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Background: Smoking is as prevalent in asthmatics as in the general population. Asthmatic smokers benefit less from inhaled corticosteroids (ICS) than non-smoking asthmatics, possibly due to more smoking-induced small airways disease. Thus targeting small airways may be important in treating asthmatic (ex-) smokers. We hypothesized that extrafine particle ICS improve small airways function more than non-extrafine particle ICS in asthmatic (ex-) smokers. Methods: We performed an open-label, randomized, three-way cross-over study comparing extrafine beclomethasone (HFA-QVAR) to non-extrafine beclomethasone (HFA-Clenil) and fluticasone (HFA-Flixotide) in 22 smokers and 21 ex-smokers with asthma (>= 5 packyears).Results: Improvement from baseline in PD20 adenosine after using QVAR, Clenil or Flixotide was 1.04 +/- 1.71, 1.09 +/- 2.12 and 0.94 +/- 1.97 doubling doses, mean +/- standard deviation (SD), respectively. The change from baseline in R-5-R-20 at PD20 adenosine after using QVAR, Clenil or Flixotide was -0.02 +/- 0.27, 0.02 +/- 0.21, and -0.02 +/- 0.31 kPa sL(-1), mean +/- SD, respectively. The change in PD20 adenosine and R5R20 at PD20 adenosine were neither statistically significant different between QVAR and Clenil (p = 0.86 and p = 0.82) nor between QVAR and Flixotide (p = 0.50 and p = 0.96).Conclusion: Similar effectiveness in improving small airways function was found for extrafine and non-extrafine particle ICS treatment for asthmatic smokers and ex-smokers. (C) 2017 Elsevier Ltd. All rights reserved.

Background: Our randomised controlled trial (RCT) evaluating the value of an inhaler-specific visual aid as adjunct to standard inhaler technique education, showed beneficial short-term (after 6-8 weeks) effects. Correct inhaler technique improved from 8% to 70% of patients with asthma or COPD. Aim: To evaluate the long-term effects of inhaler technique education in asthma or COPD. Methods: Patients who participated in our RCT and completed both visits (n=98) were invited for a 1-year follow-up (FU) visit as part of routine care. All patients had completed inhaler technique education, including the use of the visual aid at short-term FU. During long-term FU inhaler technique was (re)assessed using inhaler-specific checklists. Results: Inhaler technique was evaluated in 56 patients (mean age 64±12yrs, 52% male) with asthma (45%) or COPD (55%). Reasons for not attending long-term FU were: referral to primary care (n=13), unwilling (n=6), deceased (n=4), lost to follow-up (n=19). Inhaler technique was adequate in 37 patients (66%). The most common mistakes with incorrect technique (n=19) were: no complete exhalation before inhalation (n=10, DPI), no 5 times in- and exhaling through the mouthpiece (n=5, MDI with spacer). Incorrect technique occurred more in COPD (48%) as compared to asthma (16%). Patients with incorrect technique were significantly older (69yrs) as compared to patients with adequate technique (62yrs). Conclusion: This study demonstrates positive long-term effects of thorough inhaler technique education. Yet, the number of patients who inhaled incorrectly stresses the importance of monitoring and (repeatedly) educating correct inhaler technique, particularly in older COPD patients.

Background Bronchial provocation is often used to confirm asthma. Dyspnea sensation, however, associates poorly with the evoked drop in FEV1. Provocation tests only use the large airways parameter FEV1, although dyspnea is associated with both large- and small airways dysfunction. Aim of this study was to explore if adenosine 5′-monophosphate (AMP) and adenosine evoke an equal dyspnea sensation and if dyspnea associates better with large or small airways dysfunction. Methods We targeted large airways with AMP and small airways with dry powder adenosine in 59 asthmatic (ex)-smokers with ≥5 packyears, 14 ± 7 days apart. All subjects performed spirometry, impulse oscillometry (IOS), and Borg dyspnea score. In 36 subjects multiple breath nitrogen washout (MBNW) was additionally performed. We analyzed the association of the change (Δ) in Borg score with the change in large and small airways parameters, using univariate and multivariate linear regression analyses. MBNW was analyzed separately. Results Provocation with AMP and adenosine evoked similar levels of dyspnea. ΔFEV1 was not significantly associated with ΔBorg after either AMP or adenosine provocation, in both univariate and multivariate analyses. In multivariate linear regression, a decrease in FEF25–75 during adenosine provocation was independently associated with an increase in Borg. In the multivariate analyses for AMP provocation, no significant associations were found between ΔBorg and any large or small airways parameters. Conclusion AMP and adenosine induce equally severe dyspnea sensations. Our results suggest that dyspnea induced with dry powder adenosine is related to small airways involvement, while neither large nor small airways dysfunction was associated with AMP-induced dyspnea. Trail registration NCT01741285 at www.clinicaltrials.gov, first registered Dec 4th, 2012. Electronic supplementary material The online version of this article (10.1186/s12890-019-0783-0) contains supplementary material, which is available to authorized users.

