Device Selection and Outcomes of Aerosol Therapy: Evidence-Based Guidelines

A randomized crossover study assessing critical errors, preferences, and ease of use of two multidose powder inhalers

BACKGROUND

The effectiveness of inhaled medications in asthma and COPD is significantly impacted by inhalation errors. Feedback mechanisms, built into the design of the inhaler might reduce the number of critical errors. This study compares critical errors, preferences, and ease of use of two dry powder inhalers, the Nexthaler and the Turbuhaler.

RESEARCH DESIGN AND METHODS

In this multi-center, prospective, randomized, open-label, cross-over study, the proportions of asthma and COPD patients making critical errors were compared between the Nexthaler and Turbuhaler after 4 weeks of clinical use, after having been trained in the correct use of both inhalers.

RESULTS

90 and 49 patients with asthma and COPD, respectively were assessed. No significant difference was found in the number of critical errors between the two inhalers (3 with Nexthaler and 5 with Turbuhaler). However, more patients preferred the Nexthaler (57.6%) over the Turbuhaler (34.5%) (p = 0.006), while 7.9% stated no preference.

CONCLUSIONS

The study found no significant differences in critical error rate between the Nexthaler and Turbuhaler but the Nexthaler was preferred over the Turbuhaler. This study highlights the importance of dedicating sufficient time to instructing patients in correct inhalation technique, which can lead to long-term retention of the inhalation technique.

TRIAL REGISTRATION

The trial is registered at International Clinical Trials Registry Platform. Trial number NL-OMON55778.

Update on the pharmacological treatment of chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a common syndrome associated with smoking and environmental exposures coupled with genetic susceptibility. Recent major advancements in the treatment of COPD patients have become available.

AREAS COVERED

New data on the role of classic bronchodilators, including short-acting and long-acting beta2-agonists and anti-muscarinic antagonists, in the treatment of COPD patients are discussed. Data promoting a more targeted approach to inhaled and systemic corticosteroid use in COPD are reviewed. Phosphodiesterase (PDE) inhibitors, including the recently approved PDE 3/4 inhibitor inhaled ensifentrine, are noted. Selective use of antibiotics can play a role in complex COPD patients. COPD patients with evidence of asthma-COPD overlap syndrome and type-two lymphocytic inflammatory-mediated airway constriction appear to respond to biologics, particularly the anti-IL-4/IL-3 antagonist monoclonal antibody, dupilumab.

EXPERT OPINION

New therapeutic options have made the approach and treatment of the COPD patient much more complicated. These options tend to be very expensive. Attention to identifying the endotype and phenotype will help direct the pharmacotherapy.

Inhaled corticosteroid delivery is markedly affected by breathing pattern and valved holding chamber model

BACKGROUND

There is a scarcity of high-quality research on the efficient delivery of inhaled corticosteroids using valved holding chambers (VHCs) in children.

METHODS

The delivered dose (DD) of fluticasone from a metered dose inhaler (pMDI) was tested using four VHCs: AeroChamber plus Flow-Vu (AC), Babyhaler (BH), EasyChamber (EC), and Optichamber Diamond (OD). The in vitro setup included an anatomical child throat model, Next Generation Impactor, and a breathing simulator to generate tidal breathing of a four and a 6-year-old child, and adult type single inhalation.

RESULTS

OD showed the lowest proportion of fluticasone trapped in the throat with all breathing patterns. AC showed similar fine particle dose (FPD) in the respirable range (1-5 µm) irrespective of the breathing pattern. For BH, the median FPD 1-5 µm was highest during adult breathing. OD and EC showed higher overall DD and higher doses in the 1-5 µm range with paediatric breathing profiles compared to adult inhalation. The median DD and FPD 1-5 µm were significantly lower with BH compared to any other VHCs during tidal breathing. Compared to EC, the FPD of the other VHCs were skewed towards <2 µm particles.

CONCLUSION

Fluticasone delivery is markedly affected by breathing pattern and VHC model. The observed differences in throat deposition and FPD delivered may have significant clinical implications for side effects and controlling airway inflammation. All VHCs intended for paediatric use should undergo testing using internationally recognised standardised methods incorporating clinically relevant paediatric breathing patterns.

Prevalence and Management of Chronic Obstructive Pulmonary Disease in the Gulf Countries with a Focus on Inhaled Pharmacotherapy

Background: Chronic obstructive pulmonary disease (COPD) is a preventable, progressive disease and the third leading cause of death worldwide. The epidemiological data of COPD from Gulf countries are very limited, as it remains underdiagnosed and underestimated. Risk factors for COPD include tobacco cigarette smoking, water pipe smoking (Shisha), exposure to air pollutants, occupational dusts, fumes, and chemicals. Inadequate treatment of COPD leads to worsening of disease. The 2024 GOLD guidelines recommend use of inhaled bronchodilators, corticosteroids, and adjunct therapies for treatment and management of COPD patients based on an individual assessment of the severity of symptoms and risk of exacerbations. This article reviews COPD pharmacotherapy in the Gulf countries and explores the role of nebulization in the management of COPD in this region. Methods: To review the COPD pharmacotherapy in the Gulf Countries, literature search was conducted using PubMed, Medline, Cochrane Systematic Reviews, and Google Scholar databases (before December 2022), using search terms such as COPD, nebulization, inhalers/inhalation, aerosols, and Gulf countries. Relevant articles from the reference list of identified studies were reviewed. Consensus statements, expert opinion, and other published review articles were included. Results: In the Gulf countries, pressurized metered-dose inhalers (pMDIs), dry powder inhalers (DPIs), soft mist inhalers, and nebulizers are used for drug delivery to COPD patients. pMDIs and DPIs are most prone to errors in technique and other common device handling errors. Nebulization is another mode of inhalation drug delivery, which is beneficial in certain patient populations such as the elderly and patients with cognitive impairment, motor or neuromuscular disorders, and other comorbidities. Conclusion: There is no major difference between Gulf countries and rest of the world in the approach to management of COPD. Nebulizers should be considered for patients who have difficulties in accessing or using MDIs and DPIs, irrespective of geographical location.

Use of a Capsaicin Cough Challenge Test to Compare Four Different Techniques for Nebulization Delivery in Cats

Successful aerosol therapy might rely more heavily on proper drug delivery than on the effectiveness of the medication. This study compared four techniques for nebulization delivery in cats. Tolerance rate (TR) was subjectively evaluated (1-3). Increasing capsaicin concentrations were nebulized for objective evaluation of efficiency. The positive response (PR) was considered when more than five coughs were induced. The following delivery methods were tested: flow-by (FB); face mask (FM); plastic-covered Elizabethan collar (EC); and plexiglass chamber (PC). The number of PRs (NPR) and the concentration of capsaicin that induced a PR (CCP) were statistically compared (p < 0.05). The PC method was the best tolerated (TR = 3.0 ± 0.0), followed by the FB (2.7 ± 0.5) and FM (2.6 ± 0.5). The EC was very stressful, and the test had to be suspended in four out of nine cats. The lowest CCP was found with the FM (91.8 ± 157.2 µM), followed by the FB (166.7 ± 190.9 µM), PC (242.6 ± 244.8 µM), and EC (350.0 ± 225.7 µM), with significant differences only between the FM and EC (p = 0.02). The highest NPR (8) corresponded to the FM, followed by the FB (7), the PC (5), and the EC (3), with significant differences between the FM and EC (p = 0.016). In conclusion, the capsaicin cough test induces reproducible and quantifiable cat responses. The FM is the most efficient for nebulization delivery, offering good compliance and the best quantitative results. FB nebulization is less efficient but may be practical if the FM is not tolerated. PC offers minor efficiency but may be useful for very stressed or aggressive cats. The EC presents low efficiency and compliance.

Aerosol drug therapy in critically ill patients (Aero-in-ICU study): A multicentre prospective observational cohort study

BACKGROUND

In recent years, a significant understanding of delivering optimal aerosol therapy and the availability of various drugs and devices have led to an increase in its use in clinical practice. There are only a few studies available regarding their use in critically ill patients from a few parts of the world. We aimed to study the practice pattern of aerosol therapy in critically ill patients from Indian intensive care units (ICUs).

