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Darquenne C, Corcoran TE, Lavorini F, Sorano A, Usmani OS. The effects of airway disease on the deposition of inhaled drugs. Expert Opin Drug Deliv 2024; 21:1175-1190. [PMID: 39136493 PMCID: PMC11412782 DOI: 10.1080/17425247.2024.2392790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/06/2024] [Accepted: 08/12/2024] [Indexed: 08/15/2024]
Abstract
INTRODUCTION The deposition of inhaled medications is the first step in the pulmonary pharmacokinetic process to produce a therapeutic response. Not only lung dose but more importantly the distribution of deposited drug in the different regions of the lung determines local bioavailability, efficacy, and clinical safety. Assessing aerosol deposition patterns has been the focus of intense research that combines the fields of physics, radiology, physiology, and biology. AREAS COVERED The review covers the physics of aerosol transport in the lung, experimental, and in-silico modeling approaches to determine lung dose and aerosol deposition patterns, the effect of asthma, chronic obstructive pulmonary disease, and cystic fibrosis on aerosol deposition, and the clinical translation potential of determining aerosol deposition dose. EXPERT OPINION Recent advances in in-silico modeling and lung imaging have enabled the development of realistic subject-specific aerosol deposition models, albeit mainly in health. Accurate modeling of lung disease still requires additional refinements in existing imaging and modeling approaches to better characterize disease heterogeneity in peripheral airways. Nevertheless, recent patient-centric innovation in inhaler device engineering and the incorporation of digital technology have led to more consistent lung deposition and improved targeting of the distal airways, which better serve the clinical needs of patients.
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Affiliation(s)
- Chantal Darquenne
- Department of Medicine, University of California, San Diego, CA, USA
| | | | - Federico Lavorini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Alessandra Sorano
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London, London, UK
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2
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Wachtel H, Emerson-Stadler R, Langguth P, Hohlfeld JM, Ohar J. Aerosol Plumes of Inhalers Used in COPD. Pulm Ther 2024; 10:109-122. [PMID: 38194194 PMCID: PMC10881950 DOI: 10.1007/s41030-023-00249-5] [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: 09/12/2023] [Accepted: 11/21/2023] [Indexed: 01/10/2024] Open
Abstract
INTRODUCTION The selection of inhaler device is of critical importance in chronic obstructive pulmonary disease (COPD) as the interaction between a patient's inhalation profile and the aerosol characteristics of an inhaler can affect drug delivery and lung deposition. This study assessed the in vitro aerosol characteristics of inhaler devices approved for the treatment of COPD, including a soft mist inhaler (SMI), pressurized metered-dose inhalers (pMDIs), and dry powder inhalers (DPIs). METHODS High-speed video recording was used to visualize and measure aerosol velocity and spray duration for nine different inhalers (one SMI, three pMDIs, and five DPIs), each containing dual or triple fixed-dose combinations of long-acting muscarinic receptor antagonists and long-acting β2-agonists, with or without an inhaled corticosteroid. Measurements were taken in triplicate at experimental flow rates of 30, 60, and 90 l/min. Optimal flow rates were defined based on pharmacopoeial testing requirements: 30 l/min for pMDIs and SMIs, and the rate achieving a 4-kPa pressure drop against internal inhaler resistance for DPIs. Comparison of aerosol plumes was based on the experimental flow rates closest to the optimal flow rates. RESULTS The Respimat SMI had the slowest plume velocity (0.99 m/s) and longest spray duration (1447 ms) compared with pMDIs (velocity: 3.65-5.09 m/s; duration: 227-270 ms) and DPIs (velocity: 1.43-4.60 m/s; duration: 60-757 ms). With increasing flow rates, SMI aerosol duration was unaffected, but velocity increased (maximum 2.63 m/s), pMDI aerosol velocity and duration were unaffected, and DPI aerosol velocity tended to increase, with a more variable impact on duration. CONCLUSIONS Aerosol characteristics (velocity and duration of aerosol plume) vary by inhaler type. Plume velocity was lower and spray duration longer for the SMI compared with pMDIs and DPIs. Increasing experimental flow rate was associated with faster plume velocity for DPIs and the SMI, with no or variable impact on plume duration, whereas pMDI aerosol velocity and duration were unaffected by increasing flow rate.
