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Islam N, Suwandecha T, Srichana T. Dry powder inhaler design and particle technology in enhancing Pulmonary drug deposition: challenges and future strategies. Daru 2024:10.1007/s40199-024-00520-3. [PMID: 38861247 DOI: 10.1007/s40199-024-00520-3] [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: 09/18/2023] [Accepted: 04/27/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVES The efficient delivery of drugs from dry powder inhaler (DPI) formulations is associated with the complex interaction between the device design, drug formulations, and patient's inspiratory forces. Several challenges such as limited emitted dose of drugs from the formulation, low and variable deposition of drugs into the deep lungs, are to be resolved for obtaining the efficiency in drug delivery from DPI formulations. The objective of this study is to review the current challenges of inhaled drug delivery technology and find a way to enhance the efficiency of drug delivery from DPIs. METHODS/EVIDENCE ACQUISITION Using appropriate keywords and phrases as search terms, evidence was collected from the published articles following SciFinder, Web of Science, PubMed and Google Scholar databases. RESULTS Successful lung drug delivery from DPIs is very challenging due to the complex anatomy of the lungs and requires an integrated strategy for particle technology, formulation design, device design, and patient inhalation force. New DPIs are still being developed with limited performance and future device design employs computer simulation and engineering technology to overcome the ongoing challenges. Many issues of drug formulation challenges and particle technology are concerning factors associated with drug dispersion from the DPIs into deep lungs. CONCLUSION This review article addressed the appropriate design of DPI devices and drug formulations aligned with the patient's inhalation maneuver for efficient delivery of drugs from DPI formulations.
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Affiliation(s)
- Nazrul Islam
- Pharmacy Discipline, School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia.
- Centre for Immunology and Infection Control (CIIC), Queensland University of Technology, Brisbane, QLD, Australia.
| | - Tan Suwandecha
- Drug and Cosmetic Excellence Center and School of Pharmacy, Walailak University, Thasala, Nakhon Si Thammarat, 80160, Thailand
| | - Teerapol Srichana
- Drug Delivery System Excellence Center and Department of Pharmaceutical Technology, Prince of Songkla University, Hat Yai, Songkla, 90110, Thailand.
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2
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Islam N, Reid D. Inhaled antibiotics: A promising drug delivery strategies for efficient treatment of lower respiratory tract infections (LRTIs) associated with antibiotic resistant biofilm-dwelling and intracellular bacterial pathogens. Respir Med 2024; 227:107661. [PMID: 38729529 DOI: 10.1016/j.rmed.2024.107661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/12/2024]
Abstract
Antibiotic-resistant bacteria associated with LRTIs are frequently associated with inefficient treatment outcomes. Antibiotic-resistant Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, and Staphylococcus aureus, infections are strongly associated with pulmonary exacerbations and require frequent hospital admissions, usually following failed management in the community. These bacteria are difficult to treat as they demonstrate multiple adaptational mechanisms including biofilm formation to resist antibiotic threats. Currently, many patients with the genetic disease cystic fibrosis (CF), non-CF bronchiectasis (NCFB) and chronic obstructive pulmonary disease (COPD) experience exacerbations of their lung disease and require high doses of systemically administered antibiotics to achieve meaningful clinical effects, but even with high systemic doses penetration of antibiotic into the site of infection within the lung is suboptimal. Pulmonary drug delivery technology that reliably deliver antibacterials directly into the infected cells of the lungs and penetrate bacterial biofilms to provide therapeutic doses with a greatly reduced risk of systemic adverse effects. Inhaled liposomal-packaged antibiotic with biofilm-dissolving drugs offer the opportunity for targeted, and highly effective antibacterial therapeutics in the lungs. Although the challenges with development of some inhaled antibiotics and their clinicals trials have been studied; however, only few inhaled products are available on market. This review addresses the current treatment challenges of antibiotic-resistant bacteria in the lung with some clinical outcomes and provides future directions with innovative ideas on new inhaled formulations and delivery technology that promise enhanced killing of antibiotic-resistant biofilm-dwelling bacteria.
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Affiliation(s)
- Nazrul Islam
- Pharmacy Discipline, School of Clinical Sciences, Queensland University of Technology (QUT), Brisbane, QLD, Australia; Centre for Immunology and Infection Control (CIIC), Queensland University of Technology, Brisbane, Queensland, Australia; Centre for Materials Science, Queensland University of Technology, Brisbane, Queensland, Australia.
| | - David Reid
- Lung Inflammation and Infection, QIMR Berghofer Medical Research Institute, Australia
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Tashkin DP, Barjaktarevic I, Gomez-Seco J, Behbehani NH, Koltun A, Siddiqui UA. Prevalence and Management of Chronic Obstructive Pulmonary Disease in the Gulf Countries with a Focus on Inhaled Pharmacotherapy. J Aerosol Med Pulm Drug Deliv 2024. [PMID: 38813999 DOI: 10.1089/jamp.2023.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
Background: Chronic obstructive pulmonary disease (COPD) is a preventable, progressive disease and the third leading cause of death worldwide. The epidemiological data of COPD from Gulf countries are very limited, as it remains underdiagnosed and underestimated. Risk factors for COPD include tobacco cigarette smoking, water pipe smoking (Shisha), exposure to air pollutants, occupational dusts, fumes, and chemicals. Inadequate treatment of COPD leads to worsening of disease. The 2024 GOLD guidelines recommend use of inhaled bronchodilators, corticosteroids, and adjunct therapies for treatment and management of COPD patients based on an individual assessment of the severity of symptoms and risk of exacerbations. This article reviews COPD pharmacotherapy in the Gulf countries and explores the role of nebulization in the management of COPD in this region. Methods: To review the COPD pharmacotherapy in the Gulf Countries, literature search was conducted using PubMed, Medline, Cochrane Systematic Reviews, and Google Scholar databases (before December 2022), using search terms such as COPD, nebulization, inhalers/inhalation, aerosols, and Gulf countries. Relevant articles from the reference list of identified studies were reviewed. Consensus statements, expert opinion, and other published review articles were included. Results: In the Gulf countries, pressurized metered-dose inhalers (pMDIs), dry powder inhalers (DPIs), soft mist inhalers, and nebulizers are used for drug delivery to COPD patients. pMDIs and DPIs are most prone to errors in technique and other common device handling errors. Nebulization is another mode of inhalation drug delivery, which is beneficial in certain patient populations such as the elderly and patients with cognitive impairment, motor or neuromuscular disorders, and other comorbidities. Conclusion: There is no major difference between Gulf countries and rest of the world in the approach to management of COPD. Nebulizers should be considered for patients who have difficulties in accessing or using MDIs and DPIs, irrespective of geographical location.
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Affiliation(s)
- Donald P Tashkin
- David Geffen School of Medicine at UCLA Health Sciences, Los Angeles, California, USA
| | | | - Julio Gomez-Seco
- Department of Pulmonology, Fakeeh University Hospital, Dubai, United Arab Emirates
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Pleasants RA, Shaikh A, Henderson AG, Bayer V, Drummond MB. Changes in Peak Inspiratory Flow After Acute Bronchodilation: An Observational Study of Patients with Stable Chronic Obstructive Pulmonary Disease. J Aerosol Med Pulm Drug Deliv 2024. [PMID: 38814000 DOI: 10.1089/jamp.2023.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024] Open
Abstract
Introduction: Identifying factors influencing peak inspiratory flow (PIF) is essential for aerosol drug delivery in stable patients with chronic obstructive pulmonary disease. While a minimum PIF for dry powder inhalers (DPIs) is established, acute bronchodilator (BD) effects on PIF remain unknown. Materials and Methods: An inspiratory flow meter (In-Check™ DIAL) was used to measure PIF in stable patients during a 24-week observational cross-sectional study. Additionally, bronchodilator responsiveness (BDR) was determined using the In-Check DIAL device and spirometry. Patients received four puffs of albuterol, and pre- and post-BD PIF, forced expiratory volume in one second (FEV1), and forced vital capacity were measured. Sixty-three patients completed acute BDR data collection from July 31, 2019, to November 9, 2021. Primary endpoints were pre- and post-BD spirometry and PIF. Statistical analyses included PIF correlations with FEV1. BD change was assessed according to inhaler resistance and sex (subgroup analysis). Results: Median patient age was 64.8 years, 85.7% were non-Hispanic White, and 57.1% were female. The median increase in absolute PIF (In-Check DIAL) was 5.0 L/min, and the % PIF change was 8.9%. With albuterol, 57.1% experienced a PIF BD change >5.0%, whereas 49.2% experienced a change >10.0%. Similarly, 55.6% experienced an FEV1 BD change >5.0% and 28.6% had a >10.0% FEV1 BD change with albuterol. PIF was weakly correlated with FEV1 BD change (absolute; % PIF; r = 0.28 [p = 0.02]; r = 0.21 [p = 0.11]). Pre- and post-BD median PIF were 75.5 and 83.5 L/min for low-to-medium-resistance DPI and 45.0 and 52.0 L/min for high-resistance, respectively. The median increases in pre- and post-BD PIF were 9.0 L/min in males and 4.5 L/min in females. In contrast to when using the In-Check DIAL device, we observed no consistent bronchodilatory effects on PIF measured by spirometry. Conclusions: Using the In-Check DIAL device, ∼50% of patients experienced >10% PIF increase after acute BD, potentially enhancing medication lung deposition. Further research is required to understand PIF's impact on medication delivery. ClinicalTrials.gov Identifier: NCT04168775.