METHODS

After ethical approval, this multi-centric prospective observational study was performed over a study period of four weeks. Newly admitted adult patients considered who had an artificial airway and/or ventilation (including non-invasive). Patients were followed up for the next 14 days or until ICU discharge/death (whichever came first) for details of each aerosol therapy, including ongoing respiratory support, drug type, and aerosol-generating device.

RESULTS

From the nine participating centers across India, 218 patients were enrolled. Of 218 enrolled patients, 72.48% received 4884 aerosols with 30.91 ± 27.15 (95%CI: 26.6-35.1) aerosols per patient over 1108 patient days. Approximately 62.7% during IMV, 30.2% during NIV, 2.3% in spontaneously breathing patients with an artificial airway during weaning, and 4.7% were given without an artificial airway after weaning or decannulation. In 59%, a single drug was used, and bronchodilators were the most frequent. The jet nebulizer was the most common, followed by the ultrasonic and vibrating mesh aerosol generator. The ventilator setting was changed in only 6.6% of the aerosol sessions with IMV and none with NIV.

CONCLUSION

Aerosol therapy is frequently used with a wide variation in practices; bronchodilators are the most commonly used drugs, and jet nebulizers are the most widely used.

All shook up: how the COVID-19 pandemic rocked pediatric asthma care

PURPOSE OF REVIEW

Asthma management is a crucial aspect of public health. The landscape of asthma management underwent significant change in the wake of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. These changes greatly affected existing patients, individuals suffering with undiagnosed illness, providers, and the healthcare system as a whole.

RECENT FINDINGS

Providers had to navigate through the potential risk of exposure while weighing the benefit of office visits for patients. This promoted the rapid uptake of telemedicine and virtual outreach, as well as modifications to acute management and controller therapies. Telehealth allowed for the remote monitoring of these patient populations, increased compliance with home-based self-management, and an emphasis on patient education. Furthermore, the pandemic underscored the importance of proactive asthma management as many individuals were left untreated or undiagnosed for various reasons. It is evident that the SARS-CoV-2 pandemic reshaped the landscape of various components of the healthcare system, including asthma management, necessitating innovative approaches to monitoring and patient education.

SUMMARY

Understanding the lessons learned from this time period is crucial for enhancing the resilience of our health system in the wake of future challenges that may be posed against our system.

Comparison of the Application of Vibrating Mesh Nebulizer and Jet Nebulizer in Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-analysis

Objective

To comparison of the application of Vibrating Mesh Nebulizer and Jet Nebulizer in chronic obstructive pulmonary disease (COPD).

Research Methods

This systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statements. The primary outcome measures analyzed included: The amount of inhaler in the urine sample at 30 minutes after inhalation therapy (USAL0.5), The total amount of inhaler in urine sample within 24 hours (USAL24), Aerosol emitted, Forced expiratory volume in 1 second (FEV1), Forced vital capacity (FVC).

Results

Ten studies were included with a total of 314 study participants, including 157 subjects in the VMN group and 157 subjects in the JN group. The data analysis results of USAL0.5, MD (1.88 [95% CI, 0.95 to 2.81], P = 0.000), showed a statistically significant difference. USAL24, MD (1.61 [95% CI, 1.14 to 2.09], P = 0.000), showed a statistically significant difference. The results of aerosol emitted showed a statistically significant difference in MD (3.44 [95% CI, 2.84 to 4.04], P = 0.000). The results of FEV1 showed MD (0.05 [95% CI, -0.24 to 0.35], P=0.716), the results were not statistically significant. The results of FVC showed MD (0.11 [95% CI, -0.18 to 0.41], P=0.459), the results were not statistically significant. It suggests that VMN is better than JN and provides higher aerosols, but there is no difference in improving lung function between them.

Conclusion

VMN is significantly better than JN in terms of drug delivery and utilization in the treatment of patients with COPD. However, in the future use of nebulizers, it is important to select a matching nebulizer based on a combination of factors such as mechanism of action of the nebulizer, disease type and comorbidities, ventilation strategies and modes, drug formulations, as well as cost-effectiveness, in order to achieve the ideal treatment of COPD.

Individualized aerosol medicine: Integrating device into the patient

Pulmonary drug delivery is complex due to several challenges including disease-, patient-, and clinicians-related factors. Although many inhaled medications are available in aerosol medicine, delivering aerosolized medications to patients requires effective disease management. There is a large gap in the knowledge of clinicians who select and provide instructions for the correct use of aerosol devices. Since improper device selection, incorrect inhaler technique, and poor patient adherence to prescribed medications may result in inadequate disease control, individualized aerosol medicine is essential for effective disease management and control. The components of individualized aerosol medicine include: (1) Selecting the right device, (2) Selecting the right interface, (3) Educating the patient effectively, and (4) Increasing patient adherence to therapy. This paper reviews each of these components and provides recommendations to integrate the device and interface into the patient for better clinical outcomes.

A Retrospective Review of an Inhaler to Nebulizer Therapeutic Interchange Program Across a Health System

Background: The hospitals of the Saint Alphonsus Health System (SAHS) have implemented a metered dose inhaler (MDI) to nebulization therapeutic interchange program in which all orders for albuterol/ipratropium and inhaled corticosteroid/long-acting beta agonists (ICS/LABA) MDIs are therapeutically interchanged to nebulizers by pharmacy. Objectives: The primary outcome measure is to assess the percent of albuterol/ipratropium and ICS/LABA inhalers therapeutically interchanged to nebulized solutions. Secondary outcomes include assessment of readmission rates, the percentage of patients discharged with the appropriate MDI, and a financial analysis of the implementation of the therapeutic interchange program. Methods: This retrospective observational cohort study was approved by the system's institutional review board and conducted between October 15, 2019, and February 15, 2020. Adult patients with history of asthma or COPD admitted to one of the SAHS hosptials with an order placed for ipratropium/albuterol, fluticasone/salmeterol, mometasone/formoterol, or budesonide/formoterol MDIs were eligible for inclusion. Patients were excluded if they were presumed to have or tested positive for COVID-19. Results: Therapeutic interchanges were successfully completed in 94.3% of the orders included in this evaluation. Discharge discrepancies occurred in 14.3% of orders assessed. No correlation was found between discharge discrepancies and 30-day readmissions. The MDI to nebulized solution interchanges saved $13,908.16 in medication cost in the sample population. Conclusion: The first phase of implementing the SAHS inhaler to nebulizer therapeutic interchange program was operationally and clinically successful. The program is projected to continue to reduce medication waste and provide cost savings for the health system.

Maintenance Therapy for Children and Adolescents with Asthma: Guidelines and Recommendations from the Emilia-Romagna Asthma (ERA) Study Group

Asthma is the most frequent chronic disease of childhood, affecting up to 20% of children worldwide. The main guidelines on asthma maintenance therapy in pediatrics suggest different approaches and describe different stages of asthma to determine the most appropriate treatment. This project aims to summarize the most recent evidence regarding maintenance therapy for asthma in children and adolescents. A multidisciplinary panel of experts was asked clinical questions regarding the treatment of children and adolescents with asthma. Overall, 10 clinical questions were addressed, and the search strategy included accessing electronic databases and a manual search of gray literature published in the last 25 years. After data extraction and narrative synthesis of results, recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Results showed that the choice of medication depends on the severity of the child's asthma, phenotype, age, preference, and individual factors. In addition to medications, the identification of comorbidities and modifiable factors is crucial to obtaining good control. Asthma in children is heterogeneous, and its evolution varies over time. Since most recommendations for asthma management in childhood are extrapolated from clinical studies performed in adults, more clinical trials specifically designed for young children should be conducted.

Evaluating inhaler education interventions for hospitalized children with asthma: A randomized controlled trial

BACKGROUND

Most children with asthma have poor inhaler technique, with detrimental morbidity effects. Guidelines recommend clinicians provide inhaler education at every opportunity, yet resources are limited. A low-cost, technology-based intervention-Virtual Teach-to-Goal (V-TTG)-was developed to deliver tailored inhaler technique education with high fidelity.

OBJECTIVE

To evaluate whether V-TTG leads to less inhaler misuse among children with asthma who are hospitalized vs brief intervention (BI, reading steps aloud).

