The inhalation manager: a new computer-based device to assess inhalation technique and drug delivery to the patient

Exploration of quality criteria for the detection of peak inspiratory flow under different resistance conditions

BACKGROUND

At present, robust quality criteria and methods for the assessment of Peak inspiratory flow meter performance are lacking.

OBJECTIVE

A standard flow-volume simulator for quality control analyses of an inhalation assessment device was utilized with different simulated resistance levels in order to propose a quality testing method and associated standard for this device type.

METHODS

A standard flow-volume simulator was utilized to assess the performance of an In-Check DIAL® (Device I) and an intelligent inhalation assessment device (Device P) at a fixed volume and flow rate. Indices used to evaluate these two instruments included repeatability, accuracy, linearity, and impedance.

RESULTS

Both devices exhibited good repeatability (<± 3 L/min). The difference between test results and standard simulator values for Device P was less than ± 5 L/min at resistance level R1 but higher than ± 5 L/min at resistance levels R2-5, while Device I were greater than 5 L/min at all resistance levels. The relative error for Device P was <± 10% at resistance levels R1, R2, and R4, but > 10% at resistance levels R3 and R5. The relative error values for Device I at all five resistance levels were > 10%. Device P passed the linearity test at the R2 resistance level, while Device I partially passed the linearity test at all five resistance levels.

CONCLUSION

Standard monitoring methods and standards provide a valuable approach to the more reliable clinical assessment and application of these instruments.

The impact of inhaler technique on clinical outcomes in adolescents and adults with asthma: A systematic review

BACKGROUND

Many patients with asthma use their inhalers incorrectly, which can lead to sub-optimal asthma control and an increased risk of exacerbations. The Accuhaler/Diskus and Turbuhaler are arguably two of the most commonly used dry powder inhalers worldwide.

METHODS

A systematic literature review (SLR) was conducted to assess the impact of inhalation errors with these dry powder inhalers on clinical outcomes in asthma. Database searches were conducted in MEDLINE, Embase and proceedings from scientific conferences. Observational studies in adults and adolescents with asthma, reporting data for Accuhaler/Diskus and Turbuhaler devices and at least one outcome of interest, were included. Dual-independent screening and validation of studies was performed.

RESULTS

The search identified 35 studies. A range of inhaler errors was observed across studies and devices. In 8 out of the 9 studies that involved the two devices, the percentage of overall inhaler error rates was numerically (7 studies) or significantly (1 study) higher for Turbuhaler than Diskus, ranging from 3.7% to 71.9% for Diskus and 1.2%-83% for Turbuhaler. Critical errors, reported in three studies using similar definitions, ranged from 20% to 43% for Diskus and 32%-100% for Turbuhaler. Five studies reported a significant association between inhaler errors and worse asthma control, while one showed no difference.

CONCLUSIONS

This SLR identified a large range of inhaler errors with both devices. Across devices, a better inhalation technique was associated with better asthma outcomes. This systematic review confirms the importance of patients using their inhalers correctly as an integral part of achieving optimal asthma outcomes.

Inhalation Profiles Through a Dry Powder Inhaler: Relation Between Inhalation Technique and Spirometric Measures

Background: The understanding of the real flow profiles through a dry powder inhaler (DPI), generated by asthma patients, is a prerequisite for satisfactory drug delivery to the lungs. The aims of the study were to assess the relationship between spirometric measures and inhalation profiles through a low-resistance DPI, and to compare parameters of those profiles between optimal and suboptimal inhalation technique type. Methods: Both healthy adult volunteers and patients with asthma were included in the study. Spirometry was conducted along with modified flow-volume test to detect expiratory levels (maximum "100%" exhalation to residual volume [RV] and halfway "50%" to RV). These were the reference levels of the depth of exhalation for each patient to simulate the effect of incomplete exhalation. Individual inhalation profiles were recorded using spirometry in-house software as the volumetric airflow through the inhaler versus time. Inspiratory flow parameters were extracted: time to peak inspiratory flow through inhaler (PIF_inh), time at which peak inspiratory flow occurs (tPIF_inh), total inhalation time (T), and inhaled volume during maneuver (V). Results and Conclusions: There are significant relationships between spirometric indices and parameters of inhalation through a low-resistance, cyclohaler-type DPI (assessed by single-factor analysis of Spearman's rank correlation coefficient). Multiple regression models were constructed, predicting inspiratory flow parameters (including spirometric indices, demographic parameters, and inhaler's usage history as determinants). The exhalation halfway to RV before inhalation did not affect significantly PIF_inh and tPIF_inh (and, thus, initial flow dynamics) in asthma patients. T and V parameters were then significantly decreased, but seemed sufficient for successful DPI performance. Both exhalation to RV and incomplete exhalation halfway to RV preceding inhalation allow for effective usage of low-resistance DPI.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

