied Research, University of Edinburgh, Edinburgh, Scotland.
| | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Asthma UK Centre for Applied Research, University of Edinburgh, Edinburgh, Scotland
| | - Athanasios Tsanas
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
- Asthma UK Centre for Applied Research, University of Edinburgh, Edinburgh, Scotland
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Papadopoulos NG, Mathioudakis AG, Custovic A, Deschildre A, Phipatanakul W, Wong G, Xepapadaki P. Current and Optimal Practices in Childhood Asthma Monitoring Among Multiple International Stakeholders. JAMA Netw Open 2023; 6:e2313120. [PMID: 37171821 PMCID: PMC10182430 DOI: 10.1001/jamanetworkopen.2023.13120] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
Importance Childhood asthma control largely depends on rigorous and regular monitoring. Although various clinical parameters, biomarkers, and patient-reported outcomes are helpful for monitoring purposes, there is no consensus on the minimum and/or optimal set of parameters and their relative priority. Objective To assess actual and perceived optimal childhood asthma monitoring practices used globally. Design, Setting, and Participants This international, multistakeholder survey study surveyed health care professionals and clinical academics with a professional interest in and exposure to childhood asthma between April 12 and September 3, 2021, to test for differences between the frequency that different techniques are actually used in practice vs optimal practice, between-group differences, and differences across medical settings and country economies. Main Outcomes and Measures Outcomes were frequency of duration of asthma monitoring visits as well as actual and perceived optimal use and importance of monitoring tools and domains. Results A total of 1319 participants with expertise in childhood asthma from 88 countries completed the survey. Participants included 1228 health care professionals with a balanced distribution across different care settings (305 [22.7%] primary care, 401 [29.9%] secondary, and 522 [38.9%] tertiary care) and 91 researchers. Children with mild to moderate asthma attended regular monitoring visits at a median (IQR) of 5.0 (2.5-8.0) months, with visits lasting a median (IQR) of 25 (15-25) minutes, whereas severe asthma required more frequent visits (median [IQR], 2.5 [1.0-2.5] months; median [IQR] duration, 25 [25-35] minutes). Monitoring of symptoms and control, adherence, comorbidities, lung function, medication adverse effects, and allergy were considered to be very high or high priority by more than 75% of the respondents. Different patterns emerged when assessing differences between actual and perceived optimal use of monitoring tools. For some tools, current and optimal practices did not differ much (eg, spirometry), whereas in others, there was considerable space for improvement (eg, standardized control and adherence tests). The largest gap was observed for between-visit monitoring with electronic trackers, apps, and smart devices. Differences across country economies, care settings, and medical specialties were modest. Conclusions and Relevance These survey results suggest that pediatric asthma monitoring is performed generally homogeneously worldwide, in most cases following evidence-based standards. Wider use of standardized instruments and the intensification of continuous between-visit monitoring, supported by electronic devices, is needed for further improvement of disease outcomes. The results of this survey, in conjunction with the available evidence base, can inform recommendations toward further optimization.
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Affiliation(s)
- Nikolaos G Papadopoulos
- Allergy Department, Second Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty or Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
| | - Alexander G Mathioudakis
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty or Biology, Medicine, and Health, The University of Manchester, Manchester, United Kingdom
- North West Lung Centre, Wythenshawe Hospital, Manchester University National Health Service Foundation Trust, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Antoine Deschildre
- Center for Infection and Immunity of Lille, Institut Pasteur de Lille, Institut National de la Santé et de la Recherche Médicale, Centre National de la Recherche Scientifique, Université de Lille, Lille, France
| | - Wanda Phipatanakul
- Department of Allergy and Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Gary Wong
- Department of Pediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Paraskevi Xepapadaki
- Allergy Department, Second Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
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Hagmeyer L, van Koningsbruggen-Rietschel S, Matthes S, Rietschel E, Randerath W. From the infant to the geriatric patient-Strategies for inhalation therapy in asthma and chronic obstructive pulmonary disease. THE CLINICAL RESPIRATORY JOURNAL 2023. [PMID: 37054701 DOI: 10.1111/crj.13610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 02/26/2023] [Accepted: 03/24/2023] [Indexed: 04/15/2023]
Abstract
Inhalation therapy represents the standard of care in children, adolescents as well as in young, middle-aged and geriatric adults with asthma or chronic obstructive pulmonary disease. However, there are only few recommendations for the choice of inhalation devices, which consider both, age-specific limitations in young and geriatric patients. Transition concepts are lacking. In this narrative review, the available device technologies and the evidence for age-specific problems are discussed. Pressurized metered-dose inhalers may be favoured in patients who fulfill all cognitive, coordinative and manual power requirements. Breath-actuated metered-dose inhalers, soft-mist inhalers or the use of add-on devices such as spacers, face masks and valved holding chambers may be suitable for patients with mild to moderate impairments of these variables. In these cases, available resources of personal assistance by educated family members or caregivers should be used to allow metered-dose inhaler therapy. Dry powder inhalers may be reserved for patients with a sufficient peak inspiratory flow and good cognitive and manual abilities. Nebulizers may be indicated in persons who are either unwilling or unable to use handheld inhaler devices. After initiation of a specific inhalation therapy, close monitoring is essential to reduce handling mistakes. An algorithm is developed that considers age and relevant comorbidities to support the decision-making process for the choice of an inhaler device.
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Affiliation(s)
- Lars Hagmeyer
- Institute of Pneumology at the University of Cologne, Solingen, Germany
- Clinic for Pneumology and Allergology, Center of Sleep Medicine and Respiratory Care, Bethanien Hospital Solingen, Solingen, Germany
- Center for Rare Diseases, Faculty of Medicine, University of Cologne, Children's Hospital, Cologne, Germany
| | - Silke van Koningsbruggen-Rietschel
- Faculty of Medicine, University of Cologne, Pediatric Pulmonology, Allergology and Cystic Fibrosis Center, Children's Hospital, Cologne, Germany
- Center for Rare Diseases, Faculty of Medicine, University of Cologne, Children's Hospital, Cologne, Germany
| | - Sandhya Matthes
- Clinic for Pneumology and Allergology, Center of Sleep Medicine and Respiratory Care, Bethanien Hospital Solingen, Solingen, Germany
| | - Ernst Rietschel
- Faculty of Medicine, University of Cologne, Pediatric Pulmonology, Allergology and Cystic Fibrosis Center, Children's Hospital, Cologne, Germany
- Center for Rare Diseases, Faculty of Medicine, University of Cologne, Children's Hospital, Cologne, Germany
| | - Winfried Randerath
- Institute of Pneumology at the University of Cologne, Solingen, Germany
- Clinic for Pneumology and Allergology, Center of Sleep Medicine and Respiratory Care, Bethanien Hospital Solingen, Solingen, Germany
- Center for Rare Diseases, Faculty of Medicine, University of Cologne, Children's Hospital, Cologne, Germany
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O'Connor A, Sharrad K, King C, Carson-Chahhoud K, Carson-Chahhoud AP. An Augmented Reality Technology to Provide Demonstrative Inhaler Technique Education for Patients With Asthma: Interview Study Among Patients, Health Professionals, and Key Community Stakeholders. JMIR Form Res 2023; 7:e34958. [PMID: 36862496 PMCID: PMC10020912 DOI: 10.2196/34958] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 06/02/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Many people with asthma use incorrect inhaler technique, resulting in suboptimal disease management and increased health service use. Novel ways of delivering appropriate instructions are needed. OBJECTIVE This study explored stakeholder perspectives on the potential use of augmented reality (AR) technology to improve asthma inhaler technique education. METHODS On the basis of existing evidence and resources, an information poster displaying the images of 22 asthma inhaler devices was developed. Using AR technology via a free smartphone app, the poster launched video demonstrations of correct inhaler technique for each device. In total, 21 semistructured, one-on-one interviews with health professionals, people with asthma, and key community stakeholders were conducted, and data were analyzed thematically using the Triandis model of interpersonal behavior. RESULTS A total of 21 participants were recruited into the study, and data saturation was achieved. People with asthma were confident with inhaler technique (mean score 9.17, SD 1.33, out of 10). However, health professionals and key community stakeholders identified that this perception was misguided (mean 7.25, SD 1.39, and mean 4.5, SD 0.71, for health professionals and key community stakeholders, respectively) and facilitates persistent incorrect inhaler use and suboptimal disease management. Delivering inhaler technique education using AR was favored by all participants (21/21, 100%), particularly around ease of use, with the ability to visually display inhaler techniques for each device. There was a strongly held belief that the technology has the capacity for improving inhaler technique across all participant groups (mean 9.25, SD 0.89, for participants; mean 9.83, SD 0.41, for health professionals; and mean 9.5, SD 0.71, for key community stakeholders). However, all participants (21/21, 100%) identified some barriers, particularly regarding access and appropriateness of AR for older people. CONCLUSIONS AR technology may be a novel means to address poor inhaler technique among certain cohorts of patients with asthma and serve as a prompt for health professionals to initiate review of inhaler devices. A randomized controlled trial design is needed to evaluate the efficacy of this technology for use in the clinical care setting.
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Affiliation(s)
- Antonia O'Connor
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia.,Department of Respiratory and Sleep Medicine, Women's and Children's Hospital, Adelaide, Australia
| | - Kelsey Sharrad
- Translational Medicine and Technology Group, Australian Centre for Precision Health, University of South Australia, Adelaide, Australia
| | - Charmaine King
- Translational Medicine and Technology Group, Australian Centre for Precision Health, University of South Australia, Adelaide, Australia
| | - Kristin Carson-Chahhoud
- Adelaide Medical School, The University of Adelaide, Adelaide, Australia.,Translational Medicine and Technology Group, Australian Centre for Precision Health, University of South Australia, Adelaide, Australia.,Cancer Research Institute, University of South Australia, Adelaide, Australia.,South Australian Health and Medical Research Institute, Adelaide, Australia
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Optimal follow-up period after switching to another inhaled corticosteroid/long-acting β2 agonist in patients with asthma: A retrospective study using Japanese administrative claims data. PLoS One 2022; 17:e0276001. [PMID: 36227895 PMCID: PMC9560144 DOI: 10.1371/journal.pone.0276001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022] Open
Abstract
Switching inhalation devices is a reasonable option if problems with control, adherence, or inhalation technique occur in patients with asthma treated with inhaled corticosteroid (ICS)/long-acting β2 agonist (LABA). However, evidence to determine the extent to which the carefully monitored period persists after switching is insufficient. In this study, we aimed to investigate the duration of the carefully monitored period after switching to another ICS/LABA. This retrospective study used claims data from Japanese health insurance associations from May 2014 to April 2019. A total of 1,951 patients who switched to another ICS/LABA during the study period were selected for analysis. The relative risk of the first exacerbation after switching was calculated for each four-week interval after the switch compared with that before the switch in a self-controlled case series design. We further assessed patient background associated with exacerbations during the follow-up period. In the primary analysis, the risk of asthma exacerbation compared to the control period was derived from a conditional logistic regression model, which showed a significant decrease immediately after the switch (1 to 4 weeks, Odds ratio [OR] 0.37, 95% confidence interval [CI] 0.26–0.54). Subsequently, the risk increased again and was not significantly different from the control period until week 32 (OR 0.55, 95% CI 0.29–1.04). In a sensitivity analysis among patients with a history of exacerbations, up to week 20 was the period of no continuous risk reduction (OR 0.84, 95% CI 0.41–1.70). In the secondary analysis, chronic rhinosinusitis, sleep disorders, and a history of asthma exacerbation were significantly associated with asthma exacerbation. The incidence of exacerbation remained high for approximately 4 to 7 months after patients with asthma switched to another ICS/LABA. Therefore, these patients should be carefully monitored for at least 4 to 7 months and should be re-assessed at an earlier point in time, if necessary.