METHODS

A single-center randomized controlled trial of V-TTG vs BI was conducted with 5-to-10-year-old children with asthma hospitalized between January 2019 and February 2020. Inhaler technique was assessed pre- and post-education using 12-step validated checklists (misuse: < 10 steps correct).

RESULTS

Among 70 children enrolled, mean age was 7.8 years (SD = 1.6). Most (86%) were Black. Most had an emergency department visit (94%) or hospitalization (90%) in the previous year. At baseline, nearly all children misused inhalers (96%). The proportion of children with inhaler misuse decreased significantly in V-TTG (100%→74%, P = .002) and BI (92%→69%, P = .04) groups, with no difference between groups at both time points (P = .2 and .9). On average, children performed 1.5 more steps correctly (SD = 2.0), with greater improvement with V-TTG (mean [SD] = 1.7 [1.6]) vs BI (mean [SD] = 1.4 [2.3]), though not significant (P = .6). Concerning pre and post technique, older children were significantly more likely than younger children to show more correct steps (mean change = 1.9 vs 1.1, P = .002).

CONCLUSION

A technology-based intervention for tailored inhaler education led to improved technique among children, similarly to reading steps aloud. Older children saw greater benefits. Future studies should evaluate the V-TTG intervention across diverse populations and disease severities to identify the greatest impact.

CLINICAL TRIAL REGISTRATION

NCT04373499.

[Assessment of inhalation technique in patients with bronchial asthma and chronic obstructive pulmonary disease]

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.

Qualitative and quantitative evaluation of a standardized training model for improving patients' ability to use inhalers

Objective

Training contributes to the effectiveness of aerosol inhalation therapy. However, qualitative and quantitative evaluation of effective training methods is rarely reported. This study aimed to evaluate the effectiveness of a standardized training model by pharmacists based on verbal instruction and physical demonstration in improving patients' ability to use inhalers using qualitative and quantitative methods. Risk or protective factors affecting correct inhaler use were also explored.

Methods

431 Outpatients with asthma or COPD were recruited and randomly divided into a standardized training group (n = 280) and a usual training group (control group, n = 151). A framework of qualitative (e.g., multi-criteria analysis) and quantitative comparisons [percentage of correct use (CU%), percentage of complete error (CE%), and percentage of partial error (PE%)] was established to evaluate the two training models. In addition, the changes of key factors (age, education level, adherence, device type, etc.) influencing patients' ability to use inhalers of two models were observed.

Results

The multi-criteria analysis showed that the standardized training model had comprehensive advantages in qualitative indicators. The average correct use percentage (CU%) of the standardized training group was significantly higher than that of the usual training group (77.6% vs. 35.5%). A stratified analysis further demonstrated that the ORs (95%CI) in the usual training group of age and educational level was 2.263 (1.165-4.398) and 0.556 (0.379-0.815), while in the standardized training group, age and educational level were not the key factors influencing the ability to use inhaler devices (P > 0.05). Logistic regression analysis demonstrated that standardized training was a protective factor for inhalation ability.

Conclusion

These findings indicate that the framework of qualitative and quantitative comparisons could be used to evaluate training models, and the standardized training model by pharmacists can significantly improve patients' ability to use inhalers correctly and address the influence of older age and lower education because of its methodological advantages. Further studies with more extended follow-up are needed to validate the role of the standardized training model by pharmacists in the correct use of inhalers.

Clinical trial registration

chictr.org.cn, ChiCTR2100043592 (23-02-2021).

From the infant to the geriatric patient-Strategies for inhalation therapy in asthma and chronic obstructive pulmonary disease

Inhalation therapy represents the standard of care in children, adolescents as well as in young, middle-aged and geriatric adults with asthma or chronic obstructive pulmonary disease. However, there are only few recommendations for the choice of inhalation devices, which consider both, age-specific limitations in young and geriatric patients. Transition concepts are lacking. In this narrative review, the available device technologies and the evidence for age-specific problems are discussed. Pressurized metered-dose inhalers may be favoured in patients who fulfill all cognitive, coordinative and manual power requirements. Breath-actuated metered-dose inhalers, soft-mist inhalers or the use of add-on devices such as spacers, face masks and valved holding chambers may be suitable for patients with mild to moderate impairments of these variables. In these cases, available resources of personal assistance by educated family members or caregivers should be used to allow metered-dose inhaler therapy. Dry powder inhalers may be reserved for patients with a sufficient peak inspiratory flow and good cognitive and manual abilities. Nebulizers may be indicated in persons who are either unwilling or unable to use handheld inhaler devices. After initiation of a specific inhalation therapy, close monitoring is essential to reduce handling mistakes. An algorithm is developed that considers age and relevant comorbidities to support the decision-making process for the choice of an inhaler device.

A four-part guide to lung immunology: Invasion, inflammation, immunity, and intervention

Lungs are important respiratory organs primarily involved in gas exchange. Lungs interact directly with the environment and their primary function is affected by several inflammatory responses caused by allergens, inflammatory mediators, and pathogens, eventually leading to disease. The immune architecture of the lung consists of an extensive network of innate immune cells, which induce adaptive immune responses based on the nature of the pathogen(s). The balance of immune responses is critical for maintaining immune homeostasis in the lung. Infection by pathogens and physical or genetic dysregulation of immune homeostasis result in inflammatory diseases. These responses culminate in the production of a plethora of cytokines such as TSLP, IL-9, IL-25, and IL-33, which have been implicated in the pathogenesis of several inflammatory and autoimmune diseases. Shifting the balance of Th1, Th2, Th9, and Th17 responses have been the targets of therapeutic interventions in the treatment of these diseases. Here, we have briefly reviewed the innate and adaptive i3mmune responses in the lung. Genetic and environmental factors, and infection are the major causes of dysregulation of various functions of the lung. We have elaborated on the impact of inflammatory and infectious diseases, advances in therapies, and drug delivery devices on this critical organ. Finally, we have provided a comprehensive compilation of different inflammatory and infectious diseases of the lungs and commented on the pros and cons of different inhalation devices for the management of lung diseases. The review is intended to provide a summary of the immunology of the lung, with an emphasis on drug and device development.

Role of dispersion enhancer selection in the development of novel tratinterol hydrochloride dry powder inhalation formulations

Tratinterol hydrochloride (TH) is a new long-acting bronchodilator with strong β₂ adrenoceptor stimulation activity. The aim of this study was to design a new carrier-based dry powder inhalation (DPI) formulation for TH and to investigate the effect of dispersion enhancers on the aerosol performance of TH in vitro. To this end, coarse lactose was used as a carrier. TH was micronized by using a jet mill and blended with the carrier to obtain a reference DPI formulation. Commercial magnesium stearate (MgSt) as received, micronized MgSt (MgSt-M), and fine lactose (FL) were used as the dispersion enhancers and formulated with the micronized TH (TH-M) and the carrier as DPI formulations. The obtained DPI formulations were characterized using dynamic light scattering (DLS), X-ray powder diffraction (XRPD), thermal analysis, powder rheometer, and Raman microscopy. A next generation pharmaceutical impactor (NGI) was used to evaluate the aerodynamic performance of the dry powders. The results showed that TH-M was in an inhalable particle size range, and based on the XRPD and thermal analysis, the solid form of TH-M did not change compared to the starting materials. The NGI results showed that the fine particle fraction (FPF) of TH could be increased with the addition of MgSt and FL as dispersion enhancers in the reference formulation. In addition, the FPF of TH could be increased with a decrease in the particle size of MgSt or an increase in the amount of FL. A combination of MgSt-M and FL could further improve the aerosol performance of TH. Raman spectroscopic imaging confirmed the spatial location of MgSt and TH at the surface of the carrier. This study demonstrates that TH could be formulated into carrier-based dry powder formulation for inhalation using coarse lactose as the carrier. The dual strategy based on using both MgSt and FL as dispersion enhancers improved the aerosol performance of a novel TH dry powder formulation.

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.

Electronic Monitoring Devices to Support Inhalation Technique in Patients with Asthma: a Narrative Review

Purpose of Review

Improper inhaling technique is common and is associated with poor patient outcomes. However, digital e-health devices may offer novel opportunities for educational support. This narrative review provides an overview of electronic monitoring devices (EMDs) measuring patient inhalation technique. We summarise their technical features, capabilities and limitations and discuss the steps necessary for implementation in clinical practice.

