Mastery of pMDI technique, asthma control and quality-of-life of children with asthma: A randomized controlled study comparing two inhaler technique training approaches

Relative Lung and Systemic Bioavailability Along with Oropharyngeal Deposition of Salbutamol Post-Inhalation: A Pharmacokinetic Evaluation of Novel Inhaler Technique Training Gadgets

Background: Suboptimal use of pressurized metered dose inhaler (pMDI) remains a major barrier to inhaled therapy success. Verbal inhaler technique training (VT) fails to maintain patients' good pMDI use, thus training tools might help. Trainhaler^® (THR device) and Flo-Tone^® CR (FTCR device), two novel pMDI technique training tools, were evaluated and compared in terms of relative lung and systemic bioavailability and oropharyngeal deposition of salbutamol inhaled from Ventolin^® Evohaler^® (GlaxoSmithKline) either alone following THR or connected to FTCR. Methods: Sixteen healthy adults inhaled 2 × 100 μg salbutamol puffs (1 minute apart) from Ventolin using the THR device or FTCR device in a two-period, randomized crossover study. A 7-day washout separated THR and FTCR approaches. Immediately after each puff inhalation, each subject gargled with 20 mL water for oropharyngeal deposition determination. Urine samples were collected 0.5 hour (pre-inhalation) and 0.5, 1.0, and 2.0 hours post-inhalation. Urine was then pooled till 24-hour post-inhalation. The relative lung bioavailability (0- to 0.5-hour urinary salbutamol excretion-USAL0.5) and relative systemic bioavailability (0- to 24-hour urinary excretion of salbutamol and its metabolite-USALMET24) were determined. Results: The mean (standard deviation [SD]) USAL0.5 of the THR and FTCR groups was 5.70 (6.43) and 11.39 (9.67) μg, respectively. The mean (SD) oropharyngeal deposition was 11.11 (4.37) and 6.09 (1.89) μg, respectively. The THR and FTCR devices were statistically significantly different in USAL0.5 and oropharyngeal deposition (p < 0.001), whereas there was no statistically significant difference in USALMET24. Conclusion: The THR device and the FTCR device showed positive impact on inhaled pMDI delivery. Indeed, the FTCR device doubled the relative lung bioavailability and minimized the unwanted oropharyngeal deposition of inhaled salbutamol. In practice, these pMDI trainers would complement and maintain VT. Study Registration: The study was registered on the ISRCTN registry (Reference: ISRCTN88332465-06/12/2017 [Prospectively Registered]).

Turning green: the impact of changing to more eco-friendly respiratory healthcare - a carbon and cost analysis of Dutch prescription data

OBJECTIVES

Dry powder inhalers (DPIs) and soft mist inhalers have a substantially lower global warming potential than pressurised metered-dose inhalers (pMDIs). To help mitigate climate change, we assessed the potential emission reduction in CO₂ equivalents when replacing pMDIs by non-propellant inhalers (NPIs) in Dutch respiratory healthcare and estimated the associated cost.

DESIGN

We performed a descriptive analysis of prescription data from two national databases of two independent governmental bodies. First, we calculated the number of patients with chronic obstructive pulmonary disease (COPD) and asthma that were using inhalation medication (2020). Second, we calculated the number and total of daily defined doses of pMDIs and NPIs including DPIs and soft mist inhalers, as well as the number of dispensed spacers per patient (2020). Third, we estimated the potential emission reduction in CO₂ equivalents if 70% of patients would switch from using pMDIs to using NPIs. Fourth, we performed a budget impact analysis.

SETTING

Dutch respiratory healthcare.

PRIMARY AND SECONDARY OUTCOME MEASURES

The carbon footprint of current inhalation medication and the environmental and financial impact of replacing pMDIs with NPIs.

RESULTS

In 2020, 1.4 million patients used inhalers for COPD or asthma treatment. A total of 364 million defined daily doses from inhalers were dispensed of which 49.6% were dispensed through pMDIs. We estimated that this could be reduced by 70% which would lead to an annual reduction in greenhouse gas emission of 63 million kg.CO2 equivalents saving at best EUR 49.1 million per year.