Patient Inspiratory Maneuver Performance; Peak Lungpower, Acceleration and Volume

Background: Use of drug delivery devices between nebulizers, dry powder inhalers (DPIs), or metered dose inhalers (MDIs), for treating patients with asthma and chronic obstructive pulmonary disease (COPD), is based on patients' capability of coordinating the inhalation maneuver and achieving sufficient airflow. There are limited data available with regard to how patients meet the requirements of successful inhalation performance, and how the concept of inspiratory lungpower could be applied. The aim of this work was to study the patient inspiratory airflow profile performance in large data sets. We analyzed how the Kamin-Haidl inhalation criteria were met by patients with DPIs such as Easyhaler for combination therapy (EH-combi), Easyhaler for monotherapy (EH-mono), Diskus, and Turbuhaler (TH), and applied peak lungpower instead of peak inspiratory flow rate as an indicator of patient performance. Materials and Methods: Data sets gathered in two previous studies for DPIs, that is, EH-combi, EH-mono, Diskus, and TH, were used to analyze how inspiratory lungpower representing inspiratory muscle power, flow acceleration, and volume after peak met the inhalation criteria. The measured patient airflow profiles through inhalers were assessed for patients with asthma or COPD. Results: Based on the Kamin-Haidl inhalation criteria, successful inhalation requirements were met with EH-combi in 96.1% and with EH-mono in 92.6% of patients. The success rates were 89.5% and 84.6% with Diskus and TH, respectively, (p < 0.0001 between devices). In patients with asthma or COPD, the mean lungpower was 7.51 and 6.15 W for EH-combi, 8.79 and 6.88 W for EH-mono, 7.18 and 4.36 W for Diskus, and 9.65 and 6.86 W for TH, respectively, when patients followed the manufacturer's written instructions. Conclusions: Lungpower applied to the Kamin-Haidl inhalation criteria concept could be an applicable method for reviewing patient performance for different DPIs despite DPIs' characteristic differences in airflow resistance. In light of these results, DPIs provide a feasible treatment option for a large majority of respiratory patients.

Supporting respiratory patients in primary care: a qualitative insight from independent community pharmacists in London

Background

Community pharmacists’ (CPs’) interventions have a positive impact on managing respiratory patients. However, methods used by CPs to assess patients’ inhaler technique and adherence are subjective. New technologies to objectively assess inhaler technique and adherence were introduced to address such a gap. This study aimed to explore CPs’ perceptions towards the management of respiratory patients regarding inhaler technique and adherence. In addition, it explored the views of CPs and their need of technologies to objectively assess inhaler technique and adherence. CPs were probed with a new technology called Inhaler Compliance Assessment (INCA) device, designed to objectively monitor both inhaler technique and adherence of patients using a dry powder inhaler, as an example.

Methods

A qualitative study employing semi-structured interviews was conducted. A convenience and snowballing sampling strategy was employed to recruit CPs working in independent community pharmacies within West and South London. Twenty-three pharmacists were interviewed between August and November 2015. Data was analysed thematically using the framework methodology and coded using NVivo10 software.