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Affiliation(s)
- Roy A Pleasants
- Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Asif Shaikh
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA
| | - Ashley G Henderson
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Valentina Bayer
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA
| | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Ohar JA, Mahler DA, Davis GN, Lombardi DA, Moran EJ, Crater GD. Clinical Burden of Chronic Obstructive Pulmonary Disease in Patients with Suboptimal Peak Inspiratory Flow. Can Respir J 2024; 2024:8034923. [PMID: 38560416 PMCID: PMC10980549 DOI: 10.1155/2024/8034923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/09/2024] [Accepted: 02/22/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction Many patients with chronic obstructive pulmonary disease (COPD) may derive inadequate benefit from dry powder inhalers (DPIs) because of suboptimal peak inspiratory flow (sPIF). Objectives To assess the clinical burden of COPD by characterizing the clinical characteristics of participants with sPIF against medium-low resistance DPIs versus those with optimal PIF (oPIF) from two phase 3 clinical trials. Methods Baseline data were collected from two randomized, controlled, phase 3 trials (NCT03095456; NCT02518139) in participants with moderate-to-severe COPD. oPIF (60 L/min) against the medium-low resistance DPIs was used as the threshold for defining the PIF subgroups (<60 L/min (sPIF) vs ≥60 L/min (oPIF)). Results Most participants included in this analysis were White (92%) and male (63%); the mean (range) age was 65 (43-87) years. Participants with sPIF had significantly greater dyspnea than those with oPIF as measured using the modified Medical Research Council scoring (mean (95% CI): 2.1 (2.0-2.2) vs 1.6 (1.4-1.7); P < 0.001) and baseline dyspnea index (mean (95% CI): 5.1 (4.9-5.4) vs 6.1 (5.8-6.3); P < 0.001). Based on COPD Assessment Test scores, participants with sPIF had a higher COPD symptom burden than those with oPIF (mean (95% CI): 21.5 (19.7-23.3) vs 19.5 (18.6-20.4); P = 0.05). Conclusion In these trials, participants with COPD who had sPIF against the medium-low resistance DPIs had more dyspnea and worse health status than those with oPIF. These results demonstrate that sPIF is associated with a higher clinical burden as measured by patient-reported outcomes.
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Affiliation(s)
- Jill A. Ohar
- Section of Pulmonary, Critical Care, Allergy, and Immunologic Diseases, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Donald A. Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Valley Regional Hospital, Claremont, NH, USA
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Wachtel H, Emerson-Stadler R, Langguth P, Hohlfeld JM, Ohar J. Aerosol Plumes of Inhalers Used in COPD. Pulm Ther 2024; 10:109-122. [PMID: 38194194 PMCID: PMC10881950 DOI: 10.1007/s41030-023-00249-5] [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: 09/12/2023] [Accepted: 11/21/2023] [Indexed: 01/10/2024] Open
Abstract
INTRODUCTION The selection of inhaler device is of critical importance in chronic obstructive pulmonary disease (COPD) as the interaction between a patient's inhalation profile and the aerosol characteristics of an inhaler can affect drug delivery and lung deposition. This study assessed the in vitro aerosol characteristics of inhaler devices approved for the treatment of COPD, including a soft mist inhaler (SMI), pressurized metered-dose inhalers (pMDIs), and dry powder inhalers (DPIs). METHODS High-speed video recording was used to visualize and measure aerosol velocity and spray duration for nine different inhalers (one SMI, three pMDIs, and five DPIs), each containing dual or triple fixed-dose combinations of long-acting muscarinic receptor antagonists and long-acting β2-agonists, with or without an inhaled corticosteroid. Measurements were taken in triplicate at experimental flow rates of 30, 60, and 90 l/min. Optimal flow rates were defined based on pharmacopoeial testing requirements: 30 l/min for pMDIs and SMIs, and the rate achieving a 4-kPa pressure drop against internal inhaler resistance for DPIs. Comparison of aerosol plumes was based on the experimental flow rates closest to the optimal flow rates. RESULTS The Respimat SMI had the slowest plume velocity (0.99 m/s) and longest spray duration (1447 ms) compared with pMDIs (velocity: 3.65-5.09 m/s; duration: 227-270 ms) and DPIs (velocity: 1.43-4.60 m/s; duration: 60-757 ms). With increasing flow rates, SMI aerosol duration was unaffected, but velocity increased (maximum 2.63 m/s), pMDI aerosol velocity and duration were unaffected, and DPI aerosol velocity tended to increase, with a more variable impact on duration. CONCLUSIONS Aerosol characteristics (velocity and duration of aerosol plume) vary by inhaler type. Plume velocity was lower and spray duration longer for the SMI compared with pMDIs and DPIs. Increasing experimental flow rate was associated with faster plume velocity for DPIs and the SMI, with no or variable impact on plume duration, whereas pMDI aerosol velocity and duration were unaffected by increasing flow rate.
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Affiliation(s)
- Herbert Wachtel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany.
| | - Rachel Emerson-Stadler
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany
| | - Peter Langguth
- Institute for Pharmaceutical and Biomedical Sciences (IPBW), University of Mainz, Mainz, Germany
| | - Jens M Hohlfeld
- Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover, Germany
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Jill Ohar
- Department of Internal Medicine, Section on Pulmonary Medicine, Critical Care, Allergy and Immunologic Diseases, Atrium Health Wake Forest Baptist, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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Mahler DA, Halpin DMG. Consideration and Assessment of Patient Factors When Selecting an Inhaled Delivery System in COPD. Chest 2024; 165:323-332. [PMID: 37977266 DOI: 10.1016/j.chest.2023.11.011] [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] [Received: 08/14/2023] [Revised: 10/23/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023] Open
Abstract
Because guidelines and strategies for pharmacologic treatment of COPD focus on specific classes of inhaled medications, there is an unmet need for information to guide health care professionals for selecting an inhaled medication delivery system that matches the unique characteristics of individual patients. This article provides guidance for selecting an inhaled medication delivery system based on three "key" patient factors: cognitive function, manual dexterity/strength, and peak inspiratory flow. In addition, information is provided about specific tests to assess these patient factors. Cognitive impairment with an estimated prevalence of 25% among patients with COPD adversely affects patients' ability to correctly use a handheld device. To our knowledge, the prevalence of impaired manual dexterity/strength has not been reported in those with COPD. However, 79% of patients with COPD have reported one or more physical impediments that could influence their ability to manipulate an inhaler device. The measurement of peak inspiratory flow against the simulated resistance (PIFr) of a dry powder inhaler establishes whether the patient has the inhalation ability for creating optimal turbulent energy within the device. A suboptimal PIFr for low to medium-high resistance dry powder inhalers has been reported in 19% to 84% of stable outpatients with COPD. Health care professionals should consider cognitive function, manual dexterity/strength, and PIFr in their patients with COPD when prescribing inhaled pharmacotherapy. Impairments in these patient factors are common among those with COPD and can affect the individual's competency and effectiveness of using inhaled medications delivered by handheld devices.
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Affiliation(s)
- Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH; Respiratory Services, Valley Regional Hospital, Claremont, NH.
| | - David M G Halpin
- Respiratory Medicine, University of Exeter Medical School, University of Exeter, Exeter, England
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8
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Neary MT, Mulder LM, Kowalski PS, MacLoughlin R, Crean AM, Ryan KB. Nebulised delivery of RNA formulations to the lungs: From aerosol to cytosol. J Control Release 2024; 366:812-833. [PMID: 38101753 DOI: 10.1016/j.jconrel.2023.12.012] [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] [Received: 06/16/2023] [Revised: 12/04/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
In the past decade RNA-based therapies such as small interfering RNA (siRNA) and messenger RNA (mRNA) have emerged as new and ground-breaking therapeutic agents for the treatment and prevention of many conditions from viral infection to cancer. Most clinically approved RNA therapies are parenterally administered which impacts patient compliance and adds to healthcare costs. Pulmonary administration via inhalation is a non-invasive means to deliver RNA and offers an attractive alternative to injection. Nebulisation is a particularly appealing method due to the capacity to deliver large RNA doses during tidal breathing. In this review, we discuss the unique physiological barriers presented by the lung to efficient nebulised RNA delivery and approaches adopted to circumvent this problem. Additionally, the different types of nebulisers are evaluated from the perspective of their suitability for RNA delivery. Furthermore, we discuss recent preclinical studies involving nebulisation of RNA and analysis in in vitro and in vivo settings. Several studies have also demonstrated the importance of an effective delivery vector in RNA nebulisation therefore we assess the variety of lipid, polymeric and hybrid-based delivery systems utilised to date. We also consider the outlook for nebulised RNA medicinal products and the hurdles which must be overcome for successful clinical translation. In summary, nebulised RNA delivery has demonstrated promising potential for the treatment of several lung-related conditions such as asthma, COPD and cystic fibrosis, to which the mode of delivery is of crucial importance for clinical success.
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Affiliation(s)
- Michael T Neary
- SSPC, The SFI Research Centre for Pharmaceuticals, School of Pharmacy, University College Cork, Ireland; School of Pharmacy, University College Cork, Ireland
| | | | - Piotr S Kowalski
- School of Pharmacy, University College Cork, Ireland; APC Microbiome, University College Cork, Cork, Ireland
| | | | - Abina M Crean
- SSPC, The SFI Research Centre for Pharmaceuticals, School of Pharmacy, University College Cork, Ireland; School of Pharmacy, University College Cork, Ireland
| | - Katie B Ryan
- SSPC, The SFI Research Centre for Pharmaceuticals, School of Pharmacy, University College Cork, Ireland; School of Pharmacy, University College Cork, Ireland.
