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Lommatzsch M, Criée CP, de Jong CCM, Gappa M, Geßner C, Gerstlauer M, Hämäläinen N, Haidl P, Hamelmann E, Horak F, Idzko M, Ignatov A, Koczulla AR, Korn S, Köhler M, Lex C, Meister J, Milger-Kneidinger K, Nowak D, Nothacker M, Pfaar O, Pohl W, Preisser AM, Rabe KF, Riedler J, Schmidt O, Schreiber J, Schuster A, Schuhmann M, Spindler T, Taube C, Christian Virchow J, Vogelberg C, Vogelmeier CF, Wantke F, Windisch W, Worth H, Zacharasiewicz A, Buhl R. [Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]. Pneumologie 2023; 77:461-543. [PMID: 37406667 DOI: 10.1055/a-2070-2135] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.
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Affiliation(s)
- Marek Lommatzsch
- Zentrum für Innere Medizin, Abt. für Pneumologie, Universitätsmedizin Rostock
| | | | - Carmen C M de Jong
- Abteilung für pädiatrische Pneumologie, Abteilung für Pädiatrie, Inselspital, Universitätsspital Bern
| | - Monika Gappa
- Klinik für Kinder und Jugendliche, Evangelisches Krankenhaus Düsseldorf
| | | | | | | | - Peter Haidl
- Abteilung für Pneumologie II, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg
| | - Eckard Hamelmann
- Kinder- und Jugendmedizin, Evangelisches Klinikum Bethel, Bielefeld
| | | | - Marco Idzko
- Abteilung für Pulmologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien
| | - Atanas Ignatov
- Universitätsklinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum Magdeburg
| | - Andreas Rembert Koczulla
- Schön-Klinik Berchtesgadener Land, Berchtesgaden
- Klinik für Innere Medizin Schwerpunkt Pneumologie, Universitätsklinikum Marburg
| | - Stephanie Korn
- Pneumologie und Beatmungsmedizin, Thoraxklinik, Universitätsklinikum Heidelberg
| | - Michael Köhler
- Deutsche Patientenliga Atemwegserkrankungen, Gau-Bickelheim
| | - Christiane Lex
- Klinik für Kinder- und Jugendmedizin, Universitätsmedizin Göttingen
| | - Jochen Meister
- Klinik für Kinder- und Jugendmedizin, Helios Klinikum Aue
| | | | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU München
| | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V
| | - Oliver Pfaar
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Sektion für Rhinologie und Allergie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg
| | - Wolfgang Pohl
- Gesundheitszentrum Althietzing, Karl Landsteiner Institut für klinische und experimentelle Pneumologie, Wien
| | - Alexandra M Preisser
- Zentralinstitut für Arbeitsmedizin und Maritime Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Klaus F Rabe
- Pneumologie, LungenClinic Großhansdorf, UKSH Kiel
| | - Josef Riedler
- Abteilung für Kinder- und Jugendmedizin, Kardinal Schwarzenberg Klinikum Schwarzach
| | | | - Jens Schreiber
- Universitätsklinik für Pneumologie, Universitätsklinikum Magdeburg
| | - Antje Schuster
- Klinik für Allgemeine Pädiatrie, Neonatologie und Kinderkardiologie, Universitätsklinikum Düsseldorf
| | | | | | - Christian Taube
- Klinik für Pneumologie, Universitätsmedizin Essen-Ruhrlandklinik
| | | | - Christian Vogelberg
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Dresden
| | | | | | - Wolfram Windisch
- Lungenklinik Köln-Merheim, Lehrstuhl für Pneumologie, Universität Witten/Herdecke
| | - Heinrich Worth
- Pneumologische & Kardiologische Gemeinschaftspraxis, Fürth
| | | | - Roland Buhl
- Klinik für Pneumologie, Zentrum für Thoraxerkrankungen, Universitätsmedizin Mainz
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Lipworth B, Chan R, Kuo C. Relative lung dose from antistatic valved holding chambers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1166. [PMID: 32147135 DOI: 10.1016/j.jaip.2019.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 11/07/2019] [Indexed: 10/24/2022]
Affiliation(s)
- Brian Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, United Kingdom.
| | - Rory Chan
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, United Kingdom
| | - Chris Kuo
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Scotland, United Kingdom
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Lipworth B, Jabbal S. Impact of Spacers on Therapeutic Ratio with Inhaled Corticosteroids. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 5:1163. [PMID: 28689833 DOI: 10.1016/j.jaip.2017.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 03/08/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Brian Lipworth
- Scottish Centre for Respiratory Research, Molecular & Clinical Medicine, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland, United Kingdom.
