Home videos of cystic fibrosis patients using tobramycin inhalation powder: Relation of flow and cough

Cystic fibrosis year in review 2019: Section 2 pulmonary disease and infections

During the year 2019, research and case reports or series in the field of cystic fibrosis (CF) were in abundance. To adequately address the large body of CF research published during 2019, the CF year in review will be divided into three sections. This report is the second section, focusing specifically on new research related to pulmonary disease and infections. Additional sections will concentrate on CF transmembrane conductance regulator modulators and the multisystem effects of CF. It is an exciting time to be providing care for patients and their families with CF with all the exciting new discoveries that will be shared in these reviews.

The Use of Tobramycin for Pseudomonas aeruginosa: A Review

INTRODUCTION

Pseudomonas aeruginosa is a common respiratory pathogen that contributes to chronic pulmonary infection in individuals with cystic fibrosis. Guidelines recommend early intervention upon positive P. aeruginosa culture. Tobramycin has in vitro activity against Gram-negative bacteria, including P. aeruginosa, and TOBI Podhaler is indicated for the management of individuals with cystic fibrosis with P. aeruginosa infection. The dry powder inhaler formulation decreases the time required for treatment compared with nebulized solution and therefore may improve quality of life and adherence, which have a positive impact on disease progression.

AREAS COVERED

In this review, we discuss the safety and efficacy of tobramycin inhaled powder and provide insights into appropriate individuals who might benefit from a dry powder inhaler, keeping in mind that patient preference is an important consideration for therapy selection.

EXPERT OPINION

Providing a less burdensome alternative to delivering inhaled antibiotics that is more portable with a significantly shorter administration time may help improve adherence, and therefore improve outcomes. Continued development of new antibiotics to add to current regimens for eradication and control of airway microbiology, combined with more efficient delivery systems such as tobramycin inhaled powder, will help evolve the treatment of patients with CF.

Post-inhalation cough with therapeutic aerosols: Formulation considerations

This review provides an assessment of post-inhalation cough with therapeutic aerosols. Factors that increase cough may be mitigated through design of the drug, formulation, and device. The incidence of cough is typically less than 5% for drugs with a nominal dose less than 1 mg, including asthma and COPD therapeutics. Cough increases markedly as the dose approaches 100 mg. This is due to changes in the composition of epithelial lining fluid (e.g., increases in osmolality, proton concentration). Whether an individual exhibits cough depends on their degree of sensitization to mechanical and chemical stimuli. Hypersensitivity is increased when the drug, formulation or disease result in increases in lung inflammation. Cough related to changes in epithelial lining fluid composition can be limited by using insoluble neutral forms of drugs and excipients.

Home videos of cystic fibrosis patients using tobramycin inhalation powder: Relation of flow and cough

BACKGROUND

Many cystic fibrosis (CF) patients chronically infected with Pseudomonas aeruginosa are on maintenance tobramycin inhalation therapy. Cough is reported as a side effect of tobramycin inhalation powder (TIP) in 48% of the patients. Objectives of this study were to investigate the association between the inspiratory flow of TIP and cough and to study the inhalation technique. We hypothesized that cough is related to a fast inhalation.

MATERIALS AND METHODS

In this prospective observational study, CF patients ≥ 6 years old on TIP maintenance therapy from four Dutch CF centers were visited twice at home. Video recordings were obtained and peak inspiratory flow (PIF) was recorded while patients inhaled TIP. Between the two home visits, the patients made three additional videos. CF questionnaire-revised, spirometry data, and computed tomography scan were collected. Two observers scored the videos for PIF, cough, and mistakes in inhalation technique. The associations between PIF and cough were analyzed using a logistic mixed-effects model accounting for FEV₁ % predicted and capsule number.

RESULTS

Twenty patients were included, median age 22 (18-28) years. No significant associations were found between PIF and cough. The risk of cough was highest after inhalation of the first capsule when compared to the second, third, and fourth capsule (P ≤ .015). Fourteen patients (70%) coughed at least once during TIP inhalation. A breath-hold of less than 5 seconds after inhalation and no deep expiration before inhalation were the most commonly observed mistakes.

CONCLUSION

PIF is not related to cough in CF patients using TIP.