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Banat H, Ambrus R, Csóka I. Drug combinations for inhalation: Current products and future development addressing disease control and patient compliance. Int J Pharm 2023; 643:123070. [PMID: 37230369 DOI: 10.1016/j.ijpharm.2023.123070] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/07/2023] [Accepted: 05/21/2023] [Indexed: 05/27/2023]
Abstract
Pulmonary delivery is an alternative route of administration with numerous advantages over conventional routes of administration. It provides low enzymatic exposure, fewer systemic side effects, no first-pass metabolism, and concentrated drug amounts at the site of the disease, making it an ideal route for the treatment of pulmonary diseases. Owing to the thin alveolar-capillary barrier, and large surface area that facilitates rapid absorption to the bloodstream in the lung, systemic delivery can be achieved as well. Administration of multiple drugs at one time became urgent to control chronic pulmonary diseases such as asthma and COPD, thus, development of drug combinations was proposed. Administration of medications with variable dosages from different inhalers leads to overburdening the patient and may cause low therapeutic intervention. Therefore, products that contain combined drugs to be delivered via a single inhaler have been developed to improve patient compliance, reduce different dose regimens, achieve higher disease control, and boost therapeutic effectiveness in some cases. This comprehensive review aimed to highlight the growth of drug combinations by inhalation over time, obstacles and challenges, and the possible progress to broaden the current options or to cover new indications in the future. Moreover, various pharmaceutical technologies in terms of formulation and device in correlation with inhaled combinations were discussed in this review. Hence, inhaled combination therapy is driven by the need to maintain and improve the quality of life for patients with chronic respiratory diseases; promoting drug combinations by inhalation to a higher level is a necessity.
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Affiliation(s)
- Heba Banat
- Institute of Pharmaceutical Technology and Regulatory Affairs, Faculty of Pharmacy, University of Szeged, Hungary
| | - Rita Ambrus
- Institute of Pharmaceutical Technology and Regulatory Affairs, Faculty of Pharmacy, University of Szeged, Hungary
| | - Ildikó Csóka
- Institute of Pharmaceutical Technology and Regulatory Affairs, Faculty of Pharmacy, University of Szeged, Hungary.
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Bosnic-Anticevich S, Bender BG, Shuler MT, Hess M, Kocks JWH. Recognizing and Tackling Inhaler Technique Decay in Asthma and Chronic Obstructive Pulmonary Disesase (COPD) Clinical Practice. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:2355-2364.e5. [PMID: 37146881 DOI: 10.1016/j.jaip.2023.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 02/22/2023] [Accepted: 04/11/2023] [Indexed: 05/07/2023]
Abstract
A poor inhaler technique continues to represent a substantial barrier to effective asthma and chronic obstructive pulmonary disease management. It can result in perceived lack of treatment effectiveness even with apparent adherence to a prescribed regimen of inhaled maintenance therapies, potentially resulting in an unnecessary change or escalation of treatment. Many patients are not trained to inhaler mastery in real-world practice; furthermore, even where mastery is initially achieved, an ongoing assessment and education are seldom maintained. In this review, we present an overview of the evidence for deterioration of the inhaler technique over time after training, investigate the factors that contribute to this deterioration, and explore innovative approaches to addressing the problem. We also propose steps forward drawn from the literature and our clinical insights.
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Affiliation(s)
| | - Bruce G Bender
- Department of Pediatrics, National Jewish Health, Denver, Colo
| | - Melinda T Shuler
- Quality Mangement, Eastern Band of Cherokee Indian, Tribal Option, Cherokee, NC
| | - Mike Hess
- Patient Outreach and Education, COPD Foundation, Miami, Fla
| | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, the Netherlands; Observational and Pragmatic Research Institute, Singapore; Groningen Research Institute Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; Department of Pulmonology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Vázquez-González N, Barnestein-Fonseca P. Instruction on inhalation technique: What are we doing with our COPD patients? Rev Clin Esp 2022; 222:599-601. [PMID: 35738994 DOI: 10.1016/j.rceng.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/16/2022] [Indexed: 12/14/2022]
Affiliation(s)
- N Vázquez-González
- Departamento de Farmacología y Pediatría, Facultad de Medicina, Universidad de Málaga (UMA), Málaga, Spain; Unidad Docente Multiprofesional de Atención Familiar y Comunitaria, Distrito Sanitario Málaga-Guadalhorce (SAS), Málaga, Spain.
| | - P Barnestein-Fonseca
- Unidad Docente Multiprofesional de Atención Familiar y Comunitaria, Distrito Sanitario Málaga-Guadalhorce (SAS), Málaga, Spain; Fundación CUDECA, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA) Grupo C08, Málaga, Spain
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Imamoglu D, Yilmaz Z, Koruk I. Comparison of the knowledge and skill levels of pharmacists and pharmacy technicians on the implementation of inhaler drug-delivery devices: a cross-sectional study in Şanlıurfa, Turkey. DRUGS & THERAPY PERSPECTIVES 2022. [DOI: 10.1007/s40267-022-00933-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Exploring General Practitioners' Preferences and Experience with Respiratory Inhaler Devices. Pulm Ther 2022; 8:283-296. [PMID: 35908142 PMCID: PMC9458836 DOI: 10.1007/s41030-022-00197-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/18/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Correct inhaler technique is essential for the optimal delivery of inhaled medicines and the successfully management of respiratory conditions. The general practitioner (GP), the prescriber of inhaled medicines, plays a crucial role in educating patients on inhaler technique. However, in the real-world setting, there are barriers. For the GP, it is time and competence and for the patient, it is their ability to recognise inhaler technique as an issue and their ability to maintain correct inhaler technique over time. This study aimed to determine GPs’ experience, skills and priority placed on inhaler technique and to identify factor(s) associated with inhaler technique competence. Methods This cross-sectional observational study design surveyed GPs’ perspectives on inhaler use and preferences for inhaler prescribing within their practice setting. GP inhaler technique was assessed. GPs were recruited through an established network of GP practices. Data collected include (i) practice demographics, (ii) inhaler technique opinions and experience, (iii) inhaler prescribing preferences and (iv) inhaler education history data. Data were analysed descriptively and multivariate logistic regression modelling was used to explore the relationship between outcomes and GPs’ ability to use devices correctly. Results A total of 227 GPs completed the inhaler survey. Sixty-three percent of GPs reported receiving previous inhaler education and 73.3% educated or checked their patients’ inhaler technique; 64.5% felt they were somewhat competent in doing so. GPs who reported not demonstrating inhaler technique believed that a pharmacist or a practice nurse would do so. When prescribing new inhaler devices, GPs considered the disease being treated first and then patient’s experience with inhalers; they often already have an inhaler preference and this was related to familiarity and perceived ease of use. For GPs, inhaler competence was not associated with their previous inhaler education or the priority placed on inhaler technique. Conclusion GPs do recognise the importance of inhaler technique in respiratory management but their technique can be better supported with regular educational updates to inform them about new inhalers and management practices and to support appropriate inhaler choices for their patients. Supplementary Information The online version contains supplementary material available at 10.1007/s41030-022-00197-6.
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Basheti I, Salameh L, Mahboub B, Sakarneh MA, Saddik B, Al-Ani M, Al-Hajjaj M, Abu-Gharbieh E. A specialized training program on inhaler technique delivered by pharmacists to nurses: a study from the United Arab Emirates. Pharm Pract (Granada) 2022; 20:2726. [PMID: 36733507 PMCID: PMC9851819 DOI: 10.18549/pharmpract.2022.3.2726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/27/2022] [Indexed: 02/05/2023] Open
Abstract
Background Inhaled drug delivery has been hailed as a major advancement in respiratory therapeutics. However, a major limitation to use the inhaled medications effectively is the inability of patients and nurses to use and demonstrate the proper use of these devices correctly. Being the drug experts, pharmacists are in a pivotal position to delivered tailored education to their peers, the nurses. Aim This study aims to examine nurses' knowledge of asthma management, their ability to demonstrate proper inhaler technique, and the impact of a specialized workshop training program delivered by skilled pharmacists on improving their performance. Methods This is a pre- and post-cross-sectional study design in hospital setting where nurses were recruited from the respiratory and emergency departments within a healthcare facility in the United Arab Emirates (UAE). The nurses attended a training workshop prepared and delivered by skilled pharmacists on inhaler technique demonstration skills. Nurses' inhaler technique demonstration skills for Diskus, Turbuhaler, and pMDI were assessed at baseline, immediately after the workshop, and after four weeks. The nurses completed the demographic and Asthma Knowledge Questionnaire (AKQ). Results A random convenience sample of registered nurses (n=20) from the respiratory and emergency departments was recruited from a tertiary hospital in Sharjah, UAE, with a mean age of 35.25 (SD=6.96) years, of whom 90% were females. The mean number of years of experience was 12.00 years (SD=5.81). Inhaler technique assessment revealed low inhaler technique scores for all the three study inhalers at baseline (mean score for Diskus=3.85 (SD=2.87); Turbuhaler=3.70 (SD=3.20); pMDI=4.50 (SD=2.65)) Significant improvements in inhaler technique scores were noted after the workshop (Diskus=8.9 (SD=0.31); Turbuhaler=8.9 (SD=0.31); pMDI=8.0 (SD=0.00), P<0.001). A significant difference in AKQ scores was found before (mean=4.85 (SD=1.27)) and after (mean=7.50 (SD=0.95)) the workshop training session (P<0.001), and four weeks after the workshop training session (mean=7.55 (SD=0.76), P<0.001). Conclusion The UAE nurses' inhaler technique and AKQ scores were suboptimal at baseline. The specialized training program prepared and delivered by the skilled pharmacists improved nurses' inhaler technique demonstration skills and AKQ scores. Such improvements would reflect positively on patients' asthma management outcomes as nurses are the health care professionals who interact the most with the patients during hospitalization.
