What can be done to impact respiratory inhaler misuse: exploring the problem, reasons, and solutions

Evaluation of the quality and content of YouTube videos as an educational resource in developing patients' inhaler use skills

BACKGROUND

YouTube has educational videos on inhalers. However, their content and quality are not adequately known.

OBJECTIVES

This study investigated the quality and content of educational YouTube videos on inhalers.

METHODS

This descriptive study analyzed 178 YouTube videos on inhalers between May and July 2022. Two researchers independently evaluated the videos. The Global Quality Score (GQS), Journal of American Medical Association (JAMA) Benchmark Criteria, and Inhaler Application Checklist (IAC) were used to assess the quality and content of the videos. Spearman's correlation, Kruskal-Wallis, Mann-Whitney U, ANOVA, and Post hoc analysis Bonferroni test were used for data analysis.

RESULTS

The videos had a mean GQS score of 3.70 ± 1.24, and JAMA score of 2.22 ± 0.60. A negative correlation was between the quality score of the videos and views, likes, comments, duration, and likes/views (respectively; r = -0.237 p < 0.005, r = -0.217 p < 0.003, r = -0.220 p < 0.005, r = -0.147, p < 0.005). The videos narrated by nurses and doctors had significantly higher mean JAMA and GQS scores than others (p = 0.001). The videos missed some procedural steps [gargling (29.1%), adding no more than five ml of medication and device cleaning (41.9%), and exhaling through the nose (37.5%)]. Videos uploaded by individual missed significantly more procedural steps than professional organizations (p < 0.05).

CONCLUSIONS

YouTube videos about inhaler techniques have a moderate level of quality. Videos uploaded by doctors and nurses as content narrators were of higher quality. The videos missed some procedural steps. Individual video uploaders had higher missed procedural steps. Counseling should be provided to patients regarding the reliability of online information.

Cellular probing using phytoceuticals encapsulated advanced delivery systems in ameliorating lung diseases: Current trends and future prospects

Chronic respiratory diseases such as Chronic Obstructive Pulmonary Disease (COPD) and asthma have posed a significant healthcare and economic cost over a prolonged duration worldwide. At present, available treatments are limited to a range of preventive medicines, such as mono- or multiple-drug therapy, which necessitates daily use and are not considered as viable treatments to reverse the inflammatory processes of airway remodelling which is inclusive of the alteration of intra and extracellular matrix of the airway tract, death of epithelial cells, the increase in smooth muscle cell and the activation of fibroblasts. Hence, with the problem in mind a considerable body of study has been dedicated to comprehending the underlying factors that contribute to inflammation within the framework of these disorders. Hence, adequate literature that has unveiled the necessary cellular probing to reduce inflammation in the respiratory tract by improving the selectivity and precision of a novel treatment. However, through cellular probing cellular mechanisms such as the downregulation of various markers, interleukin 8, (IL-8), Interleukin 6 (IL-6), interleukin 1β (IL-1β) and tumor necrosis factor-α (TNF-α) have been uncovered. Hence, to target such cellular probes implementation of phytoceuticals encapsulated in an advanced drug delivery system has shown potential to be a solution with in vitro and in vivo studies highlighting their anti-inflammatory and antioxidant effects. However, the high costs associated with advanced drug delivery systems and the limited literature focused exclusively on nanoparticles pose significant challenges. Additionally, the biochemical characteristics of phytoceuticals due to poor solubility, limited bioavailability, and difficulties in mass production makes it difficult to implement this product as a treatment for COPD and asthma. This study aims to examine the integration of many critical features in the context of their application for the treatment of chronic inflammation in respiratory disorders.

Promoting knowledge of metered dose inhaler (MDI) usage among pharmacy professional students through a mobile app

INTRODUCTION

Efficient asthma management necessitates optimal usage of metered-dose inhalers (MDIs). As future health professionals, pharmacy students are pivotal in disseminating accurate methodologies for MDI usage. Despite having hands-on experience, there is room to enhance their comprehension, highlighting the need for prompt patient educational interventions.

OBJECTIVE

This study aims to evaluate the effectiveness of a mobile app-assisted educational method in improving pharmacy students' understanding of MDI usage.

METHODS

A pre-experimental study was conducted from March to August 2021 with 45 participants enrolled in the Pharmacist Professional Study Program at the Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta. Using a one-group pretest-post-test design, the study measured the app's impact on students' knowledge and MDI usage skills.

RESULTS

The intervention significantly improved students' scores on a 9-step MDI usage checklist, with increases ranging from 0.10 to 0.50 across verbal and motor components. A Mann-Whitney U test validated these findings, showing a statistically significant p-value of 0.001.

CONCLUSION

The mobile app-assisted educational approach substantially enhanced pharmacy students' proficiency in MDI use. The significant rise in mean scores for the 9-step checklist, along with the notable p-value, supports the effectiveness of this intervention in healthcare education.

