Inhaler mishandling remains common in real life and is associated with reduced disease control

Proper inhaler technique is crucial for effective management of asthma and COPD. This multicentre, cross-sectional, observational study investigates the prevalence of inhaler mishandling in a large population of experienced patients referring to chest clinics; to analyze the variables associated with misuse and the relationship between inhaler handling and health-care resources use and disease control. We enrolled 1664 adult subjects (mean age 62 years) affected mostly by COPD (52%) and asthma (42%). Respectively, 843 and 1113 patients were using MDIs and DPIs at home; of the latter, the users of Aerolizer®, Diskus®, HandiHaler® and Turbuhaler® were 82, 467, 505 and 361. We have a total of 2288 records of inhaler technique. Critical mistakes were widely distributed among users of all the inhalers, ranging from 12% for MDIs, 35% for Diskus® and HandiHaler® and 44% for Turbuhaler®. Independently of the inhaler, we found the strongest association between inhaler misuse and older age (p = 0.008), lower schooling (p = 0.001) and lack of instruction received for inhaler technique by health caregivers (p < 0.001). Inhaler misuse was associated with increased risk of hospitalization (p = 0.001), emergency room visits (p < 0.001), courses of oral steroids (p < 0.001) and antimicrobials (p < 0.001) and poor disease control evaluated as an ACT score for the asthmatics (p < 0.0001) and the whole population (p < 0.0001). We conclude that inhaler mishandling continues to be common in experienced outpatients referring to chest clinics and associated with increased unscheduled health-care resource use and poor clinical control. Instruction by health caregivers is the only modifiable factor useful for reducing inhaler mishandling.

Inhalation technique and variables associated with misuse of conventional metered-dose inhalers and newer dry powder inhalers in experienced adults

BACKGROUND

Pressurized metered-dose inhalers (pMDIs) are often poorly used, but little information is available concerning use of the newer dry powder inhalers (DPIs).

OBJECTIVE

To estimate the inhalation technique and variables associated with the misuse of pMDIs and newer DPIs in clinical practice.

METHODS

A multicenter, observational survey was used to evaluate the inhalation technique in 1,404 experienced outpatients aged 15 to 88 years affected mostly by asthma (47%) and chronic obstructive pulmonary disease (39%). A total of 1,056 patients were using pMDIs, 190 in conjunction with a large volume spacer (LVS); regarding DPIs, 230 patients were using the Aerolizer Inhaler, 524 were using the Turbuhaler, and 475 were using the Diskus. In each center, a trained observer recorded patients' inhalation techniques for each inhaler used against a standardized step-by-step checklist.

RESULTS

Twenty-four percent and 3% of patients used pMDIs poorly, alone or with an add-on LVS, respectively. Failure to correctly perform essential steps for reliable lung delivery with the Aerolizer Inhaler, Turbuhaler, and Diskus was found in 17%, 23%, and 24% of patients, respectively. There was no difference in most variables correlated with poor inhalation between patients using pMDIs and those using DPIs.

CONCLUSIONS

The use of DPIs is associated with a similar percentage of inadequate inhalation technique as the use of pMDIs in clinical practice. The addition of an LVS to a pMDI and education from health care personnel, rather than simply changing inhalers, represent the best strategies for minimizing poor inhalation technique.

Prescription bias and factors associated with improper use of inhalers

Many different inhalers are available for delivering aerosol therapy in respiratory medicine. As a consequence, the prescribing physicians may have some difficulty tailoring the most suitable inhaler to each patient. This multicenter, observational study using a self-administered questionnaire analyzed the characteristics of a large sample of patients (n = 1,305; 55% females; mean age 57.4, with a range of 15-88 years; most suffering from asthma or chronic obstructive pulmonary disease [COPD]) familiar with several different types of inhalers in relation to their most commonly used delivery device. Data on the inhalation technique for 2,057 observations of 1,126 patients using device-specific checklists and factors associated to misuse were also evaluated. Prevalent usage of newer dry powder inhalers (DPIs) was significantly associated with male sex, higher education, better respiratory function, and prescription from a respiratory physician. Patients using DPIs had received less instruction by health caregivers and were more likely to have read the instruction leaflet than users of metered dose inhalers (MDIs). Under these conditions, inhaler misuse was common and similar for both pressurized metered dose inhalers (pMDIs) and DPIs. For both types of inhalers, misuse was significantly and equally associated to increased age, less education, and less instruction by health care personnel. We conclude that many doctors are not familiar with the relevant characteristics of currently available inhalers. The prescription of newer DPIs may be subjected to gender, socio-economic, and instruction bias. The simple change of device from the pMDI to the newer DPIs is not associated with improved inhalation technique.