CONCLUSIONS

In the Netherlands, substitution of pMDIs to NPIs for eligible patients is theoretically safe and in accordance with medical guidelines, while reducing greenhouse gas emission by 63 million kg.CO2 equivalents on average and saving at best EUR 49.1 million per year. This study confirms the potential climate and economic benefit of delivering a more eco-friendly respiratory care.

How we teach children with asthma to use their inhaler: a scoping review

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).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13052-022-01237-2.

When adherence and inhalation technique matter: Difficult-to-control pediatric asthma in low- to middle-income countries

Despite relatively recent advances in our understanding of the physiopathology of asthma and the availability of highly effective controller medications, such as inhaled corticosteroids (ICS), currently many pediatric patients fail to control their asthma, especially in low- and middle-income countries (LMICs). Although some of these difficult-to-control asthmatic children have severe therapy-resistant asthma, most of them experience poor asthma control due to various modifiable factors, among which poor adherence to inhaled controller therapy and inadequate inhaler technique are the most common. Although electronic monitoring devices have been considered to be essential tools in identifying patients with severe therapy-resistant asthma, their high cost and low availability have currently limited their use in clinical practice. For these reasons, clinicians might consider using validated self-reported questionnaires and the weight of inhaler canisters and as alternative and valid options for assessing adherence to inhaled controller therapy. Furthermore, clinicians might consider adopting validated instruments as an objective measurement of the adequacy of inhaler technique. Although recognizing poor adherence does not automatically lead to improved adherence, it is usually an essential first step in effectively targeting adherence behavior, especially if the reasons for low or erratic compliance are explored by means of non-judgmental doctor-patient communication. These recommendations could assist in overcoming our inability to have pediatric asthmatic patients use ICS and in avoiding escalating their controller therapy toward more expensive medications, eventually reaching the use biologics. Promoting the rational and cost-effective use of asthma controller therapy could help to optimize the limited health resources in many LMICs.

Status of inhalable antimicrobial agents for lung infection: progress and prospects

Introduction: Available parenteral and oral administration of antimicrobial agents (AMAs) in respiratory infections often show less penetration into the lung parenchyma. Due to inappropriate dose availability, the rate of antibiotic resistance is increasing gradually. Inhaled antibiotics intensely improve the availability of drugs at the site of respiratory infections. This targeted delivery minimizes systemic exposure and associated toxicity.Area covers: This review was performed by searching in the scientific database like PubMed and several trusted government sites like fda.gov, cdc.gov, ClinicalTrials.gov, etc. For better understanding, AMAs are classified in different stages of approval. Mechanism and characterization of pulmonary drug deposition section helps to understand the effective delivery of AMAs to the respiratory tract. There is a need for proper adoption of delivery devices for inhalable AMAs. Thus, delivery devices are extensively explained. Inspiratory flow has a remarkable impact on the delivery device that has been explained in detail.Expert opinion: Pulmonary delivery restricts the bulk administration of drugs in comparison with other routes. Therefore, novel AMAs with higher bactericidal activity at lower concentrations need to be synthesized. Extensive research is indeed in developing innovative delivery devices that would able to deliver higher doses of AMAs through the pulmonary route.

Comparison of inhalation technique with the Diskus and Autohaler in asthmatic children at home

Objective

Asthma is the most common chronic disease in childhood and anti-inflammatory medication is the cornerstone of treatment. Inhalers are frequently used incorrectly when demonstrated in the hospital, suggesting poor technique at home. We aimed to 1) compare daily inhalation technique with the Diskus and Autohaler in asthmatic children by filming inhalations at home and 2) compare daily inhalation technique with technique demonstrated in the hospital.

Methods

We performed a randomised study in asthmatic children (aged 6–18 years) from the outpatient clinic of Medisch Spectrum Twente hospital (Enschede, The Netherlands) from July 2014 to April 2016. Children received inhalation instructions for the Diskus and Autohaler and were randomised to use one device in the morning and the other in the evening. During the 28-day study period, inhalations were filmed at home and subsequently demonstrated in the hospital. All inhalations were checked for seven critical errors per device.

Results

636 videos with the Diskus and 663 with the Autohaler were provided by 27 children. The most common critical error in daily life was an incorrect device position during preparation of the Diskus (n=271) and an insufficiently deep inhalation (n=39) using the Autohaler. Percentage of correct days using the Diskus was 44%, compared to 96% with the Autohaler (p<0.001). The two most common errors with the Diskus were made at least twice as often at home than in the hospital.