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Mahler DA, Halpin DMG. Personalizing Selection of Inhaled Delivery Systems in Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2023; 20:1389-1396. [PMID: 37499210 PMCID: PMC10559134 DOI: 10.1513/annalsats.202304-384cme] [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] [Received: 04/27/2023] [Accepted: 07/27/2023] [Indexed: 07/29/2023] Open
Abstract
It can be challenging for healthcare professionals (HCPs) to prescribe inhaled therapy for patients with chronic obstructive pulmonary disease (COPD) because of the multiple individual and combinations of inhaled medications available in numerous delivery systems. Guidance on the selection of an inhaled delivery system has received limited attention compared with the emphasis on prescribing the class of the inhaled molecule(s). Although numerous recommendations and algorithms have been proposed to guide the selection of an inhaled delivery system for patients with COPD, no specific approach has been endorsed in COPD guidelines/strategies or by professional organizations. To provide recommendations for an inhaler selection strategy at initial and follow-up appointments, we examined the impact of patient errors using handheld inhalers on clinical outcomes and performed a focused narrative review to consider patient factors (continuity of the inhaled delivery system, cognitive function, manual function/dexterity, and peak inspiratory flow) when selecting an inhaled delivery system. On the basis of these findings, five questions are proposed for HCPs to consider in the initial selection of an inhaler delivery system and three questions to consider at follow-up. We propose that HCPs consider the inhaled medication delivery system as a unit and to match appropriate medication(s) with the unique features of the delivery system to individual patient factors. Assessment of inhaler technique and adherence together with patient outcomes/satisfaction at each visit is essential to determine whether the inhaled medication delivery system is providing benefits. Continued and repeated education on device features and correct technique is warranted to optimize efficacy.
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Affiliation(s)
- Donald A. Mahler
- Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, New Hampshire
- Valley Regional Hospital, Claremont, New Hampshire; and
| | - David M. G. Halpin
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
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Mahler DA, Watz H, Emerson-Stadler R, Ritz J, Gardev A, Shaikh A, Drummond MB. Clinical Implications of Peak Inspiratory Flow in COPD: Post Hoc Analyses of the TRONARTO Study. Int J Chron Obstruct Pulmon Dis 2023; 18:1729-1740. [PMID: 37599896 PMCID: PMC10432827 DOI: 10.2147/copd.s404243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Background In patients with COPD, inhalation ability should be assessed when considering inhaler choice. To evaluate whether the soft mist inhaler (SMI) is suitable for COPD patients irrespective of inhalation ability, the TRONARTO study investigated the efficacy of dual long-acting bronchodilator therapy delivered via the Respimat® SMI on lung function in patients with COPD stratified by inhalation ability. Tiotropium/olodaterol delivered via the SMI was effective both in patients with peak inspiratory flow (PIF) <60 L/min and PIF ≥60 L/min, measured against medium-low resistance. Methods This congress compilation summarizes post hoc analyses from the TRONARTO study presented at the annual American Thoracic Society 2022 and European Respiratory Society 2022 meetings. These analyses evaluated PIF in over 200 patients, with PIF measurements taken daily at home for 4 weeks, and in the clinic at baseline, Weeks 2 and 4. Results Overall, 57.9% of patients had a PIF range (difference between lowest and highest PIF measurements) <20 L/min (12.4% of patients had PIF range <10 L/min). At-home PIF range decreased over the study period, suggesting that inhaler training/repeated PIF measurements may help to make patients' inspiratory effort more consistent. Some patient characteristics correlated with lower PIF (female gender, shorter stature, more severe disease, worse airflow obstruction) and lower PIF range (more severe disease). PIF measurements differed between medium-low and high-resistance settings, highlighting the importance of measuring PIF at the resistance of a patient's inhaler. PIF correlated poorly with spirometry measurements. Conclusion As indicated in COPD management guidelines, choice of inhaler is essential to optimize pharmacologic therapies for COPD. Poor inspiratory ability should be viewed as a treatable trait that can help to inform inhaler choice. Inhaler training and consideration of PIF (if patients use a dry powder inhaler) can reduce patient-to-inhaler mismatch, with potential consequences for health status and exacerbation risk.
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Affiliation(s)
- Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Valley Regional Hospital, Claremont, NH, USA
| | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Grosshansdorf, Germany
| | | | | | - Asparuh Gardev
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Asif Shaikh
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - M Bradley Drummond
- Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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11
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Hsu YC, Li HH, Chiu LC, Chiang WC, Fang TP, Lin HL. Predicting Inhaled Drug Dose Generated by Mesh Nebulizers. J Aerosol Med Pulm Drug Deliv 2023; 36:162-170. [PMID: 37219568 DOI: 10.1089/jamp.2022.0055] [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: 05/24/2023] Open
Abstract
Background: The lung dose of nebulized drugs for spontaneous breathing is influenced by breathing patterns and nebulizer performance. This study aimed to develop a system for measuring breath patterns and a formula for estimating inhaled drugs, and then to validate the hypothesized prediction formula. Methods: An in vitro model was first used to determine correlations among the delivered dose, breath patterns, and doses deposited on the accessories and reservoirs testing with a breathing simulator to generate 12 adult breathing patterns (n = 5). A pressure sensor was developed to measure breathing parameters and used along with a prediction formula that accounted for the initial charge dose, respiratory pattern, and dose on the accessory and reservoir of a nebulizer. Three brands of nebulizers were tested by placing salbutamol (5.0 mg/2.5 mL) in the drug holding chamber. Ten healthy individuals participated in the ex vivo study to validate the prediction formula. The agreement between the predicted and inhaled doses was analyzed using the Bland-Altman plot. Results: The in vitro model showed that the inspiratory time to total respiratory cycle time (Ti/Ttotal; %) was significantly directly correlated with the delivered dose among the respiratory factors, followed by inspiratory flow, respiratory rate, and tidal volume. The ex vivo model showed that Ti/Ttotal was significantly directly correlated with the delivered dose among the respiratory factors, in addition to the nebulization time and accessory dose. The Bland-Altman plots for the ex vivo model showed similar results between the two methods. Large differences in inhaled dose measured at the mouth were observed among the subjects, ranging from 12.68% to 21.68%; however, the difference between the predicted dose and inhaled dose was lower, at 3.98%-5.02%. Conclusions: The inhaled drug dose could be predicted with the hypothesized estimation formula, which was validated by the agreement between the inhaled and predicted doses of breathing patterns of healthy individuals.
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Affiliation(s)
| | - Hsin-Hsien Li
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
| | - Li-Chung Chiu
- Department of Pulmonary and Critical Care, Chang Gung Memorial Hospital-Linkou Branch, Taoyuan, Taiwan
| | | | - Tien-Pei Fang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Respiratory Care, Chang Gung University of Technology and Science, Chiayi, Taiwan
| | - Hui-Ling Lin
- Department of Respiratory Therapy, Chang Gung University, Taoyuan, Taiwan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
- Department of Respiratory Care, Chang Gung University of Technology and Science, Chiayi, Taiwan
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Borris J, Cook H, Chae S, Walker KA, McPherson ML. Evaluation of Peak Inspiratory Flow Rate in Hospitalized Palliative Care Patients with COPD. PHARMACY 2023; 11:113. [PMID: 37489344 PMCID: PMC10366912 DOI: 10.3390/pharmacy11040113] [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: 05/22/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/26/2023] Open
Abstract
Dry powder inhalers are an effective yet costly COPD medication-delivery device. Patients must possess a minimum peak inspiratory flow rate (PIFR) for inhaled medication to be properly deposited into the lungs. Hospitalized palliative-care patients with diminished lung function due to advanced COPD may not possess the minimum PIFR (30 L/min) for adequate drug delivery. This study aims to quantify PIFR values for hospitalized palliative-care patients with advanced COPD to evaluate whether these patients meet the minimum PIFR requirements. Hospitalized patients ≥18 years old with a palliative-care consultation were eligible if they had a diagnosis of advanced COPD (GOLD C or D). Patients were excluded if they lacked decision-making capacity or had a positive COVID-19 test within the previous 90 days. Three PIFR values were recorded utilizing the In-CheckTM device, with the highest of the three PIFR attempts being utilized for statistical analysis. Eighteen patients were enrolled, and the mean of the highest PIFR readings was 72.5 L/min (±29 L/min). Post hoc analysis indicated 99.9% power when comparing the average best PIFR to the minimum PIFR (30 L/min) but only 51.4% power when compared to the optimal PIFR (60 L/min). This study found that palliative-care patients possess the minimum PIFR for DPI drug delivery.