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Affiliation(s)
- Herbert Wachtel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany.
| | - Rachel Emerson-Stadler
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany
| | - Peter Langguth
- Institute for Pharmaceutical and Biomedical Sciences (IPBW), University of Mainz, Mainz, Germany
| | - Jens M Hohlfeld
- Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover, Germany
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Jill Ohar
- Department of Internal Medicine, Section on Pulmonary Medicine, Critical Care, Allergy and Immunologic Diseases, Atrium Health Wake Forest Baptist, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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Capstick TGD, Gudimetla S, Harris DS, Malone R, Usmani OS. Demystifying Dry Powder Inhaler Resistance with Relevance to Optimal Patient Care. Clin Drug Investig 2024; 44:109-114. [PMID: 38198116 PMCID: PMC10834657 DOI: 10.1007/s40261-023-01330-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 01/11/2024]
Abstract
The selection of an inhaler device is a key component of respiratory disease management. However, there is a lack of clarity surrounding inhaler resistance and how it impacts inhaler selection. The most common inhaler types are dry powder inhalers (DPIs) that have internal resistance and pressurised metered dose inhalers (pMDIs) that use propellants to deliver the drug dose to the airways. Inhaler resistance varies across the DPIs available on the market, depending largely on the design geometry of the device but also partially on formulation parameters. Factors influencing inhaler choice include measures such as flow rate or pressure drop as well as inhaler technique and patient preference, both of which can lead to improved adherence and outcomes. For optimal disease outcomes, device selection should be individualised, inhaler technique optimised and patient preference considered. By addressing the common clinically relevant questions, this paper aims to demystify how DPI resistance should guide the selection of the right device for the right patient.
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Affiliation(s)
| | | | | | | | - Omar S Usmani
- National Heart and Lung Institute (NHLI), Imperial College London, London, Guy Scadding Building, Dovehouse Street, London, SW3 6LY, UK.
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Kocks J, Bosnic-Anticevich S, van Cooten J, Correia de Sousa J, Cvetkovski B, Dekhuijzen R, Dijk L, Garcia Pardo M, Gardev A, Gawlik R, van der Ham I, Janse Y, Lavorini F, Maricoto T, Meijer J, Metz B, Price D, Roman Rodriguez M, Schuttel K, Stoker N, Tsiligianni I, Usmani O, Voorham J, Leving MT. Identifying critical inhalation technique errors in Dry Powder Inhaler use in patients with COPD based on the association with health status and exacerbations: findings from the multi-country cross-sectional observational PIFotal study. BMC Pulm Med 2023; 23:302. [PMID: 37592263 PMCID: PMC10433653 DOI: 10.1186/s12890-023-02566-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/16/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND Correct inhaler use depends on a complex interplay of factors, including device preparation and generating sufficient inspiratory flow. It is currently unknown which inhalation technique errors can be considered critical in Chronic Obstructive Pulmonary Disease (COPD) patients on Dry Powder Inhaler (DPI) maintenance therapy. OBJECTIVE To investigate the association between inhalation technique errors and health status or exacerbations in patients with COPD. Additionally, the association between the number of errors and COPD outcomes was determined. METHODS The PIFotal study is a cross-sectional multi-country observational study in a primary care setting, including 1434 COPD patients aged ≥ 40 years (50.1% female; mean age 69.2 yrs) using a DPI for their maintenance therapy. Inhalation technique was video recorded and scored by two independent researchers using inhaler-specific checklists. Health status was assessed with two questionnaires; the Clinical COPD Questionnaire (CCQ) and the COPD Assessment Test (CAT). The number of moderate and severe exacerbations in the past 12 months was recorded. Critical errors were identified based on their association with health status or exacerbations through multi-level prediction models adjusted for identified confounding. RESULTS Errors in inhalation technique steps 'Breathe in', 'Hold breath', and 'Breathe out calmly after inhalation' were significantly associated with poorer CCQ and CAT outcomes and thus deemed critical. None of the errors were significantly associated with moderate exacerbations. Patients with errors 'Preparation', 'Hold inhaler in correct position during inhalation', and 'Breathe in' had significantly more severe exacerbations, and therefore these errors were also deemed critical. 81.3% of patients with COPD made at least one critical error. Specific combinations of errors were associated with worse outcomes. The more inhalation technique errors identified, the poorer the health status and the higher the exacerbation rate. CONCLUSION In this study, we identified multiple critical inhalation technique errors in COPD patients using DPIs each associated with poorer outcomes. Explorative analysis revealed that specific combinations of errors may be of clinical relevance, especially those related to the inhalation manoeuvre. COPD outcomes worsened with increasing error count. These results warrant further prospective longitudinal studies to establish the effect of correcting these errors on COPD control. TRIAL REGISTRATION https://clinicaltrials.gov/ct2/show/NCT04532853 (31/08/2020).
