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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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Trushenko NV, Stoliarevich AA, Andriukov BG, Nuralieva GS, Tsareva NA, Lavginova BB, Avdeev SN. [Assessment of inhalation technique in patients with bronchial asthma and chronic obstructive pulmonary disease]. TERAPEVT ARKH 2023; 95:210-216. [PMID: 37167141 DOI: 10.26442/00403660.2023.03.202151] [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: 03/02/2021] [Indexed: 05/13/2023]
Abstract
AIM Investigate inhalation techniques using different inhalers types and their effect on the course of disease. MATERIALS AND METHODS This cross-sectional study included 110 patients with asthma, chronic obstructive pulmonary disease using the inhaler at least one month. Inhaler errors performed during demonstration were evaluated for each patient and entered in the check-lists. We also collected information about co-morbidities, education, mMRC dyspnea score, rate of exacerbations, and performed spirometry. RESULTS 80.9% of patients used metered-dose inhaler, 20.9% - single-dose and 21.8% - multiple-dose dry powder inhaler, 22.7% - soft-mist inhaler. Inhaler errors were made by 80.9% patients. The mean number of mistakes in metered-dose inhaler use was 2±1.6, single-dose powder inhaler -1.5±1.3, multiple-dose dry powder inhaler - 1.25±1.4, soft-mist inhaler - 0.68±0.7 (р=0.003). Age, diagnosis, duration of disease, education level, inhalers usage by relatives have no influence on the inhalation technique. A number of errors was related to female gender (р=0.007) and usage of more than 2 inhalers (r=0.3, p=0.002), previous instruction about inhalation technique (r=0.3, p=0.001). On the other hand, there were correlations between the number of errors and degree of bronchial obstruction, asthma control, severity of dyspnea by mMRC score, exacerbation rate. CONCLUSION Patients with bronchoobstructive diseases perform many inhaler errors, that substantially influences the severity and course of asthma and chronic obstructive pulmonary disease.
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Affiliation(s)
- N V Trushenko
- Sechenov First Moscow State Medical University (Sechenov University)
- Federal Pulmonology Research Institute
| | | | - B G Andriukov
- Central State Medical Academy Presidential Administration
| | - G S Nuralieva
- Sechenov First Moscow State Medical University (Sechenov University)
- Federal Pulmonology Research Institute
| | - N A Tsareva
- Sechenov First Moscow State Medical University (Sechenov University)
- Federal Pulmonology Research Institute
| | - B B Lavginova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - S N Avdeev
- Sechenov First Moscow State Medical University (Sechenov University)
- Federal Pulmonology Research Institute
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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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Cho-Reyes S, Celli BR, Dembek C, Yeh K, Navaie M. Inhalation Technique Errors with Metered-Dose Inhalers Among Patients with Obstructive Lung Diseases: A Systematic Review and Meta-Analysis of U.S. Studies. CHRONIC OBSTRUCTIVE PULMONARY DISEASES-JOURNAL OF THE COPD FOUNDATION 2019; 6:267-280. [PMID: 31342732 DOI: 10.15326/jcopdf.6.3.2018.0168] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Metered dose inhalers (MDIs) are commonly prescribed for inhalation therapy, but correct use is critical to promoting effective medication delivery. This systematic literature review and meta-analysis evaluates the overall and step-by-step prevalence of errors among adults with obstructive lung diseases in the United States who used MDIs. Methods Electronic and manual searches conducted between 1979-2018 using PubMed, EMBASE, PsycINFO, Cochrane, and Google identified 10 articles that met the following inclusion criteria: (a) English language, (b) U.S. adults diagnosed with chronic obstructive pulmonary disease, and (c) MDI use error rates. Meta-analytic techniques using random-effects models were applied to calculate effect sizes, weighted proportions, and 95% confidence intervals (CIs). Heterogeneity was assessed by the I2 statistic. Results Aggregate findings revealed that 86.7% of patients (n=390, 95% CI 77.5-96.0) made at least 1 inhalation technique error, and 76.9% (n=885, 95% CI 65.8-87.9) incorrectly performed ≥ 20% of device use steps. The most prevalent step-by-step errors across the studies (n=1105) were failure to: (a) exhale fully and away from the inhaler before inhalation (65.5% [95% CI 52.0, 78.9]); (b) hold breath for 5-10 seconds (41.9% [95% CI 29.8, 53.9]); (c) inhale slowly and deeply (39.4% [95% CI 26.2, 52.5]); (d) exhale after inhalation (35.9% [95% CI 17.0, 54.8]); and (e) shake the inhaler before use (34.2% [95% CI 30.6, 37.7]). Conclusions Across the studies used in this meta-analysis more than three-fourths of U.S. adults with obstructive lung diseases used MDIs incorrectly. Our findings suggest the need for ongoing patient education and consideration of alternative devices to mitigate errors.