Recent Findings

Six EMDs measuring inhalation were identified. The quality of published evidence varied widely. Devices differed in the inhalation technique steps measured, the feedback provided and the type of sensor employed. Sustainability and battery life differed according to whether devices were built into inhalers or add-ons. Nevertheless, all EMDs could reliably capture diverse inhaler technique errors, and some can guide educational interventions and follow-up treatment. In addition, some EMDs may serve as an early warning system for exacerbations.

Summary

New-generation EMDs can measure patient inhalation technique, yet there is limited data on patient preferences, acceptability of inhaler technique monitoring, cost-effectiveness and the influence of inhaler technique monitoring on clinical outcomes, all representing areas for further research.

Development of an inhaled anti-TSLP therapy for asthma

Thymic stromal lymphopoietin (TSLP), an epithelial cell-derived cytokine, acts as a key mediator in airway inflammation and modulates the function of multiple cell types, including dendritic cells and group 2 innate lymphoid cells. TSLP plays a role in asthma pathogenesis as an upstream cytokine, and data suggest that TSLP blockade with the anti-TSLP monoclonal antibody, tezepelumab, could be efficacious in a broad asthma population. Currently approved asthma biologic therapies target allergic or eosinophilic disease and require phenotyping; therefore, an unmet need exists for a therapy that can address Type 2 (T2)-high and T2-low inflammation in asthma. All currently approved biologic treatments are delivered intravenously or subcutaneously; an inhaled therapy route that allows direct targeting of the lung with reduced systemic impact may offer advantages. Currently in development, ecleralimab (CSJ117) represents the first inhaled anti-TSLP antibody fragment that binds soluble TSLP and prevents TSLP receptor activation, thereby inhibiting further inflammatory signalling cascades. This anti-TSLP antibody fragment is being developed for patients with severe uncontrolled asthma despite standard of care inhaled therapy. A Phase IIa proof of concept study, using allergen bronchoprovocation as a model for asthma exacerbations, found that ecleralimab was well-tolerated and reduced allergen-induced bronchoconstriction in adult patients with mild asthma. These results suggest ecleralimab may be a promising, new therapeutic class for asthma treatment.

Temporal and geographical variation in low carbon inhaler dispensing in England, 2016 to 2021: an ecological study

OBJECTIVES

In 2019-2020, four national recommendations were published in the United Kingdom to encourage use of low carbon inhalers. This study aimed to investigate whether these were associated with a change in primary care dispensing in England and to explore associations between geographical variation and clinical commissioning group (CCG) characteristics.

DESIGN

Ecological study using aggregated publicly available data.

SETTING

All CCGs in England (March 2016 to February 2021).

PARTICIPANTS

not applicable.

MAIN OUTCOME MEASURES

Percentage of low carbon inhalers dispensed.

RESULTS

The percentage of low carbon inhalers dispensed was 26.3% in 2020-2021 (of 8.8 million inhalers). This decreased over the study period for short-acting beta-agonist (SABA), inhaled corticosteroid (ICS) and ICS+long-acting beta-agonist (LABA) inhalers. The same trend was seen for LABA and ICS+LABA+long-acting muscarinic antagonist inhalers from 2019. The SABA and ICS classes were less often dispensed as low carbon inhalers (⁓6% versus 35-45%). Interrupted time series analyses found slight increases in low carbon inhaler percentage in the SABA, LABA and ICS classes after April 2019, which were soon erased by the long-term trend. There was also geographical variation, with the north-west, Birmingham and London consistently dispensing more low carbon inhalers. The presence of advice on climate change in CCG formularies/guidelines, the prevalence of asthma and population age profile were associated with significant variation in low carbon inhaler percentage for some classes.

CONCLUSIONS

The percentage of low carbon inhalers dispensed in England remains low and continues to decrease. Greater use of low carbon inhalers is achievable, but is more likely with locally implemented initiatives.

Nebulization versus metered-dose inhaler and spacer in bronchodilator responsiveness testing: a retrospective study

BACKGROUND

The recommended delivery mode for bronchodilators in bronchodilator responsiveness (BDR) testing remains controversial.

OBJECTIVE

To compare the efficacy of salbutamol administration using a nebulizer versus a metered-dose inhaler (MDI) with spacer in BDR testing.

DESIGN

A retrospective study.

METHODS

This study examined the data of patients with chronic obstructive pulmonary disease who completed BDR testing between 1 December 2021 and 30 June 2022, at Xiangya Hospital, Central South University. After administering 400 μg of salbutamol through an MDI with spacer or 2.5 mg using a nebulizer, the changes in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were analyzed in patients with moderate-to-very severe spirometric abnormalities [pre-bronchodilator FEV1 percentage predicted values (FEV1%pred) ⩽59%]. Significant responsiveness was assessed as >12% and >200 mL improvement in FEV1 and/or FVC or >10% increase in FEV1%pred or FVC percentage predicted values (FVC%pred) from pre- to post-bronchodilator administration.

RESULTS

Of the enrolled 894 patients, 83.2% were male (median age, 63 years). After propensity score matching, 240 pairs of patients were selected. The increment in FEV1 and increased FEV1 relative to the predicted value (ΔFEV1%pred) were significantly higher in patients <65 years and those with severe spirometric abnormalities in the nebulization group than patients in the MDI group (all p < 0.05). Compared with MDI with spacer, patients who used nebulization had a 30 mL greater increase in ΔFEV1 (95% CI: 0.01-0.05, p = 0.004) and a 1.09% greater increase in ΔFEV1%pred (95% CI: 0.303-1.896, p = 0.007) from baseline. According to the > 12% and >200 mL increase criterion, the significant BDR rate with nebulization was 1.67 times higher than that with an MDI with spacer (OR = 1.67, 95% CI: 1.13-2.47, p = 0.009).

CONCLUSION

Salbutamol delivered using a nebulizer may be preferable to an MDI with spacer in certain circumstances. Nebulization has the potential to increase responsiveness to salbutamol in BDR testing.

Influence of inhalation device, active substance, and drug formulation on the compliance of patients with obstructive pulmonary diseases. A physicians... perspective

AIM

To investigate the perspective of physicians treating chronic airway diseases on the importance of device and substance characteristics influencing the compliance of patients with chronic obstructive airways diseases.

OBJECTIVE

We surveyed physicians... perspective on the impact of device and substance characteristics on patients... compliance.

METHODS

This study was carried out by running a structured questionnaire, to a total of 144 physicians, conducting personal interviews and evaluating answers on a scale from 1 for most to 6 for least important influencing parameter.

RESULTS

Overall, the most important parameters influencing patients... compliance according to physicians... perspective were rapid onset of action, type of inhalation device and duration of action. Adverse events were considered as the least important parameter. When COPD and asthma were examined separately, the most important parameters influencing compliance were rapid onset of action, ease of use and duration of action. Rapid onset of action was significantly more important in asthma than COPD.

CONCLUSION

Onset and duration of action and ease of use were classified higher as important parameters to increase patients... compliance, according to physicians...

PERSPECTIVE

Therapeutic Approaches for Chronic Obstructive Pulmonary Disease (COPD) Exacerbations

Chronic Obstructive Pulmonary Disease (COPD) is a progressive pulmonary disorder underpinned by poorly reversible airflow resulting from chronic bronchitis or emphysema. The prevalence and mortality of COPD continue to increase. Pharmacotherapy for patients with COPD has included antibiotics, bronchodilators, and anti-inflammatory corticosteroids (but with little success). Oral diseases have long been established as clinical risk factors for developing respiratory diseases. The establishment of a very similar microbiome in the mouth and the lung confirms the oral-lung connection. The aspiration of pathogenic microbes from the oral cavity has been implicated in several respiratory diseases, including pneumonia and chronic obstructive pulmonary disease (COPD). This review focuses on current and future pharmacotherapeutic approaches for COPD exacerbation including antimicrobials, mucoregulators, the use of bronchodilators and anti-inflammatory drugs, modifying epigenetic marks, and modulating dysbiosis of the microbiome.