Long-acting muscarinic antagonists

Chronic obstructive pulmonary disease (COPD) is a major cause of death and disability worldwide. Inhaled bronchodilators are the mainstay of COPD pharmacological treatment. Long-acting muscarinic antagonists (LAMAs) are a major class of inhaled bronchodilators. Some LAMA/device systems with different characteristics and dosing schedules are currently approved for maintenance therapy of COPD and a range of other products are being developed. They improve lung function and patient-reported outcomes and reduce acute bronchial exacerbations with good safety. LAMAs are used either alone or associated with long-acting β₂-agonists, eventually in fixed dose combinations. Long-acting β₂-agonist/LAMA combinations assure additional benefits over the individual components alone. The reader will obtain a view of the safety and efficacy of the different LAMA/device systems in COPD patients.

Tobacco smoking habits, beliefs, and attitudes among medical students in Tirana, Albania

BACKGROUND

Many surveys throughout the world have evaluated the smoking behaviors, beliefs, and attitudes of medical students, but no information is available from Albania.

METHOD

A cross-sectional survey in classroom settings using a self-administered questionnaire was performed at the University of Tirana during October 2000.

RESULTS

In the first and fifth years of medical school, 149 (68.5% women) and 185 (55% women) students, respectively, completed the questionnaire, with overall response rates of 82 and 92%. Tobacco smoking prevailed among males. The smoking rates among first-year medical students were 34% among men and 5% among women. Among fifth-year students, 55% of the men and 34% of the women smoked. The percentages of occasional smokers were 29 and 49%, respectively, among the first- and fifth-year students who smoked. Most medical students reported knowing the health hazards of tobacco. Most students in both groups believed that smoking should be restricted in hospitals. Slightly more than half of the students stated that they will regularly advise smokers against smoking in their future jobs.

CONCLUSION

Tobacco smoking is common among medical students in Albania. Targeted antismoking training should be mandatory for medical students in Albania.

Inhaler mishandling is very common in patients with chronic airflow obstruction and long-term home nebuliser use

Inhalers and nebulisers are devices used for delivering aerosolised drugs in subjects with Chronic Airflow Obstruction (CAO). This multicentre, cross-sectional observational study was performed in a large population of outpatients with CAO regularly using home aerosol therapy and referring to chest clinics. The aims of the study were to compare the characteristics of the group of subjects with CAO who were using home nebulisers but also experienced with inhalers vs. those only using inhalers and to investigate whether the first group of subjects was particularly prone to inhaler misuse. Information was gained evaluating the responses to a standardised questionnaire on home aerosol therapy and the observations of inhaler technique. We enrolled 1527 patients (58% males; mean ± SE; aged 61.1 ± 0.4 years; FEV1% pred 69.9 ± 0.6; 51% and 44% respectively suffering from COPD and asthma) who were only inhaler users (OIU group) and 137 (85% males; aged 67.7 ± 1.3 years; FEV1% pred 62.3 ± 2.9; 60% and 23% respectively suffering from COPD and asthma) who were using both nebulisers and inhalers (NIU group). Nebuliser users were older, had more severe obstruction, related symptoms and health care resources utilisation. Nebulisers users performed more critical inhalers errors than those of the OIU group (49% vs. 36%; p = 0.009). We conclude that our patients with CAO and regular nebuliser treatment had advanced age, severe respiratory conditions and common inhaler misuse.

Long-term oxygen therapy in chronic respiratory failure: A Multicenter Italian Study on Oxygen Therapy Adherence (MISOTA)

BACKGROUND

The adherence to the prescribed oxygen therapy is difficult to obtain for patients on long-term oxygen therapy (LTOT). There is little information on the modalities of oxygen utilisation for patients on LTOT who are using liquid oxygen in real life.

STUDY OBJECTIVE

Evaluation of the behaviour and the knowledge regarding LTOT in a large group of patients mainly using liquid oxygen.

DESIGN AND SETTING

Questionnaire administered to consecutive outpatients on domiciliary LTOT for at least 6 months referring to one of 20 clinics throughout Italy. Blinded to this result, the physician who cared for the patient completed another questionnaire.