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Effectiveness of an Educational Intervention on Inhaler Technique Proficiency in Chronic Obstructive Pulmonary Disease: A Single-Center Quality Improvement Study. JOURNAL OF RESPIRATION 2022. [DOI: 10.3390/jor2030012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Albeit inhalation therapy is the cornerstone in chronic obstructive pulmonary disease (COPD) treatment, inhaler technique is rarely evaluated, and training materials are often insufficient. In this single-center study, we aimed to evaluate the effectiveness of a teaching session complemented by a flyer on inhaler technique in COPD patients and to evaluate the perceived quality of the flyer. A total of 30 participants with stable COPD who had never used a soft mist inhaler before (Respimat®, Boehringer Ingelheim) received a brief teaching session on proper inhaler technique complemented by a flyer (visit 1). The teaching intervention was completed by a pulmonologist. Epidemiological and clinical characteristics of COPD were collected by a questionnaire, and the ability to properly handle the inhaler was assessed. After 14 days, inhaler handling was re-evaluated, and patients were asked to rate the flyer (visit 2). After the initial training, proper inhaler handling was achieved in 80.0% of patients. Inhaler proficiency was maintained after 14 days (83.0% of the patients used the Respimat® correctly, p-value > 0.99). The flyer was considered at least good by 27 patients (90.0%). This study indicated that the administration of an educational intervention resulted in persistent good competence in inhaler technique at a 14-day follow-up.
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McCrossan P, Mallon O, Shields MD, Russell C, Kennedy L, O'Donoghue D. How we teach children with asthma to use their inhaler: a scoping review. Ital J Pediatr 2022; 48:52. [PMID: 35365200 PMCID: PMC8972732 DOI: 10.1186/s13052-022-01237-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 02/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND One reason that asthma remains poorly controlled in children is poor inhaler technique. Guidelines recommend checking inhaler technique at each clinical visit. However, they do not specify how best to train children to mastery of correct inhaler technique. Many children are simply shown how to use inhalers which results in less than 50% with correct inhaler technique. The aim of this scoping review is to explore published literature on teaching methods used to train children to master correct inhaler technique. METHODS We searched (from inception onwards): Medline, Embase, Scopus, Web of Science, CINAHL and the Cochrane library. We included quantitative studies, (e.g. randomised controlled trials, cohort studies and case-control studies), published from 1956 to present, on teaching inhaler technique to children with asthma. Data was extracted onto a data charting table to create a descriptive summary of the results. Data was then synthesised with descriptive statistics and visual mapping. RESULTS Thirty-three papers were identified for full text analysis. Educational interventions were found to be taking place in a variety of clinical areas and by a range of healthcare professional disciplines. 'Brief-Instruction' and 'Teach-Back' were identified as two primary methods of providing inhaler technique training in the majority of papers. Secondary themes identified were; use of written instruction, physical demonstration, video demonstrations and/or use of inhaler devices to augment inhaler technique training. CONCLUSION There are a variety of means by which inhaler technique has been taught to children. These methods are likely applicable to all inhaler types and often involve some form of physical demonstration. Children of all ages can be trained to use their inhaler correctly and by a range of healthcare professionals. We have not analysed the effectiveness of these different interventions, but have described what has been trialled before in an attempt to focus our attentions on what may potentially work best. The majority of these methods can be dichotomised to either 'Brief-Intervention' or 'Teach-Back'. Based on our analysis of this scoping review, we consider the following as areas for future research; how many times does a given intervention have to be done in order to have the desired effect? For what duration does the intervention need to continue to have a long-lasting effect? And, what is the best outcome measure for inhaler technique?. TRIAL REGISTRATION Systematic review registration: Open Science Framework (osf.io/n7kcw).
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Affiliation(s)
- Patrick McCrossan
- Department of Paediatric Respiratory Medicine, Royal Belfast Hospital for Sick Children, Belfast, UK.
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast , Belfast, UK.
| | - Orla Mallon
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast , Belfast, UK
| | - Michael D Shields
- Department of Paediatric Respiratory Medicine, Royal Belfast Hospital for Sick Children, Belfast, UK
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast , Belfast, UK
| | - Catherine Russell
- Department of Paediatric Respiratory Medicine, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Lesley Kennedy
- Department of Paediatric Respiratory Medicine, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Dara O'Donoghue
- Department of Paediatric Respiratory Medicine, Royal Belfast Hospital for Sick Children, Belfast, UK
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast , Belfast, UK
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12
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How to Choose the Right Inhaler Using a Patient-Centric Approach? Adv Ther 2022; 39:1149-1163. [PMID: 35080761 PMCID: PMC8790222 DOI: 10.1007/s12325-021-02034-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022]
Abstract
There are many different inhaler devices and medications on the market for the treatment of asthma and chronic obstructive pulmonary disease, with over 230 drug-delivery system combinations available. However, despite the abundance of effective treatment options, the achieved disease control in clinical practice often remains unsatisfactory. In this context, a key determining factor is the match or mismatch of an inhalation device with the characteristics or needs of an individual patient. Indeed, to date, no ideal device exists that fits all patients, and a personalized approach needs to be considered. Several useful choice-guiding algorithms have been developed in the recent years to improve inhaler–patient matching, but a comprehensive tool that translates the multifactorial complexity of inhalation therapy into a user-friendly algorithm is still lacking. To address this, a multidisciplinary expert panel has developed an evidence-based practical treatment tool that allows a straightforward way of choosing the right inhaler for each patient.
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13
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Sánchez-Nieto JM, Bernabeu-Mora R, Fernández-Muñoz I, Carrillo-Alcaraz A, Alcántara-Fructuoso J, Fernández-Alvarez J, Vera-Olmos JC, Martínez-Ferre MJ, Olea MGV, Valenciano MJC, Martínez DS. Effectiveness of individualized inhaler technique training on low adherence (LowAd) in ambulatory patients with COPD and asthma. NPJ Prim Care Respir Med 2022; 32:1. [PMID: 35013343 PMCID: PMC8748930 DOI: 10.1038/s41533-021-00262-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 11/12/2021] [Indexed: 11/09/2022] Open
Abstract
To analyze whether there is improvement in adherence to inhaled treatment in patients with COPD and asthma after an educational intervention based on the teach-to-goal method. This is a prospective, non-randomized, single-group study, with intervention and before-after evaluation. The study population included 120 patients (67 females and 53 males) diagnosed with asthma (70.8%) and COPD (29.1%). The level of adherence (low and optimal) and the noncompliance behavior pattern (erratic, deliberate and unwitting) were determined by the Test of the adherence to Inhalers (TAI). This questionnaire allows you to determine the level of adherence and the types of noncompliance. Low Adherence (LowAd) was defined as a score less than 49 points. All patients received individualized educational inhaler technique intervention (IEITI). Before the IEITI, 67.5% of the patients had LowAd. Following IEITI, on week 24, LowAd was 55% (p = 0.024). Each patient can present one or more types of noncompliance. The most frequent type was forgetting to use the inhaler (erratic), 65.8%. The other types were deliberate: 43.3%, and unwitting: 57.5%. All of them had decreased on the final visit: 51.7% (p = 0.009), 25.8% (p = 0.002), 39.2% (p = 0.002). There were no significant differences in adherence between asthma and COPD patients at the start of the study. The only predicting factor of LowAd was the female gender. An individualized educational intervention, in ambulatory patients with COPD and asthma, in real-world clinical practice conditions, improves adherence to the inhaled treatment.
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Affiliation(s)
- Juan Miguel Sánchez-Nieto
- Division of Pneumology, Morales Meseguer General University Hospital, 30008, Murcia, Spain.,Institute for Bio-health Research of Murcia (IMIB-Arrixaca), El Palmar, 30120, Murcia, Spain.,Department of Internal Medicine, University of Murcia, El Palmar, 30120, Murcia, Spain
| | - Roberto Bernabeu-Mora
- Division of Pneumology, Morales Meseguer General University Hospital, 30008, Murcia, Spain. .,Institute for Bio-health Research of Murcia (IMIB-Arrixaca), El Palmar, 30120, Murcia, Spain. .,Department of Internal Medicine, University of Murcia, El Palmar, 30120, Murcia, Spain.
| | - Irene Fernández-Muñoz
- Division of Pneumology, Morales Meseguer General University Hospital, 30008, Murcia, Spain
| | - Andrés Carrillo-Alcaraz
- Division of Intensive Care Unit, Morales Meseguer General University Hospital, 30008, Murcia, Spain
| | | | | | - Juan Carlos Vera-Olmos
- Division of Pneumology, Morales Meseguer General University Hospital, 30008, Murcia, Spain
| | | | | | | | - Diego Salmerón Martínez
- Institute for Bio-health Research of Murcia (IMIB-Arrixaca), El Palmar, 30120, Murcia, Spain.,Department of Health and Social Sciences, Murcia University, Murcia, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
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14
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Alwashmi MF, Mugford G, Vokey B, Abu-Ashour W, Hawboldt J. Effectiveness of the BreatheSuite Device in Assessing the Technique of Metered-Dose Inhalers: Validation Study. JMIR BIOMEDICAL ENGINEERING 2021; 6:e26556. [PMID: 38907373 PMCID: PMC11041462 DOI: 10.2196/26556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/11/2021] [Accepted: 10/03/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The majority of medications used in treating asthma and chronic obstructive pulmonary disease (COPD) are taken through metered-dose inhalers (MDIs). Studies have reported that most patients demonstrate poor inhaler technique, which has resulted in poor disease control. Digital Health applications have the potential to improve the technique and adherence of inhaled medications. OBJECTIVE This study aimed to validate the effectiveness of the BreatheSuite MDI device in assessing the technique of taking a dose via an MDI. METHODS The study was a validation study. Thirty participants who self-reported a diagnosis of asthma or COPD were recruited from community pharmacies in Newfoundland and Labrador, Canada. Participants used a BreatheSuite MDI device attached to a placebo MDI and resembled taking 3 doses. Pharmacists used a scoring sheet to evaluate the technique of using the MDI. An independent researcher compared the results of the pharmacist's scoring sheet with the results of the BreatheSuite device. RESULTS This study found that the BreatheSuite MDI can objectively detect several errors in the MDI technique. The data recorded by the BreatheSuite MDI device showed that all participants performed at least one error in using the MDI. The BreatheSuite device captured approximately 40% (143/360) more errors compared to observation alone. The distribution of participants who performed errors in MDI steps as recorded by BreatheSuite compared to errors reported by observation alone were as follows: shaking before actuation, 33.3% (30/90) versus 25.5% (23/90); upright orientation of the inhaler during actuation, 66.7% (60/90) versus 18.87% (17/90); coordination (actuating after the start of inhalation), 76.6% (69/90) versus 35.5% (32/90); and duration of inspiration, 96.7% (87/90) versus 34.4% (31/90). CONCLUSIONS The BreatheSuite MDI can objectively detect several errors in the MDI technique, which were missed by observation alone. It has the potential to enhance treatment outcomes among patients with chronic lung diseases.
