Assessment of Poor Inhaler Technique in Older Patients with Asthma or COPD: A Predictive Tool for Clinical Risk and Inhaler Performance

Recalibrating Perceptions and Attitudes Toward Nebulizers versus Inhalers for Maintenance Therapy in COPD: Past as Prologue

Aerosol therapy administered via handheld inhaler or nebulizer device has long been standard for the treatment of chronic obstructive pulmonary disease (COPD), both for maintenance therapy and for management of acute exacerbations. Of the 2 options for drug delivery, inhaler devices are the most widely used for ambulatory patients with COPD as they are small, portable, and convenient and offer an array of medication options. They are, however, prone to suboptimal inhalation technique and use errors, which decrease the amount of medication delivered, compromise efficacy, and adversely affect clinical outcomes. Nebulizers are less often employed for aerosol delivery than inhalers, particularly in the home environment. Considered bulky and expensive, nebulizers have historically had limited medication options compared with inhalers. Nonetheless, nebulizers may be preferred over inhalers in specific patient populations, such as in patients with poor lung function, lack of hand-breath coordination, or cognitive impairment. Furthermore, technological advances and development of new nebulizer-compatible medications are shifting the benefit equation for nebulizers versus inhalers in a way that merits reconsideration of the role of nebulizers in the maintenance treatment of COPD. Using the available literature, this state-of-the-art review critically evaluates the benefits and limitations of aerosol therapy delivery via inhaler or nebulizer for patients with COPD; describes the factors that may influence the benefit equation, including current advances in nebulizer technology and future developments; and provides insights on implementation of nebulizer therapy in clinical practice.

Assessing the effectiveness of inhalation therapy in patients with chronic airway diseases: A new digital measurement

BACKGROUND

This study aimed to evaluate the effectiveness of inhalation therapy in patients with chronic airway diseases via the use of a new multiparametric inhalation assessment device.

METHODS

A multiparametric inhalation evaluation device (PF810, UBREATH, Zhejiang, China) that could simulate common inhalation devices with 6 different levels (0-V) of resistance was used in this study. The device was considered suitable if the three parameters of peak inspiratory flow rate (PIFR), effective inspiratory time (EIT), and breath-hold time (BHT) after inspiration met the minimum requirements.

RESULTS

A total of 4,559 tests were performed. The qualification rates of 0-V resistance gear from low to high were 3.38 % (I), 8.42 % (0), 15.31 % (II), 16.71 % (III), 20.27 % (IV), and 46.91 % (V). The COPD patients in the 3 experimental groups had the lowest percentages of isolates classified as resistant 0, III, and V, which were 5.65 %, 11.93 %, and 40.43 %, respectively. The lowest percentage was 39.67 % (V) for insufficient EIT and 18.40 % (V) for BHT less than 5 s after inspiration. The results of 149 subjects who had used the inhalation device showed that the VIE and EIT at 0 levels were significantly greater than those before training (Z= -5.651, -5.646, P < 0.001). The VIE and EIT at I-III and V significantly increased after training (all P < 0.05).

CONCLUSIONS

Patients using portable inhaler devices do not always inhale with adequate flow patterns. The multiparametric inhalation assessment device may be useful in outpatient settings.

A comprehensive evaluation of online inhaler use techniques for obstructive airway disease

BACKGROUND

Pulmonary inhaler therapy is a core treatment modality for >600 million individuals affected by obstructive airways disease globally. Poor inhaler technique is associated with reduced disease control and increased health care utilization; however, many patients rely on the internet as a technical resource. This study assesses the content and quality of online resources describing inhaler techniques.

METHODS

A Google search was conducted in April 2023 capturing the top 5 search results for 12 common inhaler devices. Websites were compared to product monographs for preparation/first use, inhalational technique, and post-usage/device care. They were also assessed using accepted quality metrics (GQS, DISCERN, JAMA Benchmark scores) and clinically relevant aspects based on the literature and consensus statements.