RESULTS

We evaluated 1504 patients (mean age 71.6 years; males 64%; 74% suffering from COPD). Most respondents (93%) used liquid oxygen with mobile device. Fifteen per cent of patients had a prescribed length of oxygen therapy less than 15 h/day; 21% reported to practice oxygen for less than 15 h/day. Patients reported using oxygen for less hours than had been prescribed during the day at rest (P=0.02, k=0.80) during exercise (P=0.002, k=0.72) and at night (P=0.0036, k=0.77). There was no difference between the flow prescribed by the physician and that known and practised by the patient at rest or during sleep; during exercise the flow reported by patients was lower than that prescribed by the physician. Patients used in the night but not at rest or during exercise, a lower level of oxygen flow than what they knew had been prescribed. Fifty-five per cent of patients received indications to modify the oxygen flow in the various situations of life. Liquid oxygen was almost always useful to decrease breathlessness. Most (84%) patients possessed a mobile device, but only 40% declared they used it daily, 'shame' being indicated as the principal barrier. On the physicians' side, we found that the criteria used in prescribing did not always correspond to evidence-based recommendations.

CONCLUSION

The widespread use of liquid oxygen did not automatically assure optimal adherence to the prescribed treatment as regards times and modality of oxygen use. A better education of patients, relatives, and the general public, as well as increased self-assessment on the part of health caregivers would improve the practice of LTOT in Italy.

Comparing usability of NEXThaler(®) with other inhaled corticosteroid/long-acting β2-agonist fixed combination dry powder inhalers in asthma patients

BACKGROUND

Inhaler mishandling is a common issue among patients suffering from asthma and is associated with poor clinical outcomes and greater consumption of health-care resources. Ease of use can improve inhaler technique and, possibly, patients' preference for their inhaler device, which in turn may lead to better adherence to therapy.

METHODS

This study investigated usability characteristics of NEXThaler(®) versus two other dry powder inhalers (DPIs; Diskus(®) and Turbuhaler(®)). Sixty-six adult patients with asthma (mean age 42.9±17.7 years) and with no previous experience of using a DPI were included in a randomized crossover comparison of the three devices. The main measures of usability were the number of steps failed for each device and the number of people who were able to use the device successfully (effectiveness), the time it took patients to set up the device and the time to read the instructions for use (IFU; efficiency), and patient preferences (satisfaction). Inhaler technique was evaluated after the IFU leaflet was read.

RESULTS

NEXThaler was found to be superior to the other two DPIs in terms of the number of device use failures (p<0.001), time to set up (p<0.001), and time to read IFU (p<0.001). Additionally, the proportion of participants who completed a successful inhalation without any errors at all was significantly higher for NEXThaler than for Diskus and Turbuhaler (p<0.001). Patients rated NEXThaler as the easiest to use and most preferred inhaler to own (p<0.001).

CONCLUSIONS

NEXThaler displayed better usability compared with Diskus and Turbuhaler. The improved usability and higher satisfaction with the device may contribute to increased patient adherence to asthma treatment.

Management of asthma in the elderly patient

A significant number of older asthmatics, more often than in previous ages, have poorly controlled asthma, leading to increased morbidity and mortality. On the other hand, current guidelines suggest that most asthmatics can obtain achievement and maintenance of disease control and do not include sections specific to the management of asthma in the elderly so that it is more evident the contrast between poor control of asthma in the elderly and the lack of specific guidance from guidelines on asthma management in older asthmatics. Inhaled corticosteroids are the cornerstone for older asthmatics, eventually with add-on inhaled long-acting beta-agonists; inhaled short acting beta-agonists can be used as rescue medications. Triggers exacerbating asthma are similar for all ages, but inhaled viruses and drug interactions have greater clinical significance in the elderly. Older asthmatics have an increased likelihood of comorbidities and polypharmacy, with possible worsening of asthma control and reduced treatment adherence. Physicians and older asthmatics probably either do not perceive or accept a poor asthma control. We conclude that specific instruments addressed to evaluate asthma control in the elderly with concomitant comorbidities and measurements for improving self-management and adherence could assure better disease control in older asthmatics.