Conclusion

Inhalation technique at home was markedly better with the Autohaler than with the Diskus. Paediatricians should be aware that hospital-based demonstrations can overestimate daily inhalation technique with the Diskus.

Inhalation technique at home is markedly better with the Autohaler than with the Diskus. Paediatricians should be aware that hospital-based demonstrations can overestimate daily inhalation technique with the Diskus.https://bit.ly/3cYK4eq

Strategies for Improving Inhalation Technique in Children: A Narrative Review

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.

ATTACHED, DETACHED and WITHOUT inhaler technique coaching tools to optimize pMDI use competence, asthma control and quality-of-life in asthmatic adults

Background

Poor pressurized metered dose inhaler (pMDI) technique is prevalent, which will diminish treatment gains. In a two-visit study, two novel pMDI training devices with feedback mechanisms; Trainhaler (THR) and Flo-Tone CR (FTCR), were evaluated alongside the traditional verbal inhaler training (VT) in asthma outpatients.

Methods

On visit 1, 18-60 year-old asthmatics with incorrect pMDI use [including peak inhalation flow (PIF) >60 L/min] signed consent and baseline pMDI technique, lung function, asthma control and quality-of-life were measured. Participants were randomized to receive pMDI technique training using VT, THR or FTCR. One hour post-training, the pMDI coordination and PIF were re-assessed. The THR and FTCR patients were given their assigned tools to take home to facilitate regular training. All outcomes were re-evaluated 6-8 weeks later (visit 2).

Results

Ninety-two asthmatics completed visit 1 (46 attended visit 2). Pre-training, 61.3% (VT), 61.5% (THR) and 65.0% (FTCR) patients similarly made ≥2 pMDI errors with mean PIFs 175.2, 187.1 and 158.9 L/min, respectively. pMDI use was significantly improved 1 h post-training. The subjects that completed visit 2 had significantly, yet equally, maintained the improved inhaler use; only 28.0% (VT), 26.2% (THR) and 21.7% (FTCR) patients made ≥2 pMDI errors with PIF improvements; 115.3, 94.6 and 96.1 L/min, respectively. Clinical outcomes remained comparable.

Conclusions

VT improves the overall pMDI technique, however patients gradually forget their VT. The THR and FTCR devices are retained by the patients as their self-monitoring, all-time personal trainers that boost and maintain their VT between routine clinic visits.

Comparison between the health-related quality of life of children/adolescents with asthma and that of their caregivers: a systematic review and meta-analysis

Objective:

To evaluate the health-related quality of life (HRQoL) of children/adolescents with asthma and that of their caregivers, comparing the two.

Methods:

This was a systematic review and meta-analysis based on the criteria of Preferred Reporting Items for Systematic Reviews and Meta-Analyses, with a strategy of searching five health-related databases (MEDLINE/PubMed, EMBASE, ScienceDirect, SciELO, and LILACS). We included studies that evaluated the HRQoL of children/adolescents with asthma and that of their caregivers with the Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver’s Quality of Life Questionnaire, respectively, using the total scores and the scores on the domains activity limitation, symptoms (children/adolescents only), and emotional function.

Results:

We identified 291 articles, and we evaluated 133 of those. A total of 33 articles, collectively including 4,101 subjects, were included in the meta-analysis. An analysis stratified by study design showed no differences between the HRQoL of the caregivers and that of the children/adolescents in the activity limitation domain and in the total score. However, the mean emotional function domain scores were significantly higher (better) among children/adolescents with asthma than among their caregivers in longitudinal studies-Δ = 0.82 (0.21-1.44)-and randomized clinical trials-Δ = 0.52 (0.29-0.79)-although not in cross-sectional studies-Δ = −0.20 (−0.03 to 0.43).

Conclusions:

The total HRQoL scores proved to be similar between children/adolescents with asthma and their caregivers. However, the two groups differed in their perception of their emotional function, the caregivers scoring significantly lower than the children/adolescents in that domain.