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Felix SN, Agondi RC, Aun MV, Olivo CR, de Almeida FM, Amorim TS, Cezario JC, Giavina-Bianchi P, Tiberio IDFLC, de Martins MDA, Romanholo BMS. Clinical, functional and inflammatory evaluation in asthmatic patients after a simple short-term educational program: a randomized trial. Sci Rep 2021; 11:18267. [PMID: 34521963 PMCID: PMC8440547 DOI: 10.1038/s41598-021-97846-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/10/2021] [Indexed: 02/08/2023] Open
Abstract
This study aimed to evaluate the clinical evolution, functional parameters and inflammatory activity of asthma in patients who submitted to an educational intervention. 58 adult patients over 18 years of age with partly controlled and uncontrolled asthma were randomized into an intervention group (IG) (N = 32) and a control group (CG) (N = 26) and evaluated for 12 weeks. The Asthma Control Test (ACT), Asthma Control Questionnaire (ACQ), Asthma Quality Life Questionnaire (AQLQ) and Beck Depression Inventory (BDI) questionnaires were applied. Spirometry, exhaled nitric oxide (NO), exhaled breath condensate (EBC) and induced sputum (IS), measurement of the peak flow and symptoms were performed. The IG patients received an educational activity for 30 min applied by a nurse. Statistical analysis: analysis of variance with repeated intragroup measures. IG presented a decreased number of eosinophils in IS and IL-17A in EBC, an increase in the percentage of FEV1 before and after bronchodilator and an improvement in quality of life compared to the CG. There was an improvement in depression levels and a decrease in IL-4 and IL-5 in the IS and in the EBC in both groups. Our results suggest that an educational intervention can bring benefits concerning the control of inflammation, lung function alterations, quality of life and levels of depression in asthmatic patients. Registration: ClinicalTrials.gov; NCT03655392.
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Affiliation(s)
- Soraia Nogueira Felix
- Instituto de Assistência Médica Ao Servidor Público Estadual (IAMSPE), Sao Paulo, SP, Brazil.
| | - Rosana Câmara Agondi
- Serviço de Imunologia Clínica e Alergia, HCFMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Marcelo Vivolo Aun
- Serviço de Imunologia Clínica e Alergia, HCFMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | - Clarice Rosa Olivo
- Instituto de Assistência Médica Ao Servidor Público Estadual (IAMSPE), Sao Paulo, SP, Brazil
- Universidade Cidade de Sao Paulo (UNICID), Sao Paulo, SP, Brazil
- Laboratório de Terapêutica Experimental (LIM-20), Faculdade de Medicina da USP (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Francine Maria de Almeida
- Laboratório de Terapêutica Experimental (LIM-20), Faculdade de Medicina da USP (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | | | | | - Pedro Giavina-Bianchi
- Serviço de Imunologia Clínica e Alergia, HCFMUSP, Universidade de São Paulo, Sao Paulo, SP, Brazil
| | | | - Milton de Arruda de Martins
- Laboratório de Terapêutica Experimental (LIM-20), Faculdade de Medicina da USP (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Beatriz Mangueira Saraiva Romanholo
- Instituto de Assistência Médica Ao Servidor Público Estadual (IAMSPE), Sao Paulo, SP, Brazil.
- Universidade Cidade de Sao Paulo (UNICID), Sao Paulo, SP, Brazil.
- Laboratório de Terapêutica Experimental (LIM-20), Faculdade de Medicina da USP (FMUSP), Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
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16
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Spencer S, Hamer O, Berger E, Booth A, Irving GJ, Owen M, Relph N, Usmani O, Kelly C. Interventions to improve inhaler technique for adults with chronic obstructive pulmonary disease. Hippokratia 2021. [DOI: 10.1002/14651858.cd014956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Sally Spencer
- Health Research Institute, Faculty of Health, Social Care & Medicine; Edge Hill University; Ormskirk UK
| | - Oliver Hamer
- Respiratory Research Centre, Faculty of Health, Social Care & Medicine; Edge Hill University; Ormskirk UK
| | | | | | - Greg J Irving
- Department of Public Health and Primary Care; University of Cambridge; Cambridge UK
| | - Michael Owen
- Faculty of Health and Social Care; Edge Hill University; Ormskirk UK
| | - Nicola Relph
- Faculty of Health, Social Care & Medicine; Edge Hill University; Ormskirk UK
| | - Omar Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital; London UK
| | - Carol Kelly
- Respiratory Research Centre, Faculty of Health, Social Care & Medicine; Edge Hill University; Ormskirk UK
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17
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Mathioudakis AG, Miligkos M, Boccabella C, Alimani GS, Custovic A, Deschildre A, Ducharme FM, Kalayci O, Murray C, Garcia AN, Phipatanakul W, Price D, Sheikh A, Agache IO, Bacharier L, Beloukas A, Bentley A, Bonini M, Castro-Rodriguez JA, De Carlo G, Craig T, Diamant Z, Feleszko W, Felton T, Gern JE, Grigg J, Hedlin G, Hossny EM, Ierodiakonou D, Jartti T, Kaplan A, Lemanske RF, Le Souëf PN, Mäkelä MJ, Mathioudakis GA, Matricardi P, Mitrogiorgou M, Morais-Almeida M, Nagaraju K, Papageorgiou E, Pité H, Pitrez PMC, Pohunek P, Roberts G, Tsiligianni I, Turner S, Vijverberg S, Winders TA, Wong GW, Xepapadaki P, Zar HJ, Papadopoulos NG. Management of asthma in childhood: study protocol of a systematic evidence update by the Paediatric Asthma in Real Life (PeARL) Think Tank. BMJ Open 2021; 11:e048338. [PMID: 34215609 PMCID: PMC8256789 DOI: 10.1136/bmjopen-2020-048338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Clinical recommendations for childhood asthma are often based on data extrapolated from studies conducted in adults, despite significant differences in mechanisms and response to treatments. The Paediatric Asthma in Real Life (PeARL) Think Tank aspires to develop recommendations based on the best available evidence from studies in children. An overview of systematic reviews (SRs) on paediatric asthma maintenance management and an SR of treatments for acute asthma attacks in children, requiring an emergency presentation with/without hospital admission will be conducted. METHODS AND ANALYSIS Standard methodology recommended by Cochrane will be followed. Maintenance pharmacotherapy of childhood asthma will be evaluated in an overview of SRs published after 2005 and including clinical trials or real-life studies. For evaluating pharmacotherapy of acute asthma attacks leading to an emergency presentation with/without hospital admission, we opted to conduct de novo synthesis in the absence of adequate up-to-date published SRs. For the SR of acute asthma pharmacotherapy, we will consider eligible SRs, clinical trials or real-life studies without time restrictions. Our evidence updates will be based on broad searches of Pubmed/Medline and the Cochrane Library. We will use A MeaSurement Tool to Assess systematic Reviews, V.2, Cochrane risk of bias 2 and REal Life EVidence AssessmeNt Tool to evaluate the methodological quality of SRs, controlled clinical trials and real-life studies, respectively.Next, we will further assess interventions for acute severe asthma attacks with positive clinical results in meta-analyses. We will include both controlled clinical trials and observational studies and will assess their quality using the previously mentioned tools. We will employ random effect models for conducting meta-analyses, and Grading of Recommendations Assessment, Development and Evaluation methodology to assess certainty in the body of evidence. ETHICS AND DISSEMINATION Ethics approval is not required for SRs. Our findings will be published in peer reviewed journals and will inform clinical recommendations being developed by the PeARL Think Tank. PROSPERO REGISTRATION NUMBERS CRD42020132990, CRD42020171624.
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Affiliation(s)
- Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Athens Breath Centre, Athens, Greece
| | - Michael Miligkos
- First Department of Pediatrics, "Aghia Sofia" Children's Hospital, University of Athens, Athens, Attica, Greece
| | - Cristina Boccabella
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Milano, Lombardia, Italy
| | - Gioulinta S Alimani
- Athens Breath Centre, Athens, Greece
- Department of Biomedical Sciences, University of West Attica, Egaleo, Attica, Greece
| | - Adnan Custovic
- Department of Paediatrics, Imperial College London, London, UK
| | - A Deschildre
- Unité de Pneumologie et Allergologie Pédiatriques, Hôpital Jeanne de Flandre, CHU Lille, Lille, Hauts-de-France, France
| | | | - Omer Kalayci
- Pediatric Allergy and Asthma Unit, Hacettepe Universitesi, Ankara, Turkey
| | - Clare Murray
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Antonio Nieto Garcia
- Pulmonology and Allergy Unity, La Fe University and Polytechnic Hospital, Valencia, Comunidad Valenciana, Spain
| | - Wanda Phipatanakul
- Pediatric Allergy and Immunology, Children's Hospital Boston, Boston, Massachusetts, USA
| | - David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
- Observational and Pragmatic Research Institute, Singapore
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | | | - Leonard Bacharier
- Department of Allergy, Immunology, and Pulmonary Medicine, University of Washington, Seattle, Washington, USA
| | - Apostolos Beloukas
- Department of Biomedical Sciences, University of West Attica, Egaleo, Attica, Greece
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Andrew Bentley
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Acute Intensive Care Unit, University Hospital of South Manchester NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Matteo Bonini
- Department of Cardiovascular and Thoracic Sciences, Catholic University of the Sacred Heart, Milano, Lombardia, Italy
- National Heart and Lung Institute (NHLI), Imperial College London, London, UK
| | | | - Giuseppe De Carlo
- Allergy and Airway Diseases Patient's Associations, European Federation of Pharmaceutical Industries and Associations, Brussels, Belgium
| | - Timothy Craig
- Allergy, Asthma and Immunology, Penn State University, Hershey, Pennsylvania, USA
| | - Zuzana Diamant
- Department of Respiratory Medicine and Allergology, Institute for Clinical Science, Skane University Hospital Lund Hematological Clinic, Lund, Skåne, Sweden
- Department of Respiratory Medicine, First Faculty of Medicine, Charles University and Thomayer Hospital, Prague, Czech Republic
- Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Center of Groningen and QPS-NL, Groningen, Netherlands
| | - Wojciech Feleszko
- Department of Pediatric Pulmonology and Allergy, Medical University of Warsaw, Warszawa, Poland
| | - Tim Felton
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
- North West Lung Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - James E Gern
- Department of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jonathan Grigg
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Gunilla Hedlin
- Department of Women's and Children's Health, Karolinska Institute, Stockholm, Stockholm, Sweden
| | - Elham M Hossny
- Pediatric Allergy and Immunology Unit, Ain Shams University, Cairo, Egypt
| | - Despo Ierodiakonou
- Department of Social Medicine, Faculty of Medicine, University of Crete, Rethimno, Greece
| | - Tuomas Jartti
- Department of Paediatrics, University of Turku, Turku, Finland
| | - Alan Kaplan
- Family Physician, Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada
| | - Robert F Lemanske
- Department of Pediatrics and Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Peter N Le Souëf
- School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
| | - Mika J Mäkelä
- Department of Allergy, University of Helsinki, Helsinki, Uusimaa, Finland
| | | | - Paolo Matricardi
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité - University Medicine, Berlin, Germany
| | - Marina Mitrogiorgou
- Third Department of Paediatrics, National and Kapodistrian University of Athens School of Health Sciences, Athens, Greece
| | | | | | - Effie Papageorgiou
- Department of Biomedical Sciences, University of West Attica, Egaleo, Attica, Greece
| | - Helena Pité
- Allergy Center, Hospital CUF Descobertas, Lisboa, Portugal
- Allergy Center, CUF Infante Santo Hospital, Lisbon, Portugal
- Chronic Diseases Research Center (CEDOC), NOVA Medical School / Faculdade de Ciências Médicas, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Paulo M C Pitrez
- Laboratory of Respiratory Physiology, Infant Center, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Petr Pohunek
- Paediatric Department, Motol University Hospital, Praha, Czech Republic
| | - Graham Roberts
- The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Newport Isle of Wight, UK
- Faculty of Medicine, Clinical and Experimental Sciences and Human Development in Health Academic Units, University of Southampton, Southampton, UK
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ioanna Tsiligianni
- Department of Social Medicine, Faculty of Medicine, University of Crete, Rethimno, Greece
| | - Stephen Turner
- Department of Child Health, University of Aberdeen, Aberdeen, Aberdeen, UK
| | - Susanne Vijverberg
- Department of Respiratory Medicine and Department of Pediatric Pulmonology, University of Amsterdam, Amsterdam, Netherlands
