Funhaler spacer: improving adherence without compromising delivery

Overcoming challenges to develop technology for child health

Millions of children and young people (CYP) in the UK are affected by chronic or rare health conditions. Rapid advances in science and technology have resulted in CYP with chronic and rare conditions now surviving well into adulthood. New technologies have the potential to improve short- and long-term health outcomes for CYP with health conditions, prevent adult onset disease and complications, and reduce the burden on health services. There is thus a need for targeted investment and appropriate governance in child health technology development to address the specific needs of this population; health technology must be versatile to meet the social, anatomical, cognitive, psychological, and physiological changes inherent to childhood development. Despite the growing demand for health technology for a sizeable global population, industry still wrongly perceives the market size is relatively small, and health technology development is often localised and fragmented with limited scope for spread and adoption. These challenges can be overcome by validating and prioritising unmet needs, involving CYP and their families throughout the innovation pathway, facilitating effective partnerships with key stakeholders, and utilising national and international infrastructure and networks. This paper outlines five innovations supported by NIHR Children and Young People MedTech Co-operative that illustrate how common challenges in child health technology development can be overcome. It is essential that we continue to address such challenges and invest in the health and wellbeing of CYP.

Medical Device Development for Children and Young People-Reviewing the Challenges and Opportunities

Development of specific medical devices (MDs) is required to meet the healthcare needs of children and young people (CYP). In this context, MD development should address changes in growth and psychosocial maturation, physiology, and pathophysiology, and avoid inappropriate repurposing of adult technologies. Underpinning the development of MD for CYP is the need to ensure MD safety and effectiveness through pediatric MD-specific regulations. Contrary to current perceptions of limited market potential, the global pediatric healthcare market is expected to generate around USD 15,984 million by 2025. There are 1.8 billion young people in the world today; 40% of the global population is under 24, creating significant future healthcare market opportunities. This review highlights a number of technology areas that have led to successful pediatric MD, including 3D printing, advanced materials, drug delivery, and diagnostic imaging. To ensure the targeted development of MD for CYP, collaboration across multiple professional disciplines is required, facilitated by a platform to foster collaboration and drive innovation. The European Pediatric Translational Research Infrastructure (EPTRI) will be established as the European platform to support collaboration, including the life sciences industrial sector, to identify unmet needs in child health and support the development, adoption, and commercialization of pediatric MDs.

Use of spacers for patients treated with pressurized metered dose inhalers: focus on the VENTOLIN™ Mini Spacer

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.

The evolution of spacers and valved holding chambers

Spacers and valved holding chambers (VHCs) are pressurized metered dose inhaler (pMDI) accessory devices, designed to overcome problems that patients commonly experience when administering aerosol via a pMDI. Spacers were developed in direct response to patient-related issues with pMDI technique, particularly, poor coordination between actuation and inhalation, and local side-effects arising from oropharyngeal deposition. Current clinical guidelines indicate the need for widespread prescription and use of spacers, but, despite their apparent ubiquity, the devices themselves are, unfortunately, all too commonly "disused" by patients. An understanding of the background from which spacers developed, and the key factors influencing the optimization of the spacer and the later VHC, is crucial to developing an appreciation of the potential of these devices, both contemporary and future, for improving the delivery of pressurized aerosols to patients. This review, informed by a full patent search and an extensive scientific literature review, takes into account the clinical and laboratory evidence, commercial developments, and the sometimes serendipitous details of scientific anecdotes to form a comprehensive perspective on the evolution of spacers, from their origins, in the early days of the pMDI, up to the present day.

The use of incentives to reinforce medication adherence

OBJECTIVE

Poor medication adherence is a longstanding problem, and is especially pertinent for individuals with chronic conditions or diseases. Adherence to medications can improve patient outcomes and greatly reduce the cost of care. The purpose of the present review is to describe the literature on the use of incentives as applied to the problem of medication adherence.

METHODS

We conducted a systematic review of peer-reviewed empirical evaluations of incentives provided to patients contingent upon medication adherence.

