Comparison between traditional and nontraditional add-on devices used with pressurised metered-dose inhalers

Efficacy-based comparison between adults and children regarding using advanced counseling for asthma

BACKGROUND

Asthma advanced counseling using smartphone applications has recently become one of the most effective and commonly used methods among adults and children with asthma.

OBJECTIVES

We aimed to compare the advanced counseling effectiveness between adults and children with asthma.

METHODS

A cohort prospective parallel study was performed on a group of adults and children nonsmoking patients with asthma, using a pressurized metered dose inhaler (pMDI). The patients were divided into two groups namely adults with asthma with ages ranging from 19 to 60 years and Children with asthma with ages ranging from 11 to 18 years, the two groups received a 2-month course of advanced counseling using "Asthma software" and "Asthma Dodge" smartphone applications, during which the two groups were monitored using the forced expiratory volume in the first second to the forced vital capacity (FEV1/FVC) ratio and asthma control test (ACT). The study has obtained ethical approval with the serial number REC-H-PhBSU-23002, adhering to the principles outlined in The Declaration of Helsinki, from the Ethical Approval Committee of Beni-Suef University Faculty of Pharmacy.

RESULTS

With a total of 60 patients with asthma (N = 60), 31 adults (N = 31), and 29 children (N = 29), We found that starting from the first-month visit of counseling the children group showed superiority over the adult group in terms of the pulmonary function improvement p = .006. Also, regarding ACT scores the children group showed a superiority over the adult group this significance started from the first-month visit and continued to the second-month visit with p values = .032 and .011, respectively.

CONCLUSION

The advanced counseling achieved better asthma control and pulmonary function improvement in children and adults; however, the improvement was much better in children with asthma than adults with asthma.

Dynamic Analysis of Aerosol Release from a Pressurized Metered Dose Inhaler Combined with a Valved Holding Chamber Using Simplified Laser Photometry

Background: A pressurized metered dose inhaler combined with a valved holding chamber (pMDI+VHC) is used to prevent upper airway complications and improve the efficiency of inhaled drug delivery; however, the aerodynamic behavior of the released particles has not been well investigated. This study aimed at clarifying the particle release profiles of a VHC using simplified laser photometry. Methods: An inhalation simulator comprised a computer-controlled pump and a valve system that withdrew aerosol from a pMDI+VHC using a jump-up flow profile. A red laser illuminated the particles leaving VHC and evaluated the intensity of the light reflected by the released particles. Results: The data suggested that the output (OPT) from the laser reflection system represented particle concentration rather than particle mass, and the latter was calculated as OPT × instantaneous withdrawn flow (WF). Summation of OPT hyperbolically decreased with flow increment, whereas summation of OPT × instantaneous flow was not influenced by WF strength. Particle release trajectories consisted of three phases, namely increment with a parabolic curve, flat, and decrement with exponential decay phases. The flat phase appeared exclusively at low-flow withdrawal. These particle release profiles suggest the importance of early phase inhalation. The hyperbolic relationship between WF and particle release time revealed the minimal required withdrawal time at an individual withdrawal strength. Conclusions: The particle release mass was calculated as laser photometric output × instantaneous flow. Simulation of the released particles suggested the importance of early phase inhalation and predicted the minimally required withdrawal time from a pMDI+VHC.

Assessing of low-tech solutions for aerosol delivery: Comparative performance study of manufactured versus homemade spacers

PURPOSE

This study aims to evaluate the performance of low-cost homemade spacers compared with manufactured valved holding chambers (VHCs) for fluticasone propionate delivery via a pMDI (pressurized Metered Dose Inhaler).

METHODS

The Total Emitted Dose (TED) and particle size distribution were measured for pMDI alone or connected to the different spacers, according to CAN/CSA-Z264.1-02 standard. Two types of low-cost alternative and manufactured spacers were investigated: 500 mL plastic bottle and 553 mL aluminium can; non-antistatic plastic VHCs and aluminium antistatic VHCs.

RESULTS

The TED of homemade plastic bottle vs plastic VHC were similar in the 20-23% range. In contrast, the TED of homemade aluminium can was higher compared to aluminium VHC (83% vs 68%). The Fine Particle Fraction (FPF) was similar for the two plastic-based spacers (in the 12.68-17.60% range), although it was greater for the aluminium can compared to aluminium VHC (51% vs 42%). However, all spacers have limited large particles fraction, mainly deposited in the oropharyngeal tract, potentially decreasing side effects.

CONCLUSION

We demonstrated that low-tech solutions as homemade spacers have at least similar performances to VHC medical devices composed of same material (aluminium or plastic). Thus, low-cost homemade spacers represent alternatives in case of emergency and without VHCs nearby.

