Aerosol Therapy in Asthma-Why We Are Failing Our Patients and How We Can Do Better

Drug combinations for inhalation: Current products and future development addressing disease control and patient compliance

Pulmonary delivery is an alternative route of administration with numerous advantages over conventional routes of administration. It provides low enzymatic exposure, fewer systemic side effects, no first-pass metabolism, and concentrated drug amounts at the site of the disease, making it an ideal route for the treatment of pulmonary diseases. Owing to the thin alveolar-capillary barrier, and large surface area that facilitates rapid absorption to the bloodstream in the lung, systemic delivery can be achieved as well. Administration of multiple drugs at one time became urgent to control chronic pulmonary diseases such as asthma and COPD, thus, development of drug combinations was proposed. Administration of medications with variable dosages from different inhalers leads to overburdening the patient and may cause low therapeutic intervention. Therefore, products that contain combined drugs to be delivered via a single inhaler have been developed to improve patient compliance, reduce different dose regimens, achieve higher disease control, and boost therapeutic effectiveness in some cases. This comprehensive review aimed to highlight the growth of drug combinations by inhalation over time, obstacles and challenges, and the possible progress to broaden the current options or to cover new indications in the future. Moreover, various pharmaceutical technologies in terms of formulation and device in correlation with inhaled combinations were discussed in this review. Hence, inhaled combination therapy is driven by the need to maintain and improve the quality of life for patients with chronic respiratory diseases; promoting drug combinations by inhalation to a higher level is a necessity.

Inhaler technique in a pediatric emergency department: Impact of an education intervention among healthcare professionals

BACKGROUND

Inhaler technique (IT) knowledge among healthcare providers is poor. The aim was to improve Pediatric Emergency Department (PED) healthcare providers' IT technique by carrying out an education intervention and sustain it for 6 months.

METHODS

Open-label, quasi-experimental, prospective, and unicentric study. Healthcare professionals working at the PED were enrolled. The study was developed in three phases: baseline evaluation and education intervention (P1) and reevaluation 1 month (P2) and 6 months (P3) after the education intervention. Participants fulfilled an eight-question theoretical test. Practical skills were evaluated by demonstrating IT in all three phases. The education intervention consisted in a verbal explanation of IT followed by a demonstration of IT with metered-dose inhaler using a mannequin.

RESULTS

A total of 84 healthcare providers (medical residents, nurses, and nursing assistants) were involved. In the theoretical questionnaire, the mean score at baseline was 4.4/8 (SD 1.7) improving to 6.3/8 (SD 1.2) in P2 and 6.47/8 (SD 1.1) in P3. In the IT evaluation for children <7 years old, the score improved from 5.7/7 (SD 1.3) to 6.5/7 in P2 and 6.7/7 in P3 (p < 0.001). For children >7 years old, the mean score of IT at baseline was 3.1/10 (SD 4), which improved to 7.4/10 (SD 3) and 8.2/10 in P2 and P3, respectively (p < 0.001). Only professional category influenced results at baseline.

CONCLUSION

Healthcare providers' theoretical knowledge and practical skills on IT are low. The education intervention performed is a useful strategy to ameliorate IT among healthcare providers.

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

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

Mobile video directly observed therapy can be used to improve at-home inhaler technique in children with asthma

We were very pleased to read the article “Comparison of inhalation technique with the Diskus and Autohaler in asthmatic children at home”, recently published in ERJ Open Research [1]. In that paper, the authors describe using video Directly Observed Therapy (vDOT) to detect children's errors when using their inhalers at home. This is very important, and clearly shows that paediatricians and asthma specialists can wrongly assume that if a child can demonstrate correct inhaler technique in the clinic, they will continue to use correct inhaler technique when at home. The authors also report that errors were more frequent when the dry-powder Diskhaler was compared with the Autohaler.

Most children and parents have mobile smartphones that can be used to record videos while the child uses their inhaler. The timed (stamped with date and time) videos can be submitted to a secure repository. An asthma nurse then can review the video.https://bit.ly/2UyG11W

The effect of repeated education using live demonstrations and videos of how to use inhalation drugs on quality of life for COPD patients

Repeated education regarding the proper use of inhalers can reduce the error rate in inhaler-using patients and improve COPD patients' quality of life. This study investigates the effect of repeated education on the quality of life of COPD patients during the pandemic of COVID-19 from February to June 2020. Repeated education is provided using direct demonstrations to patients through educational media in the form of short videos made by the researchers for each inhaler type. This is a pre-experimental study design which was carried out prospectively at Grha Permata Ibu Hospital, Depok. The quality of life of 22 subjects was examined using the COPD assessment test (CAT) questionnaire. Each patient was given a direct verbal demonstration of the appropriate use of the inhaler. One month later, each patient was provided further education using less than 2 min of video sent to them online via the WhatsApp application. Final quality-of-life examination and assessment of inhaler technique were carried out three months after the initial examination. Assessment of proper inhaler technique was carried out using a specific checklist regarding the use of inhaler translated by the researcher. Before and after delivery of repeated education, the mean CAT score showed a decrease of two points, i.e., 12.8 ± 1.3 and 10.8 ± 2.0, respectively. This indicated that quality of life of the patients had significant improvement. However, as many as 63.6% of patients still made mistakes in using inhaler even though they had been educated. For DPI-type inhalers, mistake mostly happened at step "breath out gently, away from inhaler". For pMDI-type inhalers, mistake mostly happened at step "while holding breath, remove inhaler from mouth". It can be concluded that repeated education regarding proper inhaler technique with direct demonstrations and further maintained by videos can improve the quality of life in COPD patients.

Impact of an Asthma Education Program During Admission

OBJECTIVES

Health educational interventions improve health outcomes and quality of life in children with asthma. The main purpose of this study was to evaluate the effect of an education intervention for an asthma inhaler technique during hospital admission for an asthma exacerbation.

METHODS

This prospective study was conducted in a pediatric hospitalization unit of a third-level hospital. Children admitted for an asthma exacerbation were eligible for inclusion. It was developed in 2 phases: during hospital admission (T1) and 1 month after discharge (T2). In the T1 phase, caregivers completed the questionnaire to assess asthma control in children (CAN questionnaire) and performed the inhaler technique, which was evaluated with a 6-step checklist. An educational intervention was performed. In the T2 phase, caregivers completed the CAN questionnaire, and the inhaler technique was reevaluated. We hypothesized that the inhaler technique improved after the implementation of an asthma education program.

RESULTS

A total of 101 children were included, of whom 85 completed the T2 phase (84%). At baseline, 11.8% of participants performed the inhaler technique correctly. All steps of the inhaler technique upgraded in the T2 phase significantly (P < .01), except for the step "assemble the inhaler device correctly." Former evaluation by a pediatric pneumologist was associated with a higher score in the inhaler technique in the T1 phase. The median CAN questionnaire score in the T1 phase was 8 (interquartile range 4-16), which reduced to 4 (interquartile range 1.2-6) in the T2 phase (P < .01).

CONCLUSIONS

The development of an educational intervention during admission improved inhaler technique as well as asthma knowledge.