Tobacco smoking habits, attitudes and beliefs among nurse and medical students in Tuscany

In this study we evaluated the smoking habits, beliefs and attitudes of nurse and medical students at the University of Siena and Florence, Italy. Students who entered the 1st year of school in 1998 were asked to complete a self-administered anonymous questionnaire. Two hundred medical students completed the questionnaire; they had a mean age (+/-SD) of 19.8+/-1.7 years and 68% were females. A total of 205 nurse respondents answered to the questionnaire; they had a mean age of 21.8+/-4.1 years and females were 83% of the total. The overall response rate among students always remained higher than 85%. Thirty per cent of medical students were current smokers, and 5% former-smokers. A total of 43% of nurse students were current smokers and 11.5% former-smokers. Nurse students were more likely to smoke than medical students (p = 0.001). Among current smokers, the number of daily cigarettes smoked and the degree of nicotine addiction did not differ between groups. The prevalence of maternal smoking were higher among nurse students. In spite of students' beliefs the knowledge about smoking remained generic in both groups. Nurse students were less aware than medical students of their special responsibility towards people about tobacco smoking. Such a difference remained significant also after adjustment for smoking status (p < 0.01). Students overestimated the prevalence of current smokers among health caregivers of the local hospitals, and Italian people and adolescents. Targeted and continuous training about smoking prevention should be mandatory in Italian medical and nurse schools.

Reduced Peak Inspiratory Effort through the Diskus((R)) and the Turbuhaler((R)) due to Mishandling is Common in Clinical Practice

OBJECTIVES

A minimum peak inspiratory flow (PIF) through dry powder inhalers (DPIs) is required for effective drug delivery to the lungs. Some patients are unable to generate the minimally effective PIF through the DPI. However, little information is available about the 'real life' prevalence of reduced peak inspiratory effort through the Diskus((R)) and the Turbuhaler((R)) as a result of mishandling

METHODS

We investigated peak inhalation effort through the Diskus((R)) and the Turbuhaler((R)) by both direct observation and the In-Check Dial((R)), a portable PIF meter, in a large sample of patients consecutively referred to our laboratory who were familiar with these devices. Patients with reduced peak inspiratory effort repeated the PIF measurement after a session of instruction on the need for more forceful effort through the device.

RESULTS

We studied 644 patients (mean age 62 years, 42% female). Of these, 62% had chronic obstructive pulmonary disease and 35% had asthma. The mean baseline forced expiratory volume in 1 second was 53% of predicted. 502 patients were using the Diskus((R)) and 185 the Turbuhaler((R)). Overall, 106 patients (16.5%) showed weak inhalation by direct observation at baseline. Of 44 subjects with weak inhalation through the Turbuhaler((R)), 34 (77%) demonstrated a PIF <30 L/min. Post-counselling, only four patients did not achieve a PIF of at least 30 L/min (p < 0.01). Of 62 subjects with weak inhalation through the Diskus((R)), 37 (60%) had a PIF <30 L/min. Post-counselling, all these subjects achieved a PIF of at least 30 L/min (p < 0.001).

CONCLUSION

A significant number of patients show a reduced peak inspiratory effort through the Diskus((R)) and the Turbuhaler((R)) in real life. Our results indicate that the cause of this deficiency is often mishandling of the device because, after a brief session of instruction on the need for more forceful inhalation, most patients obtained an acceptable PIF rate. A PIF meter may identify patients with inadequately weak inhalation and offer useful feedback for obtaining the best inspiratory effort.

Changes of smoking habits and beliefs during nurse training: a longitudinal study

This prospective cohort study has been performed to evaluate the changes in student nurses smoking habits and beliefs during their training. The source of information was an anonymous questionnaire about tobacco smoking, administered to students who entered the first year of School of Nursing in Florence in 1991-1992, 1992-1993 and 1993-1994. Five hundred and thirty-six (95%) of these student nurses completed the questionnaire. Five hundred and one (93%) of these 536 respondents completed the questionnaire again at the end of the third (final) year of training. Student nurses who smoked increased the average number of cigarettes smoked per day (p < 0.01) and the degree of dependence to nicotine (p < 0.01). Tobacco smoking remained widespread and the percentage of ex-smokers who started smoking again increased (p < 0.05). The knowledge about the health hazards due to tobacco smoking remained generic and the prevalence of current smokers among student nurses and health care workers was overestimated. We conclude that Nursing School does not succeed in reducing the smoking habits of students. Effective antitobacco strategies and smoking cessation services still need be organized in Italy.