Climate-conscious inhaler prescribing for family physicians

OBJECTIVE

To provide family physicians with prescribing and diagnostic strategies that can reduce carbon emissions associated with inhalers.

SOURCES OF INFORMATION

This review is based on the authors' experience developing the climate-conscious inhaler prescribing playbooks and courses for CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis). The approach was refined through patient and provider feedback since the first playbook was published in 2021. PubMed was also searched for relevant publications on inhaler use, asthma management, and chronic obstructive pulmonary disease (COPD) management. Current asthma and COPD guidelines were also reviewed.

MAIN MESSAGE

There is growing acknowledgment of the substantial impact that inhalers have on climate emissions generated by the health sector. Recent surveys indicate that most Canadian patients care about climate change and would be willing to opt for less carbon-intensive treatment and care delivery options where available. Beyond inhaler choice, there are many opportunities to address the climate impacts of respiratory care and enhance quality of care. Working with patients to ensure they are using the right medications in the right ways will produce both carbon savings and better health outcomes. The climate crisis can therefore serve as a catalyst for improving treatment of patients with respiratory conditions. Family physicians may reduce carbon emissions associated with inhalers by reducing unnecessary inhaler prescribing; ensuring patients' control of asthma and COPD is optimized; considering whether a more sustainable inhaler may be appropriate; optimizing dosing technique to reduce emissions and waste; and disposing of inhalers appropriately if possible.

CONCLUSION

Family physicians may reduce carbon emissions associated with inhalers through the following strategies: confirming diagnosis, controlling disease, considering inhaler type, optimizing dosing technique, and encouraging appropriate disposal.

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.

Evaluating inhaler education interventions for hospitalized children with asthma: A randomized controlled trial

BACKGROUND

Most children with asthma have poor inhaler technique, with detrimental morbidity effects. Guidelines recommend clinicians provide inhaler education at every opportunity, yet resources are limited. A low-cost, technology-based intervention-Virtual Teach-to-Goal (V-TTG)-was developed to deliver tailored inhaler technique education with high fidelity.

OBJECTIVE

To evaluate whether V-TTG leads to less inhaler misuse among children with asthma who are hospitalized vs brief intervention (BI, reading steps aloud).

METHODS

A single-center randomized controlled trial of V-TTG vs BI was conducted with 5-to-10-year-old children with asthma hospitalized between January 2019 and February 2020. Inhaler technique was assessed pre- and post-education using 12-step validated checklists (misuse: < 10 steps correct).

RESULTS

Among 70 children enrolled, mean age was 7.8 years (SD = 1.6). Most (86%) were Black. Most had an emergency department visit (94%) or hospitalization (90%) in the previous year. At baseline, nearly all children misused inhalers (96%). The proportion of children with inhaler misuse decreased significantly in V-TTG (100%→74%, P = .002) and BI (92%→69%, P = .04) groups, with no difference between groups at both time points (P = .2 and .9). On average, children performed 1.5 more steps correctly (SD = 2.0), with greater improvement with V-TTG (mean [SD] = 1.7 [1.6]) vs BI (mean [SD] = 1.4 [2.3]), though not significant (P = .6). Concerning pre and post technique, older children were significantly more likely than younger children to show more correct steps (mean change = 1.9 vs 1.1, P = .002).

CONCLUSION

A technology-based intervention for tailored inhaler education led to improved technique among children, similarly to reading steps aloud. Older children saw greater benefits. Future studies should evaluate the V-TTG intervention across diverse populations and disease severities to identify the greatest impact.

CLINICAL TRIAL REGISTRATION

NCT04373499.

Delivering monoclonal antibodies via inhalation: a systematic review of clinical trials in asthma and COPD

INTRODUCTION

Advances in understanding the pathophysiology of asthma and chronic obstructive pulmonary disease (COPD) led to investigation of biologic drugs targeting specific inflammatory pathways. No biologics are licensed for COPD while all the approved monoclonal antibodies (mAbs) for severe asthma treatment are systemically administered. Systemic administration is associated with low target tissue exposure and risk of systemic adverse events. Thus, delivering mAbs via inhalation may be an attractive approach for asthma and COPD treatment due to direct targeting of the airways.

AREAS COVERED

This systematic review of randomized control trials (RCTs) evaluated the potential role of delivering mAbs via inhalation in asthma and COPD treatment. Five RCTs were deemed eligible for a qualitative analysis.

EXPERT OPINION

Compared to systemic administration, delivering mAbs via inhalation is associated with rapid onset of action, greater efficacy at lower doses, minimal systemic exposure, and lower risk of adverse events. Although some of the inhaled mAbs included in this study showed a certain level of efficacy and safety in asthmatic patients, delivering mAbs via inhalation is still challenging and controversial. Further adequately powered and well-designed RCTs are needed to assess the potential role of inhaled mAbs in the treatment of asthma and COPD.

