Prescription bias and factors associated with improper use of inhalers

Individualized aerosol medicine: Integrating device into the patient

Pulmonary drug delivery is complex due to several challenges including disease-, patient-, and clinicians-related factors. Although many inhaled medications are available in aerosol medicine, delivering aerosolized medications to patients requires effective disease management. There is a large gap in the knowledge of clinicians who select and provide instructions for the correct use of aerosol devices. Since improper device selection, incorrect inhaler technique, and poor patient adherence to prescribed medications may result in inadequate disease control, individualized aerosol medicine is essential for effective disease management and control. The components of individualized aerosol medicine include: (1) Selecting the right device, (2) Selecting the right interface, (3) Educating the patient effectively, and (4) Increasing patient adherence to therapy. This paper reviews each of these components and provides recommendations to integrate the device and interface into the patient for better clinical outcomes.

Skills in handling Turbuhaler, Diskus in the west of China

OBJECTIVE

The purpose of this study was to evaluate the inhaler skills of patients with asthma and chronic obstructive pulmonary disease in a hospital in western China after receiving one medication education by pharmacists and the factors related to these skills.

METHODS

We included 96 subjects using Turbuhaler and 74 subjects using Diskus in a hospital in western China. They were educated once by pharmacists before medication, and then their skills of operating these inhalers were visually evaluated the next time they were used. Using the seven-step inhalation administration method designed by AnnaMurphy, a clinical pharmacist at GLENFIELD Hospital in the UK, the inhaler use technique score scale was established and scored in turn. The age, sex, time of first illness, smoking status, education level and type of health insurance purchased by each patient were recorded to assess their relationship with overall inhaler skills.

RESULTS

19.8% of the subjects who used Turbuhaler could not use it correctly, and 43.2% of the subjects who used Diskus could not use it correctly. The step with the highest error rate with Turbuhaler and Diskus is to "exhale slowly to residual volume". Chi-square test was carried out for each step of the operation of the two kinds of inhalers, and it was found that there was a significant difference in the operation accuracy of the two kinds of inhalers in the first, third and eighth steps. In univariate analysis, advanced age, female and low educational level were related to the lack of inhaler technology, but in multivariate analysis, only low educational level was a significant independent risk factor.

CONCLUSION

Among the patients with asthma and chronic obstructive pulmonary disease in western China, some patients have good inhaler operation skills, but there are still many patients who can not use inhalers correctly, and the lower education level is significantly related to the incorrect use of inhalers.

Inhaler technique knowledge and skills before and after an educational program in obstructive respiratory disease patients: A real-life pilot study

INTRODUCTION AND OBJECTIVE

Patients present poor knowledge and skills about their respiratory disease and inhaler device. We aimed to: (1) evaluate COPD and asthmatic patients... ability to manage inhaled drugs (2) identify differences among devices and (3) correlate clinical data with patient ability.

MATERIAL AND METHODS

Patients (n=134) admitted for pulmonary rehabilitation (PR) were given an ad-hoc questionnaire covering 0% as the worst and 100% the best value of global ability (indicating the sum of knowledge and skills in managing inhaled drugs) at baseline (T0) and discharge (T1). Educational program was provided during PR. Setting of rehabilitation, age, sex, diagnosis, spirometry, CIRS score, level of autonomy to use medications, if na..ve about PR, educational level, and number/type of prescribed inhaled drugs were recorded.

RESULTS

Most patients used 1 drug while 37% used 2 drugs. DPIs were the main device prescribed. At baseline, patients... mean level of knowledge and skills were 73% and 58%, respectively. There was a significant difference in level of skills (p=0.046) among device families, DPIs resulting worst and pMDIs best. Global ability, skills and knowledge improved after educational support (p<0.001) but did not reach the optimal level, 88%, 87% and 89%, respectively. Baseline global ability was positively correlated to female gender, younger age, previous PR access, outpatient status, higher education level and GOLD D class.

CONCLUSIONS

At hospital admission, global ability was not optimal. Education may improve this, irrespective of the type of device used, in particular in male, elderly, na..ve to PR, low educational level patients.

Breath-actuated INhalation TheRapy: survey of phySicians' PErCepTion (INTROSPECT) in Nepal

OBJECTIVE

Breath-actuated inhalers (BAIs) are gaining attention in the management of obstructive airway diseases (OADs). In Nepal, a BAI containing fluticasone propionate/salmeterol (FPS) has been available for a year. This survey is aimed at determining the perception and experience of physicians in Nepal concerning BAIs.

METHODS

A cross-sectional, questionnaire-based survey was conducted. A total of 141 physicians participated and filled the survey.

RESULTS

Most physicians felt that the right device should be easy to teach, learn and remember. They considered coordination and multiple steps as the primary challenges with pressurized metered-dose inhalers and dry powder inhalers, respectively. Most of them agreed that BAIs could address these challenges. BAIs were not only preferred by most of the physicians for asthma and chronic obstructive pulmonary disease but were also the preferred choice in newly diagnosed patients. Physicians believed that if current patients were shifted to BAIs, it could improve inhalation technique (88%) and compliance/adherence (81%). Almost all of them (92-97%) agreed that teaching the breathing technique and the cleaning process was easier and faster in BAIs. BAIs were considered easy and simple to use. Also, BAI's dose-counter helps patients to increase adherence to inhalation therapy.

CONCLUSIONS

In this INTROSPECT survey, physicians in Nepal believed that BAIs could address the key challenges faced with using pMDIs and DPIs in asthma and COPD patients.

"It's a lonely battle": A qualitative study of older adult Canadians' experiences with chronic obstructive pulmonary disease medication adherence and support

Background

Medication adherence is critical for optimal management of chronic obstructive pulmonary disease (COPD) and is influenced by patient, treatment and societal factors. Currently, little is known about the patient perspectives of older adult Canadians with COPD regarding medication adherence. Therefore, the purpose of this study was to explore the lived experiences of older Canadian adults with COPD regarding medication adherence and management.

Methods

Semi-structured interviews were conducted with 20 community-dwelling older adults with COPD, and iterative thematic analysis was performed.

Results

Six themes emerged from these data: (1) continuity of care, (2) importance of pharmacy for information and care, (3) medication self-management, (4) "there needs to be more information," (5) drug costs a concern and (6) "it's a lonely battle."

Conclusion

Findings suggested a need for improved continuity of care, disease-related information provision and means of addressing psychosocial needs. Holistic approaches to patient education and self-management, with consideration for varying health literacy, are needed.

A randomized, cross-over study comparing critical and overall errors, learning time, and preference of the ELLIPTA versus BREEZHALER dry powder inhalers in patients with asthma

BACKGROUND

Many patients with asthma make errors using inhalers, affecting the amount of medication received. Previous evidence demonstrated that patients with asthma or chronic obstructive pulmonary disease make fewer critical errors with the ELLIPTA inhaler after reading the patient information leaflet (PIL) versus other dry powder inhalers. We assessed errors made by patients with asthma using placebo ELLIPTA or BREEZHALER inhalers.