Nebulized corticosteroids in asthma and COPD. An Italian appraisal

Inhaled corticosteroids (ICSs) are the mainstay of anti-inflammatory treatment in subjects with asthma and COPD. This review evaluates the role of nebulizers as an alternative to inhalers for delivering ICSs in asthma and COPD. I selected 16 randomized, placebo-controlled, blinded, long-term studies, mostly carried out in asthma (n = 14) and COPD. Nebulized budesonide has been demonstrated to be effective and safe in children ages 1-8 years, and, with less evidence, in infants and adults with asthma. Other investigations, with the addition of in vitro and in vivo comparison studies, have shown that nebulized beclomethasone, fluticasone, and flunisolide are effective alternatives to nebulized budesonide in asthma and COPD. Efficient delivery of nebulized ICSs requires that the nebulizer system, the nebulized drug formulation, and the inhaling subject interact properly. The practices of mixing nebulized ICSs with bronchodilators and using nebulized ICSs in acute settings are promising, but require further confirmations, and at present cannot be recommended. I conclude that nebulizers may be considered as an effective alternative to inhalers for delivering ICSs and can be recommended to asthmatic and COPD subjects who are unwilling or unable to use inhalers. Newer formulations could possibly offer a relevant advance for a more efficient nebulization of ICSs.

Maintaining Control of Chronic Obstructive Airway Disease: Adherence to Inhaled Therapy and Risks and Benefits of Switching Devices

Asthma and chronic obstructive pulmonary disease (COPD) are major obstructive airway diseases that involve underlying airway inflammation. The most widely used pharmacotherapies for asthma and COPD are inhaled agents that have been shown to be effective and safe in these patients. However, despite the availability of effective pharmacologic treatment and comprehensive treatment guidelines, the prevalence of inadequately controlled asthma and COPD is high. A main reason for this is poor adherence. Adherence is a big problem for all chronic diseases, but in asthma and COPD patients there are some additional difficulties because of poor inhalation technique and inhaler choice. Easier-to-use devices and educational strategies on proper inhaler use from health caregivers can improve inhaler technique. The type of device used and the concordance between patient and physician in the choice of inhaler can also improve adherence and are as important as the drug. Adherence to inhaled therapy is absolutely necessary for optimizing patient control. If disease control is not adequate despite good adherence, switching to a more appropriate inhaled therapy is recommended. By contrast, uninformed switching or switching to less user-friendly inhaler may impact disease control negatively. This critical review of the available literature is aimed to provide a guidance protocol on when a switch may be recommended in individual patients.

Results of a questionnaire about nurse students' smoking habits and knowledges in an Italian teaching school of nursing

Six-hundred and sixty-two nurse students (aged 25.2 +/- 4.11 years; 153 were males) answered a self-administered, anonymous questionnaire about smoking habits and knowledges in a large urban Teaching School of Nursing. The overall response rate was 88%. Current smokers were 336 (51%), former smokers 80 (12%). Nurse students claimed to know the dangers of tobacco and nurse training seemed to modify the preferential source of information about tobacco smoking towards medical fonts; however, only a quarter of nurse students considered medical smoking cessation approaches as useful for quitting and advised patients with tobacco-related diseases against smoking.

Perception of dyspnea during exercise-induced bronchoconstriction

After strenuous physical exercise, many subjects show a significant bronchoconstriction and report dyspnea. Despite this clinical condition being a commonly encountered situation during daily life, which may be responsible for substantial disability there is little information on the relationship between the perception of dyspnea and exercise-induced bronchoconstriction (EIB) after a standardized exercise challenge. For these reasons, we evaluated 200 consecutive outpatients (median age 13 years, ranging from 5 to 56 years) referred to our laboratory to perform an exercise test out of suspicion of EIB. On exercise challenge, perception of dyspnea was rated on a modified bipolar Borg scale immediately before each FEV1 measurement. Sixty-nine (35%) subjects had a positive exercise challenge, defined as a decrease of at least 20% in FEV1 from baseline. Both the onset and the decay of dyspnea preceded those of bronchoconstriction. Overall, the rating of dyspnea in the laboratory was well related with the reports of exercise-related symptoms. Similarly, 36 of 77 (47%) asthmatics with a history of exertional symptoms and 24 of 65 patients (40%) without a history had a positive challenge. Asthmatics reporting exertional symptoms perceived a greater magnitude of dyspnea after exercise independently from the degree of bronchoconstriction. Overall, dyspnea was significantly but loosely correlated to the magnitude of decrease in FEV1, being also influenced by age, gender and BMI.