| | - Tonya A Winders
- Allergy & Asthma, Global Patient Platform, Virginia, Virginia, USA
| | - Gary Wk Wong
- Department of Paediatrics, Faculty of Medicine, The Chinese University of Hong Kong, Sha Tin, Hong Kong
| | - Paraskevi Xepapadaki
- Allergy Department, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Attica, Greece
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Rondebosch, Western Cape, South Africa
- Unit on Child and Adolescent Health, Medical Reaserch Council, Cape Town, South Africa
| | - Nikolaos G Papadopoulos
- Division of Infection, Immunity and Respiratory Medicine, The University of Manchester, Manchester, UK
- Allergy Department, 2nd Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Attica, Greece
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18
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d'Ancona G, Weinman J. Improving adherence in chronic airways disease: are we doing it wrongly? Breathe (Sheff) 2021; 17:210022. [PMID: 34295423 PMCID: PMC8291927 DOI: 10.1183/20734735.0022-2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/02/2021] [Indexed: 12/19/2022] Open
Abstract
Non-adherence to medicines is a significant clinical and financial burden, but successful strategies to improve it, and thus bring about significant improvements in clinical outcome, remain elusive. Many barriers exist, including a lack of awareness amongst some healthcare professionals as to the extent and impact of non-adherence and a dearth of skills to address it successfully. Patients may not appreciate that they are non-adherent, feel they cannot disclose it or underestimate its impact on their health in the short and longer term. In describing the evidence-based frameworks that identify the causal factors behind medicines taking (or not taking) behaviours, we can start to personalise interventions to enable individuals to make informed decisions about their treatments and thus overcome real and perceived barriers to adherence. Medicines non-adherence is common and associated with significant morbidity and mortality. @GrainnedAn and colleagues outline causal factors behind this behaviour and the appropriate individualised interventions available to support optimal medicines use.https://bit.ly/3ejJNTV
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Affiliation(s)
- Gráinne d'Ancona
- Pharmacy Dept/Thoracic Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - John Weinman
- Institute of Pharmaceutical Sciences, King's College London, London, UK
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19
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Papadopoulos NG, Miligkos M, Xepapadaki P. A Current Perspective of Allergic Asthma: From Mechanisms to Management. Handb Exp Pharmacol 2021; 268:69-93. [PMID: 34085124 DOI: 10.1007/164_2021_483] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Asthma is a result of heterogenous, complex gene-environment interactions with variable clinical phenotypes, inflammation, and remodeling. It affects more than 330 million of people worldwide throughout their educational and working lives, while exacerbations put a heavy cost/burden on productivity. Childhood asthma is characterized by a predominance of allergic sensitization and multimorbidity, while in adults polysensitization has been positively associated with asthma occurrence. Despite significant improvements in recent decades, asthma management remains challenging. Recently, a group of specialists suggested that the term "asthma" should be preferably used as a descriptive term for symptoms. Moreover, type 2 inflammation has emerged as a pivotal disease mechanism including overlapping endotypes of specific IgE production, while type 2-low asthma includes several disease endotypes. Optimal asthma control requires both appropriate pharmacological interventions, tailored to each patient, as well as trigger avoidance measures. Regular monitoring for maintenance of symptom control, preservation of lung function, and detection of treatment-related adverse effects are warranted. Allergen-specific immunotherapy and the advent of new targeted therapies for patients with difficult to control asthma offer diverse treatment options. The current review summarizes up-to-date knowledge on epidemiology, definitions, diagnosis, and current therapeutic strategies.
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Affiliation(s)
- Nikolaos G Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece. .,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.
| | - Michael Miligkos
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Xepapadaki
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
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20
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Volerman A, Kan K, Carpenter D, Press VG. Strategies for Improving Inhalation Technique in Children: A Narrative Review. Patient Prefer Adherence 2021; 15:665-675. [PMID: 33824582 PMCID: PMC8018416 DOI: 10.2147/ppa.s267053] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 03/11/2021] [Indexed: 11/23/2022] Open
Abstract
Inhaled medicines are commonly utilized by children for various respiratory conditions and must be used effectively for the medication to reach the airways. Poor inhaler technique contributes to poorly controlled asthma with significant associated morbidity. Given the significant consequences of improper inhaler use in children, the goal of this review is to comprehensively describe existing and potential solutions to improve inhaler technique. Because children move through various settings, including clinical practices, schools, pharmacies, and homes, in their daily routine, there is great opportunity to teach and reinforce proper inhaler technique across settings. Within each setting, in-person and technology-based interventions have shown promise to improve technique. These solutions need to be more broadly adopted to deliver tailored education with support for provider training, team-based care, communication structures, and reimbursement. Such solutions hold the potential to improve inhaler use among children, with potential for decreasing morbidity and costs.
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Affiliation(s)
- Anna Volerman
- University of Chicago, Departments of Medicine and Pediatrics, Chicago, IL, USA
| | - Kristin Kan
- Division of Advanced General Pediatrics and Primary Care, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Northwestern University Feinberg School of Medicine, Advanced General Pediatrics Division, Department of Pediatrics, Chicago, IL, USA
| | - Delesha Carpenter
- University of North Carolina at Chapel Hill, Division of Pharmaceutical Outcomes and Policy, Chapel Hill, NC, USA
| | - Valerie G Press
- University of Chicago, Departments of Medicine and Pediatrics, Chicago, IL, USA
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21
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Fathima M, Bawa Z, Mitchell B, Foster J, Armour C, Saini B. COPD Management in Community Pharmacy Results in Improved Inhaler Use, Immunization Rate, COPD Action Plan Ownership, COPD Knowledge, and Reductions in Exacerbation Rates. Int J Chron Obstruct Pulmon Dis 2021; 16:519-533. [PMID: 33688177 PMCID: PMC7936701 DOI: 10.2147/copd.s288792] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/25/2021] [Indexed: 12/12/2022] Open
Abstract
Purpose To evaluate the effectiveness of a pilot community pharmacy care model for patients with chronic obstructive pulmonary disease (COPD) to improve: 1) inhaler technique; 2) medication adherence; and 3) uptake of non-pharmacological treatment and prevention activities. Patients and Methods Forty "host" pharmacies in Sydney were invited to recruit eligible patients and to provide a counselling room/area in their pharmacy for service provision. Eligible patients were referred to two "consultant" pharmacists, specifically trained to deliver a specialized pharmacy COPD service which involved 3 in-pharmacy visits and 2 follow-up phone calls over a 6-month period. The service consisted of 1) inhaler technique assessment; 2) medication adherence assessment; and 3) referrals to the patient's general practitioner (GP) to facilitate the uptake of non-pharmacological resources as well as to review COPD medications/devices, as required. Pre-post analyses were conducted using paired Student's t-test and Wilcoxon Signed Rank Test for independent variables and chi-squared tests for proportional data. Results Nine "host" pharmacies recruited 40 patients, of whom 37 completed the baseline Visit and 27 completed all Visits. A total of 270 interventions were provided by the "consultant" pharmacists with most provided at Visit 1 (176). The most common interventions were addressing patient gaps in COPD knowledge and inhaler technique. A total of 119 referrals were made to GPs for various reasons, the most common being for a COPD action plan, pulmonary rehabilitation, or pneumonia vaccination. There were significant improvements pre-post intervention in inhaler use competence, COPD knowledge, immunization rate for pneumonia, exacerbation rate and COPD plan ownership. Conclusion In this pilot study, the specialized pharmacy-based COPD care model delivered by "consultant" pharmacists in community pharmacies provided significant health benefits for patients. Further research is needed to assess the model's effectiveness in a larger population as well as when measured against standard care.
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Affiliation(s)
- Mariam Fathima
- Woolcock Institute of Medical Research, University of Sydney, Glebe, New South Wales, Australia
| | - Zeeta Bawa
- Woolcock Institute of Medical Research, University of Sydney, Glebe, New South Wales, Australia
| | - Bernadette Mitchell
- Woolcock Institute of Medical Research, University of Sydney, Glebe, New South Wales, Australia
| | - Juliet Foster
- Woolcock Institute of Medical Research, University of Sydney, Glebe, New South Wales, Australia
| | - Carol Armour
- Woolcock Institute of Medical Research, University of Sydney, Glebe, New South Wales, Australia
| | - Bandana Saini
- Woolcock Institute of Medical Research, University of Sydney, Glebe, New South Wales, Australia.,School of Pharmacy, University of Sydney, Camperdown, New South Wales, Australia
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Salomé GM. Development of educational material for the prevention and treatment of friction injuries. ESTIMA 2020. [DOI: 10.30886/estima.v18.923_in] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: to develop and validate an educational booklet to help health professionals to prevent and treat friction injuries. Method: methodological study. An integrative review of the literature of journals published between 2009 and 2019 was carried out in the main databases of Health Sciences. The evaluation of the educational booklet was conducted with 32 nurses, using the Delphi technique. The statistical analysis used was the Content Validity Index. Results: the judges considered the content of the educational booklet between the concepts “inadequate” and “adequate”, in the first assessment; after the corrections requested by the judges, the booklet was forwarded to the evaluators and the content of the educational booklet was rated between “adequate” and “totally adequate”. The overall Content Validity Index was 0.8118 in the first assessment and 1.0 in the second assessment. Conclusion: after the integrative literature review, the material was constructed and validated by professionals with experience in evaluating and treating individuals with wounds, obtaining consensus among the evaluators in the second evaluation.
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Affiliation(s)
- Geraldo Magela Salomé
- Universidade do Vale do Sapucaí − Programa de Mestrado Profissional em Ciências Aplicadas à Saúde − Pouso Alegre (MG), Brazil
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Salomé GM. Desenvolvimento de um material educativo para a prevenção e o tratamento das lesões por fricção. ESTIMA 2020. [DOI: 10.30886/estima.v18.923_pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objetivo: desenvolver e validar uma cartilha educativa para ajudar o profissional da saúde a prevenir e tratar da lesão por fricção. Método: estudo metodológico. Foi realizada revisão integrativa da literatura dos periódicos publicados entre 2009 e 2019 nas principais bases de dados de Ciências da Saúde. A avaliação da cartilha educativa foi conduzida com 32 enfermeiros, utilizando a técnica de Delphi. A análise estatística utilizada foi o Índice de Validade de Conteúdo. Resultados: os juízes consideraram o conteúdo da cartilha educativa entre os conceitos “inadequado” e “adequado”, na primeira avaliação; após as correções solicitadas pelos juízes, a cartilha foi reenviada aos avaliadores e o conteúdo da cartilha educativa foi avaliado entre “adequado” e “totalmente adequado”. O Índice de Validade de Conteúdo geral foi de 0,8118 na primeira avaliação e 1,0 na segunda avaliação. Conclusão: após a revisão integrativa da literatura, o material foi construído e validado por profissionais com experiência em avaliar e tratar de indivíduos com feridas, obtendo consenso entre os avaliadores na segunda avaliação.
