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Aashish Bhattarai, Rajani Shakya, Durga Bista Department of Pharmacy, School of Science, Kathmandu University, Dhulikhel, NepalCorrespondence: Aashish Bhattarai, Department of Pharmacy, School of Science, Kathmandu University, Dhulikhel, 44600, Nepal, Tel +9779807902444, Email bhattarai.aashish75@gmail.comBackground: Asthma and Chronic obstructive pulmonary disease (COPD) are chronic respiratory conditions characterized by airflow obstruction and respiratory symptoms. Adherence to prescribed inhaler therapy and correct inhalation technique are essential for effective disease management and optimal disease control. However, non-adherence and incorrect inhalation technique are common challenges faced by patients with asthma and COPD, leading to suboptimal treatment outcomes and increased healthcare burden.Purpose: To study the impact of a pharmacist-led intervention on inhaler adherence, inhalation technique, and disease control among patients with asthma and COPD.Patients and Methods: A pre-post interventional design assessed the effects of pharmacist-led intervention on inhaler adherence, inhalation techniques, and disease control in asthma and COPD patients at Dhulikhel Hospital in Nepal. Inclusion criteria: adult patient clinically diagnosed with asthma or COPD patients of all genders. The intervention comprised counseling patients with aids like videos, and informational leaflets. Impact was measured using checklist method for inhalation technique, the Test of Adherence to Inhaler (TAI) questionnaire for adherence to inhaler, and “Asthma Control Test (ACT)” or “COPD Assessment Test (CAT)” for disease control.Results: The pharmacist-led intervention significantly increased adherence to inhalers, evidenced by a notable rise in the proportion of patients with good adherence (P< 0.001). Sporadic, deliberate, and unwitting noncompliance pattern also improved significantly after the intervention (P< 0.001, P< 0.001 and P=0.001). Inhalation technique exhibited substantial improvement after intervention (P< 0.001). The analysis indicated significant moderate negative correlations between “TIA” and “CAT” [ρ=− 0.31; P=0.01], and between “inhalation technique score” and “CAT score” [ρ=− 0.31; P=0.01] suggesting that as adherence to inhaler usage and inhalation technique improve, CAT scores tend to decrease, indicating reduced disease impact on the patient.Conclusion: This study shows the potential efficacy of pharmacist-led intervention in enhancing adherence to inhaler, inhalation technique, and disease control in respiratory conditions such as asthma and COPD.Keywords: adherence to inhalers, asthma, COPD, disease control, inhalation technique, pharmacist-led intervention

