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Background: The impact of proper aspiration of nasal secretions during upper respiratory infection on the frequency and severity of symptoms of lower airways has never been investigated. The study was aimed at testing if cleaning the nasal cavities of children with recurrent wheezing using an automatic nasal aspirator improves the upper and lower respiratory symptoms during the cold season., Methods: Parents of wheezing children (age 3-72 mo.) answered questionnaires and learned using a nebulizer equipped (cases) or not equipped (controls) with an automatic nasal aspirator (DuoBaby, OMRON, Japan). During a 90-days monitoring period parents filled an electronic diary (BreathMonitor, TPS, Rome, Italy) on their child's symptoms of the upper and lower airways., Results: Eighty-nine/91 patients (43 cases, 46 controls) completed the study. Less days with upper (25.0% vs 46.4%, p = 0.004) or lower (21.8% vs 32.8%, p = 0.022) airways symptoms and less days with salbutamol inhalation (12.2% vs 16.9%, p < 0.001) were reported by cases than by controls. The episodes of upper respiratory symptoms were shorter [4.3 days (95%CI:3.8-4.9) vs 5.7 days (95%CI:5.0-6.4), p = 0.007] but not less frequent [2.3 (95%CI: 1.8-2.8) vs 2.6 (95%CI:2.2-3.0), p = 0.122] among cases than among controls. Similarly, the episodes of lower respiratory symptoms tended to be shorter [3.8 days, (95%CI: 3.4-4.2) vs 4.4 days, (95%CI: 4.4-6.0), p = 0.067] but not less frequent [1.9 (95%CI:1.5-2.3) vs 2.1 (95%CI:1.7-2.4), p = 0.240] among the group using the nasal aspirator., Conclusions: In our pilot study, the use of an automatic nasal aspirator in children with a history of recurrent wheezing was associated with an improved respiratory health during the cold season.

Background: Studies have linked ambient air pollution to chronic obstructive pulmonary disease (COPD) healthcare encounters. However, the association between air quality and rescue medication use is unknown., Objectives: We assessed the role of air pollution exposure for increased short-acting beta-2-agonist (SABA) use in patients with COPD through use of remote monitoring technology., Methods: Participants received a portable electronic inhaler sensor to record the date, time and location for SABA use over a 3-month period. Ambient air pollution data and meteorological data were collected from a centrally located federal monitoring station. Mixed-effects Poisson regression was used to examine the association of daily inhaler use with pollutant levels. Four criteria pollutants (PM 2.5 , PM 10 , O 3 and NO 2 ), two particulate matter species (elemental carbon (EC) and organic carbon), estimated coarse fraction of PM 10 (PM 10-2.5 ) and four multipollutant air quality measures were each examined separately, adjusting for covariates that passed a false discovery rate (FDR) screening., Results: We enrolled 35 patients with COPD (94.3% male and mean age: 66.5±8.5) with a mean forced expiratory volume in 1 s (FEV 1 ) % predicted of 44.9+17.2. Participants had a median of 92 observation days (range 52-109). Participants' average SABA inhaler use ranged from 0.4 to 13.1 puffs/day (median 2.8). Controlling for supplemental oxygen use, long-acting anticholinergic use, modified Medical Research Council Dyspnoea Scale and influenza season, an IQR increase in PM 10 concentration (8.0 µg/m 3 ) was associated with a 6.6% increase in daily puffs (95% CI 3.5% to 9.9%; FDR <0.001). NO 2 and EC concentration were also significantly associated with inhaler use (3.9% and 2.9% per IQR increase, respectively)., Conclusions: Exposure to increased ambient air pollution were associated with a significant increase in SABA use for patients with COPD residing in a low-pollution area., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: Asthma is a potentially serious chronic respiratory disease impacting patients quality of life. Satisfactory control requires proper use of inhaled devices. This study assesses general medical residents and pharmacy students knowledge about proper use of inhaled asthma devices., Materials and Methods: We evaluated knowledge of 43 general practice students and 43 pharmacy students in Lille for three inhaler devices (metered-dose inhaler, Turbuhaler ® and Diskus ® ) during individual interviews. Students were assessed on 8 proper use criterias for each device., Results: General practice and pharmacy students are unfamiliar with proper use of inhaler devices. However, pharmacy students get better average scores than general practice students for all devices included in this study: 6.3/8 respected criterias against 5/8 for metered-dose inhaler; 5.3/8 against 3.2/8 for Turbuhaler ® ; and 6/8 against 4.3/8 for Diskus ® . Pharmacy students more frequently perform a demonstration of proper use to patients when a device is first prescribed or when a prescription is renewed; general practice students more frequently ask patients themselves to perform a demonstration of proper use., Conclusion: Introducing trainings workshops for inhaler devices to pharmacy and general practice students appears appropriate in order to promote therapeutic patient education, to increase asthma control and better patients life quality., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Background and Objective: The impact, treatment patterns and control of mild asthma are poorly understood for Chinese patients. This study describes the characteristics, therapeutic interventions and burden of mild asthma on patients residing in major cities of China., Methods: The Respiratory Disease Specific Program 2015, a cross-sectional survey, was conducted with Chinese physicians and their patients. The survey assessed clinical characteristics, asthma symptoms, exacerbations, rescue inhaler usage, treatment adherence, asthma control, work and activity impairments and healthcare utilization for patients prescribed Global Initiative for Asthma (GINA) Step 1 or 2 treatment defined mild asthma., Results: From a total sample of 988 patients, 229 patients met the criteria for mild asthma, with 25.3% classified as Step 1 and 74.7% as Step 2. Overall, 12.6% of patients were considered of high adherence to prescribed treatment. Physicians reported that 75% of patients overall were well controlled, although well-controlled asthma as defined by GINA was achieved in only 14.2% of patients. 26.5% of patients indicated daily use of as-needed rescue medication in the last 4 weeks. 17.8% of patients experienced ≥1 exacerbations in the last 12 months and impaired work productivity was 27.2% overall., Conclusion: Less than 15% of patients were well controlled according to GINA criteria despite physicians reporting the majority of patients were well controlled. Over one-fourth of patients relied on daily rescue inhaler medication, while exacerbation frequency and work and activity impairment were higher than might reasonably be expected in a mild asthmatic population., (© 2017 Asian Pacific Society of Respirology.)

2017 ESCMID practice guidelines reported safety concerns and weak evidence of benefit supporting use of aerosolized antibiotics in mechanically ventilated patients. Our primary goal was to assess current patterns of aerosolized antibiotic prescription in mechanically ventilated patients. A sequential global survey was performed prior to the release of the ESCMID guidelines, from the 1st of February to the 30th of April 2017, using an electronic platform. Responses were analyzed comparing geographical regions. A total of 410 units responded, with 261 (177 from Europe) being eligible for the full survey. 26.8% of units reported not using aerosolized antibiotics. The two major indications amongst prescribing units were ventilator-associated pneumonia and ventilator-associated tracheobronchitis (74.3% and 49.4%, respectively). 63.6% of units indicated prescription solely in response to multi-drug resistant organisms. In comparison with a survey undertaken in 2014, there was a significant reduction in use of aerosolized antibiotics for prophylaxis (50.6% vs 7.7%, p < 0.05) and colonization (52.9% vs 25.3%, p < 0.05). The large majority of units (91.7%) reported only prescribing in patients with positive pulmonary cultures. Asia appeared to be an outlier, with 53.3% of units reporting empirical use. The most commonly used device was the jet nebulizer. The most commonly prescribed drugs were colistin methanesulfonate (57.6%), colistin base (41.9%) and amikacin (31.4%), although there was considerable heterogeneity across geographical areas. A significant gap exists between ESCMID clinical practice recommendations and the use of aerosolized antibiotics in clinical practice. Our findings indicate an urgent need for high-quality education to bring practice into line with evidence-based guidelines.

