Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT)

An approach to reduce inhaler errors using Donabedian's triad

Inhaler errors inversely affect the outcome of respiratory diseases. Inhaler devices, such as the metered-dose inhalers (MDI) and dry powder inhalers (DPI), are commonly used in treating respiratory diseases like asthma and chronic obstructive pulmonary disease (COPD), and incorrect use of these devices can result in suboptimal treatment outcomes, increased probabilities of hospitalizations or admissions, and poorer quality of life. Patient related factors to inhaler errors include age, cognitive and physical abilities, education, language barriers, and preferences. Device-related factors such as inhaler design and operational complexity can also lead to errors. Finally, factors related to healthcare professionals (HCP) such as competency, level of knowledge in disease and inhaler device and availability to educate patients, can play a role in inhaler error. Quality management is a potential solution to this problem. Quality improvement strategies towards addressing inhaler misuse can increase patient satisfaction and improve patient outcomes. Donabedian's triad, which includes structure, process, and outcome can be utilized in developing a framework for reducing inhaler errors. Institutional solutions are more towards the structural and process changes in the triad, such as HCP training, checklists on training efficacy, provision of action plans, and availability of staff to educate and train patients. Patient-centered solutions focus more on process and outcome domains, such as improvement in lung functions, patient education, re-assessment and re-education of inhaler techniques, and adherence to treatment regimen. By focusing on structural and process domains, the quality of care can be enhanced, resulting in improved outcomes.

Inhaler device selection for people with asthma or chronic obstructive pulmonary disease

There are many types of inhaler device, each with its own characteristics, benefits and limitations. Inhaler device selection should be individualised. Assessment of the patient's inspiratory flow, dexterity, coordination and preferences can help guide selection of a device that the patient can and will use effectively. For patients who require multiple inhaled drugs, prescribing combination inhalers and avoiding the use of more than one type of inhaler device can reduce errors in inhaler technique and improve adherence. Inhaler technique and adherence should be regularly reviewed. Environmental impact of inhalers can be reduced by optimising symptom control to minimise the need for short-acting beta2 agonists, and choosing inhalers with a low carbon footprint.

Inhaled corticosteroid delivery is markedly affected by breathing pattern and valved holding chamber model

BACKGROUND

There is a scarcity of high-quality research on the efficient delivery of inhaled corticosteroids using valved holding chambers (VHCs) in children.

METHODS

The delivered dose (DD) of fluticasone from a metered dose inhaler (pMDI) was tested using four VHCs: AeroChamber plus Flow-Vu (AC), Babyhaler (BH), EasyChamber (EC), and Optichamber Diamond (OD). The in vitro setup included an anatomical child throat model, Next Generation Impactor, and a breathing simulator to generate tidal breathing of a four and a 6-year-old child, and adult type single inhalation.

RESULTS

OD showed the lowest proportion of fluticasone trapped in the throat with all breathing patterns. AC showed similar fine particle dose (FPD) in the respirable range (1-5 µm) irrespective of the breathing pattern. For BH, the median FPD 1-5 µm was highest during adult breathing. OD and EC showed higher overall DD and higher doses in the 1-5 µm range with paediatric breathing profiles compared to adult inhalation. The median DD and FPD 1-5 µm were significantly lower with BH compared to any other VHCs during tidal breathing. Compared to EC, the FPD of the other VHCs were skewed towards <2 µm particles.

CONCLUSION

Fluticasone delivery is markedly affected by breathing pattern and VHC model. The observed differences in throat deposition and FPD delivered may have significant clinical implications for side effects and controlling airway inflammation. All VHCs intended for paediatric use should undergo testing using internationally recognised standardised methods incorporating clinically relevant paediatric breathing patterns.

Uncovering patterns of inhaler technique and reliever use: the value of objective, personalized data from a digital inhaler

Electronic inhalers provide information about patterns of routine inhaler use. During a 12-week study, 360 asthma patients using albuterol Digihaler generated 53,083 inhaler events that were retrospectively analyzed. A total of 41,528 (78%) of the recorded inhalation events were suitable for flow analysis (having a PIF ≥ 18 L/min and <120 L/min). Median PIF, inhalation volume, inhalation duration, and time to PIF for these events steadily decreased between the first and last 10 days of the study, by 5.1%, 12.6%, 15.9%, and 6.4%, respectively. Continuous short-acting beta2-agonist (SABA) overuse, defined as ≥2 SABA inhalations/week throughout the study period, was seen in 29% (n = 104) of patients. Of 260 patients with ≥1 instance of acute short-term SABA overuse, 55 (21%) had a confirmed exacerbation. Electronic recording of real-life inhaler use can capture valuable, objective information that could inform disease management and clinical decision-making.

Impact of Pharmacist-Led Intervention on Adherence to Inhalers, Inhalation Technique, and Disease Control Among Asthma/COPD Patients in a Resource Limited Center: An Interventional Study

Background

Asthma and Chronic obstructive pulmonary disease (COPD) are chronic respiratory conditions characterized by airflow obstruction and respiratory symptoms. Adherence to prescribed inhaler therapy and correct inhalation technique are essential for effective disease management and optimal disease control. However, non-adherence and incorrect inhalation technique are common challenges faced by patients with asthma and COPD, leading to suboptimal treatment outcomes and increased healthcare burden.

Purpose

To study the impact of a pharmacist-led intervention on inhaler adherence, inhalation technique, and disease control among patients with asthma and COPD.

Patients and Methods

A pre-post interventional design assessed the effects of pharmacist-led intervention on inhaler adherence, inhalation techniques, and disease control in asthma and COPD patients at Dhulikhel Hospital in Nepal. Inclusion criteria: adult patient clinically diagnosed with asthma or COPD patients of all genders. The intervention comprised counseling patients with aids like videos, and informational leaflets. Impact was measured using checklist method for inhalation technique, the Test of Adherence to Inhaler (TAI) questionnaire for adherence to inhaler, and "Asthma Control Test (ACT)" or "COPD Assessment Test (CAT)" for disease control.

Results

The pharmacist-led intervention significantly increased adherence to inhalers, evidenced by a notable rise in the proportion of patients with good adherence (P<0.001). Sporadic, deliberate, and unwitting noncompliance pattern also improved significantly after the intervention (P<0.001, P<0.001 and P=0.001). Inhalation technique exhibited substantial improvement after intervention (P<0.001). The analysis indicated significant moderate negative correlations between "TIA" and "CAT" [ρ=-0.31; P=0.01], and between "inhalation technique score" and "CAT score" [ρ=-0.31; P=0.01] suggesting that as adherence to inhaler usage and inhalation technique improve, CAT scores tend to decrease, indicating reduced disease impact on the patient.

Conclusion

This study shows the potential efficacy of pharmacist-led intervention in enhancing adherence to inhaler, inhalation technique, and disease control in respiratory conditions such as asthma and COPD.

Aerosol Plumes of Inhalers Used in COPD

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.