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Bronchial asthma, a chronic pulmonary disease, has a major impact on the patient‘s daily life. Medication adherence and correct inhalation technique are essential to achieve the goals of therapy. The aim of this paper is to provide a review of published literature evaluating the effect of pharmacist-led interventions on medication adherence or inhalation technique in adult patients with bronchial asthma. A total of 23 studies were identified by a literature search of PubMed and Scopus databases. The analysis of the selected studies suggested that pharmacist-led intervention in any form had a positive impact on both above mentioned oberved phenomena and clinical outcomes of bronchial asthma therapy and can significantly contribute to improvement of patients´ quality of life. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to evaluate the longitudinal relationships, both at between- and within-person levels, that adherence to inhaled corticosteroidbased maintenance treatment and inhalation technique present with symptom control, exacerbations, and health-related quality of life (HRQoL) in children and adolescents with asthma. Methods: Participants (6-14 years old) from the ARCA (Asthma Research in Children and Adolescents) cohort--a prospective, multicenter, observational study (NCT04480242)--were followed for a period from 6 months to 5 years via computer-assisted telephone interviews and a smartphone application. The Medication Intake Survey-Asthma (MIS-A) was administered to assess the implementation stage of adherence, and the Inhalation Technique Questionnaire (InTeQ) was used to assess the five key steps when using an inhaler. Symptom control was measured with the Asthma Control Questionnaire (ACQ), and HRQL was measured with the EQ-5D and the Patient-Reported Outcomes Measurement Information System-Pediatric Asthma Impact Scale (PROMIS-PAIS). Multilevel longitudinal mixed models were constructed separately with symptom control, exacerbation occurrence, EQ-5D, and PROMIS-PAIS as the dependent variables. Results: Of the 360 participants enrolled, 303 (1,203 interviews) were included in the symptom control and exacerbation analyses, 265 (732) in the EQ-5D, and 215 (617) in the PROMIS-PAIS. Around 60% of participants were male subjects, and most of them underwent maintenance treatment with inhaled corticosteroids plus longacting β-agonists in a fixed dose (73.3%). Within-person variability was 83.6% for asthma control, 98.6% for exacerbations, 36.4% for EQ-5D, and 49.1% for PROMISPAIS. At the within-person level, patients with higher adherence had better symptom control (p = 0.002) and HRQoL over time (p = 0.016). Patients with a better inhalation technique reported worse HRQoL simultaneously (p = 0.012), but they showed better HRQoL in future assessments (p = 0.012). The frequency of reliever use was associated with symptom control (p < 0.001), exacerbation occurrence (p < 0.001), and HRQoL (p = 0.042); and boys were more likely to present better symptom control and HRQoL than girls. Conclusion: Our results confirm longitudinal associations at the within-person level of the two indicators of quality use of inhalers: for adherence to maintenance treatment with symptom control and HRQoL, and for the inhalation technique with HRQoL. Although treatment adherence was shown to be excellent, a third of the participants reported a suboptimal inhalation technique, highlighting the need for actions for improving asthma management of the pediatric population. [ABSTRACT FROM AUTHOR]

Abstract Objective The purpose of this study was to evaluate the inhaler skills of patients with asthma and chronic obstructive pulmonary disease in a hospital in western China after receiving one medication education by pharmacists and the factors related to these skills. Methods We included 96 subjects using Turbuhaler and 74 subjects using Diskus in a hospital in western China. They were educated once by pharmacists before medication, and then their skills of operating these inhalers were visually evaluated the next time they were used. Using the seven-step inhalation administration method designed by AnnaMurphy, a clinical pharmacist at GLENFIELD Hospital in the UK, the inhaler use technique score scale was established and scored in turn. The age, sex, time of first illness, smoking status, education level and type of health insurance purchased by each patient were recorded to assess their relationship with overall inhaler skills. Results 19.8% of the subjects who used Turbuhaler could not use it correctly, and 43.2% of the subjects who used Diskus could not use it correctly. The step with the highest error rate with Turbuhaler and Diskus is to "exhale slowly to residual volume". Chi-square test was carried out for each step of the operation of the two kinds of inhalers, and it was found that there was a significant difference in the operation accuracy of the two kinds of inhalers in the first, third and eighth steps. In univariate analysis, advanced age, female and low educational level were related to the lack of inhaler technology, but in multivariate analysis, only low educational level was a significant independent risk factor. Conclusion Among the patients with asthma and chronic obstructive pulmonary disease in western China, some patients have good inhaler operation skills, but there are still many patients who can not use inhalers correctly, and the lower education level is significantly related to the incorrect use of inhalers.