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Affiliation(s)
- Geraldo Magela Salomé
- Universidade do Vale do Sapucaí − Programa de Mestrado Profissional em Ciências Aplicadas à Saúde − Pouso Alegre (MG), Brazil
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Tibble H, Lay-Flurrie J, Sheikh A, Horne R, Mizani MA, Tsanas A. Linkage of primary care prescribing records and pharmacy dispensing Records in the Salford Lung Study: application in asthma. BMC Med Res Methodol 2020; 20:303. [PMID: 33302885 PMCID: PMC7731758 DOI: 10.1186/s12874-020-01184-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Records of medication prescriptions can be used in conjunction with pharmacy dispensing records to investigate the incidence of adherence, which is defined as observing the treatment plans agreed between a patient and their clinician. Using prescribing records alone fails to identify primary non-adherence; medications not being collected from the dispensary. Using dispensing records alone means that cases of conditions that resolve and/or treatments that are discontinued will be unaccounted for. While using a linked prescribing and dispensing dataset to measure medication non-adherence is optimal, this linkage is not routinely conducted. Furthermore, without a unique common event identifier, linkage between these two datasets is not straightforward. METHODS We undertook a secondary analysis of the Salford Lung Study dataset. A novel probabilistic record linkage methodology was developed matching asthma medication pharmacy dispensing records and primary care prescribing records, using semantic (meaning) and syntactic (structure) harmonization, domain knowledge integration, and natural language feature extraction. Cox survival analysis was conducted to assess factors associated with the time to medication dispensing after the prescription was written. Finally, we used a simplified record linkage algorithm in which only identical records were matched, for a naïve benchmarking to compare against the results of our proposed methodology. RESULTS We matched 83% of pharmacy dispensing records to primary care prescribing records. Missing data were prevalent in the dispensing records which were not matched - approximately 60% for both medication strength and quantity. A naïve benchmarking approach, requiring perfect matching, identified one-quarter as many matching prescribing records as our methodology. Factors associated with delay (or failure) to collect the prescribed medication from a pharmacy included season, quantity of medication prescribed, previous dispensing history and class of medication. Our findings indicate that over 30% of prescriptions issued were not collected from a dispensary (primary non-adherence). CONCLUSIONS We have developed a probabilistic record linkage methodology matching a large percentage of pharmacy dispensing records with primary care prescribing records for asthma medications. This will allow researchers to link datasets in order to extract information about asthma medication non-adherence.
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Affiliation(s)
- Holly Tibble
- Usher Institute, University of Edinburgh, Bioquarter 9, 9 Little France Road, Edinburgh, Scotland, EH16 4UX.
- Asthma UK Centre for Applied Research, Bioquarter 9, 9 Little France Road, Edinburgh, Scotland, EH16 4UX.
| | | | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Bioquarter 9, 9 Little France Road, Edinburgh, Scotland, EH16 4UX
- Asthma UK Centre for Applied Research, Bioquarter 9, 9 Little France Road, Edinburgh, Scotland, EH16 4UX
- Health Data Research U004B, Edinburgh, UK
| | - Rob Horne
- Asthma UK Centre for Applied Research, Bioquarter 9, 9 Little France Road, Edinburgh, Scotland, EH16 4UX
- Centre for Behavioural Medicine, UCL School of Pharmacy, London, UK
| | - Mehrdad A Mizani
- Usher Institute, University of Edinburgh, Bioquarter 9, 9 Little France Road, Edinburgh, Scotland, EH16 4UX
- Asthma UK Centre for Applied Research, Bioquarter 9, 9 Little France Road, Edinburgh, Scotland, EH16 4UX
| | - Athanasios Tsanas
- Usher Institute, University of Edinburgh, Bioquarter 9, 9 Little France Road, Edinburgh, Scotland, EH16 4UX
- Asthma UK Centre for Applied Research, Bioquarter 9, 9 Little France Road, Edinburgh, Scotland, EH16 4UX
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Vanoverschelde A, van der Wel P, Putman B, Lahousse L. A pragmatic randomized controlled trial to improve inhaler technique using mHealth. Clin Transl Allergy 2020; 10:59. [PMID: 33372626 PMCID: PMC7722438 DOI: 10.1186/s13601-020-00363-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/26/2020] [Accepted: 11/20/2020] [Indexed: 11/10/2022] Open
Affiliation(s)
- Anna Vanoverschelde
- Department of Bioanalysis, Pharmaceutical Care Unit, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Paulien van der Wel
- Department of Bioanalysis, Pharmaceutical Care Unit, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium
| | - Barbara Putman
- Department of Bioanalysis, Pharmaceutical Care Unit, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium.,Department of Medicine and Department of Environmental Medicine, New York University School of Medicine, New York, NY, 10016, USA
| | - Lies Lahousse
- Department of Bioanalysis, Pharmaceutical Care Unit, Ghent University, Ottergemsesteenweg 460, 9000, Ghent, Belgium.
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Tibble H, Chan A, Mitchell EA, Horne E, Doudesis D, Horne R, Mizani MA, Sheikh A, Tsanas A. A data-driven typology of asthma medication adherence using cluster analysis. Sci Rep 2020; 10:14999. [PMID: 32929109 PMCID: PMC7490405 DOI: 10.1038/s41598-020-72060-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 08/20/2020] [Indexed: 11/17/2022] Open
Abstract
Asthma preventer medication non-adherence is strongly associated with poor asthma control. One-dimensional measures of adherence may ignore clinically important patterns of medication-taking behavior. We sought to construct a data-driven multi-dimensional typology of medication non-adherence in children with asthma. We analyzed data from an intervention study of electronic inhaler monitoring devices, comprising 211 patients yielding 35,161 person-days of data. Five adherence measures were extracted: the percentage of doses taken, the percentage of days on which zero doses were taken, the percentage of days on which both doses were taken, the number of treatment intermissions per 100 study days, and the duration of treatment intermissions per 100 study days. We applied principal component analysis on the measures and subsequently applied k-means to determine cluster membership. Decision trees identified the measure that could predict cluster assignment with the highest accuracy, increasing interpretability and increasing clinical utility. We demonstrate the use of adherence measures towards a three-group categorization of medication non-adherence, which succinctly describes the diversity of patient medication taking patterns in asthma. The percentage of prescribed doses taken during the study contributed to the prediction of cluster assignment most accurately (84% in out-of-sample data).
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Affiliation(s)
- Holly Tibble
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Doorway 1, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK.
- Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK.
| | - Amy Chan
- School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
- Centre for Behavioural Medicine, Department for Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Edwin A Mitchell
- Department of Paediatrics: Child and Youth Health, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Elsie Horne
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Doorway 1, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
- Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Dimitrios Doudesis
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Doorway 1, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
- BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Rob Horne
- Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
- Centre for Behavioural Medicine, Department for Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Mehrdad A Mizani
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Doorway 1, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
- Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Aziz Sheikh
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Doorway 1, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
- Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
- Health Data Research UK, London, UK
| | - Athanasios Tsanas
- Usher Institute, Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Doorway 1, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK
- Asthma UK Centre for Applied Research, Usher Institute, Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
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Pritchard JN. The Climate is Changing for Metered-Dose Inhalers and Action is Needed. Drug Des Devel Ther 2020; 14:3043-3055. [PMID: 32801643 PMCID: PMC7410333 DOI: 10.2147/dddt.s262141] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/08/2020] [Indexed: 01/17/2023] Open
Abstract
Increases in global temperature are already having a significant impact on our climate. The hydrofluorocarbon (HFC) propellants used today in pressurized metered-dose inhalers (pMDIs) have global warming potential (GWP) many times that of carbon dioxide. Their use, together with all other emissive uses of HFCs, is being phased down under the Montreal protocol. This has prompted calls to switch patients to dry powder inhalers (DPIs). This paper presents a new analysis of the top 15 respiratory drug markets by drug class. It shows that a switch to DPIs would be economically feasible for most countries and most drugs. However, a wholesale switch of reliever medications, notably short-acting β-agonists, would lead to significant increases in the cost of these life-saving medications. Reviewing the evidence, whilst most patients are capable of using DPIs, the very young, very old and those undergoing an acute exacerbation still require a pMDI. Thus, there is a clinical and economic need to have both pMDIs and DPIs available. At the same time, it is projected that the reduction in non-medical uses of propellants is likely to give rise to a 5-fold increase in their cost for pMDI uses and is likely to hit the Western world in 2025. This may lead to a price increase in reliever medication that will make it unaffordable for the poorer communities in some markets. At the same time, opportunities to save money by developing new formulations using propellants with lower GWP, such as HFC 152a or HFO 1234ze(E), are described. Two companies have made this commitment, but neither currently have a strong presence in reliever medication. For them, or other companies, now is the time to act; 2025 is not far away in terms of product development timescales and the climate cannot wait.
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Health and cost impact of stepping down asthma medication for UK patients, 2001-2017: A population-based observational study. PLoS Med 2020; 17:e1003145. [PMID: 32692744 PMCID: PMC7373267 DOI: 10.1371/journal.pmed.1003145] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 06/09/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Guidelines recommend stepping down asthma treatment to the minimum effective dose to achieve symptom control, prevent adverse side effects, and reduce costs. Limited data exist on asthma prescription patterns in a real-world setting. We aimed to evaluate the appropriateness of doses prescribed to a UK general asthma population and assess whether stepping down medication increased exacerbations or reliever use, as well as its impact on costs. METHODS AND FINDINGS We used nationwide UK primary care medical records, 2001-2017, to identify 508,459 adult asthma patients managed with preventer medication. Prescriptions of higher-level medication: medium/high-dose inhaled corticosteroids (ICSs) or ICSs + add-on medication (long-acting β2-agonist [LABA], leukotriene receptor antagonist [LTRA], theophylline, or long-acting muscarinic antagonist [LAMA]) steadily increased over time (2001 = 49.8%, 2017 = 68.3%). Of those prescribed their first preventer, one-third were prescribed a higher-level medication, of whom half had no reliever prescription or exacerbation in the year prior. Of patients first prescribed ICSs + 1 add-on, 70.4% remained on the same medication during a mean follow-up of 6.6 years. Of those prescribed medium/high-dose ICSs as their first preventer, 13.0% already had documented diabetes, cataracts, glaucoma, or osteopenia/osteoporosis. A cohort of 125,341 patients were drawn to assess the impact of stepping down medication: mean age 50.4 years, 39.4% males, 39,881 stepped down. Exposed patients were stepped down by dropping their LABAs or another add-on or by halving their ICS dose (halving their mean-daily dose or their inhaler dose). The primary and secondary outcomes were, respectively, exacerbations and an increase in reliever prescriptions. Multivariable regression was used to assess outcomes and determine the prognostic factors for initiating stepdown. There was no increased exacerbation risk for each possible medication stepdown (adjusted hazard ratio, 95% CI, p-value: ICS inhaler dose = 0.86, 0.77-0.93, p < 0.001; ICS mean daily = 0.80, 0.74-0.87, p < 0.001; LABA = 1.01, 0.92-1.11, p = 0.87, other add-on = 1.00, 0.91-1.09, p = 0.79) and no increase in reliever prescriptions (adjusted odds ratio, 95% CI, p-value: ICS inhaler dose = 0.99, 0.98-1.00, p = 0.59; ICS mean daily = 0.78, 0.76-0.79, p < 0.001; LABA = 0.83, 0.82-0.85, p < 0.001; other add-on = 0.86, 0.85-0.87, p < 0.001). Prognostic factors to initiate stepdown included medication burden, but not medication side effects. National Health Service (NHS) indicative prices were used for cost estimates. Stepping down medication, either LABAs or ICSs, could save annually around £17,000,000 or £8,600,000, respectively. Study limitations include the possibility that prescribed medication may not have been dispensed or adhered to and the reason for stepdown was not documented. CONCLUSION In this UK study, we observed that asthma patients were increasingly prescribed higher levels of treatment, often without clear clinical indication for such high doses. Stepping down medication did not adversely affect outcomes and was associated with substantial cost savings.