Effect of using acoustic flo-tone training device and its smartphone application on enhancing inhalation technique from metered-dose inhaler with spacer in asthmatic children

Aim of study: This research study aims to compare between two different counseling approaches; traditional verbal counseling vs. advanced counseling (in which we used the acoustic Flo-tone training device and its smartphone application combined with traditional verbal counseling) to determine the most beneficial counseling approach for asthmatic children who use metered-dose inhaler (MDI) with spacers concerning inhalation duration and inhalation technique mistakes. Methods: A total of 100 asthmatic children (8-18) years old were randomized into two groups (a control group, and an advanced group). Each group included 50 subjects. Every subject received 3 counseling meetings, one each month. Asthmatic children in the control group were trained on inhalation technique from MDI + spacer verbally (traditional counseling), while asthmatic children in advanced group were trained on inhalation technique from MDI + spacer verbally and by advanced counseling (whistling Flo-tone + smartphone application). At each visit mistakes in inhalation technique steps were; detected, corrected, and recorded and the inhalation duration was measured for every child in each group. Results: In both study groups, the total mean number of inhalation technique mistakes decreased significantly (p < 0.05) from visit 2, also the total mean inhalation durations in seconds showed a significant increase (p < 0.05) from visit 2. A significant (p < 0.05) reduction in the total mean number of mistakes and a significant (p < 0.05) increase in total mean inhalation durations were observed from visit 2 in advanced group compared to control group. Conclusion: Combination between traditional verbal and advanced counseling methods resulted in significant (P < 0.05) improvements in the number of inhalation technique mistakes and inhalation durations from MDI with spacer in children compared to using traditional verbal counseling alone.

Advanced counselling using training device and smartphone application on inhalation technique from metered-dose inhaler with spacer equipped with different interfaces in asthmatic children

BACKGROUND

Spacers are equipped with either facemask or mouthpiece as an interface through which patient inhale their dose. The present study aimed to evaluate the effect of advanced counselling using training devices and smartphone applications on inhalation techniques from the metered-dose inhaler (MDI) with a spacer equipped with different interfaces.

METHODS

100 paediatric asthmatic children (8-18 years) were divided into two groups. Group one was a spacer with a mouthpiece (n = 50) and group two was a spacer with a facemask group (n = 50). Both groups had three visits one month apart. At each visit, patients were asked to show the investigator their inhalation technique using MDI with spacer, and mistakes were recorded and then patients were trained on the proper inhalation technique of using MDI with a spacer. In the spacer with mouthpiece group, Flo-Tone was attached to the mouthpiece to allow the Trainhaler smartphone application to detect the duration of inhalation. In the spacer with facemask group, there was no need to use the Flo-Tone training device since the facemask was equipped with a built-in whistle detected by the Trainhaler smartphone application.

RESULTS

The total number of mistakes in the inhalation technique decreased significantly (P < .05) in visits 2 and 3 for both groups. Duration of inhalation increased significantly (P < .05) in the mouthpiece group at visit 2 and in the facemask group at visit 3. Achieving 5 seconds of slow deep inhalation, breath-holding for 5 seconds after inhalation and the tight fit of facemask represented the major obstacles in most children especially the youngest subjects. Breath out as far as comfortable had the highest number of mistakes in the first visit in both groups.

CONCLUSION

The Flo-Tone with its positive reinforcement whistle and the Trainhaler smartphone application significantly improved the inhalation technique by decreasing the total number of mistakes especially in important steps eg, shaking MDI, maintaining slow inhalation rate, breath-holding after inhalation and appropriate facemask fitting. Also, they increased the duration of inhalation of asthmatic children from MDI with a spacer. Both spacer interfaces are easy to handle once taught well.

A 3D printed human upper respiratory tract model for particulate deposition profiling

Pulmonary route is the main route of drug delivery for patients with asthma and chronic obstructive pulmonary diseases, offering several advantages over the oral route. Determining the amount of drug deposited onto various parts of the respiratory tract allows for a good correlation to clinical efficacy of inhalation drug devices. However, current in vitro cascade impactors measure only the aerodynamic particle size distribution, which does not truly represent the in vivo deposition pattern in human respiratory tract. In this study, a human upper respiratory tract model was fabricated using a 3D printer and subsequently characterized for its dimensional accuracy, surface finishing and air leaking. The effects of using a spacer and/or various airflow rates were also investigated. To assess this in vitro model, the deposition pattern of a model drug, namely, salbutamol sulphate, was tested. The resultant deposition pattern of salbutamol sulphate from a metered dose inhaler at 15 L per minute with the spacer, showed no significant difference from that of a published radiological in vivo study performed in adult humans. In addition, it was also found that the deposition pattern of salbutamol at 35 L per minute was comparable to the results of another published study in human. This in vitro model, showing reasonable in vitro-in vivo correlation, may provide opportunities for personalized medicine in special populations or disease states.