Demystifying Dry Powder Inhaler Resistance with Relevance to Optimal Patient Care

The selection of an inhaler device is a key component of respiratory disease management. However, there is a lack of clarity surrounding inhaler resistance and how it impacts inhaler selection. The most common inhaler types are dry powder inhalers (DPIs) that have internal resistance and pressurised metered dose inhalers (pMDIs) that use propellants to deliver the drug dose to the airways. Inhaler resistance varies across the DPIs available on the market, depending largely on the design geometry of the device but also partially on formulation parameters. Factors influencing inhaler choice include measures such as flow rate or pressure drop as well as inhaler technique and patient preference, both of which can lead to improved adherence and outcomes. For optimal disease outcomes, device selection should be individualised, inhaler technique optimised and patient preference considered. By addressing the common clinically relevant questions, this paper aims to demystify how DPI resistance should guide the selection of the right device for the right patient.

Perception of burden of oral and inhaled corticosteroid adverse effects on asthma-specific quality of life

BACKGROUND

A multistakeholder core outcome set created for asthma trials showed that asthma-specific quality of life (QoL) was a critically meaningful outcome. However, the definition and measurement methods were undetermined. The adverse effects (AEs) of corticosteroids may be a vital clinical trial outcome. Nevertheless, the AE burden from the patient perspective has not yet been elucidated in an asthma population.

OBJECTIVE

To characterize patient burden of AEs in oral (OCS) and inhaled corticosteroids (ICS) and how this relates to QoL within an asthma population.

METHODS

We used a convergent parallel mixed-methods design with quantitative surveys of known ICS and OCS AEs that were distributed through the Allergy & Asthma Network database, social channels, and the Asthma UK newsletter. Participants rated the AEs that were (1) most burdensome and (2) most desired to be eliminated. Qualitative interviews and focus groups were performed to better understand patient views on barriers reported in the quantitative data, and to identify patient-important barriers that were not a part of the quantitative survey.

RESULTS

The 3 most burdensome AEs for OCS were bone mineral density, infectious complications, and weight gain, whereas weight gain was the most desired to be eliminated. The 3 most burdensome AEs for ICS were pneumonia, hoarse voice, and oral thrush, with concordant results for the most desired to be eliminated. In the focus groups, OCS AEs were concordant with quantitative findings. Focus groups identified unmeasured psychosocial effects, such as embarrassment.

CONCLUSION

The most burdensome AEs may not be those that would cause patients to stop therapy. Furthermore, qualitative focus groups suggest a psychosocial burden associated with ICS, which needs further investigation.

Inhalation Dosage Forms: A Focus on Dry Powder Inhalers and Their Advancements

In this review, an extensive analysis of dry powder inhalers (DPIs) is offered, focusing on their characteristics, formulation, stability, and manufacturing. The advantages of pulmonary delivery were investigated, as well as the significance of the particle size in drug deposition. The preparation of DPI formulations was also comprehensively explored, including physico-chemical characterization of powders, powder processing techniques, and formulation considerations. In addition to manufacturing procedures, testing methods were also discussed, providing insights into the development and evaluation of DPI formulations. This review also explores the design basics and critical attributes specific to DPIs, highlighting the significance of their optimization to achieve an effective inhalation therapy. Additionally, the morphology and stability of 3 DPI capsules (Spiriva, Braltus, and Onbrez) were investigated, offering valuable insights into the properties of these formulations. Altogether, these findings contribute to a deeper understanding of DPIs and their development, performance, and optimization of inhalation dosage forms.

Chronic Obstructive Pulmonary Disease Part 3: Inhaler Technique and Counseling Pearls

Chronic obstructive pulmonary disease therapy management can be complex given the various types of inhaler devices available, even within a therapeutic class. Appropriateness of an inhaler relies on many patient-specific factors. Senior care pharmacists can positively impact patient care by providing appropriate inhaler assessment as well as education on inhaler technique to ensure maximal benefit from therapeutic treatment choices.

Repurposing mucosal delivery devices for live attenuated tuberculosis vaccines

Tuberculosis (TB) remains one of the most lethal infectious diseases globally. The only TB vaccine approved by the World Health Organization, Bacille Calmette-Guérin (BCG), protects children against severe and disseminated TB but provides limited protection against pulmonary TB in adults. Although several vaccine candidates have been developed to prevent TB and are undergoing preclinical and clinical testing, BCG remains the gold standard. Currently, BCG is administered as an intradermal injection, particularly in TB endemic countries. However, mounting evidence from experimental animal and human studies indicates that delivering BCG directly into the lungs provides enhanced immune responses and greater protection against TB. Inhalation therapy using handheld delivery devices is used for some diseases and allows the delivery of drugs or vaccines directly into the human respiratory tract. Whether this mode of delivery could also be applicable for live attenuated bacterial vaccines such as BCG or other TB vaccine candidates remains unknown. Here we discuss how two existing inhalation devices, the mucosal atomization device (MAD) syringe, used for influenza vaccines, and the Respimat® Soft Mist™ inhaler, used for chronic obstructive pulmonary disease (COPD) therapy, could be repurposed for mucosal delivery of live attenuated TB vaccines. We also outline the challenges and outstanding research questions that will require further investigations to ensure usefulness of respiratory delivery devices that are cost-effective and accessible to lower- and middle-income TB endemic countries.

Is Inhaler Technique Adequately Assessed and Reported in Clinical Trials of Asthma and Chronic Obstructive Pulmonary Disease Therapy? A Systematic Review and Suggested Best Practice Checklist

BACKGROUND

Inhaled medications are central to treating asthma and chronic obstructive pulmonary disease (COPD), yet critical inhaler technique errors are made by up to 90% of patients. In the clinical research setting, recruitment of subjects with poor inhaler technique may give a false impression of both the benefits and the necessity of add-on treatments such as biologic therapies.

OBJECTIVE

To assess the frequency with which inhaler technique is assessed and reliably optimized before and during patient enrollment into randomized controlled trials (RCTs) addressing the efficacy of topical therapy, and the escalation of therapy for asthma and COPD.

METHODS

Systematic searches were conducted of PubMed and Embase for RCTs published in the past 10 years involving patients with a diagnosis of asthma or COPD undergoing escalation of baseline inhaled therapy (stepping up, changing, adding, switching, increasing, etc) or the introduction of biologic agents.

RESULTS

Searches highlighted 1,014 studies, 118 of which were eligible after the removal of duplicates as well as screening and full text review. Of these, only 14 (11.9%) included accessible information in the methods section or referred to such information in online supplements or protocols concerning assessment of participants' inhaler technique. We therefore developed the proposed Best Practice Inhaler Technique Assessment and Reporting Checklist.

CONCLUSIONS

Our study identifies a concerning lack of checking and correcting inhaler technique, or at least reporting that this was undertaken, before enrollment in asthma and COPD RCTs, which may affect the conclusions drawn. Mandating the use of a standardized checklist in RCT protocols and ensuring all published RCTs report checking and correcting inhaler technique before enrollment are important next steps.

How to Choose the Right Inhaler Using a Patient-Centric Approach?