| | - Sunny Jabbal
- Scottish Centre for Respiratory Research, Molecular & Clinical Medicine, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, Scotland, United Kingdom
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Lipworth BJ, Jabbal S. Drug-device interaction for systemic effects of fluticasone in patients with asthma. Ann Allergy Asthma Immunol 2019; 119:194. [PMID: 28801019 DOI: 10.1016/j.anai.2017.01.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 01/25/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Brian J Lipworth
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Ninewells Hospital, Dundee, Scotland, United Kingdom.
| | - Sunny Jabbal
- Scottish Centre for Respiratory Research, Ninewells Hospital and Medical School, University of Dundee, Ninewells Hospital, Dundee, Scotland, United Kingdom
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Dissanayake S, Suggett J. A review of the in vitro and in vivo valved holding chamber (VHC) literature with a focus on the AeroChamber Plus Flow-Vu Anti-static VHC. Ther Adv Respir Dis 2018; 12:1753465817751346. [PMID: 29378477 PMCID: PMC5937155 DOI: 10.1177/1753465817751346] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/20/2017] [Indexed: 11/16/2022] Open
Abstract
Valved holding chambers (VHCs) reduce the need for inhalation-actuation coordination with pressurized metered dose inhalers (pMDIs), reduce oropharyngeal drug deposition and may improve lung deposition and clinical outcomes compared to pMDIs used alone. While VHCs are thus widely advocated for use in vulnerable patient groups within clinical and regulatory guidelines, there is less consensus as to whether the performance differences between different VHCs have clinical implications. This review evaluates the VHC literature, in particular the data pertaining to large- versus small-volume chambers, aerosol performance with a VHC adjunct versus a pMDI alone, charge dissipative/conducting versus non-conducting VHCs, and facemasks, to ascertain whether potentially meaningful differences between VHCs exist. Inconsistencies in the literature are examined and explained, and relationships between in vitro and in vivo data are discussed. A particular focus of this review is the AeroChamber Plus® Flow-Vu® Anti-static VHC, the most recent iteration of the AeroChamber VHC family.
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Affiliation(s)
| | - Jason Suggett
- Trudell Medical International, London, Ontario,
Canada
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Kolasani BP, Lanke VM, Diyya S. Influence of delivery devices on efficacy of inhaled fluticasone propionate: a comparative study in stable asthma patients. J Clin Diagn Res 2013; 7:1908-12. [PMID: 24179895 PMCID: PMC3809634 DOI: 10.7860/jcdr/2013/6705.3348] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 07/25/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Inhaled corticosteroids are the preferred treatment for long-term control of all grades of persistent asthma. These are administered by various delivery devices with very little information whether these devices can affect the efficacy of inhaled corticosteroids. Fluticasone propionate is a relatively new inhalational corticosteroid compared to older ones like beclomethasone and budesonide. Aims & Objective: To assess the relative efficacy of fluticasone propionate administered from different delivery devices to adult patients of chronic stable bronchial asthma as measured by pulmonary function test parameters. MATERIAL AND METHODS This prospective study was undertaken to assess the relative efficacy of fluticasone propionate administered from different delivery devices to adult patients of chronic stable bronchial asthma as measured by pulmonary function test parameters. Fourty eight subjects were administered, fluticasone propionate (250 μg) by dry powder inhaler, metered dose inhaler, metered dose inhaler with spacer and fluticasone (1mg) via nebulizer consecutively each week for four weeks under direct supervision. Pulmonary function test was done before and one hour after administration of the drug on each visit. RESULTS After excluding nine patients who were lost to follow up, data was analysed for the remaining thirty nine patients and no significant difference in peak expiratory flow rate (p=0.77), forced expiratory volume in one second (p=0.95), forced vital capacity (p=0.24) and forced expiratory volume in one second and forced vital capacity ratio (p=0.22) was seen after giving fluticasone by different devices. CONCLUSION Fluticasone propionate delivered by different devices like dry powder inhaler, metered dose inhaler, metered dose inhaler with spacer and nebulizer have similar effect on lung function in patients of chronic stable bronchial asthma and may be used interchangeably.