CONCLUSIONS

We conclude that dyspnea recorded in the laboratory after exercise test is related to exertional symptoms reported during real life, but not completely related to EIB. The rating of dyspnea is a well-suited model to study naturally occurring exercise-induced dyspnea and a useful tool to enlarge the results of an exercise challenge.

Time Required to Rectify Inhaler Errors Among Experienced Subjects With Faulty Technique

BACKGROUND

Regardless of the device used, many patients have difficulty maintaining proper inhaler technique over time. Repeated education from caregivers is required to ensure persistence of correct inhaler technique, but no information is available to evaluate the time required to rectify inhaler errors in experienced users with a baseline faulty technique and whether this time of re-education to restore inhaler mastery can differ between devices.

METHODS

This was a multi-center, single-visit, open-label, cross-sectional study in a large group of 981 adult subjects (mean ± SD age 64 ± 15 y) experienced with inhaler use, mainly suffering from COPD and asthma, who showed faulty inhaler technique at a follow-up visit in chest clinics. These subjects received face-to-face practical education from trained caregivers until proper inhaler use could be demonstrated, and the time of instruction was recorded.

RESULTS

The mean times (95% CIs) in minutes of instruction required for rectifying misuse and demonstrating inhaler mastery were 5.0 (3.6-6.4) min for the Diskus (n = 199), 5.3 (3.7-6.8) min for the HandiHaler (n = 219), 8.1 (5.6-10.5) min for the metered-dose inhaler (MDI) (n = 532), and 6.0 (5.0-7.0) min for the Turbuhaler (n = 169). The time to demonstrate good inhaler use for MDIs was higher (P < .05) than for all dry powder inhalers (DPIs). Between the DPIs, only the HandiHaler required more time for achieving mastery than the Diskus (P = .005). The variables associated with increasing time for correcting inhaler errors were an older age (0.05 min/y, 95% CI 0.03-0.07), a lower level of education (0.4 min/schooling level, 95% CI 0.7-0.1), and no reported previous instruction in inhaler use (1.96 min, 95% CI 1.35-2.58).

CONCLUSIONS

In experienced subjects with baseline faulty inhaler use, the mean time of education required to achieve and demonstrate mastery with DPIs was lower than with MDIs.

GENebu Project: home nebulizer use and maintenance in Italy

Due to the lack of information on this topic, the Educational Group of the Italian Association of Hospital Pneumologists performed an open, multicentre, observational survey to evaluate home nebulizer practices in Italy. From May-December 1999, all patients attending one of the 27 participating chest clinics throughout Italy and who were or had been using a home nebulizer in the previous 6 months were consecutively enrolled. All patients completed a self-administered questionnaire on their current practices of home nebulization. Of the 1,721 questionnaires delivered, 1,257 were returned with an overall response rate of 73%. Most patients (82.8%) reported using their nebulizer for bronchopulmonary symptoms and the remaining patients only used theirs for upper respiratory tract diseases. Subjects using their nebulizer for lower respiratory symptoms were older (p<0.001), predominantly female (p<0.001) and used their nebulizer more frequently (p<0.001). Forty per cent of patients >60 yrs old used their nebulizer regularly, at least once a day. More than 60% of respondents never received any information from healthcare workers on the correct usage of their nebulizer, and >75% received no information on nebulizer hygiene and care. Patients who received information on the use and maintenance of their nebulizer from caregivers more commonly attended to these practices (p<0.01). The present survey suggests that home nebulizer use and maintenance in Italy are heterogeneous, and there is the need to implement better nebulizer practice.

Inhaler technique in asthma and COPD: challenges and unmet knowledge that can contribute to suboptimal use in real life

Introduction: Inhalers are the most commonly used devices for lung drug delivery in asthma and COPD. Inhaler use offers several advantages but requires the user's proper mastery. The issue of inhaler technique is very important as inhaler misuse remains common in real life regardless of the inhaler used and is associated with poor disease control.Areas covered:This narrative review analyses the key-steps of inhaler mastery and the significance of the errors of use for the main devices. There are uncertainties on many tasks of inhaler use and on those variations from recommended steps that are considered as critical errors.Expert opinion: Despite technological advancements, an easy-to-use device is not yet available. Whatever the chosen inhaler, health care givers' proper practical education with the opportunity of feedback learning has a key-role for improving inhaler technique, but is time-consuming, and remains limited to few successful experiences. Newer digital technologies will be applied to the field of inhaler education, but the lack of knowledge on many practical aspects of inhaler technique might be a limit for its extensive implementation. Possibly digital innovation might substantially contribute to reduce inhaler misuse only if clinicians, manufacturers, and subjects will cooperate together on this issue.