There are many different inhaler devices and medications on the market for the treatment of asthma and chronic obstructive pulmonary disease, with over 230 drug-delivery system combinations available. However, despite the abundance of effective treatment options, the achieved disease control in clinical practice often remains unsatisfactory. In this context, a key determining factor is the match or mismatch of an inhalation device with the characteristics or needs of an individual patient. Indeed, to date, no ideal device exists that fits all patients, and a personalized approach needs to be considered. Several useful choice-guiding algorithms have been developed in the recent years to improve inhaler–patient matching, but a comprehensive tool that translates the multifactorial complexity of inhalation therapy into a user-friendly algorithm is still lacking. To address this, a multidisciplinary expert panel has developed an evidence-based practical treatment tool that allows a straightforward way of choosing the right inhaler for each patient.

Aerosolized drug delivery in awake and anesthetized children to treat bronchospasm

Bronchospasm is a common respiratory adverse event in pediatric anesthesia. First-line treatment commonly includes inhaled salbutamol. This review focuses on the current best practice to deliver aerosolized medications to awake as well as anesthetized pediatric patients and discusses the advantages and disadvantages of various administration techniques. Additionally, we detail the differences between various airway devices used in anesthesia. We highlight the unmet need for innovation of orally inhaled drug products to deliver aerosolized medications during pediatric respiratory critical events such as bronchospasm. It is therefore important that clinicians remain up to date with the best clinical practice for aerosolized drug delivery in order to prevent and efficiently treat pediatric patients experiencing life-threatening respiratory emergencies.

Effectiveness of individualized inhaler technique training on low adherence (LowAd) in ambulatory patients with COPD and asthma

To analyze whether there is improvement in adherence to inhaled treatment in patients with COPD and asthma after an educational intervention based on the teach-to-goal method. This is a prospective, non-randomized, single-group study, with intervention and before-after evaluation. The study population included 120 patients (67 females and 53 males) diagnosed with asthma (70.8%) and COPD (29.1%). The level of adherence (low and optimal) and the noncompliance behavior pattern (erratic, deliberate and unwitting) were determined by the Test of the adherence to Inhalers (TAI). This questionnaire allows you to determine the level of adherence and the types of noncompliance. Low Adherence (LowAd) was defined as a score less than 49 points. All patients received individualized educational inhaler technique intervention (IEITI). Before the IEITI, 67.5% of the patients had LowAd. Following IEITI, on week 24, LowAd was 55% (p = 0.024). Each patient can present one or more types of noncompliance. The most frequent type was forgetting to use the inhaler (erratic), 65.8%. The other types were deliberate: 43.3%, and unwitting: 57.5%. All of them had decreased on the final visit: 51.7% (p = 0.009), 25.8% (p = 0.002), 39.2% (p = 0.002). There were no significant differences in adherence between asthma and COPD patients at the start of the study. The only predicting factor of LowAd was the female gender. An individualized educational intervention, in ambulatory patients with COPD and asthma, in real-world clinical practice conditions, improves adherence to the inhaled treatment.

Switching to the Dry-Powder Inhaler Easyhaler®: A Narrative Review of the Evidence

Asthma and chronic obstructive pulmonary disease (COPD) are major causes of morbidity and mortality worldwide. Optimal control of these conditions is a constant challenge for both physicians and patients. Poor inhaler practice is widespread and is a substantial contributing factor to the suboptimal clinical control of both conditions. The practicality, dependability, and acceptability of different inhalers influence the overall effectiveness and success of inhalation therapy. In this paper, experts from various European countries (Finland, Germany, Hungary, Italy, Poland, Spain, and Sweden) address inhaler selection with special focus on the Easyhaler^® device, a high- or medium–high resistance dry-powder inhaler (DPI). The evidence examined indicates that use of the Easyhaler is associated with effective control of asthma or COPD, as shown by the generally accepted indicators of treatment success. Moreover, the Easyhaler is widely accepted by patients, is reported to be easy to learn and teach, and is associated with patient adherence. These advantages help patient education regarding correct inhaler use and the rational selection of drugs and devices. We conclude that switching inhaler device to the Easyhaler may improve asthma and COPD control without causing any additional risks. In an era of climate change, switching from pressurized metered-dose inhalers to DPIs is also a cost-effective way to reduce emissions of greenhouse gases.

Pulmonary rehabilitation: promising nonpharmacological approach for treating asthma?

PURPOSE OF REVIEW

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation with a history of respiratory symptoms that vary over time and in intensity, together with variable expiratory airflow limitation. The goal of asthma treatment is to reach symptoms control, reduction in future risk and improvement in quality of life (QoL). Guideline-based pharmacologic therapies and the effect of inhaled steroids and bronchodilators have been widely studied over the past decades. We provide an overview of the available evidence on pulmonary rehabilitation as a nonpharmacologic therapy in asthmatic patients.

RECENT FINDINGS

Recently, some studies have highlighted the promising role of nonpharmacologic therapies in asthma, such as pulmonary rehabilitation demonstrating that a pulmonary rehabilitation programme consisting of exercise training, breathing retraining, educational and psychological support, improve exercise capacity, asthma control and QoL and reduce dyspnea, anxiety, depression and bronchial inflammation at any step of the disease.

SUMMARY

Pulmonary rehabilitation shows positive results on exercise tolerance, respiratory symptoms and QoL in asthmatic patients at any steps of the diseases. However, additional information is required to better characterize rehabilitation programmes in order to improve clinical care in asthma.

The Role of the Pharmacist in Inhaler Selection and Education in Chronic Obstructive Pulmonary Disease

Objective: To review the role of pharmacists in educating and monitoring patients with chronic obstructive pulmonary disease (COPD) on inhalation technique. Data Sources: A PubMed search (January 2000 to May 2020) was performed using the following keywords and associated medical subject headings: adherence, chronic obstructive pulmonary disease/COPD, education, inhaler, pharmacist, and technique. Study Selection and Data Extraction: The search was conducted to identify English language articles highlighting the importance of correct inhaler technique in COPD management and benefits of pharmacist inhaler training such as improved adherence, quality of life (QoL), and disease control. Randomized controlled trials, retrospective studies, observational studies, systematic reviews, and meta-analysis reporting pharmacist training were included. Data Synthesis: This review summarizes that incorrect inhaler use negatively affects treatment outcomes, prognosis, and QoL. Pharmacists are in a unique position to educate and monitor patients with COPD on optimal inhaler technique and an individualized, multifactorial approach to COPD management involving pharmacists could provide cost-effective patient care and improve adherence and minimize inhaler misuse. Several strategies used by pharmacists can optimize patient inhaler use, such as face-to-face technique demonstrations, the "teach-back" method, telemonitoring, instructional videos, or informational leaflets. An individualized action plan involving education and regular monitoring of inhaler use further enhances optimal adherence and disease management. Conclusions: As pharmacists are easily accessible to both patients and health care providers, they are ideally placed to play an important role in the enhancement of education on, and continuous assessment of, optimal inhaler technique, thereby improving adherence, disease control, and QoL.

Medication Therapy Management for Texas MediCAID Patients With Asthma and Chronic Obstructive Pulmonary Disease-A Pilot Study

BACKGROUND

Pharmacists can play an important role in providing medication therapy management (MTM) services, which focus on appropriate medication use. This pilot study aimed to describe pharmacists' MTM service provision, results/outcomes of pharmacists' recommendations and resolution/acceptance rate among patients with high-risk asthma and/or chronic obstructive pulmonary disease (COPD).