Introduction: We aimed to evaluate the longitudinal relationships, both at between- and within-person levels, that adherence to inhaled corticosteroid-based maintenance treatment and inhalation technique present with symptom control, exacerbations, and health-related quality of life (HRQoL) in children and adolescents with asthma.Methods: Participants (6–14 years old) from the ARCA (Asthma Research in Children and Adolescents) cohort—a prospective, multicenter, observational study (NCT04480242)—were followed for a period from 6 months to 5 years via computer-assisted telephone interviews and a smartphone application. The Medication Intake Survey–Asthma (MIS-A) was administered to assess the implementation stage of adherence, and the Inhalation Technique Questionnaire (InTeQ) was used to assess the five key steps when using an inhaler. Symptom control was measured with the Asthma Control Questionnaire (ACQ), and HRQL was measured with the EQ-5D and the Patient-Reported Outcomes Measurement Information System–Pediatric Asthma Impact Scale (PROMIS-PAIS). Multilevel longitudinal mixed models were constructed separately with symptom control, exacerbation occurrence, EQ-5D, and PROMIS-PAIS as the dependent variables.Results: Of the 360 participants enrolled, 303 (1,203 interviews) were included in the symptom control and exacerbation analyses, 265 (732) in the EQ-5D, and 215 (617) in the PROMIS-PAIS. Around 60% of participants were male subjects, and most of them underwent maintenance treatment with inhaled corticosteroids plus long-acting β-agonists in a fixed dose (73.3%). Within-person variability was 83.6% for asthma control, 98.6% for exacerbations, 36.4% for EQ-5D, and 49.1% for PROMIS-PAIS. At the within-person level, patients with higher adherence had better symptom control (p = 0.002) and HRQoL over time (p = 0.016). Patients with a better inhalation technique reported worse HRQoL simultaneously (p = 0.012), but they showed better HRQoL in future assessments (p = 0.012). The frequency of reliever use was associated with symptom control (p < 0.001), exacerbation occurrence (p < 0.001), and HRQoL (p = 0.042); and boys were more likely to present better symptom control and HRQoL than girls.Conclusion: Our results confirm longitudinal associations at the within-person level of the two indicators of quality use of inhalers: for adherence to maintenance treatment with symptom control and HRQoL, and for the inhalation technique with HRQoL. Although treatment adherence was shown to be excellent, a third of the participants reported a suboptimal inhalation technique, highlighting the need for actions for improving asthma management of the pediatric population.

Background: Incorrect inhalation technique (IT) is an important issue for chronic obstructive pulmonary disease (COPD) patients and healthcare professionals. Studies in which counseling is carried out with healthcare professionals beforehand so that they can properly educate their patients are required. The objective of the present trial is to assess the improvement in the performance of the IT in subjects with COPD and prescribed inhaled therapy after the implementation of an educational intervention conducted by their general practitioners. Methods: A cluster randomized clinical trial was conducted. A total of 286 COPD patients received scheduled inhalation therapy from 27 general practices in seven primary care centers. A teach-back educational intervention was implemented for both healthcare professionals and patients. The primary outcome of this study was the performance of the correct inhalation technique. It is considered a good technique if all steps in the inhalation data sheet are correctly performed. The secondary outcomes were assessed using forced spirometry, the basal dyspnea index, the Medical Research Council dyspnea scale, St George's Respiratory Questionnaire (SGRQ), and EuroQoL5D-5L for health-related quality of life. A one-year follow-up was conducted using an intention-to-treat analysis. Results: After the intervention, incorrect IT was observed in 92% of professionals and patients, with rates reaching 50% and 69.2%, respectively. The effectiveness in patients was significant, with a number needed to treat of 2.14 (95% CI 1.79-2.66). Factors related to correct IT in patients included the type of intervention, length of intervention (>25 min), good pulmonary function, age (youngest <=65, oldest >83), and less limitation of activity due to dyspnea. There was no relation with the cluster. Conclusion: This study shows the effectiveness of direct inhaler technique training provided by a trained professional on an appropriate timescale (for example, a specific consultation for medication reviews), aiming to help subjects improve their performance using the teach-back method. This could be an encouraging intervention to improve medication adherence and health promotion in people with COPD. Clinical Trial Registration: clinicaltrials.gov, identifier ISRCTN93725230. [ABSTRACT FROM AUTHOR]