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Affiliation(s)
- Bhanu Prakash Kolasani
- Assistant Professor, Department of Pharmacology, Ragiv Gandhi Institute of Medical Sciences, Principal, RIMS, Kadapa, Andhra Pradesh, India
| | - Venu Madhavi Lanke
- Assistant Professor, Department of Pharmacology, Ragiv Gandhi Institute of Medical Sciences, Putlampalli, Kadapa, Andhra Pradesh-516002, India
| | - Sudheer Diyya
- Assistant Professor, Department of Pulmonology, Ragiv Gandhi Institute of Medical Sciences, Putlampalli, Kadapa, Andhra Pradesh-516002, India
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Lipworth B. Targeting the small airways asthma phenotype: if we can reach it, should we treat it? Ann Allergy Asthma Immunol 2013; 110:233-9. [PMID: 23535085 DOI: 10.1016/j.anai.2013.02.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 02/08/2013] [Accepted: 02/10/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review the available methods of evaluating the small airways disease in asthma and the therapeutic strategies to achieve better control using emerging extrafine particle inhaler technologies. DATA SOURCES The PubMed, MEDLINE (Ebsco), Scirus, Scopus, and Google Scholar databases were all scanned with Cross-search using the following keywords: asthma, small airways, hydrofluoroalkane 134a, extrafine particle, inhaled corticosteroid, long-acting β-agonist, spirometry, impulse oscillometry, nitrogen washout, exhaled nitric oxide, airway hyperresponsiveness, and adrenal suppression. STUDY SELECTION Key clinical studies considered to being relevant to the topic under review were evaluated. RESULTS There is an unmet need in current asthma guidelines for those individuals who exhibit the small airways asthma phenotype with a preserved forced expiratory volume in 1 second but abnormal forced midexpiratory flow and peripheral airway resistance, which tends to be associated with poorer control. Extrafine hydrofluoroalkane solution formulations of inhaled corticosteroid either alone or in combination with long-acting β-agonist may improve small airways outcomes and associated control. CONCLUSION From a pragmatic perspective, it makes sense to try to deliver asthma treatment to more of the lung to improve clinical outcomes, especially in patients who exhibit the small airways asthma phenotype.
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Affiliation(s)
- Brian Lipworth
- Asthma and Allergy Research Group, Ninewells Hospital and Medical School, Dundee, Scotland.
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Mansfield LE, Maynes R. A valved holding chamber does not decrease the bronchodilator activity of budesonide-formoterol combination metered dose inhaler. J Asthma 2012; 50:71-4. [PMID: 23176189 DOI: 10.3109/02770903.2012.745093] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Spacers and valved holding chambers (VHCs) were developed to facilitate using pressurized metered dose inhaler (pMDI) by patients who could not coordinate the actions required for successful pMDI use. There is little in vivo evidence about how VHC may affect the bronchodilation from combination drugs in pMDI. This study was to determine the effect, if any, of VHC on the bronchodilating actions of the pMDI budesonide/formoterol combination. METHODS Sixteen adult asthmatic subjects with 15% or greater reversibility of forced expiratory volume in one second (FEV-1), 15 minutes after inhaling 180-360 μg of albuterol, participated. The study had a randomized crossover design with each subject using budesonide-formoterol pMDI as described in the product information one timeand on a second occasion using the pMDI with a VHC. Spirometry and impedance osscilometry were measured at baseline and repeatedly over a 12-hour period. This study was approved by IntegReview Institutional Review Board, Austin, TX, USA. The clinical trial number for this study was NCT 009-15538 (http://www.westernskymed.com). RESULTS The area under the curve of FEV-1, the FEV-1, and the fraction FEV-1/FVC was similar over the 12-hour time frame with both methods. Resistance was not different at any time point. In both procedures, the onset of bronchodilation occurred rapidly within 3 to 5 minutes. CONCLUSIONS In well-trained asthmatic subjects, both tested methods caused equivalent bronchodilation. This suggests a VHC itself has no deleterious effect on the bronchodilator activity in the combined drug. These results may not apply to patients who have coordination problems with the pMDI and further study is indicated.
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Kroening-Roche JC, Soroudi A, Castillo EM, Vilke GM. Antibiotic and bronchodilator prescribing for acute bronchitis in the emergency department. J Emerg Med 2012; 43:221-7. [PMID: 22341759 DOI: 10.1016/j.jemermed.2011.06.143] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 04/14/2011] [Accepted: 06/05/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although the overuse of antibiotics and underuse of bronchodilators for treatment of acute bronchitis is well known, few studies have analyzed these trends in the emergency department (ED). STUDY OBJECTIVES To characterize the antibiotic and bronchodilator prescribing practices of physicians at two academic EDs in the diagnosis of acute bronchitis, and to identify factors that may or may not be associated with these practices. METHODS A computer database was searched retrospectively for all patients with an ED discharge diagnosis of acute bronchitis, and analyzed, looking at the frequency of antibiotic prescriptions, the class of antibiotic prescribed, and several other related factors including age, gender, chief complaint, duration of cough, and comorbid conditions. RESULTS During the study period, there were 836 cases of acute bronchitis in adults. Of these, 622 (74.0%) were prescribed antibiotics. Of those prescribed antibiotics, 480 (77.2%) were prescribed broad-spectrum antibiotics. Using multivariate analysis (odds ratio, 95% confidence interval), antibiotics were prescribed significantly more often in patients aged 50 years or older (1.7, 1.2-2.5) and in smokers (1.5, 1.0-2.2). Of patients without asthma, 346 (49.9%) were discharged without a bronchodilator, and 631 (91.1%) were discharged without a spacer device. CONCLUSION Antibiotics are over-prescribed in the ED for acute bronchitis, with broad-spectrum antibiotics making up the majority of the antibiotics prescribed. Age ≥50 years and smoking are associated with higher antibiotic prescribing rates.