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Affiliation(s)
- Janwillem Kocks
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands.
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands.
- Observational and Pragmatic Research Institute, Singapore, Singapore.
- Department of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- Sydney Local Health District, Sydney, Australia
| | - Joyce van Cooten
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute (ICVS), PT Government Associate Laboratory, School of Medicine, University of Minho, Braga, Portugal
| | - Biljana Cvetkovski
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | | - Lars Dijk
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Marina Garcia Pardo
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma, Spain
| | - Asparuh Gardev
- Boehringer Ingelheim International GmbH, Ingelheim Am Rhein, Germany
| | - Radosław Gawlik
- Department of Internal Medicine, Allergology, Clinical Immunology, Medical University of Silesia, Katowice, Poland
| | - Iris van der Ham
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Ymke Janse
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Federico Lavorini
- Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Tiago Maricoto
- Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal
| | - Jiska Meijer
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Boyd Metz
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Miguel Roman Rodriguez
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma, Spain
| | - Kirsten Schuttel
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Nilouq Stoker
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
| | - Ioanna Tsiligianni
- Department of Social Medicine, Health Planning Unit, Faculty of Medicine, University of Crete, Rethymno, Greece
| | - Omar Usmani
- Airway Disease, National Heart and Lung Institute (NHLI), Imperial College London and Royal Brompton Hospital, London, UK
| | - Jaco Voorham
- Data to Insights Research Solutions, Lisbon, Portugal
| | - Marika T Leving
- General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, 9713 GH, Groningen, The Netherlands
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Miravitlles M, Matsunaga K, Dreher M. Stepwise management of COPD: What is next after bronchodilation? Ther Adv Respir Dis 2023; 17:17534666231208630. [PMID: 37936381 PMCID: PMC10631322 DOI: 10.1177/17534666231208630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 09/29/2023] [Indexed: 11/09/2023] Open
Abstract
Inhaled bronchodilator therapy with long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) in combination is currently the mainstay of treatment for chronic obstructive pulmonary disease (COPD). Treatment guidelines recommend the addition of inhaled corticosteroids (ICS) to LABA/LAMA only in patients with a history of frequent/severe exacerbations and high blood eosinophil counts, or in those with concomitant asthma. Despite this, real-world data suggest that clinicians are not adhering to this guidance and that ICS are frequently overused. This is possibly due to the incorrect assumption that when LABA/LAMA therapy is not sufficient, adding an ICS to the treatment regimen is the logical next step. In this narrative review, we describe global and country-specific guideline recommendations from Germany, Spain, and Japan and compare these with real-world data on LABA/LAMA and ICS use in clinical practice. We also provide a clinical guide to the use of add-on therapies with LABA/LAMA for different patient phenotypes, including (1) patients still symptomatic (but not exacerbating) despite LABA/LAMA treatment; (2) patients still exacerbating despite LABA/LAMA treatment who have high blood eosinophil counts; and (3) patients still exacerbating despite LABA/LAMA treatment who do not have high blood eosinophils or concomitant asthma.