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Affiliation(s)
- Iman Basheti
- Department of Clinical Pharmacy and Therapeutics, Faculty of Pharmacy, Applied Science Private University, P.O. Box 166, Amman 11931, Jordan.
| | - Laila Salameh
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah 27272, Rashid Hospital, Dubai Health Authority, Dubai 4545, United Arab Emirates.
| | - Bassam Mahboub
- Rashid Hospital, Dubai Health Authority, Dubai 4545, United Arab Emirates.
| | - Mohammad Abed Sakarneh
- Department of Special Education, Princess Rahama University College, Al-Balqa Applied University, Al Salt 19117, Jordan.
| | - Basema Saddik
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah 27272, Department of Family and Community Medicine and Behavioral Sciences, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates.
| | - Mena Al-Ani
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah 27272, United Arab Emirates, UCL Great Ormond Street Institute of Child Health, Developmental Biology and Cancer Department, London WC1N 1EH, United Kingdom.
| | - Mohamed Al-Hajjaj
- Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah 27272, University Hospital Sharjah, Sharjah, Sharjah 72772, United Arab Emirates.
| | - Eman Abu-Gharbieh
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah 27272, Department of Clinical Sciences, College of Medicine, University of Sharjah, Sharjah 27272, United Arab Emirates.
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Instrucción sobre la técnica de inhalación: ¿Qué estamos haciendo con nuestros pacientes EPOC? Rev Clin Esp 2022. [DOI: 10.1016/j.rce.2022.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Swart M, Laher AE. Secondary asthma prevention measures are not adequately addressed prior to emergency department discharge! Am J Emerg Med 2022; 53:196-200. [DOI: 10.1016/j.ajem.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/02/2022] [Accepted: 01/09/2022] [Indexed: 11/25/2022] Open
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Thebault JL, Pecqueur R, Teixeira AP. [Assessment of general practitioners' knowledge of inhalers]. Rev Mal Respir 2021; 38:873-881. [PMID: 34462151 DOI: 10.1016/j.rmr.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 07/02/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Inhaled drug delivery is the cornerstone treatment for asthma. General practitioners (GPs) have a key role for educating patient about how to use their inhalers. The purpose of this study was to find out whether GPs know how to use the inhalers they usually prescribe. METHOD This was a descriptive and analytical cross-sectional study among GPs from the Paris metropolitan area. GPs had to choose the inhalers they usually prescribe and then demonstrate their use. The technique of use was assessed using a scale specific to each type of inhaler. Overall success was defined by the use of prescribed inhalers without critical errors. RESULTS Thirty-seven GPs were recruited between July 2018 and July 2019. Nineteen GPs (51.4%) were able to use the inhalers they prescribed without critical errors. The success rate without critical error was better with the pressurized metered dose inhalers with spacer than with other inhalers. The overall success rate was better among GPs who had previously used an inhaler on a personal basis (OR 7.58 95%CI [1.86, 37.02]) or who had prescribed only one type of inhaler (OR 4,8 95%CI [1.21, 22.41]). CONCLUSION Half of the GPs in our study did not know how to use the inhalers they prescribe and therefore may have difficulty educating their patients.
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Affiliation(s)
- J-L Thebault
- Département de médecine générale, faculté de Santé, UFR de médecine Paris Centre, université de Paris, 24 rue du faubourg Saint-Jacques, 75014 Paris, France.
| | - R Pecqueur
- Département de médecine générale, faculté de Santé, UFR de médecine Paris Centre, université de Paris, 24 rue du faubourg Saint-Jacques, 75014 Paris, France
| | - A P Teixeira
- Service de pneumologie, allergologie, oncologie thoracique, Groupe Hospitalier Saint-Joseph, 75014 Paris, France
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Abdelrahman MA, Saeed H, Osama H, Harb HS, Madney YM, Abdelrahim MEA. Effect of verbal counselling on metred-dose inhaler proper use and lung function test amongst asthmatic patients: A meta-analysis. Int J Clin Pract 2021; 75:e14077. [PMID: 33550651 DOI: 10.1111/ijcp.14077] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 02/03/2021] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION The main cause of poor asthma control is mostly related to the inability of the asthmatic subjects to use their metred-dose inhaler (pMDI) correctly. The present study aimed to evaluate the role of contentious pMDI verbal-counselling on the pMDI inhalation technique and pulmonary functions of asthmatics. METHODS Through a systematic literature search up to December 2020, 10 studies with 1937 asthmatic subjects, who had at least two pMDI inhalation technique verbal counselling sessions (visits), were identified reporting relationships between contentious pMDI verbal counselling, and the number of inhalation technique mistakes and lung functions score. Mean difference (MD) with 95% confidence intervals (CIs) was calculated comparing counselling visits results using the continuous method with a random effect model. RESULTS Visit 1 had a significantly higher mean number of mistakes compared with visit 2 (MD, 19.98; 95% CI, 11.54-28.41, P < .001); Also, visit 2 had a significantly higher mean number of mistakes compared with visit 3 (MD, 12.17; 95% CI, 9.31-15.02, P < .001). The extent of improvement in the inhalation technique was higher between visits 1 and 2 compared with that between visits 2 and 3. The impact of continuous verbal counselling was also observed on the forced expiratory volume in one second as percentage of vital capacity [(MD, -5.56; 95% CI, -6.50 to -4.61, P < .001) between visits 1 and 2 and (MD, -6.40; 95% CI, -7.71 to -5.10, P < .001) between visits 2 and 3] and the peak expiratory flow rate [(MD, -11.47; 95% CI, -18.73 to -4.22, P < .001) between visits 1 and 2 and (MD, -16.53; 95% CI, -25.80 to -7.26, P < .001) between visits 2 and 3]. The extent of improvement in lung functions was similar between visits 1 and 2 and visits 2 and 3. CONCLUSION Based on this meta-analysis, Continuous pMDI verbal counselling, at every possible opportunity, is a must since lung functions and pMDI inhalation technique improvements were observed with continuous pMDI verbal counselling.
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Affiliation(s)
- Mona A Abdelrahman
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Haitham Saeed
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Hasnaa Osama
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Hadeer S Harb
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Yasmin M Madney
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
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Cvetkovski B, Hespe C, Tan R, Kritikos V, Azzi E, Bosnic-Anticevich S. General Practitioner Use of Generically Substitutable Inhaler Devices and the Impact of Training on Device Mastery and Maintenance of Correct Inhaler Technique. Pulm Ther 2020; 6:315-331. [PMID: 33038005 PMCID: PMC7672138 DOI: 10.1007/s41030-020-00131-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Generic substitution of inhaler devices is a relatively new phenomenon. The best patient outcomes associated with generic substitution occur when prescribers obtain consent from their patients to prescribe a generic inhaler and also teach their patient how to correctly use the new device. To date, no prospective observational study has assessed the level of training required for general practitioners (GPs) to demonstrate correct inhaler technique using two dry powder inhaler devices delivering fixed-dose combination budesonide/formoterol therapy. This study aims to (1) determine the level of training required for GPs to master and maintain correct IT when using two different dry powder inhalers that are able to be substituted in clinical practice and (2) determine the number and types of errors made by GPs on each device and inhaler device preference at each training visit. METHOD A randomized, parallel-group cross-over study design was used to compare the inhaler technique of participants with a Spiromax® placebo device and a Turbuhaler® placebo device. This study consisted of two visits with each participant over a period of 4 ± 1 weeks (visit 1 and visit 2). A total of six levels of assessment and five levels of training were implemented as required. Level 1, no instruction; level 2, following use of written instruction; level 3, following viewing of instructional video; level 4, expert tuition from the researcher; level 5/level 6, repeats of expert tuition from the researcher when required. Participants progressed through each level and stopped at the point at which they demonstrated device mastery. At each level, trained researchers assessed the inhaler technique of the participants. Participants were also surveyed about their previous inhaler use and training. RESULTS In total, 228 GPs participated in this study by demonstrating their ability to use a Turbuhaler® and a Spiromax® device. There was no significant difference between the proportion of participants who demonstrated device mastery with the Turbuhaler® compared with the Spiromax® at level 1, (no instruction), (119/228 (52%) versus 131/228 (57%), respectively, n = 228, p = 0.323 (McNemar's test of paired data). All but one participant had demonstrated correct inhaler technique for both devices by level 3(instructional video). There was a significant difference between the proportion of participants who demonstrated maintenance of device mastery with the Turbuhaler® compared with the Spiromax® at visit 2, level 1 (127/177 (72%) versus 151/177 (85%) respectively, p = 0.003; McNemar's test of paired data). All but two participants achieved device mastery by level 3, visit 2. More participants reported previous training with the Turbuhaler® than with Spiromax®. DISCUSSION This study demonstrates that GPs are able to equally demonstrate correct use of the Turbuhaler® and Spiromax® devices, even though most had not received training on a Spiromax® device prior to this study. The significance of being able to demonstrate correct technique on these two devices equally has ramifications on practice and supported generic substitution of inhaler devices at the point of prescribing, as the most impactful measure a GP can take to ensure effective use of inhaled medicine is the correct demonstration of inhaler technique.
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Affiliation(s)
- Biljana Cvetkovski
- Quality Use of Respiratory Medicine Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.
| | - Charlotte Hespe
- School of Medicine, The University of Notre Dame Australia, Sydney, Australia
| | - Rachel Tan
- Quality Use of Respiratory Medicine Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Vicky Kritikos
- Quality Use of Respiratory Medicine Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Elizabeth Azzi
- Quality Use of Respiratory Medicine Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Sinthia Bosnic-Anticevich
- Quality Use of Respiratory Medicine Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- Sydney Local Health District, Sydney, Australia
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Choosing the right inhaler for the right patient: Considerations for effective management of patients with chronic obstructive pulmonary disease or asthma. J Am Assoc Nurse Pract 2020; 32:89-99. [PMID: 31895754 DOI: 10.1097/jxx.0000000000000366] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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).