Consequences of not-shaking and shake-fire delays on the emitted dose of some commercial solution and suspension pressurized metered dose inhalers

BACKGROUND

Pressurized metered-dose inhalers (pMDIs) include hydrofluoroalkane (HFA) propellant to generate a drug aerosol upon actuation and drugs can be formulated as solution or suspension. Suspended particles can cream or sediment depending on density differences between drug and propellant and shaking the pMDI is an essential step to ensure a uniform drug dose release.

RESEARCH DESIGN AND METHODS

The effect of the delay (0, 10, 30, 60 seconds) in pMDI actuation after shaking and the effect of no-shaking during the canister life on the emitted dose (ED) for commercial solution and suspension pMDIs was investigated.

RESULTS

The ED for solutions was unaffected by no-shaking or by the progressive increasing delay in actuation after shaking (between 77% and 97%). For all the suspension products, shaking was demonstrated to be critical to assure the close to nominal drug delivery. In detail, the actuation delay after shaking led to an increase up to 380% or a drop to 32% of ED in relation to the label claim with high variability.

CONCLUSION

The drug delivered can vary widely for no-shaking and over different shake-fire delays with suspension pMDIs while solution formulations appear to remain stable.

Effects on aerosol performance of mixing of either budesonide or beclomethasone dipropionate with albuterol and ipratropium bromide

BACKGROUND

Mixing of nebulized drugs is common in real life, but its consequences on aerosol output and granulometry are poorly known.

METHODS

In an in vitro study I evaluated the effects on aerosol output, drug output, and aerosol particle size characteristics of mixing either beclomethasone dipropionate or budesonide with albuterol and ipratropium bromide. I tested the SideStream and VentStream-Pro nebulizers, run with the AirClinic compressor. Using the same fill volume in all experiments, I nebulized and evaluated each studied drug alone, and 2 drug mixtures: beclomethasone plus albuterol plus ipratropium; and budesonide plus albuterol plus ipratropium. I measured aerosol output via gravimetrics. I measured drug delivery by collecting the aerosol on a filter in the inspiratory limb, and the residual solution in the reservoir and the circuit after nebulization, and assayed those liquids with chromatography. I measured particle size distribution via cascade impaction.

RESULTS

Mixing tended to reduce drug output and to increase mass median aerodynamic diameter with the SideStream, but not always with the VentStream-Pro. However, the drug output always remained satisfactory and the mass median aerodynamic diameters were within the respirable range. When nebulized alone, the respirable mass of bronchodilators ranged from 18% to 40% of the nominal dose; when mixed, it ranged from 13% to 37%. When nebulized alone, the respirable mass of corticosteroids ranged from 10% to 24% of the nominal dose; when mixed, it ranged from 10% to 17%.

CONCLUSIONS

Both the SideStream and VentStream-Pro have good aerosol performance in nebulizing budesonide or beclomethasone dipropionate alone, and when mixed with albuterol and ipratropium bromide.

A Comprehensive Review of Sarcoidosis Diagnosis and Monitoring for the Pulmonologist

Sarcoidosis is a systemic granulomatous disease with heterogenous clinical manifestations. Here we review the diagnosis of sarcoidosis and propose a clinically feasible diagnostic work-up and monitoring protocol. As sarcoidosis is a systemic disease, a multidisciplinary approach is recommended for best outcomes. However, since the lungs are frequently involved, the pulmonologist is often the referral physician for diagnosis and management. When sarcoidosis is suspected, diagnosis needs to be confirmed and organ involvement/impairment assessed. This process is also required to establish whether the patient is likely to benefit from treatment, as many cases of sarcoidosis are self-limited and remit spontaneously. Whether or not treatment is started, effective regular follow-up is necessary to monitor changes in the disease, including extension, progression, remissions, flare-ups, and complications.