Results

Analysis revealed five main themes: services and limitations of patient support, the need and acceptability of new technologies to support respiratory patients, fragmented primary care, the need to promote the clinical role of CPs, and professional identity. Patient support was patchy and affected by several barriers related to pharmacists and patients. In addition, lack of communications with different healthcare professionals in primary care and inaccessibility to clinical records were identified as problematic issues. Some CPs perceived their clinical role to be lacking within the patient care pathway. Interestingly, CPs showed positive a attitude towards the use of technologies, such as the INCA technology to support patients and were willing to provide new services. However, remuneration appeared to be a major driver for willingness to offer new services or promote existing services.

Conclusion

The current study highlighted some measures that can augment CPs’ clinical practice while managing patients, such as having accessibility to patients’ medical records and the use of technologies such as the INCA technology to promote objective counselling of patients.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3814-2) contains supplementary material, which is available to authorized users.

Ability of using different dry powder inhalers during COPD exacerbations

BACKGROUND

Guidelines suggest that patients hospitalized for acute COPD exacerbations (AECOPD) are treated with short acting bronchodilators. Long acting bronchodilators, offer longer symptom relief but since they are usually administered via Dry Powder Inhalers (DPIs) it is considered that during AECOPD patients would not be able to achieve appropriate inspiratory flow (IF) to receive appropriate drug doses. The aim of the present study was to evaluate whether patients admitted to the hospital for AECOPD, are able to achieve the necessary IF using different DPIs.

METHODS

IF was measured daily in patients admitted for AECOPD with a portable IF meter (In-Check Oral inhaler assessment kit), containing a series of adapters that simulate the resistance of 4 DPIs [Turbuhaler (T), Breezhaler/Aerolizer (B/F), Discus (A/A/D) and Handinhaler (HH)]. Dyspnea, spirometry and arterial blood gases were also recorded daily.

RESULTS

44 consecutive patients were included in the study. The majority of patients were able to achieve an IF over 30 L/min with all four device resistances. This minimum required IF was achieved in 90.9%, 100%, 95.5% and 81.8% of patients on admission and in 100%, 100%, 97.7%, and 95.5% of patients on discharge for T, B/F, A/A/D and HH respectively. No functional characteristic was able to predict the achievement of this minimum necessary IF.

CONCLUSION

Most patients hospitalized for AECOPD, are able to receive treatment with long acting bronchodilators administered via DPIs. The possible beneficial effects of such an intervention should be tested in further studies.

Appropriate use of a dry powder inhaler based on inhalation flow pattern

Background

An optimal inhalation flow pattern is essential for effective use of a dry powder inhaler (DPI). We wondered whether DPI instructors inhale from a DPI with an appropriate pattern, and if not, whether self-training with visual feedback is effective.

Methods

Subjects were 14 pharmacists regularly engaged in instruction in DPI use. A newly designed handy inhalation flow visualizer (Visual Trainer: VT) was used to assess inhalation profiles and to assist in self-training. With a peak inhalation flow rate (PIFR) > 50 L/min, time reaching PIFR (T_PF) < 0.4 s, inhalation volume (V_I) > 1 L, and flow at 0.3 s after the onset of inhalation (F_0.3) > 50 L/min, the pattern was considered optimal.

Results

Using Diskus or Turbuhaler 12 and 10 subjects respectively inhaled with a suitable PIFR. Those with a satisfactory F_0.3 were 10 and 7 respectively. The T_PF was short enough in only 1 and 2 respectively. All 14 subjects inhaled deeply (V_I) through Diskus, and 10 did so through Turbuhaler. In the self-training session, only 3 subjects satisfied all three variables at the first trial, while 2 or 3 trials were required in other subjects. Among the three variables, optimal T_PF was the most difficult to attain. Once a satisfactory inhalation pattern was achieved using one DPI, eleven out of 12 subjects inhaled with a satisfactory pattern through the other DPI.

Conclusion

Visualization of the inhalation flow pattern facilitates the learning of proper inhalation technique through a DPI.

How many instructions are required to correct inhalation errors in patients with asthma and chronic obstructive pulmonary disease?