Evolution of Web-Based Training Videos Provided by the German Respiratory League for the Correct Inhalation Technique

<b><i>Background/Objective:</i></b> To assess whether and how the use of scientifically established Web-based training videos for teaching correct inhalation technique in patients with chronic airway diseases has become accepted among the wider population. <b><i>Methods:</i></b> The viewing trends of 141 freely available YouTube videos (full playing time, 01:31–04:37 min:s) provided by the German Respiratory League, covering a broad range of internationally prescribed devices, were analyzed over a 10-year period. Specific emphasis was placed both on German and international videos. <b><i>Results:</i></b> The total number of views was 3,350,678. Non-German videos (English, Russian, Turkish, Greek, Arabic, Farsi, and Slovakian) accounted for 23.2% of the views. The number of views steadily increased between 2011 and 2020 with a mean annual increase of 54.0% (range 24.5/119.9%) compared to the respective previous year. By 2020, the incidence of views per 100,000 German inhabitants was 725 for German videos only and 1,030 for all videos. In terms of the annual trend, there were two peak viewing periods, namely in spring and late fall, while the lowest amount of views occurred in summer. <b><i>Conclusion:</i></b> This study highlights the rising impact of Web-based training videos used for teaching the correct use of inhalation devices, with a steady increase in the number of annual views and a clear seasonal peaking of views in spring and late fall.

The Use of Puzzles in Inhaler Technique Training

Objective: Inhaled drugs are essential for the treatment of several chronic respiratory diseases. However, patient inhaler techniques are frequently suboptimal; here, educational games may enhance patients' understanding of educational interventions. In addition, patients may practice repetitively, learning in a more relaxed and fun environment. In this study we aimed to compare two methods of inhaler technique training: (1) face-to-face training only and (2) face-to-face training and a subsequent puzzle game.Methods: The participants in group 1 were provided only face-to-face training. In group 2, the participants were given a puzzle after receiving the face-to-face training. Subsequently, the inhaler technique scores of both groups were compared. The chi-squared (χ² ) test was used for categorical variables and the Mann-Whitney U test (non-parametric) or Student's t test (parametric) were employed to compare the numerical variables between the groups.Results: In total, 170 patients with asthma and their parents were included in the study. It was found that the median total scores for the inhaler technique (p < 0.001) and the number of correct users (p < 0.001) were higher in group 2, whereas the inhaler technique error rate in shaking the inhaler tube (p < 0.001) was higher in group 1.Conclusion: The present study revealed that the success rate of correct users and participants' total scores were higher in the puzzle game group. Therefore, a game may help patients to better remember and visualize the steps of the inhaler technique. Our study supports the use of puzzles as real-world applications to teach patients optimal inhaler technique.

The Inhaler Technique Questionnaire (InTeQ): Development and Validation of a Brief Patient-Reported Measure

There is a need for instruments designed for patients with asthma to self-report their performance of inhaling steps. We aimed to develop an accessible and easy-to-use patient-reported tool for inhaler technique assessment, which could also serve as a training and monitoring resource for any type of inhaler device, and to evaluate its feasibility, validity, and reliability in adults with asthma. The development was based on literature review and pilot testing with clinicians and patients. The Inhaler Technique Questionnaire (InTeQ) asks about the frequency of performing five steps when using inhalers (on a five-point Likert scale). We analyzed data from adults with persistent asthma (n = 361). We examined the measurement model using Mokken scaling analysis, construct validity by assessing hypotheses on expected discrimination among known groups, and reliability based on internal consistency and reproducibility. Means of the InTeQ items were in the range of 0.23–1.61, and coefficients of homogeneity were above the cutoff point, demonstrating the unidimensionality of the scale. Known groups’ global score differences were statistically significant between patients reporting having “Discussed in detail” or having “Not discussed/Only in general” the inhaler technique with their healthcare providers (p = 0.023). The Cronbach’s alpha coefficient was 0.716, and the intraclass correlation coefficient was 0.775. The InTeQ is a feasible, valid, and reliable instrument for self-reporting inhaler technique on any type of device.

Inhaler technique in asthma and COPD: challenges and unmet knowledge that can contribute to suboptimal use in real life

Introduction: Inhalers are the most commonly used devices for lung drug delivery in asthma and COPD. Inhaler use offers several advantages but requires the user's proper mastery. The issue of inhaler technique is very important as inhaler misuse remains common in real life regardless of the inhaler used and is associated with poor disease control.Areas covered:This narrative review analyses the key-steps of inhaler mastery and the significance of the errors of use for the main devices. There are uncertainties on many tasks of inhaler use and on those variations from recommended steps that are considered as critical errors.Expert opinion: Despite technological advancements, an easy-to-use device is not yet available. Whatever the chosen inhaler, health care givers' proper practical education with the opportunity of feedback learning has a key-role for improving inhaler technique, but is time-consuming, and remains limited to few successful experiences. Newer digital technologies will be applied to the field of inhaler education, but the lack of knowledge on many practical aspects of inhaler technique might be a limit for its extensive implementation. Possibly digital innovation might substantially contribute to reduce inhaler misuse only if clinicians, manufacturers, and subjects will cooperate together on this issue.