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Affiliation(s)
- Joshua Borris
- Department of Practice, Sciences, and Heath Outcomes Research, School of Pharmacy, University of Maryland, Baltimore, MD 21201, USA
| | - Heather Cook
- MedStar Franklin Square Medical Center, Baltimore, MD 21237, USA
| | - Sulgi Chae
- Department of Psychiatry, Kaiser Permanente, Santa Clara, CA 95051, USA
| | - Kathryn A Walker
- Department of Practice, Sciences, and Heath Outcomes Research, School of Pharmacy, University of Maryland, Baltimore, MD 21201, USA
- MedStar Health, Columbia, MD 21044, USA
| | - Mary Lynn McPherson
- Department of Practice, Sciences, and Heath Outcomes Research, School of Pharmacy, University of Maryland, Baltimore, MD 21201, USA
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13
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Tan X, Liu S, Huang L, Wu Y, Wen L, Liu J, Tang Y, Liu X. Correlation Analysis of the Therapy Adherence to Long-Acting Inhalers Among Patients with Stable COPD. Patient Prefer Adherence 2023; 17:1467-1475. [PMID: 37350779 PMCID: PMC10284155 DOI: 10.2147/ppa.s413948] [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: 03/24/2023] [Accepted: 06/08/2023] [Indexed: 06/24/2023] Open
Abstract
Purpose Long-acting inhalers are the mainstay maintenance therapy for stable chronic obstructive pulmonary disease (COPD) management. The aim of this study was to assess adherence to inhalers among adults with COPD in China and to develop strategies to improve adherence for the next step. Patients and Methods A cross-sectional study was conducted among 246 adult patients with COPD using long-acting inhalers to explore different demographic characteristics, disease characteristics and medication regimens. Adherence to inhalers was assessed using the Medication Adherence Report Scale (MARS). Results Among the 246 patients included in the present study, 93 (37.80%) had good adherence, while 153 (62.20%) had poor adherence. From the comparison of patients with good and poor adherence, we found that the course of disease and education background had a significant effect on adherence (p < 0.05). Among the LAMA therapy group, inhaled tiotropium bromide spray (Ingelheim am Rhein, Germany) with active release technology had better adherence than inhaled tiotropium bromide powder (Ingelheim am Rhein, Germany) (p < 0.05). Moreover, COPD patients with good adherence had better pulmonary function and fewer moderate or severe exacerbations in the past year (p < 0.05). Conclusion The factors affecting the use of inhalers in patients with stable COPD are complicated. Medical staff should select appropriate inhalers according to the patient's disease status and duration and provide medication education to improve adherence.
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Affiliation(s)
- Xin Tan
- Department of Pediatric, The First Hospital of Changsha, Changsha, Hunan, People’s Republic of China
| | - Shanling Liu
- Department of Laboratory Medicine, The First Hospital of Changsha, Changsha, Hunan, People’s Republic of China
| | - Li Huang
- Department of Pharmacy, Zhuzhou Central Hospital, Zhuzhou, 412007, People’s Republic of China
| | - Ying Wu
- Department of Laboratory Medicine, The First Hospital of Changsha, Changsha, Hunan, People’s Republic of China
| | - Long Wen
- Department of Respiratory and Critical Care Medicine, The First Hospital of Changsha, Changsha, Hunan, People’s Republic of China
| | - Jiheng Liu
- Department of Hematology & Oncology, The First Hospital of Changsha, Changsha, Hunan, People’s Republic of China
| | - Yuling Tang
- Department of Respiratory and Critical Care Medicine, The First Hospital of Changsha, Changsha, Hunan, People’s Republic of China
| | - Xiaohui Liu
- Department of Pharmacy, The First Hospital of Changsha, Changsha, Hunan, People’s Republic of China
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14
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Ohnishi H, Okazaki M, Anabuki K, Akita S, Kawase S, Tsuji KS, Miyamura M, Yokoyama A. An Investigation into the Factors Associated with Incorrect Use of a Pressurized Metered-Dose Inhaler in Japanese Patients. J Aerosol Med Pulm Drug Deliv 2023; 36:12-19. [PMID: 36577056 DOI: 10.1089/jamp.2022.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Rationale: Inhalation of the correct dose of a short-acting beta 2 agonist (SABA) from a pressurized metered-dose inhaler (pMDI) is essential for the relief of symptoms in patients with asthma and/or chronic obstructive pulmonary disease. The aim of this study was to evaluate the prevalence and factors associated with the incorrect use of a pMDI. Methods: This study retrospectively assessed the electronic medical records of 161 patients with various respiratory diseases. The patients had never used a pMDI and underwent training by pharmacists educated in the use of a pMDI followed by bronchodilator reversibility testing at our hospital. The patients' characteristics and various lung capacity parameters were evaluated for association with the incorrect use of a pMDI. Results: Thirty-nine of the 161 (24.2%) patients, including 46% of 28 patients older than 80 years, used the pMDI incorrectly, mainly because of incoordination between activation of the device and inhalation (n = 11), inadequate strength to manipulate the device (n = 9), too short duration of inhalation (n = 6), and difficulty in breath holding (n = 3). Advanced age; lower height; and decreased lung volumes, including vital capacity (VC), inspiratory capacity, inspiratory reserve volume (IRV), forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and peak expiratory flow rate, were associated with the incorrect use of a pMDI. Neither the body weight, tidal volume, expiratory reserve volume, %FVC predicted, %FEV1 predicted, nor FEV1% was associated with the incorrect use of a pMDI. Multivariate binomial logistic regression analysis identified decreased IRV as the only independent predictor associated with the incorrect use of a pMDI. Conclusions: Physicians should be aware that elderly patients or patients with decreased IRV might be unable to obtain the correct SABA dose from a pMDI. A large-scale prospective study is required to confirm these findings from our retrospective study with a small group of patients.
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Affiliation(s)
- Hiroshi Ohnishi
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Masafumi Okazaki
- Department of Pharmacy, Kochi Medical School Hospital, Kochi, Japan
| | - Kazuki Anabuki
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Shin Akita
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Shigeo Kawase
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | - Kimiko Sakai Tsuji
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
| | | | - Akihito Yokoyama
- Department of Respiratory Medicine and Allergology, Kochi Medical School, Kochi University, Kochi, Japan
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15
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Clark B, Wells BJ, Saha AK, Franchino-Elder J, Shaikh A, Donato BMK, Ohar JA. Low Peak Inspiratory Flow Rates are Common Among COPD Inpatients and are Associated with Increased Healthcare Resource Utilization: A Retrospective Cohort Study. Int J Chron Obstruct Pulmon Dis 2022; 17:1483-1494. [PMID: 35791340 PMCID: PMC9250781 DOI: 10.2147/copd.s355772] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 06/02/2022] [Indexed: 11/29/2022] Open
Abstract
Background Patients with chronic obstructive pulmonary disease (COPD) can have low peak inspiratory flow (PIF), especially after hospitalization for acute exacerbation of COPD (AECOPD). Purpose To characterize patients hospitalized for AECOPD, and to assess the prevalence of low PIF, changes in PIF after hospitalization, and the association of low PIF with healthcare resource utilization (HRU) outcomes. Patients and Methods A retrospective cohort study was conducted using electronic health record data of hospitalized COPD patients in the Wake Forest Baptist Health system (01/01/2017 through 06/30/2020). Patients with a first eligible AECOPD hospitalization (index hospitalization) who were discharged before 05/31/2020 were included. PIF was measured using the In-Check DIAL™ at both medium-low resistance (R-2) and high resistance (R-5) during the index hospitalization. For R-2 and R-5, PIF was divided into low PIF (< 60 L/min; < 30 L/min) and high PIF (≥ 60 L/min; ≥ 30 L/min) groups. The primary outcome was the prevalence of low PIF. The stability of PIF after hospitalization was described. Adjusted regression models evaluated associations between low PIF and subsequent 30-day readmissions, 90-day readmissions, and HRU outcomes, including hospitalizations, emergency department visits, inpatient days, and intensive care unit (ICU) days. Results In total, 743 patients with PIF measured at R-2 and R-5 during a AECOPD hospitalization were included. The prevalence of low PIF was 56.9% at R-2 and 14.7% at R-5. PIF values were relatively stable after hospitalization. Adjusted analyses showed significant increases in HRU (all-cause hospitalizations [31%], COPD hospitalizations [33%], COPD inpatient days [46%], and COPD ICU days [24%]) during the follow-up period among patients with low PIF (< 60 L/min) at R-2. The 30- and 90-day readmission risks were similar between patients with low PIF and high PIF. Conclusion Low PIF is common among patients hospitalized for AECOPD, relatively stable after hospital discharge, and associated with increased HRU.
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Affiliation(s)
- Brendan Clark
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | - Brian J Wells
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Amit K Saha
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Jessica Franchino-Elder
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | - Asif Shaikh
- Clinical Development and Medical Affairs, Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | - Bonnie M K Donato
- Health Economics and Outcomes Research, Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT, USA
| | - Jill A Ohar
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunology, Wake Forest School of Medicine, Winston-Salem, NC, USA
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16
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Mahler DA, Niu X, Deering KL, Dembek C. Prospective Evaluation of Exacerbations Associated with Suboptimal Peak Inspiratory Flow Among Stable Outpatients with COPD. Int J Chron Obstruct Pulmon Dis 2022; 17:559-568. [PMID: 35313719 PMCID: PMC8934117 DOI: 10.2147/copd.s353441] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/28/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose A suboptimal peak inspiratory flow (PIF) against a dry powder inhaler (DPI) may result in ineffective inhalation of medications, which may affect outcomes. The primary objective of this study was to examine the association between PIF status and COPD exacerbations among outpatients with moderate to very severe COPD. Patients and Methods This was a prospective, observational study of patients from 7 US outpatient centers. PIF was measured using an inspiratory flow meter (In-Check™ DIAL G16) set to medium low resistance. Patients were classified by suboptimal (<60 L/min) or optimal PIF (≥60 L/min). The primary outcome was the proportion of patients with moderate/severe COPD exacerbations collected by medical record review over 12 months. Secondary outcomes were time to first exacerbation and mortality. Results Of 474 patients screened, 38.8% had suboptimal PIF, and 71 patients with optimal PIF were excluded from the study. The enrolled sample included 184 and 219 patients with suboptimal and optimal PIF, respectively. Suboptimal PIF was associated with shorter stature (66.6±4.1 vs 67.8±3.8 inches, P = 0.002), female sex (45.1 vs 34.7%, P = 0.033), Black race (27.2 vs 11.0%, P < 0.001), and greater symptom burden (CAT: 22.3±7.7 vs 19.0±7.0, P < 0.001; mMRC: 2.0±1.1 vs 1.7±1.1, P = 0.003). The proportion of patients with COPD exacerbations at 12 months was not significantly different (29.3 vs 27.9%, P = 0.751). Suboptimal PIF was associated with shorter time to first COPD exacerbation (3.8±2.7 vs 4.9±3.0 months, P = 0.048). The mortality rate at 12 months was higher in the suboptimal cohort but not significantly different (6.5 vs 2.8%, P = 0.073). Conclusion Over one-third of outpatients with stable moderate to very severe COPD had a suboptimal PIF against a medium low resistance DPI. The phenotype of suboptimal PIF was short stature, female, and Black. Suboptimal PIF status was associated with shorter time to moderate/severe COPD exacerbations compared with optimal PIF.