Introduction: Projects comparing bronchodilator response by aerosol devices in the ED are limited. Evidence suggests that the vibrating mesh nebulizer (VMN) provides 5-fold greater aerosol delivery to the lung as compared to a jet nebulizer (JN). The aim of this project was to evaluate a new nebulizer deployed in an Emergency Department., Methods: A quality improvement evaluation using a prospectively identified data set from the electronic medical record comparing all ED patients receiving aerosolized bronchodilators with the JN during September 2015 to those receiving aerosolized bronchodilators with the VMN during October 2015., Results: 1594 records were extracted, 879 patients received bronchodilators via JN and 715 patients via the VMN. Admission rates in the VMN group were 28.1% and in the JN group at 41.4%. The total albuterol dose administered was significantly lower in the VMN group compared to the JN (p<0.001). No patient in the VMN group required >5mg albuterol to control symptoms (85% of the VMN group received only 2.5mg) whereas dosing in the JN group was higher in some patients (with 47% receiving only 2.5mg). The use of VMN was also associated with a 13% (37min) reduction in median length of stay in the ED., Conclusions: The VMN was associated with fewer admissions to the hospital, shorter length of stay in the ED and a reduction in albuterol dose. The device type was a predictor of discharge, disposition and amount of drug used. Randomized controlled studies are needed to corroborate these findings., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Aims and Objectives: To investigate the clinical benefits of using humidification in low-flow oxygen therapy. Specific objectives were to investigate via an assessment of the number of nasal lavages whether humidification can help to decrease the nasal mucus viscosity, to determine whether it can relieve feeding difficulties by comparing the weight gain in infants, to ascertain whether it can relieve respiratory distress by assessing the heart and respiratory rates and contribute to improved clinical outcomes, measured by the length of stay and oxygen requirements., Background: There is no evidence to support the use of humidification in low-flow oxygen therapy as a usual clinical practice in the management of bronchiolitis., Design: A controlled quasi-experimental study., Methods: A total of 97 infants were included, aged ≤6 months, with bronchiolitis, low-flow oxygen therapy and bronchodilators nebulised with hypertonic saline 3%. Data from the control group (nonhumidified) were gathered from 2010-2012 (49 infants), and data from the group with humidification from 2012-2014 (48 infants). Linear and Poisson regressions were performed adjusting for relevant characteristics of patients., Results: Humidification was shown to be associated with significant reductions in the number of nasal lavages in infants with Sant Joan de Déu Bronchiolitis Scores of BROSJOD≤7, in the heart rate of infants with mixed bronchodilators treatment, and in the length of stay and oxygen requirements of infants with Score BROSJOD≤5. No differences in weight and respiratory rate were found., Conclusions: Humidification in low-flow oxygen therapy is an effective nursing intervention to improve the clinical outcomes of infants with mild-moderate bronchiolitis., Relevance to Clinical Practice: Humidifying the nasal mucosa can help to reduce the need for professional procedures, oxygen requirements and hospitalisation length. Further research into the economic savings involved is recommended., (© 2017 John Wiley & Sons Ltd.)

Background: Respiratory disease is a common co-morbidity with rheumatoid arthritis (RA). RA commonly affects the hands, but there is little research investigating whether these patients are physically able to operate inhalers., Aim: To compare the physical ability of people with and without RA to use four commonly prescribed inhaler devices (pressurised metered dose inhaler (pMDI), Easi-Breathe ® , HandiHaler ® and Turbohaler ® )., Methods: Adults with RA and an equal number of age-sex matched controls were observed using placebo inhaler devices. Maximum inhalation flow rate was measured with an In-Check Dial device. Dichotomous data were compared (RA versus control) using Fisher's exact test., Results: Thirty four participants were recruited for each group. For all inhalers, fewer participants with RA were able to complete all the steps necessary to operate the device: pMDI (50% vs. 91%), Easi-Breathe ® (77% vs. 97%), HandiHaler ® (15% vs. 94%) and Turbohaler ® (85% vs. 100%). This difference was significant (p < .05) for the pMDI, Easi-Breathe ® and HandiHaler ® . Significantly fewer people (p < .05) with RA were able to depress the pMDI canister, or to complete three steps in the operation of the Handihaler ® (open the dust cap, remove the capsule from its blister, pierce the capsule). Only one participant (RA group) was unable to achieve the minimum flow rates required to operate the Turbohaler ® and HandiHaler ® (p = 1.000)., Conclusions: People with RA have varying physical abilities to use inhalers effectively. A person-centred approach is required to assess which inhaler device is appropriate for each individual patient., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Understanding the advantages and limitations of inhaler devices for chronic obstructive pulmonary disease helps clinicians in choosing the proper device for the individual patient's clinical needs and preferences. However, with the wide range of permutations of drug combinations now possible, inhaler selection remains challenging. For all inhaler devices, adequate training for patients on how to use their device is required to achieve optimal therapeutic benefits.

Background: Single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) 100/62.5/25 μg has been shown to improve lung function and health status, and reduce exacerbations, versus budesonide/formoterol in patients with chronic obstructive pulmonary disease (COPD). We evaluated the non-inferiority of single-inhaler FF/UMEC/VI versus FF/VI + UMEC using two inhalers., Methods: Eligible patients with COPD (aged ≥40 years; ≥1 moderate/severe exacerbation in the 12 months before screening) were randomized (1:1; stratified by the number of long-acting bronchodilators [0, 1 or 2] per day during run-in) to receive 24-week FF/UMEC/VI 100/62.5/25 μg and placebo or FF/VI 100/25 μg + UMEC 62.5 μg; all treatments/placebo were delivered using the ELLIPTA inhaler once-daily in the morning. Primary endpoint: change from baseline in trough forced expiratory volume in 1 s (FEV 1 ) at Week 24. The non-inferiority margin for the lower 95% confidence limit was set at - 50 mL., Results: A total of 1055 patients (844 [80%] of whom were enrolled on combination maintenance therapy) were randomized to receive FF/UMEC/VI (n = 527) or FF/VI + UMEC (n = 528). Mean change from baseline in trough FEV 1 at Week 24 was 113 mL (95% CI 91, 135) for FF/UMEC/VI and 95 mL (95% CI 72, 117) for FF/VI + UMEC; the between-treatment difference of 18 mL (95% CI -13, 50) confirmed FF/UMEC/VI's was considered non-inferior to FF/VI + UMEC. At Week 24, the proportion of responders based on St George's Respiratory Questionnaire Total score was 50% (FF/UMEC/VI) and 51% (FF/VI + UMEC); the proportion of responders based on the Transitional Dyspnea Index focal score was similar (56% both groups). A similar proportion of patients experienced a moderate/severe exacerbation in the FF/UMEC/VI (24%) and FF/VI + UMEC (27%) groups; the hazard ratio for time to first moderate/severe exacerbation with FF/UMEC/VI versus FF/VI + UMEC was 0.87 (95% CI 0.68, 1.12). The incidence of adverse events was comparable in both groups (48%); the incidence of serious adverse events was 10% (FF/UMEC/VI) and 11% (FF/VI + UMEC)., Conclusions: Single-inhaler triple therapy (FF/UMEC/VI) is non-inferior to two inhalers (FF/VI + UMEC) on trough FEV 1 change from baseline at 24 weeks. Results were similar on all other measures of efficacy, health-related quality of life, and safety., Trial Registration: GSK study CTT200812; ClinicalTrials.gov NCT02729051 (submitted 31 March 2016).

Mist tent therapy for cystic fibrosis went through a rise and fall in popularity between the 1950s and 1970s, providing an opportunity to explore the nature of therapeutic change in medicine. The therapy "worked" in the context of a particularly grim life expectancy in the early 1950s and in the setting of a comprehensive therapeutic program that began in Cleveland in 1957. Although clinical studies published in the 1970s provided evidence that mist tents were ineffective or even harmful, these later studies were not necessarily more robust than earlier studies that provided evidence of mist tent efficacy, suggesting that other factors may have also contributed to mist tent abandonment. In fact, the unpalatable nature of mist tent therapy, which was described by one doctor as akin to incarceration, and studies that questioned the theoretical underpinnings of the therapy also played important roles in the eventual abandonment of mist tents.

Smoke inhalation injury (SIJ) is associated with an increase in morbidity and mortality in patients with burns. SIJ causes airway damage, inflammation, and bronchial obstruction, resulting in decreased oxygenation and perfusion status in these patients. Retrospective studies have compared the use of nebulized heparin (NH) plus nebulized N-acetylcysteine (NAC) and albuterol in patients with SIJ to those who received standard ventilator support with bronchodilator therapy. These studies are associated with a decrease in mortality when NH and nebulized NAC are administered to patients with SIJ. Approximately 20% of patients who develop SIJ will also develop acute respiratory distress syndrome (ARDS). Epoprostenol, a selective pulmonary vasodilator, has been utilized in the treatment of ARDS with mixed results for improving gas exchange. To our knowledge, this is the first case report of the concomitant administration of NH, nebulized NAC, and nebulized epoprostenol following SIJ in a burn patient with ARDS.