Inhalable microparticles as drug delivery systems to the lungs in a dry powder formulations

Inhalation-administrated drugs remain an interesting possibility of addressing pulmonary diseases. Direct drug delivery to the lungs allows one to obtain high concentration in the site of action with limited systemic distribution, leading to a more effective therapy with reduced required doses and side effects. On the other hand, there are several difficulties in obtaining a formulation that would meet all the criteria related to physicochemical, aerodynamic and biological properties, which is the reason why only very few of the investigated systems can reach the clinical trial phase and proceed to everyday use as a result. Therefore, we focused on powders consisting of polysaccharides, lipids, proteins or natural and synthetic polymers in the form of microparticles that are delivered by inhalation to the lungs as drug carriers. We summarized the most common trends in research today to provide the best dry powders in the right fraction for inhalation that would be able to release the drug before being removed by natural mechanisms. This review article addresses the most common manufacturing methods with novel modifications, pros and cons of different materials, drug loading capacities with release profiles, and biological properties such as cytocompatibility, bactericidal or anticancer properties.

Scientific and regulatory activities initiated by the U.S. Food and drug administration to foster approvals of generic dry powder inhalers: Bioequivalence perspective

Regulatory science for generic dry powder inhalers (DPIs) in the United States (U.S.) has evolved over the last decade. In 2013, the U.S. Food and Drug Administration (FDA) published the draft product-specific guidance (PSG) for fluticasone propionate and salmeterol xinafoate inhalation powder. This was the first PSG for a DPI available in the U.S., which provided details on a weight-of-evidence approach for establishing bioequivalence (BE). A variety of research activities including in vivo and in vitro studies were used to support these recommendations, which have led to the first approval of a generic DPI in the U.S. for fluticasone propionate and salmeterol xinafoate inhalation powder in January of 2019. This review describes the scientific and regulatory activities that have been initiated by FDA to support the current BE recommendations for DPIs that led to the first generic DPI approvals, as well as research with novel in vitro and in silico methods that may potentially facilitate generic DPI development and approval.

Perceptions and Attitudes of Patients and Their Family Caregivers on Nebulization Therapy for COPD

Purpose

The aim of the survey was to evaluate attitudes and perceptions toward nebulization therapy for the management of chronic obstructive pulmonary disease (COPD) in Indian population.

Patients and methods

A cross-sectional, multicenter, quantitative survey was conducted from July to August 2019 among 103 COPD patients [>40 years, either gender, belonging to socio-economic class (SEC) A or SEC B] and their family caregivers. One-on-one interviews were conducted telephonically via an online survey platform (KoBo data collection tool) using a structured questionnaire. Patients receiving home nebulization were included, and the usage of nebulizers, satisfaction, and benefits and concerns with nebulizers were assessed.

Results

Overall, 47% patients were on handheld inhalers + nebulizer, 54% used nebulizer for >8 weeks, and 27% used nebulizers daily for home maintenance. Majority of the patients (77%) were satisfied with nebulization therapy. Around 70% family caregivers opined that the quality of life of COPD patients improved post-nebulization therapy. The benefits of nebulizers perceived by patients were easier breathing (89%), feeling of well-being (86%), and ease of use (86%), while family caregivers reported reduced hospitalization (76%) and easier breathing (75%). Among those with prior experience with inhalers, 72% felt nebulizers gave long-term relief, while 65% perceived having immediate relief compared to inhaler. Overall, 61% opined that benefits with nebulizers outweighed the inconvenience associated with its use. Key concerns regarding nebulizers cited by patients were time-consuming procedure (50%), feeling of dependency (49%), and social embarrassment (48%), while family caregivers highlighted social embarrassment (45%) and multiple daily use (45%) as major concerns. Majority of the patients (73%) were compliant with their recommended frequency of the nebulizer.

Conclusion

This first-of-its-kind survey highlights that the majority of patients and family caregivers were satisfied with nebulizers and reported improvements in symptoms and reduced hospitalizations with nebulizer therapy. The patients preferred nebulized therapy to inhalers.

Effectiveness of an Educational Intervention on Inhaler Technique Proficiency in Chronic Obstructive Pulmonary Disease: A Single-Center Quality Improvement Study

Albeit inhalation therapy is the cornerstone in chronic obstructive pulmonary disease (COPD) treatment, inhaler technique is rarely evaluated, and training materials are often insufficient. In this single-center study, we aimed to evaluate the effectiveness of a teaching session complemented by a flyer on inhaler technique in COPD patients and to evaluate the perceived quality of the flyer. A total of 30 participants with stable COPD who had never used a soft mist inhaler before (Respimat®, Boehringer Ingelheim) received a brief teaching session on proper inhaler technique complemented by a flyer (visit 1). The teaching intervention was completed by a pulmonologist. Epidemiological and clinical characteristics of COPD were collected by a questionnaire, and the ability to properly handle the inhaler was assessed. After 14 days, inhaler handling was re-evaluated, and patients were asked to rate the flyer (visit 2). After the initial training, proper inhaler handling was achieved in 80.0% of patients. Inhaler proficiency was maintained after 14 days (83.0% of the patients used the Respimat® correctly, p-value > 0.99). The flyer was considered at least good by 27 patients (90.0%). This study indicated that the administration of an educational intervention resulted in persistent good competence in inhaler technique at a 14-day follow-up.

[Inhalation therapy in dogs and cats with chronic lower airway disease - a literature review]

Chronic respiratory diseases are prevalent medical conditions in dogs and cats requiring lifelong treatment. Mainstay of therapy for chronic inflammatory respiratory diseases are glucocorticoids. Concurrent treatment with bronchodilators may be necessary to control clinical signs sufficiently. Due to the successful use in people as well as subsequent reduction of adverse effects of long-term glucocorticoid therapy, inhalative therapy has become increasingly important in veterinary medicine as well. Primarily spacers or valved holding chambers, in combination with metered dose inhalers, are used in dogs and cats. The technical properties of these devices, as well as their use and maintenance will be described in the following article. Furthermore, the existing literature regarding efficacy of inhalative medications for therapy of chronic inflammatory airway diseases in dogs and cats will be summarized.

Exploring General Practitioners' Preferences and Experience with Respiratory Inhaler Devices

Introduction

Correct inhaler technique is essential for the optimal delivery of inhaled medicines and the successfully management of respiratory conditions. The general practitioner (GP), the prescriber of inhaled medicines, plays a crucial role in educating patients on inhaler technique. However, in the real-world setting, there are barriers. For the GP, it is time and competence and for the patient, it is their ability to recognise inhaler technique as an issue and their ability to maintain correct inhaler technique over time. This study aimed to determine GPs’ experience, skills and priority placed on inhaler technique and to identify factor(s) associated with inhaler technique competence.

Methods

This cross-sectional observational study design surveyed GPs’ perspectives on inhaler use and preferences for inhaler prescribing within their practice setting. GP inhaler technique was assessed. GPs were recruited through an established network of GP practices. Data collected include (i) practice demographics, (ii) inhaler technique opinions and experience, (iii) inhaler prescribing preferences and (iv) inhaler education history data. Data were analysed descriptively and multivariate logistic regression modelling was used to explore the relationship between outcomes and GPs’ ability to use devices correctly.

Results

A total of 227 GPs completed the inhaler survey. Sixty-three percent of GPs reported receiving previous inhaler education and 73.3% educated or checked their patients’ inhaler technique; 64.5% felt they were somewhat competent in doing so. GPs who reported not demonstrating inhaler technique believed that a pharmacist or a practice nurse would do so. When prescribing new inhaler devices, GPs considered the disease being treated first and then patient’s experience with inhalers; they often already have an inhaler preference and this was related to familiarity and perceived ease of use. For GPs, inhaler competence was not associated with their previous inhaler education or the priority placed on inhaler technique.

Conclusion

GPs do recognise the importance of inhaler technique in respiratory management but their technique can be better supported with regular educational updates to inform them about new inhalers and management practices and to support appropriate inhaler choices for their patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41030-022-00197-6.