Shubing Chen,&ast; Yongyi Peng,&ast; Beilan Shen, Liping Zhong, Zhongping Wu, Jinping Zheng, Yi Gao State Key Laboratory of Respiratory Disease, National Center for Respiratory Medicine, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Yi Gao; Jinping Zheng, Email misstall2@163.com; jpzhenggy@163.comPurpose: To develop and internally validate a nomogram for predicting the risk of incorrect inhalation techniques in patients with chronic airway diseases.Methods: A total of 206 patients with chronic airway diseases treated with inhaled medications were recruited in this study. Patients were divided into correct (n=129) and incorrect (n=77) cohorts based on their mastery of inhalation devices, which were assessed by medical professionals. Data were collected on the basis of questionnaires and medical records. The least absolute shrinkage and selection operator method (LASSO) and multivariate logistic regression analyses were conducted to identify the risk factors of incorrect inhalation techniques. Then, calibration curve, Harrell’s C-index, area under the receiver operating characteristic curve (AUC), decision curve analysis (DCA) and bootstrapping validation were applied to assess the apparent performance, clinical validity and internal validation of the predicting model, respectively.Results: Seven risk factors including age, education level, drug cognition, self-evaluation of curative effect, inhalation device use instruction before treatment, post-instruction evaluation and evaluation at return visit were finally determined as the predictors of the nomogram prediction model. The ROC curve obtained by this model showed that the AUC was 0.814, with a sensitivity of 0.78 and specificity of 0.75. In addition, the C-index was 0.814, with a Z value of 10.31 (P< 0.001). It was confirmed to be 0.783 by bootstrapping validation, indicating that the model had good discrimination and calibration. Furthermore, analysis of DCA showed that the nomogram had good clinical validity.Conclusion: The application of the developed nomogram to predict the risk of incorrect inhalation techniques during follow-up visits is feasible.Keywords: inhalation technique, incorrect, chronic airway disease, nomogram, predictors

Background: Incorrect inhalation technique (IT) is an important issue for chronic obstructive pulmonary disease (COPD) patients and healthcare professionals. Studies in which counseling is carried out with healthcare professionals beforehand so that they can properly educate their patients are required. The objective of the present trial is to assess the improvement in the performance of the IT in subjects with COPD and prescribed inhaled therapy after the implementation of an educational intervention conducted by their general practitioners.Methods: A cluster randomized clinical trial was conducted. A total of 286 COPD patients received scheduled inhalation therapy from 27 general practices in seven primary care centers. A teach-back educational intervention was implemented for both healthcare professionals and patients. The primary outcome of this study was the performance of the correct inhalation technique. It is considered a good technique if all steps in the inhalation data sheet are correctly performed. The secondary outcomes were assessed using forced spirometry, the basal dyspnea index, the Medical Research Council dyspnea scale, St George’s Respiratory Questionnaire (SGRQ), and EuroQoL5D-5L for health-related quality of life. A one-year follow-up was conducted using an intention-to-treat analysis.Results: After the intervention, incorrect IT was observed in 92% of professionals and patients, with rates reaching 50% and 69.2%, respectively. The effectiveness in patients was significant, with a number needed to treat of 2.14 (95% CI 1.79–2.66). Factors related to correct IT in patients included the type of intervention, length of intervention (>25 min), good pulmonary function, age (youngest 83), and less limitation of activity due to dyspnea. There was no relation with the cluster.Conclusion: This study shows the effectiveness of direct inhaler technique training provided by a trained professional on an appropriate timescale (for example, a specific consultation for medication reviews), aiming to help subjects improve their performance using the teach-back method. This could be an encouraging intervention to improve medication adherence and health promotion in people with COPD.Clinical Trial Registration:clinicaltrials.gov, identifier ISRCTN93725230.