Background: Revefenacin is a once-daily long-acting muscarinic antagonist (LAMA) in clinical development for the treatment of patients with chronic obstructive pulmonary disease (COPD). In a dose-ranging study, nebulized once-daily revefenacin had a long duration of action in patients after 7 days' administration of doses up to 700 μg. In this multiple-dose study, the bronchodilation efficacy and adverse events profile were characterized in patients administered nebulized revefenacin once daily for 28 days., Methods: A total of 355 COPD patients (mean age 62 years, mean forced expiratory volume in 1 s [FEV 1 ] 44% of predicted) were randomized in a double-blind, placebo-controlled parallel group study. Inhaled corticosteroids as well as short-acting bronchodilators were permitted. Once-daily treatments (44, 88, 175 or 350 μg revefenacin or matching placebo) were administered by a standard jet nebulizer, for 28 days. The primary endpoint was change from baseline in D28 trough FEV 1 , and secondary endpoints included weighted mean FEV 1 over 0 to 24 h and rescue medication (albuterol) use. Safety evaluations included adverse events, laboratory assessments, electrocardiograms and 24-h Holter profiles., Results: Revefenacin (88, 175 and 350 μg) significantly improved D28 trough FEV 1 over placebo (187.4, 166.6 and 170.6 mL, respectively, all p < 0.001); 44 μg produced a sub-therapeutic response. At doses ≥88 μg, more than 80% of patients achieved at least a 100-mL increase from baseline FEV 1 in the first 4 h post dose compared with 33% of placebo patients. For doses ≥88 μg, D28 24 h weighted mean differences from placebo for FEV 1 were numerically similar to respective trough FEV 1 values, indicating bronchodilation was sustained for 24 h post dose. Doses ≥88 μg reduced the average number of albuterol puffs/day by more than one puff/day. The 350 μg dose did not demonstrate additional efficacy over that observed with 175 μg revefenacin. Revefenacin was generally well tolerated, with minimal reports of systemic anti-cholinergic effects., Conclusions: These data suggest that 88 and 175 μg revefenacin are appropriate doses for use in longer-term safety and efficacy trials. Revefenacin offers the potential for the first once-daily LAMA for nebulization in patients with COPD who require or prefer a nebulized drug delivery option., Trial Registration: ClinicalTrials.gov NCT02040792 . Registered January 16, 2014.

Objective: To compare the Inhaler Compliance Assessment TM (INCA TM ), a novel audio-recording device objectively measuring timing and proficiency of inhaler use, against established adherence measures, and explore its discriminant and predictive validity., Design: Prospective observational study; 184 chronic obstructive pulmonary disease (COPD) patients used an INCA TM -enabled salmeterol/fluticasone inhaler for one-month post-hospital discharge., Main Outcome Measures: INCA TM (Attempted, Attempted Interval, Actual) adherence correlated with Doses Used Rate, self-reported adherence and prescription refill for concurrent validity. Discriminant validity for reason for admission, cognition and lung function; predictive validity for health status and quality-of-life., Results: Rates of Attempted, Attempted Interval and Actual adherence were 59, 47 and 23%, respectively. Only 7% of participants had Actual adherence >80%. INCA TM variables significantly correlated with Doses Used Rate but not with self-report; Attempted and Attempted Interval were weakly associated with prescription refill. Higher cognitive and lung functioning groups had better INCA TM adherence. Attempted and Attempted Interval predicted health status, while Doses Used Rate predicted quality-of-life., Conclusion: INCA TM did not strongly correlate with self-report or prescription refill data. Discriminant and predictive validity demonstrated by INCA TM suggests the potential utility of the INCA TM as a method to identify intentional and unintentional adherence to inhaled medication and facilitate targeted intervention.

Background: Upper and lower airways diseases share in part their pathogenic mechanisms and frequently occur simultaneously as "United Airway Disease." Local treatment with nebulizers delivers anti-symptomatic drugs in either the upper or the lower airways, according to the particle size generated by the nebulizer. To our knowledge, no nebulizer combines both application ways. The aim of this study is to test the efficacy and usability of a new nebulizer (OMRON A3 complete), generating aerosols with particles diameters of 2-4.5 μm, 4.5-7.5 μm or >7.5 μm, according to the user's choice., Methods: Seventy-seven patients between 5 and 17 years of age with a diagnosis of rhinitis or asthma were examined. Oxymetazoline or Salbutamol were prescribed according to best clinical practice guidelines. Both drugs were administered through the OMRON A3 Complete nebulizer, with a particle dimension of >7.5 μm to treat nasal obstruction and 2-4.5 μm for bronchial obstruction. The efficacy of treatment was assessed by total nasal inspiratory airflow and FEV-1, Tiffeneau index (FEV1/FVC) and MMEF 25/75 respectively, 10 min before and after treatment. Symptom improvement and usability were measured by patients' and doctors' questionnaires., Results: Overall, 77 patients seeking care for acute respiratory symptoms were assigned to the upper (n = 39) or lower (n = 38) airways disease group. For symptoms of the upper airways, 92% (95% CI, 77-97%) of the patients reported subjective improvement, while 87% (95% CI, 73-94%) did so for the lower airways. The average total nasal inspiratory airflow improved significantly (p = 0.030) among the patients with upper airways symptoms, from 275 ml/s (95% CI, 207-342 ml/s) to 359 ml/s (95% CI, 300-419 ml/s) after Oxymetazoline administration. All selected lung function parameters (FEV1, Tiffeneau Index and MMEF25-75) significantly improved among the patients with lower airways symptoms after inhalation of Salbutamol (p < 0.001). The nebulizer was assessed as "easy to use" by over 95% of participants in both groups., Conclusions: The OMRON A3 efficiently delivers anti-symptomatic drugs in both upper and lower airways in a user-friendly way. This device may be useful to facilitate adherence to a complete treatment of respiratory symptoms in patients with symptoms of the so-called United Airway Disease.

