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Au CY, Koh KJX, Lim HF, Bhagat AAS. Metered-Dose Inhaler Spacer with Integrated Spirometer for Home-Based Asthma Monitoring and Drug Uptake. Bioengineering (Basel) 2024; 11:552. [PMID: 38927788 PMCID: PMC11200977 DOI: 10.3390/bioengineering11060552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024] Open
Abstract
This work introduces Spiromni, a single device incorporating three different pressurised metered-dose inhaler (pMDI) accessories: a pMDI spacer, an electronic monitoring device (EMD), and a spirometer. While there are devices made to individually address the issues of technique, adherence and monitoring, respectively, for asthma patients as laid out in the Global Initiative for Asthma's (GINA) global strategy for asthma management and prevention, Spiromni was designed to address all three issues using a single, combination device. Spiromni addresses the key challenge of measuring both inhalation and exhalation profiles, which are different by an order of magnitude. Moreover, the innovative design prevents exhalation from entering the spacer chamber and prevents medication loss during inhalation using umbrella valves without a loss in flow velocity. Apart from recording the peak exhalation flow rate, data from the sensors allow us to extract other key lung volume and capacities measures similar to a medical pulmonary function test. We believe this low-cost portable multi-functional device will benefit both asthma patients and clinicians in the management of the disease.
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Affiliation(s)
- Cheuk-Yan Au
- Institute for Health Innovation & Technology (iHealthtech), National University of Singapore (NUS) MD6, 14 Medical Drive, #14-01, Singapore 117599, Singapore; (C.-Y.A.); (K.J.X.K.)
| | - Kelleen J. X. Koh
- Institute for Health Innovation & Technology (iHealthtech), National University of Singapore (NUS) MD6, 14 Medical Drive, #14-01, Singapore 117599, Singapore; (C.-Y.A.); (K.J.X.K.)
| | - Hui Fang Lim
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Health System, Singapore 119074, Singapore;
| | - Ali Asgar Saleem Bhagat
- Institute for Health Innovation & Technology (iHealthtech), National University of Singapore (NUS) MD6, 14 Medical Drive, #14-01, Singapore 117599, Singapore; (C.-Y.A.); (K.J.X.K.)
- Department of Biomedical Engineering, National University of Singapore (NUS), 4 Engineering Drive 3, Singapore 117583, Singapore
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Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
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Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
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Sivaramakrishnan G, Sridharan K, Alsobaiei M. The association between erosive toothwear and asthma - is it significant? A meta-analysis. BDJ Open 2023; 9:9. [PMID: 36859415 PMCID: PMC9977957 DOI: 10.1038/s41405-023-00137-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/15/2023] [Accepted: 02/19/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND The association of asthma with oral conditions such as dental caries, dental erosion, periodontal diseases and oral mucosal changes has been the subject of debate among dental practitioners. Existing evidence indicates that an inhaler is the most common and effective way of delivering the asthma medications directly into the lungs. Few studies in the past attributed this association to the changes in salivary flow caused due to these medications. Considering this unclear association, the aim of the present meta-analyses is to identify the association between erosive toothwear and asthma from individual studies conducted until date. METHODOLOGY Electronic databases were systematically searched until 30th September 2022. Articles identified using the search strategy were imported to RAYYAN systematic review software. Data was extracted relating to study design, geographic location, year of publication, sample size, the assessment method for erosive toothwear and asthma. The Newcastle Ottawa scale was utilized to assess the quality of evidence reported from the included studies. RevMan Version 5.3 was used to perform a random-effects meta-analysis to produce pooled estimates from OR and 95% CI of included studies. The I² statistic was used to determine the extent of heterogeneity. A funnel plot was generated to visually assess the potential for publication bias. Sensitivity analyses were performed by excluding individual studies one at a time. GRADE approach was used for grading the evidence for key comparisons. RESULTS Twelve articles were included in the final meta-analysis. A total of 1027 asthmatics and 5617 non-asthmatics were included. All studies demonstrated moderate to low risk of bias. The overall pooled estimate (OR: 2.03; 95% CI: 0.96, 4.29) and subgroup analyses in children (OR: 1.67; 95% CI: 0.63, 4.42) did not show statistically significant difference in the occurrence of dental erosion between the asthmatic and non-asthmatic group. However, asthmatic adults had significantly greater dental erosion in comparison to the control adults (OR: 2.76; 95% CI: 1.24, 6.16). Sensitivity analyses also provided inconclusive evidence. Funnel plot asymmetry indicated significant heterogeneity, changes in effect size and selective publication. CONCLUSION The association between inhalational asthmatic medication and tooth wear is inconclusive. There are a number of confounding factors that play a greater role in causing dental erosion in these patients. Dentist must pay particular attention to these factors while treating asthmatic patients. The authors produce a comprehensive checklist in order to ensure complete assessment before providing advice on their medications alone.
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Affiliation(s)
- Gowri Sivaramakrishnan
- Specialist Prosthodontist and Dental Tutor, Dental Postgraduate training department, Ministry of Health, Manama, Bahrain.
| | - Kannan Sridharan
- grid.411424.60000 0001 0440 9653Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Muneera Alsobaiei
- grid.415725.0Acting Head of Training Affairs, Dental Postgraduate training department, Ministry of Health, Manama, Bahrain
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Lu R, Li Y, Hu C, Pan P, Zhao Q, He R. Nebulization versus metered-dose inhaler and spacer in bronchodilator responsiveness testing: a retrospective study. Ther Adv Respir Dis 2023; 17:17534666231214134. [PMID: 38073272 PMCID: PMC10712271 DOI: 10.1177/17534666231214134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 10/27/2023] [Indexed: 12/18/2023] Open
Abstract
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.
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Affiliation(s)
- Rongli Lu
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Hunan, China
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Hunan, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Hunan, China
| | - Ying Li
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Hunan, China
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Hunan, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Hunan, China
| | - Chengping Hu
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Hunan, China
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Hunan, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Hunan, China
| | - Pinhua Pan
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Hunan, China
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Hunan, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Hunan, China
| | - Qiaohong Zhao
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, Hunan, China
- Center of Respiratory Medicine, Xiangya Hospital, Central South University, Hunan, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Hunan, China
| | - Ruoxi He
- Department of Respiratory Medicine, National Key Clinical Specialty, Branch of National Clinical Research Center for Respiratory Disease, Xiangya Hospital, Central South University, 87th Xiangya Road, Changsha, Hunan 410008, China
- Clinical Research Center for Respiratory Diseases in Hunan Province, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Hunan, China
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Zaazouee MS, Alwarraqi AG, Mohammed YA, Badheeb MA, Farhat AM, Eleyan M, Morad A, Zeid MAA, Mohamed AS, AbuEl-Enien H, Abdelalim A, Elsnhory AB, Hrizat YSM, Altahir NT, Atef D, Elshanbary AA, Alsharif KF, Alzahrani KJ, Algahtani M, Theyab A, Hawsawi YM, Aldarmahi AA, Abdel-Daim MM. Dupilumab efficacy and safety in patients with moderate to severe asthma: A systematic review and meta-analysis. Front Pharmacol 2022; 13:992731. [PMID: 36263132 PMCID: PMC9574251 DOI: 10.3389/fphar.2022.992731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/11/2022] [Indexed: 11/19/2022] Open
Abstract
Background: Dupilumab is a human monoclonal antibody directed against the alpha subunit of the interleukin-4 receptor and inhibits the signaling of IL-4 and IL-13. It is approved for treating asthma and other type-2 inflammatory diseases. There is a conflict in the literature regarding the safety and efficacy of dupilumab. Thus, we aimed to assess the safety and efficacy of dupilumab in patients with moderate to severe asthma. Methods: Six databases (PubMed, Embase, Scopus, Web of Science, Cochrane library, and clinicaltrials.gov registry) were searched until January 2022. We included randomized controlled trials that compared dupilumab with the placebo in moderate to severe asthma patients. We extracted the data at 12 and 24 weeks and analyzed them using review manager 5.4. Findings: Thirteen trials were included. Dupilumab significantly improved the forced expiratory volume in 1 s, asthma control questionnaire score, the fraction of exhaled nitric oxide level, and immunoglobulin E level at 12 and 24 weeks (p < 0.05). However, it was associated with increased blood eosinophils at 12 and 24 weeks. Dupilumab was generally a safe agent for asthmatic patients. It showed no significant difference compared with the placebo regarding most adverse events. Conclusion: Dupilumab improves pulmonary function and reduces local and systemic inflammatory markers with minimal adverse events in patients with moderate to severe asthma.