Introduction: We aimed to evaluate the longitudinal relationships, both at between- and within-person levels, that adherence to inhaled corticosteroid-based maintenance treatment and inhalation technique present with symptom control, exacerbations, and health-related quality of life (HRQoL) in children and adolescents with asthma. Methods: Participants (6-14 years old) from the ARCA (Asthma Research in Children and Adolescents) cohort-a prospective, multicenter, observational study (NCT04480242)-were followed for a period from 6 months to 5 years via computer-assisted telephone interviews and a smartphone application. The Medication Intake Survey-Asthma (MIS-A) was administered to assess the implementation stage of adherence, and the Inhalation Technique Questionnaire (InTeQ) was used to assess the five key steps when using an inhaler. Symptom control was measured with the Asthma Control Questionnaire (ACQ), and HRQL was measured with the EQ-5D and the Patient-Reported Outcomes Measurement Information System-Pediatric Asthma Impact Scale (PROMIS-PAIS). Multilevel longitudinal mixed models were constructed separately with symptom control, exacerbation occurrence, EQ-5D, and PROMIS-PAIS as the dependent variables. Results: Of the 360 participants enrolled, 303 (1,203 interviews) were included in the symptom control and exacerbation analyses, 265 (732) in the EQ-5D, and 215 (617) in the PROMIS-PAIS. Around 60% of participants were male subjects, and most of them underwent maintenance treatment with inhaled corticosteroids plus long-acting β-agonists in a fixed dose (73.3%). Within-person variability was 83.6% for asthma control, 98.6% for exacerbations, 36.4% for EQ-5D, and 49.1% for PROMIS-PAIS. At the within-person level, patients with higher adherence had better symptom control (p = 0.002) and HRQoL over time (p = 0.016). Patients with a better inhalation technique reported worse HRQoL simultaneously (p = 0.012), but they showed better HRQoL in future assessments (p = 0.012). The frequency of reliever use was associated with symptom control (p < 0.001), exacerbation occurrence (p < 0.001), and HRQoL (p = 0.042); and boys were more likely to present better symptom control and HRQoL than girls. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to assess clinical, humanistic and economic outcomes of telepharmacy in asthma patients. Material and Methods: A quasi-experimental research design, with one-group pretest-posttest, was conducted to study telepharmacy. This real-time pharmaceutical care using communication technology was conducted in 29 asthma patients, over 12 weeks. Clinical outcomes were evaluated; including, asthma control, drug-related problems, adherence to use of inhaled corticosteroids (ICS), ICS-side effects, emergency room visits and hospitalizations due to acute exacerbation. Patient satisfaction was used to assess humanistic outcomes, and cost-saving was used to assess economic outcomes. Results: Clinical outcomes showed statistically significant improvement in the number of well-controlled patients; increasing from 34.48% to 89.66% (p-value

Despite traditional inhaler technique counseling, many patients make clinically important mistakes when they use their inhalers. This study investigates the value of using a connected inhalation aid when adults with asthma use their metered-dose inhaler (pMDI). Adult asthmatics (n = 221), using a pMDI, were randomly divided into a verbal training group (n = 110) and an enhanced training group (n = 111). 21 subjects were lost during the study, each group included 100 subjects at the end of the study. The study was divided into 3 visits. Traditional pMDI training was delivered at visit 1 to both groups which included an explanation of the steps with special stress on frequently mistaken steps e.g. exhalation before use and inhaling slowly and deeply. The enhanced training group was enhanced by using the Clip-Tone training aid linked to its dedicated smartphone app. enhanced training patients were encouraged to use this connected training aid during real-life use between the study visits. Baseline data were collected at the first visit. At all three visits (baseline, 1 month, and 2 months), subjects first completed all inhaler techniques, health outcome measures, received inhaler training, then took bronchodilators, and 30 min later repeated the lung function outcome measures. Both groups showed a significant decrease (p < 0.001) in the total mean number of pMDI inhalation techniques mistakes at visits 2 and 3, with a lower number of mistakes (p < 0.05) for slower inhalations for the enhanced training group compared to the verbal training group. Inhalation time (an indicator of a slow inhalation) significantly (p < 0.05) improved at each visit in the enhanced training group. In the enhanced training group, there was a gradual significant increase (p < 0.05) in lung functions while the improvements in the verbal training group were only significant (p < 0.05) at visit 3, and by visit 3, the enhanced training group had significantly higher scores than the verbal training group on both FEV1 and PEF% predicted. The asthma control test (ACT) score improved at each visit in both groups with a greater increase in the enhanced training group (p < 0.05) and more patients (44 and 21) improved their score by 3 or more in the second and third visit respectively. The connected Clip-Tone training aid helped patients improve their pMDI inhaler technique and their asthma control compared to traditional methods. These results highlight the potential of connected inhalers in the future management of inhaled therapy. [ABSTRACT FROM AUTHOR]