METHODS

This was a prospective descriptive study of MTM services provided by community pharmacists to Texas Medicaid patients (5-63 years) with "high risk" asthma or COPD. Patients received in-person and telephone consultations that included medication review, asthma control test assessment, and education on adherence and proper medication/device use. Data extracted from MTM software was used to describe: reasons for MTM services, type of pharmacists' interventions, outcomes of pharmacists' recommendations and acceptance rate.

RESULTS

Twenty-eight pharmacists provided 139 MTM interventions with 63 patients (2.2 interventions per patient). The most frequent intervention reason was complex drug therapy (53.2%), underuse of medication (8.6%), need for drug therapy (8.6%), new or changed prescription therapy (6.5%), and administration technique (5.0%). The resolution rate was 77.7%. Patient and prescriber, respectively, refused recommendation in 12% and 6% of the interventions. Outcomes included comprehensive medication review (46.7%), improved adherence (6.5%), therapeutic success (6.5%), improved administration technique (5.0%), and initiation of new therapy (5.0%).

CONCLUSION

Through the provision of MTM, pharmacists were able to identify and intervene with medication-related problems. These interventions are instrumental in helping patients better manage their asthma/COPD. The high resolution rate was encouraging. Larger scale studies are needed to assess clinical and economic outcomes.

Small Airway Disease in Pediatric Asthma: the Who, What, When, Where, Why, and How to Remediate. A Review and Commentary

Asthma affects all portions of the airways. Small airways, however, comprise a substantial component of the conducting lung air flow. In asthma, inflammatory processes can affect the whole respiratory tract, from central to peripheral/small airways. The emphasis in adult and pediatric respiratory disease clinics is to focus on large airway obstruction and reversibility. This information, although valuable, underemphasizes a large portion of the conduction airway of asthmatics. Standard descriptions of asthma management focus on a multiple medication approaches. We particularly focused on the management of asthma in the international guidelines for the Global Initiative for Asthma (GINA). Overall, however, minimal attention is placed on the small airway pool in asthma medical management. We took the opportunity to thoroughly review and present specific data from the adult asthma literature which supported the concept that small airway abnormalities may play a role in the pathogenesis and clinical expression of asthma. Based on the conclusions of the adult asthma literature, we here present a thorough review of the literature as it relates to small airway disease in children with asthma. We used, collectively, individual data sources of data to expand the information available from standard diagnostic techniques, especially spirometry, in the evaluation of small airway disease. As the pharmacological approaches to moderate to severe asthma are advancing rapidly into the realm of biologics, we sought to present potential pharmacological options for small airway dysfunction in pediatrics prior to biological modifier intervention.

The Burden of Self-Reported Rhinitis and Associated Risk for Exacerbations with Moderate-Severe Asthma in Primary Care Patients

Purpose

There is a dearth of research regarding the prevalence and nature of patient-reported rhinitis and its relationship with risk of asthma exacerbations. The aim of this study was to (i) determine the prevalence, severity and treatment of self-reported rhinitis symptoms among adults aged ≥18 years with asthma treated at Global Initiative for Asthma (GINA) Step 3 and above and (ii) compare the demographics, clinical characteristics, medication use, side-effects and healthcare practitioner review between patients who report rhinitis symptoms and those who do not and (iii) determine whether patient-reported rhinitis is associated with risk of asthma exacerbations in the total patient sample.

Patients and Methods

This analysis used data from the iHARP (Initiative Helping Asthma in Real-life Patients) asthma review service – a cross-sectional observational study (2011 and 2014) in seven countries that captured data on patient demographics, rhinitis symptoms, asthma symptoms, indicators of exacerbations, medication use, oropharyngeal effects and side-effects, using practitioner- and patient-reported questionnaires. Comparisons between patients with and without rhinitis were tested. Univariate logistic regression was used to identify variables associated with risk of exacerbations for entry into multivariable logistic regression.

Results

This report contains data from 4274 patients: 67.4% (2881/4274) reported rhinitis symptoms and of which 65.7% (1894/2881) had not received a doctor diagnosis; 36.5% (1052/2881) had moderate-severe rhinitis, 12.4% (358/2881) had used intranasal corticosteroids and 19.8% (569/2881) oral antihistamines. Patients with coexisting moderate-severe rhinitis were more likely to have GINA-defined uncontrolled asthma than those with mild rhinitis or no rhinitis. Moderate-severe rhinitis was associated with 40% increased risk of asthma exacerbations (OR=1.40, 95% CI: 1.02–1.90).

Conclusion

This study identified a major gap in the diagnosis and management of rhinitis in a cohort of people with asthma treated at GINA Step 3 and above who are managed in general practice. It highlights the need for practitioners to identify, evaluate and optimally treat rhinitis in adults with asthma, which is a significant factor associated with exacerbation risk.

The Climate is Changing for Metered-Dose Inhalers and Action is Needed

Increases in global temperature are already having a significant impact on our climate. The hydrofluorocarbon (HFC) propellants used today in pressurized metered-dose inhalers (pMDIs) have global warming potential (GWP) many times that of carbon dioxide. Their use, together with all other emissive uses of HFCs, is being phased down under the Montreal protocol. This has prompted calls to switch patients to dry powder inhalers (DPIs). This paper presents a new analysis of the top 15 respiratory drug markets by drug class. It shows that a switch to DPIs would be economically feasible for most countries and most drugs. However, a wholesale switch of reliever medications, notably short-acting  β-agonists, would lead to significant increases in the cost of these life-saving medications. Reviewing the evidence, whilst most patients are capable of using DPIs, the very young, very old and those undergoing an acute exacerbation still require a pMDI. Thus, there is a clinical and economic need to have both pMDIs and DPIs available. At the same time, it is projected that the reduction in non-medical uses of propellants is likely to give rise to a 5-fold increase in their cost for pMDI uses and is likely to hit the Western world in 2025. This may lead to a price increase in reliever medication that will make it unaffordable for the poorer communities in some markets. At the same time, opportunities to save money by developing new formulations using propellants with lower GWP, such as HFC 152a or HFO 1234ze(E), are described. Two companies have made this commitment, but neither currently have a strong presence in reliever medication. For them, or other companies, now is the time to act; 2025 is not far away in terms of product development timescales and the climate cannot wait.

Pulmonary Rehabilitation and Asthma

Asthma is a chronic inflammatory disease characterized by airflow limitation and variable respiratory symptoms. It is characterized by variable symptoms such as cough, wheeze, chest tightness, and shortness of breath which vary in intensity and time. In order to reach a comprehensive approach of disease management, the importance of non-pharmacological treatment in addition to pharmacological therapy has been recently highlighted. Studies have documented that pulmonary rehabilitation has beneficial effects in patients with asthma, at any stage of the disease, improving exercise capacity, asthma control, and quality of life and reducing wheezing, anxiety, depression, and bronchial inflammation. Although several evidences suggest a role of pulmonary rehabilitation in patients with asthma, additional information is required to identify a specific program in order to improve clinical care based on specific patient’s needs.