METHODS

This randomized, multicenter, open-label placebo inhaler-handling study (ClinicalTrials.gov: NCT04813354) with 2x2 complete block crossover design was conducted at three centers in the Netherlands and enrolled patients aged ≥18 years with mild-to-moderate asthma. Inclusion criteria were inhaler use for ≥12 weeks prior to enrollment and naivety to ELLIPTA and BREEZHALER inhalers. Patients were randomized to ELLIPTA or BREEZHALER inhaler first and were assessed for errors in use of both inhalers after 1) reading PIL instructions, 2) receiving further instruction from a healthcare professional (HCP) if they made an error.

RESULTS

114 patients with asthma (57% female; mean age of 55.3 years) were assessed. After reading the PIL, 6% of patients made ≥1 critical error with ELLIPTA versus 26% with BREEZHALER (odds ratio [OR]: 0.11 [95% confidence interval (CI): 0.01-0.40]; p < 0.001). With ELLIPTA, 27% of patients made ≥1 overall error after reading the PIL versus 41% with BREEZHALER (OR: 0.25 [95% CI: 0.03-0.74]; p = 0.005). Fewer patients required HCP instruction with ELLIPTA than BREEZHALER (25% versus 32%).

CONCLUSIONS

Fewer patients made critical and overall errors using the ELLIPTA inhaler versus BREEZHALER after reading the PIL.

Brashier DB. A study to monitor errors in use of inhalation devices in patients of mild-to-moderate bronchial asthma in a tertiary care hospital in Eastern India

Context:

Aims:

Settings and Design:

Methods and Material:

Statistical analysis used:

Results:

Conclusion:

Managing asthma in primary healthcare

Asthma brings considerable challenges for family doctors because of its variety of shapes, different levels of severity, a wide age range, and the fact that in the last decades clinicians are able to offer much better treatment options with a better level of disease control and a higher quality of life. The objectives of the current review article are to provide an up-to-date review by primary care respiratory leaders from different countries of the most significant challenges regarding asthma diagnosis and management, the importance of team work and the problems in recognizing and dealing with difficult-to-manage and severe asthma in primary care. The article provides a short review of the main challenges faced by family physicians and other primary health care professionals in supporting their patients in the management of asthma, such as asthma diagnosis, promoting access to spirometry, the importance of a multiprofessional team for the management of asthma, how to organize an asthma review, the promotion of patient autonomy and shared decision-making, improving the use of inhalers, the importance of the personalized asthma action plan, dealing with difficult-to-manage and severe asthma in primary care and choosing when, where and how to refer patients with severe asthma. The article also discusses the development of an integrated approach to asthma care in the community and the promotion of Asthma Right Care.

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.

Factors associated with improper metered-dose inhaler technique among adults with asthma in a primary care clinic in Malaysia

INTRODUCTION

Metered-dose inhalers (MDI) are the most used inhalers worldwide. However, improper MDI techniques remain a significant problem and cause uncontrolled asthma. Studies worldwide have reported that the causes of inefficient inhaler technique are multifactorial. However, this topic has been less well studied in the Asian population. This study aimed to evaluate the MDI technique and associated factors among adults with asthma in a primary care setting in Malaysia.

METHOD

This was a cross-sectional study with universal sampling conducted between July and October 2017. A total of 146 patients with asthma aged 18 years and older in a primary care clinic in Putrajaya, Malaysia were recruited. Logistic regressions were used for statistical analysis to examine the association between improper MDI techniques and their related factors.

RESULTS

The majority (83%) of respondents were female with a median age of 37 (IQR = 30.75-49.25) years, and the median duration of asthma of 20 (IQR = 10-30) years. An improper MDI technique was observed in 100 (71.9%) patients. The most frequently missed step was exhaling gently and fully before inhalation (51.4%). Respondents who were not on an MDI preventer (adjusted OR: 2.487, 95% CI: 1.121-5.519, p = 0 .025) or had used an MDI 5 years or fewer (adjusted OR: 3.369, 95% CI: 1.425-7.964, p = 0.006) were more likely to employ an improper MDI technique.

CONCLUSION

There was a high proportion of improper MDI techniques among patients with asthma. Patients not using an MDI preventer or who had used an MDI less than 5 years were at higher risk of improper MDI technique.

Sex differences in COPD management

Introduction: A growing body of evidence indicates that prevalence of chronic obstructive pulmonary disease (COPD) has been increasing more rapidly among women compared to men, but the available data on the differences between the sexes in the responses to the various COPD therapies are still scarce.Areas covered: The aim of this narrative review is to provide an overview of current knowledge on sex differences in COPD management.Expert opinion: There is no solid evidence of sex differences in response to usual COPD treatments but there are sex-related differences in management of patients with a clinical diagnosis of COPD. It is difficult to explain the reason for these differences, but most likely they are due to local prescribing habits, rather than solid scientific reasons. However, there are also signals of different sex-related responses, the qualification and quantification of which is difficult with the information currently available. These signals should lead to the inclusion of more women in clinical trials, but also to the design of prospective clinical studies to assess the possible differences linked to sex in COPD treatment responses, whose identification is an important step toward the definition of personalized COPD therapy.

Choosing the right inhaler for the right patient: Considerations for effective management of patients with chronic obstructive pulmonary disease or asthma

BACKGROUND AND PURPOSE

Effective management of chronic respiratory disorders such as chronic obstructive pulmonary disease and asthma necessitates that patients inhale their medication. However, lack of detailed guidelines on the technological and mechanical functions of inhalers limits the ability of health care providers (HCPs) to personalize inhaler choice for patients. Numerous types of inhalers are currently available which offer their own distinct advantages and disadvantages. Independent of the drug class, the choice of inhaler may be influenced by many factors (e.g., inhaler attributes and the efficiency with which it delivers the medication, patient characteristics and preferences, dosing regimen, clinical setting, and support available for both patients and HCPs). This article attempts to summarize the inhalation technology and factors influencing inhaler choice and use and to provide an approach for matching the right inhaler to the right patient.

CONCLUSIONS

Identifying factors related to inhaler choice is critical to ensuring adherence to treatment and patients' ability to use their inhaler correctly.

IMPLICATIONS FOR PRACTICE

This review will help HCPs engage their patients in decision-making for inhaler choice and facilitate selection of the correct inhaler for each patient (i.e., one that they will use).

Asthma and COPD Patients' Perception of Appropriate Metered-Dose Inhaler Technique

Objectives:

Asthma and chronic obstructive pulmonary disease (COPD) are chronic illnesses of the airways affecting a good number of people in Lebanon and the Middle East. Pressurized metered-dose inhalers (pMDIs) are important drug delivery systems used to treat such pulmonary diseases. Drugs proven to be valuable and effective may fail to act effectively if such inhalers are used incorrectly. The purpose of this study was to assess the technical use of pMDIs by patients with pulmonary diseases presenting to the community pharmacies in Lebanon.