Une mauvaise technique d'inhalation est une cause majeure de non-contrôle de l'asthme chez l'enfant. L'évaluation de l'utilisation du système d'inhalation est un élément essentiel de la prise en charge de l'enfant asthmatique. Le but de cette étude prospective d'une année est de décrire les erreurs des techniques d'utilisation des systèmes d'inhalation chez l'enfant asthmatique et d'identifier les déterminants car la pierre angulaire de la prise en charge d'un enfant asthmatique est la maîtrise de la technique d'inhalation. Ceci souligne l'intérêt de réévaluer régulièrement l'utilisation du système d'inhalation. Poor inhaler technique is a major cause of uncontrolled asthma in children. Assessment of inhaler system use is an essential part of the management of the asthmatic child. The aim of this one-year prospective study is to describe the errors in the use of inhalation systems in children with asthma and to identify the determinants because the cornerstone of the management of a child with asthma is the mastery of the inhalation technique. This underlines the interest of regularly reassessing the use of the inhalation system. [ABSTRACT FROM AUTHOR]

Abstract Background Pressurized metered-dose inhalers (pMDIs) are among the most common devices that asthmatic patients use. The poor pMDI inhalation technique mostly results in poor lung deposition. The present work aimed to compare the impact of introducing two different training devices combined with their related smartphone applications on the proper performance of the inhalation technique and lung function in asthmatic adults. Methods A total of 316 patients were allocated to 3 groups, 105 in the control group (normal patient education group), 104 in the group using the Clip-Tone device and its smartphone applications, and 107 in the group using the Flo-Tone and its smartphone applications. Each group had three visits. Their number of inhalation technique mistakes was recorded, their forced expiratory volume in the first second (FEV1) was measured, and an asthma control test (ACT) was given. Afterward, they had their allocated training. Differences in medians of outcomes among repeated visits per group and different groups per visit were measured. Finally, correlation statistics between FEV1% of predicted and the correct performance of inhalation technique (as a whole and as separate steps) per visit were conducted to study any associations if existed. Results In the short term (after 2 visits), the Clip-Tone group showed significant superiority (p

The review article presents an analysis of the data of foreign and domestic researchers characterizing the effectiveness of nebulizer therapy for bronchial asthma in children. The paper considers new data comparing the effectiveness of aerosol delivery devices. The advantage of inhalation therapy, which determines its widespread use in childhood, is its rapid delivery to the respiratory tract, high local and low systemic concentrations of the drug in target organs. Difficulties in observing the correct inhalation technique due to the difficulty of synchronizing inhalation and drug delivery, especially in young children, remain an urgent problem in the practice of treating chronic bronchopulmonary diseases, which leads to a severe and uncontrolled course, disability and adverse outcomes. The main disadvantage of ultrasonic nebulizers is the inactivation of suspensions, antibiotics and other drugs. Widely used jet nebulizers create noise during inhalation, have a large residual volume in the nebulizer chamber. In this regard, the improvement of delivery forms continues, taking into account the anatomical and physiological characteristics of the respiratory organs, the age of patients and comorbid conditions. The characteristics of the optimal inhaler include simplicity and ease of use, reliability, the possibility of effective inhalation of various drugs in combination with economical consumption. From this point of view, one of the universal means of transporting aerosols is membrane or electronic mesh (mesh) nebulizers, which provide excellent regional drug deposition in all age groups of children. The rapid achievement of clinical effect, compactness, mobility expand the possibilities of using mesh nebulizers at all levels of medical care.