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Affiliation(s)
| | | | | | | | | | - Mohammed Eleyan
- Department of Laboratory Medical Sciences, Alaqsa University, Gaza, Palestine
- Faculty of Medicine, Al-Azhar University, Gaza, Palestine
| | - Afnan Morad
- Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Marwa Abdel-Aziz Zeid
- Clinical Pharmacist, Pediatrics Department, Ministry of Health, Qalyubia, Egypt
- Faculty of Pharmacy, October 6 University, Giza, Egypt
| | - Aya Shaban Mohamed
- Department of Pharmacology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Hazem AbuEl-Enien
- Faculty of Pharmacy and Drug Manufacturing, Pharos University, Alexandria, Egypt
| | | | | | | | | | - Doaa Atef
- Department of Emergency Medicine, Assiut University, Assiut, Egypt
| | | | - Khalaf F. Alsharif
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
| | - Khalid J. Alzahrani
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
| | - Mohammad Algahtani
- Department of Laboratory and Blood Bank, Security Forces Hospital, Mecca, Saudi Arabia
| | - Abdulrahman Theyab
- Department of Laboratory and Blood Bank, Security Forces Hospital, Mecca, Saudi Arabia
- College of Medicine, Al-Faisal University, Riyadh, Saudi Arabia
| | - Yousef M. Hawsawi
- College of Medicine, Al-Faisal University, Riyadh, Saudi Arabia
- Research Center, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Ahmed A. Aldarmahi
- Basic Science Department, College of Science and Health Professions, King Saud Bin Abdulaziz University for Health Sciences, National Guard-Health Affairs, Jeddah, Saudi Arabia
| | - Mohamed M. Abdel-Daim
- Department of Pharmaceutical Sciences, Pharmacy Program, Batterjee Medical College, Jeddah, Saudi Arabia
- Pharmacology Department, Faculty of Veterinary Medicine, Suez Canal University, Ismailia, Egypt
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Tony SM, Abdelrahman MA, Abd Elsalam M, Sameer Shafik M, Abdelrahim MEA. 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. Exp Lung Res 2022; 48:224-238. [PMID: 35997099 DOI: 10.1080/01902148.2022.2113573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Sara M Tony
- Beni-Suef Specialized Hospital, Beni-Suef, Egypt
| | - Mona A Abdelrahman
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | | | | | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
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Tony SM, Abdelrahman MA, Osama H, Abdelrahim MEA. Advanced counselling using training device and smartphone application on inhalation technique from metered-dose inhaler with spacer equipped with different interfaces in asthmatic children. Int J Clin Pract 2021; 75:e14413. [PMID: 34047001 DOI: 10.1111/ijcp.14413] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Sara M Tony
- Clinical pharmacy department, Beni-Suef Specialized Hospital, Beni-Suef, Egypt
- Technical Office of Deputy Minister of Health in Beni-Suif Directorate of Health Affairs, Beni-Suef, Egypt
| | - Mona A Abdelrahman
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Hasnaa Osama
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
| | - Mohamed E A Abdelrahim
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni-Suef University, Beni-Suef, Egypt
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Legh-Land V, Haddrell AE, Lewis D, Murnane D, Reid JP. Water Uptake by Evaporating pMDI Aerosol Prior to Inhalation Affects Both Regional and Total Deposition in the Respiratory System. Pharmaceutics 2021; 13:pharmaceutics13070941. [PMID: 34202458 PMCID: PMC8309010 DOI: 10.3390/pharmaceutics13070941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 06/05/2021] [Accepted: 06/06/2021] [Indexed: 11/29/2022] Open
Abstract
As pulmonary drug deposition is a function of aerosol particle size distribution, it is critical that the dynamics of particle formation and maturation in pMDI sprays in the interim between generation and inhalation are fully understood. This paper presents an approach to measure the evaporative and condensational fluxes of volatile components and water from and to solution pMDI droplets following generation using a novel technique referred to as the Single Particle Electrodynamic Lung (SPEL). In doing so, evaporating aerosol droplets are shown capable of acting as condensation nuclei for water. Indeed, we show that the rapid vaporisation of volatile components from a volatile droplet is directly correlated to the volume of water taken up by condensation. Furthermore, a significant volume of water is shown to condense on droplets of a model pMDI formulation (hydrofluoroalkane (HFA), ethanol and glycerol) during evaporative droplet ageing, displaying a dramatic shift from a core composition of a volatile species to that of predominantly water (non-volatile glycerol remained in this case). This yields a droplet with a water activity of 0.98 at the instance of inhalation. The implications of these results on regional and total pulmonary drug deposition are explored using the International Commission of Radiological Protection (ICRP) deposition model, with an integrated semi-analytical treatment of hygroscopic growth. Through this, droplets with water activity of 0.98 upon inhalation are shown to produce markedly different dose deposition profiles to those with lower water activities at the point of inspiration.
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Affiliation(s)
- Victoria Legh-Land
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (V.L.-L.); (D.M.)
| | | | - David Lewis
- Chiesi Farmaceutici S.p.A, Chippenham SN14 0AB, UK;
| | - Darragh Murnane
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK; (V.L.-L.); (D.M.)
| | - Jonathan P. Reid
- School of Chemistry, University of Bristol, Bristol BS8 1TS, UK;
- Correspondence: ; Tel.: +44-117-331-7388
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Management of Asthma Exacerbations in the Emergency Department. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:2599-2610. [PMID: 33387672 DOI: 10.1016/j.jaip.2020.12.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 02/06/2023]
Abstract
Asthma exacerbations occur across a wide spectrum of chronic severity; they contribute to millions of emergency department (ED) visits in both children and adults every year. Management of asthma exacerbations is an important part of the continuum of asthma care. The best strategy for ED management of an asthma exacerbation is early recognition and intervention, continuous monitoring, appropriate disposition, and, once improved, multifaceted transitional care that optimizes subacute and chronic asthma management after ED discharge. This article concisely reviews ED evaluation, treatment, disposition, and postdischarge care for patients with asthma exacerbations, based on high-quality evidence (eg, systematic reviews from the Cochrane Collaboration) and current international guidelines (eg, the National Asthma Education and Prevention Program Expert Panel Report 3, Global Initiative for Asthma, and Australian guidelines). Special populations (young children, pregnant women, and the elderly) also are addressed. Despite advances in asthma science, there remain many important evidence gaps in managing ED patients with asthma exacerbation. This article summarizes several of these controversial areas and challenges that merit further investigation.
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Harb HS, Saeed H, Madney YM, Abdelrahman MA, Osama H, Esquinas AM, Abdelrahim ME. Update efficacy of aerosol therapy with noninvasive ventilator approach (non-invasive ventilation and nasal high flow). J Drug Deliv Sci Technol 2020. [DOI: 10.1016/j.jddst.2020.101922] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sorino C, Negri S, Spanevello A, Visca D, Scichilone N. Inhalation therapy devices for the treatment of obstructive lung diseases: the history of inhalers towards the ideal inhaler. Eur J Intern Med 2020; 75:15-18. [PMID: 32113944 DOI: 10.1016/j.ejim.2020.02.023] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/12/2020] [Accepted: 02/18/2020] [Indexed: 01/04/2023]
Abstract
Inhalation therapy allows conveying drugs directly into the airways. The devices used to administer inhaled drugs play a crucial role in the management of obstructive lung diseases such as asthma and chronic obstructive pulmonary disease (COPD). To ensure high bronchial deposition of the drug, a device should deliver a high proportion of fine particles, be easy to use, and provide constant and accurate doses of the active substance. Nowadays, four different types of inhalers are widely used: nebulizers, dry powder inhalers (DPIs), pressurized metered-dose inhalers (pMDIs), and soft mist inhalers (SMIs). Nebulizers can be used by patients unable to use other inhalers. However, they require long times of administration and do not ensure precise dosages. The first pMDIs became popular since they were small, inexpensive, fast, and silent. Their performance was improved by spacers and then by new technologies which reduced the delivery speed. In DPIs, micronized drug particles are attached to larger lactose carrier particles. No coordination between actuation and inhalation is required. However, the patient is supposed to produce an adequate inspiratory flow to extract the drug and disaggregate it from the carrier. In SMIs, the medication is dissolved in an aqueous solution, without propellant, and it is dispensed as a slow aerosol cloud thanks to the energy of a spring. Smart inhalers, connected to smartphones, are promising tools that can provide information about patient's adherence and their inhaler technique. Inhalation has also been proposed as a route of administration for several systemic drugs.
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Affiliation(s)
- Claudio Sorino
- Division of Pulmonology, Sant'Anna Hospital, Como, Italy; University of Insubria, Faculty of Medicine and Surgery, Varese, Italy.
| | - Stefano Negri
- University of Insubria, Faculty of Medicine and Surgery, Varese, Italy
| | - Antonio Spanevello
- University of Insubria, Faculty of Medicine and Surgery, Varese, Italy; Division of Pulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS, Tradate, Italy
| | - Dina Visca
- University of Insubria, Faculty of Medicine and Surgery, Varese, Italy; Division of Pulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS, Tradate, Italy
| | - Nicola Scichilone
- Division of Respiratory Medicine, Department PROMISE, "Giaccone" University Hospital, University of Palermo, Italy
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Gleeson PK, Feldman S, Apter AJ. Controller Inhalers: Overview of Devices, Instructions for Use, Errors, and Interventions to Improve Technique. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2234-2242. [PMID: 32173505 DOI: 10.1016/j.jaip.2020.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 02/16/2020] [Accepted: 03/04/2020] [Indexed: 11/28/2022]
Abstract
Inadequate inhaler technique in persistent asthma is frequently reported. However, there is little consensus on inhaler checklists, and critical elements of technique are not uniformly described. In addition, inhaler error rates and risk factors for poor technique are variable across studies. This Clinical Commentary Review summarizes the literature on inhaler design, use, and interventions to improve technique. Our aim is to help clinicians identify patients with poor inhaler technique, recognize the most important errors, and correct technique using evidence-based interventions.