Controller Inhalers: Overview of Devices, Instructions for Use, Errors, and Interventions to Improve Technique

Inadequate inhaler technique in persistent asthma is frequently reported. However, there is little consensus on inhaler checklists, and critical elements of technique are not uniformly described. In addition, inhaler error rates and risk factors for poor technique are variable across studies. This Clinical Commentary Review summarizes the literature on inhaler design, use, and interventions to improve technique. Our aim is to help clinicians identify patients with poor inhaler technique, recognize the most important errors, and correct technique using evidence-based interventions.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Spacers and Valved Holding Chambers-The Risk of Switching to Different Chambers

Spacers are pressurized metered-dose inhaler (pMDI) accessory devices developed to reduce problems of poor inhaler technique with pMDIs. Spacers that feature a 1-way inspiratory valve are termed valved holding chambers (VHCs); they act as aerosol reservoirs, allowing the user to actuate the pMDI device and then inhale the medication in a 2-step process that helps users overcome challenges in coordinating pMDI actuation with inhalation. Both spacers and VHCs have been shown to increase fine particle delivery to the lungs, decrease oropharyngeal deposition, and reduce corticosteroid-related side effects such as throat irritation, dysphonia, and oral candidiasis commonly seen with the use of pMDIs alone. Spacers and VHCs are not all the same, and also are not interchangeable: the performance may vary according to their size, shape, material of manufacture and propensity to become electrostatically charged, their mode of interface with the patient, and the presence or otherwise of valves and feedback devices. Thus, pairing of a pMDI plus a spacer or a VHC should be considered as a unique delivery system. In this Rostrum we discuss the risk potential for a patient getting switched to a spacer or VHC that delivers a reduced dose medication.

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

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

Inhalation technique practical skills and knowledge among physicians and nurses in two pediatric emergency settings

Introduction: Correct technique with a pressurized metered-dose inhaler (pMDI) equipped with a valved holding chamber (VHC) or spacer provides an important advantage for adequate control of asthma and virus-induced wheezing in young children. The aim of this study was to assess the ability and knowledge of physicians and nurses to use a pMDI with a masked VHC in two pediatric emergency units.Methods: Study design: Two-center observational study. Inhaler use technique was assessed in 50 physicians and 50 nurses using a child mannequin and a validated videotaped nine-step scoring method. The participants' knowledge was evaluated by a questionnaire.Results: The inhalation technique was perfectly mastered by 49% of the study participants and almost perfectly mastered by another 34% (mean score 8.3 ± 0.7; range 5-9). Nurses were more likely than doctors to demonstrate the technique perfectly (66% vs. 32%, p < 0.05). The two most common errors were forgetting to shake the pMDI between two consecutive puffs (38% of the participants) and putting the patient in an incorrect position (11%). About half of the participants reported that they checked each patient's inhalation technique at every opportunity and knew how to clean the VHC. A large majority did not employ a reliable method to determine the amount of medication remaining in pMDIs without a counter.Conclusion: Healthcare professionals' practical skills and knowledge on inhalation therapy were not completely mastered and could be improved with a mandatory training program.

Biological Obstacles for Identifying In Vitro-In Vivo Correlations of Orally Inhaled Formulations

Oral inhalation of drugs is the classic therapy of obstructive lung diseases. In contrast to the oral route, the link between in vitro and in vivo findings is less well defined and predictive models and parameters for in vitro-in vivo correlations are missing. Frequently used in vitro models and problems in obtaining in vivo values to establish such models and to identify the action of formulations in vivo are discussed. It may be concluded that major obstacles to link in vitro parameters on in vivo action include lack of treatment adherence and incorrect use of inhalers by patients, variation in inhaler performance, changes by humidity, uncertainties about lung deposition, and difficulties to measure drug levels in epithelial lining fluid and tissue. Physiologically more relevant in vitro models, improvement in inhaler performance, and better techniques for in vivo measurements may help to better understand importance and interactions between individual in vitro parameters in pulmonary delivery.

Choosing the right inhaler for your asthma or COPD patient

Appropriate selection and correct use of inhalation devices is an integral component in the management of asthma and chronic obstructive pulmonary disease (COPD). It is well known that there are many challenges with the use of inhalers, and no one device suits all patients. Challenges can range from difficulties related to lung disease severity and pulmonary function to physical considerations, including manual dexterity and comorbidities such as arthritis. In terms of device selection and adherence, patient engagement and satisfaction are also important factors to consider. Furthermore, problems with inhaler use can be most evident in children and older patients. Here, we discuss aspects for consideration with commonly used devices, including nebulizers, pressurized metered-dose inhalers, dry powder inhalers, and the soft mist inhaler. As each inhaler offers varying technical properties, a tailored and personalized approach to the selection of the most appropriate device for the patient is highly recommended in order to increase the likelihood of achieving improved disease outcomes and enhance persistence with device adherence. Importantly, education and support is crucial, not only to enable patients to recognize the need for optimal disease management, but also to help them develop good inhaler technique. In addition, health care professionals should also aim to increase their knowledge of the devices they prescribe, and develop systems to ensure that they offer comprehensive support to patients in clinical practice. Considering these aspects, this review discusses potential strategies to help address the challenges of inhaler use in asthma and COPD.

Asthma 101: Teaching children to use metered dose inhalers

Providers across the spectrum of healthcare must be aware of their patients' inhaler use. This article addresses common errors and the proper use of pressurized metered-dose inhalers in pediatric patients.

Inhaler training and asthma knowledge are associated with a higher proportion of patients with correct inhaler technique in young but not in elderly asthmatic patients

Objective: Incorrect inhaler usage is frequent, particularly in elderly asthmatic patients. This study aimed at comparing inhaler technique errors and their determinants, as well inhaler technique self-perception versus real performance, between elderly and non-elderly asthmatics. Methods: Cross-sectional assessment of 92 elderly and 100 non-elderly asthmatics followed at specialty clinics. A standardized questionnaire was applied and inhaler technique demonstration was requested. Errors were assessed using checklists based on manufacturers' instructions and inhaler technique was graded as correct, acceptable or incorrect. Chi-Square Test and Fischer's Exact Test were used for comparative analysis of nominal variables. A p value equal to or less than 0.05 was considered statistically significant. Results: Inhaler technique was correct in a minority of elderly and young patients, without significant differences between study groups. Only 11.1% of the elderly who classified their inhaler as easy and 12.7% who stated their technique was correct had no errors. Previous regular inhaler training was associated with better actual performance in young but not in elderly patients. Conclusion: Our study showed that in spite of regular follow up at specialized outpatient clinics, inhaler devices are associated with a high frequency of errors in elderly and non-elderly asthmatics. In addition, most patients tend to overestimate their technique as correct. Finally, previous, frequent training was associated with a significantly higher percentage of patients showing correct or acceptable technique but only in non-elderly asthmatics, which suggests that elderly asthmatics may need specifically tailored inhaler education programs.