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Affiliation(s)
- Marc Miravitlles
- Pneumology Department, University Hospital Vall d′Hebron/Vall d’Hebron Research Institute (VHIR, Vall d’Hebron Barcelona Hospital Campus; CIBER de Enfermedades Respiratorias [CIBERES]), P. Vall d’Hebron 119–129, Barcelona 08035, Spain
| | - Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Graduate School of Medicine, Yamaguchi University, Yamaguchi, Japan
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, University Hospital Aachen, Aachen, Germany
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Leving MT, Bosnic-Anticevich S, van Cooten J, de Sousa JC, Cvetkovski B, Dekhuijzen R, Dijk L, Pardo MG, Gardev A, Gawlik R, van der Ham I, Janse Y, Lavorini F, Maricoto T, Meijer J, Metz B, Price D, Roman-Rodriguez M, Schuttel K, Stoker N, Tsiligianni I, Usmani O, Emerson-Stadler R, Kocks JWH. Clinical recommendations for dry powder inhaler use in the management of COPD in primary care. NPJ Prim Care Respir Med 2022; 32:59. [PMID: 36575175 PMCID: PMC9794707 DOI: 10.1038/s41533-022-00318-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 11/11/2022] [Indexed: 12/28/2022] Open
Abstract
Over 1400 patients using dry powder inhalers (DPIs) to deliver COPD maintenance therapies were recruited across Europe and Australia. Their peak inspiratory flow (PIF) was measured, inhaler technique was observed, and adherence to treatment assessed. From relating the findings with patient health status, and thereby identifying critical errors, key clinical recommendations for primary care clinicians were determined, namely - measure PIF before prescribing a DPI to ensure inhalation manoeuvre ability is well-matched with the device. Some patients could benefit from inhalation training whereas others should have their DPI changed for one better suited to their inspiratory ability or alternatively be prescribed an active device (such as a soft mist inhaler or pressurized metered dose inhaler). Observing the inhalation technique was valuable however this misses suboptimal PIF (approaching one fourth of patients with a satisfactory observed manoeuvre had a suboptimal PIF for their DPI). Assess adherence as deliberate non-adherence can point to a mismatch between a patient and their inhaler (deliberate non-adherence was significantly associated with PIFs below the minimum for the DPI). In-person observation of inhalation technique was found to be inferior to video rating based on device-specific checklists. Where video assessments are not possible, observation training for healthcare professionals would therefore be valuable particularly to improve the ability to identify the critical errors associated with health status namely 'teeth and lips sealed around mouthpiece', 'breathe in' and 'breathing out calmly after inhalation'. However, it is recommended that observation alone should not replace PIF measurement in the DPI selection process.Trial registration: https://clinicaltrials.gov/ct2/show/NCT04532853 .
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Affiliation(s)
- Marika T. Leving
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Sinthia Bosnic-Anticevich
- grid.1013.30000 0004 1936 834XWoolcock Institute of Medical Research, University of Sydney, Sydney, Australia ,grid.410692.80000 0001 2105 7653Sydney Local Health District, Sydney, Australia
| | - Joyce van Cooten
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Jaime Correia de Sousa
- grid.10328.380000 0001 2159 175XLife and Health Sciences Research Institute (ICVS), PT Government Associate Laboratory, School of Medicine, University of Minho, Braga, Portugal
| | - Biljana Cvetkovski
- grid.1013.30000 0004 1936 834XWoolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Richard Dekhuijzen
- grid.10417.330000 0004 0444 9382Radboud University Medical Center, Nijmegen, Netherlands
| | - Lars Dijk
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Marina Garcia Pardo
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Asparuh Gardev
- grid.420061.10000 0001 2171 7500Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Radosław Gawlik
- grid.411728.90000 0001 2198 0923Department of Internal Medicine, Allergology, Clinical Immunology, Medical University of Silesia, Katowice, Poland