In the treatment of asthma and chronic obstructive pulmonary disease (COPD), errors in handling and wrong techniques in using inhalation devices are associated with poor disease control. The aim of this study was to evaluate the number of instructions that are necessary to minimize errors in using pressurized metered-dose inhaler (pMDI), soft mist inhaler (SMI), and dry powder inhaler (DPI). Among 216 patients with asthma (n = 135) and COPD (n = 81), we studied 245 cases that used different types of inhalation devices. After initial guidance, 145 of 245 cases (59%) made at least one error that could affect efficacy. For every device, at least three instructions were required to achieve entirely no errors or less than 10% errors in total. The most common error on the use of pMDI was device handling, whereas that of DPI was inhalation manner. Both errors were associated with low peak flow rate. In both patients with asthma and in patients with COPD, the most common error was inhalation manner. We concluded that it is necessary to repeat at least three times of instructions to achieve effective inhalation skills in both asthma and COPD patients.

Inhalation device requirements for patients' inhalation maneuvers

BACKGROUND

Inhaled drugs are the mainstay of treatment for lung diseases such as asthma and chronic obstructive pulmonary disease. However, failure to use inhalation devices correctly can lead to a poorly controlled status. A vast number of inhalation devices exist and each device has specific requirements to achieve optimum inhalation of the drug. Currently, there is no overview of inhalation requirements considering all devices. This article presents a review of the literature on different inhalation device requirements and incorporates the data into a new inhalation flow algorithm.

METHODS

Data from literature on commercially available inhalation devices were evaluated and parameters, such as inhalation flow rate, flow acceleration, inhalation volume, and inspiration time assessed for the required inhalation maneuver specific to the device. All agreed upon data points were used to develop an inhalation flow algorithm.

RESULTS

The literature analysis revealed availability of robust data for the required inhalation flow characteristics for most devices and thus for the development of an algorithm. For those devices for which these parameters are not published, the minimum required flow criteria were defined based on published data regarding individual aspects of aerosol quality.

CONCLUSIONS

This review provides an overview of inhalation devices available on the market regarding requirements for an acceptable inhalation maneuver and shows which goals should be achieved in terms of inhalation flows. The presented algorithm can be used to develop a new computer based measurement system which could help to test and train patients' individual inhalation maneuvers with their inhalation devices.

Characteristics of patients making serious inhaler errors with a dry powder inhaler and association with asthma-related events in a primary care setting

OBJECTIVE

Correct inhaler technique is central to effective delivery of asthma therapy. The study aim was to identify factors associated with serious inhaler technique errors and their prevalence among primary care patients with asthma using the Diskus dry powder inhaler (DPI).

METHODS

This was a historical, multinational, cross-sectional study (2011-2013) using the iHARP database, an international initiative that includes patient- and healthcare provider-reported questionnaires from eight countries. Patients with asthma were observed for serious inhaler errors by trained healthcare providers as predefined by the iHARP steering committee. Multivariable logistic regression, stepwise reduced, was used to identify clinical characteristics and asthma-related outcomes associated with ≥1 serious errors.

RESULTS

Of 3681 patients with asthma, 623 (17%) were using a Diskus (mean [SD] age, 51 [14]; 61% women). A total of 341 (55%) patients made ≥1 serious errors. The most common errors were the failure to exhale before inhalation, insufficient breath-hold at the end of inhalation, and inhalation that was not forceful from the start. Factors significantly associated with ≥1 serious errors included asthma-related hospitalization the previous year (odds ratio [OR] 2.07; 95% confidence interval [CI], 1.26-3.40); obesity (OR 1.75; 1.17-2.63); poor asthma control the previous 4 weeks (OR 1.57; 1.04-2.36); female sex (OR 1.51; 1.08-2.10); and no inhaler technique review during the previous year (OR 1.45; 1.04-2.02).

CONCLUSIONS

Patients with evidence of poor asthma control should be targeted for a review of their inhaler technique even when using a device thought to have a low error rate.

Comparing usability of NEXThaler(®) with other inhaled corticosteroid/long-acting β2-agonist fixed combination dry powder inhalers in asthma patients

BACKGROUND

Inhaler mishandling is a common issue among patients suffering from asthma and is associated with poor clinical outcomes and greater consumption of health-care resources. Ease of use can improve inhaler technique and, possibly, patients' preference for their inhaler device, which in turn may lead to better adherence to therapy.