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Affiliation(s)
| | - Bartolome R Celli
- Harvard Medical School, Boston, Massachusetts and Chronic Obstructive Pulmonary Disease Center, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carole Dembek
- Global Health Economics and Outcomes Research, Sunovion Pharmaceuticals, Inc., Marlborough, Massachusetts
| | - Karen Yeh
- Advance Health Solutions, LLC, New York, New York
| | - Maryam Navaie
- Advance Health Solutions, LLC, New York, New York.,Columbia University, School of Professional Studies, New York, New York
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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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Shum J, Poureslami I, Wiebe D, Doyle-Waters MM, Nimmon L, FitzGerald JM. Airway diseases and health literacy (HL) measurement tools: A systematic review to inform respiratory research and practice. PATIENT EDUCATION AND COUNSELING 2018; 101:596-618. [PMID: 29107399 DOI: 10.1016/j.pec.2017.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/24/2017] [Accepted: 10/19/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To identify and evaluate asthma/COPD measurement tools that assess any of the five health literacy (HL) domains: (1) access, (2) understand, (3) evaluate, (4) communicate, and (5) use, as well as numeracy. METHODS MEDLINE/Embase (via Ovid) databases from 1974 to 2016 were searched and complimented by grey literature. Study selection and data extraction were conducted by two reviewers independently. RESULTS We identified 65 tools including 40 asthma, 22 COPD, and 3 asthma/COPD focused tools. Thirty tools had been validated and two assessed all five domains. The 'understand' domain was captured in 49 tools, followed by 'access' in 29 tools, 'use' in 24 tools, 'evaluate' in 20 tools, and 'communicate' in 10 tools. Two tools assessed 'numeracy'. Tool content comprised disease physiology, triggers, symptoms, inhaler technique, self-management practices, and rehab programs. CONCLUSIONS This review highlights paucity of HL tools that have been validated and/or assess the 'communicate' domain and makes a valuable contribution to filling an existing research gap in the field of HL by determining the deficiencies of such tools. PRACTICE IMPLICATIONS Our review uncovers which HL domains are under-measured, justifying the need to develop an airways HL measurement tool which applies the 5-domain model for asthma/COPD management.
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Affiliation(s)
- Jessica Shum
- Division of Respiratory Medicine, Department of Medicine, The University of British Columbia, Gordon and Leslie Diamond Health Care Centre, 7th floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, 7th floor, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Iraj Poureslami
- Division of Respiratory Medicine, Department of Medicine, The University of British Columbia, Gordon and Leslie Diamond Health Care Centre, 7th floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, 7th floor, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Darrin Wiebe
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, 7th floor, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Mary M Doyle-Waters
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, 7th floor, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.
| | - Laura Nimmon
- Centre for Health Education Scholarship (CHES), Department of Occupational Science and Occupational Therapy, The University of British Columbia, P.A. Woodward Instructional Resources Centre (IRC), 429-2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada.
| | - J Mark FitzGerald
- Division of Respiratory Medicine, Department of Medicine, The University of British Columbia, Gordon and Leslie Diamond Health Care Centre, 7th floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, The University of British Columbia, 7th floor, 828 West 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.
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Anderson G, Johnson N, Mulgirigama A, Aggarwal B. Use of spacers for patients treated with pressurized metered dose inhalers: focus on the VENTOLIN™ Mini Spacer. Expert Opin Drug Deliv 2018; 15:419-430. [PMID: 29415579 DOI: 10.1080/17425247.2018.1437414] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Spacers offer a multitude of benefits by reducing the requirement to coordinate inhalation with actuation and improving inhaler technique in patients using a pressurized metered dose inhaler (pMDI). Spacers improve drug targeting by retaining within the spacer large particles normally deposited in the oropharynx, and by creating a prolonged aerosol cloud of fine particles to give the user increased time to inhale after actuation. This is particularly important in young children and the elderly to effectively deliver medication to the airways. AREAS COVERED By investigating the history and features of spacers, we demonstrate that the advantages of using spacers far outweigh their limitations. We also discuss the optimal characteristics of spacers in terms of shape, volume, presence of valve and static charge, and present a detailed discussion of the VENTOLIN™ Mini Spacer. EXPERT OPINION Generally, the shape and size of spacers makes them inherently inconvenient. Consideration of human factors and modern design may make them more attractive to patients. However, the incentive to use spacers should be their ability to help patients correctly use inhaled medications delivered by pMDIs. Understanding of these principles through education is key to their acceptance by patients.