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Perumal R, Leite M, van Zyl-Smit RN. The Relationship Between Clinical Trial Participation and Inhaler Technique Errors in Asthma and COPD Patients. Int J Chron Obstruct Pulmon Dis 2020; 15:1217-1224. [PMID: 32581528 PMCID: PMC7277230 DOI: 10.2147/copd.s249620] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Incorrect inhaler use is associated with poorer health outcomes, reduced quality of life, and higher healthcare utilisation in patients with asthma and COPD. Methods We performed an observational study of pressurized metered-dose inhaler technique in patients with asthma or COPD. Patients were assessed using a six-point inhaler checklist to identify common critical inhaler technique errors. An inadequate inhaler technique was defined as the presence of one or more critical errors. A multivariate logistic regression model was used to determine the odds of an inadequate inhaler technique. Results During the 14-month study period, 357 patients were enrolled. At least one critical error was executed by 66.7% of participants, and 24.9% made four or more critical errors. The most common errors were failure to exhale completely prior to pMDI activation and inhalation (49.6%), failure to perform a slow, deep inhalation following device activation (48.7%), and failure to perform a breath-hold at the end of inspiration (47.3%). The risk of a critical error was higher in COPD patients (aOR 2.25, 95% CI 1.13–4.47). Prior training reduced error risk specifically when trained by a doctor (aOR 0.08, 95% CI 0.1–0.57) or a pharmacist (aOR 0.02, 95% CI 0.01–0.26) compared to those with no training. Previous clinical trial participation significantly reduced error risk and rate: <3 trials (aOR 0.35, 95% CI 0.19–0.66) and ≥3 trials (aOR 0.17, 95% CI 0.07–0.42). The rate of critical errors was not significantly associated with age, sex, or prior pMDI experience. Conclusion This study found a high rate of critical inhaler technique errors in a mixed population of asthma and COPD patients; however, prior training and, in particular, multiple previous clinical trial participation significantly reduced the risk of errors.
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Affiliation(s)
- Rubeshan Perumal
- Division of Pulmonology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Western Cape, South Africa
| | - Marcia Leite
- UCT Lung Institute, University of Cape Town, Western Cape, South Africa
| | - Richard Nellis van Zyl-Smit
- Division of Pulmonology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Western Cape, South Africa.,UCT Lung Institute, University of Cape Town, Western Cape, South Africa
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Kellman DA, Iserson KV, Levy RD, McIntosh B, Maxwell Y. Brief Education Improves Proper Metered-Dose Inhaler Use. J Emerg Med 2020; 58:667-672. [PMID: 32245688 DOI: 10.1016/j.jemermed.2020.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/28/2019] [Accepted: 02/15/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Inhaled β-agonists are the cornerstone of acute treatment for asthma and chronic lung disease. Upon emergency department (ED) discharge, patients optimally receive prescriptions for metered-dose inhalers (MDIs) with instructions on their proper use. Yet prior studies suggest that ED personnel have limited knowledge of proper MDI techniques. It is unclear how effectively brief education will improve this knowledge to enable them to provide adequate patient instructions. OBJECTIVE Our aim was to evaluate ED medical personnel's baseline knowledge of MDI use and the utility of brief education on their ability to use MDIs. METHODS After providing written consent, a spirometry nurse evaluated emergency physicians and nurses on their ability to properly perform three (open-mouth/two-finger, spacer, and closed-mouth) MDI techniques. The same spirometry nurse then gave a short educational session demonstrating the proper MDI techniques. Two weeks later, the nurse re-evaluated the same personnel on their MDI techniques. RESULTS All emergency medical personnel initially performed poorly in demonstrating proper MDI technique, averaging 29.8% steps done correctly. Two weeks after their educational session, they improved greatly, averaging 89.4% steps done correctly. CONCLUSIONS This study demonstrated both that ED personnel had poor initial knowledge about MDI techniques and that a brief educational intervention improved most people's ability to use, and presumably to instruct patients/parents in proper use of, MDIs.
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Affiliation(s)
- Dwayne A Kellman
- Department of Emergency Medicine, Georgetown Public Hospital, Georgetown, Guyana
| | - Kenneth V Iserson
- Department of Emergency Medicine, Georgetown Public Hospital, Georgetown, Guyana; Department of Emergency Medicine, The University of Arizona, Tucson, Arizona
| | - Robert D Levy
- Pulmonary Hypertension Program, Vancouver Hospital and Health Sciences Centre, Vancouver, British Columbia, Canada
| | - Belinda McIntosh
- Spirometry Clinic, Georgetown Public Hospital, Georgetown, Guyana
| | - Yusiny Maxwell
- Spirometry Clinic, Georgetown Public Hospital, Georgetown, Guyana
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Al-Otaibi HM. Evaluation of health-care providers' knowledge in the science of aerosol drug delivery: Educational sessions are necessary. J Family Community Med 2020; 27:62-66. [PMID: 32030080 PMCID: PMC6984029 DOI: 10.4103/jfcm.jfcm_138_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 09/25/2019] [Accepted: 10/08/2019] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND: Aerosolized drugs are widely used to treat and control a variety of pulmonary diseases. However, there is increasing evidence that patients are unable to use their drug delivery device correctly. The failure of aerosolized treatment is usually the result of poorly communicated instructions. The aim of this investigation was to evaluate the knowledge of health-care providers in the science of aerosol drug delivery (ADD) and assess the impact of further education on their knowledge. MATERIALS AND METHODS: One hundred and seventeen health-care providers attended a 4-hour educational course on ADD science. The course was conducted from June to August 2018 in Jeddah, Riyadh, and Dammam. Pre-course assessment done with a 12-item multiple-choice questionnaire. Post-course assessment was conducted after the end of course in which participants were asked to rate their knowledge of ADD on a scale of 1–10 (before and after the course). RESULTS: Sixty-six health-care providers (physicians, pharmacists, respiratory therapists, and health educators) completed the course. The participants' clinical experience, on average (±standard deviation), was 7.6 ± 7.3 years. Clinical experience favored physicians over other groups. The precourse score for all participants was 3.2 ± 1.9 out of 12 and the postcourse score was 6.97 ± 2.7. There was a significant statistical difference between pre- and postcourse assessment scores (P < 0.05). Differences between the four specialties were insignificant (P = 0.216), without a correlation between clinical experience and preassessment scores (P = 0.202). CONCLUSION: The present data indicate that health-care providers' knowledge of ADD is completely inadequate. There is an urgent need to introduce an ADD educational package in the curricula. An annual competency-based evaluation for health-care providers is critical as well.
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Affiliation(s)
- Hajed M Al-Otaibi
- Department of Respiratory Therapy, Faculty of Medical Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
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16
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Amin S, Soliman M, McIvor A, Cave A, Cabrera C. Understanding Patient Perspectives on Medication Adherence in Asthma: A Targeted Review of Qualitative Studies. Patient Prefer Adherence 2020; 14:541-551. [PMID: 32210541 PMCID: PMC7071882 DOI: 10.2147/ppa.s234651] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 01/30/2020] [Indexed: 01/11/2023] Open
Abstract
Adherence to asthma medications is generally poor and undermines clinical outcomes. Poor adherence is characterized by underuse of inhaled corticosteroids (ICS), often accompanied by over-reliance on short-acting β2-agonists for symptom relief. To identify drivers of poor medication adherence, a targeted literature search was performed in MEDLINE and EMBASE for articles presenting qualitative data evaluating medication adherence in asthma patients (≥12 years old), published from January 1, 2012 to February 26, 2018. A thematic analysis of 21 relevant articles revealed several key themes driving poor medication adherence, including asthma-specific drivers and more general drivers common to chronic diseases. Due to the episodic nature of asthma, many patients felt that their daily life was not substantially impacted; consequently, many harbored doubts about the accuracy of their diagnosis or were in denial about the impact of the disease and, in turn, the need for long-term treatment. This was further compounded by poor patient-physician communication, which contributed to suboptimal knowledge about asthma medications, including lack of understanding of the distinction between maintenance and reliever inhalers, suboptimal inhaler technique, and concerns about ICS side effects. Other drivers of poor medication adherence included the high cost of asthma medication, general forgetfulness, and embarrassment over inhaler use in public. Overall, patients' perceived lack of need for asthma medications and medication concerns, in part due to suboptimal knowledge and poor patient-physician communication, emerged as key drivers of poor medication adherence. Optimal asthma care and management should therefore target these barriers through effective patient- and physician-centered strategies.
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Affiliation(s)
- Suvina Amin
- US Oncology Medical Affairs, AstraZeneca, Gaithersburg, MD, USA
- Correspondence: Suvina Amin AstraZeneca, One Medimmune Way, Gaithersburg, MD20878, USATel +1 800 565 5877 Email
| | - Mena Soliman
- BioPharmaceuticals Medical (Europe and Canada), AstraZeneca, Mississauga, ON, Canada
| | - Andrew McIvor
- Department of Medicine, Firestone Institute for Respiratory Health, St. Joseph’s Healthcare and McMaster University, Hamilton, ON, Canada
| | - Andrew Cave
- Department of Family Medicine, University of Alberta, Edmonton, AL, Canada
| | - Claudia Cabrera
- BioPharmaceuticals Medical (Evidence), AstraZeneca, Gothenburg, Sweden
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Evaluation of the knowledge and correct use of metered-dose inhalers by healthcare professionals and medical students in Gauteng Province. Afr J Thorac Crit Care Med 2019; 25. [PMID: 34286261 PMCID: PMC8278855 DOI: 10.7196/ajtccm.2019.v25i3.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2019] [Indexed: 11/08/2022] Open
Abstract
Background
The Global Initiative for Asthma (GINA) estimates that South Africa (SA) has over 3.9 million asthma sufferers, of whom 1.5%
die of the condition annually. SA has the world’s fourth highest asthma death rate among 5 - 35-year-olds. Chronic obstructive pulmonary
disease (COPD) will be the third leading cause of death globally by 2030, and will surpass HIV/AIDS in Africa. Uncontrolled asthma and
COPD are frequent causes of emergency department visits and hospital admissions. Poor metered-dose inhaler (MDI) technique is probably
a major contributory cause. It is the responsibility of all treating doctors and healthcare professionals to educate patients on inhaled therapy
with the correct MDI technique, as well as to routinely check and repeatedly demonstrate the technique to them.