METHODS

This study investigated usability characteristics of NEXThaler(®) versus two other dry powder inhalers (DPIs; Diskus(®) and Turbuhaler(®)). Sixty-six adult patients with asthma (mean age 42.9±17.7 years) and with no previous experience of using a DPI were included in a randomized crossover comparison of the three devices. The main measures of usability were the number of steps failed for each device and the number of people who were able to use the device successfully (effectiveness), the time it took patients to set up the device and the time to read the instructions for use (IFU; efficiency), and patient preferences (satisfaction). Inhaler technique was evaluated after the IFU leaflet was read.

RESULTS

NEXThaler was found to be superior to the other two DPIs in terms of the number of device use failures (p<0.001), time to set up (p<0.001), and time to read IFU (p<0.001). Additionally, the proportion of participants who completed a successful inhalation without any errors at all was significantly higher for NEXThaler than for Diskus and Turbuhaler (p<0.001). Patients rated NEXThaler as the easiest to use and most preferred inhaler to own (p<0.001).

CONCLUSIONS

NEXThaler displayed better usability compared with Diskus and Turbuhaler. The improved usability and higher satisfaction with the device may contribute to increased patient adherence to asthma treatment.

Safeguarding the process of drug administration with an emphasis on electronic support tools

AIMS

The aim of this work is to understand the process of drug administration and identify points in the workflow that resulted in interventions by clinical information systems in order to improve patient safety.

METHODS

To identify a generic way to structure the drug administration process we performed peer-group discussions and supplemented these discussions with a literature search for studies reporting errors in drug administration and strategies for their prevention.

RESULTS

We concluded that the drug administration process might consist of up to 11 sub-steps, which can be grouped into the four sub-processes of preparation, personalization, application and follow-up. Errors in drug handling and administration are diverse and frequent and in many cases not caused by the patient him/herself, but by family members or nurses. Accordingly, different prevention strategies have been set in place with relatively few approaches involving e-health technology.

CONCLUSIONS

A generic structuring of the administration process and particular error-prone sub-steps may facilitate the allocation of prevention strategies and help to identify research gaps.

Reduced Peak Inspiratory Effort through the Diskus((R)) and the Turbuhaler((R)) due to Mishandling is Common in Clinical Practice

OBJECTIVES

A minimum peak inspiratory flow (PIF) through dry powder inhalers (DPIs) is required for effective drug delivery to the lungs. Some patients are unable to generate the minimally effective PIF through the DPI. However, little information is available about the 'real life' prevalence of reduced peak inspiratory effort through the Diskus((R)) and the Turbuhaler((R)) as a result of mishandling

METHODS

We investigated peak inhalation effort through the Diskus((R)) and the Turbuhaler((R)) by both direct observation and the In-Check Dial((R)), a portable PIF meter, in a large sample of patients consecutively referred to our laboratory who were familiar with these devices. Patients with reduced peak inspiratory effort repeated the PIF measurement after a session of instruction on the need for more forceful effort through the device.

RESULTS

We studied 644 patients (mean age 62 years, 42% female). Of these, 62% had chronic obstructive pulmonary disease and 35% had asthma. The mean baseline forced expiratory volume in 1 second was 53% of predicted. 502 patients were using the Diskus((R)) and 185 the Turbuhaler((R)). Overall, 106 patients (16.5%) showed weak inhalation by direct observation at baseline. Of 44 subjects with weak inhalation through the Turbuhaler((R)), 34 (77%) demonstrated a PIF <30 L/min. Post-counselling, only four patients did not achieve a PIF of at least 30 L/min (p < 0.01). Of 62 subjects with weak inhalation through the Diskus((R)), 37 (60%) had a PIF <30 L/min. Post-counselling, all these subjects achieved a PIF of at least 30 L/min (p < 0.001).

CONCLUSION

A significant number of patients show a reduced peak inspiratory effort through the Diskus((R)) and the Turbuhaler((R)) in real life. Our results indicate that the cause of this deficiency is often mishandling of the device because, after a brief session of instruction on the need for more forceful inhalation, most patients obtained an acceptable PIF rate. A PIF meter may identify patients with inadequately weak inhalation and offer useful feedback for obtaining the best inspiratory effort.