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Affiliation(s)
- Gregor Anderson
- a GSK, Respiratory Centre of Excellence, Global Manufactory & Supply , Ware, Herts , UK
| | - Neil Johnson
- b Respiratory, Global Classic & Established Products , GSK , Middlesex , UK
| | - Aruni Mulgirigama
- b Respiratory, Global Classic & Established Products , GSK , Middlesex , UK
| | - Bhumika Aggarwal
- c GSK , Respiratory, Global Classic & Established Products , Singapore
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Chrystyn H, van der Palen J, Sharma R, Barnes N, Delafont B, Mahajan A, Thomas M. Device errors in asthma and COPD: systematic literature review and meta-analysis. NPJ Prim Care Respir Med 2017; 27:22. [PMID: 28373682 PMCID: PMC5434773 DOI: 10.1038/s41533-017-0016-z] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 12/16/2016] [Accepted: 02/01/2017] [Indexed: 11/09/2022] Open
Abstract
Inhaler device errors are common and may impact the effectiveness of the delivered drug. There is a paucity of up-to-date systematic reviews (SRs) or meta-analyses (MAs) of device errors in asthma and chronic obstructive pulmonary disease (COPD) patients. This SR and MA provides an estimate of overall error rates (both critical and non-critical) by device type and evaluates factors associated with inhaler misuse. The following databases from inception to July 23, 2014 (Embase®, MEDLINE®, MEDLINE® In-Process and CENTRAL) were searched, using predefined search terms. Studies in adult males and females with asthma or COPD, reporting at least one overall or critical error, using metered dose inhalers and dry powder inhalers were included. Random-effect MAs were performed to estimate device error rates and to compare pairs of devices. Overall and critical error rates were high across all devices, ranging from 50-100% and 14-92%, respectively. However, between-study heterogeneity was also generally >90% (I-squared statistic), indicating large variability between studies. A trend towards higher error rates with assessments comprising a larger number of steps was observed; however no consistent pattern was identified. This SR and MA highlights the relatively limited body of evidence assessing device errors and the lack of standardised checklists. There is currently insufficient evidence to determine differences in error rates between different inhaler devices and their impact on clinical outcomes. A key step in improving our knowledge on this topic would be the development of standardised checklists for each device. CHRONIC LUNG DISEASES CALL TO STANDARDISE RESEARCH INTO INHALER DEVICE ERRORS: Researchers should adopt a standardised approach to investigate the incorrect use of inhalers and its associated clinical implications. Henry Chrystyn at Plymouth University, together with scientists across the UK and the Netherlands, conducted a review of research related to inhaled medication errors made by patients with asthma or chronic obstructive pulmonary disease. It is widely acknowledged that many patients with lung conditions don't use their inhaler devices correctly, which affects drug effectiveness and disease control. While Chrystyn's team found high critical error rates reported across all devices, their meta-analysis and systematic review highlighted significant gaps in knowledge regarding different inhalers and associated error rates, and how these affect clinical outcomes. The researchers call for in-depth studies into device use, alongside standardised checklists and definitions for such studies to use to ensure consistency.
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Affiliation(s)
- Henry Chrystyn
- Inhalation Consultancy Ltd, Yeadon, Leeds and Faculty of Human and Health Sciences, Plymouth University, Plymouth, UK.
| | - Job van der Palen
- Department of Research Methodology, Measurement, and Data Analysis, Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands.,Department of Epidemiology, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Neil Barnes
- GSK, Brentford, UK.,William Harvey Institute, St Bartholomew Hospital and The London School of Medicine and Dentistry, London, UK
| | | | | | - Mike Thomas
- Primary Care and Population Sciences, University of Southampton, Southampton, UK.,NIHR Southampton Respiratory Biomedical Research Unit, Southampton, UK.,NIHR Wessex Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Southampton, UK
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10
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Sanchis J, Gich I, Pedersen S. Systematic Review of Errors in Inhaler Use: Has Patient Technique Improved Over Time? Chest 2016; 150:394-406. [PMID: 27060726 DOI: 10.1016/j.chest.2016.03.041] [Citation(s) in RCA: 316] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 03/23/2016] [Accepted: 03/28/2016] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Problems with the use of inhalers by patients were noted shortly after the launch of the metered-dose inhaler (MDI) and persist today. We aimed to assess the most common errors in inhaler use over the past 40 years in patients treated with MDIs or dry powder inhalers (DPIs). METHODS A systematic search for articles reporting direct observation of inhaler technique by trained personnel covered the period from 1975 to 2014. Outcomes were the nature and frequencies of the three most common errors; the percentage of patients demonstrating correct, acceptable, or poor technique; and variations in these outcomes over these 40 years and when partitioned into years 1 to 20 and years 21 to 40. Analyses were conducted in accordance with recommendations from Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Strengthening the Reporting of Observational Studies in Epidemiology. RESULTS Data were extracted from 144 articles reporting on a total number of 54,354 subjects performing 59,584 observed tests of technique. The most frequent MDI errors were in coordination (45%; 95% CI, 41%-49%), speed and/or depth of inspiration (44%; 40%-47%), and no postinhalation breath-hold (46%; 42%-49%). Frequent DPI errors were incorrect preparation in 29% (26%-33%), no full expiration before inhalation in 46% (42%-50%), and no postinhalation breath-hold in 37% (33%-40%). The overall prevalence of correct technique was 31% (28%-35%); of acceptable, 41% (36%-47%); and of poor, 31% (27%-36%). There were no significant differences between the first and second 20-year periods of scrutiny. CONCLUSIONS Incorrect inhaler technique is unacceptably frequent and has not improved over the past 40 years, pointing to an urgent need for new approaches to education and drug delivery.