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Pulmonary Procedures During the COVID-19 Pandemic: A Work Group Report of the AAAAI Asthma Diagnosis and Treatment (ADT) Interest Section

The COVID-19 pandemic has placed increased demands on the ability to safely perform pulmonary procedures in keeping with Centers for Disease Control and Prevention (CDC), American Thoracic Society (ATS), and the Occupational Safety and Health Administration (OSHA) recommendations. Accordingly, the American Academy of Allergy, Asthma & Immunology (AAAAI) Asthma Diagnosis and Treatment convened this work group to offer guidance. The work group is composed of specialist practitioners from academic and both large and small practices. Individuals with special expertise were assigned sections on spirometry, fractional exhaled nitric oxide, nebulized treatments, and methacholine challenge. The work group met periodically to achieve consensus. This resulting document has recommendations for the allergy/asthma/immunology health care setting based on available evidence including reference documents from the CDC, ATS, and OSHA.

Fractional exhaled Nitric Oxide (FeNO) level as a predictor of COVID-19 disease severity

Objective

To assess the feasibility of Fractional exhaled Nitric Oxide (FeNO) as a simple, non-invasive, cost-effective and portable biomarker and decision support tool for risk stratification of COVID-19 patients.

Methods

We conducted a single-center prospective cohort study of COVID-19 patients whose FeNO levels were measured upon ward admission by the Vivatmo-me handheld device. Demographics, COVID-19 symptoms, and relevant hospitalization details were retrieved from the hospital databases. The patients were divided into those discharged to recover at home and those who died during hospitalization or required admission to an intensive care unit, internal medicine ward, or dedicated facility (severe outcomes group).

Results

Fifty-six patients were enrolled. The only significant demographic difference between the severe outcomes patients (n = 14) and the home discharge patients (n = 42) was age (64.21 ± 13.97 vs. 53.98 ± 15.57 years, respectively, P = .04). The admission FeNO measurement was significantly lower in the former group compared with the latter group (15.86 ± 14.74 vs. 25.77 ± 13.79, parts per billion [PPB], respectively, P = .008). Time to severe outcome among patients with FeNO measurements ≤11.8 PPB was significantly shorter compared with patients whose FeNO measured >11.8 PPB (19.25 ± 2.96 vs. 24.41 ± 1.09 days, respectively, 95% confidence interval [CI] 1.06 to 4.25). An admission FeNO ≤11.8 PPB was a significant risk factor for severe outcomes (odds ratio = 12.8, 95% CI: 2.78 to 58.88, P = .001), with a receiver operating characteristics curve of 0.752.

Conclusions

FeNO measurements by the Vivatmo-me handheld device can serve as a biomarker and COVID-19 support tool for medical teams. These easy-to-use, portable, and noninvasive devices may serve as valuable ED bedside tools during a pandemic.

Nanotechnology-Assisted Metered-Dose Inhalers (MDIs) for High-Performance Pulmonary Drug Delivery Applications

PURPOSE

Respiratory disorders pose a major threat to the morbidity and mortality to public health. Here we reviewed the nanotechnology based pulmonary drug delivery using metered dose inhalers.

METHODS

Major respiratory diseases such as chronic obstructive pulmonary diseases (COPD), asthma, acute lower respiratory tract infections, tuberculosis (TB) and lung cancer. At present, common treatments for respiratory disorders include surgery, radiation, immunotherapy, and chemotherapy or a combination. The major challenge is development of systemic delivery of the chemotherapeutic agents to the respiratory system. Conventional delivery of chemotherapy has various limitation and adverse side effected. Hence, targeted, and systemic delivery need to be developed. Towards this direction nanotechnology, based controlled, targeted, and systemic drug delivery systems are potential candidate to enhance therapeutic efficacy with minimum side effect. Among different route of administration, pulmonary delivery has unique benefits such as circumvents first pass hepatic metabolism and reduces dose and side effects.

RESULTS

Respiratory disorders pose a major threat to the morbidity and mortality to public health globally. Pulmonary delivery can be achieved through various drug delivery devices such as nebulizers, dry powder inhalers, and metered dose inhalers. Among them, metered dose inhalers are the most interesting and first choice of clinician over others. This review focused on nanotechnology based pulmonary drug delivery using metered dose inhalers. This report focused on delivery of various types of therapeutics using nanocarriers such as polymeric nanoparticles and micelles, dendrimers, lipid nanocarriers such as liposomes, solid lipid nanostructures and nanostructured lipid carriers, and other using metered dose inhalers discussed comprehensively. This report provides insight about the effect of parameters of MDI such as co-solvent, propellants, actuators shape, nozzle diameters, and jet lengths, and respiratory flow rate, and particle size of co-suspension of drug on aerodynamics and lung deposition of formulation. This review also provided the insight about various metered dose inhalers market scenario and digital metered dose inhalers.

CONCLUSION

This report concluded the clinical potential of metered dose inhalers, summary of current progress and future perspectives towards the smart digital metered dose inhalers development.

Mixing of dry powders for inhalation: A review

The process of solids mixing is applied across a considerable range of industries. Pharmaceutical science is one of those industries that utilizes solids mixing extensively. Specifically, solids mixing as a key factor in the preparation of dry powder inhalers using the ordered mixing process will be discussed here. This review opens with a history of dry powder mixing theory, continues to ordered mixing in the preparation for dry powder inhalers, details key interparticulate interactions, explains formulation components for dry powder blends, and finally discusses different types of mixers used in the production of dry powder blends for inhalation. Lastly, the authors offer some suggestions for future work on this topic.

Nano-delivery to the lung - by inhalation or other routes and why nano when micro is largely sufficient?

Respiratory diseases gather a wide range of disorders which are generally difficult to treat, partly due to a poor delivery of drugs to the lung with adequate dose and minimum side effects. With the recent developments of nanotechnology, nano-delivery systems have raised interest. In this review, we detail the main types of nanocarriers that have been developed presenting their respective advantages and limitations. We also discuss the route of administration (systemic versus by inhalation), also considering technical aspects (different types of aerosol devices) with concrete examples of applications. Finally, we propose some perspectives of development in the field such as the nano-in-micro approaches, the emergence of drug vaping to generate airborne carriers in the submicron size range, the development of innovative respiratory models to assess regional aerosol deposition of nanoparticles or the application of nano-delivery to the lung in the treatment of other diseases.

Safety and Efficacy of Devices Delivering Inhaled Antibiotics among Adults with Non-Cystic Fibrosis Bronchiectasis: A Systematic Review and a Network Meta-Analysis

It remains unknown whether the type of aerosol generating device is affecting efficacy and safety among non-cystic fibrosis bronchiectasis (NCFB) adults. The proposal of this network meta-analysis (NMA) is to evaluate effectiveness and safety of inhaled antibiotics administered via dry powder inhaler (DPI) and via nebulizers (SVN) among adult patients with NCFB. Inclusion criteria were randomized-controlled trials, adults (≥18 years) with NCFB, and inhaled antibiotics administered via DPI as intervention. Search strategy was performed in PubMed, Web of Science, and Cochrane Library from 2000 to 2019. Sixteen trials (2870 patients) were included. Three trials (all ciprofloxacin) used DPIs and thirteen used SVN (three ciprofloxacin). Both DPI and SVN devices achieved similar safety outcomes (adverse events, antibiotic discontinuation, severe adverse events, and bronchospasm). Administration of ciprofloxacin via DPI significantly improved time to first exacerbation (87 days, 95% CI 34.3-139.7) and quality of life (MD -7.52; 95% CI -13.06 to -1.98) when compared with via SVN. No other significant differences were documented in clinical efficacy (at least one exacerbation, FEV1% predicted) and microbiologic response (bacterial eradication, emergence of new potential pathogens, and emergence of antimicrobial resistance) when comparing devices. Our NMA documented that time to first exacerbation and quality of life, were more favorable for DPIs. Decisions on the choice of devices should incorporate these findings plus other criteria, such as simplicity, costs or maintenance requirements.

Assessment of High-Power Electronic Nicotine Delivery System as an Alternative Aerosol Device for Terbutaline Delivery

PURPOSE

The performance of new-generation high-power electronic nicotine delivery system (ENDS) for the administration of inhaled terbutaline was assessed.