Methods:

A structured questionnaire was developed to collect data. A total of 601 patients using drugs delivered through pMDIs and presenting to 12 Lebanese community pharmacies were recruited to participate in the research project. The questionnaire items were divided into 3 subscales: subscale 1—assessing the device preparation; subscale 2—investigating the device use; and subscale 3—examining the knowledge and use of spacers. After confirming the reliability and validity of the survey tool, patients’ responses were analyzed and compared according to many variables.

Results:

Many patients answered inaccurately to questions assessing both the device preparation and use. Around 40% of patients said they do not coordinate the inhalation with pressing the canister down. The mean scores were 1.72 (± 0.73) over 6 and 5.67 (± 1.44) over 7 for subscales 1 and 2, respectively. The mean total score on all questions was 7.39 over 13, with a standard deviation of 1.75. While patients’ age did not impact the results, asthmatic, well-educated, male patients had fewer wrong answers when it comes to preparing and using the device (P < .01).

Conclusions:

Our study showed that many patients with asthma and COPD might not be properly using their pMDIs. Appropriate inhaler use is crucial for successful pulmonary disease management. As pMDIs are one of the most difficult devices to use, proper and tailored instructions should be given to patients.

Identifying patients at risk of poor asthma outcomes associated with making inhaler technique errors

OBJECTIVES

Correct inhaler technique is essential to optimal clinical outcomes in asthma patients. The study aim was to use real-life data from the iHARP database to determine patient factors associated with the performance of inhaler technique errors associated with poor asthma outcomes (as identified in the Critikal study) in patients with asthma prescribed the Turbuhaler (TH), Metered Dose Inhaler (MDI), and Accuhaler (AH) device.

METHODS

This was a retrospective cross-sectional study using the iHARP database, a multinational initiative including questionnaires and technique review. Identification of inhaler technique errors specifically associated with poor asthma outcomes was performed by reference to the Critikal study. Multivariable logistic regression was used to identify demographic and clinical factors associated with ≥ 1 of these errors.

RESULTS

Factors significantly associated with ≥ 1 inhaler technique error and worsening asthma outcomes for the TH cohort include female gender, very poor to average self-assessment of inhaler technique; for the MDI cohort, female gender, secondary education, and current smoking status; and, in the AH cohort, lack of inhaler technique review by a trained healthcare professional in the previous twelve months and very poor to average self-assessment of inhaler technique.

CONCLUSIONS

Numerous specific patient demographic and clinical factors associated with the performance of these errors have been identified, differing according to device. Inhaler technique error associated with poor asthma outcomes is further widespread across devices. Knowledge of these factors and the frequency of their occurence may assist in optimizing device selection and training.

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.

Effectiveness and Patient Satisfaction with Budesonide/Formoterol Easyhaler® Among Patients with Asthma or COPD Switching from Previous Treatment: a Real-World Study of Patient-Reported Outcomes

INTRODUCTION

Persistent symptoms, poor disease control, and reduced quality of life (QoL) are common in patients with asthma and chronic obstructive pulmonary disease (COPD). Current therapies are only partially effective and inhaler misuse contributes to insufficient disease control and poor outcomes. This real-world study aimed to evaluate the effectiveness of budesonide/formoterol fumarate (B/F) Easyhaler® in everyday clinical practice in Hungary.

METHODS

Post hoc, subgroup analyses of this 12-week, real-world, multicenter, open-label study were conducted in adults diagnosed with asthma or COPD. Endpoints included the change in patient-reported outcome measures; i.e., symptoms and disease control measured by Asthma Control Test or COPD Assessment Test and health-related (HR)QoL measured by mini-Asthma Quality of Life Questionnaire or modified Medical Research Council dyspnea scale. Changes in lung function and patient satisfaction with B/F Easyhaler versus their previous inhaler were also evaluated. Results were stratified by the inhaler device used at visit 1 (baseline, when patients switched device); comparisons were made with B/F Easyhaler use after 12 weeks, assessed at visit 3.

RESULTS

In total, 398 and 563 patients with asthma and COPD, respectively, were analyzed. Significant improvements (p < 0.0001) in symptoms and disease control, HRQoL, and lung function were reported 12 weeks after switching treatment to B/F Easyhaler from the most commonly used devices (≥ 10% of patients). Significant increases in patient satisfaction were also reported versus comparators.

CONCLUSIONS

Patients with asthma or COPD who switched to B/F Easyhaler from their previous inhaler due to lack of disease control achieved significant improvements in symptoms and disease control, HRQoL, and lung function within 12 weeks of real-world use with significant increase in patient satisfaction also observed. Such comparative information may reassure clinicians and patients that may be viewed as an appropriate and potentially beneficial treatment option.

TRIAL REGISTRATION NUMBER

OGYÉI/13942-5/2016 (National Pharmaceutical Institute of Pharmacy and Nutrition of Hungary).

FUNDING

Orion Corporation, Orion Pharma. Plain language summary available for this article.

Outcome of illustrated information leaflet on correct usage of asthma-metered dose inhaler

Background

Research globally has shown that metered dose inhaler (MDI) technique is poor, with patient education and regular demonstration critical in maintaining correct use of inhalers. Patient information containing pictorial aids improves understanding of medicine usage; however, manufacturer leaflets illustrating MDI use may not be easily understood by low-literacy asthma patients.

Aim

To develop and evaluate the outcome of a tailored, simplified leaflet on correct MDI technique in asthma patients with limited literacy skills.

Setting

A rural primary health care clinic in the Eastern Cape, South Africa.

Methods

Pictograms illustrating MDI steps were designed to ensure cultural relevance. The design process of the leaflet was iterative and consultative involving a range of health care professionals as well as patients. Fifty-five rural asthma patients were recruited for the pre-post design educational intervention study. Metered dose inhaler technique was assessed using a checklist, and patients were then educated using the study leaflet. The principal researcher then demonstrated correct MDI technique. This process was repeated at follow-up 4 weeks later.

Results

The number of correct steps increased significantly post intervention from 4.6 ± 2.2 at baseline to 7.9 ± 2.7 at follow-up (p < 0.05). Statistically significant improvement of correct technique was established for 10 of the 12 steps. Patients liked the pictograms and preferred the study leaflet over the manufacturer leaflet.

Conclusion

The tailored, simple, illustrated study leaflet accompanied by a demonstration of MDI technique significantly increased correct MDI technique in low-literacy patients. Patients approved of the illustrated, simple text leaflet, and noted its usefulness in helping them improve their MDI technique.

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.

Knowledge and practice of dry powder inhalation among patients with chronic obstructive pulmonary disease in a regional hospital, Nepal

Purpose

Dry powder inhalation is a cornerstone of treatment in patients with COPD. This study was undertaken to study the knowledge and practice of dry powder inhalation among such patients.