Inhaler mishandling remains common in real life and is associated with reduced disease control

Proper inhaler technique is crucial for effective management of asthma and COPD. This multicentre, cross-sectional, observational study investigates the prevalence of inhaler mishandling in a large population of experienced patients referring to chest clinics; to analyze the variables associated with misuse and the relationship between inhaler handling and health-care resources use and disease control. We enrolled 1664 adult subjects (mean age 62 years) affected mostly by COPD (52%) and asthma (42%). Respectively, 843 and 1113 patients were using MDIs and DPIs at home; of the latter, the users of Aerolizer®, Diskus®, HandiHaler® and Turbuhaler® were 82, 467, 505 and 361. We have a total of 2288 records of inhaler technique. Critical mistakes were widely distributed among users of all the inhalers, ranging from 12% for MDIs, 35% for Diskus® and HandiHaler® and 44% for Turbuhaler®. Independently of the inhaler, we found the strongest association between inhaler misuse and older age (p = 0.008), lower schooling (p = 0.001) and lack of instruction received for inhaler technique by health caregivers (p < 0.001). Inhaler misuse was associated with increased risk of hospitalization (p = 0.001), emergency room visits (p < 0.001), courses of oral steroids (p < 0.001) and antimicrobials (p < 0.001) and poor disease control evaluated as an ACT score for the asthmatics (p < 0.0001) and the whole population (p < 0.0001). We conclude that inhaler mishandling continues to be common in experienced outpatients referring to chest clinics and associated with increased unscheduled health-care resource use and poor clinical control. Instruction by health caregivers is the only modifiable factor useful for reducing inhaler mishandling.

Skills in handling turbuhaler, diskus, and pressurized metered-dose inhaler in korean asthmatic patients

Purpose

The objective of this study was to evaluate skills in handling inhalers and factors associated with these skills among patients with asthma who had undergone treatment at special asthma and allergy clinics in Korea.

Methods

We enrolled 78 subjects who used Turbuhaler and 145 who used Diskus for asthma control at special clinics in 10 university hospitals and visually assessed their skills in handling these inhalers. We also evaluated skills in 137 subjects who had used pressurized metered-dose inhalers (pMDIs) for symptom relief. Age, sex, duration of asthma and inhaler use, smoking status, monthly income, highest grade completed in school and previous instruction for handling inhalers were also measured to evaluate their association with overall inhaler skills.

Results

Performance grade was inadequate for 12.8% of participants using Turbuhaler, 6.2% for Diskus, and 23.4% for pMDIs. The success rates for each step in handling the inhalers were relatively high except for the "exhale slowly to residual volume" step, in which success rates ranged from 24.2% to 28.5%. Older age, male sex, lower educational grade, and absence of previous instruction for handling inhalers were associated with inadequate inhaler technique in univariate analysis; however, only older age and absence of previous instruction remained significant independent risk factors in multivariate analysis.

Conclusions

Among Korean asthmatic patients in special asthma and allergy clinics, skills in handling their inhalers were mostly excellent; meanwhile, older age and absence of previous instruction for handling inhalers were associated with inadequate techniques.

Personalizing aerosol medicine: development of delivery systems tailored to the individual

Inhalation of drugs for therapeutic effects is not a recent innovation as illicit drugs have been ‘smoked’ for millennia. Nicotine delivery ‘devices’ in convenient packaged cartons of cigarettes are simple to use, inexpensive per dose and accessible to people of most ages and lung function, but of course their use leads to increased cancer, emphysema, heart disease and other medical and societal problems. In contrast, many inhalation pharmaceutical medical devices are expensive, nonportable, inconvenient, and/or are used improperly thus leading to poor therapeutic benefit. We review the current state of the art with respect to aerosol delivery, inhalation devices and the ability to personalize the treatment and management of lung disease. The confluence of many drivers will lead to more programmable and flexible devices in the future: the transition from the blockbuster model to customized therapy, technological advancements (e.g., smartphones) and cultural changes including social networking.