It takes a village - asthma networks utilized by parents when managing childhood asthma medications

Objective: We are yet to understand how widely parents seek asthma medication management information for their children, how they are used for health information, how parents engage with them and their influence on parent's decision-making. This study aimed to gauge the current level of asthma knowledge and skills of parents of children with asthma and gain insight into who and what influences their child's asthma medication management decisions. Method: Social network theory was used to map parents' asthma networks and identify the level of influence of each individual/resource nominated. Parents of children with asthma (aged 4-18 years) were interviewed, completed an asthma network map, questionnaires and an inhaler technique assessment. Results: Twenty-six parents participated and had significant gaps in asthma knowledge and inhaler technique skills. The asthma networks of participants ranged from two to ten individuals/resources, with an average number of five. The most commonly nominated individual/resource was general practitioners followed by family members and the internet. Professional connections represented 44% of individuals/resources in networks, personal connections 42% and impersonal connections 14%. When parents were asked about how influential individuals/resources were, professional connections represented 53% of parents influences, personal connections 36% and impersonal connections 11%. Conclusion: This study highlights the priority and co-influence of non-medical sources of information/support on parent's behaviors and decision-making with regards to their child's asthma medicine taking. In further understanding the complexities surrounding these connections and relationships, HCPs are better positioned to assist parents in addressing their needs and better supporting them in the management of their child's asthma.

Correct use and ease of use of a placebo dry powder inhaler in subjects with asthma and chronic obstructive pulmonary disease

Correct use and ease of use of a placebo dry powder inhaler was evaluated in two single-arm, United States-multicenter, phase-IV studies in adults with asthma ( n = 259) or chronic obstructive pulmonary disease (COPD; n = 278) who were receiving maintenance inhaler therapy. Subjects demonstrating correct placebo inhaler use within three attempts at screening were instructed to take once-daily inhalations from the inhaler for 28 ± 2 days (continuing usual maintenance), followed by randomization to complete one of two versions of an ease-of-use questionnaire and reassessment for correct inhaler use. At study end, 96% asthma/93% COPD subjects rated the placebo inhaler as "easy" or "very easy" to use while demonstrating correct use. Furthermore, 99% asthma/99% COPD subjects indicated it was "easy" or "very easy" to determine number of doses remaining, and 81%/84%, respectively, indicated they would be "likely" or "very likely" to request their current medication in the inhaler, if available. Adverse event (AE) rates were 12% asthma/15% COPD, most frequently headache (3%/3%). Treatment-related AEs were reported in one subject with asthma (cough) and four subjects with COPD (cough, n = 3; back pain, n = 1). At study end, most subjects with asthma or COPD operated the placebo inhaler correctly and found it easy to use.

Inhalation Technique Errors with Metered-Dose Inhalers Among Patients with Obstructive Lung Diseases: A Systematic Review and Meta-Analysis of U.S. Studies

Background

Metered dose inhalers (MDIs) are commonly prescribed for inhalation therapy, but correct use is critical to promoting effective medication delivery. This systematic literature review and meta-analysis evaluates the overall and step-by-step prevalence of errors among adults with obstructive lung diseases in the United States who used MDIs.

Methods

Electronic and manual searches conducted between 1979-2018 using PubMed, EMBASE, PsycINFO, Cochrane, and Google identified 10 articles that met the following inclusion criteria: (a) English language, (b) U.S. adults diagnosed with chronic obstructive pulmonary disease, and (c) MDI use error rates. Meta-analytic techniques using random-effects models were applied to calculate effect sizes, weighted proportions, and 95% confidence intervals (CIs). Heterogeneity was assessed by the I² statistic.

Results

Aggregate findings revealed that 86.7% of patients (n=390, 95% CI 77.5-96.0) made at least 1 inhalation technique error, and 76.9% (n=885, 95% CI 65.8-87.9) incorrectly performed ≥ 20% of device use steps. The most prevalent step-by-step errors across the studies (n=1105) were failure to: (a) exhale fully and away from the inhaler before inhalation (65.5% [95% CI 52.0, 78.9]); (b) hold breath for 5-10 seconds (41.9% [95% CI 29.8, 53.9]); (c) inhale slowly and deeply (39.4% [95% CI 26.2, 52.5]); (d) exhale after inhalation (35.9% [95% CI 17.0, 54.8]); and (e) shake the inhaler before use (34.2% [95% CI 30.6, 37.7]).

Conclusions

Across the studies used in this meta-analysis more than three-fourths of U.S. adults with obstructive lung diseases used MDIs incorrectly. Our findings suggest the need for ongoing patient education and consideration of alternative devices to mitigate errors.

What to consider before prescribing inhaled medications: a pragmatic approach for evaluating the current inhaler landscape

Inhaled therapies are the cornerstone of treatment in asthma and chronic obstructive pulmonary disease, and there are a multitude of devices available. There is, however, a distinct lack of evidence-based guidance for healthcare providers on how to choose an appropriate inhaler. This review aims to summarise recent updates on topics related to inhaler choice, and to offer practical considerations for healthcare providers regarding currently marketed devices. The importance of choosing the right inhaler for the right patient is discussed, and the relative merits of dry powder inhalers, pressurised metered dose inhalers, breath-actuated pressurised metered dose inhalers, spacers and soft mist inhalers are considered. Compiling the latest studies in the devices therapy area, this review focuses on the most common types of handling errors, as well as the comparative rates of incorrect inhalation technique between devices. The impact of device-specific handling errors on inhaler performance is also discussed, and the characteristics that can impair optimal drug delivery, such as inhalation flow rate, inhalation volume and particle size, are compared between devices. The impact of patient perceptions, behaviours and problems with inhalation technique is analysed, and the need for appropriate patient education is also highlighted. The continued development of technology in inhaler design and the need to standardise study assessment, endpoints and patient populations are identified as future research needs. The reviews of this paper are available via the supplemental material section.

Errors in Aerosol Inhaler Use and Their Effects on Maternal and Fetal Outcomes among Pregnant Asthmatic Women (Subanalysis from QAKCOP Study)

Data on inhaler technique and its effects on maternal and fetal outcomes during pregnancy are seldom reported. The primary objective of this study was to evaluate inhaler technique and identify errors in inhaler use among pregnant women with asthma. Secondary objectives were to identify factors associated with poor inhaler technique and study the association between inhaler technique and maternal and fetal outcomes. This was a cross-sectional, face-to-face, prospective study of 80 pregnant women with physician-diagnosed asthma. Seventy-three and 41 asthmatic pregnant women reported using pressurized metered dose inhalers (pMDIs) and dry powder inhalers (DPIs), respectively. Overall, wrong inhaler technique was observed in 47 (64.4%) subjects. Among pMDI users, correct inhaler use was observed in only 26/73 (35.6%) of the patients, with lack of coordination between inhalation and generation of the aerosol and failure to breathe out gently before using the inhaler, being the most common errors. Among DPI users, 21 (51.2%) demonstrated correct inhaler use, with failure to perform a breath-hold for 10 seconds after inhaling the powder and to exhale gently before using the inhaler being the most common errors. Significant associations between inhaler technique and patient's understanding of asthma medications and the kind of follow-up clinic (respiratory versus nonrespiratory clinic) were found. No significant associations between inhaler technique and various maternal and fetal outcomes or asthma control were found. In conclusion, improper inhalation technique is significantly prevalent in pregnant asthmatic women, particularly among those being followed in nonspecialized respiratory clinics. The lack of significant association between the inhaler technique and asthma control (and hence maternal and fetal outcomes) may simply reflect the high prevalence of uncontrolled asthma and significant contribution of other barriers to poor asthma control in the current patient's cohort. Multidisciplinary management of asthma during pregnancy with particular emphasis on patient's education is imperative.