Background: Both inhaled corticosteroids (ICS) and long-acting ?-agonists (LABA) have been recommended for the treatment of severe/moderate chronic obstructive pulmonary disease (COPD), but mild COPD has not been frequently studied., Methods: We performed a prospective cohort study to compare the effect of inhaled corticosteroid (ICS) and ICS/long-acting ?-agonist (LABA) in a single inhaler on all-cause mortality and adverse events, such as pneumonia and fracture, in patients with newly diagnosed chronic obstructive pulmonary disease (COPD). We used representative nationwide cohort data from the Korean National Health Insurance claims database (2002-2013). Patients who were at least 40-years-old, newly diagnosed with COPD, and prescribed ICS or ICS/LABA in a single inhaler (N = 1995). To analyze the data, we utilized a Cox's proportional hazard regression., Results: Among the total of 1995 patients, 807 had severe COPD (FEV 1  < 50%) and 1188 had mild/moderate COPD (FEV 1  ? 50%). The cumulative incidence and 5-year cumulative incidence of all-cause mortality was 59.5% and 29.6% for ICS users, and 35.8% and 20.2% for single inhaler ICS/LABA users, respectively. The adjusted hazard ratio (HR) of all-cause mortality for new ICS/LABA users, compared with that in new ICS users, was 0.77 (95% CI: 0.62-0.95) for the total population. For the severe and non-severe COPD groups, the adjusted HRs of all-cause mortality for new ICS/LABA users were 1.07 (95% CI: 0.65-1.76) and 0.70 (95% CI: 0.55-0.89), respectively. There was no difference in the risk for the first hospitalization due to pneumonia between new ICS and ICS/LABA users among the total population (HR: 1.02; 95% CI: 0.79-1.34). The adjusted HR of the first hospitalization for fractures in new ICS/LABA users, compared with that in new ICS users, was 0.60 (95% CI: 0.39-0.92) for the total population., Conclusions: Among newly diagnosed COPD patients and new users of ICS or ICS/LABA, use of ICS/LABA in a single inhaler was associated with lowered risk of all-cause mortality and delayed first hospitalization for fracture, as compared with use of ICS alone. However, there was no significant difference in terms of first hospitalization for pneumonia., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: Community pharmacists are well placed and evidence clearly demonstrates that they can be suitably trained to deliver professional services that improve the management of asthma patients in clinical, economic and humanistic terms. However the gap between this evidence and practice reality remains wide. In this study we measure the implementation process as well as the service benefits of an asthma service model., Methods: Using an effectiveness-implementation hybrid design, a defined implementation process (progression from Exploration through Preparation and Testing to Operation stages) supporting an asthma service (promoting asthma control and inhaler technique) was tested in 17 community pharmacies across metropolitan Sydney., Results: Seven pharmacies reached the Operation stage of implementation. Eight pharmacies reached the Testing stage of implementation and two pharmacies did not progress beyond the Preparation stage of implementation. A total of 128 patients were enrolled in the asthma service with 110 patients remaining enrolled at the close of the study. Asthma control showed a positive trend throughout the service with the overall proportion of patients with 'poor' asthma control at baseline decreasing from 72% to 57% at study close. There was a statistically significant increase in the proportion of patients with correct inhaler technique from 12% at Baseline (Visit 1) to 33% at Visit 2 and 57% at study close., Conclusion: Implementation of the asthma service varied across pharmacies. Different strategies specific to practice sites at different stages of the implementation model may result in greater uptake of professional services. The asthma service led to improved patient outcomes overall with a positive trend in asthma control and significant change in inhaler technique., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Little is known about patients' perceptions of electronic inhaler reminders, which have emerged in recent years as adherence promotion aids. This study explored asthma patients' attitudes toward the acceptability and utility of inhaler reminders., Methods: Participants from a 6-month cluster randomized controlled trial who received reminders for missed doses via SmartTrack adherence monitors (Adherium Ltd) were interviewed to explore their perceptions; interviews were audio-recorded, transcribed and analysed thematically., Results: 18 participants (50% male, mean age 39 years [range 17-68]) were interviewed. Three themes were identified. Acceptability and Feasibility: Interviewees found the monitor easy to use. For some, concerns about the monitor itself affected adherence, e.g. leaving it at home to avoid breakage. Positive features included that reminders played only for missed doses, and the choice of reminder tunes. Utility and Behavioural Impact: Interviewees described reminders as an effective "training" tool for adherence, encouraging habit-formation, behaviour change and attitude change. Reminders were considered less acceptable or useful by participants who preferred taking medication only when symptomatic or who doubted the necessity or safety of their medication. Sustainability: Some interviewees reported sustained behaviour change, supported by reminders, through the establishment of routine or via experiential learning that good adherence improved their asthma. Other interviewees wanted ongoing support (i.e. reminders or substitute adherence cues) after study end., Conclusion: Patients with asthma found 6-months' use of reminders and adherence feedback acceptable and useful for improving their adherence attitudes, adherence behaviours and confidence in asthma self-management. Some patients may benefit from ongoing adherence support., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objective: To determine the characteristics of persons with cognitive impairment being able to self-manage in chronic obstructive pulmonary disease (COPD)., Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance this systematic review examined all studies in English from 1st January 2000 to 20 February 2016, describing the relationship between cognition and COPD self-management domains in older community dwelling persons with dementia or cognitive impairment., Results: Of 4474 studies identified, thirteen studies were eligible for inclusion. No studies differentiated populations into recognized dementia subtypes. Study aims were variable; most (n = 7) examined inhaler competency alone. Studies identified a link between worsening cognition and the need for assistance in activities of daily living. Only one study evaluated the impact of cognition on overall self-management and found no association between cognitive impairment and self-rated self-management. Mild degrees of cognitive impairment were associated with reduced symptom recall. Cognitive impairment in COPD was associated with high degrees of inhaler incompetency. Basic cognitive screening tests were able to predict inhaler incompetence with reduced overall cognitive function, dyspraxia, and/or executive function identified as predictors of incompetency., Conclusions: Multiple measures of disability consistently demonstrated that cognitive impairment in COPD significantly increased the need for assistance in many aspects of daily living, treatment adherence, and effective self-management. Given the nature of neuropsychological deficits seen in COPD, dedicated screening tools are required. Future research should investigate the impact of cognitive dysfunction in COPD and identify how to support those that lack capacity to self-manage., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Asthma and chronic obstructive pulmonary disease (COPD) are widespread chronic conditions with medication frequently delivered by inhalers. These can be challenging to use correctly, but the scale of misuse and the specific aspects of failure are unclear., Methods: We used systematic review methods to search 9 databases in May 2015 to identify and review studies that assessed adults (18 years or older) with asthma or COPD using inhalers of various types including pressurised metered dose inhalers (pMDIs), dry powder inhalers and the Respimat inhaler. Studies must have reported the scale of inhaler misuse, variation by type of inhaler or which steps patients had difficulty completing accurately., Results: The types of inhalers, inhaler interventions and definitions of failure and misuse varied widely in the 38 studies identified. It was not possible to draw conclusions on the differential failure rates between different types of inhalers or any patient characteristics. Of the studies reporting failure or misuse rates, the majority ranged between 0 and 20%. Studies were inconsistent regarding the number of inhaler steps collected, reported and labelled as critical., Conclusions: There is evidence for all identified inhalers that some people may be using them incorrectly, but it is unclear which inhalers have higher rates of misuse or which steps within the inhaler technique are most difficult for patients. The optimal techniques for using inhalers are not standardised. Researchers undertaking future inhaler studies are respectfully directed to our recommendations for future research., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Inhaled agents are widely used in the treatment of chronic airway diseases. Correct technique is required to ensure appropriate drug deposition, but poor technique is common. This study investigated whether inhalation technique could be improved by patient training using short videos from the German Airway League., Methods: Outpatients from a university hospital respiratory clinic who had incorrect inhalation technique were asked to demonstrate this again immediately after viewing the training videos, and after 4-8 weeks' follow-up. Inhalation technique was rated by a study nurse using specific checklists., Results: One hundred and twelve patients with obstructive lung disease treated with inhaled bronchodilators or corticosteroids were included. More than half (51.8%) had at least one mistake in inhalation technique at baseline. Of these, most (88%) understood the training videos, 76% demonstrated correct device use immediately after training, and 72% were still able to demonstrate correct inhalation technique at follow-up (p = 0.0008 for trend). In addition, the number of mistakes decreased significantly after video training (by 1.82 [95% confidence interval 1.39-2.25]; p < 0.0001 vs. baseline)., Conclusions: German Airway League inhalation technique training videos were easy to understand and effectively improved inhalation technique in patients with airway diseases., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: Inhaled medications are used in chronic airway disease including chronic obstructive pulmonary disease (COPD) and give the opportunity of low doses, lower side effects, and fast effectiveness. Inhaler devices are frequently used incorrectly by patients. Today, it is generally accepted that poor device use is one of the reasons for poor disease control and low adherence. The aim of the study was to investigate a sample of patients with COPD prescribed with inhaled medication and to evaluate the frequency and pattern of incorrect inhaler use as well as affecting factors., Materials and Methods: One hundred and eighty consecutive patients who attended the outpatient clinic with the diagnosis of COPD and were prescribed and receiving different types of inhaler drugs at least for one month were included. The patient's ability to use the devices according to steps was scored face to face after they had replied a questionnaire consisting of 26 questions about their inhaler training and disease specifications. The parameters that may affect incorrect use, pattern of incorrect use, characteristics of the patients who experienced incorrect use, and impact of training were evaluated. Chi-Square and Fisher's Exact test were used for statistical analysis., Result: The rate of correct use including all steps was 26.3% for metered-dose inhaler (pressurized MDI), 30.4% for inhalation capsule aerolizer, 40.5% for diskus, and 46.3% for turbuhaler. The parameters affecting correct use and number of critical errors causing insufficient drug inhalation were type and duration of initial training due to inhaler devices and also duration and stage of the disease., Conclusions: COPD patients who were prescribed an inhaler drug should be regularly checked and re-trained during out-patient visits on how to use the inhaler device correctly step by step.

Asthma is a very common chronic disease that affects a large portion of population in many nations. Driven by the fast development in sensor and mobile communication technology, a smart asthma management system has become available to continuously monitor the key health indicators of asthma patients. Such data provides opportunities for healthcare practitioners to examine patients not only in the clinic (on-site) but also outside of the clinic (off-site) in their daily life. In this paper, taking advantage from this data availability, we propose a correlated gamma-based hidden Markov model framework, which can reveal and highlight useful information from the rescue inhaler-usage profiles of individual patients for practitioners. The proposed method can provide diagnostic information about the asthma control status of individual patients and can help practitioners to make more informed therapeutic decisions accordingly. The proposed method is validated through both numerical study and case study based on real world data. Copyright © 2017 John Wiley & Sons, Ltd., (Copyright © 2017 John Wiley & Sons, Ltd.)