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Affiliation(s)
- Patrick K Gleeson
- Section of Allergy and Immunology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
| | - Scott Feldman
- Section of Allergy and Immunology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Andrea J Apter
- Section of Allergy and Immunology, Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
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13
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Ari A, Fink JB. Recent advances in aerosol devices for the delivery of inhaled medications. Expert Opin Drug Deliv 2020; 17:133-144. [PMID: 31959028 DOI: 10.1080/17425247.2020.1712356] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Aerosolized medications are commonly prescribed for the treatment of patients with pulmonary diseases, and there has been an increased interest in the development of aerosol delivery devices over the years. Technical innovations have advanced device design, novel features such as breath actuation, dose tracking, portability, and feedback mechanism during treatment that improved the performance of aerosol devices, and effectiveness of inhalation therapy.Areas covered: The purpose of this paper is to review recent advances in aerosol devices for delivery of inhaled medications.Expert opinion: Drug formulations and device designs are rapidly evolving to make more consistent dosing across a broad range of inspiratory efforts, to maximize dose and target specific areas of the diseased lung.
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Affiliation(s)
- Arzu Ari
- Department of Respiratory Care, Texas State University, College of Health Professions, Round Rock, TX, USA
| | - James B Fink
- Department of Respiratory Care, Texas State University, College of Health Professions, Round Rock, TX, USA.,Aerogen Pharma Corp, San Mateo, CA, USA
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Abstract
Asthma is one of the commonest respiratory diseases in the United States, affecting approximately 8% of adults. This article reviews the epidemiology, diagnosis, and treatment of asthma, with integration of recommendations from professional societies, with special attention to differential diagnosis. A framework for outpatient management of patients with asthma is presented, including indications for subspecialist referral. With integration of objective diagnostic information, systematic approach through modification of disease triggers and adjustment of controller medications, and patient empowerment to respond to varying symptoms using an asthma action plan, most individuals with asthma are successfully managed in the primary care setting.
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Affiliation(s)
- Tianshi David Wu
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th Floor, Baltimore, MD 21205, USA
| | - Emily P Brigham
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th Floor, Baltimore, MD 21205, USA
| | - Meredith C McCormack
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, 5th Floor, Baltimore, MD 21205, USA.
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Vincken W, Levy ML, Scullion J, Usmani OS, Dekhuijzen PNR, Corrigan CJ. Spacer devices for inhaled therapy: why use them, and how? ERJ Open Res 2018; 4:00065-2018. [PMID: 29928649 PMCID: PMC6004521 DOI: 10.1183/23120541.00065-2018] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/18/2018] [Indexed: 11/05/2022] Open
Abstract
We present an extensive review of the literature to date pertaining to the rationale for using a spacer/valved holding chamber (VHC) to deliver inhaled therapy from a pressurised, metered-dose inhaler, a discussion of how the properties of individual devices may vary according to their physical characteristics and materials of manufacture, the potential risks and benefits of ancillaries such as valves, and the evidence that they contribute tangibly to the delivery of therapy. We also reiterate practical recommendations for the correct usage and maintenance of spacers/VHCs, which we trust offer practical help and advice to patients and healthcare professionals alike.
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Affiliation(s)
- Walter Vincken
- Respiratory Division, University Hospital Brussels (UZ Brussel), Vrije Universiteit Brussel, Brussels, Belgium
| | | | | | | | | | - Chris J Corrigan
- Faculty of Life Sciences and Medicine, King's College London/Guy's and St Thomas's NHS Foundation Trust, London, UK
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Fakih F, Spangenthal S, Sigal B, Darken P, Maes A, Siddiqui S, Gillen M, Reisner C, Martin UJ. Randomized study of the effects of Aerochamber Plus ® Flow-Vu ® on the efficacy, pharmacokinetics and safety of glycopyrronium/formoterol fumarate dihydrate metered dose inhaler in patients with chronic obstructive pulmonary disease. Respir Med 2018; 138:74-80. [DOI: 10.1016/j.rmed.2018.03.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 02/14/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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Anderson G, Johnson N, Mulgirigama A, Aggarwal B. Use of spacers for patients treated with pressurized metered dose inhalers: focus on the VENTOLIN™ Mini Spacer. Expert Opin Drug Deliv 2018; 15:419-430. [PMID: 29415579 DOI: 10.1080/17425247.2018.1437414] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Spacers offer a multitude of benefits by reducing the requirement to coordinate inhalation with actuation and improving inhaler technique in patients using a pressurized metered dose inhaler (pMDI). Spacers improve drug targeting by retaining within the spacer large particles normally deposited in the oropharynx, and by creating a prolonged aerosol cloud of fine particles to give the user increased time to inhale after actuation. This is particularly important in young children and the elderly to effectively deliver medication to the airways. AREAS COVERED By investigating the history and features of spacers, we demonstrate that the advantages of using spacers far outweigh their limitations. We also discuss the optimal characteristics of spacers in terms of shape, volume, presence of valve and static charge, and present a detailed discussion of the VENTOLIN™ Mini Spacer. EXPERT OPINION Generally, the shape and size of spacers makes them inherently inconvenient. Consideration of human factors and modern design may make them more attractive to patients. However, the incentive to use spacers should be their ability to help patients correctly use inhaled medications delivered by pMDIs. Understanding of these principles through education is key to their acceptance by patients.
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Affiliation(s)
- Gregor Anderson
- a GSK, Respiratory Centre of Excellence, Global Manufactory & Supply , Ware, Herts , UK
| | - Neil Johnson
- b Respiratory, Global Classic & Established Products , GSK , Middlesex , UK
| | - Aruni Mulgirigama
- b Respiratory, Global Classic & Established Products , GSK , Middlesex , UK
| | - Bhumika Aggarwal
- c GSK , Respiratory, Global Classic & Established Products , Singapore
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#Asthma #Inhaler: Evaluation of visual social media depictions of inhalers and spacers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1787-1788. [PMID: 28533122 DOI: 10.1016/j.jaip.2017.04.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 03/13/2017] [Accepted: 04/17/2017] [Indexed: 11/20/2022]
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19
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Spantideas N, Drosou E, Bougea A, Assimakopoulos D. Inhaled Corticosteroids and Voice Problems. What Is New? J Voice 2016; 31:384.e1-384.e7. [PMID: 27742496 DOI: 10.1016/j.jvoice.2016.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/05/2016] [Accepted: 09/08/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Voice problems are the most common and most annoying local side effect of inhaled corticosteroids (ICS), affecting not only patients' treatment compliance but also their quality of life. The literature is very poor regarding prevalence, mechanism, prevention, and management of voice problems attributed to ICS use and especially for the new ICS, ciclesonide. Prevalence of dysphonia seems to be less common with the use of ciclesonide and beclomethasone dipropionate. METHOD We conducted a bibliography review based on recently published data, including data from the recently introduced ICS, ciclesonide, which are lacking in previous reviews. RESULTS Very little improvement, based on limited number of new papers published during previous years without any direct comparison between available ICS, has been made in our understanding of ICS local side effects. CONCLUSION Our understanding concerning basic information of ICS effects on voice still remains poor, and further investigation is needed to have a better understanding on epidemiology, predisposing factors, mechanisms, prevention, and treatment of voice problems attributed to ICS.
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Affiliation(s)
- Nikolaos Spantideas
- Athens Speech, Language and Swallowing Institute, 10 Lontou Street, Glyfada, Athens 16675, Greece.
| | - Eirini Drosou
- Athens Speech, Language and Swallowing Institute, 37 Oinois Street, Glyfada, Athens 16674, Greece
| | - Anastasia Bougea
- Athens Speech, Language and Swallowing Institute, 10 Lontou Street, Glyfada, Athens 16675, Greece
| | - Dimitrios Assimakopoulos
- ENT Department in University Hospital of Ioannina, Medical School of the University of Ioannina, 51 Napoleontos Zerva Street, Ioannina 45332, Greece
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20
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Haidl P, Heindl S, Siemon K, Bernacka M, Cloes RM. Inhalation device requirements for patients' inhalation maneuvers. Respir Med 2016; 118:65-75. [PMID: 27578473 DOI: 10.1016/j.rmed.2016.07.013] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/19/2016] [Accepted: 07/19/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Inhaled drugs are the mainstay of treatment for lung diseases such as asthma and chronic obstructive pulmonary disease. However, failure to use inhalation devices correctly can lead to a poorly controlled status. A vast number of inhalation devices exist and each device has specific requirements to achieve optimum inhalation of the drug. Currently, there is no overview of inhalation requirements considering all devices. This article presents a review of the literature on different inhalation device requirements and incorporates the data into a new inhalation flow algorithm. METHODS Data from literature on commercially available inhalation devices were evaluated and parameters, such as inhalation flow rate, flow acceleration, inhalation volume, and inspiration time assessed for the required inhalation maneuver specific to the device. All agreed upon data points were used to develop an inhalation flow algorithm. RESULTS The literature analysis revealed availability of robust data for the required inhalation flow characteristics for most devices and thus for the development of an algorithm. For those devices for which these parameters are not published, the minimum required flow criteria were defined based on published data regarding individual aspects of aerosol quality. CONCLUSIONS This review provides an overview of inhalation devices available on the market regarding requirements for an acceptable inhalation maneuver and shows which goals should be achieved in terms of inhalation flows. The presented algorithm can be used to develop a new computer based measurement system which could help to test and train patients' individual inhalation maneuvers with their inhalation devices.