Patients and methods

The current study was a cross-sectional study conducted in Western Regional Hospital, Pokhara, Nepal. The study was conducted among 204 COPD patients (outpatients and inpatients) aged ≥20 years who had been using rotahaler, a dry powder inhaler device, and a purposive sampling technique was used. Data were collected from February 28, 2016, to March 26, 2016. A questionnaire was administered by the interviewer to assess the knowledge about dry powder inhaler (DPI) and inhalation while a Dutch Asthma Foundation observation checklist for rotahaler was used to evaluate the practice of dry powder inhalation. The collected data were analyzed using descriptive statistics and inferential statistics (chi-square test).

Results

Findings from the study showed that a low proportion of the respondents had accurate knowledge and correctly practiced inhalation technique (3.9%). However, majority of the respondents (77.5%) performed the critical steps correctly. The correct practice of dry powder inhalation was associated with younger age (p=0.008), urban residence (p=0.024), and literacy (p=0.012). The practice was comparatively more accurate among those who received practical classes/demonstration on the inhalation technique from health care providers (p<0.001).

Conclusion

Based on the study findings, it was concluded that COPD patients attending Western Regional Hospital possessed satisfactory knowledge but poor technique of dry powder inhalation. The most important modifiable factor for incorrect practice was a lack of demonstration on inhalation technique by the health care provider. Therefore, it is necessary for health care providers to supplement verbal instruction on dry powder inhalation with demonstration and re-demonstration from the patients to improve the knowledge and practice of dry powder inhalation for COPD patients.

Revised (2018) COPD Clinical Practice Guideline of the Korean Academy of Tuberculosis and Respiratory Disease: A Summary

Chronic obstructive pulmonary disease (COPD) results in high morbidity and mortality among patients nationally and globally. The Korean clinical practice guideline for COPD was revised in 2018. The guideline was drafted by the members of the Korean Academy of Tuberculosis and Respiratory Diseases as well as the participating members of the Health Insurance Review and Assessment Service, Korean Physicians' Association, and Korea Respiration Trouble Association. The revised guideline encompasses a wide range of topics, including the epidemiology, diagnosis, assessment, monitoring, management, exacerbation, and comorbidities of COPD in Korea. We performed systematic reviews assisted by an expert in meta-analysis to draft a guideline on COPD management. We expect this guideline to facilitate the treatment of patients with respiratory conditions by physicians as well other health care professionals and government personnel in South Korea.

Teaching Pharmacy Undergraduate Students Inhaler Device Technique and Exploring Factors Affecting Maintenance of Technique

Aim

To determine the effect of inhaler device technique education on the maintenance of the inhaler device technique of undergraduate pharmacy students over time and to determine the factors, if any, related to inhaler device technique maintenance in the academic setting.

Methods

This study took the form of a prospective, unpaired samples repeated measures design. Participants had their inhaler technique assessed at baseline. Participants were then shown how to use an inhaler as a group. Participants then worked in pairs and took turns teaching and assessing each other on the correct inhaler technique using the 9-step checklist. Immediately following the delivery of the intervention, participants had their inhaler technique reassessed. All participants were then trained to mastery through individualised training. Twelve months following the collection of baseline data, all participants had their inhaler technique assessed and completed two questionnaires.

Results

Following the delivery of the intervention, there was a significant increase in the proportion of participants with the correct inhaler technique when compared to baseline (11% to 61%, resp.). There was a significant reduction in the proportion of participants demonstrating the correct technique 12 months following training (28%). The strongest determinant of inhaler technique maintenance is experience with showing patients how to use their inhalers.

Conclusion

Repeated training is essential to ensure that the technique is mastered and maintained, and consolidation of skills through exposure to train others may be most effective.

Exploding asthma and ADHD caseloads: The role of medicaid managed care

In the U.S., nearly 11% of school-age children have been diagnosed with ADHD, and approximately 10% of children suffer from asthma. In the last decade, the number of children diagnosed with these conditions has inexplicably been on the rise. This increase has been concentrated in the Medicaid caseload nationwide. One of the most striking changes in Medicaid has been the transition from fee-for-service (FFS) reimbursement to Medicaid managed care (MMC), which had taken place in 80% of states by 2016. Using Medicaid claims from South Carolina, we show that this change contributed to the increase in asthma and ADHD caseloads. Empirically, we rely on variation in MMC enrollment due to a change in the "default" Medicaid plan from FFS to MMC, and on rich panel data that allow us to follow the same children before and after they were required to switch. We find that the transition from FFS to MMC explains about a third of the rise in the number of Medicaid children being treated for ADHD and asthma, along with increases in treatment for many other conditions. These are likely to be due to the incentives created by the risk adjustment and quality control systems in MMC.

Inhaler technique: does age matter? A systematic review

Poor inhaler technique and inferior asthma outcomes are evident in older adults. Reviews comparing metered dose inhaler (MDI) and dry powder inhaler (DPI) techniques across older adults and younger cohorts are scarce. This systematic review aimed to determine whether differences exist between such cohorts with regards to the number and type of MDI and DPI errors made. A systematic literature search was conducted in Embase, Medline and PubMed from July 1 to December 31, 2016. Studies were selected in accordance with preset inclusion criteria, relevant data were extracted, and quality was assessed with validated checklists. 14 studies were identified. Evidence suggests a negative correlation between advancing age and correct technique across MDI and varying DPI devices when examined collectively. Differences appear to exist between older adult and younger cohorts prescribed MDIs in error types. There is evidence of age-associated differences in the number and type of inhaler technique errors. Further research is required to assess outcomes in individual DPIs, reproducibility and the effects of confounders.

Role of nebulized glycopyrrolate in the treatment of chronic obstructive pulmonary disease

In the upcoming years, the proportion of elderly patients with chronic obstructive pulmonary disease (COPD) will increase, according to the progressively aging population and the increased efficacy of the pharmacological treatments, especially considering the management of chronic comorbidities. The issue to prescribe an appropriate inhalation therapy to COPD patients with significant handling or coordination difficulties represents a common clinical experience; in the latter case, the choice of an inadequate inhalation device may jeopardize the adherence to the treatment and eventually lead to its ineffectiveness. Treatment options that do not require particular timing for coordination between activation and/or inhalation or require high flow thresholds to be activated should represent the best treatment option for these patients. Nebulized bronchodilators, usually used only in acute conditions such as COPD exacerbations, could fulfill this gap, enabling an adequate drug administration during tidal breathing and without the need for patients' cooperation. However, so far, only short-acting muscarinic antagonists have been available for nebulization. Recently, a nebulized formulation of the inhaled long-acting muscarinic antagonist glycopyrrolate, delivered by means of a novel proprietary vibrating mesh nebulizer closed system (SUN-101/eFlow®), has progressed to Phase III trials and is currently in late-stage development as an option for maintenance treatment in COPD. The present critical review describes the current knowledge about the novel nebulizer technology, the efficacy, safety, and critical role of nebulized glycopyrrolate in patients with COPD. To this end, PubMed, ClinicalTrials.gov, Embase, and Cochrane Library have been searched for relevant papers. According to the available results, the efficacy and tolerability profile of nebulized glycopyrrolate may represent a valuable and dynamic treatment option for the chronic pharmacological management of patients with COPD.