Introduction: Aerosol therapy is an efficient, but complex procedure. National and international practice guidelines are regularly updated. However, only a few studies have assessed the application of guidelines by users. The aim of this study is to assess the knowledge and practices of physicians and nurses regarding these guidelines., Methods: Two self-administered questionnaires were designed by a working team and presented to physicians and nurses of four university hospitals in Paris. A pharmacy resident collected and analyzed the data with the aid of an online survey website., Results: A total of 481 physicians and nurses completed the questionnaires (33 % of physicians and 67 % of nurses). Only 241/480 physicians and nurses (50 %) knew that several intravenous drugs cannot be nebulized. Ninety-four of 422 (22 %) of them always choose oxygen as the driving gas and 239/311 nurses (77 %) think that single use nebulizers can be re-used for the same patient., Conclusions: This survey shows that many physicians and nurses lack knowledge and use inappropriate practices. Based on these results, a booklet has been designed by the working team. This booklet should help health professionals to harmonize practices across hospitals and to follow the guidelines correctly., (Copyright © 2016 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: Inhaled therapy is the mainstay of asthma treatment due to its local and rapid action. However, its efficiency relies on the teaching of a good inhalation technique by health care providers. We assessed health care providers' knowledge and practical skills in the use of inhalation devices., Methods: An observational multicenter study was conducted in the pulmonology and paediatric wards in Marseille. The departments' common practices, theoretical knowledge and practical skills were assessed through a questionnaire and a demonstration using a spacer device., Results: Forty health care providers were interviewed (9 attending physicians, 14 residents, 16 nurses and 1 physiotherapist), in 8 different pulmonology and paediatric wards. A total of 42.5% reported previous training in inhalation device technique. When evaluating theoretical knowledge, we found a mean of 54% correct answers. Attending physicians did significantly better than residents and nurses. With regard to practical skills, we found a mean of 1.12 failed steps out of 7. Here again attending physicians did significantly better than residents and nurses., Conclusion: Based on the results of our study, we recommend that attending physicians provide training of inhalation technique to nurses and residents, as they did significantly better theoretically and practically., (Copyright © 2016 SPLF. Published by Elsevier Masson SAS. All rights reserved.)

Objective: To compare the effectiveness of 4 different instructional interventions in training proper inhaler technique., Design: Randomized, noncrossover trial., Setting: Health fair and indigent clinic., Participants: Inhaler-naive adult volunteers who spoke and read English., Interventions: Subjects were assigned to complete the following: (1) read a metered dose inhaler (MDI) package insert pamphlet, (2) watch a Centers for Disease Control and Prevention (CDC) video demonstrating MDI technique, (3) watch a YouTube video demonstrating MDI technique, or (4) receive direct instruction of MDI technique from a pharmacist., Primary Outcome: Inhaler use competency (completion of all 7 prespecified critical steps)., Results: Of the 72 subjects, 21 (29.2%) demonstrated competent inhaler technique. A statistically significant difference between pharmacist direct instruction and the remaining interventions, both combined ( P < .0001) and individually ( P ≤ .03), was evident. No statistically significant difference was detected among the remaining 3 intervention groups. Critical steps most frequently omitted or improperly performed were exhaling before inhalation and holding of breath after inhalation., Conclusion: A 2-minute pharmacist counseling session is more effective than other interventions in successfully educating patients on proper inhaler technique. Pharmacists can play a pivotal role in reducing the implications of improper inhaler use.

Background: The impact of various aerosol delivery devices on patient outcomes during mechanical ventilation is unknown. If one method of delivery results in a higher ventilator-associated pneumonia (VAP) rate than another, multiple patient outcomes may be affected. This study aimed to determine whether there was a difference in VAP occurrence and patient outcomes (days receiving ventilation and in-hospital mortality) between the vibrating mesh nebulizer (AeroNeb Solo) and the metered-dose inhaler (MDI)., Methods: This retrospective study reviewed medical records for all mechanically ventilated, adult patients with an order for aerosol treatment from August 2011 to August 2013. The hospital converted from MDI to vibrating mesh nebulizers in August 2012, and data were gathered 1 y before/after conversion. Excluded were patients with a tracheostomy, patients who were mechanically ventilated for <24 h, patients who received a combination of nebulizer and MDI treatments, or patients who were re-intubated., Results: Two hundred twenty-eight subjects were included. Forty-eight (21%) received treatment with an MDI, and 180 (79%) were treated with the vibrating mesh nebulizer. Descriptive data did not significantly differ for age or APACHE II (Acute Physiology and Chronic Health Evaluation II) scores between the groups but did for sex ( P = .03). Difference in median days receiving ventilation for the MDI (5 d, interquartile range 3.0-8.5 d) and the vibrating mesh nebulizer (6 d, interquartile range 4.0-10.0 d) was not statistically significant. No correlation was found between the use of either device and the primary outcomes of VAP and in-hospital mortality. In multivariable logistic regression analysis, the number of days receiving ventilation increased the odds of VAP (odds ratio [OR] 1.3, 95% CI 1.14-1.49, P < .001) and mortality (OR 1.12, 95% CI 1.04-1.21, P = .002). Higher APACHE II scores increased the odds of mortality (OR 1.05, 95% CI 1.001-1.092, P = .044)., Conclusion: We found no association between an MDI or vibrating mesh nebulizer and our primary outcomes, days receiving ventilation, in-hospital mortality, or VAP, in mechanically ventilated subjects., (Copyright © 2017 by Daedalus Enterprises.)

Background: After the bronchodilator effect of magnesium was shown, the use of magnesium in treatment of asthma exacerbations became common. With the results of recent studies, the use of intravenous magnesium in severe asthma exacerbations took its place. We aimed to examine the effects of adding isotonic magnesium sulphate instead of isotonic saline into nebulised salbutamol on the Modified Pulmonary Index Score (MPIS) and the hospitalisation rate in moderate asthma exacerbations., Methods: Our study population included 100 children age between 3 and 15 years with asthma admitted to emergency department due to moderate asthma exacerbations. The patients were randomised to placebo or magnesium, with 50 patients in each arm. All patients received 1mg/kg of systemic methylprednisolone at the beginning of treatment and thereafter received either nebulised salbutamol (0.15mg/kg/dose) and 1ml magnesium sulphate (15%)+1.5ml isotonic saline on three occasions at roughly 20min intervals (Magnesium group) or nebulised salbutamol (0.15mg/kg/dose) and 2.5ml isotonic saline mixture on three occasions at roughly 20min intervals (Placebo group). The MPIS of patients on 0th min, 20th min, 40th and 120th min were calculated and compared. The primary outcome was to compare MPIS values at the end of 120th min., Results: Both groups have similar demographic, allergic characteristics and baseline MPIS scores. When the MPIS scores in the 120th min and admission rates in the 200th min, there was no significant difference between the two groups., Conclusions: The use of nebulised magnesium sulphate in moderate asthma exacerbation as adjuvant treatment showed no benefit to standard treatment in our study., (Copyright © 2016 SEICAP. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Inhaled medication is the cornerstone of the pharmacological treatment for patients with asthma and chronic obstructive pulmonary disease (COPD). Several inhaler devices exist, and each device has specific characteristics to achieve the optimal inhalation of drugs. The correct use of inhaler devices is not granted and patients may incur in mistakes when using pressurized metered-dose inhalers (pMDIs) or dry-powder inhaler (DPIs). The incorrect use of inhaler devices can lead to a poorly controlled disease status. Unfortunately, guidelines provide limited guidance regarding the choice of devices. This article presents a review of the literature on different inhaler device requirements. Data from literature (PubMed and Google Scholar) on the commercially available inhaler devices have been evaluated and the history of inhaler medicine described. Furthermore, advantages and disadvantages of each type of device have been analyzed. The evaluation of literature indicated the availability of robust data on the devices characteristics and factors influencing selection of delivery devices. Each type of device has its own pro and cons. The age, cognitive status, visual acuity, manual dexterity, manual strength and ability to coordinate the inhaler actuation with inhalation may be as important as the disease severity in determining the correct approach to delivery of respiratory medication. The administration of effective therapies via a device that is simple to use and accepted by patients may help to improve treatment outcomes in patients with COPD., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: Inhaled medications are recommended as first-line treatment for chronic obstructive pulmonary disease (COPD) and can reduce exacerbations and hospitalizations. Low health literacy is associated with poor inhaler technique., Objective: This study examined whether handouts written specifically for patients with low health literacy are more effective in showing patients how to use their medications when compared to standard education materials., Methods: A prospective, experimental study was performed at a community-based hospital. Patients included in the study were admitted to the hospital with a diagnosis of COPD, taking at least 1 inhaled medication and identified as having low health literacy based on a Rapid Estimate of Adult Literacy in Medicine-Short Form. Low health literacy handouts were compared against the standard hospital educational materials for inhalers. Correct technique during each demonstration was evaluated using a standardized checklist., Results: Mean baseline scores for inhaler technique were 12.2 ± 2.2 steps correct for the control group and 13.4 ± 1.3 for the low health-literacy group of the 18 maximum points ( P = nonsignificant). The mean change in inhaler technique score for the control group was 1.0 ± 1.8, while the mean change in inhaler technique score for the low health-literacy group was 2.1 ± 2.7 ( P = .03).