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21
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Ogrodnik N, Azzi V, Sprigge E, Fiset S, Matida E. Nonuniform Deposition of Pressurized Metered-Dose Aerosol in Spacer Devices. J Aerosol Med Pulm Drug Deliv 2016; 29:490-500. [PMID: 27224033 DOI: 10.1089/jamp.2015.1257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Pressurized metered-dose inhalers (pMDIs) are commonly used to administer medication to patients suffering from chronic lower respiratory tract diseases such as asthma. Inhaling medication directly from a pMDI can prove difficult for some patients and, as a result, add-on devices (or spacers) have been designed to aid in the delivery of medication. Although spacers increase the percentage of medication that reaches the patient, medication will also nonsymmetrically deposit on the walls of the device and will be lost to the device itself. METHODS The deposition of medication, salbutamol sulfate, within a large- and a small-volume spacer, has been studied through an experimental and numerical analysis. Experiments were conducted at inspiratory flow rates ranging from 30 to 60 L/min. The amount of deposition of the medication on the walls of the spacer was quantified through an application of spectrophotometry. Computational fluid dynamics was used to quantify the deposition numerically. Simulations were conducted by implementing mean flow and turbulent tracking of particles using unsteady Reynolds-averaged Navier-Stokes (URANS) equations with a shear stress transport turbulence model. Regions of deposition are of interest, as well as how the method of deposition varied for different inhalation flow rates. RESULTS AND CONCLUSIONS The deposition of salbutamol sulfate in the Volumatic® and OptiChamber® spacers was found to be greater in the lower half as opposed to the upper half of the spacer due to a downward spray angle. With an increased flow rate, these spacers demonstrated a slight increase in medication delivered to the inline filter, which is analogous to that reaching the patient, and an increase in distal deposition. For the numerical analysis, the results indicated that inertial impaction is the most likely method of deposition for the Volumatic spacer, and turbulence is more likely to cause deposition in the OptiChamber spacer.
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Affiliation(s)
- Nicholas Ogrodnik
- Department of Mechanical and Aerospace Engineering, Carleton University , Ottawa, Canada
| | - Victor Azzi
- Department of Mechanical and Aerospace Engineering, Carleton University , Ottawa, Canada
| | - Elizabeth Sprigge
- Department of Mechanical and Aerospace Engineering, Carleton University , Ottawa, Canada
| | - Sandra Fiset
- Department of Mechanical and Aerospace Engineering, Carleton University , Ottawa, Canada
| | - Edgar Matida
- Department of Mechanical and Aerospace Engineering, Carleton University , Ottawa, Canada
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22
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Levy ML, Dekhuijzen PNR, Barnes PJ, Broeders M, Corrigan CJ, Chawes BL, Corbetta L, Dubus JC, Hausen T, Lavorini F, Roche N, Sanchis J, Usmani OS, Viejo J, Vincken W, Voshaar T, Crompton GK, Pedersen S. Inhaler technique: facts and fantasies. A view from the Aerosol Drug Management Improvement Team (ADMIT). NPJ Prim Care Respir Med 2016; 26:16017. [PMID: 27098045 PMCID: PMC4839029 DOI: 10.1038/npjpcrm.2016.17] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 01/23/2016] [Accepted: 02/09/2016] [Indexed: 01/04/2023] Open
Abstract
Health professionals tasked with advising patients with asthma and chronic obstructive pulmonary disease (COPD) how to use inhaler devices properly and what to do about unwanted effects will be aware of a variety of commonly held precepts. The evidence for many of these is, however, lacking or old and therefore in need of re-examination. Few would disagree that facilitating and encouraging regular and proper use of inhaler devices for the treatment of asthma and COPD is critical for successful outcomes. It seems logical that the abandonment of unnecessary or ill-founded practices forms an integral part of this process: the use of inhalers is bewildering enough, particularly with regular introduction of new drugs, devices and ancillary equipment, without unnecessary and pointless adages. We review the evidence, or lack thereof, underlying ten items of inhaler ‘lore’ commonly passed on by health professionals to each other and thence to patients. The exercise is intended as a pragmatic, evidence-informed review by a group of clinicians with appropriate experience. It is not intended to be an exhaustive review of the literature; rather, we aim to stimulate debate, and to encourage researchers to challenge some of these ideas and to provide new, updated evidence on which to base relevant, meaningful advice in the future. The discussion on each item is followed by a formal, expert opinion by members of the ADMIT Working Group.
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Affiliation(s)
- Mark L Levy
- General Practitioner and Respiratory Lead, Harrow, London, UK
| | - P N R Dekhuijzen
- Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - P J Barnes
- National Heart and Lung Institute, Imperial College London, London, UK
| | - M Broeders
- University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - C J Corrigan
- Department of Respiratory Medicine and Allergy, King's College London School of Medicine, London, UK
| | - B L Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - L Corbetta
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - J C Dubus
- Unité de Medicine Infantile, Marseille, France
| | | | - F Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - N Roche
- Service de Pneumologie et Soins Intensifs Respiratoires, Groupe Hospitalier Cochin, Université Paris-Descartes, Paris, France
| | - J Sanchis
- Departament de Pneumologia, Hospital de la Santa Creuide Sant Pau, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Omar S Usmani
- NIHR Career Development Fellow, National Heart and Lung Institute (NHLI), Imperial College London, UK.,Royal Brompton Hospital, London, UK
| | - J Viejo
- Hospital General Yagüe de Burgos, Spain
| | - W Vincken
- Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Dienst Pneumologie, Brussels, Belgium
| | | | | | - Soren Pedersen
- Pediatric Research Unit, University of Southern Denmark, Kolding Hospital, Kolding, Denmark
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Hussein RRS, M. A. Ali A, Salem HF, Abdelrahman MM, Said ASA, Abdelrahim MEA. In vitro/in vivo correlation and modeling of emitted dose and lung deposition of inhaled salbutamol from metered dose inhalers with different types of spacers in noninvasively ventilated patients. Pharm Dev Technol 2015; 22:871-880. [DOI: 10.3109/10837450.2015.1116567] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Raghda R. S. Hussein
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt,
| | - Ahmed M. A. Ali
- Pharmaceutics and Industrial Pharmacy Department, Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt,
- Pharmaceutics Department, Faculty of Pharmacy, Taif University, Taif, Saudi Arabia, and
| | - Heba F. Salem
- Pharmaceutics and Industrial Pharmacy Department, Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt,
| | - Maha M. Abdelrahman
- Analytical Chemistry Department, Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt
| | - Amira S. A. Said
- Clinical Pharmacy Department, Faculty of Pharmacy, Beni Suef University, Beni Suef, Egypt,
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24
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Dhar R, Salvi S, Rajan S, Dalal S, Tikkiwal S, Bhagat R, Ahmed MM, Balki A, Jain M, Gogtay J. Salmeterol/fluticasone through breath-actuated inhaler versus pMDI: a randomized, double-blind, 12 weeks study. J Asthma 2015; 52:1065-72. [PMID: 26288199 DOI: 10.3109/02770903.2015.1050499] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Salmeterol/fluticasone combination (SFC) formulated in a breath-actuated inhaler (BAI) overcomes the co-ordination problem associated with the pressurized-metered dose inhaler (pMDIs). Our aim was to compare the efficacy and the safety of SFC given through the BAI versus the conventional pMDI in moderate-to-severe asthmatics. METHODS In this randomized, double-blind, double-dummy, prospective, active-controlled, parallel group, multicenter, 12 weeks study, 150 asthmatics were randomized to receive SFC (25/125 mcg) through either BAI or pMDI. The primary efficacy endpoint was mean change in pre-dose morning PEFR value at 12 weeks and the secondary efficacy endpoints included, mean change in FEV(1), pre-bronchodilator FVC, pre-dose morning and evening PEFR, symptom scores at 2, 4, 8, and 12 weeks. Patient preferences for device and safety were also assessed. RESULTS At 12 weeks, the mean change in pre-dose morning PEFR in BAI and pMDI groups was 50.72 L/min and 48.82 L/min, respectively (p < 0.0001; both groups) and the difference between the two groups was not significant. Both the treatment groups showed a statistically significant improvement in secondary endpoints at all-time points compared with baseline. The usability questionnaire assessment results showed that the BAI device was preferred by 75% of patients as compared with 25% preferring pMDI. SFC in both BAI and pMDI devices was found to be safe and well tolerated. CONCLUSION This is the first study to demonstrate that SFC given through the BAI produces comparable efficacy and safety endpoints as pMDI. Additionally, BAI was the preferred inhaler by patients compared to conventional pMDI.
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Affiliation(s)
- Raja Dhar
- a Department of Pulmonology and Critical Care , Fortis Hospital , Kolkata , India
| | | | | | | | | | - Raj Bhagat
- f Dr. Bhagat's Allergy - Asthma Clinic & Respiratory Care Centre , Ahmedabad , India
| | | | - Akash Balki
- h Shree Hospital and Critical Care Centre , Nagpur , India
| | - Manish Jain
- i Swaash Clinic, Navkar Hospital , Jaipur , India , and
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Plume Characteristics of Two HFA-Driven Inhaled Corticosteroid/Long-Acting Beta2-Agonist Combination Pressurized Metered-Dose Inhalers. Adv Ther 2015; 32:567-79. [PMID: 26100350 DOI: 10.1007/s12325-015-0219-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION New inhalers propelled by hydrofluoroalkanes (HFAs) have improved plume characteristics: higher fine particle fraction, and warmer plumes with reduced force and velocity. Together, this may avoid reflex interruption of inhalation and improve lung deposition of the inhaled drugs. However, even with HFA-propelled pressurized metered-dose inhalers (pMDIs), there are notable differences in device properties. Here we compared the duration, velocity, force, and temperature of two inhaled corticosteroid/long-acting β2-agonist combination therapies, administered via HFA pMDIs: fluticasone propionate/formoterol 125/5 µg (FP/FORM; flutiform(®)) and fluticasone propionate/salmeterol 125/25 µg (FP/SAL; Seretide(®) Evohaler(®)). METHODS Inhalers were fired into ambient air. Plume duration and velocity were recorded with a high-speed camera and a pulsed laser light source. A copper disc attached to a sensitive load cell measured the plume force at various distances from the device. A thermal imaging video camera recorded impaction temperature in line with the device. RESULTS The average plume duration for FP/FORM was longer than that of FP/SAL: 168.3 vs. 114.0 ms, respectively. The mean maximum plume velocities observed at 95 mm (the approximate distance between mouthpiece and throat) was consistently slower for FP/FORM (10.08 m/s) compared to FP/SAL (15.55 m/s). FP/FORM had a slower velocity at the outset, remaining relatively constant before declining steadily over the plume duration. The force of the FP/SAL plume was greater than that of FP/FORM at all distances: maximum force for FP/FORM was 138.2 vs. 278.9 mN for FP/SAL. The minimum impaction temperature was +5.9 °C for FP/FORM and -37.8 °C for FP/SAL; this difference became less pronounced over distance. CONCLUSION There were substantial differences between the plumes of the two pMDIs. FP/FORM was warmer, less forceful, had a longer plume duration and slower maximal velocity. These plume characteristics of FP/FORM may lead to improved lung deposition. FUNDING Mundipharma Research Limited, Cambridge, UK.