Patterns of use of dry powder inhalers versus pressurized metered-dose inhalers devices in adult patients with chronic obstructive pulmonary disease or asthma: An observational comparative study

Numerous patients with chronic obstructive pulmonary disease (COPD) and asthma do not use inhaler devices properly, which can contribute to poor disease control. The objective of this study is to assess the technical and safety use of dry powder inhalers (DPIs) versus pressurized metered-dose inhalers (MDIs) in adult patients with COPD or asthma in Lebanon. A concurrent, prospective comparative observational study was conducted at one hospital and 15 community pharmacies in Lebanon. Over a period of 18 months, 246 questionnaires were filled. Patients included were adults with COPD or asthma. Answers were entered into the Statistical Package for Social Sciences software and excel sheet. T-test and correlation were used to analyze the results; 67.8% and 38.4% of those using DPIs and MDIs, respectively, performed the exact technical steps adequately ( p = 0.003, relative risk: 2.134, 95% confidence interval: 0.910-4.842). When compared to MDI, a higher percentage of DPI users found their devices easy to use. Moreover, 81.4% of the MDI users found difficulty in coordinating between pressing the canister and inhaling. Rates of exacerbations were significantly higher in MDIs vs. DPI users (59.4% vs. 21.7%). Overall, 44.31% of patients did not receive education from their healthcare professionals about the devices. A significant number of COPD/asthma adult patients do not use their devices properly. Even though DPIs were significantly easier to use, proper education on the technical use of all types of inhalers is needed.

Efficacy and safety of glycopyrrolate/eFlow® CS (nebulized glycopyrrolate) in moderate-to-very-severe COPD: Results from the glycopyrrolate for obstructive lung disease via electronic nebulizer (GOLDEN) 3 and 4 randomized controlled trials

BACKGROUND

SUN-101 is a combination of glycopyrrolate delivered through an innovative, electronic nebulizer, intended for the treatment of patients with COPD. The objective of this study was to assess the efficacy and safety of this new drug device combination.

METHODS

Replicate Phase III randomized, double-blind, placebo-controlled studies were conducted to evaluate the efficacy and safety of glycopyrrolate solution administered by an investigational eFlow^® Closed System (eFlow^® CS) nebulizer in subjects with moderate-to-very-severe COPD, including those with continued background use of a long-acting beta₂-agonist ± inhaled corticosteroid and/or history of cardiovascular (CV) disease. Subjects were randomized in a 1:1:1 ratio to receive placebo or glycopyrrolate (25 μg or 50 μg twice daily [BID]) for 12 weeks. The primary efficacy endpoint was the change from baseline in trough forced expiratory volume in 1 s (FEV₁) at Week 12 compared with placebo. Secondary endpoints included change from baseline in forced vital capacity (FVC) after 12 weeks, change from baseline in health status measured by St George's Respiratory Questionnaire (SGRQ) at 12 weeks/end of study (EOS), and change in rescue medication use, as well as change from baseline in FEV₁ area under the curve from 0 to 12 h after 12 weeks in the GOLDEN 3 sub-study. Daytime and night-time symptoms were recorded using an electronic diary. Safety was monitored throughout the study, including major adverse cardiovascular events.

RESULTS

A total of 653 subjects were randomized in GOLDEN 3 and 641 in GOLDEN 4. Treatment with glycopyrrolate 25 μg BID and 50 μg BID resulted in statistically significant and clinically important changes from baseline in trough FEV₁ compared with placebo at Week 12 (GOLDEN 3: 0.105 L and 0.126 L; p ≤ 0.0001; GOLDEN 4: 0.084 L and 0.082 L; p ≤ 0.0001). Nebulized glycopyrrolate 25 μg BID and 50 μg BID also resulted in improvements in FVC change from baseline versus placebo at Week 12 (GOLDEN 3: 0.149 L and 0.167 L, p < 0.001; GOLDEN 4: 0.130 L and 0.113 L, p < 0.01), and in SGRQ change from baseline score versus placebo at Week 12/EOS (GOLDEN 3: -3.072 [p < 0.05] and -1.848; GOLDEN 4: -3.585 and -3.557, p < 0.01). LS mean change from baseline in EXACT-respiratory symptoms total score at Week 12 for placebo and nebulized glycopyrrolate 25 and 50 μg BID were -0.936, -1.903 and -1.502 for GOLDEN 3 and -0.376, -1.647 and -1.532 for GOLDEN 4. Rescue medication use was unchanged. Nebulized glycopyrrolate was well tolerated at both doses based on the incidence of adverse events and CV events.

CONCLUSIONS

The results of these studies demonstrated statistically significant and clinically important improvements in pulmonary function and patient-reported health outcomes, with an acceptable safety profile, support the use of glycopyrrolate/eFlow^® CS as a potential maintenance treatment for moderate-to-very-severe COPD.

Inhaler Training Delivered by Internet-Based Home Videoconferencing Improves Technique and Quality of Life

BACKGROUND

COPD is common, and inhaled medications can reduce the risk of exacerbations. Incorrect inhaler use is also common and may lead to worse symptoms and increased exacerbations. We examined whether inhaler training could be delivered using Internet-based home videoconferencing and its effect on inhaler technique, self-efficacy, quality of life, and adherence.

METHODS

In this pre-post pilot study, participants with COPD had 3 monthly Internet-based home videoconference visits with a pharmacist who provided inhaler training using teach-to-goal methodology. Participants completed mailed questionnaires to ascertain COPD severity, self-efficacy, health literacy, quality of life, adherence, and satisfaction with the intervention.

RESULTS

A total of 41 participants completed at least one, and 38 completed all 3 home videoconference visits. During each visit, technique improved for all inhalers, with significant improvements for the albuterol metered-dose inhaler, budesonide/formoterol metered-dose inhaler, and tiotropium dry powder inhaler. Improved technique was sustained for nearly all inhalers at 1 and 2 months. Quality of life measured with the Chronic Respiratory Questionnaire improved following the training: dyspnea (+0.3 points, P = .01), fatigue (+0.6 points, P < .001), emotional function (+0.5 points, P = .001), and mastery (+0.7 points, P < .001). Coping skills measured with the Seattle Obstructive Lung Disease Questionnaire improved (+9.9 points, P = .003). Participants reported increased confidence in inhaler use; for example, mean self-efficacy for using albuterol increased 3 points (P < .001). Inhaler adherence improved significantly after the intervention from 1.6 at the initial visit to 1.1 at month 2 (P = .045). The pharmacist reported technical issues in 64% of visits.

CONCLUSIONS

Inhaler training using teach-to-goal methodology delivered by home videoconference is a promising means to provide training to patients with COPD that can improve technique, quality of life, self-efficacy, and adherence.