RESULTS

This review suggests that incentive-based medication adherence interventions can be very effective, but there are few controlled studies. The studies on incentive-based medication adherence interventions most commonly feature patients taking medication for drug or alcohol dependence, HIV, or latent tuberculosis. Across studies that reported percent adherence comparisons, incentives increased adherence by a mean of 20 percentage points, but effects varied widely. Cross-study comparisons indicate a positive relationship between the value of the incentive and the impact of the intervention. Post-intervention evaluations were rare, but tended to find that adherence effects diminish after the interventions are discontinued.

CONCLUSIONS

Incentive-based medication adherence interventions are promising but understudied. A significant challenge for research in this area is the development of sustainable and cost-effective long-term interventions.

Incentive device improves spacer technique but not clinical outcome in preschool children with asthma

AIM

To investigate the influence of an incentive device, the Funhaler, on spacer technique and symptom control in young children with asthma and recurrent wheeze.

METHODS

Randomised controlled trial where 132 2-6 year old asthmatic children received regular inhaled fluticasone through Aerochamber Plus, or Funhaler. The setting was a research clinic at Princess Margaret Hospital for Children, Perth, Australia. Subjects were followed up for a year. The main outcome measure was asthma symptoms. Proficiency in spacer technique was measured as salbutamol inhaled from spacer onto filter. Quality of life was measured every three months. Groups were compared in terms of spacer technique, symptoms and quality of life. The relationship between spacer technique and clinical outcome was examined.

RESULTS

There was no difference between Funhaler and Aerochamber groups in wheeze free days, cough free days, bronchodilator free days or quality of life (P = 0.90, 0.87, 0.74 and 0.11 respectively). Spacer technique was better in the Funhaler group (P = 0.05), particularly in subjects younger than 4 years of age (P = 0.002). Drug dose on filter (as the mean of five 100 mg doses) ranged from zero to 136 mg.

CONCLUSIONS

Use of Funhaler incentive device does not improve clinical outcome, but improves spacer technique in children younger than 4 years. Variability in drug delivery is large in young children using pressurised metered dose inhalers and spacers.

Medication use in children with asthma: not a child size problem

OBJECTIVE

The global burden of pediatric asthma is high. Governments and health-care systems are affected by the increasing costs of childhood asthma--in terms of direct health-care costs and indirect costs due to loss of parental productivity, missed school days, and hospitalizations. Despite the availability of effective treatment, the current use of medications in children with asthma is suboptimal. The purpose of this review is to scope the empirical literature to identify the problems associated with the use of pediatric asthma medications. The findings will help to design interventions aiming to improve the use of asthma medications among children.

METHODS

A literature search using electronic search engines (i.e., Medline, International Pharmaceutical Abstracts (IPA), PubMed, PsycINFO, and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) and the search terms "asthma," "children," and "medicines" (and derivatives of these keywords) was conducted.

RESULTS

The search terms were expanded to include emergent themes arising out of search findings. Content themes relating to parents, children themselves, health-care professionals, organizational systems, and specific medications and devices were found. Within these themes, key issues included a lack of parental knowledge about asthma and asthma medications, lack of information provided to parents, parental beliefs and fears, parental behavioral problems, the high costs of medications and devices, the child's self-image, the need for more child responsibility, physician nonadherence to prescribing guidelines, "off-label" prescribing, poor understanding of teachers, lack of access to educational resources, and specific medications.

CONCLUSION

These key issues should be taken into account when modifying the development of educational tools. These tools should focus on targeting the children themselves, the parent/carers, the health-care professionals, and various organizational systems.

Assessing adherence and factors associated with adherence in young children with asthma

BACKGROUND AND OBJECTIVE

Adherence with preventive asthma medication by young children is an important factor when evaluating a suboptimal response to treatment. However, few data exist regarding the accuracy of subjective measures of adherence and factors associated with adherence in young children.