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26
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Xu Z, Hsu W, von Hollen D, Viswanath A, Nikander K, Dalby R. Methodology for the In Vitro Evaluation of the Delivery Efficiency from Valved Holding Chambers with Facemasks. J Aerosol Med Pulm Drug Deliv 2014; 27 Suppl 1:S44-54. [DOI: 10.1089/jamp.2013.1074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zhen Xu
- School of Pharmacy, University of Maryland, Baltimore, MD 21201
| | - Wenchi Hsu
- School of Pharmacy, University of Maryland, Baltimore, MD 21201
| | - Dirk von Hollen
- Respironics Inc., a Philips Healthcare company, Murrysville, PA, USA
| | - Ashwin Viswanath
- Philips Respironics, Respiratory Drug Delivery, Parsippany, NJ 07054
| | | | - Richard Dalby
- School of Pharmacy, University of Maryland, Baltimore, MD 21201
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27
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Abstract
The market for inhalable dry powder medication has consistently grown over past years. Targeting the lungs has been recognized to offer several advantages compared with oral application of drugs. The successive development of inhalation products has led to advances in local treatment of different respiratory diseases, but has also demonstrated the possibility to utilize the lungs for systemic drug delivery. Since a dry powder inhalation product is always a combination of drug formulation and inhalation device, the requirements for the development of such a system may be particularly complex. Therefore, this review aims to give an overview of the necessary considerations for a successful dry powder inhaler development.
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Abstract
The human body interacts with the environment in many different ways. The lungs interact with the external environment through breathing. The enormously large surface area of the lung with its extremely thin air-blood barrier is exposed to particles suspended in the inhaled air. The particle-lung interaction may cause deleterious effects on health if the inhaled pollutant aerosols are toxic. Conversely, this interaction can be beneficial for disease treatment if the inhaled particles are therapeutic aerosolized drugs. In either case, an accurate estimation of dose and sites of deposition in the respiratory tract is fundamental to understanding subsequent biological response, and the basic physics of particle motion and engineering knowledge needed to understand these subjects is the topic of this article. A large portion of this article deals with three fundamental areas necessary to the understanding of particle transport and deposition in the respiratory tract. These are: (i) the physical characteristics of particles, (ii) particle behavior in gas flow, and (iii) gas-flow patterns in the respiratory tract. Other areas, such as particle transport in the developing lung and in the diseased lung are also considered. The article concludes with a summary and a brief discussion of areas of future research.
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Affiliation(s)
- Akira Tsuda
- Harvard School of Public Health, Boston, Massachusetts
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The challenge of delivering therapeutic aerosols to asthma patients. ISRN ALLERGY 2013; 2013:102418. [PMID: 23984095 PMCID: PMC3747606 DOI: 10.1155/2013/102418] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 06/23/2013] [Indexed: 11/17/2022]
Abstract
The number of people with asthma continues to grow around the world, and asthma remains a poorly controlled disease despite the availability of management guidelines and highly effective medication. Patient noncompliance with therapy is a major reason for poor asthma control. Patients fail to comply with their asthma regimen for a wide variety of reasons, but incorrect use of inhaler devices is amongst the most common. The pressurised metered-dose inhaler (pMDI) is still the most frequently used device worldwide, but many patients fail to use it correctly, even after repeated tuition. Breath-actuated inhalers are easier to use than pMDIs. The rationale behind inhaler choice should be evidence based rather than empirical. When choosing an inhaler device, it is essential that it is easy to use correctly, dosing is consistent, adequate drug is deposited in both central and peripheral airways, and that drug deposition is independent of airflow. Regular checking of inhalation technique is crucial, as correct inhalation is one of the cornerstones of successful asthma management.
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Abstract
Electrostatics continues to play an important role in pharmaceutical aerosols for inhalation. Despite its ubiquitous nature, the charging process is complex and not well understood. Nonetheless, significant advances in the past few years continue to improve understanding and lead to better control of electrostatics. The purpose of this critical review is to present an overview of the literature, with an emphasis on how electrostatic charge can be useful in improving pulmonary drug delivery.
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Vargas O, Martinez J, Ibanez M, Pena C, Santamaria M. The use of metered-dose inhalers in hospital environments. J Aerosol Med Pulm Drug Deliv 2013; 26:287-96. [PMID: 23458577 DOI: 10.1089/jamp.2011.0940] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Metered-dose inhalers (MDIs) have become a firsthand therapeutic strategy for the management of respiratory diseases, mainly for chronic obstructive pulmonary disease (COPD) and asthma. It has been determined, however, that patients do not always use these devices correctly. Our primary goal was to establish the level of technical knowledge of patients with COPD and/or asthma on the use of MDIs, as well as other associated factors related to the effective use of this delivery method. METHODOLOGY This study was performed with 191 patients (49.2% male, 50.8% female) diagnosed with COPD and/or asthma at Hospital Universitario Mayor (Bogotá, Colombia). The agreement between different observers on nine aspects of the use of the inhaler was assessed by testing the unweighted kappa correlation coefficient and its significance. The correlations between demographic variables, risk factors, and proper knowledge of the adequate use of inhalers were established by means of the Pearson chi-square test (also called Fisher exact test) (expected values less than 5). Statistical tests were evaluated at a significance level equivalent to 5% (p<0.05). RESULTS AND CONCLUSIONS The study detected deficiencies in educational factors, specifically regarding the initial contact with the patient and regular follow-up by the team of health professionals. It also showed insufficient strategies for the training of patients in the use of the inhalers. There were no significant differences by gender (p>0.05) in the implementation of the various aspects of the proper use sequence for MDIs. However, there were significant differences related to education levels, socioeconomic status, age, and current occupation. A worse inhaler technique was associated with lower education level (0.034), higher age (p=0.003), and absence of job (p=0.005). Changes in the education of patients on the issue, together with the use of the spacer/valved holding chamber proved to be valid strategies that, with the support of the patients' health-care team, were able to improve the MDI technique of the studied group.
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Affiliation(s)
- O Vargas
- 1 Rosario University , Program of Physiotherapy, Bogotá, Colombia
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Goncalves TM, Alhanout K, Nicolay A, Dubus JC, de Santana DP, Andrieu V. Comparative in vitro performance of three small-volume valved holding chambers with beclomethasone/formoterol pressurized metered dose inhaler. J Aerosol Med Pulm Drug Deliv 2012; 26:223-7. [PMID: 23094686 DOI: 10.1089/jamp.2011.0952] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The use of valved holding chambers (VHCs) with pressurized metered dose inhalers (pMDIs) is reported to reduce the oral deposition of inhaled drugs and to facilitate the handling of these devices by patients, especially children. Although the number of commercially available VHCs is increasing, the correct choice of VHC in clinical practice is important, because VHCs are not equally effective regarding medication delivery. Hence, we aimed to evaluate the use of three small-volume VHCs-Vortex(®), AeroChamber(®) Plus (ACP), and Able Spacer™ (AS)-along with a commercial pMDI containing a combination of beclomethasone and formoterol (Innovair(®)) frequently used by asthma patients. METHODS Evaluation of the delivered dose of both drugs and analysis of particle size distribution of aerosols emitted for the inhaler were performed using the Next Generation Impactor with and without the tested VHCs. RESULTS The VHCs retained significant quantities of both drugs and dramatically reduced the quantity of drugs deposited in the throat of the impactor, indicating that particles with large size were preferably retained in the VHCs. Interestingly, although the delivered dose of both drugs was reduced by the use of VHCs, the use of the Vortex and the ACP resulted in comparable fine particle doses (FPDs) to that obtained when the pMDI was used alone, whereas the AS VHC significantly reduced the FPDs of both drugs. This may be due to the fact that, unlike the AS VHC, the Vortex and the ACP VHCs are made of antistatic materials that minimize the electrostatic interaction with emitted aerosols, enhancing medication delivery. CONCLUSION The Vortex and the ACP VHCs present interesting advantages over the AS VHC to be used with Innovair pMDI. However, these results are based on an in vitro evaluation and need to be validated in an in vivo study in order to clinically assess the performance of these VHCs.