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Affiliation(s)
- Donald A Mahler
- Geisel School of Medicine, Dartmouth, Hanover, NH, USA and Valley Regional Hospital, Claremont, NH, USA
- Correspondence: Donald A Mahler, Emeritus Professor of Medicine, Geisel School of Medicine, Dartmouth, Director of Respiratory Services, Valley Regional Hospital, 1 Rope Ferry Road, Hanover, NH, 03755, USA, Tel +1 603 542-6777, Fax +1 603 543-5613, Email
| | - Xiaoli Niu
- Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
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17
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Leving MT, Kocks J, Bosnic-Anticevich S, Dekhuijzen R, Usmani OS. Relationship between Peak Inspiratory Flow and Patient and Disease Characteristics in Individuals with COPD—A Systematic Scoping Review. Biomedicines 2022; 10:biomedicines10020458. [PMID: 35203667 PMCID: PMC8962311 DOI: 10.3390/biomedicines10020458] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 11/16/2022] Open
Abstract
Optimal delivery of medication via dry powder inhalers, the most commonly prescribed inhaler type, is dependent on a patient achieving a minimum level of inspiratory flow during inhalation. However, measurement of peak inspiratory flow (PIF) against the simulated resistance of a dry powder inhaler is not frequently performed in clinical practice due to time or equipment limitations. Therefore, defining which patient characteristics are associated with lower PIF is critically important to help clinicians optimize their inhaler choice through a more personalized approach to prescribing. The objective of this scoping review was to systematically evaluate patient and disease characteristics determining PIF in patients with chronic obstructive pulmonary disease (COPD). Medline, Cochrane and Embase databases were systematically searched for relevant studies on PIF in patients with COPD published in English between January 2000 and May 2021. The quality of evidence was assessed using a modified Grading of Recommendations Assessment, Development and Evaluation checklist. Of 3382 citations retrieved, 35 publications were included in the review (nine scored as high quality, 13 as moderate, nine as low, and four as very low). Factors correlating with PIF in >70% of papers included both patient characteristics (lower PIF correlated with increased age, female gender, shorter height, decreased handgrip and inspiratory muscle strength, and certain comorbidities) and disease characteristics (lower PIF correlated with markers of lung hyperinflation, lower peak expiratory flow [PEF] and increased disease severity). Other factors correlating with adequate/optimal or improved PIF included education/counseling and exercise/inspiratory muscle training; impaired physical function and errors in inhalation technique/non-adherence were associated with low/suboptimal PIF. In conclusion, clinicians should measure PIF against the simulated resistance of a particular device wherever possible. However, as this often cannot be done due to lack of resources or time, the patient and disease characteristics that influence PIF, as identified in this review, can help clinicians to choose the most appropriate inhaler type for their patients.
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Affiliation(s)
- Marika T. Leving
- General Practitioners Research Institute, 9713 GH Groningen, The Netherlands;
- Correspondence:
| | - Janwillem Kocks
- General Practitioners Research Institute, 9713 GH Groningen, The Netherlands;
- GRIAC Research Institute, University Medical Center Groningen, University of Groningen, 9700 RB Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore 573969, Singapore
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, Sydney, NSW 2037, Australia;
- Sydney Pharmacy School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW 2006, Australia
- Sydney Local Health District, Sydney, NSW 2050, Australia
| | | | - Omar S. Usmani
- National Heart and Lung Institute (NHLI), Imperial College London, London SW3 6LY, UK;
- Royal Brompton Hospital, London SW3 6NP, UK
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18
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Ohar JA, Ferguson GT, Mahler DA, Drummond MB, Dhand R, Pleasants RA, Anzueto A, Halpin DMG, Price DB, Drescher GS, Hoy HM, Haughney J, Hess MW, Usmani OS. Measuring Peak Inspiratory Flow in Patients with Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2022; 17:79-92. [PMID: 35023914 PMCID: PMC8747625 DOI: 10.2147/copd.s319511] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022] Open
Abstract
Dry powder inhalers (DPIs) are breath actuated, and patients using DPIs need to generate an optimal inspiratory flow during the inhalation maneuver for effective drug delivery to the lungs. However, practical and standardized recommendations for measuring peak inspiratory flow (PIF)—a potential indicator for effective DPI use in chronic obstructive pulmonary disease (COPD)—are lacking. To evaluate recommended PIF assessment approaches, we reviewed the Instructions for Use of the In-Check™ DIAL and the prescribing information for eight DPIs approved for use in the treatment of COPD in the United States. To evaluate applied PIF assessment approaches, we conducted a PubMed search from inception to August 31, 2021, for reports of clinical and real-life studies where PIF was measured using the In-Check™ DIAL or through a DPI in patients with COPD. Evaluation of collective sources, including 47 applicable studies, showed that instructions related to the positioning of the patient with their DPI, instructions for exhalation before the inhalation maneuver, the inhalation maneuver itself, and post-inhalation breath-hold times varied, and in many instances, appeared vague and/or incomplete. We observed considerable variation in how PIF was measured in clinical and real-life studies, underscoring the need for a standardized method of PIF measurement. Standardization of technique will facilitate comparisons among studies. Based on these findings and our clinical and research experience, we propose specific recommendations for PIF measurement to standardize the process and better ensure accurate and reliable PIF values in clinical trials and in daily clinical practice.
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Affiliation(s)
- Jill A Ohar
- Section of Pulmonary, Critical Care, Allergy, and Immunology, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | | | - M Bradley Drummond
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rajiv Dhand
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
| | - Roy A Pleasants
- Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Quality, University of Michigan, Ann Arbor, MI, USA
| | - Antonio Anzueto
- Pulmonology Section, University of Texas Health, and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - David M G Halpin
- University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, UK
| | - David B Price
- Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.,Observational and Pragmatic Research Institute, Singapore
| | - Gail S Drescher
- Pulmonary Services Department, MedStar Washington Hospital Center, Washington, DC, USA
| | - Haley M Hoy
- Transplant Center, Vanderbilt University Medical Center, Nashville, TN, USA
| | - John Haughney
- Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
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Valipour A, Aisanov Z, Avdeev S, Koblizek V, Kocan I, Kopitovic I, Lupkovics G, Man M, Bukovskis M, Tudoric N, Vukoja M, Naumnik W, Yanev N. Recommendations for COPD management in Central and Eastern Europe. Expert Rev Respir Med 2022; 16:221-234. [PMID: 35001780 DOI: 10.1080/17476348.2021.2023498] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report provides guidance on effective management of chronic obstructive pulmonary disease (COPD) according to local healthcare systems. However, COPD is a heterogenous disease and certain aspects, including prevalence, disease-time course and phenotype distribution, can differ between countries. Moreover, features of clinical practice and healthcare systems for COPD patients can vary widely, even in geographically close and economically similar countries. AREAS COVERED Based on an initial workshop of respiratory physicians from eleven countries across Central and Eastern Europe (CEE) in December 2018 and subsequent discussions, this article offers region-specific insights from clinical practice and healthcare systems in CEE. Taking GOLD 2020 recommendations into account, we suggest approaches to adapt these into national clinical guidelines for COPD management in CEE. EXPERT OPINION Several factors should be considered when optimizing management of COPD in CEE compared with other regions, including differences in smoking status, vaccination uptake, prevalence of tuberculosis and nontuberculous mycobacteria, and variations in healthcare systems. We provide guidance and algorithms for pharmacologic and non-pharmacologic management of COPD for the following scenarios: initial and follow-up treatment, treatment of patients with frequent exacerbations, and withdrawal of inhaled corticosteroids where appropriate.