METHODS

Fifty-one asthmatic children aged 18 months to 7 years had their use of preventive asthma medication monitored using an electronic monitoring device (Smartinhaler) for 1 month. At a follow-up visit the child's parent was asked how often medication had been given and they also completed a confidential questionnaire that included questions about medication usage, barriers to optimal adherence and parenting. The treating physician made an estimate of the child's likely use of medication.

RESULTS

The median use of medication as determined by the Smartinhaler was 70.5% (range 21.4-100%). The parents' verbal reports (85.1%) and questionnaire responses (84.2%) overestimated medication usage. The physician was not able to determine which parents correctly estimated their child's use of medication (P = 0.28). The child's age, level of parental education and annual family income did not influence adherence. Parents reported simply 'forgetting' or their child's 'reaction to being given medication' as the principal barriers to adherence. There was a significant association between how stressful the parent found parenting and adherence (P = 0.05).

CONCLUSION

Adherence with preventive medication, even within the context of a research study, was generally low and highly variable. Subjective measures of adherence were found to overestimate adherence in young asthmatics.

Novel spacer device does not improve adherence in childhood asthma

The Funhaler (FH) is a novel spacer device (holding chamber) that has been designed to improve adherence and aerosol delivery in young asthmatic children using a metered dose inhaler. A pilot study reported a 38% increase in parent-reported adherence over 2 weeks compared with the child's normal spacer. The aim of this study was to investigate whether the FH would be associated with superior adherence in the medium term (3 months) using an objective assessment. Forty-seven children aged 18 months to 7 years were randomised to a FH or control small volume spacer. Participants were reviewed monthly for 3 months. Adherence was measured using an electronic monitoring device (Smartinhaler). Disease control was based on symptom scores and exacerbation rates. Twenty-six children were randomised to the FH and 21 to the control spacer. Three children withdrew (FH = 2). Median adherence each month for the 3 months was 74%, 54%, and 46% for the FH and 70%, 73%, and 54% for the control spacer. The difference in adherence was not statistically significant (P = 0.47, 0.37, and 0.23, respectively). There was also no significant difference in exacerbation rates or symptom scores. Seven of the FHs broke during the study. The FH was preferred by 21/24 parents randomised to the FH compared with their child's normal spacer. Despite the FH being popular with children and parents its use was not associated with improved adherence or disease control.

Recent advances in aerosol therapy for children with asthma

Inhalational drug delivery is the primary mode of asthma therapy in children and is the main focus of this article. Pressurized metered dose inhalers (pMDIs) are now the method of choice in infants and children under 5 years old, when used in combination with an appropriate valved holding chamber or spacer. Spacers are particularly important for steroid inhalation to maximize lung deposition and minimize unwanted oropharyngeal deposition. Optimal inhalation technique with a pMDI-spacer in infants is to inhale the drug by breathing tidally through the spacer. Drug delivery to the lungs using pMDIs can vary greatly, depending on the formulation used and the age of the child. Dry powder inhalers (DPIs) are driven by the peak inspiratory flow of the patient and are usually not appropriate for children under 5 or 6 years of age. Nebulizers continue to play a role in the treatment of acute asthma where high doses of bronchodilator are required, though multiple doses via pMDI spacer may suffice. Important drug delivery issues specific to children include compliance, use of mask versus mouthpiece, lower tidal volumes and inspiratory flows, determination of appropriate dosages, and minimization of adverse local and systemic effects.

How do you improve compliance?

Compliance, or adherence, as it relates to health care is the extent to which a person's behavior coincides with medical or health advice. Medication compliance is critical for all aspects of pediatrics, specifically in successful treatment, disease prevention, and health promotion. Compliance depends on the patient's and physician's committing to the same objectives. It is unfortunate that numerous studies and physician accounts reveal difficulties in achieving compliance with pediatric medication therapy. Medication compliance in pediatric patients ranges from 11% to 93%. At least one third of all patients fail to complete relatively short-term treatment regimens. Poor compliance places children at risk for problems such as continued disease, complicates the physician-patient relationship, and prevents accurate assessment of the quality of care provided. This article presents the issue in the context of its incidence of and barriers to compliance and provides general principles to improve compliance in pediatrics by improving communication and characteristics of the practice setting. A one-on-one relationship between physician and patient is needed for communication and improved compliance.