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Affiliation(s)
- Joaquin Sanchis
- Respiratory Medicine Department, Hospital Santa Creu i Sant Pau, IIB Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain.
| | - Ignasi Gich
- Clinical Epidemiology and Public Health Service, IIB Sant Pau, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Soren Pedersen
- Department of Paediatric Respiratory Medicine, University of Southern Denmark, Odense, Denmark; Pediatric Research Unit, Kolding Hospital, Kolding, Denmark
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Forno E, Gogna M, Cepeda A, Yañez A, Solé D, Cooper P, Avila L, Soto-Quiros M, Castro-Rodriguez JA, Celedón JC. Asthma in Latin America. Thorax 2015; 70:898-905. [PMID: 26103996 DOI: 10.1136/thoraxjnl-2015-207199] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 06/02/2015] [Indexed: 12/20/2022]
Abstract
Consistent with the diversity of Latin America, there is profound variability in asthma burden among and within countries in this region. Regional variation in asthma prevalence is likely multifactorial and due to genetics, perinatal exposures, diet, obesity, tobacco use, indoor and outdoor pollutants, psychosocial stress and microbial or parasitic infections. Similarly, non-uniform progress in asthma management leads to regional variability in disease morbidity. Future studies of distinct asthma phenotypes should follow-up well-characterised Latin American subgroups and examine risk factors that are unique or common in Latin America (eg, stress and violence, parasitic infections and use of biomass fuels for cooking). Because most Latin American countries share the same barriers to asthma management, concerted and multifaceted public health and research efforts are needed, including approaches to curtail tobacco use, campaigns to improve asthma treatment, broadening access to care and clinical trials of non-pharmacological interventions (eg, replacing biomass fuels with gas or electric stoves).
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Affiliation(s)
- Erick Forno
- Division of Pediatric Pulmonary Medicine, Allergy, and Immunology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Mudita Gogna
- Division of Pediatric Pulmonary Medicine, Allergy, and Immunology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alfonso Cepeda
- Fundación Hospital Universitario Metropolitano, Laboratorio de Alergia e Inmunología, Universidad Metropolitana, Barranquilla, Barranquilla, Colombia
| | - Anahi Yañez
- Division of Allergy and Immunology, Servicio de Alergia e Inmunología Clínica, Hospital Aeronáutico Central, Buenos Aires, Argentina
| | - Dirceu Solé
- Escola Paulista de Medicina, São Paulo, Brazil
| | - Philip Cooper
- Laboratorio de Investigaciones FEPIS, Quinindé, Esmeraldas, Ecuador Institute of Infection and Immunity, St George's University of London, London, UK
| | | | | | - Jose A Castro-Rodriguez
- Departments of Pediatrics and Public Health, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan C Celedón
- Division of Pediatric Pulmonary Medicine, Allergy, and Immunology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Newman S. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert Opin Drug Deliv 2014; 11:365-78. [PMID: 24386924 DOI: 10.1517/17425247.2014.873402] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The inhaled route has many advantages, but requires the patient to use, and to master the use of, an inhaler device. Poor inhaler technique and non-adherence to therapy lead to a highly variable lung dose in clinical practice, with subsequent loss of clinical efficacy and wastage of economic resources. AREAS COVERED This paper discusses problems of poor inhaler technique, non-adherence to inhaler therapy, other issues relating to the precision of dose delivery, the consequences of these problems and how they can be addressed. EXPERT OPINION The precision of dosing by the pulmonary route can be improved by appropriate choice of inhaler device and by education. It is vital to educate patients about their disease, about the importance of taking prescribed medications and about correct inhaler use. One-on-one sessions with healthcare professionals probably represent the most effective educational method. For some drugs and patient groups, inhalers containing small microprocessors may also be used to control inhalation technique, and hence, to obtain a more reproducible lung dose. As the range of drugs delivered by inhalation increases, the need for correct inhaler technique, adherence to therapy and precise dosing becomes more and more important.
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