Comparative pharmacokinetics of salbutamol inhaled from a pressurized metered dose inhaler either alone or connected to a newly enhanced spacer design

BACKGROUND

Coordination between actuation of a pressurized metered dose inhaler (pMDI) and inhalation is a critical manoeuvre that many patients fail to perform correctly. pMDIs connected to spacers do not require hand-lung coordination. This study evaluated the relative lung and systemic bioavailability and oropharyngeal deposition of salbutamol post-inhalation from Ventolin® Evohaler® (GlaxoSmithKline) either alone following verbal inhaler technique counselling (VC) or connected to a newly improved Able Spacer® (AS).

METHODS

In a two-period, randomized crossover study, 16 healthy adults inhaled 2 × 100 µg salbutamol puffs (1 min gap) from Ventolin using VC or AS. Immediately after each puff inhalation, each subject gargled with 20 mL water for oropharyngeal deposition (OD) determination. Urine samples were collected 0.5 h (pre-) and 0.5, 1.0 and 2.0 h post-inhalation. Urine was then pooled 2-24 h post-inhalation. The relative lung bioavailability (0-0.5 h urinary salbutamol excretion - USAL0.5) and systemic bioavailability (0-24 h urinary excretion of salbutamol and its metabolite - USALMET24) were determined. A one week washout separated VC and AS use.

RESULTS

The mean (SD) USAL0.5 of VC and AS was 5.36 (4.48) and 12.80 (10.83) µg, respectively. The mean (SD) OD was 11.35 (3.37) and 0.48 (0.30) µg, respectively. VC and AS were significantly different in USAL0.5 and OD (p<0.001). USALMET24 was comparable (p>0.05).

CONCLUSIONS

Compared with VC, AS doubled the inhaled salbutamol lung dose and minimised its precipitation in the oral cavity. The results suggest this inhalation aid can add therapeutic and safety benefits particularly in patients with continued pMDI technique issues despite repeated VC.

Wrong inhalation technique is associated to poor asthma clinical outcomes. Is there room for improvement?

PURPOSE OF REVIEW

The long-term goals of asthma management are to control symptoms and to reduce the risk of exacerbations. Inhaled medication is the cornerstone of pharmacological treatment for asthma; therefore, good inhalation technique is the key for asthma management. However, up to 70% of asthma patients do not use their inhalers correctly. There is evidence on how poor inhalation technique is associated to poor asthma control. The purpose of this review is to present the most recent research in this field to help clinicians understand the importance of proper inhalers use and the possible interventions to optimize patients' inhalation technique.

RECENT FINDINGS

New evidence on how poor inhaler technique and specific critical errors are significantly associated to poor asthma control and exacerbations and how this negative impact could be improved by optimizing device selection, enhancing shared decision-making and giving more importance to education, both for patients and healthcare professionals. New devices and additional tools might help patients to achieve the correct inhaler technique and could form the basis of simplified educational interventions.

SUMMARY

There is an urgent need for specific interventions including new educational strategies to minimize the negative effects of wrong inhalation technique in asthma clinical outcomes.

Aerosol Therapy in Asthma-Why We Are Failing Our Patients and How We Can Do Better

In order for inhaled corticosteroids to be delivered adequately to the airways they require patients to take them regularly using an effective technique. Patients often have a poor inhaler technique, and this has been shown to result in sub-optimal asthma control. It is important for all clinicians prescribing inhaled medication to be experienced in the correct technique, and take time to train children so that they have mastered corrected inhaler technique. Using Teach to Goal or teach back methodology is a simple and effective way to provide this in the clinic setting. More than one training session is typically needed before children can master correct inhaler technique. Adherence to inhaled therapy has been shown to be sub-optimal in pediatric populations, with studies showing an average rate of around 50%. Subjective methods of measuring adherence have been shown to be inaccurate and overestimate rates. The advent of new technology has allowed adherence rates to be measured electronically, and it has been shown that regular feedback of these data can be effective at improving asthma control. New mobile apps and smart technology aim to engage patients and families with their asthma care. Effective use of these apps in collaboration with health care professionals has a vast potential to improve adherence rates and inhaler technique, resulting in improved asthma control.