Summary of the Chronic Obstructive Pulmonary Disease Clinical Practice Guideline Revised in 2014 by the Korean Academy of Tuberculosis and Respiratory Disease

Chronic obstructive pulmonary disease (COPD) results in high morbidity and mortality among patients both domestically and globally. The Korean clinical practice guideline for COPD was revised in 2014. It was drafted by the members of the Korean Academy of Tuberculosis and Respiratory Diseases, as well as participating members of the Health Insurance Review and Assessment Service, Korean Physicians' Association, and Korea Respiration Trouble Association. This revised guideline covers a wide range of topics, including the epidemiology, diagnosis, assessment, monitoring, management, exacerbation, and comorbidities of COPD in Korea. We drafted a guideline on COPD management by performing systematic reviews on the topic of management with the help of a meta-analysis expert. We expect this guideline will be helpful medical doctors treating patients with respiratory conditions, other health care professionals, and government personnel in South Korea.

Nebulized drug delivery in respiratory medicine: what does the future hold?

In the later half of the 20th century, nebulized therapy was in decline, but in the 21st century the prospects for the expanded use of nebulized therapy within respiratory medicine look bright. The advent of mesh nebulizers, which combine the universal applicability of the nebulizer in the treatment of all respiratory patients with the convenience of portable inhaler use, is ideally timed to capitalize on the forecast of increased numbers of patients who will require nebulized therapy in the future. This special report will highlight some of the opportunities that the development of mesh nebulizers presents in the field of respiratory medicine.

Device errors in asthma and COPD: systematic literature review and meta-analysis

Inhaler device errors are common and may impact the effectiveness of the delivered drug. There is a paucity of up-to-date systematic reviews (SRs) or meta-analyses (MAs) of device errors in asthma and chronic obstructive pulmonary disease (COPD) patients. This SR and MA provides an estimate of overall error rates (both critical and non-critical) by device type and evaluates factors associated with inhaler misuse. The following databases from inception to July 23, 2014 (Embase®, MEDLINE®, MEDLINE® In-Process and CENTRAL) were searched, using predefined search terms. Studies in adult males and females with asthma or COPD, reporting at least one overall or critical error, using metered dose inhalers and dry powder inhalers were included. Random-effect MAs were performed to estimate device error rates and to compare pairs of devices. Overall and critical error rates were high across all devices, ranging from 50-100% and 14-92%, respectively. However, between-study heterogeneity was also generally >90% (I-squared statistic), indicating large variability between studies. A trend towards higher error rates with assessments comprising a larger number of steps was observed; however no consistent pattern was identified. This SR and MA highlights the relatively limited body of evidence assessing device errors and the lack of standardised checklists. There is currently insufficient evidence to determine differences in error rates between different inhaler devices and their impact on clinical outcomes. A key step in improving our knowledge on this topic would be the development of standardised checklists for each device.

CHRONIC LUNG DISEASES

CALL TO STANDARDISE RESEARCH INTO INHALER DEVICE ERRORS: Researchers should adopt a standardised approach to investigate the incorrect use of inhalers and its associated clinical implications. Henry Chrystyn at Plymouth University, together with scientists across the UK and the Netherlands, conducted a review of research related to inhaled medication errors made by patients with asthma or chronic obstructive pulmonary disease. It is widely acknowledged that many patients with lung conditions don't use their inhaler devices correctly, which affects drug effectiveness and disease control. While Chrystyn's team found high critical error rates reported across all devices, their meta-analysis and systematic review highlighted significant gaps in knowledge regarding different inhalers and associated error rates, and how these affect clinical outcomes. The researchers call for in-depth studies into device use, alongside standardised checklists and definitions for such studies to use to ensure consistency.

Mastery of pMDI technique, asthma control and quality-of-life of children with asthma: A randomized controlled study comparing two inhaler technique training approaches

OBJECTIVE

Verbal counselling (VC) is the clinical standard for training patients on correct inhaler use. Patients fail to recall their VC with time. Ethical approval was obtained to compare the pressurized metered dose inhaler (pMDI) VC with Trainhaler (TH), a novel pMDI inhalation flow and technique training device, in children with asthma.

METHODS

At visit 1, 7-17 year-old children with a pMDI hand-lung coordination problem including a fast peak inhalation flow (PIF) through pMDI >60 L/min were randomized into either VC group that received verbal pMDI training; or into TH group that were trained on- and given TH to practice at home. Whereas, children with correct pMDI use formed the control group (CT). Overall pMDI technique, PIF through inhaler, asthma control (AC) and quality of life (QoL) were evaluated. Participants were re-evaluated 6-8 weeks later (visit 2).

RESULTS

Of 105 enrolled children; 76 completed the study (VC = 21, TH = 25 and CT = 30). VC decreased non-significantly (p > 0.05) the mean PIF from 104.0 L/min at visit 1 to 84.8 at visit 2. Whilst, the TH did significantly (p < 0.05) reduce the PIF from 113.5 to 71.4 L/min. The two approaches similarly and significantly (p < 0.05) improved the inhaler technique, AC and QoL scores.

CONCLUSIONS

The TH improved the inhalation flow through the pMDI close to the ideal needed for adequate lung deposition. Both methods equally enhanced the children's mastery of pMDI use. This was reflected on better AC and QoL. Accessibility to TH might help maintaining the good inhaler use and decreasing regular VC.

A randomised open-label cross-over study of inhaler errors, preference and time to achieve correct inhaler use in patients with COPD or asthma: comparison of ELLIPTA with other inhaler devices

Errors in the use of different inhalers were investigated in patients naive to the devices under investigation in a multicentre, single-visit, randomised, open-label, cross-over study. Patients with chronic obstructive pulmonary disease (COPD) or asthma were assigned to ELLIPTA vs DISKUS (Accuhaler), metered-dose inhaler (MDI) or Turbuhaler. Patients with COPD were also assigned to ELLIPTA vs Handihaler or Breezhaler. Patients demonstrated inhaler use after reading the patient information leaflet (PIL). A trained investigator assessed critical errors (i.e., those likely to result in the inhalation of significantly reduced, minimal or no medication). If the patient made errors, the investigator demonstrated the correct use of the inhaler, and the patient demonstrated inhaler use again. Fewer COPD patients made critical errors with ELLIPTA after reading the PIL vs: DISKUS, 9/171 (5%) vs 75/171 (44%); MDI, 10/80 (13%) vs 48/80 (60%); Turbuhaler, 8/100 (8%) vs 44/100 (44%); Handihaler, 17/118 (14%) vs 57/118 (48%); Breezhaler, 13/98 (13%) vs 45/98 (46%; all P<0.001). Most patients (57–70%) made no errors using ELLIPTA and did not require investigator instruction. Instruction was required for DISKUS (65%), MDI (85%), Turbuhaler (71%), Handihaler (62%) and Breezhaler (56%). Fewer asthma patients made critical errors with ELLIPTA after reading the PIL vs: DISKUS (3/70 (4%) vs 9/70 (13%), P=0.221); MDI (2/32 (6%) vs 8/32 (25%), P=0.074) and significantly fewer vs Turbuhaler (3/60 (5%) vs 20/60 (33%), P<0.001). More asthma and COPD patients preferred ELLIPTA over the other devices (all P⩽0.002). Significantly, fewer COPD patients using ELLIPTA made critical errors after reading the PIL vs other inhalers. More asthma and COPD patients preferred ELLIPTA over comparator inhalers.