RESULTS

Websites regularly excluded critical steps important for proper inhaler technique. They performed best on information related directly to inhalation technique (average median score 78%), whereas steps related to preparation/first use (58%) or post-usage/device care (50%) were less frequently addressed. Median GQS, DISCERN, and JAMA Benchmark scores were 3 [IQR 3-4], 3 [IQR 2-4], and 1 [IQR 1-3], respectively. Clinically relevant factors were only addressed in about one-fifth of websites with no websites addressing smoking cessation, environmental considerations, or risk factors for poor technique.

CONCLUSIONS

This study highlights gaps in online resources describing inhaler technique, particularly related to preparation/first use and post-usage/device care steps. Clinically relevant factors were rarely addressed across websites. Improvements in these areas could lead to enhanced inhaler technique and clinical outcomes.

Impact of treatment adherence and inhalation technique on asthma outcomes of pediatric patients: a longitudinal study

Introduction: We aimed to evaluate the longitudinal relationships, both at between- and within-person levels, that adherence to inhaled corticosteroid-based maintenance treatment and inhalation technique present with symptom control, exacerbations, and health-related quality of life (HRQoL) in children and adolescents with asthma. Methods: Participants (6-14 years old) from the ARCA (Asthma Research in Children and Adolescents) cohort-a prospective, multicenter, observational study (NCT04480242)-were followed for a period from 6 months to 5 years via computer-assisted telephone interviews and a smartphone application. The Medication Intake Survey-Asthma (MIS-A) was administered to assess the implementation stage of adherence, and the Inhalation Technique Questionnaire (InTeQ) was used to assess the five key steps when using an inhaler. Symptom control was measured with the Asthma Control Questionnaire (ACQ), and HRQL was measured with the EQ-5D and the Patient-Reported Outcomes Measurement Information System-Pediatric Asthma Impact Scale (PROMIS-PAIS). Multilevel longitudinal mixed models were constructed separately with symptom control, exacerbation occurrence, EQ-5D, and PROMIS-PAIS as the dependent variables. Results: Of the 360 participants enrolled, 303 (1,203 interviews) were included in the symptom control and exacerbation analyses, 265 (732) in the EQ-5D, and 215 (617) in the PROMIS-PAIS. Around 60% of participants were male subjects, and most of them underwent maintenance treatment with inhaled corticosteroids plus long-acting β-agonists in a fixed dose (73.3%). Within-person variability was 83.6% for asthma control, 98.6% for exacerbations, 36.4% for EQ-5D, and 49.1% for PROMIS-PAIS. At the within-person level, patients with higher adherence had better symptom control (p = 0.002) and HRQoL over time (p = 0.016). Patients with a better inhalation technique reported worse HRQoL simultaneously (p = 0.012), but they showed better HRQoL in future assessments (p = 0.012). The frequency of reliever use was associated with symptom control (p < 0.001), exacerbation occurrence (p < 0.001), and HRQoL (p = 0.042); and boys were more likely to present better symptom control and HRQoL than girls. Conclusion: Our results confirm longitudinal associations at the within-person level of the two indicators of quality use of inhalers: for adherence to maintenance treatment with symptom control and HRQoL, and for the inhalation technique with HRQoL. Although treatment adherence was shown to be excellent, a third of the participants reported a suboptimal inhalation technique, highlighting the need for actions for improving asthma management of the pediatric population.

Recognizing and Tackling Inhaler Technique Decay in Asthma and Chronic Obstructive Pulmonary Disesase (COPD) Clinical Practice

A poor inhaler technique continues to represent a substantial barrier to effective asthma and chronic obstructive pulmonary disease management. It can result in perceived lack of treatment effectiveness even with apparent adherence to a prescribed regimen of inhaled maintenance therapies, potentially resulting in an unnecessary change or escalation of treatment. Many patients are not trained to inhaler mastery in real-world practice; furthermore, even where mastery is initially achieved, an ongoing assessment and education are seldom maintained. In this review, we present an overview of the evidence for deterioration of the inhaler technique over time after training, investigate the factors that contribute to this deterioration, and explore innovative approaches to addressing the problem. We also propose steps forward drawn from the literature and our clinical insights.