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Affiliation(s)
- Talita Mota Goncalves
- Aix Marseille Université, Laboratoire de Pharmacie Galénique Industrielle et Cosmétologie, Faculté de Pharmacie, 13385 Marseille, France
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Bracamonte T, Schauer U, Emeryk A, Godwood A, Balsara S. Efficacy and Safety of Salmeterol/Fluticasone Propionate Combination Delivered by the Diskustrade mark or Pressurised Metered-Dose Inhaler in Children with Asthma. Clin Drug Investig 2012; 25:1-11. [PMID: 17523742 DOI: 10.2165/00044011-200525010-00001] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND OBJECTIVE Salmeterol and fluticasone propionate are well established in the treatment of childhood asthma, and their combination is effective in children aged 4-11 years. Asthma guidelines recommend that the inhaler device best suited to the individual should be used to administer asthma treatment. The aim of this study was to further evaluate the efficacy of salmeterol/fluticasone propionate combination (SFC) delivered by the Diskustrade mark (50/100mug, one inhalation twice daily) and compare it with that observed when SFC is delivered by a chlorofluorocarbon-free pressurised metered-dose inhaler (pMDI) [25/50mug, two inhalations twice daily] in children aged 4-11 years with persistent asthma. PATIENTS AND METHODS This equivalence study had a multicentre, randomised, double-blind, double-dummy, parallel-group design and comprised asthmatic children aged 4-11 years who required beclometasone (beclomethasone dipropionate) </=500 mug/day (or equivalent). After a 2-week run-in using existing inhaled corticosteroid therapy, patients were randomised to receive SFC via Diskustrade mark (n = 213) or pMDI (n = 215, with 82% using a spacer) for 12 weeks. Salbutamol (Ventolin((R))) was provided for symptomatic relief. The primary endpoint was mean morning peak expiratory flow rate (PEF) recorded by patients during weeks 1-12. Secondary endpoints included other lung function parameters, day- and night-time symptoms, use of rescue medication and percentage of symptom- and salbutamol-free days. Adverse events and 12-hour overnight urinary cortisol concentrations were monitored to assess safety. RESULTS Treatment with SFC, delivered by either device, was highly effective in improving patients' morning PEF and asthma symptoms. Over the whole study period, morning PEF (mean +/- standard error) improved by 37.7 +/- 3.1 L/min in the Diskustrade mark group and by 38.6 +/- 3.0 L/min in the pMDI group. The -0.9 L/min difference between groups (95% CI -7.1, 5.4) was within the predefined criterion for equivalence of (i.e. -15, 15 L/min). The median percentage of symptom-free and rescue medication-free days and nights increased considerably in both groups. For all efficacy parameters assessed, improvement occurred for all age groups as early as weeks 1-4, and was sustained over the 12 weeks. Both Diskustrade mark and pMDI treatments were well tolerated and their safety profiles were comparable. CONCLUSION SFC delivered via Diskustrade mark or pMDI was shown to be highly effective in asthmatic children aged 4-11 years. Children as young as 4 years were able to use the Diskustrade mark and pMDI effectively. The combination is clinically equivalent when administered via either device in this patient population. This means that both Diskustrade mark and pMDI (+ spacer) are suitable for administration of SFC, which provides prescribers/users with a choice of device.
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Affiliation(s)
- Teresa Bracamonte
- Paediatric Department, Pneumology Section, Severo Ochoa Hospital, Madrid, Spain
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Coelho ACC, Souza-Machado A, Leite M, Almeida P, Castro L, Cruz CS, Stelmach R, Cruz AA. Use of inhaler devices and asthma control in severe asthma patients at a referral center in the city of Salvador, Brazil. J Bras Pneumol 2012; 37:720-8. [PMID: 22241028 DOI: 10.1590/s1806-37132011000600004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 09/21/2011] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To evaluate the use of inhaler devices by patients with severe asthma treated via the Programa para o Controle da Asma e Rinite Alérgica na Bahia(ProAR, Bahia State Asthma and Allergic Rhinitis Control Program), recording the frequency of their errors in performing key steps and the relationship between such errors and the lack of asthma control. METHODS A cross-sectional study involving 467 patients enrolled in the ProAR in the city of Salvador, Brazil. The devices evaluated were metered dose inhalers (MDIs), with or without a spacer, and dry powder inhalers (DPIs; Pulvinal® or Aerolizer®). For the assessment of the inhalation technique, a checklist was used; the patients were asked to demonstrate the technique so that an interviewer could observe all of the steps performed. For the assessment of asthma control, we used the 6-item asthma control questionnaire. RESULTS Most of the patients showed appropriate inhalation techniques when using the devices. When using an MDI, few patients made mistakes in the key step of "coordinating activation and inhalation" (5.2% and 9.1% with and without the use of a spacer, respectively). During Pulvinal® use, 39% of the patients did not inhale quickly and deeply, compared with only 5.8% during Aerolizer® use. Of the patients that made use of Aerolizer® alone, 71.3% appropriately performed all of the essential steps, and their asthma was controlled. CONCLUSIONS Most of the patients in this sample, all of whom had been submitted to periodic checks of their inhalation technique (as part of the program), used the devices appropriately. Proper inhalation technique is associated with asthma symptom control.
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Araújo FDB, Corrêa RDA, Pereira LFF, Silveira CD, Mancuso EV, Rezende NAD. Spirometry with bronchodilator test: effect that the use of large-volume spacers with antistatic treatment has on test response. J Bras Pneumol 2012; 37:752-8. [PMID: 22241032 DOI: 10.1590/s1806-37132011000600008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 09/19/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate whether the use of inhaled albuterol via a metered-dose inhaler with a large-volume spacer with antistatic treatment modifies the bronchodilator test results when compared with the usual technique (no spacer). METHODS A prospective study involving 24 patients, 18-45 years of age, clinically suspected of having asthma, and under treatment at the Outpatient Pulmonary Clinic of the Federal University of Minas Gerais Hospital das Clínicas, located in the city of Belo Horizonte, Brazil. All of the patients underwent two bronchodilator tests: one with and one without the use of a large-volume spacer. RESULTS There was no significant difference in the variation of FEV1 prior to and after bronchodilator use between the two techniques (mean ΔFEV1 = 0.01 L; 95% CI: -0.05 to 0.06; p = 0.824). No statistically significant difference was found between the two techniques regarding the qualitative results on the bronchodilator test (p = 1.00). There was concordance between the techniques in terms of the bronchodilator test results (kappa coefficient = 0.909; p < 0.005). CONCLUSIONS According to the results of this study, the use of large-volume spacers does not significantly modify bronchodilator test results.
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Capstick TGD, Clifton IJ. Inhaler technique and training in people with chronic obstructive pulmonary disease and asthma. Expert Rev Respir Med 2012; 6:91-101; quiz 102-3. [PMID: 22283582 DOI: 10.1586/ers.11.89] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Asthma and chronic obstructive pulmonary disease are both common conditions with an increasing prevalence worldwide. Inhaled therapy for these conditions has a number of advantages over systemic therapy, including reduced side effects and quicker onset of action. The effective use of inhaled therapy is critically dependent upon the nature of the drug-delivery system and the ability of the patient to use the system correctly. There are a wide number of inhaler devices on the market, each with positive and negative aspects. A crucial part of patient care is to ensure that the choice of inhaler device for the individual is an effective therapy. There are a number of interventions that can help with the choice of inhaler device and also improve the ability of the patient to use inhaled therapy. Inhaler technique training needs to be a cornerstone of the care of patients with asthma or chronic obstructive pulmonary disease to ensure optimal therapy.
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Affiliation(s)
- Toby G D Capstick
- Department of Respiratory Medicine, St James's University Hospital, Beckett Street, Leeds, UK
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Kroening-Roche JC, Soroudi A, Castillo EM, Vilke GM. Antibiotic and bronchodilator prescribing for acute bronchitis in the emergency department. J Emerg Med 2012; 43:221-7. [PMID: 22341759 DOI: 10.1016/j.jemermed.2011.06.143] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 04/14/2011] [Accepted: 06/05/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although the overuse of antibiotics and underuse of bronchodilators for treatment of acute bronchitis is well known, few studies have analyzed these trends in the emergency department (ED). STUDY OBJECTIVES To characterize the antibiotic and bronchodilator prescribing practices of physicians at two academic EDs in the diagnosis of acute bronchitis, and to identify factors that may or may not be associated with these practices. METHODS A computer database was searched retrospectively for all patients with an ED discharge diagnosis of acute bronchitis, and analyzed, looking at the frequency of antibiotic prescriptions, the class of antibiotic prescribed, and several other related factors including age, gender, chief complaint, duration of cough, and comorbid conditions. RESULTS During the study period, there were 836 cases of acute bronchitis in adults. Of these, 622 (74.0%) were prescribed antibiotics. Of those prescribed antibiotics, 480 (77.2%) were prescribed broad-spectrum antibiotics. Using multivariate analysis (odds ratio, 95% confidence interval), antibiotics were prescribed significantly more often in patients aged 50 years or older (1.7, 1.2-2.5) and in smokers (1.5, 1.0-2.2). Of patients without asthma, 346 (49.9%) were discharged without a bronchodilator, and 631 (91.1%) were discharged without a spacer device. CONCLUSION Antibiotics are over-prescribed in the ED for acute bronchitis, with broad-spectrum antibiotics making up the majority of the antibiotics prescribed. Age ≥50 years and smoking are associated with higher antibiotic prescribing rates.