Objectives
This study evaluated study participants’ knowledge of MDI technique, and their compliance in checking and demonstrating
MDI use to patients prescribed inhaled therapy. The study participants included doctors, nurses and final-year medical students at Helen
Joseph Hospital and Chris Hani Baragwanath Academic Hospital, in the Departments of Internal Medicine and Emergency Medicine, and
the Division of Pulmonology.
Methods
A total of 195 study participants volunteered to take part in the study. A questionnaire was administered to participants to gauge
their perceptions, level of knowledge and understanding of MDI technique. They were then requested to demonstrate correct inhaler
technique via a placebo MDI. Participants’ use of a placebo MDI was evaluated by a scoring system.
Results
The total sample of 195 comprised 130 (67%) female and 65 (33%) male participants. Of these, 133 (68%) were qualified medical
staff, and 62 were final-year medical students. Only 32 (16%) could demonstrate correct MDI technique. Over 50% of participants did not
demonstrate MDI technique to patients, or check their patients’ technique at every hospital-related visit.
Conclusion
Healthcare professionals and final-year medical students have poor knowledge of inhaler technique and are ill-prepared to teach
patients. Also of concern is that the majority do not routinely demonstrate or observe patients’ inhaler technique.
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Munteanu LA, Fildan AP, Tudorache E, Fira-Mladinescu O, Frandes M, Timar B, Oancea C, Tofolean DE. Inhaler technique errors in Romanian patients with asthma - a multicenter study. Patient Prefer Adherence 2019; 13:1401-1414. [PMID: 31695337 PMCID: PMC6707372 DOI: 10.2147/ppa.s209717] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/07/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Non-adherence to treatment is associated with poor asthma control, increased exacerbations, decline in lung function, and decreased quality of life. M-health applications have become increasingly in the last years, but little research regarding the efficiency of the instructional videos for correct inhaler use exist. The aim of this study is to assess and improve the inhalator technique and to establish which types of errors were made more often with the help of a mobile health application. MATERIALS AND METHODS Seventy-five patients with partially controlled or uncontrolled asthma, using any of turbuhaler, diskus, pressurized metered dose inhaler (pMDI) or soft mist inhaler (SMI), were included in the study. When they first entered the study, the patient's inhaler technique was assessed by a trained medical professional and the technique errors were categorized in handling, respectively inhalation errors. After the first evaluation, the patients downloaded an application on their Smartphone and were encouraged to use the application as much as needed to remind them the correct inhalation technique. The patients were re-called every three months for evaluation, treatment, and assessment of inhalation technique. RESULTS We analyzed both handling and inhalation errors for each of the four considered inhalers. We observed a significantly reduced number of inhalation technique errors after using the mobile phone application. Turbuhaler median errors were 6.00, and after six months we did not observe errors. Diskus median error was 6.00, and after six months we observed a maximum of one error. pMDI median errors were 7.00, and after six months we observed just one error. Similarly, SMI median error was 7.00, and after six months we observed just one error. CONCLUSION Although technique inhalation errors are very common among asthma patients, video instructions provided through specific mobile phone applications could improve the inhaler technique in order to achieve a better control of the disease.
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Affiliation(s)
- Laura Adela Munteanu
- Department of Pulmonology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Ariadna Petronela Fildan
- Faculty of Medicine, Internal Medicine Discipline, Medical Clinical Disciplines I, “Ovidius” University of Constanta, Constanta, Romania
| | - Emanuela Tudorache
- Department of Pulmonology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Ovidiu Fira-Mladinescu
- Department of Pulmonology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Mirela Frandes
- Department of Biostatistics and Medical Informatics, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Bogdan Timar
- Department of Biostatistics and Medical Informatics, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Cristian Oancea
- Department of Pulmonology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, Romania
| | - Doina Ecaterina Tofolean
- Faculty of Medicine, Internal Medicine Discipline, Medical Clinical Disciplines I, “Ovidius” University of Constanta, Constanta, Romania
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Kerwin EM, Preece A, Brintziki D, Collison KA, Sharma R. ELLIPTA Dry Powder Versus Metered-Dose Inhalers in an Optimized Clinical Trial Setting. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1843-1849. [PMID: 30836228 DOI: 10.1016/j.jaip.2019.02.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Reduced error rates have been demonstrated with the ELLIPTA inhaler versus other commonly used devices. OBJECTIVE This phase IV, randomized, crossover study evaluated correct use of ELLIPTA compared with 2 commonly prescribed metered-dose inhalers (MDIs) in adults with asthma and optimized inhaler technique. METHODS The study comprised 2 crossover substudies (ELLIPTA vs MDI-1 and ELLIPTA vs MDI-2). Inhaler use was assessed at the start of each period, following instruction from a health care professional, and after 28 days of use without instruction. Data for each inhaler were pooled within substudies, irrespective of treatment sequence; study objectives were addressed in each substudy. The primary end point, percentage of participants making 0 errors after 28 days of use, was analyzed separately for each substudy using a Mainland-Gart test for each ELLIPTA versus MDI comparison. RESULTS Correct use rates after 28 days were higher with ELLIPTA than with MDI-1 and MDI-2 (ELLIPTA vs MDI-1, 96% vs 84%; ELLIPTA vs MDI-2, 98% vs 91%). Among discordant cases, statistically significantly more participants correctly used ELLIPTA but made 1 or more overall error with MDIs than did those who correctly used the MDIs but made 1 or more overall error using ELLIPTA (87% vs 13% in both substudies; P < .001 and P = .007 for ELLIPTA vs MDI-1 and ELLIPTA vs MDI-2, respectively). More participants made multiple device errors with MDIs than with ELLIPTA. CONCLUSIONS Inhaler technique can be optimized in trial settings. In such settings, ELLIPTA is associated with higher rates of correct use and lower error rates than are MDIs.
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Affiliation(s)
- Edward M Kerwin
- Clinical Research Institute of Southern Oregon, Medford, Ore.
| | - Andrew Preece
- Respiratory Therapy Area Unit, GlaxoSmithKline plc., Stockley Park West, Uxbridge, Middlesex, United Kingdom
| | - Dimitra Brintziki
- Respiratory Clinical Statistics, GlaxoSmithKline plc., Stockley Park West, Uxbridge, Middlesex, United Kingdom
| | | | - Raj Sharma
- Respiratory Medical Franchise, GlaxoSmithKline plc., Brentford, Middlesex, United Kingdom
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Adeniyi BO, Adebayo AM, Ilesanmi OS, Obaseki DO, Akinwalere OO, Erhabor GE. Knowledge of spacer device, peak flow meter and inhaler technique (MDIs) among health care providers: an evaluation of doctors and nurses. Ghana Med J 2018; 52:15-21. [PMID: 30013256 DOI: 10.4314/gmj.v52i1.4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Background Metered dose inhalers are cornerstone in effective management of bronchial asthma when correctly used. Most studies hitherto have focused on assessing patient's knowledge of inhaler technique. We sought to assess the knowledge of inhaler technique, spacer device and peak flow meter among doctors and nurses in a tertiary healthcare institution in Nigeria. Method A cross sectional survey of nurses and doctors from emergency department, family and internal medicine; who were attending a continuous professional development lecture, was carried out. From a total of 100 questionnaires administered, we retrieved 87 of which 75 were completed, giving a response rate of 75%. It was a self-administered questionnaire. Data was analysed with SPSS version 21.0. Descriptive statistics were done. Association was examined using chi-square test. Result Mean age of respondent was 35.8 years ± 8.7, 47(62.7%) were < 40 years, 33(44%) were male, nurses were 30(40.0%). Only 28(37.3%) had ever used a peak flow meter. Only 4(14.3%) used peak flow meter frequently, while 12(26.7%) checked patient's inhaler technique often. Only 9 out of the 75 (12%) participants all of who are doctors knew at least 3 essential steps of the techniques in using the metered dose inhaler correctly. None of the participants got all the steps for the use of pMDI totally correct. Conclusion Knowledge regarding the use of the metered dose inhaler and spacer device was poor. Health practitioners should have constant reminders in the form of continuous medical education to update their knowledge regarding correct inhaler technique. Funding self-funded.