Cognitive impairment according to Montreal Cognitive Assessment independently predicts the ability of chronic obstructive pulmonary disease patients to maintain proper inhaler technique

BACKGROUND

Maintaining correct inhaler technique is crucial in the management of chronic obstructive pulmonary disease (COPD). We aimed to investigate the inhaler technique in patients with COPD, to compare it immediately after and at 1 month after training, and to identify the predictors of incorrect inhaler use at 1 month after training.

METHODS

This prospective study was conducted at the COPD clinic of Siriraj Hospital (Bangkok, Thailand). Patients demonstrating improper inhaler use were trained face-to-face by pharmacists. Inhaler technique was re-assessed immediately after and at 1 month after training. The Montreal Cognitive Assessment (MoCA) score, pulmonary function tests, 6-min walk distance (6 MWD), modified Medical Research Council scale score, and COPD Assessment Test (CAT) score were evaluated.

RESULTS

Sixty-six patients with COPD who demonstrated at least one critical error during the use of any controller inhaler were enrolled. The mean age was 73.0 ± 9.0 years, and 75.8% patients had moderate/severe COPD. Immediately after training, all patients used dry powder inhalers correctly and 88.1% used pressurized metered-dose inhalers correctly. At 1 month, the number of patients demonstrating the correct technique decreased across all devices. Multivariable analysis revealed that MoCA score ≤ 16 was independently associated with a critical error at 1 month after training (adjusted odds ratio: 12.7, 95% confidence interval: 1.8-88.2, p = 0.010). At 1 month, CAT score (11.4 ± 8.9 vs. 8.4 ± 5.5, p = 0.018) and 6 MWD (351 ± 93 m vs. 372 ± 92 m, p = 0.009) had significantly improved in patients demonstrating the correct technique, and CAT score met the minimal clinically important difference.

CONCLUSIONS

Face-to-face training by pharmacists improved patient performance. However, the number of patients following proper technique had decreased at 1 month after training. Cognitive impairment (MoCA score ≤ 16) independently predicted the ability of COPD patients to maintain proper inhaler technique. Assessment of cognitive function combined with technical re-assessment and repeated training should improve COPD management.

Determining factors associated with inhaled therapy adherence on asthma and COPD: A systematic review and meta-analysis of the global literature

BACKGROUND

Adherence to therapy has been reported worldwide as a major problem, and that is particularly relevant on inhaled therapy for Asthma and Chronic Obstructive Pulmonary Disease (COPD), considering its barriers and features. We reviewed the global literature reporting the main determinants for adherence on these patients.

METHODS

Searches were made using the Cochrane Library, MEDLINE, EMBASE and ISI Web of Science databases. Analytical, observational and epidemiological studies (cohort, case-control and cross-sectional studies) were included, reporting association between any type of determinant and the adherence for inhaler therapy on Asthma or COPD. Random-effects meta-analysis were used to summarise the numerical effect estimates.

RESULTS

47 studies were included, including a total of 54.765 participants. In meta-analyses, the significant determinants of adherence to inhaled therapy were: older age [RR = 1.07 (1.03-1.10); I² = 94; p < 0.0001] good disease knowledge/literacy [RR = 1.37 (1.28-1.47); I² = 14; p = 0.33]; obesity [RR = 1.30 (1.12-1.50); I² = 0; p = 0.37]; good cognitive performance [RR = 1.28 (1.17-1.40); I² = 0; p = 0.62]; higher income [RR = 1.63 (1.05-2.56); I² = 0; p = 0.52]; being employed [RR = 0.87 (0.83-0.90); I² = 0; p = 0.76] and using multiple drugs/inhalers [RR = 0.81 (0.79-0.84); I² = 0; p = 0.80]. Overall, the strength of the underlying evidence was only low to moderate.

CONCLUSIONS

Many determinants may be associated to patient's adherence, and personalised interventions should be taken in clinical practice to address it by gaining an understanding of their individual features.

A Systematic Review of Published Algorithms for Selecting an Inhaled Delivery System in COPD

RATIONALE

Medication for treatment of COPD is available in many different delivery systems; however, national and international guidelines do not provide recommendations on how to select the optimal system for an individual patient.

OBJECTIVES

To perform a systematic review of published algorithms for inhaler selection in out-patients with COPD.