Mask Use with Spacers/Valved Holding Chambers and Metered Dose Inhalers among Children with Asthma

Inhaler misuse is highly prevalent and associated with high morbidity and costs. For metered dose inhalers, proper use can be supported with devices such as spacers/valved holding chambers (VHCs) and masks to effectively deliver inhaled medication to the lungs. However, guidelines are vague about which children with asthma should use spacers/VHCs with masks to deliver medication from metered dose inhalers as well as when they should transition to spacers/VHCs with mouthpieces. In this paper, we provide a focused review of the evidence for mask use, highlighting unclear and conflicting information in guidelines and studies. We synthesize the differences in recommendations and practice. Based on these findings, we call for future research to determine the appropriate age and necessary skills for transitioning children from using metered dose inhalers with spacers/VHCs and masks to using spacers/VHCs and mouthpieces. Guidelines about mask use should be standardized to help ensure optimal medical delivery for patients, provide consistent inhaler prescriptions and education across settings, and support team-based care to help lower pediatric asthma morbidity and costs.

Impact of an Asthma Education Program During Admission

OBJECTIVES

Health educational interventions improve health outcomes and quality of life in children with asthma. The main purpose of this study was to evaluate the effect of an education intervention for an asthma inhaler technique during hospital admission for an asthma exacerbation.

METHODS

This prospective study was conducted in a pediatric hospitalization unit of a third-level hospital. Children admitted for an asthma exacerbation were eligible for inclusion. It was developed in 2 phases: during hospital admission (T1) and 1 month after discharge (T2). In the T1 phase, caregivers completed the questionnaire to assess asthma control in children (CAN questionnaire) and performed the inhaler technique, which was evaluated with a 6-step checklist. An educational intervention was performed. In the T2 phase, caregivers completed the CAN questionnaire, and the inhaler technique was reevaluated. We hypothesized that the inhaler technique improved after the implementation of an asthma education program.

RESULTS

A total of 101 children were included, of whom 85 completed the T2 phase (84%). At baseline, 11.8% of participants performed the inhaler technique correctly. All steps of the inhaler technique upgraded in the T2 phase significantly (P < .01), except for the step "assemble the inhaler device correctly." Former evaluation by a pediatric pneumologist was associated with a higher score in the inhaler technique in the T1 phase. The median CAN questionnaire score in the T1 phase was 8 (interquartile range 4-16), which reduced to 4 (interquartile range 1.2-6) in the T2 phase (P < .01).

CONCLUSIONS

The development of an educational intervention during admission improved inhaler technique as well as asthma knowledge.

Improving adherence in chronic airways disease: are we doing it wrongly?

Non-adherence to medicines is a significant clinical and financial burden, but successful strategies to improve it, and thus bring about significant improvements in clinical outcome, remain elusive. Many barriers exist, including a lack of awareness amongst some healthcare professionals as to the extent and impact of non-adherence and a dearth of skills to address it successfully. Patients may not appreciate that they are non-adherent, feel they cannot disclose it or underestimate its impact on their health in the short and longer term. In describing the evidence-based frameworks that identify the causal factors behind medicines taking (or not taking) behaviours, we can start to personalise interventions to enable individuals to make informed decisions about their treatments and thus overcome real and perceived barriers to adherence.

Medicines non-adherence is common and associated with significant morbidity and mortality. @GrainnedAn and colleagues outline causal factors behind this behaviour and the appropriate individualised interventions available to support optimal medicines use.https://bit.ly/3ejJNTV

Quality improvement approach to increasing respiratory therapist driven teach back style asthma education

OBJECTIVE

Asthma is a common chronic medical condition that can require treatment with multiple inhaled medications. Our quality improvement group established a standard asthma teaching protocol with respiratory therapists utilizing the teach back method. We aimed to increase the percentage of pulmonary asthma clinic visits receiving this education from a baseline of 42.7% in 2016 to 80% by December 2019.

METHODS

Multiple interventions were put in place and data was collected monthly from the electronic medical record system. Data was recorded in statistical process control charts using a p chart. Nelson's established rules for determining special versus common cause variation were used.

RESULTS

Over the three-year project the percentage of asthma clinic visits receiving the standardized respiratory therapist driven teach back asthma education increased to 82.3%.

CONCLUSION

Utilizing a standardized approach, it's possible to deliver standardized asthma education in a busy pulmonary clinic.