ObjectiveTraining contributes to the effectiveness of aerosol inhalation therapy. However, qualitative and quantitative evaluation of effective training methods is rarely reported. This study aimed to evaluate the effectiveness of a standardized training model by pharmacists based on verbal instruction and physical demonstration in improving patients' ability to use inhalers using qualitative and quantitative methods. Risk or protective factors affecting correct inhaler use were also explored.Methods431 Outpatients with asthma or COPD were recruited and randomly divided into a standardized training group (n = 280) and a usual training group (control group, n = 151). A framework of qualitative (e.g., multi-criteria analysis) and quantitative comparisons [percentage of correct use (CU%), percentage of complete error (CE%), and percentage of partial error (PE%)] was established to evaluate the two training models. In addition, the changes of key factors (age, education level, adherence, device type, etc.) influencing patients' ability to use inhalers of two models were observed.ResultsThe multi-criteria analysis showed that the standardized training model had comprehensive advantages in qualitative indicators. The average correct use percentage (CU%) of the standardized training group was significantly higher than that of the usual training group (77.6% vs. 35.5%). A stratified analysis further demonstrated that the ORs (95%CI) in the usual training group of age and educational level was 2.263 (1.165–4.398) and 0.556 (0.379–0.815), while in the standardized training group, age and educational level were not the key factors influencing the ability to use inhaler devices (P > 0.05). Logistic regression analysis demonstrated that standardized training was a protective factor for inhalation ability.ConclusionThese findings indicate that the framework of qualitative and quantitative comparisons could be used to evaluate training models, and the standardized training model by pharmacists can significantly improve patients' ability to use inhalers correctly and address the influence of older age and lower education because of its methodological advantages. Further studies with more extended follow-up are needed to validate the role of the standardized training model by pharmacists in the correct use of inhalers.Clinical trial registrationchictr.org.cn, ChiCTR2100043592 (23-02-2021).

Objective: To investigate whether one additional educational session about inhaler use, delivered to patients with COPD in primary healthcare, could affect the patients' skills in inhaler use. Specifically, to study the effects on errors related to handling the device, to inhalation technique, and to both.Methods: This nonrandomized controlled clinical trial included 64 patients who used devices and made errors. COPD nurses assessed inhaler use using a checklist and educated patients. Intervention group received one additional educational session after two weeks.Results: At baseline, patients in the IG had more devices (n = 2,1) compared to patients in the CG (n = 1,6) (p = 0.003). No other statistically significant differences were seen at baseline. At follow-up, intervention group showed a lower proportion of patients who made errors related to handling the device (p = 0.006). No differences were seen in the other categories.Conclusion: One additional educational session in inhaler use for patients with COPD was effective in reducing the proportion of patients making errors related to handling of their devices.Practice Implications: Categorization of errors might help healthcare professionals to assess the suitability of patients' devices, tailor patient education, and thus improve patient health. [ABSTRACT FROM AUTHOR]

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

Background/Objective: To assess whether and how the use of scientifically established Web-based training videos for teaching correct inhalation technique in patients with chronic airway diseases has become accepted among the wider population. Methods: The viewing trends of 141 freely available YouTube videos (full playing time, 01:31–04:37 min:s) provided by the German Respiratory League, covering a broad range of internationally prescribed devices, were analyzed over a 10-year period. Specific emphasis was placed both on German and international videos. Results: The total number of views was 3,350,678. Non-German videos (English, Russian, Turkish, Greek, Arabic, Farsi, and Slovakian) accounted for 23.2% of the views. The number of views steadily increased between 2011 and 2020 with a mean annual increase of 54.0% (range 24.5/119.9%) compared to the respective previous year. By 2020, the incidence of views per 100,000 German inhabitants was 725 for German videos only and 1,030 for all videos. In terms of the annual trend, there were two peak viewing periods, namely in spring and late fall, while the lowest amount of views occurred in summer. Conclusion: This study highlights the rising impact of Web-based training videos used for teaching the correct use of inhalation devices, with a steady increase in the number of annual views and a clear seasonal peaking of views in spring and late fall. [ABSTRACT FROM AUTHOR]