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Affiliation(s)
- Jason C Kroening-Roche
- University of California (UC) San Diego School of Medicine, San Diego, California 92102, USA
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Wolthers OD, Sergio F. Systemic activity of inhaled beclomethasone dipropionate: a double-blind comparison of volume spacers. Acta Paediatr 2012; 101:159-63. [PMID: 21790779 DOI: 10.1111/j.1651-2227.2011.02430.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND To which extent volume spacers may influence systemic activity of inhaled beclomethasone dipropionate (BDP) has not been evaluated. AIM To assess whether the AeroChamber Plus™ spacer is equivalent to the Volumatic™ spacer for administration of inhaled hydroflouroalkane 134a propelled BDP in terms of lower leg growth rate (LLGR). PATIENTS AND METHODS Prepubertal children with mild asthma (n = 26, aged 6-14 years) were included in a 3-time periods of 2 weeks duration randomized double-blind cross-over study with a single-blind placebo run-in and two washout periods. LLGR was measured with the knemometer. Interventions were inhaled BDP hydroflouroalkane 134a pressurized metered dose inhaler 100 μg and 200 μg b.i.d. with the AeroChamber Plus and 200 μg b.i.d. with the Volumatic spacer. RESULTS Beclomethasone dipropionate 200 μg b.i.d. from the AeroChamber Plus was non-inferior to BDP 200 b.i.d. from the Volumatic spacer as the lower margin of confidence interval of the difference between treatments (-0.18 to 0.13 mm/week) was greater than the prespecified lower limit for non-inferiority (-0.20 mm/week). UFC/creatinine data showed no statistically significant variations. CONCLUSION The systemic activity of BDP, via the Volumatic™, and AeroChamber Plus™ spacers is similar. The AeroChamber Plus spacer may be used in children without risk of increasing systemic activity of BDP.
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Sims MW. Aerosol therapy for obstructive lung diseases: device selection and practice management issues. Chest 2011; 140:781-788. [PMID: 21896522 DOI: 10.1378/chest.10-2068] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Inhaled aerosol therapies are the mainstay of treatment of obstructive lung diseases. Aerosol devices deliver drugs rapidly and directly into the airways, allowing high local drug concentrations while limiting systemic toxicity. While numerous clinical trials, literature reviews, and expert panel guidelines inform the choice of inhalational drugs, deciding which aerosol device (ie, metered-dose inhaler, nebulizer, or dry powder inhaler) best suits a given patient and clinical setting can seem arbitrary and confusing. Similar confusion regarding Current Procedural Terminology (CPT) coding for administration of aerosol therapies can lead to lost revenue from underbilling and wasted administrative effort handling denied claims. This article reviews the aerosol devices currently available, discusses their relative merits in various clinical settings, and summarizes appropriate CPT coding for aerosol therapy.
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Affiliation(s)
- Michael W Sims
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA.
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Singh D, Collarini S, Poli G, Acerbi D, Amadasi A, Rusca A. Effect of AeroChamber Plus™ on the lung and systemic bioavailability of beclometasone dipropionate/formoterol pMDI. Br J Clin Pharmacol 2011; 72:932-9. [PMID: 21615456 PMCID: PMC3244640 DOI: 10.1111/j.1365-2125.2011.04024.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 05/19/2011] [Indexed: 11/27/2022] Open
Abstract
AIM To assess the effect of AeroChamber Plus™ on lung deposition and systemic exposure to extra-fine beclometasone dipropionate (BDP)/formoterol (100/6 µg) pMDI (Foster®). The lung deposition of the components of the combination given with the pMDI was also evaluated using the charcoal block technique. METHODS Twelve healthy male volunteers received four inhalations of extra-fine BDP/formoterol (100/6 µg) using (i) pMDI alone, (ii) pMDI and AeroChamber Plus™ and (iii) pMDI and charcoal ingestion. RESULTS Compared with pMDI alone, use of AeroChamber Plus™ increased the peak plasma concentrations (C(max)) of BDP (2822.3 ± 1449.9 vs. 5454.9 ± 3197.1 pg ml(-1)), its active metabolite beclometasone 17-monopropionate (17-BMP) (771.6 ± 288.7 vs. 1138.9 ± 495.6 pg ml(-1)) and formoterol (38.4 ± 17.8 vs. 54.7 ± 20.0 pg ml(-1)). For 17-BMP and formoterol, the AUC(0,30 min), indicative of lung deposition, was increased in the AeroChamber Plus™ group by 41% and 45%, respectively. This increase was mainly observed in subjects with inadequate inhalation technique. However, use of AeroChamber Plus™ did not increase the total systemic exposure to 17-BMP and formoterol. Results after ingestion of charcoal confirmed that AUC(0,30 min) can be taken as an index of lung bioavailability and that more than 30% of the inhaled dose of extra-fine BDP/formoterol 100/6 µg was delivered to the lung using the pMDI alone. CONCLUSIONS The use of AeroChamber Plus™ optimizes the delivery of BDP and formoterol to the lung in subjects with inadequate inhalation technique. The total systemic exposure was not increased, supporting the safety of extra-fine BDP/formoterol pMDI with AeroChamber Plus™.
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Affiliation(s)
- Dave Singh
- The University of Manchester, Medicines Evaluation UnitManchester, UK
| | | | | | | | - Alessio Amadasi
- Department of Scientific Affairs, Chiesi Farmaceutici S.p.A.Parma, Italy
| | - Antonio Rusca
- Clinical Department, Cross Research S.AArzo, Switzerland
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Oliveira RF, Teixeira SFCF, Silva LF, Teixeira JCF, Antunes H. Development of new spacer device geometry: a CFD study (part I). Comput Methods Biomech Biomed Engin 2011; 15:825-33. [PMID: 21491261 DOI: 10.1080/10255842.2011.563359] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Asthma is a widespread disease, affecting more than 300 million individuals. The treatment in children is based upon an administration of a pressurised metered-dose inhaler added with a spacer. The efficiency of drug delivery to the patient is strongly affected by the transient airflow pattern inside the spacer device. This paper presents a computational fluid dynamics (CFD) analysis of airflow inside a commercially available spacer device with wide application. This study, carried out in Fluent™, was the basis of an optimisation procedure developed to improve the geometry of the spacer and develop a more efficient product. The results show that an appropriate control of the boundary layer development, by changing the spacer shape, reduces the length of the recirculation zones and improves the flow. It can be concluded that CFD is a powerful technique that can be successfully applied to optimise the geometry of such medical devices.
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Affiliation(s)
- Ricardo F Oliveira
- Mechanical Engineering Department, School of Engineering, University of Minho, 4800-058, Guimarães, Portugal.
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Misra A, Hickey AJ, Rossi C, Borchard G, Terada H, Makino K, Fourie PB, Colombo P. Inhaled drug therapy for treatment of tuberculosis. Tuberculosis (Edinb) 2011; 91:71-81. [DOI: 10.1016/j.tube.2010.08.009] [Citation(s) in RCA: 129] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 08/12/2010] [Accepted: 08/29/2010] [Indexed: 11/16/2022]
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Desalu OO, Onyedum CC, Iseh KR, Salawu FK, Salami AK. Asthma in Nigeria: are the facilities and resources available to support internationally endorsed standards of care? Health Policy 2010; 99:250-4. [PMID: 21056506 DOI: 10.1016/j.healthpol.2010.10.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2010] [Revised: 10/05/2010] [Accepted: 10/10/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The objective of this study was to assess the facilities and resources available to support internationally endorsed standards of asthma care at tertiary hospitals (University teaching, Federal Medical Centre and State specialist Hospitals) in Nigeria. METHODS This cross sectional study was conducted among 68 tertiary hospitals (TH) in Nigeria from June 2009 to December 2009. Structured standards of care questionnaires on asthma based on the Global initiative for asthma (GINA) guideline were completed by physician working in each of the TH. RESULTS Most TH lacked the services of respiratory physicians, internists, and pediatricians. Available basic infrastructures were asthma clinics (0%), clinic registers (20.6%), and hospital protocol (17.6%), doctor's attendance of asthma CME (8.8%) and nurse educator with a bias for asthma (14.7%). Thirty eight percent of TH had peak flow meter, 29.4% had spirometer, skin allergy test kits (15.6%), pulse oximeter (38.2%) while 17.6% had arterial blood gases analyser. Nebuliser and spacer were available in 41.2% and 20.6% of TH respectively. Oral short acting beta 2 agonist (SABA) was available in 79.4% of the hospitals, glucocorticosteroid (79.4%), theophyllines (76.5%), and SABA (metered-dose inhaler MDI: 76.5%, Nebules: 35.3%). Long acting beta 2 agonist (LABA) and steroid fixed dose combination inhaler (50%) was available in 50% of TH. Glucocorticosteroid nasal spray was available in 33.3% of TH and <10% reported the availability of anti-cholinergic and chromoglycate inhaler and oral leukotriene antagonist. Standard oxygen delivery system and self-educational support materials were available in 52.9% of TH. CONCLUSION The available facilities and human resources for asthma management in Nigerian tertiary hospitals were not enough to support the standard internationally endorsed for asthma care. Provisions of deficient infrastructures and continuous training of health care personnel in asthma management are imperative to enhance the quality of care.