Evaluation of a structured pharmacist-led inhalation technique assessment service for patients with asthma and COPD in Norwegian pharmacies

OBJECTIVE

To investigate whether the inhalation technique improved among patients with asthma and chronic obstructive pulmonary disease after an Inhalation Technique Assessment Service (ITAS), and to assess the patients' and pharmacists' perceptions of ITAS.

METHODS

This uncontrolled, pre-post study included 405 patients recruited from 42 Norwegian pharmacies. Inhalation technique was assessed by trained pharmacists before ITAS (baseline), directly after (follow-up 1) and three months after ITAS (follow-up 2), and analyzed statistically using SPSS. Perceptions of ITAS were assessed using a questionnaire.

RESULTS

488 ITAS were performed. At baseline, 8% of the inhalation technique demonstrations were rated as optimal and 31% as acceptable. Following ITAS, this increased to 72% (optimal) and 86% (acceptable). At follow-up 2 inhalation technique remained significantly higher than baseline (optimal: 52%, acceptable: 75%). The median rate of wrong steps decreased from 25% (baseline) to 0% (follow-ups). The usefulness of ITAS was rated 4 on a 5-point Likert scale.

CONCLUSION

Inhalation technique improved significantly after ITAS for both new and experienced users and all assessed devices. The technique remained significantly improved at follow-up 2. ITAS was well accepted by pharmacists and patients.

PRACTICE IMPLICATIONS

ITAS can contribute to significant improvements in inhalation technique among patients using inhaler devices.

Impact of a single 10 min education session on asthma control as measured by ACT

BACKGROUND

Aim: Despite the availability of effective treatments for asthma, many patients still suffer from uncontrolled asthma. This study evaluates whether a single educational session could improve asthma control assessed by Asthma Control Test (ACT) score as well as knowledge of the inhaler device, knowledge of medication and inhalation technique.

METHODS

This prospective single blinded randomized controlled trial of 160 adults with asthma, examined the effectiveness of a single standardized, educational intervention, performed by a respiratory nurse specialist. The education provided to the intervention group consisted of basic information about asthma treatment and instructions on inhalation technique for about 10min. This additional education was not offered to the control group. In both groups ACT scores, knowledge of medication, knowledge of inhaler device and inhalation technique were assessed at baseline and after three months. Asthma was considered well-controlled when the ACT score exceeded 19.

RESULTS

At baseline there were no significant differences in patient demographics, degree of asthma control, knowledge of medication or device and inhalation technique between the intervention group and the control group. In the intervention group the educational session resulted in a significantly higher proportion of well-controlled asthma patients with an ACT>19 (43% versus 77%) (p < 0.001) after three months. In the control group this proportion remained similar (57% versus 67%) (p > 0.1). We also observed improvements in knowledge of medication (p < 0.001), knowledge of device (p < 0.001) and inhalation technique (p = 0.004) in the intervention group and not in the control group.

CONCLUSION

A single 10 min, educational session provided by a respiratory nurse specialist can substantially improve asthma control determined by the ACT score after three months.

Spacer devices for inhaled therapy: why use them, and how?

We present an extensive review of the literature to date pertaining to the rationale for using a spacer/valved holding chamber (VHC) to deliver inhaled therapy from a pressurised, metered-dose inhaler, a discussion of how the properties of individual devices may vary according to their physical characteristics and materials of manufacture, the potential risks and benefits of ancillaries such as valves, and the evidence that they contribute tangibly to the delivery of therapy. We also reiterate practical recommendations for the correct usage and maintenance of spacers/VHCs, which we trust offer practical help and advice to patients and healthcare professionals alike.

Identifying Critical Errors: Addressing Inhaler Technique in the Context of Asthma Management

Medication use has always played a highly significant role in the overall management of asthma, with appropriate use being linked to good asthma control. However, while patients with asthma enjoy the 'luxury' of having medications delivered directly to the lungs via inhaler devices, with that comes the additional challenge of ensuring that inhaler devices are used correctly. Research and practice provides evidence to the challenges associated with inhaler use and the particular steps that patients perform incorrectly. While this problem is well documented, acknowledged and reported, little has changed in 40 years, and the proportion of patients using inhaler devices remains unacceptably high. This review focuses on aspects specific to the errors that patient's make, the significance of these errors, and the important considerations for health care practitioners in supporting patients in correctly using their inhalers. This review highlights the complexities associated with patient's making inhaler technique errors and highlights the opportunities that lie in future technological developments of inhaler devices. Now more than ever, in the era of precision medicine, it is important that we address inhaler technique use once and for all.

Matching Inhaler Devices with Patients: The Role of the Primary Care Physician

Poor inhaler technique and nonadherence impair the efficacy of medications for asthma and chronic obstructive pulmonary disease (COPD). A range of factors, including age, dexterity, inspiratory capacity, cognitive ability, health literacy, and ethnicity, can impact a patient's ability and intention to use their device. Treatment success can also be influenced by patient preferences and perceptions. Therefore, it is important that healthcare professionals effectively match inhaler devices to individual patients' needs and abilities and empower patients by including them in treatment decisions. Physicians must, therefore, fully understand the characteristics of each device, as well as their patients' demographic characteristics and comorbidities. Following device selection, patient training and education, including a physical demonstration of the device, are key to eliminate any critical errors that may impact on health outcomes. Inhaler technique should be frequently rechecked. This review will examine the important role of primary care providers in the selection of appropriate inhaler devices and provision of training for patients with COPD and asthma to optimize correct inhaler use and adherence. An overview of the key features of available devices and of the factors to consider when selecting devices will be provided in the context of current asthma and COPD guidelines.

Continued Innovation in Respiratory Care: The Importance of Inhaler Devices

When it comes to the use in inhalers in the management of chronic obstructive pulmonary diseases, there are many options, considerations and challenges, which health care professionals need to address. Considerations for prescribing and dispensing, administering and following up, education, and adherence; all of these factors impact on treatment success and all are intrinsically linked to the device selected. This review brings together relevant evidence, real-life data and practice tools to assist health care professionals in making decisions about the use of inhalers in the management of chronic obstructive pulmonary diseases. It covers some of the key technical device issues to be considered, the evidence behind the role of inhalers in disease control, population studies which link behaviors and adherence to inhaler devices as well as practice advice on inhaler technique education and the advantages and disadvantages in selecting different inhaler devices. Finally, a list of key considerations to aid health care providers in successfully managing the use of inhaler devices are summarized.

Maintenance inhaler preference, attribute importance, and satisfaction in prescribing physicians and patients with asthma, COPD, or asthma-COPD overlap syndrome consulting for routine care

Background

In respiratory disorders, patient- and physician-perceived satisfaction with the maintenance inhaler device is an important factor driving treatment compliance and outcomes. We examine inhaler preferences in asthma and COPD from patient and physician perspectives, particularly focusing on the relative importance of individual device attributes and patient characteristics guiding inhaler choice.