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Affiliation(s)
- Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna Health Care Group, Vienna, Austria
| | - Zaurbek Aisanov
- Department of Pulmonology, Pirogov Russian State National Research Medical University, Moscow, Russia
| | - Sergey Avdeev
- Pulmonology Department, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Vladimir Koblizek
- Department of Pneumology, Faculty of Medicine in Hradec Kralove, Charles University Hospital, Hradec Kralove, Czech Republic
| | - Ivan Kocan
- University Hospital Martin, Jessenius Faculty of Medicine, Commenius University, Martin, Slovakia
| | - Ivan Kopitovic
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Gergely Lupkovics
- Adult Pulmonary Department, Institute for Pulmonary Diseases, Törökbálint, Hungary
| | - Milena Man
- Pulmonology Department, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Maris Bukovskis
- Department of Internal Diseases, Faculty Medicine, University of Latvia, Riga, Latvia
| | - Neven Tudoric
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Marija Vukoja
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Wojciech Naumnik
- First Department of Lung Diseases and Chemotherapy of Respiratory Neoplasms, Medical University of Bialystok, Bialystok, Poland
| | - Nikolay Yanev
- Department of Pulmonary Diseases, Medical University of Sofia, Sofia, Bulgaria
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20
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Blaylock B, Niu X, Davidson HE, Gravenstein S, DePue R, Williams GR, Steinberg KE. Development of MDS-Based Predication Model for COPD Severity in Nursing Home Residents. Ann Pharmacother 2021; 56:878-887. [PMID: 34963317 DOI: 10.1177/10600280211059241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Assessing chronic obstructive pulmonary disease (COPD) severity is challenging in nursing home (NH) residents due to incomplete symptom assessments and exacerbation history. OBJECTIVE The objective of this study was to predict COPD severity in NH residents using the Minimum Data Set (MDS), a clinical assessment of functional capabilities and health needs. METHODS A cohort analysis of prospectively collected longitudinal data was conducted. Residents from geographically varied Medicare-certified NHs with age ≥60 years, COPD diagnosis, and ≥6 months NH residence at enrollment were included. Residents with severe cognitive impairment were excluded. Demographic characteristics, medical history, and MDS variables were extracted from medical records. The care provider-completed COPD Assessment Test (CAT) and COPD exacerbation history were used to categorize residents by Global Initiative for Chronic Lung Disease (GOLD) A to D groups. Multivariate multinomial logit models mapped the MDS to GOLD A to D groups with stepwise selection of variables. RESULTS Nursing home residents (N = 175) were 64% women and had a mean age of 77.9 years. Among residents, GOLD B was most common (A = 13.1%; B = 44.0%; C = 5.7%; D = 37.1%). Any long-acting bronchodilator (LABD) use and any dyspnea were significant predictors of GOLD A to D groups. The predicted MDS-GOLD group (A = 6.9%; B = 52.6%; C = 4.6%; D = 36.0%) showed good model fit (correctly predicted = 60.6%). Nursing home residents may underuse group-recommended LABD treatment (no LABD: B = 53.2%; C = 80.0%; D = 40.0%). CONCLUSION AND RELEVANCE The MDS, completed routinely for US NH residents, could potentially be used to estimate COPD severity. Predicted COPD severity with additional validation could provide a map to evidence-based treatment guidelines and may help to individualize treatment pathways for NH residents.
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Affiliation(s)
| | - Xiaoli Niu
- Health Economics and Outcomes Research, Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
| | | | - Stefan Gravenstein
- Department of Health Services, Policy and Practice, Center for Gerontology and Health Care Research, Brown University, Providence, RI, USA
| | - Ronald DePue
- Health Economics and Outcomes Research, Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
| | - G Rhys Williams
- Health Economics and Outcomes Research, Sunovion Pharmaceuticals Inc., Marlborough, MA, USA
| | - Karl E Steinberg
- Shiley Institute for Palliative Care, The California State University, San Marcos, CA, USA
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21
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Matuszak M, Ochowiak M, Włodarczak S, Krupińska A, Doligalski M. State-of-the-Art Review of The Application and Development of Various Methods of Aerosol Therapy. Int J Pharm 2021; 614:121432. [PMID: 34971755 DOI: 10.1016/j.ijpharm.2021.121432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/09/2021] [Accepted: 12/23/2021] [Indexed: 12/23/2022]
Abstract
Aerosol therapy is a rapidly developing field of science. Due to a number of advantages, the administration of drugs to the body with the use of aerosol therapy is becoming more and more popular. Spraying drugs into the patient's lungs has a significant advantage over other methods of administering drugs to the body, including injection and oral methods. In order to conduct proper and effective aerosol therapy, it is necessary to become familiar with the basic principles and applications of aerosol therapy under various conditions. The effectiveness of inhalation depends on many factors, but most of all on: the physicochemical properties of the sprayed system, the design of the medical inhaler and its correct application, the dynamics of inhalation (i.e. the frequency of breathing and the volume of inhaled air). It is worth emphasizing that respiratory system diseases are one of the most frequently occurring and fastest growing diseases in the world. Accordingly, in recent years, a significant increase in the number of new spraying devices and pharmaceutical drugs for spraying has appeared on the market. It should also be remembered that the process of spraying a liquid is a complicated and complex process, and its efficiency is very often characterized by the use of micro- and macro parameters (including average droplet diameters or the spectrum of droplet diameter distribution). In order to determine the effectiveness of the atomization process and in the delivery of drugs to the patient's respiratory tract, the analysis of the size of the generated aerosol droplets is most often performed. Based on the proposed literature review, it has been shown that many papers dealt with the issues related to aerosol therapy, the selection of an appropriate spraying device, the possibility of modifying the spraying devices in order to increase the effectiveness of inhalation, and the possibility of occurrence of certain discrepancies resulting from the use of various measurement methods to determine the characteristics of the generated aerosol. The literature review presented in the paper was prepared in order to better understand the spraying process. Moreover, it can be helpful in choosing the right medical inhaler for a given liquid with specific rheological properties. The experimental data contained in this study are of great cognitive importance and may be of interest to entities involved in pharmaceutical product engineering (in particular in the case of the production of drugs containing liquids with complex rheological properties).
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Affiliation(s)
- M Matuszak
- Faculty of Chemical Technology, Poznan University of Technology, Institute of Chemical Technology and Engineering, 4 Berdychowo Street, 60-965 Poznan, Poland.
| | - M Ochowiak
- Faculty of Chemical Technology, Poznan University of Technology, Institute of Chemical Technology and Engineering, 4 Berdychowo Street, 60-965 Poznan, Poland
| | - S Włodarczak
- Faculty of Chemical Technology, Poznan University of Technology, Institute of Chemical Technology and Engineering, 4 Berdychowo Street, 60-965 Poznan, Poland
| | - A Krupińska
- Faculty of Chemical Technology, Poznan University of Technology, Institute of Chemical Technology and Engineering, 4 Berdychowo Street, 60-965 Poznan, Poland
| | - M Doligalski
- Faculty of Computer, Electrical and Control Engineering, University of Zielona Góra, 4a Szafrana Street, 65-516 Zielona Góra, Poland
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22
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Roche N, Devillier P, Berger P, Bourdin A, Dusser D, Muir JF, Martinat Y, Terrioux P, Housset B. Individual trajectory-based care for COPD: getting closer, but not there yet. ERJ Open Res 2021; 7:00451-2021. [PMID: 34912881 PMCID: PMC8666575 DOI: 10.1183/23120541.00451-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/17/2021] [Indexed: 11/05/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a main cause of death due to interplaying factors, including comorbidities that interfere with symptoms and response to therapy. It is now admitted that COPD management should be based on clinical symptoms and health status and should consider the heterogeneity of patients' phenotypes and treatable traits. This precision medicine approach involves a regular assessment of the patient's status and of the expected benefits and risks of therapy. The cornerstone of COPD pharmacological therapy is inhaled long-acting bronchodilation. In patients with persistent or worsened symptoms, factors likely to interfere with treatment efficacy include the patient's non-adherence to therapy, treatment preference, inhaler misuse and/or comorbidities, which should be systematically investigated before escalation is considered. Several comorbidities are known to impact symptoms, physical and social activity and lung function. The possible long-term side-effects of inhaled corticosteroids contrasting with their over-prescription in COPD patients justify the regular assessment of their benefits and risks, and de-escalation under close monitoring after a sufficient period of stability is to be considered. While commonly used in clinical trials, the relevance of routine blood eosinophil counts to guide therapy adjustment is not fully clear. Patients' characteristics, which define phenotypes and treatable traits and thus guide therapy, often change during life, forming the basis of the concept of clinical trajectory. The application of individual trajectory-based management of COPD in clinical practice therefore implies that the benefit:risk ratio is regularly reviewed according to the evolution of the patient's traits over time to allow optimised therapy adjustments.
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Affiliation(s)
- Nicolas Roche
- Pneumologie, Hôpital Cochin, AP-HP. Centre - Université de Paris, Institut Cochin (UMR1016), Paris, France
| | - Philippe Devillier
- UPRES EA 220, Université Versailles Saint-Quentin, Pôle des Maladies des Voies Respiratoires, Hôpital Foch, Suresnes, France
| | - Patrick Berger
- Service d'exploration fonctionnelle respiratoire, CIC 1401, CHU de Bordeaux, Pessac, France
| | - Arnaud Bourdin
- Département de Pneumologie et Addictologie, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Daniel Dusser
- Pneumologie, Hôpital Cochin, AP-HP. Centre - Université de Paris, Institut Cochin (UMR1016), Paris, France
| | - Jean-François Muir
- Service de Pneumologie, Oncologie Thoracique et Soins Intensifs Respiratoires, Centre Hospitalier Universitaire de Rouen, Rouen, France
| | | | | | - Bruno Housset
- Service de Pneumologie, Hôpital Intercommunal de Créteil, Créteil, France
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23
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A Systematic Review of Published Algorithms for Selecting an Inhaled Delivery System in COPD. Ann Am Thorac Soc 2021; 19:1213-1220. [PMID: 34856108 DOI: 10.1513/annalsats.202108-930oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
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).