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Affiliation(s)
- Jason C Kroening-Roche
- University of California (UC) San Diego School of Medicine, San Diego, California 92102, USA
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Lipworth BJ, Short P, Burns P, Nair A. Effects of intranasal salmeterol and fluticasone given alone and in combination in persistent allergic rhinitis. Ann Allergy Asthma Immunol 2011; 108:54-59. [PMID: 22192967 DOI: 10.1016/j.anai.2011.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 09/26/2011] [Accepted: 10/03/2011] [Indexed: 10/15/2022]
Abstract
BACKGROUND β(2)-Agonists have previously been shown to be effective inhibitors of mediator release from airway mucosal mast cells. OBJECTIVE To evaluate the effects of intranasal salmeterol and fluticasone propionate alone and in combination on the response to nasal adenosine monophosphate (AMP) challenge to assess mast cell activation. METHODS Twenty-three patients with persistent allergic rhinitis completed a randomized, double-blind, placebo-controlled, 4-way crossover trial. They received once daily treatment with placebo, salmeterol, 50 μg, fluticasone propionate, 500 μg, or fluticasone propionate and salmeterol combination, 500/50 μg, delivered via an antistatic spacer with nasal adapter for 1 week each, with trough measurements being made 12 hours after the first and last dose. The primary outcome was the maximum percentage decrease in peak nasal inspiratory flow after nasal AMP challenge. RESULTS For the primary outcome there was significant protection after single and long-term dosing with fluticasone alone and fluticasone-salmeterol combination, whereas salmeterol alone only afforded protection after the first dose. Fluticasone-salmeterol combination and fluticasone but not salmeterol conferred significant chronic dosing effects on secondary outcomes of nasal symptoms and disease-specific quality of life. There was no potentiation of the response to fluticasone by salmeterol on any outcomes when given in combination. CONCLUSION Chronic dosing with fluticasone but not salmeterol confers anti-inflammatory activity against nasal AMP challenge, but there was no potentiation of fluticasone when given in combination with salmeterol. Thus, salmeterol may not be an effective treatment for use in allergic rhinitis. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01388595.
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Affiliation(s)
- Brian J Lipworth
- Asthma & Allergy Research Group, University of Dundee, Ninewells Hospital & Medical School, Dundee, Scotland.
| | - Philip Short
- Asthma & Allergy Research Group, University of Dundee, Ninewells Hospital & Medical School, Dundee, Scotland
| | - Patricia Burns
- Asthma & Allergy Research Group, University of Dundee, Ninewells Hospital & Medical School, Dundee, Scotland
| | - Arun Nair
- Asthma & Allergy Research Group, University of Dundee, Ninewells Hospital & Medical School, Dundee, Scotland
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Systemic exposure to fluticasone MDI delivered through antistatic chambers. J Allergy Clin Immunol 2011; 128:1113-5.e1-3. [PMID: 21783234 DOI: 10.1016/j.jaci.2011.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 06/14/2011] [Accepted: 06/16/2011] [Indexed: 11/20/2022]
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Abstract
Aerosolised drugs are prescribed for use in a range of inhaler devices and systems. Delivering drugs by inhalation requires a formulation that can be successfully aerosolised and a delivery system that produces a useful aerosol of the drug; the particles or droplets need to be of sufficient size and mass to be carried to the distal lung or deposited on proximal airways to give rise to a therapeutic effect. Patients and caregivers must use and maintain these aerosol drug delivery devices correctly. In recent years, several technical innovations have led to aerosol drug delivery devices with efficient drug delivery and with novel features that take into account factors such as dose tracking, portability, materials of manufacture, breath actuation, the interface with the patient, combination therapies, and systemic delivery. These changes have improved performance in all four categories of devices: metered dose inhalers, spacers and holding chambers, dry powder inhalers, and nebulisers. Additionally, several therapies usually given by injection are now prescribed as aerosols for use in a range of drug delivery devices. In this Review, we discuss recent developments in the design and clinical use of aerosol devices over the past 10-15 years with an emphasis on the treatment of respiratory disorders.
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Affiliation(s)
- Myrna B Dolovich
- Firestone Institute of Respiratory Health, St Joseph's Healthcare, Department of Medicine, McMaster University, Hamilton, ON, Canada.
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