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Volerman A, Carpenter D, Press V. What can be done to impact respiratory inhaler misuse: exploring the problem, reasons, and solutions. Expert Rev Respir Med 2020; 14:791-805. [PMID: 32306774 DOI: 10.1080/17476348.2020.1754800] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Respiratory inhalers, when used correctly, provide critical treatments for managing pulmonary conditions. However, many patients misuse inhalers, negatively affecting disease control, quality of life, healthcare utilization, and costs. Numerous factors are associated with misuse and are nested within four levels of influence: individual, interpersonal, organizational/institutional, and policy. AREAS COVERED This review analyzed published literature and identified the most salient factors at each socio-ecological framework level. English language articles from any year were identified from PubMed, Google Scholar, and Embase databases. Misuse exists across clinical settings, patient populations, and device types. Several potential solutions are highlighted. Published interventions to improve inhaler technique have utilized handouts, in-person, virtual, and biofeedback approaches both inside and outside of healthcare settings with varied effectiveness. However, some interventions have superior effectiveness for improving technique and reducing acute care utilization. EXPERT OPINION To robustly address inhaler misuse, future solutions should focus on multi-level approaches to account for the myriad of factors contributing to inhaler misuse. Solutions should also streamline inhaler equipment, identify innovative technology-based solutions, support collaborations across healthcare and non-healthcare settings, and ensure reimbursement to healthcare professionals for inhaler education. Rigorous research studies must be funded and supported to identify and disseminate solutions.
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Affiliation(s)
- Anna Volerman
- University of Chicago Biological Sciences Division, Departments of Medicine and Pediatrics , Chicago, IL, USA
| | - Delesha Carpenter
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy , Asheville, NC, USA
| | - Valerie Press
- University of Chicago Biological Sciences Division, Departments of Medicine and Pediatrics , Chicago, IL, USA
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Baba R, Nakachi I, Masaki K, Amagai T, Ohno R, Takaoka H, Kamo T, Arai D, Takahashi H, Shinoda H, Fukunaga K. Repetitive instructions at short intervals contribute to the improvement of inhalation technique. Asia Pac Allergy 2020; 10:e19. [PMID: 32411584 PMCID: PMC7203431 DOI: 10.5415/apallergy.2020.10.e19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 04/24/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Inhaled medicines are key drugs for the treatment of asthma or chronic obstructive pulmonary disease. However, the variety of inhaler devices and complicated inhalation procedures have created confusion among patients, affecting their correct understanding of inhalation. Recent studies reported that up to 80% of patients made technical errors in inhalation and emphasized the necessity for patient education. OBJECTIVE We aimed to assess the importance of inhalation-related instructions and to find clinical factors associated with improvements in the inhalation technique. METHODS We conducted a retrospective, single-center study at a regional core hospital in Japan. Physicians and community pharmacists constructed an interactive instruction system and shared a common inhalation procedure manual. Patients who received instructions for the inhalation technique at least 3 times were recruited. RESULTS A total of 125 patients were analyzed in this study. The median age was 73 years (interquartile range, 67-80 years). At the second visit, 67 patients (53.6%) failed to correctly perform the technique despite being guided at the first visit. At the third visit, 48.8% of patients made some errors. After excluding 40 patients who were not subjected to analysis, the remaining 85 were divided into "improvement" and "no-improvement" groups. The total improvement rate was 57.6%. The median time interval between consecutive instructions in the "improvement" groups was 84 days, whereas that in the "no-improvement" group was 128 days (p < 0.05, U test). No significant difference in the age, sex, or primary disease was seen between these groups. CONCLUSION Repetitive instructions at shorter intervals may be helpful for patients to develop and maintain an improved inhalation technique.
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Affiliation(s)
- Rie Baba
- Department of Medicine, Saiseikai Utsunomiya Hospital, Tochigi, Japan
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Ichiro Nakachi
- Department of Medicine, Saiseikai Utsunomiya Hospital, Tochigi, Japan
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Katsunori Masaki
- Department of Medicine, Saiseikai Utsunomiya Hospital, Tochigi, Japan
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takuya Amagai
- Department of Pharmacy, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Rintaro Ohno
- Department of Pharmacy, Saiseikai Utsunomiya Hospital, Tochigi, Japan
| | - Hatsuyo Takaoka
- Department of Medicine, Saiseikai Utsunomiya Hospital, Tochigi, Japan
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tetsuro Kamo
- Department of Medicine, Saiseikai Utsunomiya Hospital, Tochigi, Japan
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Arai
- Department of Medicine, Saiseikai Utsunomiya Hospital, Tochigi, Japan
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | | | - Hiromi Shinoda
- Department of Medicine, Saiseikai Utsunomiya Hospital, Tochigi, Japan
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Koichi Fukunaga
- Division of Pulmonary Medicine, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
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Gleeson PK, Feldman S, Apter AJ. Controller Inhalers: Overview of Devices, Instructions for Use, Errors, and Interventions to Improve Technique. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2234-2242. [PMID: 32173505 DOI: 10.1016/j.jaip.2020.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 02/16/2020] [Accepted: 03/04/2020] [Indexed: 11/28/2022]
Abstract
Inadequate inhaler technique in persistent asthma is frequently reported. However, there is little consensus on inhaler checklists, and critical elements of technique are not uniformly described. In addition, inhaler error rates and risk factors for poor technique are variable across studies. This Clinical Commentary Review summarizes the literature on inhaler design, use, and interventions to improve technique. Our aim is to help clinicians identify patients with poor inhaler technique, recognize the most important errors, and correct technique using evidence-based interventions.
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Affiliation(s)
- Patrick K Gleeson
- Section of Allergy and Immunology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Scott Feldman
- Section of Allergy and Immunology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Andrea J Apter
- Section of Allergy and Immunology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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Ramadan AA, Gaffin JM, Israel E, Phipatanakul W. Asthma and Corticosteroid Responses in Childhood and Adult Asthma. Clin Chest Med 2020; 40:163-177. [PMID: 30691710 DOI: 10.1016/j.ccm.2018.10.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Corticosteroids are the most effective treatment for asthma; inhaled corticosteroids (ICSs) are the first-line treatment for children and adults with persistent symptoms. ICSs are associated with significant improvements in lung function. The anti-inflammatory effects of corticosteroids are mediated by both genomic and nongenomic factors. Variation in the response to corticosteroids has been observed. Patient characteristics, biomarkers, and genetic features may be used to predict response to ICSs. The existence of multiple mechanisms underlying glucocorticoid insensitivity raises the possibility that this might indeed reflect different diseases with a common phenotype.
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Affiliation(s)
- Amira Ali Ramadan
- Division of Allergy and Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Beth Israel Deaconess Center, Cardiovascular institute, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Jonathan M Gaffin
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Elliot Israel
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Brigham and Women's Hospital, 15 Francis Street, Boston, MA 02115, USA
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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Milanese M, Terraneo S, Baiardini I, Di Marco F, Corsico A, Molino A, Scichilone N. Effects of a structured educational intervention in moderate-to-severe elderly asthmatic subjects. World Allergy Organ J 2019; 12:100040. [PMID: 31316712 PMCID: PMC6593309 DOI: 10.1016/j.waojou.2019.100040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 05/04/2019] [Accepted: 05/13/2019] [Indexed: 11/18/2022] Open
Abstract
Background Adherence to inhaled drugs is linked to patients’ satisfaction with their device, and an incorrect use can negatively affect the outcomes of asthma treatment. We speculated that this is particularly true in elderly asthmatic subjects. Aim We performed a national pre-post interventional multicentre study, enrolling moderate-to-severe asthmatic subjects aged ≥65 years treated with fixed inhaled combination drugs by dry powder inhaler (DPI) or pressurized metered dose inhaler (pMDI). Adherence and critical errors were evaluated by means of validated questionnaires at first visit (V1) and after 3–6 months (V2). At V1, subjects underwent intensive training on the correct use of their device by physical demonstration. Results A total of 411 asthmatics (F/M: 238/173, mean age±SD: 72 ± 5 years) participated to the study. At V1, 50% of the study subjects showed an Asthma Control Test (ACT) score ≤19 despite GINA step 3 and 4 treatment, and 40% had experienced at least one severe asthma exacerbation in the previous year. Poor adherence to treatment was recorded in 43% of subjects, and at least one error in using the device was registered in 56% of subjects. At V2, available for 318 patients, both the percentage of individuals with poor adherence and with at least one critical error significantly decreased (from 46% to 25%, and from 49% to 25%, respectively; p < 0.001 for both comparisons) with a significant increase of the ACT score (from 19 ± 4.9 to 20 ± 4.0, p < 0.001). Conclusions Asthma in the elderly is characterized by low levels of symptom control. Educational interventions are strongly advocated in this age group in order to increase adherence to treatment and inhaler techniques.
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Key Words
- ACT, asthma control test
- AHDS, hospital anxiety depression scale
- Asthma
- CFC, chlorofluorocarbons
- Device misuse
- EDUCA, elderly and device use in chronic asthma
- Education
- Elderly
- FEV1, forced expiratory volume 1s second
- FVC, forced vital capacity
- ICS, inhaled corticosteroids
- LABA, long-acting β2 agonist
- LAMA, long-acting muscarinic antagonists
- MCS, mental health composite score
- PCS, physical health composite score
- PROs, patient-reported outcomes
- SAE, severe asthma exacerbation
- SF12, short form health survey
- mMRC, modified medical research council
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Affiliation(s)
- M. Milanese
- Department of Medicine, Respiratory Unit, ASL2 Savonese, Savona, Italy
- Corresponding author.