METHODS

The formulation of e-liquid was carried out using terbutaline in combination with 1, 3- propanediol. Several terbutaline concentrations (from 0.3125 to 2.500 mg / mL) and power levels (from 15 to 35 W) were assessed using a box type ENDS. The respirable drug dose was determined using a Glass Twin Impinger and quantified by liquid chromatography coupled with a UV-detector. The Next Generation Impactor and the Dekati Low Pressure Impactor were used to measure the aerosol particle size distribution in drug mass. The results were compared with a jet nebulizer (Cirrus TM 2) similar to the usual clinical conditions (2 mL at [terbutaline] of 2.5 mg / mL).

RESULTS

The optimal conditions to maximize terbutaline delivery using ENDS are a drug concentration at 1 mg/mL, and a power level at 30 W, to reach a respirable dose of 8.73 ± 0.90 µg/puff. By contrast, during a 5 min nebulization, the respirable dose of terbutaline was 1040 ± 33 µg whatever the cascade impactors and the aerosol devices used. The mass median aerodynamic diameter (MMAD) remains similar for jet nebulizer and ENDS in the 1.74-2.07 µm range.

CONCLUSION

Compared to the jet nebulizer, a same respirable dose of terbutaline at the same range of aerosol size distribution was delivered by ENDS if 120 puffs were performed. The ENDS can be considered as an alternative aerosol device for terbutaline delivery.

A Systematic Review of Published Algorithms for Selecting an Inhaled Delivery System in COPD

RATIONALE

Medication for treatment of COPD is available in many different delivery systems; however, national and international guidelines do not provide recommendations on how to select the optimal system for an individual patient.

OBJECTIVES

To perform a systematic review of published algorithms for inhaler selection in out-patients with COPD.

METHODS

PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were search for articles on inhaler selection published between January 1, 1990 and March 10, 2021. The results were reviewed for articles containing an algorithm for inhaler selection. The quality of publications containing an algorithm was assessed using the JBI SUMARI text and opinion critical appraisal checklist. Individual steps recommended in the algorithms and the order in which they were considered were extracted independently by the two authors using the JBI text and opinion data extraction tool. Textual syntheses and a table of factors included were used to appraise and compare algorithms.

RESULTS

The search identified 1016 publications. After removing duplicate studies (n = 409), 607 abstracts were examined. Nine different algorithms or hierarchical recommendations for device selection were identified. All nine publications were considered of good quality. Most algorithms contain only a few decision steps. There were significant differences between the algorithms. None of the algorithms have been validated. Three domains for factors included in the algorithms were identified: patient factors, device attributes, and HCP factors. Patient factors were considered most frequently (19 times) compared with device attributes (10 times) and HCP factors (7 times). Five specific attribute/factors with at least three rankings in different algorithms, were identified as key factors for device selection.

CONCLUSION

Although the algorithms generally provide step-by-step approaches based on a literature review and/or the experiences of the different authors, none were developed using item generation/reduction methodology nor included input from patients with COPD. There were considerable differences between the algorithms; however, the review identified key factors that should be considered by HCPs when selecting therapy. Registration: PROSPERO (CRD42021244475).

Quantifying Delivered Dose with Jet and Mesh Nebulizers during Spontaneous Breathing, Noninvasive Ventilation, and Mechanical Ventilation in a Simulated Pediatric Lung Model with Exhaled Humidity

Acutely ill children may transition between spontaneous breathing (SB), noninvasive ventilation (NIV), and mechanical ventilation (MV), and commonly receive the same drug dosage with each type of ventilatory support and interface. This study aims to determine the aerosol deposition with jet (JN) and mesh nebulizers (MN) during SB, NIV, and MV using a pediatric lung model. Drug delivery with JN (Mistymax10) and MN (Aerogen Solo) was compared during SB, NIV, and MV using three different lung models set to simulate the same breathing parameters (Vt 250 mL, RR 20 bpm, I:E ratio 1:3). A heated humidifier was placed between the filter and test lung to simulate exhaled humidity (35 ± 2 °C, 100% RH) with all lung models. Albuterol sulfate (2.5 mg/3 mL) was delivered, and the drug deposited on an absolute filter was eluted and analyzed with spectrophotometry. Aerosol delivery with JN was not significantly different during MV, NIV, and SB (p = 0.075), while inhaled dose obtained with MN during MV was greater than NIV and SB (p = 0.001). The delivery efficiency of MN was up to 3-fold more than JN during MV (p = 0.008), NIV (p = 0.005), and SB (p = 0.009). Delivered dose with JN was similar during MV, NIV, and SB, although the delivery efficiency of MN differs with different modes of ventilation.

Association of depression with improper use of inhaler devices by patients with obstructive disease

INTRODUCTION

Obstructive pulmonary disease may cause some psychiatric disorders such as depression, similar to other chronic diseases. Patients with chronic obstructive pulmonary disease or asthma are especially susceptible to inhaler technique errors. The aim of this study was to evaluate the depression that can affect improper use of inhaler devices and to show the contribution of age, sex, and education to correct usage.

MATERIALS AND METHODS

In this study, trained health care workers in the presence of Chest specialist requested patients to demonstrate their inhaler technique and assessed it according to the checklist. If any of the steps were missing or done incorrectly, it was marked as an incorrect technique.

RESULTS

We included 188 participants, mean age of 58.3 ± 12.7 years. Significant variables of individual risk were having comorbidities, age, sex, smoking status, and educational level. There was an inverse relationship between education level and incorrect inhaler technique. Even after controlling for age, gender, and education, depressive symptoms were a significant and independent predictor of improper use of inhaler devices. High levels of depressive symptoms were associated with a 22-fold increase (95% confidence interval, 8.9 to 53.5) in the odds of improper use of inhaler devices after adjustment for potential confounders.

CONCLUSIONS

As a result, the presence of depression symptoms may increase the improper use of inhaler devices. Further research is needed to determine if screening for and treating depression improves improper use of inhaler devices and obstructive disease outcomes in this population.

Effect of different accessory devices on the dose delivered from pressurised metred-dose inhalers

INTRODUCTIONS

Improved aerosol delivery of bronchodilators to chronic obstructive pulmonary disease (COPD) subjects is a cornerstone in the treatment approach. Drug delivery and response are improved with the use of accessory devices [spacers and valved holding chambers (VHCs)] with metred-dose inhalers (pMDIs). However, different accessory devices are available in the market with different properties that could affect aerosol delivery. Thus, this study aimed to assess the relative lung deposition and systemic bioavailability and compare bronchodilator response of salbutamol delivered using different accessory devices attached to pMDIs.

METHODS

Twelve healthy subjects and twelve COPD subjects inhaled 300 μg salbutamol (3 pMDI puffs) using five different accessory devices with either masks or mouthpieces (Able, Aerochamber plus flow Vu, Dolphin chamber, Tipshaler spacer, and modified Drink bottle spacer). Urine samples were collected thirty minutes post-dosing and cumulatively for the next twenty-four hours, to determine and compare the relative lung deposition [0-0.5 hour excretion of urinary salbutamol (USAL0.5)] and systemic bioavailability [0.5-24 hours excretion of urinary salbutamol (USAL24)] of salbutamol from the selected accessory devices. Also, the difference between pre and post-inhalation forced expiratory volume in one second (ΔFEV₁ %) of predicted was determined for each accessory device.

RESULTS

Urinary excretion of salbutamol (both USAL0.5 and USAL24 samples) in COPD subjects was significantly (P < .05) lower than in healthy subjects for all accessory devices. USAL0.5 and USAL24 in non-antistatic spacers (modified Drink bottle spacer and Dolphin chamber spacers) were significantly lower (P < .05) than that for antistatic spacers (Aerochamber plus flow Vu, Able and Tips-haler). No significant difference in USAL0.5 and USAL24 was observed between facemasks and mouthpieces. There was a significant difference (P < .05) in ΔFEV₁ % of predicted values between COPD subjects and healthy subjects. However, within the COPD group and the healthy group there was no significant difference in ΔFEV₁ % of predicted values between all accessory devices or between with mouthpiece or with a mask.

CONCLUSIONS

COPD subjects had lower aerosol delivered compared with healthy subjects. Anti-static accessory devices delivered a higher amount of aerosol compared with non-antistatic accessory devices. Even though the presence of a significant difference in aerosol delivery between non-antistatic and antistatic accessory devices no significant difference was found in the ΔFEV₁ % between all accessory devices.