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Affiliation(s)
- Bamidele O Adeniyi
- Department of Medicine, Respiratory Unit, Federal Medical Centre, Owo, Ondo State, Nigeria
| | - Ayodeji M Adebayo
- Department of Community Medicine, University of Ibadan, Oyo State, Nigeria
| | - Olayinka S Ilesanmi
- Department of Community Health, Federal Medical Centre, Owo, Ondo State, Nigeria
| | - Daniel O Obaseki
- Department of Medicine, Respiratory Unit, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
| | - Olubukola O Akinwalere
- Department of Medicine, Respiratory Unit, Federal Medical Centre, Owo, Ondo State, Nigeria
| | - Gregory E Erhabor
- Department of Medicine, Respiratory Unit, Obafemi Awolowo University, Ile-Ife, Osun State, Nigeria
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Adib-Hajbaghery M, Karimi Z. Comparing the Effects of Face-to-face and Video-based Education on Inhaler Use: A Randomized, Two-group Pretest/posttest Study. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2018; 23:352-357. [PMID: 30186339 PMCID: PMC6111659 DOI: 10.4103/ijnmr.ijnmr_17_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background: The quality of inhaler use can significantly affect the effectiveness of inhalation medications. This study was done to compare the effects of face-to-face and video-based education methods on inhaler use. Materials and Methods: A quasi-experimental, pretest/posttest clinical trial study was conducted on 120 patients with respiratory diseases who were under treatment with metered-dose inhalers. Patients were randomly allocated into two groups to receive either face-to-face (n = 60) or video-based education (n = 60) about correct inhaler use. Inhaler use was assessed using a 15-item checklist before, 2 weeks, and 1 month after the education. Chi-square and independent sample t-test as well as repeated-measures analysis of variance were used for data analysis. Results: At baseline, the groups did not differ significantly in inhaler use as shown by the mean score (t = 0.81, p = 0.33). Repeated-measures analysis showed that the mean score of inhaler use significantly increased in both groups 2 weeks and 1 month after the intervention (F = 585.07, p < 0.001). The t-test showed that at 2 weeks and 1 month after intervention the amount of increase in the face-to-face group was significantly greater than the video-based group (t = 3.31 and 5.93, p < 0.001). Conclusions: Both face-to-face and video-based education methods significantly improve inhaler use, even though the effects of the face-to-face method are significantly greater. Nurses can use either of these two methods or both for education of patients about inhaler use.
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Affiliation(s)
- Mohsen Adib-Hajbaghery
- Trauma Nursing Research Centre, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran
| | - Zeynab Karimi
- Trauma Nursing Research Centre, Faculty of Nursing and Midwifery, Kashan University of Medical Sciences, Kashan, Iran
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A novel approach of using educational pharmaceutical pictogram for improving inhaler techniques in patients with asthma. Respir Med 2018; 143:103-108. [PMID: 30261980 DOI: 10.1016/j.rmed.2018.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 09/03/2018] [Accepted: 09/05/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Proper inhaler technique is essential to maximize the benefit of medications and improve asthma outcomes. OBJECTIVE To evaluate newly developed pictogram-incorporated medals and their utility on improving the inhaler techniques in asthmatic patients. METHODS A prospective, an open label, randomized controlled clinical study was conducted in Jordan from November 2016 to November 2017. The recruited patients were randomly allocated into two groups; control and intervention. Both groups were verbally counselled about proper use of their inhaler devices, however, pictogram medals were attached to the inhalers of patients in the intervention group only. Both groups were met at baseline and followed-up after 3 months to evaluate their inhaler techniques using standard checklists. RESULTS Of the 219 patients that were recruited and randomized in our study, 49.8% (n = 109) were allocated in the intervention group and 50.2% (n = 110) were in the control group. Both groups had comparable baseline demographics and clinical data (P > 0.05). Significant differences in the improvement of metered dose inhaler (MDI; p < 0.001) and Turbohaler (p = 0.005) techniques were observed between the two groups at the end of study. Patients who used MDI (OR = 7.06, 95% CI = 3.21-15.56, p < 0.001) and Turbohaler (OR = 5.08, 95% CI = 1.57-16.43, p = 0.007) in the intervention group were 7 and 5 times more likely to have improved inhaler techniques as compared to those in the control group respectively. CONCLUSIONS Educational pharmaceutical pictograms represent an inexpensive and feasible intervention that can positively affect the proper use of inhalers in asthmatic patients.
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Gómez-Angelats E, Sánchez C. Care Bundles after Discharging Patients with Chronic Obstructive Pulmonary Disease Exacerbation from the Emergency Department. Med Sci (Basel) 2018; 6:E63. [PMID: 30087300 PMCID: PMC6164584 DOI: 10.3390/medsci6030063] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/02/2018] [Accepted: 08/06/2018] [Indexed: 12/02/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is the second leading cause of emergency department (ED) admissions to hospital, and nearly a third of patients with acute exacerbation (AE) of COPD are re-admitted to hospital within 28 days after discharge. It has been suggested that nearly a third of COPD admissions could be avoided through the implementation of evidence-based care interventions. A COPD discharge bundle is a set of evidence-based practices, aimed at improving patient outcomes after discharge from AE COPD; body of evidence supports the usefulness of discharge care bundles after AE of COPD, although there is a lack of consensus of what interventions should be implemented. On the other hand, the implementation of those interventions also involves different challenges. Important care gaps remain regarding discharge care bundles for patients with acute exacerbation of COPD discharged from EDs There is an urgent need for investigations to guide future implementation of care bundles for those patients discharged from EDs.
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Affiliation(s)
- Elisenda Gómez-Angelats
- Emergency Department, Hospital Clínic de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain.
| | - Carolina Sánchez
- Emergencies Group: Processes and Pathologies, Institut d'Investigacions Biomèdiques August Pi i Sunyer, C/Rosselló 149, 08036 Barcelona, Spain.
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Bosnic-Anticevich SZ, Cvetkovski B, Azzi EA, Srour P, Tan R, Kritikos V. Identifying Critical Errors: Addressing Inhaler Technique in the Context of Asthma Management. Pulm Ther 2018; 4:1-12. [PMID: 32026244 PMCID: PMC6966926 DOI: 10.1007/s41030-018-0051-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Indexed: 12/24/2022] Open
Abstract
Medication use has always played a highly significant role in the overall management of asthma, with appropriate use being linked to good asthma control. However, while patients with asthma enjoy the 'luxury' of having medications delivered directly to the lungs via inhaler devices, with that comes the additional challenge of ensuring that inhaler devices are used correctly. Research and practice provides evidence to the challenges associated with inhaler use and the particular steps that patients perform incorrectly. While this problem is well documented, acknowledged and reported, little has changed in 40 years, and the proportion of patients using inhaler devices remains unacceptably high. This review focuses on aspects specific to the errors that patient's make, the significance of these errors, and the important considerations for health care practitioners in supporting patients in correctly using their inhalers. This review highlights the complexities associated with patient's making inhaler technique errors and highlights the opportunities that lie in future technological developments of inhaler devices. Now more than ever, in the era of precision medicine, it is important that we address inhaler technique use once and for all.
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Affiliation(s)
- Sinthia Z Bosnic-Anticevich
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia.
- Woolcock Emphysema Centre, University of Sydney, Sydney, Australia.
- Sydney Local Health District, Sydney, Australia.
| | - Biljana Cvetkovski
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Elizabeth A Azzi
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Pamela Srour
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Rachel Tan
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Vicky Kritikos
- Quality Use of Respiratory Medicines Group, Woolcock Institute, Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, Australia
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McIvor RA, Devlin HM, Kaplan A. Optimizing the Delivery of Inhaled Medication for Respiratory Patients: The Role of Valved Holding Chambers. Can Respir J 2018; 2018:5076259. [PMID: 29849831 PMCID: PMC5904796 DOI: 10.1155/2018/5076259] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/26/2018] [Accepted: 02/12/2018] [Indexed: 02/02/2023] Open
Abstract
Valved holding chambers (VHCs) have been used with pressurized metered-dose inhalers since the early 1980s. They have been shown to increase fine particle delivery to the lungs, decrease oropharyngeal deposition, and reduce side effects such as throat irritation, dysphonia, and oral candidiasis that are common with use of pressurized metered-dose inhalers (pMDIs) alone. VHCs act as aerosol reservoirs, allowing the user to actuate the pMDI device and then inhale the medication in a two-step process that helps users overcome challenges in coordinating pMDI actuation with inhalation. The design of VHC devices can have an impact on performance. Features such as antistatic properties, effective face-to-facemask seal feedback whistles indicating correct inhalation speed, and inhalation indicators all help improve function and performance, and have been demonstrated to improve asthma control, reduce the rate of exacerbations, and improve quality of life. Not all VHCs are the same, and they are not interchangeable. Each pairing of a pMDI device plus VHC should be considered as a unique delivery system.
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Affiliation(s)
- R. Andrew McIvor
- St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, ON, Canada
| | | | - Alan Kaplan
- Family Physician Airways Group of Canada, Richmond Hill, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Health Quality Ontario COPD Community Standards Project, Toronto, ON, Canada
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Abdulameer SA. Knowledge and pharmaceutical care practice regarding inhaled therapy among registered and unregistered pharmacists: an urgent need for a patient-oriented health care educational program in Iraq. Int J Chron Obstruct Pulmon Dis 2018; 13:879-888. [PMID: 29559772 PMCID: PMC5856302 DOI: 10.2147/copd.s157403] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Inadequate inhaled aerosol device demonstration and technique by health care professionals can lead to poor disease control. The aims of this study were to develop and validate Knowledge of Aerosol Tool (KAT) among registered and unregistered pharmacists and to assess the pharmaceutical care practice among registered pharmacists. Methods The KAT and pharmaceutical care practice questionnaires were developed and modified from previous reports, then an observational cross-sectional study with a convenience sample size of 340 was carried out among registered and unregistered pharmacists. The validation process included face validity and reliability, and item analysis was carried out. Results The results showed good face validity and reliability with Cronbach’s alpha test and Pearson’s correlation coefficient for test–retest of 0.637 and 0.440, respectively. The KAT item difficulty index for most items was between 0.130 and 0.667. The total KAT scores for registered and unregistered pharmacists were 10.13±3.152 and 8.29±2.930, respectively, which revealed inadequate pharmacist knowledge of inhaled aerosol device technique and therapies. In addition, only 38.38% of the total sample was found to have a high KAT level score. The results showed higher KAT scores among males, pharmacists with a family history of respiratory disease, and pharmacists with a master’s degree. For the registered pharmacists, there were positive correlations between the total KAT score and the total pharmaceutical care practice score and the average number of patients with a respiratory disease seen by the pharmacist weekly, respectively. Moreover, there was a positive correlation between the total KAT score and its aerosol administration subscale with pharmacotherapy care and comorbid disease management practice care. Conclusion The KAT showed good validity and reliability, hence, it can be used for training or educational purposes. This study showed that professional knowledge and pharmaceutical care are a major concern in Iraq. KAT implementation depends on the whole educational process from undergraduate study to residence training.