The role of inspiratory flow in selection and use of inhaled therapy for patients with chronic obstructive pulmonary disease

Inhalation therapy is the mainstay of chronic obstructive pulmonary disease management, and inhaler selection can have a profound impact on drug delivery and medication adherence, as well as on treatment outcomes. Although multiple delivery systems, such as pressurized metered-dose inhalers, dry powder inhalers, slow-mist inhalers, and nebulizers, are available, clinical benefits achieved by patients rely on effective delivery of the inhaled medication to the airways. Among several factors influencing drug deposition, inspiratory flow is one of the most important. Inspiratory flow impacts drug delivery and subsequent clinical efficacy, making it necessary to adequately train patients to ensure correct inhaler use. Peak inspiratory flow is the maximal airflow generated during a forced inspiratory maneuver. Health care professionals need to select the appropriate delivery system after carefully considering patient characteristics, including lung function, optimal inspiratory flow, manual dexterity, and cognitive function. Herein, the role of inspiratory flow in the selection and use of inhaled therapy in patients with COPD is reviewed.

Evaluation of patients' real-world post-dispensing use and storage environments of tiotropium bromide Respimat® soft mist inhaler on its in vitro dose delivery and lung deposition

BACKGROUND

Oral inhalation is the main drug delivery route for treating obstructive lung conditions. Thus, many inhaler devices with various design and pharmaceutical formulation have been introduced. The fine particle dose (FPD) and mass median aerodynamic diameter (MMAD ≤ 5 μm) of the aerosol delivered dose (DD) dictate the therapeutically effective peripheral lung deposition. This study evaluated the in vitro aerosol emission performance of tiotropium bromide emitted from Spiriva® Respimat® soft mist inhalers (R) after living under patients' real-world, post-dispensing handling environments.

METHODS

This was a two-stage investigation. In the first clinical stage, research ethical approval was obtained to enrol patients already been using R for at least 3 months. Those who signed consent were given both new R to use and temperature and relative humidity (RH) handheld, portable data loggers to keep in the vicinity of the given R. The participants returned the given R and data loggers after 2 weeks. Patient recruitment took place in Amman, Jordan, during the summer (RS) and winter (RW). Subsequently, in the second laboratory stage, other R were strictly stored at an average of 21.0 °C and 46.9% RH as control (RC). The Next Generation Impactor (NGI) was used to evaluate the RS, RW and RC. The NGI was operated at a flow rate of 30 L/min.

RESULTS

The RS were exposed to an average (range) 23.6 °C (18.2-37.5 °C) and 43.8% RH (21.4-60.0% RH) that were statistically comparable (p > 0.05) to that of the RW; 17.3 °C (13.2-26.7 °C) and 52.8% RH (26.3-69.1% RH). The RW and RC retention environments were statistically different (p < 0.05), whilst the RS and RC had comparable (p > 0.05) conditions. No significant differences (p > 0.05) were found in the tiotropium bromide DD (2.39 vs 2.43 μg), FPD (0.88 vs 0.90 μg) and MMAD (5.1 vs 4.98 μm) between the RS and RW, respectively. Compared to the RC inhalers, both the RS and RW devices had significantly higher FPD and relatively smaller tiotropium bromide particles.

CONCLUSIONS

Using the R under the fluctuating summer and winter environments of our patients would not affect its overall tiotropium bromide emission performance. The significant increase in the respirable mass of the RS and RW might be offset by the increase in particles <1 μm particularly in patients with poor inhaler technique.

Delivered Lung Dose and Aerodynamic Particle Size Distribution of Salbutamol Pressurized Metered Dose Inhaler After Living Under Patients' Realistic Retention Environments

Background: The impact of inhalers' postdispensing, real-life temperature and relative humidity (RH) environments on their delivered dose (DD) and aerodynamic particle size distribution (APSD) is usually overlooked. This work evaluated the salbutamol DD and APSD of Ventolin^® Evohaler^® (V) inhalers already been used and stored by respiratory patients. Methods: Adult patients, prescribed V for ≥3 months before study enrollment, were dispensed both new V to use and portable, handheld electronic temperature and RH data loggers to keep close to the given V before returning them both after 2-3 weeks. Patients' enrollment took place during summer (VS) and winter (VW) seasons. The returned V was then in vitro evaluated using the Next Generation Impactor, and compared with control V (VC) counterparts stored under 21°C and 46% RH. Results: The VS survived in fluctuating habitats of 21.2°C-40.4°C and 16.2%-63.2% RH, which significantly (p < 0.05) decreased the salbutamol DD from 80.4 to 70.5 μg compared with VC. This 12.3% DD reduction was accompanied with a decrease in the fine particle dose from 26.2 to 20.4 μg (p < 0.05), and an increase in the mass median aerodynamic diameter from 2.3 to 2.5 μm (p < 0.05). The VW and VC had equivalent DD and APSD. Conclusion: Patients using V are expected to receive smaller lung doses during the hot summer season compared with intentionally well-kept VC. To have equivalent lung deposition, V users should be advised to retain their inhalers around 20°C with minimal daily environmental fluctuations during summer times.