Who will teach the teachers: An analysis of the inhaler technique of Indian patients and health care providers in a tertiary health care centre

INTRODUCTION

The proper use of inhalers is essential for ensuring proper control of the disease. Various studies have shown high levels of improper use and lack of knowledge of the correct technique among patients with asthma. However, less data are available on how health care workers (HCW's) use inhalers.

MATERIALS AND METHODS

The study was conducted at a Tertiary Care Hospital in Mumbai. We evaluated the pMDI technique in 141 consecutive adult asthmatics and 100 HCW's. All patients and HCW's were graded out of 10 points for following 10 steps. These were derived from Melani et al.'s study on inhaler mishandling.

RESULTS

Techniques of 141 patients and 100 HCW's (55 nurses and 45 doctors) were analyzed. The average technique score among patients ranged from 0 to 10 with a mean of 4.65 ± 2.00. The combined score for health workers ranged from 3 to 9 with a mean of 5.45 ± 1.47. Doctors had a higher score of 6.35 ± 1.33 as opposed to the nurses' score of 4.70 ± 1.13 (P < 0.05). There was no significant difference between scores of nurses and patients (P > 0.05).

CONCLUSIONS

Our study highlights the need for better education of not only patients but also health care providers regarding the appropriate use of inhaler devices in order to achieve optimal control of obstructive airway diseases.

Empowering family physicians to impart proper inhaler teaching to patients with chronic obstructive pulmonary disease and asthma

BACKGROUND

Patients with chronic obstructive pulmonary disease (COPD) and asthma depend on inhalers for management, but critical errors committed during inhaler use can limit drug effectiveness. Outpatient education in inhaler technique remains inconsistent due to limited resources and inadequate provider knowledge.

OBJECTIVE

To determine whether a simple, two-session inhaler education program can improve physician attitudes toward inhaler teaching in primary care practice.

METHODS

An inhaler education program with small-group hands-on device training was instituted for family physicians (FP) in British Columbia and Alberta. Sessions were spaced one to three months apart. All critical errors were corrected in the first session. Questionnaires surveying current inhaler teaching practices and attitudes toward inhaler teaching were distributed to physicians before and after the program.

RESULTS

Forty-one (60%) of a total 68 participating FPs completed both before and after program questionnaires. Before the program, only 20 (49%) reported providing some form of inhaler teaching in their practices, and only four (10%) felt fully competent to teach patients inhaler technique. After the program, 40 (98%) rated their inhaler teaching as good to excellent. Thirty-four (83%) reported providing inhaler teaching in their practices, either by themselves or by an allied health care professional they had personally trained. All stated they could teach inhaler technique within 5 min. Observation of FPs during the second session by certified respiratory educators found that none made critical errors and all had excellent technique.

CONCLUSION

A physician inhaler education program can improve attitudes toward inhaler teaching and facilitate implementation in clinical practices.

Sex Difference in Chronic Obstructive Lung Disease. Does it Matter? A Concise Review

Chronic obstructive lung disease (COPD) primarily affects men; however, its epidemiology has been changing because more women have become smokers. Recently, investigators found that although women and men were exposed to the same amount of smoke fume, women tended to have more severe disease and higher mortality rate. They also complain of more dyspnoea and may experience more severe exacerbations than men. This led to the question of whether sex has an impact on COPD course and whether women have a higher susceptibility to smoke fumes than men. That may be explained by multiple complex factors highlighting the relationship between sex, epidemiology, method of diagnostics and the clinical course of the disease. In this review, sex differences in epidemiology, clinical presentation, exacerbation, co-morbidities and treatment are covered.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The assessment of new drugs for asthma and COPD: a Delphi study examining the perspectives of Italian payers and clinicians

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) are disorders of the lungs characterized by airflow obstruction, inflammation and tissue remodeling. Management of patients with these diseases is complex and the improvement of diagnostic-therapeutic strategies represents a critical challenge for the healthcare system. In this context, investigating the criteria and information needed for an appropriate and effective evaluation of incoming treatment options is crucial to ensure that clinicians and policy-makers are provided with the best available evidence to make decisions aimed at improving patient outcomes. Therefore, the objective of this study was to investigate the degree of agreement among Health Technology Assessment (HTA) experts on issues crucial to the evaluation of new drugs for asthma and COPD and to appropriately manage the clinical pathway for patients.

METHOD

This research was conducted using an e-Delphi technique organized in three subsequent rounds and involving a panel of ten experts (six regional and local payers and four clinicians). Panelists were asked to comment in written form on a set of statements, explaining qualitatively the extent to which they agreed or disagreed with the assertions. Statements were subsequently modified and resubmitted for assessment.

RESULTS

Panelists expressed their opinions during each round and, after round III, a consensus document was finalized. The degree of consensus was high among experts and concerned five main topics: (a) the need to address current unmet needs of patients with asthma or COPD, (b) the importance of further studies and real-life information in the evaluation of treatments, (c) existing evidence and evidence needed to assess drugs, (d) critical issues in obtaining a positive evaluation from regional and local authorities for new treatments to be included in regional formularies and to have an important place in therapeutic categories, and (e) the major obstacles to the appropriate administration of drugs and management of patients.

CONCLUSION

The final document highlights that no proof of difference among drugs exists, that evidence on final endpoints (and particularly on mortality) should be strengthened and that actions regarding risk factors, appropriate diagnosis, patient staging and adherence to therapy are particularly important for a better clinical management.

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.

Benefit of educational feedback for the use of positive expiratory pressure device

BACKGROUND

Positive expiratory pressure (PEP) is regularly used as a self-administered airway clearance technique.

OBJECTIVE

The aim of this study was to evaluate the need to teach the correct use of the PEP device and to measure the progress of the success rate of the maneuver after training.

METHOD

A PEP system (PariPEP-S Sytem) was used to generate PEP in 30 healthy volunteers. They were instructed by a qualified physical therapist to breathe correctly through the PEP device. Then they were evaluated during a set of ten expirations. Two other evaluations were performed at day 2 and day 8 (before and after feedback). The mean PEP and the success rate were calculated for each set of expirations. The number of maneuvers needed to obtain a correct use was calculated on the first session.

RESULTS

An optimal PEP was reached after 7.5 SD 2.7 attempts by all subjects. Success rates and mean pressures were similar between the different sets of expirations (p=0.720 and p=0.326, respectively). Pressure variability was around 10%. After one week, 30% of subjects generated more than two non-optimal pressures in the set of ten expirations. No difference in success rate was observed depending on the evaluations.

CONCLUSION

This study demonstrates that good initial training on the use of the PEP device and regular follow-up are required for the subject to reach optimal expiratory pressure.