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Plaza V, Giner J, Rodrigo GJ, Dolovich MB, Sanchis J. Errors in the Use of Inhalers by Health Care Professionals: A Systematic Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:987-995. [PMID: 29355645 DOI: 10.1016/j.jaip.2017.12.032] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/15/2017] [Accepted: 12/30/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Inefficient inhaler technique (IT) compromises the optimal delivery of medication. However, the IT knowledge of health care professionals (HCPs) has received scant attention. OBJECTIVE The objective of this study was to perform a systematic review of published reports assessing the IT proficiency of HCPs in using pressurized metered dose (pMDI) and dry powder (DPI) inhalers. METHODS Studies published between 1975 and 2014 that directly assessed the IT skills of HCPs were selected according to predefined selection criteria. RESULTS Data were extracted from 55 studies involving 6,304 HCPs who performed 9,996 tests to demonstrate their IT proficiency. Overall, the IT was considered correct in 15.5% of cases (95% confidence interval [CI], 12-19.3), decreasing over time from 20.5% (95% CI, 14.9-26.8) from the early period (defined as 1975-1995) to 10.8% (95% CI, 7.3-14.8) during the late period (1996-2014). The most common errors in the use of pMDIs were as follows: not breathing out completely before inhalation (75%; 95% CI, 56-90), lack of coordination (64%; 95% CI, 29-92), and postinhalation breath-hold (63%; 95% CI, 52-72). The most common errors using DPI were deficient preparation (89%; 95% CI, 82-95), not breathing out completely before inhalation (79%; 95% CI, 68-87), and no breath-hold (76%; 95% CI, 67-84). CONCLUSIONS HCPs demonstrated inadequate knowledge of the proper use of inhalers. The poor understanding of the correct use of these devices may prevent these professionals from being able to adequately assess and teach proper inhalation techniques to their patients.
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Affiliation(s)
- Vicente Plaza
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Jordi Giner
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Gustavo J Rodrigo
- Departamento de Emergencia, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
| | - Myrna B Dolovich
- Department of Medicine, Division of Respirology, St Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada
| | - Joaquin Sanchis
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
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Addressing the Impact and Unmet Needs of Nonadherence in Asthma and Chronic Obstructive Pulmonary Disease: Where Do We Go From Here? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:785-793. [PMID: 29339126 DOI: 10.1016/j.jaip.2017.11.027] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/01/2017] [Accepted: 11/02/2017] [Indexed: 01/08/2023]
Abstract
Nonadherence to treatment, and its associated health and economic burden, is particularly problematic in asthma and chronic obstructive pulmonary disease management because of heterogeneous patient populations and the need for an inhaled route of drug administration. Symptom variability, comorbidities, and device switching further add to suboptimal adherence rates. As opposed to controlled clinical trials, real-life studies show consistently low inhaler adherence in daily practice, yet exact adherence rates have long been affected by disagreement on standardized definitions. The recently developed Ascertaining Barriers to Compliance taxonomy helps to address adherence research disparities by identifying 3 phases of adherence (initiation, implementation [including correct inhaler technique], and discontinuation). This review considers the reasons for and impact of suboptimal adherence, together with summaries of key studies that demonstrate how improving adherence can reduce exacerbations, inhaled corticosteroid use (in cases of better inhaler technique), hospitalizations, and treatment costs. Strategies to help ensure optimal adherence are discussed, including the choice of a patient-tailored inhaler, patient empowerment, education and training, and the potential of electronic monitoring and digital technology. It is concluded that a combined effort from payers, health care professionals, and manufacturers could make a real difference to asthma and chronic obstructive pulmonary disease control, as well as to health care budgets.
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DePietro M, Gilbert I, Millette LA, Riebe M. Inhalation device options for the management of chronic obstructive pulmonary disease. Postgrad Med 2017; 130:83-97. [PMID: 29210318 DOI: 10.1080/00325481.2018.1399042] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is characterized by chronic respiratory symptoms and airflow limitation, resulting from abnormalities in the airway and/or damage to the alveoli. Primary care physicians manage the healthcare of a large proportion of patients with COPD. In addition to determining the most appropriate medication regimen, which usually includes inhaled bronchodilators with or without inhaled corticosteroids, physicians are charged with optimizing inhalation device selection to facilitate effective drug delivery and patient adherence. The large variety of inhalation devices currently available present numerous challenges for physicians that include: (1) gaining knowledge of and proficiency with operating different device classes; (2) identifying the most appropriate inhalation device for the patient; and (3) providing the necessary education and training for patients on device use. This review provides an overview of the inhalation device types currently available in the United States for delivery of COPD medications, including information on their successful operation and respective advantages and disadvantages, factors to consider in matching a device to an individual patient, the need for device training for patients and physicians, and guidance for improving treatment adherence. Finally, the review will discuss established and novel tools and technology that may aid physicians in improving education and promoting better adherence to therapy.
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Affiliation(s)
| | - Ileen Gilbert
- a Medical Affairs , AstraZeneca LP , Wilmington , DE , USA
| | | | - Michael Riebe
- b Inhalation Product Development , AstraZeneca LP , Durham , NC , USA
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Abdel Fattah MT, Abdel Aziz AO, Abdel Aziz MO, Atta MI, Mounir SM, Amin SA. Prescription of inhalers among pulmonologists and nonpulmonologists: is there a difference. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2017. [DOI: 10.4103/ejb.ejb_26_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Inhaler Devices: Better Management or New Devices? The Blind Leading the Blind. Arch Bronconeumol 2017; 54:245-246. [PMID: 29103669 DOI: 10.1016/j.arbres.2017.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/06/2017] [Accepted: 07/06/2017] [Indexed: 11/20/2022]
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Braido F, Chrystyn H, Baiardini I, Bosnic-Anticevich S, van der Molen T, Dandurand RJ, Chisholm A, Carter V, Price D. "Trying, But Failing" - The Role of Inhaler Technique and Mode of Delivery in Respiratory Medication Adherence. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 4:823-32. [PMID: 27587316 DOI: 10.1016/j.jaip.2016.03.002] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/02/2016] [Accepted: 03/05/2016] [Indexed: 11/24/2022]
Abstract
Inhaled therapies are the backbone of asthma and chronic obstructive pulmonary disease management, helping to target therapy at the airways. Adherence to prescribed treatment is necessary to ensure achievement of the clinician's desired therapeutic effect. In the case of inhaled therapies, this requires patients' acceptance of their need for inhaled therapy together with successful mastery of the inhaler technique specific to their device(s). This article reviews a number of challenges and barriers that inhaled mode of delivery can pose to optimum adherence-to therapy initiation and, thereafter, to successful implementation and persistence. The potential effects on adherence of different categories of devices, their use in multiplicity, and the mixing of device categories are discussed. Common inhaler errors identified by the international Implementing Helping Asthma in Real People (iHARP) study are summarized, and adherence intervention opportunities for health care professionals are offered. Better knowledge of common errors can help practicing clinicians identify their occurrence among patients and prompt remedial actions, such as tailored education, inhaler technique retraining, and/or shared decision making with patients regarding suitable alternatives. Optimizing existing therapy delivery, or switching to a suitable alternative, can help avoid unnecessary escalation of treatment and health care resources.
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Affiliation(s)
- Fulvio Braido
- Respiratory and Allergy Diseases Clinic, Department of Internal Medicine, University of Genoa, IRCCS AOU San Martino-IST, Genoa, Italy.
| | | | - Ilaria Baiardini
- Respiratory and Allergy Diseases Clinic, Department of Internal Medicine, University of Genoa, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney, NSW, Australia; Sydney Local Health District, Sydney, NSW, Australia
| | - Thys van der Molen
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ronald J Dandurand
- Montreal Chest Institute & Meakins-Christie Laboratories, McGill University Health Centre, Montreal, QC, Canada
| | - Alison Chisholm
- The Respiratory Effectiveness Group, Oakington, Cambridge, United Kingdom
| | - Victoria Carter
- Optimum Patient Care, Unit 5-6, Oakington, Cambridge, United Kingdom
| | - David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
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Sulaiman I, Cushen B, Greene G, Seheult J, Seow D, Rawat F, MacHale E, Mokoka M, Moran CN, Sartini Bhreathnach A, MacHale P, Tappuni S, Deering B, Jackson M, McCarthy H, Mellon L, Doyle F, Boland F, Reilly RB, Costello RW. Objective Assessment of Adherence to Inhalers by Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2017; 195:1333-1343. [PMID: 27409253 DOI: 10.1164/rccm.201604-0733oc] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
RATIONALE Objective adherence to inhaled therapy by patients with chronic obstructive pulmonary disease (COPD) has not been reported. OBJECTIVES To objectively quantify adherence to preventer Diskus inhaler therapy by patients with COPD with an electronic audio recording device (INCA). METHODS This was a prospective observational study. On discharge from hospital patients were given a salmeterol/fluticasone inhaler with an INCA device attached. Analysis of this audio quantified the frequency and proficiency of inhaler use. MEASUREMENTS AND MAIN RESULTS Patients with COPD (n = 244) were recruited. The mean age was 71 years, mean FEV1 was 1.3 L, and 59% had evidence of mild/moderate cognitive impairment. By combining time of use, interval between doses, and critical technique errors, thus incorporating both intentional and unintentional nonadherence, a measure "actual adherence" was calculated. Mean actual adherence was 22.6% of that expected if the doses were taken correctly and on time. Six percent had an actual adherence greater than 80%. Hierarchical clustering found three equally sized well-separated clusters corresponding to distinct patterns. Cluster 1 (34%) had low inhaler use and high error rates. Cluster 2 (25%) had high inhaler use and high error rates. Cluster 3 (36%) had overall good adherence. Poor lung function and comorbidities were predictive of poor technique, whereas age and cognition with poor lung function distinguished those with poor adherence and frequent errors in technique. CONCLUSIONS These data may inform clinicians in understanding why a prescribed inhaler is not effective and to devise strategies to promote adherence in COPD.