| | - Iris van der Ham
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Ymke Janse
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Federico Lavorini
- grid.24704.350000 0004 1759 9494Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Tiago Maricoto
- grid.7427.60000 0001 2220 7094Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal
| | - Jiska Meijer
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Boyd Metz
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - David Price
- grid.500407.6Observational and Pragmatic Research Institute, Singapore, Singapore ,grid.7107.10000 0004 1936 7291Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Miguel Roman-Rodriguez
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Kirsten Schuttel
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Nilouq Stoker
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands
| | - Ioanna Tsiligianni
- grid.8127.c0000 0004 0576 3437Department of Social Medicine, Health Planning Unit, Faculty of Medicine, University of Crete, Rethymno, Greece
| | - Omar Usmani
- grid.7445.20000 0001 2113 8111Airway Disease, National Heart and Lung Institute (NHLI), Imperial College London and Royal Brompton Hospital, London, United Kingdom
| | - Rachel Emerson-Stadler
- grid.420061.10000 0001 2171 7500Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Janwillem W. H. Kocks
- grid.512383.e0000 0004 9171 3451General Practitioners Research Institute, Groningen, The Netherlands ,grid.500407.6Observational and Pragmatic Research Institute, Singapore, Singapore ,grid.4494.d0000 0000 9558 4598University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands ,grid.4494.d0000 0000 9558 4598Dept. of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Leving MT, van Boven JFM, Bosnic-Anticevich SZ, van Cooten J, Correia de Sousa J, Cvetkovski B, Dekhuijzen R, Dijk L, García Pardo M, Gardev A, Gawlik R, van der Ham I, Hartgers-Gubbels ES, Janse Y, Lavorini F, Maricoto T, Meijer J, Metz B, Price DB, Roman-Rodríguez M, Schuttel K, Stoker N, Tsiligianni I, Usmani OS, Kocks JH. Suboptimal Peak Inspiratory Flow and Critical Inhalation Errors are Associated with Higher COPD-Related Healthcare Costs. Int J Chron Obstruct Pulmon Dis 2022; 17:2401-2415. [PMID: 36185173 PMCID: PMC9521797 DOI: 10.2147/copd.s380736] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/12/2022] [Indexed: 12/03/2022] Open
Abstract
Purpose To assess the relationship between suboptimal Peak Inspiratory Flow (sPIF), inhalation technique errors, and non-adherence, with Healthcare Resource Utilisation (HCRU) in Chronic Obstructive Pulmonary Disease (COPD) patients receiving maintenance therapy via a Dry Powder Inhaler (DPI). Patients and methods The cross-sectional, multi-country PIFotal study included 1434 COPD patients (≥40 years) using a DPI for maintenance therapy. PIF was measured with the In-Check DIAL G16, and sPIF was defined as a typical PIF lower than required for the device. Inhalation technique was assessed by standardised evaluation of video recordings and grouped into 10 steps. Patients completed the “Test of Adherence to Inhalers” questionnaire. HCRU was operationalised as COPD-related costs for primary healthcare, secondary healthcare, medication, and total COPD-related costs in a 1-year period. Results Participants with sPIF had higher medication costs compared with those with optimal PIF (cost ratio [CR]: 1.07, 95% CI [1.01, 1.14]). Multiple inhalation technique errors were associated with increased HCRU. Specifically, “insufficient inspiratory effort” with higher secondary healthcare costs (CR: 2.20, 95% CI [1.37, 3.54]) and higher total COPD-related costs (CR: 1.16, 95% CI 1.03–1.31). “no breath-hold following the inhalation manoeuvre (<6 s)” with higher medication costs (CR: 1.08, 95% CI [1.02, 1.15]) and total COPD-related costs (CR 1.17, 95% CI [1.07, 1.28]), and “not breathing out calmly after inhalation” with higher medication costs (CR: 1.19, 95% CI [1.04, 1.37]). Non-adherence was not significantly associated with HCRU. Conclusion sPIF and inhalation technique errors were associated with higher COPD-related healthcare utilisation and costs in COPD patients on DPI maintenance therapy.