A new asthma spacer device to improve compliance in children: a pilot study

OBJECTIVE

This pilot study was designed to compare the acceptance, ease of use, and effects on compliance between currently used spacer devices and the Funhaler--a new small volume spacer device designed to improve adherence to asthma medication in children.

METHODOLOGY

A matched questionnaire-based survey was conducted by two interviews of each caregiver by the same person. A total of 32 children were randomly recruited from seven clinics spanning widely differing socioeconomic and geographical areas of Perth, Western Australia. Preschool children taking regular inhaled asthma medication using an existing low volume spacer device and aged between 1.5 and 6 years, took part in the pilot study. Parents completed two matched questionnaires. The first questionnaire was completed at the beginning of the study and the second after 2 weeks' use of the Funhaler spacer. Data collected related primarily to ease of use of the devices, child and parental compliance, and treatment attitudes. During the study, parents were also called at random on one occasion to ascertain whether they had attempted to medicate their child the previous day.

RESULTS

Using the Funhaler incentive spacer device, parents reported significantly more success at medicating their children (22/30 always successful) in comparison to using their existing spacer device (3/30). Parental adherence to prescribed frequency and the delivery technique of children were also improved. The children also showed improved satisfaction and willingness to use the device and parents' attitude towards medicating their children was improved with the Funhaler spacer device.

CONCLUSIONS

Use of a novel, incentive spacer device (Funhaler) appeared to be associated with increased success and fewer problems in medicating children, improved child and parental adherence, and a more positive attitude towards treatment, suggesting that more extensive long-term efficacy trials with the device are warranted.

In Vitro Performance Characteristics of Valved Holding Chamber and Spacer Devices with a Fluticasone Metered-Dose Inhaler

STUDY OBJECTIVE

To compare the in vitro aerosol deposition characteristics of several commercially available valved holding chamber (VHC) and spacer devices used with a fluticasone metered-dose inhaler (MDI).

DESIGN

In vitro aerosol deposition study

SETTING

University-affiliated research center.

DEVICES

Seven VHC devices: BreatheRite, E-Z Spacer, EasiVent, AeroChamber, InspirEase, OptiChamber, and Space Chamber. Six spacer devices: OptiHaler, Aerosol Cloud Enhancer (ACE), Gentle-Haler, MediSpacer, Ellipse, and a 6-inch tube (1-inch inside diameter).

INTERVENTION

The respirable dose (aerosol particles 1-5 microm) of fluticasone was determined by sampling 10 220-microg actuations from five runs with each spacer or VHC plus MDI combination, by using a well-established in vitro cascade impactor method.

MEASUREMENTS AND MAIN RESULTS

Fluticasone aerosol was washed from the impactor with methanol and quantified by means of high-performance liquid chromatography. Differences among outcomes were determined with analysis-of-variance testing. Among spacers, Ellipse had the highest respirable dose (104 microg, p < 0.01). Respirable doses for the 6-inch tube (74.3 microg), Gentle-Haler (81.7 microg), and MediSpacer (82.6 microg) were no different from that of the MDI (p > 0.05), whereas respirable doses of OptiHaler (44.6 microg) and ACE (47.2 microg) were less than those of all other spacers (p < 0.001). Among VHC devices, respirable doses from EasiVent (35.6 microg), AeroChamber (47.0 microg), InspirEase (52.7 microg), OptiChamber (53.1 microg), and Space Chamber (58.3 microg) were not different (p > 0.05), whereas BreatheRite (13.1 microg) and E-Z Spacer (27.3 microg) respirable doses were less than those of the other VHC devices (p < 0.05).

CONCLUSION

Spacers and VHC devices available in the United States do not demonstrate equivalent in vitro performance with the fluticasone MDI. The difference between highest and lowest respirable doses in each device category would likely lead to clinically relevant differences in the quantity of fluticasone delivered to a patient.