A discussion about disadvantages of electronic cigarettes (e-cigarettes) has recently broken out. There are even opinions that they are as harmful as regular cigarettes. However, this has not been proved, and theoretical premises suggest that e-cigarettes should be definitely less harmful as while using them, tobacco is not burned and harmful substances, in particular carcinogens are not produced. Certain premises assume that e-cigarettes may be used as a new form of nicotine replacement therapy, but this has not been confirmed yet. Therefore, further research into harmfulness and safety of the use of e-cigarettes is required. This paper presents solely reasons for the possibility of recommending e-cigarettes to people addicted to nicotine.

Background: Albeit not recommended because of contradictory results, nebulized 3% hypertonic saline is widely used for treating acute viral bronchiolitis. Whether clinical differences may be attributed to the type of nebulizer used has never been studied., Objectives: By modifying the amount of salt deposited into the airways, the nebulizer characteristics might influence clinical response., Methods: A prospective, randomized, controlled trial included infants hospitalized in a French university hospital for a first episode of bronchiolitis. Each child received 6 nebulizations of 3% hypertonic saline during 48 h delivered with 1 of the 3 following nebulizers: 2 jet nebulizers delivering large or small particles, with a low aerosol output, and 1 mesh nebulizer delivering small particles, with a high aerosol output. The primary endpoint was the difference in the Wang score at 48 h., Results: Only 61 children of 168 were recruited before stopping this study because of severe adverse events (n = 4) or parental requests for discontinuation due to discomfort to their child during nebulization (n = 2). One minor adverse event was noted in 91.8% (n = 56/61) of children. A high aerosol output induced 75% of the severe adverse events; it was significantly associated with the nebulization-induced cough between 24 and 48 h (p = 0.036). Decreases in Wang scores were not significantly different between the groups at 48 h, 9 recoveries out of 10 being obtained with small particles., Conclusion: No beneficial effects and possibly severe adverse events are observed with 3% hypertonic saline in the treatment of bronchiolitis., (© 2017 S. Karger AG, Basel.)

Electronic cigarettes are more and more frequently used to deliver nicotine. They are used both by the users of regular cigarettes and those who to date have not smoked. The literature about potential impact of electronic nicotine delivery systems on health is constantly growing. Particular concern is expressed about toxicity of chemical compounds and elements delivered with the vapour of electronic cigarettes. It turns out that products that have positive image in media, actually are not so beneficial. Furthermore, they not only may cause damage to health but also death.

Introduction: Upper respiratory tract infections are common childhood diseases. Children are more susceptible to middle ear infections because their Eustachian tube is short, straight and wide. As a consequence of these inflammatory changes while impaired patency of the Eustachian tube often arises conductive hearing., Objective: The aim of this study was to Assessment effectiveness of treatment Eustachian tube dysfunction using inhaler AMSA., Material and Methods: The study group comprised 30 patients. Same was in the control group. All patients reported conductive hearing loss. Test group was treated as an inhaler AMSA. The control group was treated pharmacologically. Patients were examined with the use of pure-tone audiometry, and impedance at baseline, after one week and four weeks., Results: Statistical analysis showed improvement in the studied parameters in patients treated with inhaler AMSA in a much shorter time than patients treated with pharmacotherapy.

Rationale: Currently, studies on adherence to inhaled medications report average adherence over time. This measure does not account for variations in the interval between doses, nor for errors in inhaler use., Objectives: To investigate whether adherence calculated as a single area under the (concentration-time) curve (AUC) measure, incorporating the interval between doses and inhaler technique, was more reflective of patient outcomes than were current methods of assessing adherence., Methods: We attached a digital audio device (INhaler Compliance Assessment) to a dry powder inhaler. This recorded when the inhaler was used, and analysis of the audio data indicated if the inhaler had been used correctly. These aspects of inhaler use were combined to calculate adherence over time, as an AUC measure. Over a 3-month period, a cohort of patients with asthma was studied. Adherence to a twice-daily inhaler preventer therapy using this device and clinical measures were assessed., Measurements and Main Results: Recordings from 239 patients with severe asthma were analyzed. Average adherence that was based on the dose counter was 84.4%, whereas the ratio of expected to observed accumulated AUC, actual adherence, was 61.8% (P < 0.01). Of all the adherence measures, only adherence calculated as AUC reflected changes in asthma quality of life, β-agonist reliever use, and peak expiratory flow over the 3 months (P < 0.05 compared with other measures of adherence)., Conclusions: Adherence that incorporates the interval between doses and inhaler technique, and calculated as AUC, is more reflective of changes in quality of life and lung function than are the currently used measures of adherence. Clinical trial registered with www.clinicaltrials.gov (NCT 01529697).