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Affiliation(s)
| | | | | | | | - Dexter Seow
- 1 Clinical Research Centre, Beaumont Hospital
| | - Fiona Rawat
- 1 Clinical Research Centre, Beaumont Hospital
| | | | | | | | | | | | | | - Brenda Deering
- 3 COPD Outreach, Beaumont Hospital, Dublin, Ireland; and
| | | | | | | | | | | | - Richard B Reilly
- 5 Trinity Centre of Bioengineering.,6 School of Engineering, and.,7 School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
| | - Richard W Costello
- 1 Clinical Research Centre, Beaumont Hospital.,8 Department of Respiratory Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
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Bell D, Mansfield L, Lomax M. A Randomized, Crossover Trial Evaluating Patient Handling, Preference, and Ease of Use of the Fluticasone Propionate/Formoterol Breath-Triggered Inhaler. J Aerosol Med Pulm Drug Deliv 2017; 30:425-434. [PMID: 28683212 DOI: 10.1089/jamp.2017.1385] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Appropriate inhaler selection is of fundamental importance in obstructive lung disease management. Key factors in device selection include a patient's capacity to operate a particular device and their preference for it. METHODS This randomized, open-label, two-period, crossover study (NCT01739387) compared the ability of adolescent and adult patients with obstructive lung disease to correctly handle the fluticasone propionate/formoterol fumarate (FP/FORM; Flutiform®) pressurized metered-dose inhaler (pMDI) and FP/FORM K-haler®, a novel breath-triggered inhaler (BTI), following a simple, standardized training regimen. The primary endpoint was the ability to perform all steps correctly at the first attempt. Secondary endpoints included the ability to perform all critical steps correctly at the first attempt, the requisite number of attempts to successfully use the inhaler, the ability to be trained within 15 minutes, and the ability to trigger the K-haler BTI to actuate at the first attempt. Ease of device use and device preference versus patients' usual maintenance inhalers were also assessed. RESULTS AND CONCLUSIONS At the first attempt, an identical proportion (77.2% [95% confidence interval [CI]: 72.1, 81.8]) of 307 patients performed all pMDI and K-haler BTI handling steps correctly, whereas the corresponding proportions performing all critical steps correctly were 82.4% (95% CIs: 77.7, 86.5) and 87.0% (95% CI: 82.7, 90.5), respectively. For both devices, >90% of patients required only two attempts to master device usage; >99% of patients could be trained to correctly use each device within 15 minutes. Virtually all patients (99.0% [95% CIs: 97.2, 99.8]) were able to successfully trigger the K-haler BTI's dose-release mechanism at first attempt. Ease of use and preference data for FP/FORM pMDI challenged the perceived wisdom that dry powder inhalers are necessarily simpler to use, whereas the corresponding data for FP/FORM K-haler strongly favored this novel BTI over the Turbuhaler®, Accuhaler®, and other pMDIs.
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Affiliation(s)
- David Bell
- 1 BioKinetic Europe Limited , Belfast, Northern Ireland
| | | | - Mark Lomax
- 2 Mundipharma Research Limited , Cambridge, United Kingdom
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Amin AN, Ganapathy V, Roughley A, Small M. Confidence in correct inhaler technique and its association with treatment adherence and health status among US patients with chronic obstructive pulmonary disease. Patient Prefer Adherence 2017; 11:1205-1212. [PMID: 28744110 PMCID: PMC5513874 DOI: 10.2147/ppa.s140139] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Improper use of bronchodilators is associated with poor disease control, nonadherence to long-term therapy, and poor clinical outcomes. Our current understanding of factors associated with correct inhaler use and adherence is limited. We measured physician-and patient-reported confidence in device usage and associations with treatment adherence and COPD-related health status. METHODS This was an analysis of a US observational, point-in-time survey of physicians and patients. Physicians who met study eligibility criteria completed surveys for 5 consecutive, eligible patients who were then invited to respond to questionnaires. We assessed patient demographics, type of prescribed inhaler device(s), device training, COPD severity, comorbidities, physician-and patient self-reported confidence in device usage, treatment adherence, and health status. RESULTS Completed questionnaires for 373 patients were provided by 134 physicians. Complete confidence in device usage was observed for 22% and 17% of patients as reported by patients and physicians, respectively. Greater confidence was associated with higher self-reported adherence to inhaler usage. Physicians were more likely than patients to report lower levels of patient confidence in device usage. High physician- and patient-reported confidence were associated with more favorable health status. Predictors of confidence in device usage included fewer comorbidities, no depression, and higher education levels. CONCLUSION Low confidence in inhaler usage was associated with lower adherence and poor COPD-related health status. Choice of inhaler device tailored to patients' ability to use specific devices and ongoing education to support optimal inhaler usage may improve patient confidence and enhance both adherence and health status.
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Affiliation(s)
- Alpesh N Amin
- Department of Medicine, University of California, Irvine, USA
- Correspondence: Alpesh N Amin, Department of Medicine, University of California, Irvine, 101 The City Drive South, Orange, CA 92868, USA, Tel +1 714 456 3785, Email
| | - Vaidyanathan Ganapathy
- Global Health Economics & Outcomes Research, Sunovion Pharmaceuticals Inc, Marlborough, USA
| | - Adam Roughley
- Respiratory Research, Adelphi Real World, Bollington, UK
| | - Mark Small
- Respiratory Research, Adelphi Real World, Bollington, UK
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Roche N, Scheuch G, Pritchard JN, Nopitsch-Mai C, Lakhani DA, Saluja B, Jamieson J, Dundon A, Wallace R, Holmes S, Cipolla D, Dolovich MB, Shah SA, Lyapustina S. Patient Focus and Regulatory Considerations for Inhalation Device Design: Report from the 2015 IPAC-RS/ISAM Workshop. J Aerosol Med Pulm Drug Deliv 2016; 30:1-13. [PMID: 27537608 DOI: 10.1089/jamp.2016.1326] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This article reports on discussions at the 2015 workshop cosponsored by the International Pharmaceutical Aerosol Consortium on Regulation and Science (IPAC-RS) and the International Society for Aerosols in Medicine (ISAM), entitled "Regulatory and Patient Considerations for Inhalation Device Design, Development and Use." Key topics addressed at the workshop and presented here include patient-focused device design for orally inhaled products (OIPs), instructions for use (IFU), human factors, regulatory considerations in the United States and Europe, development of generic inhalers, quality-by-design, and change management of OIP devices. Workshop participants also identified several areas for further consideration and emphasized the need for increased focus on the patient to create therapeutic products (inclusive of device design, IFU, education, training) that support adherence with an individual patient's treatment regimen. Advances in patient-centric product development will require engagement and collaboration by industry, regulators, patients, physicians, and other stakeholders. The article includes summaries of presented talks as well as of panel and audience discussions.
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Affiliation(s)
- Nicolas Roche
- 1 Hôpital Cochin, AP-HP and University Paris Descartes (EA2511) , Sorbonne Paris Cité, Paris, France
| | | | | | | | - Deepika A Lakhani
- 5 US Food and Drug Administration, Center for Devices and Radiological Health , Silver Spring, Maryland
| | - Bhawana Saluja
- 6 US Food and Drug Administration, Center for Drug Evaluation and Research , Silver Spring, Maryland
| | - Janine Jamieson
- 7 Medicines and Healthcare Products Regulatory Agency , London, United Kingdom
| | - Andrew Dundon
- 8 GlaxoSmithKline , Ware, Hertfordshire, United Kingdom
| | | | - Susan Holmes
- 10 GlaxoSmtithKline, Research Triangle Park , North Carolina
| | | | - Myrna B Dolovich
- 12 Department of Medicine, McMaster University , Hamilton, Canada
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Empowering family physicians to impart proper inhaler teaching to patients with chronic obstructive pulmonary disease and asthma. Can Respir J 2016; 22:266-70. [PMID: 26436910 DOI: 10.1155/2015/731357] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Leiva-Fernández J, Vázquez-Alarcón RL, Aguiar-Leiva V, Lobnig-Becerra M, Leiva-Fernández F, Barnestein-Fonseca P. Efficacy of an educational intervention in primary health care in inhalation techniques: study protocol for a pragmatic cluster randomised controlled trial. Trials 2016; 17:144. [PMID: 26988095 PMCID: PMC4794820 DOI: 10.1186/s13063-016-1269-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 02/26/2016] [Indexed: 11/29/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) accounts for 10–12 % of primary care consultations, 7 % of hospital admissions and 35 % of chronic incapacity related to productivity. The misuse of inhalers is a significant problem in COPD because it is associated with reduced therapeutic drug effects leading to lack of control of both symptoms and disease. Despite all advice, health care professionals’ practice management of inhalation treatments is usually deficient. Interventions to improve inhaler technique by health care professionals are limited, especially among primary care professionals, who provide the most care to patients with COPD. The aim of this study is to evaluate the efficacy of an educational intervention to train general practitioners (GPs) in the right inhalation technique for the most commonly used inhalers. Methods/design We are conducting a pragmatic cluster randomised controlled trial. The sample population is composed of 267 patients diagnosed with COPD using inhalation therapy selected from among those in 20 general practices, divided into two groups (control and intervention) by block randomisation at 8 primary care centres. The sample has two levels. The first level is patients with COPD who agree to participate in the trial and receive the educational intervention from their GPs. The second level is GPs who are primary health care professionals and receive the educational intervention. The intervention is one session of the educational intervention with a monitor given to GPs for training in the right inhalation technique. The primary outcome is correct inhalation technique in patients. Secondary outcomes are functional status (spirometry) and quality of life. The follow-up period will be 1 year. GPs will have two visits (baseline and at the 1-year follow-up visit. Patients will have four visits (at baseline and 3, 6 and 12 months). Analysis will be done on an intention-to-treat basis. Discussion We carried out three previous clinical trials in patients with COPD, which showed the efficacy of an educational intervention based on monitor training to improve the inhalation technique in patients. This intervention is suitable and feasible in the context of clinical practice. Now we are seeking to know if we can improve it when the monitor is the GP (the real care provider in daily practise). Trial registration ISRCTN Registry identifier ISRCTN93725230. Registered on 18 August 2014.