| | - S. Terraneo
- Respiratory Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - I. Baiardini
- Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genova, Azienda Policlinico IRCCS San Martino, Genoa, Italy
| | - F. Di Marco
- Department of Health Sciences, Università degli Studi di Milano, Respiratory Unit, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - A. Corsico
- Department of Internal Medicine and Therapeutics, Pneumology Unit, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - A. Molino
- Department of Respiratory Diseases, Division of Pneumology, University of Naples Federico II, Napoli, Italy
| | - N. Scichilone
- Department of Biomedicine and Internal and Specialistic Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - EDUCA GroupAlbiciniF.hBenfanteA.iBraidoF.jCaminatiM.kCostantinoM.T.lCottiniM.mCrivellaroM.nDe TullioR.oGiniE.pGrossoA.pGuarnieriG.qLombardiC.rPatellaV.sPirinaP.tPolverinoM.uRaccanelliR.vRidoloE.wRollaG.xSteinhilberG.yVianelloA.zDepartment of Internal Medicine and Therapeutics, Pneumology Unit, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, ItalyDepartment of Biomedicine and Internal and Specialistic Medicine (DIBIMIS), University of Palermo, Palermo, ItalyDepartment of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genova, Azienda Policlinico IRCCS San Martino, Genoa, ItalyUnità Operativa di Allergologia Azienda Ospedaliero-Universitaria Integrata di Verona, Verona, ItalyInternal Medicine and Rheumatology Department, Azienda Sanitaria Romagna, Rimini, ItalyAllergy and Pneumology Outpatient Clinic, Bergamo, ItalyDepartment of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, ItalyOspedale consorziale Policlinico di Bari, Unità di Pneumologia, Bari, ItalyDepartment of Internal Medicine and Therapeutics, Pneumology Unit, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, ItalyDepartment of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, ItalyDepartmental Unit of Allergology and Respiratory Diseases, Fondazione Poliambulanza, Brescia, ItalyUnità Operativa di Allergologia ed Immunologia, Dipartimento di Discipline Mediche, Battipaglia SA, ItalyDepartment of Clinical and Experimental Medicine, University of Sassari, Sassari, ItalyDepartment of Pneumology and Endoscopic Unit, Ospedale Scarlato, Scafati SA, ItalyFondazione Salvatore Maugeri, Istituto Scientifico di Milano, IRCCS, MilanoDepartment of Medicine and Surgery, University of Parma, Parma, ItalyAllergy and Immunology, AO Mauriziano Hospital, University of Turin, Turin, ItalyAO Spedali Civili di Brescia, Divisione di Pneumologia, Brescia, ItalyDepartment of Cardiologic, Thoracic, and Vascular Science, University of Padua, Padua, Italy
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Gleeson PK, Perez L, Localio AR, Morales KH, Han X, Bryant-Stephens T, Apter AJ. Inhaler Technique in Low-Income, Inner-City Adults with Uncontrolled Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2683-2688. [PMID: 31173936 DOI: 10.1016/j.jaip.2019.05.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 05/21/2019] [Accepted: 05/24/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND Poor inhaler technique has been shown to be associated with less asthma control and increased health care utilization. Little is known about the impact of inhaler technique on the most vulnerable patients. OBJECTIVE This study examined inhaler technique in low-income, inner-city adults with uncontrolled asthma. METHODS Inhaler technique data and other patient characteristics were evaluated in adults drawn from 2 studies conducted at the University of Pennsylvania. Subjects were from low-income Philadelphia neighborhoods and had uncontrolled asthma. Baseline characteristics were collected. Inhaler technique was rated by research coordinators who were trained with written materials. RESULTS In 584 adults, 56% of metered dose inhaler users and 64% of dry powder inhaler users had adequate visually assessed inhaler technique. Inhaler technique did not vary by reading comprehension or numeracy levels. CONCLUSIONS In this group of patients with uncontrolled asthma, visually assessed inhaler technique was adequate in more than one-half. Although incorrect inhaler technique is generally common and must be routinely addressed, this study suggests that other factors that lead to poor control must be identified.
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Affiliation(s)
- Patrick K Gleeson
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Luzmercy Perez
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - A Russell Localio
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Knashawn H Morales
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Xiaoyan Han
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | | | - Andrea J Apter
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, & Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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Roche N, Campbell JD, Krishnan JA, Brusselle G, Chisholm A, Bjermer L, Thomas M, van Ganse E, van den Berge M, Christoff G, Quint J, Papadopoulos NG, Price D. Quality standards in respiratory real-life effectiveness research: the REal Life EVidence AssessmeNt Tool (RELEVANT): report from the Respiratory Effectiveness Group-European Academy of Allergy and Clinical Immunology Task Force. Clin Transl Allergy 2019; 9:20. [PMID: 30962875 PMCID: PMC6436229 DOI: 10.1186/s13601-019-0255-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Accepted: 01/31/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION A Task Force was commissioned jointly by the European Academy of Allergy and Clinical Immunology (EAACI) and the Respiratory Effectiveness Group (REG) to develop a quality assessment tool for real-life observational research to identify high-quality real-life asthma studies that could be considered within future guideline development. METHODS The resulting REal Life EVidence AssessmeNt Tool (RELEVANT) was achieved through an extensive analysis of existing initiatives in this area. The first version was piloted among 9 raters across 6 articles; the revised, interim, version underwent extensive testing by 22 reviewers from the EAACI membership and REG collaborator group, leading to further revisions and tool finalisation. RELEVANT was validated through an analysis of real-life effectiveness studies identified via systematic review of Medline and Embase databases and relating to topics for which real-life studies may offer valuable evidence complementary to that from randomised controlled trials. The topics were selected through a vote among Task Force members and related to the influence of adherence, smoking, inhaler device and particle size on asthma treatment effectiveness. RESULTS Although highlighting a general lack of high-quality real-life effectiveness observational research on these clinically important topics, the analysis provided insights into how identified observational studies might inform asthma guidelines developers and clinicians. Overall, RELEVANT appeared reliable and easy to use by expert reviewers. CONCLUSIONS Using such quality appraisal tools is mandatory to assess whether specific observational real-life effectiveness studies can be used to inform guideline development and/or decision-making in clinical practice.
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Affiliation(s)
- Nicolas Roche
- Pneumologie, Hôpital Cochin, 27 rue du Faubourg Saint Jacques, 75014 Paris, France
| | - Jonathan D. Campbell
- Center for Pharmaceutical Outcomes Reasearch, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Anschutz Medical Campus, Aurora, CO USA
| | | | - Guy Brusselle
- Department of Respiratory Medicine, Ghent University Hospital, 9000 Ghent, Belgium
| | | | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Skane University Hospital, 221, 85 Lund, Sweden
| | - Mike Thomas
- University of Southampton, University Road, Southampton, SO17 1BJ UK
| | - Eric van Ganse
- Claude-Bernard Lyon1 University, 43 Boulevard du 11 Novembre 1918, 69100 Villeurbanne, France
| | | | - George Christoff
- Medical University - Sofia, Faculty of Public Health, 8 “Bialo more” str, 1527, Sofia, Bulgaria
| | - Jennifer Quint
- Imperial College London, South Kensington Campus, London, SW7 2AZ UK
| | | | - David Price
- Observational and Pragmatic Research Institute, 60 Paya Lebar Road, Paya Lebar Square, #05-33/34, Singapore, 409051 Singapore
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Vogelberg C. Anticholinergics in asthma: are we utilizing asthma therapies effectively? Ther Clin Risk Manag 2019; 15:405-408. [PMID: 30936703 PMCID: PMC6422406 DOI: 10.2147/tcrm.s190363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Christian Vogelberg
- Department of Pediatric Pulmonology and Allergy, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany,
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Abstract
Appropriate selection and correct use of inhalation devices is an integral component in the management of asthma and chronic obstructive pulmonary disease (COPD). It is well known that there are many challenges with the use of inhalers, and no one device suits all patients. Challenges can range from difficulties related to lung disease severity and pulmonary function to physical considerations, including manual dexterity and comorbidities such as arthritis. In terms of device selection and adherence, patient engagement and satisfaction are also important factors to consider. Furthermore, problems with inhaler use can be most evident in children and older patients. Here, we discuss aspects for consideration with commonly used devices, including nebulizers, pressurized metered-dose inhalers, dry powder inhalers, and the soft mist inhaler. As each inhaler offers varying technical properties, a tailored and personalized approach to the selection of the most appropriate device for the patient is highly recommended in order to increase the likelihood of achieving improved disease outcomes and enhance persistence with device adherence. Importantly, education and support is crucial, not only to enable patients to recognize the need for optimal disease management, but also to help them develop good inhaler technique. In addition, health care professionals should also aim to increase their knowledge of the devices they prescribe, and develop systems to ensure that they offer comprehensive support to patients in clinical practice. Considering these aspects, this review discusses potential strategies to help address the challenges of inhaler use in asthma and COPD.
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Affiliation(s)
- Omar S Usmani
- National Heart and Lung Institute (NHLI), Imperial College London and Royal Brompton Hospital, Airways Disease Section, London, UK,
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39
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Volerman A, Toups MM, Hull A, Press VG. A feasibility study of a patient-centered educational strategy for rampant inhaler misuse among minority children with asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2028-2030. [PMID: 30711556 DOI: 10.1016/j.jaip.2019.01.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 01/13/2019] [Accepted: 01/20/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Anna Volerman
- Department of Medicine, University of Chicago Medicine, Chicago, Ill; Department of Pediatrics, University of Chicago Medicine, Chicago, Ill.
| | | | - Ashley Hull
- Department of Medicine, University of Chicago Medicine, Chicago, Ill
| | - Valerie G Press
- Department of Medicine, University of Chicago Medicine, Chicago, Ill; Department of Pediatrics, University of Chicago Medicine, Chicago, Ill
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Maricoto T, Correia-de-Sousa J, Taborda-Barata L. Inhaler technique education in elderly patients with asthma or COPD: impact on disease exacerbations-a protocol for a single-blinded randomised controlled trial. BMJ Open 2019; 9:e022685. [PMID: 30696670 PMCID: PMC6352786 DOI: 10.1136/bmjopen-2018-022685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD)and asthma affect more than 10% of the population. Most patients use their inhaler incorrectly, mainly the elderly, thereby becoming more susceptible to poor clinical control and exacerbations. Placebo device training is regarded as one of the best teaching methods, but there is scarce evidence to support it as the most effective one to improve major clinical outcomes. Our objective is to perform a single-blinded RCT to assess the impact of this education tool in these patients. METHODS AND ANALYSIS A multicentre single-blinded Randomised Controlled Trial (RCT) will be set up, comparing an inhaler education programme with a teach-to-goal placebo-device training versus usual care, with a 1-year follow-up, in patients above 65 years of age with asthma or COPD. Intervention will be provided at baseline, and after 3 and 6 months, with interim analysis at an intermediate time point. Exacerbation rates were set as primary outcomes, and quality of life, adherence rates, clinical control and respiratory function were chosen as secondary outcomes. A sample size of 146 participants (73 in each arm) was estimated as adequate to detect a 50% reduction in event rates. Two-sample proportions χ² test will be used to study primary outcome and subgroup analysis will be carried out according to major baseline characteristics. ETHICS AND DISSEMINATION Every participant will sign a written consent form. A Data Safety Monitoring Board will be set up to evaluate data throughout the study and to monitor early stopping criteria. Identity of all participants will be protected. This protocol was approved on 22 November 2017 by the local Ethics Committee of University of Beira Interior, with the reference number CE-UBI-Pj-2017-025. Results will be presented in scientific meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03449316; Pre-Results.