Background: Asthma and chronic obstructive pulmonary disease are preventable and treatable chronic airway diseases with high incidence and prevalence. Pharmacists and clinical pharmacy based pharmaceutical care services have positive impact on therapy outcomes., Objective: The aim of this study is to describe drug related problems in a cohort of patients with asthma and chronic obstructive pulmonary disease and to assess interventions provided by the pharmacist to address these problems in a community pharmacy., Method: Study population consisted of patients with asthma and chronic obstructive pulmonary disease older than 18 years who visited the study pharmacy during the pre-determined six-month period. The patients whose disease control states were "not fully controlled" were included in our study for further steps. On the first interview, present and potential drug related problems were addressed, interventions were provided. Follow-up interviews were held one month and two months later than the first interview., Results: For the 44 patients with asthma, 59 drug-related problems and 134 causes for these problems were identified. Eighty-four interventions were made to resolve the problems; and 54.2% of the problems were resolved. For the 37 patients with chronic obstructive pulmonary disease, 60 drug-related problems and 128 causes for these problems were identified. Ninety-five interventions were made to resolve the problems; and 63.3% of the problems were resolved., Conclusion: Pharmacists taking part in therapy and management of asthma and chronic obstructive pulmonary disease can help patients be more educated about their disease and medications; and improve disease control and therapy outcomes., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Acute respiratory infections are the most common illness in childhood, and caregivers often make an excessive use of medication and medical consultations. It is vital to design and implement educational interventions in order to minimize the burden of the disease., Objective: This study aimed to evaluate the impact of a health education session (HES) about respiratory infections on the indicators of individual health and health care utilization of day-care children., Methods: Randomized controlled trial in 10 day-care centres in Porto, including caregivers (parents or legal tutors) of children under 3 years of age. Children's caregivers were randomly distributed into an Intervention Group (IG), who attended a HES, and a Comparison Group (CG). Children's indicators of individual health and health care utilization were evaluated in both groups, during the month after HES., Results: Children whose caregivers attended to the HES had fewer lower respiratory tract infections (IG = 5.8%; CG = 19.0%; P = 0.050) and fewer acute otitis media (IG = 9.5%; CG = 27.0%; P = 0.030), as well as fewer medical consultations (IG = 38.5% versus CG = 61.9%; P = 0.015) and less antibiotic consumption (IG = 11.5% versus CG = 29.5%; P = 0.022). They were also less absent from day care (IG = 21 days versus CG = 59 days; P = 0.037) and their caregivers were less absent from work (IG = 15 days versus CG = 44 days; P = 0.046). Caregivers who attended HES made more use of nasal irrigation (IG = 79.6% versus CG = 53.3%; P = 0.011)., Conclusions: The HES about respiratory infections has positively influenced the indicators of individual health and health care utilization of children attending day-care centres in Porto., (© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Cystic fibrosis (CF) caregivers focus on correct inhalation technique for nebulisers as this is essential to optimize efficacy of inhaled drugs. However, little is known on this nebuliser technique of patients at home., Methods: Three "hidden" video registrations were made of 32 children with CF (6-18years) nebulising at home. Videos were randomly scored on inhalation technique items using nebuliser-specific checklists and a total score was calculated., Results: Median nebuliser technique was 91.9% of max score. Nebuliser technique was perfect (score 100%) in 23.3% of the patients and incorrect (score 0%) in 13.3%. Most mistakes were made in the required optimal breathing pattern., Conclusion: Most CF patients had good nebuliser technique on a day-to-day basis. However, errors observed likely resulted in reduced treatment efficacy and, in 13%, no treatment at all. Regular "real life" evaluation by the CF-team can improve inhaled therapy substantially., (Copyright © 2016 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Background: Inhaled drugs are the mainstay of treatment for lung diseases such as asthma and chronic obstructive pulmonary disease. However, failure to use inhalation devices correctly can lead to a poorly controlled status. A vast number of inhalation devices exist and each device has specific requirements to achieve optimum inhalation of the drug. Currently, there is no overview of inhalation requirements considering all devices. This article presents a review of the literature on different inhalation device requirements and incorporates the data into a new inhalation flow algorithm., Methods: Data from literature on commercially available inhalation devices were evaluated and parameters, such as inhalation flow rate, flow acceleration, inhalation volume, and inspiration time assessed for the required inhalation maneuver specific to the device. All agreed upon data points were used to develop an inhalation flow algorithm., Results: The literature analysis revealed availability of robust data for the required inhalation flow characteristics for most devices and thus for the development of an algorithm. For those devices for which these parameters are not published, the minimum required flow criteria were defined based on published data regarding individual aspects of aerosol quality., Conclusions: This review provides an overview of inhalation devices available on the market regarding requirements for an acceptable inhalation maneuver and shows which goals should be achieved in terms of inhalation flows. The presented algorithm can be used to develop a new computer based measurement system which could help to test and train patients' individual inhalation maneuvers with their inhalation devices., (Copyright © 2016 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Tiotropium, a long-acting anticholinergic bronchodilator, has demonstrated efficacy and safety as add-on therapy to inhaled corticosteroids (ICS), with or without other maintenance therapies, in patients with symptomatic asthma., Objective: To evaluate safety and tolerability of tiotropium delivered via the Respimat(®) device, compared with placebo, each as add-on to at least ICS therapy, in a pooled sample of adults with symptomatic asthma at different treatment steps., Methods: Data were pooled from seven Phase II and III, randomised, double-blind, parallel-group trials of 12-52 weeks' treatment duration, which investigated once-daily tiotropium Respimat(®) (5 μg, 2.5 μg) versus placebo as add-on to different background maintenance therapy including at least ICS. Adverse events (AEs) including serious AEs were assessed throughout treatment + 30 days after the last dose of trial medication., Results: Of 3474 patients analysed, 2157 received tiotropium. The percentage of patients with AEs was comparable between treatment groups: tiotropium 5 μg, 60.8%; placebo 5 μg pool, 62.5%; tiotropium 2.5 μg, 57.1%; placebo 2.5 μg pool, 55.1%. Consistent with the disease profile, the most frequent AEs overall were asthma, decreased peak expiratory flow rate (both less frequent with tiotropium) and nasopharyngitis. Overall incidence of dry mouth, commonly associated with use of anticholinergics, was low: tiotropium 5 μg, 1.0%; placebo 5 μg pool, 0.5%; tiotropium 2.5 μg, 0.4%; placebo 2.5 μg pool, 0.5%. The percentage of cardiac disorder AEs was comparable between tiotropium and placebo: tiotropium 5 μg, 1.4%; placebo 5 μg pool, 1.4%; tiotropium 2.5 μg, 1.4%; placebo 2.5 μg pool, 1.1%. The proportions of patients with serious AEs were balanced across groups: tiotropium 5 μg, 4.0%; placebo 5 μg pool, 4.9%; tiotropium 2.5 μg, 2.0%; placebo 2.5 μg pool, 3.3%., Conclusion: Tiotropium Respimat(®) demonstrated safety and tolerability comparable with those of placebo, as add-on to at least ICS therapy, at different treatment steps in adults with symptomatic asthma., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: While active smoking is a causal agent in respiratory disease, the independent role of secondhand smoke (SHS) merits further investigation. We investigated associations between lifetime active smoking and exposure to secondhand smoke - studied independently - and current use of 1 or more inhaled medications as a surrogate for prevalent pulmonary disease in post-menopausal women., Study Design: Information on lifetime active and passive tobacco exposure and inhaled pulmonary medication usage at enrollment was collected from 88,185 postmenopausal women aged 50-79 enrolled in the Women's Health Initiative Observational Study from 1993 to 1998 at 40 centers in the United States. Participants were recruited from localities surrounding the study centers using a variety of methods, including informational mailings and mass media campaigns., Main Outcome Measures: Multivariate adjusted regression models were used to estimate odds ratios and 95% CI according to levels of active smoking and SHS exposure, and trends were tested across categories., Results: Ever active smokers had an overall OR of 1.97 (95% CI 1.58-2.45) for having one or more prescribed inhaled medication compared with never-smoking women not exposed to active or passive smoke. The overall OR for using inhalers for never-smoking women exposed to any SHS compared with the same reference group was 1.33 (95% CI 1.07-1.65). In a quantified analysis of SHS, never-smoking women with the highest levels of lifetime SHS exposure had an estimated risk of inhaled medication usage of 1.74 (95% CI 1.32-2.30)., Conclusions: The risk of requiring one or more prescribed inhaled medications for pulmonary disease was significantly higher in post-menopausal women who ever smoked or who had lifetime exposure to SHS., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Intratracheal antibiotic administration is increasingly used for treating respiratory infections. Limited information is available on delivery devices, techniques, and safety., Methods: An online survey on intratracheal administration of anti-infective agents in mechanically ventilated adults was answered by health-care workers from 192 ICUs to assess the most commonly used devices, current delivery practices, and safety issues. We investigated whether ICU usage experience (≥3 y) impacted its performance., Results: Intratracheal antibiotic administration was a current practice in 87 ICUs (45.3%), with 40 (46%) having experience with the technique (≥3 y). Sixty-six (78.6%) of 84 health-care workers reported avoiding intratracheal antibiotic administration due to an absence of evidence-based guidelines (78.6%). Jet nebulizers were the most commonly used devices for delivery, in 24 less experienced ICUs (27.6%) and in 18 (20.7%) experienced ICUs. Direct tracheal instillation (6; 6.9%) was still considered for drug prescription in 12 ICUs (6.9%). More experience resulted in neither greater adherence to measures improving the drug's delivery efficiency (93 measures in the experienced group; 27.9%) nor a greater adoption of measures to increase safety. Indeed, the expiratory filter was changed after each nebulization in only 2 experienced ICUs (6.9%), whereas 15 (51.7%) changed it daily instead., Conclusions: Intratracheal antibiotic administration is a common therapeutic modality in ICUs, but inadequate practices were widely encountered, independent of the level of experience with the technique. This suggests a need to develop standardization to reduce variability and improve safety and efficacy., (Copyright © 2016 by Daedalus Enterprises.)