Assessment of the safety and anti-inflammatory effects of three Bacillus strains in the respiratory tract

Chronic respiratory diseases are part of accumulating health problems partly due to worldwide increase in air pollution. By their antimicrobial and immunomodulatory properties, some probiotics constitute promising alternatives for the prevention and treatment of chronic respiratory diseases. We have isolated Bacillus strains from Korean fermented foods and selected three potentially probiotic strains (two Bacillus subtilis and one Bacillus amyloliquefaciens) based on safety, antimicrobial efficacy, activity against airborne pathogens and their immunomodulatory properties in vivo. Safety evaluation included in silico analysis for confirming absence of virulence genes. Safety for the respiratory tract was confirmed by an in vivo pathogenicity test using a murine model. Antimicrobial activity was displayed against several airborne pathogens. Potential antimicrobial metabolites such as 2,3-butanediol and propylene glycol were identified as possible antagonistic agents. Immunomodulatory properties in vitro were confirmed by upregulation of IL-10 expression in a macrophage cell line. Intranasal instillation and inhalation in an ovalbumin (OVA)-induced lung inflammation murine model reduced T helper type 2 (Th2) cytokines at transcriptional and protein levels in the lungs. The safety and potentially beneficial role of these Bacillus strains could be demonstrated for the respiratory tract of a murine model.

The Impact of Inhaler Device Regimen in Patients with Asthma or COPD

Many inhaler devices with varying handling requirements for optimal use are available for the treatment of asthma and chronic obstructive pulmonary disease (COPD). Patients may be prescribed different device types for reliever and maintenance medications, which may lead to confusion and suboptimal device use. We aimed to understand whether simplifying inhaler regimens by employing a single device type in patients who use multiple devices or prescribing a device with which a patient was already experienced could improve clinical and economic outcomes in asthma and COPD management. A targeted literature search was performed and additional articles were identified through hand searching citations within screened publications. A total of 114 articles were included in the final review. Findings suggest that simplifying inhaler regimens by applying the same type of inhaler for concomitant inhaled medications over time minimizes device misuse, leading to improved clinical outcomes and reduced health care use in patients with asthma or COPD. Physicians should consider a patient's suitability for a device and training needs when prescribing an inhaled medication and before changing the medication type or dose, especially when suboptimal treatment outcomes are observed. Further research is required to determine whether consistent use of the same device type is associated with better treatment adherence and persistence in patients with asthma or COPD. Nevertheless, this literature review identified clinical benefits and reduced health care use with simplified inhaler regimens.

Review of aerosol delivery in the emergency department

Aerosol delivery is a vital therapeutic strategy for both adult and pediatric patients presenting to the emergency department with respiratory distress. Aerosolized bronchodilators are frequently used as rescue medications for patients with diagnoses of asthma, chronic obstructive pulmonary disease (COPD), or pneumonia. Historically, emergency department providers utilized jet nebulizers (JNs) for medication delivery, but were challenged by a need for increasingly higher bronchodilator doses to elicit the desired response. Advancements in technology have led to the development of newer specialized aerosol delivery devices and treatment strategies which provide clinicians with improved options for aerosol delivery but may also cause some uncertainty regarding appropriate device selection. Initial investigations comparing these devices presented valuable evidence of in vitro benefit but were unable to demonstrate corresponding improvement in clinical results. More recently there has been an influx of clinical evidence that suggests improved clinical outcomes associated with more efficient aerosol delivery devices such as vibrating mesh nebulizers (VMN) compared to the standard JN device. VMN will likely become an increasingly important tool in emergency department treatment of patients with respiratory distress. Additional controlled studies are needed both to examine the effects of VMN on patient outcomes, as well as to analyze how performance differences between aerosol devices may affect dosing strategies. Future efforts should also focus on applying new evidence in the form of updated consensus guidelines and standardized treatment strategies.

Administration of dry powders during respiratory supports

Inhaled drugs are routinely used for the treatment of respiratory-supported patients. To date, pressurized metered dose inhalers and nebulizers are the two platforms routinely employed in the clinical setting. The scarce utilization of the dry powder inhaler (DPI) platform is partly due to the lack of in vivo data that proves optimal delivery and drug efficacy are achievable. Additionally, fitting a DPI in-line to the respiratory circuit is not as straightforward as with the other aerosol delivery platforms. Importantly, there is a common misconception that the warm and humidified inspiratory air in respiratory supports, even for a short exposure, will deteriorate powder formulation compromising its delivery and efficacy. However, some recent studies have dispelled this myth, showing successful delivery of dry powders through the humidified circuit of respiratory supports. Compared with other aerosol delivery devices, the use of DPIs during respiratory supports possesses unique advantages such as rapid delivery and high dose. In this review, we presented in vitro studies showing various setups employing commercial DPIs and effects of ventilator parameters on the aerosol delivery. Inclusion of novel DPIs was also made to illustrate characteristics of an ideal inhaler that would give high lung dose with low powder deposition loss in tracheal tubes and respiratory circuits. Clinical trials are urgently needed to confirm the benefits of administration of dry powders in ventilated patients, thus enabling translation of powder delivery into practice.

The Role of the Pharmacist in Inhaler Selection and Education in Chronic Obstructive Pulmonary Disease

Objective: To review the role of pharmacists in educating and monitoring patients with chronic obstructive pulmonary disease (COPD) on inhalation technique. Data Sources: A PubMed search (January 2000 to May 2020) was performed using the following keywords and associated medical subject headings: adherence, chronic obstructive pulmonary disease/COPD, education, inhaler, pharmacist, and technique. Study Selection and Data Extraction: The search was conducted to identify English language articles highlighting the importance of correct inhaler technique in COPD management and benefits of pharmacist inhaler training such as improved adherence, quality of life (QoL), and disease control. Randomized controlled trials, retrospective studies, observational studies, systematic reviews, and meta-analysis reporting pharmacist training were included. Data Synthesis: This review summarizes that incorrect inhaler use negatively affects treatment outcomes, prognosis, and QoL. Pharmacists are in a unique position to educate and monitor patients with COPD on optimal inhaler technique and an individualized, multifactorial approach to COPD management involving pharmacists could provide cost-effective patient care and improve adherence and minimize inhaler misuse. Several strategies used by pharmacists can optimize patient inhaler use, such as face-to-face technique demonstrations, the "teach-back" method, telemonitoring, instructional videos, or informational leaflets. An individualized action plan involving education and regular monitoring of inhaler use further enhances optimal adherence and disease management. Conclusions: As pharmacists are easily accessible to both patients and health care providers, they are ideally placed to play an important role in the enhancement of education on, and continuous assessment of, optimal inhaler technique, thereby improving adherence, disease control, and QoL.

Application of aerosol therapy in respiratory diseases in children: A Saudi expert consensus

The Saudi Pediatric Pulmonology Association (SPPA) is a subsidiary of the Saudi Thoracic Society (STS), which consists of a group of Saudi experts with well-respected academic and clinical backgrounds in the fields of asthma and other respiratory diseases. The SPPA Expert Panel realized the need to draw up a clear, simple to understand, and easy to use guidance regarding the application of different aerosol therapies in respiratory diseases in children, due to the high prevalence and high economic burden of these diseases in Saudi Arabia. This statement was developed based on the available literature, new evidence, and experts' practice to come up with such consensuses about the usage of different aerosol therapies for the management of respiratory diseases in children (asthma and nonasthma) in different patient settings, including outpatient, emergency room, intensive care unit, and inpatient settings. For this purpose, SPPA has initiated and formed a national committee which consists of experts from concerned specialties (pediatric pulmonology, pediatric emergency, clinical pharmacology, pediatric respiratory therapy, as well as pediatric and neonatal intensive care). These committee members are from different healthcare sectors in Saudi Arabia (Ministry of Health, Ministry of Defence, Ministry of Education, and private healthcare sector). In addition to that, this committee is representing different regions in Saudi Arabia (Eastern, Central, and Western region). The subject was divided into several topics which were then assigned to at least two experts. The authors searched the literature according to their own strategies without central literature review. To achieve consensus, draft reports and recommendations were reviewed and voted on by the whole panel.