This document contains supplementary Tables S1 and S2, as referred to in the text. Table S1 is The change (post - pre) in all pulmonary function parameters evoked by the provocation. Table S2 shows Spearmanâ s univariate correlation of the change in Borg dyspnea score with gender, smoking status, and all pulmonary function parameters. (DOCX 27â kb)

We performed a post-hoc analysis of the OLiVIA-study investigating whether current and ex-smoking asthmatics with small airways dysfunction (SAD) show a better response in airway hyperresponsiveness (AHR) to small particle adenosine after treatment with extrafine compared to non-extrafine particle inhaled corticosteroids (ICS), and to investigate which clinical parameters predict a favorable response to both treatments. We show that smoking and ex-smoking asthmatics with and without SAD have a similar treatment response with either extrafine or non-extrafine particle ICS. We also found that lower blood neutrophils are associated with a smaller ICS-response in smokers and ex-smokers with asthma, independent from the level of blood eosinophils. Electronic supplementary material The online version of this article (10.1186/s12931-018-0961-2) contains supplementary material, which is available to authorized users.

Aim: Incorrect inhaler use is common and is associated with poor disease control, outcomes and healthcare costs. Optimizing inhaler technique education is crucial. Applying an interdisciplinary might result in the development of a thorough and didactic-based inhaler technique instruction method. Method: We propose a new instruction method based on data from three sub studies: 1) interviews with 127 asthma and COPD patients in the Netherlands, Spain and Greece about experiences with inhaler instructions and inhaler use 2) six focus groups with healthcare professionals involved inhaler education (the Netherlands, Spain and Greece) 3) a literature review (46 papers) to reveal theories on motor skill acquisition was conducted. Results: Most patients did not receive inhaler technique instruction for years. A timely follow-up ( Conclusion: A proposal for a new inhaler technique instruction method based the results of the IRW study has been developed. Embedding this method in a well-organised healthcare system is crucial. The feasibility and the effectiveness of this promising new inhaler technique instruction method needs to be examined in future research.

Background: Bronchial provocation is often used to confirm asthma. Dyspnea sensation correlates poorly with the provocative dose that causes the FEV1 to drop ≥20% (PD20). Aim: To explore if dyspnea sensation associates better with small airways then large airways function. Methods: We induced dyspnea with dry powder adenosine and nebulized adenosine 5’‑monophosphate (AMP), targeting the small and large airways, respectively, 14±7 days apart. We obtained spirometry, impulse oscillometry (IOS), and Borg score in all subjects, but multiple breath nitrogen washout (MBNW) was only limited available. Subjects were asthmatic (ex‑)smokers with ≥5 packyears. We analyzed the correlation between the change (Δ) in large and small airways parameters to ΔBorg in univariate and multivariate linear regression analysis. MBNW was analyzed separately. Results: We included 61 subjects of which 36 performed MBNW. Provocation with adenosine and AMP evoked similar levels of dyspnea. The large airways parameter, ΔFEV1 was not significantly correlated with ΔBorg after either adenosine or AMP provocation, in both univariate and multivariate analyses. Multivariate linear regression models for ΔBorg included for adenosine: gender, smoking status, ΔFEV1, ΔFEF25-75, ΔR20, ΔR5‑R20, and ΔScond and for AMP: gender, smoking status, ΔFEV1, ΔFEF25-75, ΔR20, ΔX5, and ΔLCI5%. ΔFEF25-75 during adenosine provocation was independently associated with ΔBorg, but for ΔBorg during AMP provocation no significant associations were found. Conclusion: Our results suggest that dyspnea sensation induced with dry powder adenosine is related to small airways involvement, while neither large nor airways small airways dysfunction was associated with AMP induced dyspnea.

Table S1. Baseline characteristics. Table S2. Baseline values of measurements of small airways dysfunction. Table S3. Difference in Î PD20 adenosine in patients with and without small airways dysfunction after treatment with QVAR, Clenil and Flixotide. Table S4. Univariate linear regression analysis of baseline variables and change in airway hyperresponsiveness (Î PD20) in patients treated with QVAR, Clenil and Flixotide. Figure S1. Scatterplots of significant correlations between baseline variables and Î PD20 adenosine. (PDF 731 kb)

Background: It is generally known that inhaler technique is poor. This is illustrated by many stories form real-life clinical practice among which the story of dog Max. Max9s boss was prescribed with an inhaler, to be used max. 4 times a day. Patient9s symptoms did not improve and it appeared to be that the dog Max was the inhaler medication. 4 times a day. Aim: The Inhaler Research Workgoup (IRW) study aims to improve inhaler instructions in patients with asthma and COPD with a multidisciplinairy approach. Method: In the Netherlands we have interviewed 67 (age 6-90 years) patients and performed 2 focusgroups with 21 health care profesisonals. Moreover, we are performing a literature studie to detect effective theory based instruction methods that can be used to teach inhaler technique. Results: Patients provided us with relevant suggestions to improve inhaler technique. Asthmatics would like to know the reasoning behind the technique. COPD patients have sometimes difficulties with handling the device. We have videorecorded patients9 inhaler technique and permission to show at conferences. Communication between professionals is suboptimal and it is a challenge to obtain enough time for instructions. Literature provided us with promissing suggestions for evidence based teachning methods. Conclusion: We found several achievable options for improvement. At the ERS we would like to share this knowledge about inhaler technique. We wil provide suggestions for improvement at organisational level, at educational level and for contemplation of the correct inhaler technique. Epilogue: After explanation, Max9s boss started to use his inhaler...