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24
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Thomashow BM, Mannino DM, Tal-Singer R, Crapo JD. A rapidly changing understanding of COPD: World COPD Day from the COPD Foundation. Am J Physiol Lung Cell Mol Physiol 2021; 321:L983-L987. [PMID: 34612086 DOI: 10.1152/ajplung.00400.2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
World COPD Day raises awareness about chronic obstructive pulmonary disease (COPD). COPD accounts for over 150,000 US deaths per year. A major challenge is that COPD receives only a fraction of the research funding provided to other major diseases. Control of COPD is dependent on developing new approaches to diagnose the disease earlier with a recognition of either pre-COPD or established COPD based on symptoms, lung structural change and/or loss of lung function that occurs before meeting long established criteria for a population-based definition of obstruction. Optimization of current therapies improves lung function, exercise capacity, quality of life, and survival. New pathways of disease progression are being identified creating new opportunities for development of therapies that could stop or cure this disease.
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Affiliation(s)
- Byron M Thomashow
- COPD Foundation, Miami, Florida.,Department of Medicine, Columbia University, New York, New York
| | - David M Mannino
- COPD Foundation, Miami, Florida.,Department of Medicine, University of Kentucky College of Medicine, Lexington, Kentucky
| | | | - James D Crapo
- COPD Foundation, Miami, Florida.,Department of Medicine, National Jewish Health, Denver, Colorado
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25
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Mahler DA, Ludwig-Sengpiel A, Ferguson GT, de la Hoz A, Ritz J, Shaikh A, Watz H. TRONARTO: A Randomized, Placebo-Controlled Study of Tiotropium/Olodaterol Delivered via Soft Mist Inhaler in COPD Patients Stratified by Peak Inspiratory Flow. Int J Chron Obstruct Pulmon Dis 2021; 16:2455-2465. [PMID: 34511891 PMCID: PMC8414074 DOI: 10.2147/copd.s324467] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/12/2021] [Indexed: 12/04/2022] Open
Abstract
Background Inhaled bronchodilator therapy is currently the mainstay of treatment for patients with chronic obstructive pulmonary disease (COPD). Some inhalers require patients to achieve certain inhalation efforts either to activate the device or to deliver medication to the site of action. For dry powder inhalers, low peak inspiratory flow (PIF) can result in poor medication delivery but the clinical significance of this is not well understood. Methods TRONARTO was a 4-week, randomized, double-blind, placebo-controlled, multicenter, parallel-group study which stratified patients with moderate-to-severe COPD according to their PIF against medium-low resistance at screening. Patients were randomized to receive tiotropium/olodaterol (5 μg/5 μg) or matched placebo delivered via the Respimat® Soft Mist™ inhaler (SMI). After 4 weeks of treatment, we assessed change from baseline in forced expiratory volume in 1 second (FEV1) area under the curve 0–3 hours (FEV1 AUC0–3h) and trough FEV1. Results Overall, 213 patients were randomized, of whom 106 received tiotropium/olodaterol (PIF <60 L/min, 55; PIF ≥60 L/min, 51) and 107 received placebo (PIF <60 L/min, 55; PIF ≥60 L/min, 52). For FEV1 AUC0–3h, the adjusted mean change from baseline versus placebo was 336 mL (95% confidence interval [CI] 246–425 mL; P<0.0001) in the PIF <60 L/min group and 321 mL (95% CI 233–409 mL; P<0.0001) in the PIF ≥60 L/min group. For trough FEV1, the adjusted mean change from baseline versus placebo was 201 mL (95% CI 117–286 mL; P<0.0001) in the PIF <60 L/min group and 217 mL (95% CI 135–299 mL; P<0.0001) in the PIF ≥60 L/min group. Conclusion In the TRONARTO study, which included patients with moderate-to-severe COPD and varying inspiratory flow abilities, treatment with tiotropium/olodaterol resulted in significant lung function improvements versus placebo. This SMI can be used irrespective of the PIF that a patient can generate.
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Affiliation(s)
- Donald A Mahler
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA.,Section of Pulmonary Medicine, Valley Regional Hospital, Claremont, NH, USA
| | | | - Gary T Ferguson
- Department of Medicine, Pulmonary Research Institute of Southeast Michigan, Farmington Hills, MI, USA
| | - Alberto de la Hoz
- Cardio-Metabolism and Respiratory, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - John Ritz
- Biostatistics, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Asif Shaikh
- Clinical Development & Medical Affairs, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, USA
| | - Henrik Watz
- Pulmonary Research Institute at LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
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Nigro SC, Sobieraj DM. Budesonide/Glycopyrrolate/Formoterol Fumarate Co-suspension Metered Dose Inhaler: A Triple Therapy for the Treatment of Chronic Obstructive Pulmonary Disease. Ann Pharmacother 2021; 56:582-591. [PMID: 34382422 DOI: 10.1177/10600280211038353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To review current evidence on the use of a fixed-dose combination (FDC) of budesonide/glycopyrrolate/formoterol fumarate (BGFF) triple therapy delivered via metered dose inhaler (MDI) in patients with chronic obstructive pulmonary disease (COPD) and offer clinical practice insights. DATA SOURCES We used PubMed to conduct the literature search from 1946 through June 30, 2021, using budesonide, glycopyrrolate or glycopyrronium, and formoterol. STUDY SELECTION AND EXTRACTION We included clinical trials in patients with COPD along with pharmacokinetic or pharmacodynamic studies. DATA SYNTHESIS In all, 19 citations were included. BGFF MDI reduces the risk of exacerbations regardless of exacerbation history compared with dual bronchodilators or inhaled corticosteroid/long-acting β-agonist. Rescue inhaler use decreased, and patient-reported outcomes of symptoms and well-being improved with triple therapy. Mortality was decreased with the higher-dose BGFF MDI in comparison to dual bronchodilator therapy. Dysphonia and candidiasis were more common with BGFF MDI compared with dual bronchodilators, as was pneumonia. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE BGFF MDI is the second FDC triple therapy approved for COPD treatment. BGFF MDI improves important patient outcomes in COPD, including exacerbation risk. The unique co-suspension technology allows delivery of 3 active ingredients in 1 inhaler, a potential benefit to overcome adherence and technique-related barriers. These benefits must be gently weighed against the increased risk of pneumonia. CONCLUSION The findings from phase 3 trials support the efficacy and safety of triple therapy in COPD. Future studies are needed to confirm potential mortality benefit and the role of triple therapy in patients without an exacerbation history.
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27
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Debnath SK, Srivastava R, Debnath M, Omri A. Status of inhalable antimicrobial agents for lung infection: progress and prospects. Expert Rev Respir Med 2021; 15:1251-1270. [PMID: 33866900 DOI: 10.1080/17476348.2021.1919514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Sujit Kumar Debnath
- Department of Biosciences and Bioengineering, Indian Institute of Technology, Bombay, Mumbai, India
| | - Rohit Srivastava
- Department of Biosciences and Bioengineering, Indian Institute of Technology, Bombay, Mumbai, India
| | - Monalisha Debnath
- School of Medical Sciences and Technology, Indian Institute of Technology, Kharagpur, India
| | - Abdelwahab Omri
- Chemistry and Biochemistry, Laurentian University, Sudbury, Canada
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28
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Davidson HE, Radlowski P, Han L, Shireman TI, Dembek C, Niu X, Gravenstein S. Clinical Characterization of Nursing Facility Residents With Chronic Obstructive Pulmonary Disease. Sr Care Pharm 2021; 36:248-257. [PMID: 33879286 DOI: 10.4140/tcp.n.2021.248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE AND DESIGN To describe clinical characteristics, medication use, and low peak inspiratory flow rate (PIFR) (< 60 L/min) prevalence in nursing facility residents with chronic obstructive pulmonary disease (COPD). PATIENTS AND SETTING Residents 60 years of age and older with a COPD diagnosis and≥ 6 months' nursing facility residence, were enrolled between December 2017 and February 2019 from 26 geographically varied United States nursing facilities. OUTCOME MEASURES Data, extracted from residents' charts, included demographic/clinical characteristics, COPD-related medications, exacerbations and hospitalizations within the past 6 months, and functional status from the most recent Minimum Data Set. At enrollment, residents completed the modified Medical Research Council (mMRC) Dyspnea Scale and COPD Assessment Test (CAT™). Spirometry and PIFR were also assessed. RESULTS Residents' (N = 179) mean age was 78.0 ± 10.6 years, 63.7% were female, and 57.0% had low PIFR. Most prevalent comorbidities were hypertension (79.9%), depression (49.2%), and heart failure (41.9%). The average forced expiratory volume in 1 second (FEV11) % predicted was 45.9% ± 20.9%. On the CAT, 78.2% scored≥ 10 and on the mMRC Dyspnea Scale, 74.1% scored≥ 2, indicating most residents had high COPD symptom burden. Only 49.2% were receiving a scheduled long-acting bronchodilator (LABD). Among those with low PIFR prescribed a LABD, > 80% used dry powder inhalers for medication delivery. CONCLUSION This study highlights underutilization of scheduled LABD therapy in nursing facility residents with COPD. Low PIFR was prevalent in residents while the majority used suboptimal medication delivery devices. The findings highlight opportunities for improving management and outcomes for nursing facility residents with COPD.