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Affiliation(s)
- Marika T Leving
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Job F M van Boven
- University Medical Centre Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, the Netherlands
- University Medical Centre Groningen, Department of Clinical Pharmacy & Pharmacology, University of Groningen, Groningen, the Netherlands
- Medication Adherence Expertise Centre of the Northern Netherlands (MAECON), Groningen, the Netherlands
| | - Sinthia Z Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- Sydney Local Health District, Sydney, Australia
| | - Joyce van Cooten
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute (ICVS), PT Government Associate Laboratory, School of Medicine, University of Minho, Braga, Portugal
| | - Biljana Cvetkovski
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | | | - Lars Dijk
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Marina García Pardo
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Asparuh Gardev
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | - Radosław Gawlik
- Department of Internal Medicine, Allergology, Clinical Immunology, Medical University of Silesia, Katowice, Poland
| | - Iris van der Ham
- General Practitioners Research Institute, Groningen, the Netherlands
| | | | - Ymke Janse
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Federico Lavorini
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Tiago Maricoto
- Faculty of Health Sciences, University of Beira Interior, Covilha, Portugal
| | - Jiska Meijer
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Boyd Metz
- General Practitioners Research Institute, Groningen, the Netherlands
| | - David B Price
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Observational and Pragmatic Research Institute, Singapore
| | - Miguel Roman-Rodríguez
- Primary Care Respiratory Research Unit, Instituto De Investigación Sanitaria De Baleares (IdISBa), Palma de Mallorca, Spain
| | - Kirsten Schuttel
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Nilouq Stoker
- General Practitioners Research Institute, Groningen, the Netherlands
| | - Ioanna Tsiligianni
- Department of Social Medicine, Health Planning Unit, Faculty of Medicine, University of Crete, Rethymno, Greece
| | - Omar S Usmani
- Airway Disease, National Heart and Lung Institute (NHLI), Imperial College London and Royal Brompton Hospital, London, UK
| | - Janwillem H Kocks
- General Practitioners Research Institute, Groningen, the Netherlands
- University Medical Centre Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, Groningen, the Netherlands
- Observational and Pragmatic Research Institute, Singapore
- Department of Pulmonology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
- Correspondence: Janwillem H Kocks, General Practitioners Research Institute, Professor Enno Dirk Wiersmastraat 5, Groningen, 9713 GH, the Netherlands, Tel +31 50 211 3898, Email
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Valipour A, Aisanov Z, Avdeev S, Koblizek V, Kocan I, Kopitovic I, Lupkovics G, Man M, Bukovskis M, Tudoric N, Vukoja M, Naumnik W, Yanev N. Recommendations for COPD management in Central and Eastern Europe. Expert Rev Respir Med 2022; 16:221-234. [PMID: 35001780 DOI: 10.1080/17476348.2021.2023498] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy report provides guidance on effective management of chronic obstructive pulmonary disease (COPD) according to local healthcare systems. However, COPD is a heterogenous disease and certain aspects, including prevalence, disease-time course and phenotype distribution, can differ between countries. Moreover, features of clinical practice and healthcare systems for COPD patients can vary widely, even in geographically close and economically similar countries. AREAS COVERED Based on an initial workshop of respiratory physicians from eleven countries across Central and Eastern Europe (CEE) in December 2018 and subsequent discussions, this article offers region-specific insights from clinical practice and healthcare systems in CEE. Taking GOLD 2020 recommendations into account, we suggest approaches to adapt these into national clinical guidelines for COPD management in CEE. EXPERT OPINION Several factors should be considered when optimizing management of COPD in CEE compared with other regions, including differences in smoking status, vaccination uptake, prevalence of tuberculosis and nontuberculous mycobacteria, and variations in healthcare systems. We provide guidance and algorithms for pharmacologic and non-pharmacologic management of COPD for the following scenarios: initial and follow-up treatment, treatment of patients with frequent exacerbations, and withdrawal of inhaled corticosteroids where appropriate.
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Affiliation(s)
- Arschang Valipour
- Department of Respiratory and Critical Care Medicine, Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna Health Care Group, Vienna, Austria
| | - Zaurbek Aisanov
- Department of Pulmonology, Pirogov Russian State National Research Medical University, Moscow, Russia
| | - Sergey Avdeev
- Pulmonology Department, I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Vladimir Koblizek
- Department of Pneumology, Faculty of Medicine in Hradec Kralove, Charles University Hospital, Hradec Kralove, Czech Republic
| | - Ivan Kocan
- University Hospital Martin, Jessenius Faculty of Medicine, Commenius University, Martin, Slovakia
| | - Ivan Kopitovic
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Gergely Lupkovics
- Adult Pulmonary Department, Institute for Pulmonary Diseases, Törökbálint, Hungary
| | - Milena Man
- Pulmonology Department, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Maris Bukovskis
- Department of Internal Diseases, Faculty Medicine, University of Latvia, Riga, Latvia
| | - Neven Tudoric
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Marija Vukoja
- Department for Respiratory Pathophysiology and Sleep Disordered Breathing, The Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, Serbia.,Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - Wojciech Naumnik
- First Department of Lung Diseases and Chemotherapy of Respiratory Neoplasms, Medical University of Bialystok, Bialystok, Poland
| | - Nikolay Yanev
- Department of Pulmonary Diseases, Medical University of Sofia, Sofia, Bulgaria
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