Background: Repellents such as coils, vaporizers, mats and creams can be used to reduce the risk of malaria and other infectious diseases. Although evidence for their effectiveness is limited, they are advertised as providing an additional approach to mosquito control in combination with other strategies, e.g. insecticide-treated nets. We examined the use of repellents in India in an urban setting in Chennai (mainly Plasmodium vivax malaria), a peri-urban setting in Nadiad (both P. vivax and P. falciparum malaria), and a more rural setting in Raurkela (mainly P. falciparum malaria)., Methods: The use of repellents was examined at the household level during a census, and at the individual level in cross-sectional surveys and among patients visiting a clinic with fever or other symptoms. Factors associated with their use were examined in a multivariate analysis, and the association between malaria and the use of repellents was assessed among survey- and clinic participants., Results: Characteristics of participants differed by region, with more people of higher education present in Chennai. Use of repellents varied between 56-77 % at the household level and between 32-78 % at the individual level. Vaporizers were the main repellents used in Chennai, whereas coils were more common in Nadiad and Raurkela. In Chennai and Nadiad, vaporizers were more likely to be used in households with young male children. Vaporizer use was associated with higher socio-economic status (SES) in households in Chennai and Nadiad, whereas use of coils was greater in the lower SES strata. In Raurkela, there was a higher use of coils among the higher SES strata. Education was associated with the use of a repellent among survey participants in Chennai and clinic study participants in Chennai and Nadiad. Repellent use was associated with less malaria in the clinic study in Chennai and Raurkela, but not in the surveys, with the exception of the use of coils in Nadiad., Conclusions: Repellents are widely used in India. Their use is influenced by the level of education and SES. Information on effectiveness and guidance on choices may improve rational use.

Background: Along with changes in cannabis laws in the United States and other countries, new products for consuming cannabis are emerging, with unclear public health implications. Vaporizing or "vaping" cannabis is gaining popularity, but little is known about its prevalence or consequences., Methods: This study characterized the prevalence and current patterns of vaping cannabis among a large national sample of cannabis users. An online survey was distributed through Facebook ads targeting individuals with interests related to cannabis use. The sample comprised 2910 cannabis users (age: 18-90, 84% male, 74% Caucasian)., Results: A majority (61%) endorsed lifetime prevalence of ever vaping, 37% reported vaping in the past 30 days, 20% reported vaping more than 100 lifetime days, and 12% endorsed vaping as their preferred method. Compared to those that had never vaped, vaporizer users were younger, more likely to be male, initiated cannabis at an earlier age, and were less likely to be African American. Those that preferred vaping reported it to be healthier, better tasting, produced better effects, and more satisfying. Only 14% reported a reduction in smoking cannabis since initiating vaping, and only 5% mixed cannabis with nicotine in a vaporizer. Many cannabis users report vaping cannabis, but currently only a small subset prefers vaping to smoking and reports frequent vaping., Conclusion: Increases in availability and marketing of vaping devices, and the changing legal status of cannabis in the United States and other countries may influence patterns of use. Frequent monitoring is needed to assess the impact of changing cannabis laws and regulations., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Objective: This aim of this study was to assess inhaler technique of people with intellectual disability (ID), and evaluate the effectiveness of teaching with respect to their individual ability to adopt correct technique., Methods: Seventeen people with ID were recruited through existing networks of general practitioners and disability support organisations. Inhaler technique was assessed using validated checklists and placebo devices, followed by provision of individualised training. The educational interaction between participant and researcher was captured via video recording and analysed qualitatively., Results: Seventeen people with ID participated; females comprised 65%. At baseline, no participants correctly used any device. Pressurised metered dose inhalers, with or without accessory devices, were the most poorly used devices. Inhalation steps were poorly performed across all devices. Following training, the proportions of assessed participants that were able to master inhaler technique were 100% of Accuhaler users, 40% of Turbuhaler users, 25% of pressurised metered dose inhaler users and 0% of Handihaler users. Barriers identified included poor comprehension of breathing processes, the lack of attentiveness and poor dexterity. Facilitators for educator delivery of inhaler technique education included the use of analogies and being patient., Conclusions: This is the first study to examine inhaler technique mastery in people with ID. Results show that with education that addresses the unique patient barriers inherent in this group, some individuals can be trained to mastery. Structured modules of inhaler technique training tailored for people with ID, but which can be individualised, are recommended.

Background: Electronic cigarettes as possibly healthier alternative to conventional cigarettes are gaining popularity worldwide, although they are still hazardous to human health. Partly it is caused by unregulated advertising and online sales. Unfortunately it is more and more popular for youth to try electronic cigarettes., Objective: The aim of the study was to assess the marketing claims used by Polish websites offering electronic cigarettes., Material and Methods: A search using Google search engine was performed in July 2015 for two keywords: e-papierosy [e-cigarettes] and elektroniczne papierosy [electronic cigarettes]. First 150 websites (15 pages) were listed. After initial review 86 pages met all inclusion criteria and were included in the study. Pages were searched for presence of 13 selected marketing claims as well as age-related warning and any social websites connections., Results: Age-related warning was present on only 33.72% (n=29) websites. Two thirds has its own Facebook fan-page with average 1922.09 ± 3634.86 likes. Articles about health are available on 10.46% (n=9) websites, 53.49% (n=46) states that e-cigarettes are healthier than conventional ones, 39.53% (n=34) emphasized that during usage of e-cigarettes no tarry substances are produced. Two pages had special article in which conventional and electronic cigarettes were compared. Almost half (44.19%) remarked that e-cigarettes are cheaper in usage than conventional, one third pointed out the simplicity of usage. 32.56% advertised e-cigarettes as aid in quitting smoking. One fourth stated that e-cigarettes are harmless for surroundings. 33.72% marketed them as a way of bypassing public smoking act. 56.98% remarked the variety of liquid tastes offered., Conclusions: Electronic cigarettes and their rising popularity create another new possible threat for public health as the widely available information emphasize safety of e-cigarettes usage and as their availability and usage is not limited or restricted by law., Key Words: electronic cigarettes, e-cigarettes, internet retail websites.

Asthma is a common, complex and multifactorial respiratory condition affecting a significant number of children within the UK. Recent department of health reports and national guidance has highlighted that healthcare professionals have a poor understanding of asthma treatments and are failing to provide patients with basic care. This article aims to explore some of the reasons why the use of inhalers is inadequate and discusses the research surrounding the reported knowledge of healthcare professionals' ability to counsel on inhaler devices. We hope the article will help clinicians explore their understanding of how to administer commonly prescribed inhaler devices, provide useful general and simple steps for inhaler counselling and act as a prompt to review personal competence and confidence in counselling on inhaler devices., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: The impact of poor adherence and medication administration is well documented, as are the difficulties with asthma inhaler and device usage. However, difficulties with these devices and inhalers continue to present significant challenges to many healthcare providers and patients., Methods: A systematic review of the published, peer-reviewed international literature was performed to identify likely teaching needs as well as available and recommended resources to address same., Results: Asthma inhaler and device use and educational needs vary as widely as do the types and severity of usage errors committed. Multiple interventions have been studied and found to be effective at improving both patient technique and overall asthma outcomes., Conclusion: Providers must ensure that patient teaching is performed by suitably prepared staff members. Education should be device-specific, patient-centered, and repeated at frequent intervals. Providers must frequently reassess patient understanding and ability with regard to asthma inhalers and devices in order to maximize therapeutic outcomes., (© 2015 ARS-AAOA, LLC.)

The emergence of electronic cigarettes (e-cigs) has given cannabis smokers a new method of inhaling cannabinoids. E-cigs differ from traditional marijuana cigarettes in several respects. First, it is assumed that vaporizing cannabinoids at lower temperatures is safer because it produces smaller amounts of toxic substances than the hot combustion of a marijuana cigarette. Recreational cannabis users can discretely "vape" deodorized cannabis extracts with minimal annoyance to the people around them and less chance of detection. There are nevertheless several drawbacks worth mentioning: although manufacturing commercial (or homemade) cannabinoid-enriched electronic liquids (e-liquids) requires lengthy, complex processing, some are readily on the Internet despite their lack of quality control, expiry date, and conditions of preservation and, above all, any toxicological and clinical assessment. Besides these safety problems, the regulatory situation surrounding e-liquids is often unclear. More simply ground cannabis flowering heads or concentrated, oily THC extracts (such as butane honey oil or BHO) can be vaped in specially designed, pen-sized marijuana vaporizers. Analysis of a commercial e-liquid rich in cannabidiol showed that it contained a smaller dose of active ingredient than advertised; testing our laboratory-made, purified BHO, however, confirmed that it could be vaped in an e-cig to deliver a psychoactive dose of THC. The health consequences specific to vaping these cannabis preparations remain largely unknown and speculative due to the absence of comprehensive, robust scientific studies. The most significant health concerns involve the vaping of cannabinoids by children and teenagers. E-cigs could provide an alternative gateway to cannabis use for young people. Furthermore, vaping cannabinoids could lead to environmental and passive contamination.