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Affiliation(s)
- José Leiva-Fernández
- Vélez Sur Primary Care Centre / IBIMA Institute, Málaga Este-Axarquía Health Area / Málaga University, Vélez Málaga, Málaga, Spain
| | - Rubén L Vázquez-Alarcón
- Multiprofessional Family and Community Attention Teaching Unit, Málaga-Guadalhorce Trust, Málaga University, Málaga, Spain
| | - Virginia Aguiar-Leiva
- Multiprofesional Family and Community Medicine Attention Teaching Unit, Málaga-Guadalhorce Trust, Málaga University, Málaga, Spain
| | - Mireya Lobnig-Becerra
- Multiprofesional Family and Community Medicine Attention Teaching Unit, Málaga-Guadalhorce Trust, Málaga University, Málaga, Spain
| | - Francisca Leiva-Fernández
- Multiprofessional Family and Community Attention Teaching Unit / IBIMA Institute, Málaga-Guadalhorce Trust / Málaga University, Málaga, Spain
| | - Pilar Barnestein-Fonseca
- Multiprofessional Family and Community Attention Teaching Unit / IBIMA Institute, Málaga-Guadalhorce Trust / Málaga University, Málaga, Spain.
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Giner J, Roura P, Hernández C, Torrejón M, Peiró M, Fernández MJ, de Santa María EL, Gimeno MA, Macian V, Tarragona E, Plaza V. Knowledge and Attitudes of Nurses in Spain about Inhaled Therapy: Results of a National Survey. J Aerosol Med Pulm Drug Deliv 2016; 29:86-93. [DOI: 10.1089/jamp.2014.1198] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jordi Giner
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomédica Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Department of Medicine, Barcelona, Spain
| | - Pere Roura
- Service of Clinical Epidemiology, Hospital General de Vic, Barcelona, Spain
| | - Carme Hernández
- Integrated Care Unit, Medical and Nursing Direction, Hospital Clínic, IDIBAPS, CIBER de Enfermedades Respiratorias (CIBERES), Universitat de Barcelona, Spain
| | - Montserrat Torrejón
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomédica Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Department of Medicine, Barcelona, Spain
| | - Meritxell Peiró
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomédica Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Department of Medicine, Barcelona, Spain
| | - M Jesús Fernández
- Lung Management Area, Central University Hospital of Asturias, Oviedo, Spain
| | | | - M Angeles Gimeno
- Service of Pneumology, Hospital de Palamós, Palamós, Girona, Spain
| | - Vicente Macian
- Service of Pneumology, Hospital Arnau de Vilanova, Valencia, Spain
| | - Eduard Tarragona
- Medical Advisor of Medical Department Chiesi, L'Hospitalet del Llobregat, Barcelona, Spain
| | - Vicente Plaza
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomédica Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Department of Medicine, Barcelona, Spain
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[Inhaled therapy in asthma]. Med Clin (Barc) 2015; 146:316-23. [PMID: 26683076 DOI: 10.1016/j.medcli.2015.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 09/25/2015] [Accepted: 09/30/2015] [Indexed: 11/20/2022]
Abstract
Because of its advantages, inhaled administration of aerosolized drugs is the administration route of choice for the treatment of asthma and COPD. Numerous technological advances in the devices used in inhaled therapy in recent decades have boosted the appearance of multiple inhalers and aerosolized drugs. However, this variety also requires that the prescribing physician is aware of their characteristics. The main objective of the present review is to summarize the current state of knowledge on inhalers and inhaled drugs commonly used in the treatment of asthma. The review ranges from theoretical aspects (fundamentals and available devices and drugs) to practical and relevant aspects for asthma care in the clinical setting (therapeutic strategies, education, and adherence to inhalers).
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Ryan D, Murphy A, Ställberg B, Baxter N, Heaney LG. 'SIMPLES': a structured primary care approach to adults with difficult asthma. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2014; 22:365-73. [PMID: 23974674 PMCID: PMC6442837 DOI: 10.4104/pcrj.2013.00075] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The substantial majority of patients with asthma can expect minimal breakthrough symptoms on standard doses of inhaled corticosteroids with or without additional add-on therapies. SIMPLES is a structured primary care approach to the review of a person with uncontrolled asthma which encompasses patient education monitoring, lifestyle and pharmacological management and addressing support needs which will achieve control in most patients. The small group of patients presenting with persistent asthma symptoms despite being prescribed high levels of treatment are often referred to as having 'difficult asthma'. Some will have difficult, 'therapy resistant' asthma, some will have psychosocial problems which make it difficult for them to achieve asthma control and some may prove to have an alternative diagnosis driving their symptoms. A few patients will benefit from referral to a 'difficult asthma' clinic. The SIMPLES approach, aligned with close co-operation between primary and specialist care, can identify this patient group, avoid inappropriate escalation of treatment, and streamline clinical assessment and management.
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Affiliation(s)
- Dermot Ryan
- General Practitioner, Woodbrook Medical Centre, Loughborough, UK; Honorary Clinical Research Fellow, Allergy and Respiratory Research Group, The University of Edinburgh, Edinburgh, UK
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Zhu Z, Zheng J, Wu Z, Xie Y, Gao Y, Zhong L, Jiang M. Clinical practice of nebulized therapy in China: a national questionnaire survey. J Aerosol Med Pulm Drug Deliv 2014; 27:386-91. [PMID: 24383963 DOI: 10.1089/jamp.2013.1053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite having been used in the clinical practice of respiratory diseases for decades in China, the overall description of nebulized therapy has not been reported to date. The purpose of this study was to investigate the basic characteristics and information on the application of nebulized therapy in the clinical practice of respiratory diseases in China. METHODS A questionnaire survey with 17 questions relating to nebulized therapy was carried out in three levels (tertiary, secondary, and primary) of hospitals throughout mainland China. The perspectives of various professional degrees of the medical staffs from different levels of hospitals were further studied. RESULTS A total of 6,449 effective questionnaires were collected from 1,328 hospitals or clinics located in 27 provinces or autonomous regions of mainland China. Nebulized therapy was applied in 91.1% of the hospitals, significantly more in tertiary and secondary levels of hospitals than in the primary level of hospitals. Jet and ultrasonic nebulizers were used in 53.3% and 47.7% of the hospitals, respectively. Only 50.8% of the responders identified the brands of the devices. 82.5 Percent of the responders had prescribed nebulized therapy. 68.8 Percent and 41.5% of responders agreed that nebulized therapy can be used for the treatment of asthma and COPD, respectively. 86.5 Percent of responders agreed that nebulized therapy can be used for patients with acute exacerbation, whereas 27.5% stated that it can be used for stable patients. The most commonly used medicines were short-acting bronchodilators, followed by corticosteroids, mucolytics, and antibiotics. 17.2 Percent of the responders reported adverse events of nebulized therapy experienced by the patients. Continuous medical education and training on nebulized therapy were required by 72.1% of responders. CONCLUSIONS The present national survey, firstly, provided the basic characteristics and information on the application of nebulizer therapy in the clinical practice of respiratory diseases in China. Certainly, this will help facilitate nebulized therapy, especially in the community hospitals. Continuous medical education and technical training are essential to improve the clinical application of nebulized therapy.
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Affiliation(s)
- Zheng Zhu
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University , Guangzhou 510120, China
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Ehrmann S, Roche-Campo F, Sferrazza Papa GF, Isabey D, Brochard L, Apiou-Sbirlea G. Aerosol therapy during mechanical ventilation: an international survey. Intensive Care Med 2013; 39:1048-56. [DOI: 10.1007/s00134-013-2872-5] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 01/31/2013] [Indexed: 11/28/2022]
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Abstract
The final article in this series evaluates the approaches undertaken to treating the small-airway region of the lungs and the clinical implications of inhaled therapy targeting the periphery in patients with asthma and chronic obstructive pulmonary disease.
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Affiliation(s)
- Omar S Usmani
- Airway Disease Section, National Heart and Lung Institute, Imperial College London, and Royal Brompton Hospital, London, UK.
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Plaza V, Calle M, Molina J, Quirce S, Sanchis J, Viejo JL, Caballero F. Validación externa de las recomendaciones del Consenso multidisciplinar sobre Terapia Inhalada. Arch Bronconeumol 2012; 48:189-96. [DOI: 10.1016/j.arbres.2012.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 12/23/2011] [Accepted: 01/09/2012] [Indexed: 10/28/2022]
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