Importance of inhaler devices in the management of airway disease

The delivery of drugs by inhalation is an integral component of asthma and chronic obstructive pulmonary disease (COPD) management. However, even with effective inhaled pharmacological therapies, asthma, particularly, remains poorly controlled around the world. The reasons for this are manifold, but limitations of treatment guidelines in terms of content, implementation and relevance to everyday clinical life, including insufficient patient education, access to health care and cost of medication as well as poor inhaler technique are likely to contribute. Considering that inhalation therapy is a cornerstone in asthma and COPD management, little advice is provided in the guidelines regarding inhaler selection. The pressurised metered dose inhaler (pMDI) is still the most frequently prescribed device worldwide, but even after repeated tuition many patients fail to use it correctly. In addition, the correct technique can be lost over time. Although several improvements in pMDIs such as a change in the propellant and actuation have resulted in improvements in lung deposition, many dry powder inhalers (DPIs) are easier to use. However, these devices also have limitations such as dependency of drug particle size on flow rate and loss of the metered dose if the patient exhales through the device before inhaling. Improvements in using inhalation devices more efficiently, in inhaler design for supporting patient compliance, and advances in inhaler technology to assure drug delivery to the lungs, have the potential to improve asthma and COPD management and control. New and advanced devices are considered being helpful to minimise the most important problems patients have with current DPIs.

The need to improve inhalation technique in Europe: a report from the Aerosol Drug Management Improvement Team

Although the principles of asthma management are well established in Europe, the available data indicate that asthma in patients is not well controlled. Many patients derive incomplete benefit from their inhaled medication because they do not use inhaler devices correctly and this may compromise asthma control. The Aerosol Drug Management Improvement Team (ADMIT), incorporating clinicians from the UK, Germany, France, Italy, Spain and The Netherlands, reviewed published evidence to examine ways to improve the treatment of reversible airways disease in Europe. Data indicate that there is a clear need for specific training of patients in correct inhalation technique for the various devices currently available, and this should be repeated frequently to maintain correct inhalation technique. Devices which provide reassurance to patients and their physicians that inhalation is performed correctly should help to improve patient compliance and asthma control. Educational efforts should also focus on primary prescribers of inhaler devices. ADMIT recommends dissemination of information on the correct inhalation technique for each model of device by the use of an accessible dedicated literature base or website which would enable to match the appropriate inhaler to the individual patient. There is also a need for standardisation of prescribing practices throughout Europe. Regular checking of inhalation technique by prescribers is crucial as correct inhalation is one of the keystones of successful asthma management.

What plays a role in the choice of inhaler device for asthma therapy?

Inhalation is the preferred route of delivery for anti-asthma drugs. However, in reality inhalers are often prescribed on an empirical basis rather than on evidence-based awareness. Asthma management guidelines also guide inhaler choice, but they offer non-specific advice regarding inhaler choice, are very long and complicated and not conducive to rapid assimilation by a busy GP. In addition, device selection criteria differ according to who you are asking (i.e. the inhalation technologist, the physician or the patient). The ideal inhaler should be small and have a guided sequence of inhalation, leading patients in a logical sequence of events through the inhalation manoeuvre. It should be breath-activated, releasing medication only when all prerequisites for successful inhalation are met. Most importantly, there should be flow-independent deposition of drug in the lungs and feedback on the successfully performed inhalation manoeuvre to reassure the patient that the drug has been successfully released from the inhaler. The ideal inhaler should also have a low intrinsic airflow resistance, making it suitable for use by patients who have a low inspiratory airflow (e.g. children and elderly patients). In order to check for compliance, the ideal inhaler should have an accurate dose counter which is linked to correct inhalation rather than simply to dose release, and patients should be able to use an identical inhaler device to deliver each of their different medications. Finally, from an environmental and cost-effectiveness point of view, the ideal inhaler should be refillable. Among the currently available dry powder inhalers the Novolizer device fulfils several characteristics of an ideal inhaler for the treatment of asthma and chronic obstructive pulmonary disease (COPD).