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Affiliation(s)
- Tiago Maricoto
- Aveiro-Aradas Family Health Unit, Aveiro Health Centre, Aveiro, Portugal
- Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Jaime Correia-de-Sousa
- Life and Health Sciences Research Institute (ICVS)/3B’s—PT Government Associate Laboratory, University of Minho, Braga, Portugal
- Horizonte Family Health Unit, Matosinhos Health Centre, Matosinhos, Portugal
| | - Luís Taborda-Barata
- CICS—Health Sciences Research Centre; NuESA—Environment & Health Study Group, Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal
- Department of Allergy & Clinical Immunology, Cova da Beira University Hospital Centre, Covilhã, Portugal
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Lavorini F, Janson C, Braido F, Stratelis G, Løkke A. What to consider before prescribing inhaled medications: a pragmatic approach for evaluating the current inhaler landscape. Ther Adv Respir Dis 2019; 13:1753466619884532. [PMID: 31805823 PMCID: PMC6900625 DOI: 10.1177/1753466619884532] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/12/2019] [Indexed: 12/16/2022] Open
Abstract
Inhaled therapies are the cornerstone of treatment in asthma and chronic obstructive pulmonary disease, and there are a multitude of devices available. There is, however, a distinct lack of evidence-based guidance for healthcare providers on how to choose an appropriate inhaler. This review aims to summarise recent updates on topics related to inhaler choice, and to offer practical considerations for healthcare providers regarding currently marketed devices. The importance of choosing the right inhaler for the right patient is discussed, and the relative merits of dry powder inhalers, pressurised metered dose inhalers, breath-actuated pressurised metered dose inhalers, spacers and soft mist inhalers are considered. Compiling the latest studies in the devices therapy area, this review focuses on the most common types of handling errors, as well as the comparative rates of incorrect inhalation technique between devices. The impact of device-specific handling errors on inhaler performance is also discussed, and the characteristics that can impair optimal drug delivery, such as inhalation flow rate, inhalation volume and particle size, are compared between devices. The impact of patient perceptions, behaviours and problems with inhalation technique is analysed, and the need for appropriate patient education is also highlighted. The continued development of technology in inhaler design and the need to standardise study assessment, endpoints and patient populations are identified as future research needs. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Federico Lavorini
- Careggi University Hospital, Department of
Experimental and Clinical Medicine, Largo Brambilla 3, 50134, Florence,
Italy
| | - Christer Janson
- Department of Medical Sciences: Respiratory,
Allergy and Sleep Research, Uppsala University, Akademiska sjukhuset,
Uppsala, Sweden
| | - Fulvio Braido
- Allergy and Respiratory Disease Clinic,
DIMI-University of Genova, IRCCS AOU San Martino-IST, Genova, Italy
| | - Georgios Stratelis
- Department of Medical Sciences: Respiratory,
Allergy and Sleep Research, Uppsala University, Akademiska sjukhuset,
Uppsala, Sweden
- AstraZeneca Nordic-Baltic, Astraallén,
Sødertälje, Sweden
| | - Anders Løkke
- Department of Respiratory Diseases and Allergy,
Aarhus University Hospital, Aarhus C, Denmark
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Adib-Hajbaghery M, Karimi Z. Comparing the Effects of Face-to-face and Video-based Education on Inhaler Use: A Randomized, Two-group Pretest/posttest Study. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2018; 23:352-357. [PMID: 30186339 PMCID: PMC6111659 DOI: 10.4103/ijnmr.ijnmr_17_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background: The quality of inhaler use can significantly affect the effectiveness of inhalation medications. This study was done to compare the effects of face-to-face and video-based education methods on inhaler use. Materials and Methods: A quasi-experimental, pretest/posttest clinical trial study was conducted on 120 patients with respiratory diseases who were under treatment with metered-dose inhalers. Patients were randomly allocated into two groups to receive either face-to-face (n = 60) or video-based education (n = 60) about correct inhaler use. Inhaler use was assessed using a 15-item checklist before, 2 weeks, and 1 month after the education. Chi-square and independent sample t-test as well as repeated-measures analysis of variance were used for data analysis. Results: At baseline, the groups did not differ significantly in inhaler use as shown by the mean score (t = 0.81, p = 0.33). Repeated-measures analysis showed that the mean score of inhaler use significantly increased in both groups 2 weeks and 1 month after the intervention (F = 585.07, p < 0.001). The t-test showed that at 2 weeks and 1 month after intervention the amount of increase in the face-to-face group was significantly greater than the video-based group (t = 3.31 and 5.93, p < 0.001). Conclusions: Both face-to-face and video-based education methods significantly improve inhaler use, even though the effects of the face-to-face method are significantly greater. Nurses can use either of these two methods or both for education of patients about inhaler use.
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Affiliation(s)
- Mohsen Adib-Hajbaghery
- Trauma Nursing Research Centre, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran
| | - Zeynab Karimi
- Trauma Nursing Research Centre, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran
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Tariq SM. Exacerbation of asthma due to inadvertent use of a dummy inhaler. Respir Med Case Rep 2018; 24:133-134. [PMID: 29977780 PMCID: PMC6010635 DOI: 10.1016/j.rmcr.2018.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 11/13/2022] Open
Abstract
Asthma is a common airways disease. Fortunately most patients respond well to inhaled therapy. Regular use of a combination inhaler delivering corticosteroid and a long-acting beta-2 agonist, is the mainstay of treatment and allows asthmatics to live a relatively normal life. However, management of asthma depends not only on the choice of drug/inhaler but also on patient compliance and optimal inhaler technique. This report describes a patient who continued to deteriorate despite adhering to prescribed treatment and demonstrating a good inhaler technique. Unfortunately the combination inhaler she was taking inadvertently was a designated placebo device for a branded product. This error was identified and corrected only after she was admitted with an asthma attack.
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Taylor TE, Zigel Y, Egan C, Hughes F, Costello RW, Reilly RB. Objective Assessment of Patient Inhaler User Technique Using an Audio-Based Classification Approach. Sci Rep 2018; 8:2164. [PMID: 29391489 PMCID: PMC5794789 DOI: 10.1038/s41598-018-20523-w] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 01/16/2018] [Indexed: 12/29/2022] Open
Abstract
Many patients make critical user technique errors when using pressurised metered dose inhalers (pMDIs) which reduce the clinical efficacy of respiratory medication. Such critical errors include poor actuation coordination (poor timing of medication release during inhalation) and inhaling too fast (peak inspiratory flow rate over 90 L/min). Here, we present a novel audio-based method that objectively assesses patient pMDI user technique. The Inhaler Compliance Assessment device was employed to record inhaler audio signals from 62 respiratory patients as they used a pMDI with an In-Check Flo-Tone device attached to the inhaler mouthpiece. Using a quadratic discriminant analysis approach, the audio-based method generated a total frame-by-frame accuracy of 88.2% in classifying sound events (actuation, inhalation and exhalation). The audio-based method estimated the peak inspiratory flow rate and volume of inhalations with an accuracy of 88.2% and 83.94% respectively. It was detected that 89% of patients made at least one critical user technique error even after tuition from an expert clinical reviewer. This method provides a more clinically accurate assessment of patient inhaler user technique than standard checklist methods.
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Affiliation(s)
- Terence E Taylor
- Trinity Centre for Bioengineering, Trinity College, The University of Dublin, Dublin, Ireland. .,School of Engineering, Trinity College, The University of Dublin, Dublin, Ireland.
| | - Yaniv Zigel
- Trinity Centre for Bioengineering, Trinity College, The University of Dublin, Dublin, Ireland.,Department of Biomedical Engineering, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Clarice Egan
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fintan Hughes
- Trinity Centre for Bioengineering, Trinity College, The University of Dublin, Dublin, Ireland
| | - Richard W Costello
- Department of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard B Reilly
- Trinity Centre for Bioengineering, Trinity College, The University of Dublin, Dublin, Ireland.,School of Engineering, Trinity College, The University of Dublin, Dublin, Ireland.,School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
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Abstract
BACKGROUND Asthma is a common chronic disease worldwide. Inhalers are often prescribed to help control asthma symptoms, improve quality of life and reduce the risk of exacerbations or flare-ups. However, evidence suggests that many people with asthma do not use their inhaler correctly. It is therefore important to evaluate whether interventions aimed specifically at improving technique are effective and safe, and whether use of these interventions translates into improved clinical outcomes. OBJECTIVES To assess the impact of interventions to improve inhaler technique on clinical outcomes and safety in adults and children with asthma. SEARCH METHODS We searched the Cochrane Airways Trials Register, which contains records compiled from multiple electronic and handsearched resources. We also searched trial registries and reference lists of primary studies. We conducted the most recent search on 23 November 2016. SELECTION CRITERIA We included studies comparing a group of adults or children with asthma receiving an inhaler technique intervention versus a group receiving a control or alternative intervention. We included parallel and cluster-randomised trials of any duration conducted in any setting, and planned to include only the first phase of any cross-over trials identified. We included studies reported as full-text articles, those published as abstracts only and unpublished data. DATA COLLECTION AND ANALYSIS Two review authors screened the search results for eligible studies. We extracted outcome data, assessed risk of bias in duplicate and resolved discrepancies by involving another review author. We grouped studies making similar comparisons by consensus (e.g. all those comparing enhanced inhaler technique education vs usual care) and conducted meta-analyses only if treatments, participants and the underlying clinical question were similar enough for pooling to make sense. We analysed dichotomous data as odds ratios, and continuous data as mean differences or standardised mean differences, all with random-effects models. We described skewed data narratively. We graded the results and presented evidence in 'Summary of findings' tables for each comparison. Primary outcomes were inhaler technique, asthma control and exacerbations requiring at least oral corticosteroids (OCS). MAIN RESULTS This review includes 29 parallel randomised controlled trials (RCTs) (n = 2210), although not all reported relevant or useable data. All participants had asthma, and follow-up ranged from 2 to 26 weeks. Most studies were at low or unclear risk of selection and attrition biases and at high risk for biases associated with blinding. We considered most of the evidence to be of low quality owing to these biases and to imprecision in the estimates of effect.We classified studies into three comparisons: enhanced face-to-face training session(s), multi-media-delivered inhaler training (e.g. DVD, computer app or game) and technique feedback devices. Differences between interventions, populations and outcome measures limited quantitative analyses, particularly for exacerbations, adverse events, unscheduled visits to a healthcare provider and absenteeism from work or school.Enhanced inhaler technique education and multi-media training improved technique in most studies immediately after the intervention and at follow-up, although the variety of checklists used meant that this was difficult to assess reliably. For both adults and children, how and when inhaler technique was assessed appeared to affect whether inhaler technique improved and by how much.Analyses of the numbers of people who demonstrated correct or 'good enough' technique were generally more useful than checklist scores. Adult studies of enhanced education showed benefit when this metric was used at 2 to 26 weeks' follow-up (odds ratio (OR) 5.00, 95% confidence interval (CI) 1.83 to 13.65; 258 participants; three studies; 31 per 100 with correct technique in the control group compared with 69 (95% CI 45 to 86) in the education group; moderate-quality evidence). A similar result was seen in studies looking at feedback devices at four weeks' follow-up (OR 4.80, 95% CI 1.87 to 12.33; 97 participants; one study; 51 per 100 with correct technique in the control group compared with 83 (95% CI 66 to 93) in the feedback group; low-quality evidence). However, the benefit of multi-media training for adults even immediately after the intervention was uncertain (OR 2.15, 95% CI 0.84 to 5.50; 164 participants; two studies; I² = 49%; 30 per 100 in the control group with correct technique compared with 47 (95% CI 26 to 70) in the multi-media group; moderate-quality evidence). Evidence tended to be less clear for children, usually because results were based on fewer and smaller studies.Some studies did not report exacerbations in a way that allowed meta-analysis; others provided inconclusive results. Inhaler technique interventions provided some benefit for asthma control and quality of life but generally did not lead to consistent or important clinical benefits for adults or children. Confidence intervals included no difference or did not reach a threshold that could be considered clinically important. Responder analyses sometimes showed improvement among more people in the intervention groups, even though the mean difference between groups was small. We found no evidence about harms. AUTHORS' CONCLUSIONS Although interventions to improve inhaler technique may work in some circumstances, the variety of interventions and measurement methods used hampered our ability to perform meta-analyses and led to low to moderate confidence in our findings. Most included studies did not report important improvement in clinical outcomes. Guidelines consistently recommend that clinicians check regularly the inhaler technique of their patients; what is not clear is how clinicians can most effectively intervene if they find a patient's technique to be inadequate, and whether such interventions will have a discernible impact on clinical outcomes.
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Affiliation(s)
- Rebecca Normansell
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK, SW17 0RE
| | - Kayleigh M Kew
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK, SW17 0RE
- British Medical Journal Technology Assessment Group (BMJ-TAG), BMJ Knowledge Centre, BMA House, Tavistock Square, London, UK, WC1H 9JR
| | - Alexander G Mathioudakis
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
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