Maintaining Control of Chronic Obstructive Airway Disease: Adherence to Inhaled Therapy and Risks and Benefits of Switching Devices

Asthma and chronic obstructive pulmonary disease (COPD) are major obstructive airway diseases that involve underlying airway inflammation. The most widely used pharmacotherapies for asthma and COPD are inhaled agents that have been shown to be effective and safe in these patients. However, despite the availability of effective pharmacologic treatment and comprehensive treatment guidelines, the prevalence of inadequately controlled asthma and COPD is high. A main reason for this is poor adherence. Adherence is a big problem for all chronic diseases, but in asthma and COPD patients there are some additional difficulties because of poor inhalation technique and inhaler choice. Easier-to-use devices and educational strategies on proper inhaler use from health caregivers can improve inhaler technique. The type of device used and the concordance between patient and physician in the choice of inhaler can also improve adherence and are as important as the drug. Adherence to inhaled therapy is absolutely necessary for optimizing patient control. If disease control is not adequate despite good adherence, switching to a more appropriate inhaled therapy is recommended. By contrast, uninformed switching or switching to less user-friendly inhaler may impact disease control negatively. This critical review of the available literature is aimed to provide a guidance protocol on when a switch may be recommended in individual patients.

Nurses' knowledge of inhaler technique in the inpatient hospital setting

PURPOSE/OBJECTIVES

High rates of inhaler misuse in patients with chronic obstructive pulmonary disease and asthma contribute to hospital readmissions and increased healthcare cost. The purpose of this study was to examine inpatient staff nurses' self-perception of their knowledge of proper inhaler technique compared with demonstrated technique and frequency of providing patients with inhaler technique teaching during hospitalization and at discharge.

DESIGN

A prospective, descriptive study.

SETTING

A 495-bed urban academic medical center in the Midwest United States.

SAMPLE

A convenience sample of 100 nurses working on inpatient medical units.

METHODS

Participants completed a 5-item, 4-point Likert-scale survey evaluating self-perception of inhaler technique knowledge, frequency of providing patient education, and responsibility for providing education. Participants demonstrated inhaler technique to the investigators using both a metered dose inhaler (MDI) and Diskus device inhaler, and performance was measured via a validated checklist.

FINDINGS

Overall misuse rates were high for both MDI and Diskus devices. There was poor correlation between perceived ability and investigator-measured performance of inhaler technique. Frequency of education during hospitalization and at discharge was related to measured level of performance for the Diskus device but not for the MDI.

CONCLUSIONS

Nurses are a key component of patient education in the hospital; however, nursing staff lack adequate knowledge of inhaler technique.

IMPLICATIONS

Identifying gaps in nursing knowledge regarding proper inhaler technique and patient education about proper inhaler technique is important to design interventions that may positively impact patient outcomes. Interventions could include one-on-one education, Web-based education, unit-based education, or hospital-wide competency-based education. All should include return demonstration of appropriate technique.

Assessment of inhaler techniques employed by patients with respiratory diseases in southern Brazil: a population-based study

OBJECTIVE:

To identify incorrect inhaler techniques employed by patients with respiratory diseases in southern Brazil and to profile the individuals who make such errors.

METHODS:

This was a population-based, cross-sectional study involving subjects ≥ 10 years of age using metered dose inhalers (MDIs) or dry powder inhalers (DPIs) in 1,722 households in the city of Pelotas, Brazil.

RESULTS:

We included 110 subjects, who collectively used 94 MDIs and 49 DPIs. The most common errors in the use of MDIs and DPIs were not exhaling prior to inhalation (66% and 47%, respectively), not performing a breath-hold after inhalation (29% and 25%), and not shaking the MDI prior to use (21%). Individuals ≥ 60 years of age more often made such errors. Among the demonstrations of the use of MDIs and DPIs, at least one error was made in 72% and 51%, respectively. Overall, there were errors made in all steps in 11% of the demonstrations, whereas there were no errors made in 13%.Among the individuals who made at least one error, the proportion of those with a low level of education was significantly greater than was that of those with a higher level of education, for MDIs (85% vs. 60%; p = 0.018) and for DPIs (81% vs. 35%; p = 0.010).

CONCLUSIONS:

In this sample, the most common errors in the use of inhalers were not exhaling prior to inhalation, not performing a breath-hold after inhalation, and not shaking the MDI prior to use. Special attention should be given to education regarding inhaler techniques for patients of lower socioeconomic status and with less formal education, as well as for those of advanced age, because those populations are at a greater risk of committing errors in their use of inhalers.

A systematic review of patient medication error on self-administering medication at home

INTRODUCTION

Medication errors have been analyzed as a health professionals' responsibility (due to mistakes in prescription, preparation or dispensing). However, sometimes, patients themselves (or their caregivers) make mistakes in the administration of the medication. The epidemiology of patient medication errors (PEs) has been scarcely reviewed in spite of its impact on people, on therapeutic effectiveness and on incremental cost for the health systems.

AREAS COVERED

This study reviews and describes the methodological approaches and results of published studies on the frequency, causes and consequences of medication errors committed by patients at home. A review of research articles published between 1990 and 2014 was carried out using MEDLINE, Web-of-Knowledge, Scopus, Tripdatabase and Index Medicus.

EXPERT OPINION

The frequency of PE was situated between 19 and 59%. The elderly and the preschooler population constituted a higher number of mistakes than others. The most common were: incorrect dosage, forgetting, mixing up medications, failing to recall indications and taking out-of-date or inappropriately stored drugs. The majority of these mistakes have no negative consequences. Health literacy, information and communication and complexity of use of dispensing devices were identified as causes of PEs. Apps and other new technologies offer several opportunities for improving drug safety.

Assessment of the factors affecting the failure to use inhaler devices before and after training

BACKGROUND

Inhaler devices used for the treatment of chronic respiratory diseases are frequently incorrectly used by the patients. The effects of training on the correct use of these devices are unquestionable. However, despite the training provided on the correct technique of using the inhaler device, some patients still continue using the device incorrectly. The aims of the present study are to determine the rate of incorrect use of the inhaler devices, assess the parameters that affect the incorrect use, demonstrate the contribution of training, and determine the characteristics of the patients who use the devices incorrectly despite training.

METHODS

342 consecutive patients were included in the study. The patients' ability to use the devices correctly was scored before and after face-to-face trainings. The parameters affecting incorrect use, the impact of training, and characteristics of the patients who continued the incorrect usage after training were evaluated.

RESULTS

The rate of correct usage was 58.9% for dry powder inhalers (DPI) and 31.1% for pressurized metered dose inhalers (pMDI) before the training. The parameters affecting correct usage were educational status, gender, living in rural areas, duration of disease, and being diagnosed and followed-up by a chest diseases specialist. The rate of correct usage increased to 92.6% for DPI and 45.2% for pMDI after the training. The factors affecting continued incorrect usage after standard training were old age and the type of the pMDI device.

CONCLUSIONS

The technique for using the inhaler device should be described to the patients in a face-to-face session by the prescribing physician. Device selection should be done on a "trial" basis and it should be considered that particularly older patients and those using pMDIs continue using the devices incorrectly despite training; hence, alternative treatment options should be reviewed for these patients.