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Affiliation(s)
| | | | - Lisa Han
- 1Insight Therapeutics, LLC, Norfolk, Virginia
| | - Theresa I Shireman
- 2Brown University, Center for Gerontology and Health Care Research, Providence, Rhode Island
| | - Carole Dembek
- 3Sunovion Pharmaceuticals, Incorporated, Marlborough, Massachusetts
| | - Xiaoli Niu
- 3Sunovion Pharmaceuticals, Incorporated, Marlborough, Massachusetts
| | - Stefan Gravenstein
- 2Brown University, Center for Gerontology and Health Care Research, Providence, Rhode Island
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29
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Anderson M, Collison K, Drummond MB, Hamilton M, Jain R, Martin N, Mularski RA, Thomas M, Zhu CQ, Ferguson GT. Peak Inspiratory Flow Rate in COPD: An Analysis of Clinical Trial and Real-World Data. Int J Chron Obstruct Pulmon Dis 2021; 16:933-943. [PMID: 33883890 PMCID: PMC8055277 DOI: 10.2147/copd.s291554] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background The influence of peak inspiratory flow (PIF) on dose delivery from dry powder inhalers (DPIs) and association with treatment efficacy in patients with chronic obstructive pulmonary disease (COPD) has not been fully determined. In vitro studies have demonstrated adequate dose delivery through ELLIPTA DPI at PIF ≥30 L/min. This analysis of two clinical trials and a real-world population of COPD patients determined spirometric PIF distribution, and explored the relationship between PIF and outcomes in the trials. Methods The replicate Phase IV, 12-week, randomized, double-blind 207608/207609 (NCT03478683/NCT03478696) trials evaluated fluticasone furoate/umeclidinium/vilanterol via ELLIPTA DPI versus budesonide/formoterol+tiotropium in COPD patients. This post hoc analysis assessed spirometric PIF distribution at screening and relationship between PIF and lung function outcomes in the pooled 207608/207609 population. Spirometric PIF distributions in a real-world population of COPD patients were evaluated by retrospective analysis of the Kaiser Permanente Northwest (KPNW) database to assess similarities between clinical trial and real-world populations. Results A total of 1460 (207608/207609) and 3282 (KPNW) patients were included. There was considerable overlap between spirometric PIF distributions for both populations. Overall, 99.7% and 99.8% of the 207608/207609 and KPNW populations, respectively, reported spirometric PIF ≥50 L/min, estimated as equivalent to ELLIPTA PIFR ≥30 L/min. In the 207608/207609 combined analysis, there was no significant interaction between spirometric PIF and treatment for lung function endpoints, indicating treatment effect is independent of PIF. Conclusion Nearly all COPD patients in the 207608/207609 and KPNW populations achieved spirometric PIF values estimated as equivalent to PIFR of ≥30 L/min through the ELLIPTA DPI. Lack of correlation between spirometric PIF at screening and treatment efficacy aligns with consistent dose performance from the ELLIPTA DPI across a wide range of PIFs, achieved by patients with COPD of all severities.
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Affiliation(s)
- Martin Anderson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - M Bradley Drummond
- Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Renu Jain
- Respiratory Therapy Area, GSK, Research Triangle Park, NC, USA
| | - Neil Martin
- Global Medical Affairs, GSK, Brentford, Middlesex, UK.,Institute for Lung Health, University of Leicester, Leicester, Leicestershire, UK
| | - Richard A Mularski
- Department of Pulmonary and Critical Care Medicine, Kaiser Permanente Northwest Center for Health Research, Portland, OR, USA
| | - Mike Thomas
- Primary Care Research, University of Southampton, Southampton, UK
| | - Chang-Qing Zhu
- Biostatistics, GSK, Stockley Park West, Uxbridge, Middlesex, UK
| | - Gary T Ferguson
- Pulmonary Research, Institute of Southeast Michigan, Farmington Hills, MI, USA
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30
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Mahler DA, Halpin DMG. Peak Inspiratory Flow as a Predictive Therapeutic Biomarker in COPD. Chest 2021; 160:491-498. [PMID: 33812852 DOI: 10.1016/j.chest.2021.03.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/21/2021] [Accepted: 03/28/2021] [Indexed: 11/19/2022] Open
Abstract
Biomarkers in COPD may be clinical (prior exacerbation history), physiologic (FEV1), or blood based (eosinophil count or fibrinogen level). Recent interest in using biomarkers to predict response to therapy in clinical practice has emerged. The benefits of inhaled therapy depend on the correct use of the inhaler, including an appropriate inspiratory flow. Of the available delivery systems, dry powder inhalers are unique because they have an internal resistance, are breath actuated, and are flow dependent. Ideally, the user inhales "forcefully" to generate turbulent energy (determined by an individual's inspiratory flow and the resistance of the device) within the device that disaggregates the powder so that the individual inhales the medication particles into the lower respiratory tract. Because of specific features of dry powder inhalers and the required optimal inspiratory flow, an unmet need exists to identify individuals who are likely or unlikely to benefit from dry powder medications. Peak inspiratory flow, defined as the maximum airflow generated during inhalation against the simulated resistance of a dry powder inhaler, is a physiologic measure that has biological plausibility, has good test characteristics (repeatability and reliability), and is generalizable. Current evidence supports peak inspiratory flow as a predictive therapeutic biomarker to optimize therapy in both outpatients with COPD as well as those hospitalized for an exacerbation before discharge. This approach is consistent with the precepts of precision medicine, which considers differences in a person's biological features, exposure, and lifestyle to prevent and treat disease.
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Affiliation(s)
- Donald A Mahler
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH; Department of Respiratory Services, Valley Regional Hospital, Claremont, NH.
| | - David M G Halpin
- Department of Respiratory Medicine, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, England
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Critical inhaler technique errors in Swedish patients with COPD: a cross-sectional study analysing video-recorded demonstrations. NPJ Prim Care Respir Med 2021; 31:5. [PMID: 33563979 PMCID: PMC7873256 DOI: 10.1038/s41533-021-00218-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/06/2021] [Indexed: 11/24/2022] Open
Abstract
A correct use of inhaler devices is essential in chronic obstructive pulmonary disease (COPD) treatment. Critical errors were studied by analysing 659 video-recorded demonstrations of inhaler technique from 364 COPD patients using six different inhaler device models. The majority of the included patients used two (55%) or more (20%) device models. Overall, 66% of the patients made ≥1 critical error with at least one device model. The corresponding numbers for patients using 1, 2 and ≥3 device models were 43%, 70% and 86%, respectively. The only factor associated with making ≥1 critical error was simultaneous use of two (adjusted odds ratios (aOR) 3.17, 95% confidence interval (95% CI) 1.81, 5.64) or three or more (aOR 8.97, 95% CI 3.93, 22.1) device models. In conclusion, the proportion of patients making critical errors in inhaler technique was substantial, particularly in those using several different device models. To obtain optimal COPD treatment, it is important to assess a patient’s inhaler technique and to minimise the number of inhaler device models.
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Evaluation of Suboptimal Peak Inspiratory Flow in Patients with Stable COPD. J Clin Med 2020; 9:jcm9123949. [PMID: 33291438 PMCID: PMC7762130 DOI: 10.3390/jcm9123949] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 11/29/2020] [Accepted: 12/02/2020] [Indexed: 01/02/2023] Open
Abstract
Objective: Although the importance of assessing inspiratory flow in the selection of treatments for chronic obstructive pulmonary disease (COPD) is understood, evaluation of this factor is not yet widespread or standardized. The objective of the present work was to evaluate the peak inspiratory flow (PIF) of patients with COPD and to explore the variables associated with a suboptimal PIF. Methods: An observational, cross-sectional study was carried out at specialized nursing consultations over a period of 6 months. We collected clinical data as well as data on symptoms, treatment adherence, and patient satisfaction with their inhalers via questionnaires. PIF was determined using the In-Check Dial G16® device (Clement Clarke International, Ltd., Harlow, UK). In each case, the PIF was considered suboptimal when it was off-target for any of the prescribed inhalers. The association with suboptimal PIF was evaluated using multivariate logistic regression and the results were expressed as the odds ratio (OR) with 95% confidence interval (CI). Results: A total of 122 COPD patients were included in this study, of whom 34 (27.9%) had suboptimal PIF. A total of 229 inhalers were tested, of which 186 (81.2%) were dry powder devices. The multivariate analysis found an association between suboptimal PIF and age (OR = 1.072; 95% CI (1.019, 1.128); p = 0.007) and forced vital capacity (OR = 0.961; 95% CI (0.933, 0.989); p = 0.006). Conclusions: About a third of patients in complex specialized COPD care have suboptimal PIFs, which is related to age and forced vital capacity.
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Mahler DA, Ohar JA, Ferguson GT, Donohue JF. Pharmacotherapy for Chronic Obstructive Pulmonary Disease: Molecules and Delivery Are Equally Important. Am J Respir Crit Care Med 2020; 202:1482. [PMID: 32791005 PMCID: PMC7667917 DOI: 10.1164/rccm.202004-1489le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Donald A Mahler
- Geisel School of Medicine at Dartmouth Hanover, New Hampshire.,Valley Regional Hospital Claremont, New Hampshire
| | - Jill A Ohar
- Wake Forest University School of Medicine Winston-Salem, North Carolina
| | - Gary T Ferguson
- Pulmonary Research Institute of Southeast Michigan Farmington Hills, Michigan and
| | - James F Donohue
- University of North Carolina School of Medicine Chapel Hill, North Carolina
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