The impact of patients' real-life environmental temperature and humidity use conditions of tiotropium dry powder inhaler on its aerosol emission characteristics

INTRODUCTION

Many factors can affect dry powder inhalers' (DPIs) aerosol emission and lung deposition. The fluctuation of environmental temperature and relative humidity (RH) that inhalers experience in realistic daily use has not been extensively evaluated. This work aimed to evaluate the delivered dose (DD) and aerodynamic particle size distribution (APSD) of tiotropium Handihaler DPI (H) after exposure to patients' real-life use environments.

METHODS

Ethical approval was obtained to enrol adult patients already using H. Patients who gave written consent were given new H to use and HygroLog temperature and RH data loggers to keep in the vicinity of the given inhaler. The H and HygroLog were returned after 2 weeks. Patient recruitment was done during the summer (HS) and winter (HW). As control, other HC were stored as per the leaflet storage instructions. The Next Generation Impactor was used to evaluate the inhalers.

RESULTS

The HC were stored under an average of 21.0 °C and 46.9% RH. The patients' HS and HW lived in an average (range) temperature (°C) 23.2 (18.3-38.2) and 17.8 (13.5-24.6), respectively, and RH 50.8% (24.3-65.3%) and 50.4% (30.6-72.4%), respectively. All H groups had comparable environments (p > 0.05). The HC, HS and HW gave similar tiotropium DD (μg) 7.60, 8.01 and 7.61, respectively (p > 0.05). Moreover, the fine particle dose μg (median diameter (μm)) were HC 2.41 (3.84), HS 2.55 (3.81) and HW 2.37 (3.83) (p > 0.05).

CONCLUSIONS

The aerosol emission behaviour of tiotropium Handihaler was tolerant to real-life retention environments of patients in Amman, Jordan.

Mishandling of pMDI and DPI inhalers in asthma and COPD - Repetitive and non-repetitive errors

BACKGROUND

Pharmacological treatment of asthma and chronic obstructive pulmonary disease (COPD) is based mainly on inhaled medications. There is a continuous need to examine and train patients in their inhalation technique. The objective of the presented study is to determine whether the errors which patients made during inhalations are repetitive, and therefore easier to eradicate, or rather accidental, hence require more attention and effort from the health care professionals.

METHODS

It was a prospective, cohort study which included adults with asthma or COPD, who have used at least one inhaler daily on a regular basis. Inhalation technique was evaluated twice in a six months interval basing on a list of the most common errors in the inhalation technique. There was no training of inhalation skills between visits.

RESULTS

There were 92 patients (46 asthmatics, 46 with COPD; median age 66 years, median duration of the disease 10 years) included into the analysis. 92% of patients made at least one error during their inhalation. Among pMDI users the most common device mishandlings were: no or too short breath-holding after inhalation (60% of the patients during the first visit; 50% during the 2nd), too rapid and too forceful inhalation (52%; 61%) and lack of exhalation before the use of the medicine (48%; 43%). Among the DPI users, the most numerous errors were: no or too short (less than 3 s) breath-holding after inhalation (62%; 55%) and slow and not forceful enough inhalation (38%; 36%). When comparing the mishandlings in the inhalation technique conducted during the first and second visit the majority of the errors conducted by the patients were repetitive. However, some errors such as too early termination of inhalation (p = 0.016), inhalation through the nose during actuation (p = 0.002) among pMDI users and lack of expiration before inhalation (p = 0.027) among DPI users, were non-permanent.

CONCLUSIONS

Improper inhalation technique is very common and the majority of errors made in inhalation technique are repetitive. This emphasizes the role of an ongoing verification and training of a proper inhalation technique in all patients that are regularly treated with inhalers.

Objective Assessment of Patient Inhaler User Technique Using an Audio-Based Classification Approach

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.