Background: Smoking is as prevalent in asthmatics as in the general population. Asthmatic smokers benefit less from inhaled corticosteroids (ICS) than non-smoking asthmatics, possibly due to smoking-induced small airways disease. Aim: Targeting the small airways may be important in treating asthmatic smokers and ex-smokers. We hypothesized that extrafine particle ICS improves small airways function more than non-extrafine particle ICS in these patients. Methods: We performed a two-center, open-label, randomized, three-way cross-over study comparing two-week extrafine beclomethasone (HFA-QVAR 200 µg b.i.d.) to non-extrafine beclomethasone (HFA-Clenil 400 µg b.i.d.) and fluticasone (HFA-Flixotide 250 µg b.i.d.) in 22 smokers and 21 ex-smokers with asthma (≥5 packyears). Primary outcomes were the provocative dose of adenosine inducing a 20% fall in FEV1 (PD20) and peripheral airway resistance measured with impulse oscillometry (R5-R20) at PD20. Results: Improvement from baseline in the PD20 adenosine after using QVAR, Clenil or Flixotide was 1.04±1.71, 1.09±2.12 and 0.94±1.97 doubling doses mean ± standard deviation (SD), respectively. The change from baseline in R5-R20 at PD20 adenosine after using QVAR, Clenil or Flixotide was 0.02±0.27, 0.02±0.21, and -0.02±0.31 kPa·sL−1 mean ± SD, respectively. For the change in PD20 adenosine and R5-R20 at PD20 adenosine, the differences between QVAR and Clenil (p=0.86 and p=0.82) or between QVAR and Flixotide (p=0.50 and p=0.96) were not statistically significant. Conclusion: Similar results were found for extrafine and non-extrafine particle ICS treatment for asthmatic smokers and ex-smokers. Both were equally effective in improving airway hyperresponsiveness.

Background: Inhaler medication is the cornerstone of treatments for patients with asthma and COPD. Unfortunately 70 to 80% of the patients have poor inhaler technique which leads to poor disease control, high burden of disease and high health care costs. Most studies focus on patients with poor inhaler technique in this study we want to evaluate patients with good inhaler technique and see what the can learn from them. Aim: Evaluate patient characteristics and illness perceptions of patients with correct inhaler technique Method: First we analysed a real-life database with 9676 primary care patients (49% asthma, 20% COPD, 9% overlap and other/unclear (22%) who have had their inhaler technique checked. We compared characteristics of patients with correct inhaler technique with patients with poor inhaler technique. Second we interviewed 12 patients and discussed their inhaler medication use and tools or information used to train inhaler technique. Finally we have performed a questionnaire study in primary care patients to the evaluates self-efficacy and illness perceptions. Results: patients with proper inhaler technique are somewhat younger (mean age: good 51 years, poor 54 years) and more likely to be men (good: 60% men, poor 56% men). The interviews showed that patients have found ways to incorporate their medication use in their daily lives and are well informed about their disease. No differences were found in self-efficacy. However, remarkably COPD patients with poor technique have poor knowledge about their COPD (see figure 1). Conclusion: We have learnt from patients with correct inhaler technique that inhaler technique is predomintly related with patients knowledge about their disease.

Background: Although the importance of teaching a correct inhalation technique in patients with asthma or COPD is recognised, the optimal method of inhalation technique education is unknown. To improve this, inhaler-specific visual instruction cards as an adjunct to standard education have been developed. Aim: To evaluate the value of these visual instruction cards in optimising inhalation technique in patients with asthma or COPD. Methods: Randomised controlled trial in 100 outpatients with asthma or COPD (49% male, mean age 63 years). Patients received either usual inhalation technique education (Usual Care) or received the visual instruction card in addition to the usual inhalation technique education (Usual Care + ). At baseline and follow-up (at 6-8 weeks) inhalation technique was assessed using inhaler-specific checklists. Disease control was measured by ACQ or CCQ. Results: In both groups the proportion of patients with an adequate inhalation technique significantly improved. The improvement in the Usual Care + group was significantly higher as compared to the Usual Care group (4% to 85% and 12% to 57% respectively, p + group as compared to the Usual Care group (-0.5 and -0.3 respectively, p + group (–0.5 in the Usual Care + and –0.3 in the Usual Care group, p=0.09). Conclusion: This study emphasises the importance of proper inhalation technique education, and in particular, the value of the newly developed visual instruction cards.