Fluticasone propionate/formoterol: a fixed-combination therapy with flexible dosage

International guidelines describe asthma control as the main outcome of asthma management. Prevention of symptoms, improved quality of life, and reduction of exacerbations are the main components, consequently decreasing health care costs. However, many of these objectives remain unmet in real life: several surveys show that a large proportion of asthmatic patients are not well controlled despite the efficacy of current available treatment. Several randomized controlled clinical trials indicate that combining inhaled corticosteroids and long-acting β2-agonists, by means of a single inhaler, greatly improves the management of the disease. The results of 9 multicenter phase III clinical studies demonstrate that the fixed combination of fluticasone propionate/formoterol in a single inhaler is effective in terms of lung function and symptom control. These studies highlight the dose flexibility, safety and tolerability of this new inhaled combination. These characteristics meet the recommendations of international guidelines, and the preferences of respiratory physicians who identified these aspects as critical components of a successful asthma therapy. Combination of fluticasone propionate/formoterol in a single inhaler provides potent anti-inflammatory activity of fluticasone propionate and rapid onset of action of the β2-agonist formoterol making this association a viable treatment option both in terms of effectiveness and compliance.

Home oxygen therapy: re-thinking the role of devices

INTRODUCTION

A range of devices are available for delivering and monitoring home oxygen therapy (HOT). Guidelines do not give indications for the choice of the delivery device but recommend the use of an ambulatory system in subjects on HOT whilst walking. Areas covered: We provide a clinical overview of HOT and review traditional and newer delivery and monitoring devices for HOT. Despite relevant technology advancements, clinicians, faced with many challenges when they prescribe oxygen therapy, often remain familiar to traditional devices and continuous flow delivery of oxygen. Some self-filling delivery-less devices could increase the users' level of independence with ecological advantage and, perhaps, reduced cost. Some newer portable oxygen concentrators are being available, but more work is needed to understand their performances in different diseases and clinical settings. Pulse oximetry has gained large diffusion worldwide and some models permit long-term monitoring. Some closed-loop portable monitoring devices are also able to adjust oxygen flow automatically in accordance with the different needs of everyday life. This might help to improve adherence and the practice of proper oxygen titration that has often been omitted because difficult to perform and time-consuming. Expert commentary: The prescribing physicians should know the characteristics of newer devices and use technological advancements to improve the practice of HOT.

Inhaled corticosteroid therapy with nebulized beclometasone dipropionate

Inhaled corticosteroids (ICS) are the most effective anti-inflammatory agents for the management of chronic persistent asthma and are therefore recommended as first-line antiasthmatic therapy in children and adults. In various settings, the administration of ICS via nebulizer rather than hand-held inhaler (HHI) may have certain advantages, as many patients with HHI fail to use these devices properly or efficiently. In particular, young children, the elderly, the acutely ill, and those with restricted dexterity may be unable to coordinate inhalation with actuation of the device or to generate sufficient inspiratory flow to operate breath-actuated devices effectively. Compliance with nebulized therapy may also be better than that with a pressurized metered-dose inhaler (pMDI) plus spacer. Systematic reviews conclude that there is no significant difference in clinical effects between nebulizers and HHI. Performance and clinical effect of nebulization are influenced by several technical aspects such as the nebulizer-drug combination, nebulizer type, output and lung deposition. Among the currently available ICS, nebulized beclometasone dipropionate (BDP) has been in clinical use for more than 35 years, and has demonstrated marked clinical efficacy and a favorable tolerability profile in children and adults with chronic persistent asthma. The clinical efficacy of nebulized beclometasone is discussed in the present review using data from 13 published studies, which included a total of 1250 patients. Three multicenter, randomized, double-blind studies showed that nebulized BDP is as effective as BDP via pMDI plus spacer in a 2:1 dose ratio. Controlled trials involving 497 adults and children demonstrated similar clinical efficacy between nebulized BDP and either nebulized fluticasone propionate or nebulized budesonide. In all these trials, treatment-related adverse effects were generally uncommon, most were mild-to-moderate in severity, and most were associated with the respiratory system. Meta-analyses show that BDP, like other inhaled corticosteroids, has no major influence on patient height, urinary cortisol concentration, or bone metabolism, thus suggesting the absence of growth retardation or any marked effect on adrenal function or the hypothalamic-pituitary-adrenal axis when used in the approved dose range. Overall, nebulized BDP appears to have a particularly important place in asthma therapy: as a general alternative to HHIs (e.g. in patients with poor HHI compliance); when patients such as children or the elderly are unable to operate HHIs because of poor hand-lung coordination, lack of cooperation, or low inspiratory flow rate; and when high dosages of ICS are required, such as in adults with severe, corticosteroid-dependent asthma.