[Evaluation of the ability of asthmatic children to use a breath-actuated pressurized inhaler]

[Therapeutic adherence in asthma in France: A general review]

INTRODUCTION

Adherence in asthma is a paramount issue of disease management. A general review of the French publications on this topic has been conducted.

METHODS

Research equations used for bibliographic databases (MEDLINE, Science Direct, Banque de données en santé publique, Cochrane and Cairn.info) comprised the following keywords: "asthma", "therapeutic adherence" and "France". These publications unrelated to asthma, focused on asthma management without exploring adherence, or those conducted in populations without French patients were excluded.

RESULTS

A total of 82 articles have been selected (36 surveys, 4 randomized trials and 42 reviews/syntheses). Whatever the methodology used and publication year, the inadequate therapeutic adherence in asthma was steadily reported, notably for controllers and the quality of use of inhaled devices.

CONCLUSION

The present review highlights the sustainability of adherence-related issues in asthma and the need to improve patients' knowledge on asthma and the finality of therapy. It also highlights the need of an improved communication between patients and physicians is also advocated. Further studies with more recent data are desirable to assess changes in disease management of asthma and the impact of potential future corrective interventions.

Systematic Review of Errors in Inhaler Use: Has Patient Technique Improved Over Time?

BACKGROUND

Problems with the use of inhalers by patients were noted shortly after the launch of the metered-dose inhaler (MDI) and persist today. We aimed to assess the most common errors in inhaler use over the past 40 years in patients treated with MDIs or dry powder inhalers (DPIs).

METHODS

A systematic search for articles reporting direct observation of inhaler technique by trained personnel covered the period from 1975 to 2014. Outcomes were the nature and frequencies of the three most common errors; the percentage of patients demonstrating correct, acceptable, or poor technique; and variations in these outcomes over these 40 years and when partitioned into years 1 to 20 and years 21 to 40. Analyses were conducted in accordance with recommendations from Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Strengthening the Reporting of Observational Studies in Epidemiology.

RESULTS

Data were extracted from 144 articles reporting on a total number of 54,354 subjects performing 59,584 observed tests of technique. The most frequent MDI errors were in coordination (45%; 95% CI, 41%-49%), speed and/or depth of inspiration (44%; 40%-47%), and no postinhalation breath-hold (46%; 42%-49%). Frequent DPI errors were incorrect preparation in 29% (26%-33%), no full expiration before inhalation in 46% (42%-50%), and no postinhalation breath-hold in 37% (33%-40%). The overall prevalence of correct technique was 31% (28%-35%); of acceptable, 41% (36%-47%); and of poor, 31% (27%-36%). There were no significant differences between the first and second 20-year periods of scrutiny.

CONCLUSIONS

Incorrect inhaler technique is unacceptably frequent and has not improved over the past 40 years, pointing to an urgent need for new approaches to education and drug delivery.

Délivrance des traitements inhalés en pédiatrie

The most efficient method to deliver drugs to the lungs in children is the inhaled way. Its success depends on the characteristics of the aerosol, on those of the patient, and mainly on the inhalatory system. Before the age of 8 years, the most efficient system is the pressurised metered dose inhaler used together with a spacer device. Above this age, the use either of the pressurised metered dose inhaler, with a spacer device or a breath-actuated inhaler, or of a dry powder inhaler is discussed. Nebulisation is rarely indicated, except in cystic fibrosis. Demonstration with repeated medical instructions allows adequate inhalation technique. Inhaled treatments are efficient when used in diseases requiring this type of treatment, when several inhalers with different inhalatory techniques are not prescribed together, and when delivery is once or twice daily. At last, inhaled way is a new approach for different drugs with an extra-respiratory activity.

Efficacy response of inhaled HFA-albuterol delivered via the breath-actuated Autohaler inhalation device is comparable to dose in patients with asthma

Handling difficulties, such as poor coordination of actuation and inhalation, are common in patients using press and breathe (P&Bs) metered-dose inhalers to administer asthma medication. Although spacers can help overcome some difficulties, the cumbersome nature of these devices often detracts from their use for the administration of rescue medications, where portability is important. This randomized, placebo-controlled, multicenter, crossover study investigated the efficacy, dose-response and safety of HFA-albuterol delivered via a breath-actuated Autohaler inhalation device in comparison with the same medication delivered using a conventional P&B device. In total, 39 patients received six study treatments in a random sequence at clinic visits separated by 2-7 days: 2 puffs from a HFA-placebo Autohaler; 1, 2, or 4 puffs from a HFA-albuterol Autohaler; I or 2 puffs from a HFA-albuterol P&B. Both active inhalers delivered 90 microg albuterol base equivalent/actuation from the actuator. The change from baseline in forced expiratory volume in 1 s (FEV1) and the area under the FEV1 curve (FEV1 AUC) were significantly greater than placebo for all active treatment groups (p < or = 0.01) and were suggestive of a dose response for each inhaler. Examination of the pooled slope of the dose responses for the Autohaler and P&B using Finney's Parallel Line Bioassay Methodology found a highly statistically significant relationship indicating the equivalence of the two inhalers on both parameters (p < or = 0.002). The relative potency of the two inhalers was 0.8 (95% CI: 0.47, 1.46) for the mean change from baseline in FEV1 and 0.9 (95% CI, 0.56, 1.48) for the change from baseline in FEV1 AUC. There was also a trend toward an increase in the mean percentage change from baseline in FEV1 as the number of puffs increased for both inhalers. Furthermore, there were no significant differences between the treatment groups with regard to time to onset of bronchodilator effect and the duration of effect was significantly greater than placebo (p < or = 0.01) in each of the active groups. Adverse events were generally mild to moderate in nature and were of similar incidence (< or = 18% of patients) in each group. This study demonstrates a dose-response for HFA-albuterol on bronchodilation using both the Autohaler and P&B devices and illustrates that, in patients with good coordination of inhalation with actuation, the efficacy and safety of the two inhalers is similar at equivalent doses.

The influence of inhaler selection on efficacy of asthma therapies

Many different devices are available to aid inhalational drug delivery. Although each device is claimed to have advantages over its rivals, the evidence to support greater efficacy of a particular device is scanty. Most comparative studies are underpowered or flawed in their design. They may use inappropriate end-points, or involve healthy subjects, whose response may be very different from the patient with acute severe asthma. The dosage of drug used in a trial may be at the shallow part of the dose-response curve, masking differences in devices. Only in a few cases have clinical trials detected a significant difference between devices, and trials have rarely taken patient preference into account. The most efficacious device in practice is likely to be the one that the patient will use regularly and in accordance with a health care workers' recommendations.