METHODS

PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were search for articles on inhaler selection published between January 1, 1990 and March 10, 2021. The results were reviewed for articles containing an algorithm for inhaler selection. The quality of publications containing an algorithm was assessed using the JBI SUMARI text and opinion critical appraisal checklist. Individual steps recommended in the algorithms and the order in which they were considered were extracted independently by the two authors using the JBI text and opinion data extraction tool. Textual syntheses and a table of factors included were used to appraise and compare algorithms.

RESULTS

The search identified 1016 publications. After removing duplicate studies (n = 409), 607 abstracts were examined. Nine different algorithms or hierarchical recommendations for device selection were identified. All nine publications were considered of good quality. Most algorithms contain only a few decision steps. There were significant differences between the algorithms. None of the algorithms have been validated. Three domains for factors included in the algorithms were identified: patient factors, device attributes, and HCP factors. Patient factors were considered most frequently (19 times) compared with device attributes (10 times) and HCP factors (7 times). Five specific attribute/factors with at least three rankings in different algorithms, were identified as key factors for device selection.

CONCLUSION

Although the algorithms generally provide step-by-step approaches based on a literature review and/or the experiences of the different authors, none were developed using item generation/reduction methodology nor included input from patients with COPD. There were considerable differences between the algorithms; however, the review identified key factors that should be considered by HCPs when selecting therapy. Registration: PROSPERO (CRD42021244475).

Managing asthma in primary healthcare

Asthma brings considerable challenges for family doctors because of its variety of shapes, different levels of severity, a wide age range, and the fact that in the last decades clinicians are able to offer much better treatment options with a better level of disease control and a higher quality of life. The objectives of the current review article are to provide an up-to-date review by primary care respiratory leaders from different countries of the most significant challenges regarding asthma diagnosis and management, the importance of team work and the problems in recognizing and dealing with difficult-to-manage and severe asthma in primary care. The article provides a short review of the main challenges faced by family physicians and other primary health care professionals in supporting their patients in the management of asthma, such as asthma diagnosis, promoting access to spirometry, the importance of a multiprofessional team for the management of asthma, how to organize an asthma review, the promotion of patient autonomy and shared decision-making, improving the use of inhalers, the importance of the personalized asthma action plan, dealing with difficult-to-manage and severe asthma in primary care and choosing when, where and how to refer patients with severe asthma. The article also discusses the development of an integrated approach to asthma care in the community and the promotion of Asthma Right Care.

Metabolic Phenotypes in Asthmatic Adults: Relationship with Inflammatory and Clinical Phenotypes and Prognostic Implications

Bronchial asthma is a chronic disease that affects individuals of all ages. It has a high prevalence and is associated with high morbidity and considerable levels of mortality. However, asthma is not a single disease, and multiple subtypes or phenotypes (clinical, inflammatory or combinations thereof) can be detected, namely in aggregated clusters. Most studies have characterised asthma phenotypes and clusters of phenotypes using mainly clinical and inflammatory parameters. These studies are important because they may have clinical and prognostic implications and may also help to tailor personalised treatment approaches. In addition, various metabolomics studies have helped to further define the metabolic features of asthma, using electronic noses or targeted and untargeted approaches. Besides discriminating between asthma and a healthy state, metabolomics can detect the metabolic signatures associated with some asthma subtypes, namely eosinophilic and non-eosinophilic phenotypes or the obese asthma phenotype, and this may prove very useful in point-of-care application. Furthermore, metabolomics also discriminates between asthma and other “phenotypes” of chronic obstructive airway diseases, such as chronic obstructive pulmonary disease (COPD) or Asthma–COPD Overlap (ACO). However, there are still various aspects that need to be more thoroughly investigated in the context of asthma phenotypes in adequately designed, homogeneous, multicentre studies, using adequate tools and integrating metabolomics into a multiple-level approach.

Distribution of COPD Comorbidities and Creation of Acute Exacerbation Risk Score: Results from SCICP

Background

Chronic obstructive pulmonary disease (COPD) often coexists with multiple comorbidities which may have a significant impact on acute exacerbations of patients. At present, what kind of comorbidities affects acute exacerbations and how comorbidities lead to poor prognosis are still controversial. The purpose of our study is to determine the impact of comorbidities on COPD exacerbation and establish an acute exacerbation risk assessment system related to comorbidities.