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Murphy KR. Adherence to inhaled corticosteroids: comparison of available therapies. Pulm Pharmacol Ther 2010; 23:384-8. [PMID: 20542129 DOI: 10.1016/j.pupt.2010.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2010] [Revised: 05/28/2010] [Accepted: 06/03/2010] [Indexed: 11/24/2022]
Abstract
Adherence to daily anti-inflammatory therapy, the cornerstone being inhaled corticosteroids (ICSs), is critical for the control of persistent asthma. Many factors, both behavioral and treatment-related, can affect treatment adherence. In the pediatric population, adherence is often the responsibility of parents/caregivers. Thus, parents may need improved awareness of the major asthma controller medications, especially regarding the efficacy and safety of ICSs; their beliefs or concerns regarding asthma therapy have a bearing on their diligence in encouraging adherence with the prescribed treatment regimen. Dosing complexity and factors relating to inhaler use are also important components of adherence. There are currently 6 ICSs (excluding nebulized ICSs) approved for children in the United States. The purpose of this review is to examine and compare the features of the available ICSs that may influence adherence in the treatment of pediatric asthma.
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Affiliation(s)
- Kevin R Murphy
- Boys Town National Research Hospital, Allergy, Asthma & Pediatric Pulmonology, Boys Town, NE 68010, USA.
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Boss H, Minic P, Nave R. Similar Results in Children with Asthma for Steady State Pharmacokinetic Parameters of Ciclesonide Inhaled with or without Spacer. CLINICAL MEDICINE INSIGHTS-PEDIATRICS 2010; 4:1-10. [PMID: 23761990 PMCID: PMC3666986 DOI: 10.4137/cmped.s4311] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Ciclesonide is an inhaled corticosteroid administered by a metered dose inhaler (MDI) to treat bronchial asthma. After inhalation, the inactive ciclesonide is converted by esterases in the airways to active metabolite desisobutyryl-ciclesonide (des-CIC). Aim: To compare the pharmacokinetic (PK) parameters of des-CIC in children after administration of therapeutic dose of ciclesonide with and without spacer (AeroChamber Plus™). Methods: Open-label, 3 period, cross over, repeated dose, PK study in 37 children with mild to moderate stable asthma (age: 6–11 y; body weight: 20–53 kg). During each 7-day treatment period, ciclesonide was inhaled once in the morning: A) 160 μg MDI with spacer, B) 80 μg MDI with spacer, and C) 160 μg MDI without spacer. Serum PK parameters of ciclesonide and des-CIC were determined on Day 7 of each period. The primary PK parameters were the AUCτ and Cmax for des-CIC. Results: Inhaling ciclesonide with spacer led to a dose proportional systemic exposure (AUCτ) of des-CIC (0.316 μg*h/L for 80 μg and 0.663 μg*h/L for 160 μg). The dose-normalized systemic exposure for des-CIC (based on AUCτ) was 27% higher after inhalation of ciclesonide 80 μg or 160 μg with spacer than without spacer; the corresponding Cmax values for des-CIC were, respectively, 63% and 55% higher with spacer. No clinically relevant abnormalities or adverse drug reactions were observed. Conclusions: Inhalation of therapeutic ciclesonide dose with spacer led to a slight increase in the systemic exposure of des-CIC, which does not warrant dose adjustment.
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Affiliation(s)
- H Boss
- Nycomed GmbH, Byk Gulden Str. 2, 78467 Konstanz, Germany
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Abstract
Abstract
Objectives
This review focuses on the key findings and developments in the rapidly expanding research area of pharmaceutical aerosol electrostatics.
Key findings
Data from limited in-vivo and computational studies suggest that charges may potentially affect particle deposition in the airways. Charging occurs naturally in the absence of electric fields through triboelectrification, that is contact or friction for solids and flowing or spraying for liquids. Thus, particles and droplets emitted from pulmonary drug delivery devices (dry powder inhalers, metered dose inhalers with or without spacers, and nebulisers) are inherently charged. Apparatus with various operation principles have been employed in the measurement of pharmaceutical charges. Aerosol charges are dependent on many physicochemical parameters, such as formulation composition, device construction, relative humidity and solid-state properties. In some devices, electrification has been purposefully applied to facilitate powder dispersion and liquid atomisation.
Summary
Currently, there are no regulatory requirements on characterising electrostatic properties of inhalation aerosols. As research in this area progresses, the new knowledge gained may become valuable for the development and regulation of inhalation aerosol products.
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Affiliation(s)
- Philip Chi Lip Kwok
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, New South Wales, Australia
| | - Hak-Kim Chan
- Advanced Drug Delivery Group, Faculty of Pharmacy, The University of Sydney, New South Wales, Australia
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Hoe S, Traini D, Chan HK, Young PM. The influence of flow rate on the aerosol deposition profile and electrostatic charge of single and combination metered dose inhalers. Pharm Res 2009; 26:2639-46. [PMID: 19806433 DOI: 10.1007/s11095-009-9979-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Accepted: 09/14/2009] [Indexed: 11/30/2022]
Abstract
PURPOSE The capability of the electrostatic next generation impactor (eNGI) has been investigated as a tool capable of measuring the electrostatic charge of single (Flixotide; containing fluticasone propionate (FP)) and combination (Seretide; FP and salmeterol xinafoate (SX)) pressurised metered dose inhalers (pMDIs) at different flow rates. METHODS Aerosol mass distributions were investigated at 30, 60 and 90 l.min(-1) and simultaneous charge measurements recorded. RESULTS Analysis of the mass distribution data indicated a flow dependent relationship, where the aerosol performance (aerodynamic diameter <5 mum) of FP significantly increased between 30 l.min(-1) and 60 l.min(-1) for both formulations. No significant increase in SX was observed for Seretide with increased flow rate. Analysis of the charge distribution indicated both formulations to primarily charge negatively with a concurrent increase in charge with increased flow rate. Interestingly, the charge-tomass ratio remained relatively constant between 30 l.min(-1) and 60 l.min(-1) and increased at 90 l.min(-1), indicating that charging was majorly influenced at the highest flow rate. CONCLUSIONS This study has shown how the eNGI could be used as a simple Pharmacopeia based methodology for the evaluation of mass and charge profiles of single and combination pMDIs at a series of flow rates.
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Affiliation(s)
- Susan Hoe
- Advanced Drug Delivery Group, Faculty of Pharmacy, University of Sydney, Sydney, NSW, 2006, Australia
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Engelstätter R, Szlávik M, Gerber C, Beck E. Once-daily ciclesonide via metered-dose inhaler: Similar efficacy and safety with or without a spacer. Respir Med 2009; 103:1643-50. [PMID: 19596188 DOI: 10.1016/j.rmed.2009.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Revised: 06/04/2009] [Accepted: 06/05/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND Inhaled corticosteroids (ICS) are recommended as first-line treatment for adults and children with persistent asthma. The Global Initiative for Asthma recommends that patients taking medium- or high-dose ICS delivered by metered-dose inhalers (MDIs) should use a spacer device. METHODS This randomized, open-label, 12-week, non-inferiority study compared the efficacy and safety of ciclesonide 160microg once daily delivered via hydrofluoroalkane-MDI alone (CIC160) or with a spacer (either an AeroChamber Plus [CIC160P] or an AeroChamber MAX [CIC160M]) in patients with persistent asthma. The primary efficacy variable was change in forced expiratory volume in 1s (FEV(1)) from baseline to study end. RESULTS Significant improvements in FEV(1) were observed from baseline to study end in each treatment group; least squares mean change from baseline ranged between 0.32 and 0.34L in the per-protocol (PP) analysis and similar results were observed for the intention-to-treat (ITT) analysis (p<0.0001 for all). Non-inferiority of CIC160P and CIC160M to CIC160 was observed for both PP and ITT populations (p<0.0001 [one-sided]). In all groups, daily asthma symptom scores were reduced to 0 and significant reductions were observed in rescue medication use at study end (p<0.0001 versus baseline for all). Ciclesonide was well tolerated in all groups and no cases of oral candidiasis were reported. Morning serum cortisol levels significantly increased in all groups from baseline to study end (p< or =0.0389), with no significant between-treatment differences. CONCLUSION In patients with persistent asthma, ciclesonide was shown to have similar efficacy and tolerability when administered via MDI alone or with a spacer.
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Lavorini F, Fontana GA. Targeting drugs to the airways: The role of spacer devices. Expert Opin Drug Deliv 2009; 6:91-102. [PMID: 19236210 DOI: 10.1517/17425240802637862] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIM Spacer devices are inhalation aids of varying dimension and complexity, specifically designed to overcome problems with the use of pressurised metered dose inhalers (pMDIs). The aim of this review is to examine the current understanding about these inhalation devices and discuss their advantages and disadvantages. METHODS The pertinent literature concerning the characteristics and effects of spacers on delivery and lung deposition of inhaled medications, as well as their clinical efficacy in patients with reversible airway obstruction, is examined. RESULTS Spacers minimise problems of poor inhalation technique with pMDI, reduce oropharyngeal deposition and increase lung deposition. Spacers improve the clinical effect of inhaled medications, especially in patients unable to use a pMDI properly. Compared to both pMDIs and dry-powder inhalers, spacers may increase the response to beta-adrenergic bronchodilators, even in patients with correct inhalation technique. A pMDI plus spacer has proven to be viable lower cost alternative to the use of a nebuliser for delivering large bronchodilator doses in patients with severe acute asthma or chronic obstructive pulmonary disease. The use of large-volume spacers is recommended for delivering high doses of inhaled corticosteroids, and may permit a lower maintenance dose to be used. CONCLUSION pMDIs may be routinely fitted with a spacer, especially in situations where correct pMDI use is unlikely.
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Affiliation(s)
- Federico Lavorini
- Università degli Studi di Firenze, Dipartimento di Area Critica Medico Chirurgica, Firenze, Italy.
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Affiliation(s)
- Christopher H Fanta
- Partners Asthma Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
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