Materials and methods

Real-world data from >7,300 patients with asthma, COPD, or asthma–COPD overlap syndrome (ACOS) consulting for routine care were derived from respiratory Disease Specific Programs conducted in Europe, USA, Japan, and China. Outcome variables included current pattern of inhaled maintenance therapy and device type, physician preference, patient-reported device attribute importance, and satisfaction.

Results

The most commonly prescribed inhalers for maintenance therapy of asthma, COPD, and ACOS were dry powder inhalers (62.8%–88.5% of patients) and pressurized metered dose inhalers (18.9%–35.3% of patients). One-third of physicians stated no preference for maintenance device when prescribing treatment, and less than one-third of patients reported being “extremely satisfied” with any attribute of their device. Instructions being “simple and easy to follow” was the inhaler attribute most commonly selected as important. For approximately one-third of patients across all groups, “ease of use/suitability of inhaler device” was a reason for the prescribing decision, as stated by the physician. Device characteristics were more likely to impact the prescribing decision in older patients (in asthma and COPD; P<0.01) and those with worse disease severity (in COPD; P<0.001).

Conclusion

A relatively high proportion of physicians had no preference for inhaler type across asthma, COPD, and ACOS. Simplicity of use was the most important inhaler attribute from a patient’s perspective. Physicians appeared to place most importance on ease of use and device suitability when selecting inhalers for older patients and those with more severe disease, particularly in COPD.

WeChat Public Account Use Improves Clinical Control of Cough-Variant Asthma: A Randomized Controlled Trial

Background

WeChat is a convenient and popular social medium, and it seems to be an appropriate platform for education and management of patients. This study sought to identify usefulness in clinical control of cough-variant asthma (CVA).

Material/Methods

A randomized controlled trial was conducted among 80 CVA patients. After being assigned to either the traditional group (TG) or the WeChat group (WG), they received the same inhalation therapy, but patients in WG received additional education and instruction via our public account on the WeChat application. Questionnaires on asthma and chronic cough, data on pulmonary function, blood-related items, follow-up adherence, and Emergency Department (ED) visits were collected at the initial visit and at 3 months.

Results

A total of 67 participants completed the trial for analysis. FEV₁/predicted and FEV₁/FVC were significantly increased in WG (p<0.001; p=0.012) after 3 months. PD₂₀-FEV₁ was increased in both groups compared with baseline, but more pronounced in WG (p=0.004). ACQ-7 scores were improved in both groups (p=0.024; p<0.001). Participants allocated to WG experienced a greater improvement in AQLQ and LCQ scores, and between-group differences were significant at 3 months (p=0.040; p=0.001). Furthermore, we observed decreases in blood eosinophil count and FeNO in WG (p=0.048; p=0.014), and WG presented better follow-up compliance (p=0.034).

Conclusions

Using WeChat as part of treatment and management of CVA can help patients learn about their disease and medications, as well as improve disease control and therapy outcomes.

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

Many patients make critical user technique errors when using pressurised metered dose inhalers (pMDIs) which reduce the clinical efficacy of respiratory medication. Such critical errors include poor actuation coordination (poor timing of medication release during inhalation) and inhaling too fast (peak inspiratory flow rate over 90 L/min). Here, we present a novel audio-based method that objectively assesses patient pMDI user technique. The Inhaler Compliance Assessment device was employed to record inhaler audio signals from 62 respiratory patients as they used a pMDI with an In-Check Flo-Tone device attached to the inhaler mouthpiece. Using a quadratic discriminant analysis approach, the audio-based method generated a total frame-by-frame accuracy of 88.2% in classifying sound events (actuation, inhalation and exhalation). The audio-based method estimated the peak inspiratory flow rate and volume of inhalations with an accuracy of 88.2% and 83.94% respectively. It was detected that 89% of patients made at least one critical user technique error even after tuition from an expert clinical reviewer. This method provides a more clinically accurate assessment of patient inhaler user technique than standard checklist methods.

Impact of inhalation therapy on the incidence of carious lesions in patients with asthma and COPD

Objective:

The aim of this study was to investigate the incidence of carious lesions, the amount of salivary flow rate and pH value in patients with asthma and chronic obstructive pulmonary diseases (COPD), using inhalation therapy. The obtained results were compared with the results of adult healthy subjects, forming a control group.

Material and Methods:

The study included 80 participants aging between 18 and 65 years. The experimental group (EG) was comprised of 40 participants, previously diagnosed with asthma or COPD undergoing inhalation therapy for more than five years. The control group (CG), comprised of 40 participants, mirrored the same age and gender status of the EG. Dental status was determined by decayed, missing, and filled teeth (DMFT index). Quantity and pH value of saliva were determined in the laboratory.

Results:

In the EG, the mean value of the salivary flow rate and pH value were statistically significantly lower than in the CG (p<0.001). Patients in the EG had a higher value of DMFT index when compared with the CG, although the difference was not statistically significant (p=0.199). Mean number of decayed teeth, as well as missing teeth, in the EG was statistically significantly higher than in the CG (p<0.001). Mean number of filled teeth in the EG was statistically significantly lower than in the CG (p<0.001).

Conclusion:

It was found that patients undergoing inhalation therapy face increasing risk of dental caries due to the lower salivary flow rate and pH value along with the inhalation therapy. They should receive intensive preventive care, including oral hygiene instruction and dietary advice.

Irregular and Ineffective: A Quantitative Observational Study of the Time and Technique of Inhaler Use

BACKGROUND

Cross-sectional observational studies suggest that between 50% and 60% of patients misuse a dry powder inhaler, whereas studies with electronic monitors indicate that patients sometimes overuse/underuse their inhalers. It is not known what impact errors and erratic use have on inhaler adherence.

OBJECTIVES

The purpose of this study was to longitudinally quantify when and how patients adhered to a twice-daily preventer treatment by using a novel acoustic recording device attached to an inhaler (INhaler Compliance Assessment).

METHODS

Patients with a history of asthma or chronic obstructive pulmonary disease (n = 123) from primary care and community pharmacies were given an INhaler Compliance Assessment-adapted inhaler for 1 month. Analysis of the audio files provided quantitative information on time and technique of inhaler use.

RESULTS

Data were available for 103 patients. Twenty-one patients (20%) used their inhaler in the correct manner at the correct interval. There were 5045 audio files with attempted inhalations, of which 1204 had technique errors (24%). Errors included inadequate flow (27%), drug priming without inhalation (19%), exhalation into the inhaler (18%), and multiple inhalations (25%). On average, participants made errors 20% of the time. Of 60 doses expected to be taken in a month per person, on average 49 doses (82%) were attempted and when errors were accounted for, the average number of actual doses taken was 34 doses (57%; P < .01) comparing attempted to actual doses.

DISCUSSION

These data highlight that ineffective and irregular inhaler use is common and when combined in a single calculation indicate that only 20% of participants used their inhaler correctly and on time.