Methods

A total of 742 COPD patients participated in the Shanghai COPD Investigation on Comorbidity Program (SCICP, ChiCTR2000030911). Finally, the baseline information of 415 participants and one-year follow-up data were involved in the analysis. We collected hemogram indices, pulmonary function tests and acute exacerbation of COPD with regular medical follow-up. Q-type cluster analysis was used to determine the clusters of participants. Receiver operating characteristic (ROC) analysis was constructed to assess the ability of indicators in predicting acute exacerbations.

Results

Almost 65% of the population we investigated had at least one comorbidity. The distribution and incidence of comorbidities differed between exacerbation group and non-exacerbation group. Three comorbidity clusters were identified: (1) respiratory, metabolic, immune and psychologic disease (non-severe cases); (2) cardiovascular and neoplastic disease (severe cases); (3) less comorbidity. Different sub-phenotypes of COPD patients showed significant distinction in health status. Anxiety (OR=5.936, P=0.001), angina (OR=10.155, P=0.025) and hypertension (OR=3.142, P=0.001) were found to be independent risk factors of exacerbation in a year. The novel risk score containing BODEx and four diseases showed great prognostic value of COPD exacerbation in developing sample.

Conclusion

Our study detailed the major interaction between comorbidities and exacerbation in COPD. Noteworthily, a novel risk score using comprehensive index – BODEx – and comorbidity parameters can identify patients at high risk of acute exacerbation.

Association of depression with improper use of inhaler devices by patients with obstructive disease

INTRODUCTION

Obstructive pulmonary disease may cause some psychiatric disorders such as depression, similar to other chronic diseases. Patients with chronic obstructive pulmonary disease or asthma are especially susceptible to inhaler technique errors. The aim of this study was to evaluate the depression that can affect improper use of inhaler devices and to show the contribution of age, sex, and education to correct usage.

MATERIALS AND METHODS

In this study, trained health care workers in the presence of Chest specialist requested patients to demonstrate their inhaler technique and assessed it according to the checklist. If any of the steps were missing or done incorrectly, it was marked as an incorrect technique.

RESULTS

We included 188 participants, mean age of 58.3 ± 12.7 years. Significant variables of individual risk were having comorbidities, age, sex, smoking status, and educational level. There was an inverse relationship between education level and incorrect inhaler technique. Even after controlling for age, gender, and education, depressive symptoms were a significant and independent predictor of improper use of inhaler devices. High levels of depressive symptoms were associated with a 22-fold increase (95% confidence interval, 8.9 to 53.5) in the odds of improper use of inhaler devices after adjustment for potential confounders.

CONCLUSIONS

As a result, the presence of depression symptoms may increase the improper use of inhaler devices. Further research is needed to determine if screening for and treating depression improves improper use of inhaler devices and obstructive disease outcomes in this population.

Integrating Comorbidities and Phenotype-Based Medicine in Patient-Centered Medicine in COPD

Despite recent notable innovations in the management of chronic obstructive pulmonary disease (COPD), no major advances in patient-centered medicine have been achieved. Current guidelines base their proposals on the average results from clinical trials, leading to what could be termed ‘means-based’ medical practice. However, the therapeutic response is variable at the patient level. Additionally, the variability of the clinical presentation interacts with comorbidities to form a complex clinical scenario for clinicians to deal with. Consequently, no consensus has been reached over a practical approach for combining comorbidities and disease presentation markers in the therapeutic algorithm. In this context, from the patients’ first visit, the clinician faces four major dilemmas: (1) establishing the correct diagnosis of COPD as opposed to other airway diseases, such as bronchial asthma; (2) deciding on the initial therapeutic approach based on the clinical characteristics of each case; (3) setting up a study strategy for non-responding patients; (4) pursuing a follow-up strategy with two well-defined periods according to whether close or long-term follow-up is required. Here, we will address these major dilemmas in the search for a patient-centered approach to COPD management and suggest how to combine them all in a single easy-to-use strategy.