The effectiveness of inhalation therapy can be significantly reduced by a number of problems. For example, inhalation technique errors can reduce the dose delivered by 22-95% compared to the optimal value in patients with technical errors in the use of the inhaler. Sub-optimal inspiratory flow rates in a number of patients with chronic obstructive pulmonary disease and asthma are often the cause of technical errors during inhalation. Patient education does not produce the expected results, as the underlying cause of reduced flow is high hyperinflation and weakening of the respiratory musculature. The use of technologically outdated inhalers is another significant cause of reduced therapy effectiveness. Patient education and even conversion to a different inhaler do not always increase the effectiveness of therapy. Respimat, a brand new delivery agent introduced in 2004, allows 39% to 67% of the nominal dose to be delivered to the airways, while the degree of pulmonary deposit is independent of inspiratory flow and pulmonary drug deposit does not decrease with increasing obstruction. Compared to powder inhalers, Respimat creates less resistance to airflow on inhalation. In addition, Respimat is an active device that requires no effort on the part of the patient to move the aerosol particles. These features make Respimat the new standard for inhalation therapy. This review aims to familiarise readers with the main features of the Respimat and the latest research findings

Background: The severity of airway obstruction may affect patient's ability to perform an effective drug inhalation from a dry powder inhaler (DPI). Also, an incorrect inhalation technique may negatively affect the efficacy of asthma treatment. The aims of the study were (1) to analyze and compare inhalation profiles recorded with the use of different inhalation techniques, and thus, (2) to establish model inhalation profiles representative for healthy subjects and subjects with mild and moderate-to-severe asthma. Methods: This study was performed in healthy volunteers, patients with mild and moderate-to-severe asthma. A modified flow-volume test to define two different expiratory levels (to residual volume and half-way to residual volume) was performed. Inspiratory flow parameters were extracted: peak inspiratory flow rate (PIFinh), time at which peak inspiratory flow rate occurs (tPIFinh), total inhalation time (T), and inhaled volume (V). Test of frequency for tPIFinh100% and tPIFinh50% by asthma severity was performed, to provide information about initial flow accelerations. The impact of two different expiratory levels preceding inhalation (with severity of asthma as a categorical factor) on inspiratory flow parameters was examined. Results: PIFinh was dependent upon asthma severity (p = 0.046). Type of exhalation before inhalation had no effect on PIFinh values. V value was significantly affected both by asthma severity (p = 0.024) and type of exhalation before inhalation (p < 0.0001). Mean T value was influenced by type of exhalation before inhalation (p = 0.0003), but not by asthma severity. Mean tPIFinh value was affected by the type of exhalation before inhalation only in healthy subjects (p = 0.01). Conclusions: Both asthma severity and type of exhalation before inhalation have little impact on the dynamics of inhalation through a DPI. An alternative form of equation describing inhalation profiles demonstrating a relationship between lung mechanics and dynamics of inspiratory profile has been proposed. [ABSTRACT FROM AUTHOR]

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Background: The understanding of the real flow profiles through a dry powder inhaler (DPI), generated by asthma patients, is a prerequisite for satisfactory drug delivery to the lungs. The aims of the study were to assess the relationship between spirometric measures and inhalation profiles through a low-resistance DPI, and to compare parameters of those profiles between optimal and suboptimal inhalation technique type. Methods: Both healthy adult volunteers and patients with asthma were included in the study. Spirometry was conducted along with modified flow-volume test to detect expiratory levels (maximum "100%" exhalation to residual volume [RV] and halfway "50%" to RV). These were the reference levels of the depth of exhalation for each patient to simulate the effect of incomplete exhalation. Individual inhalation profiles were recorded using spirometry in-house software as the volumetric airflow through the inhaler versus time. Inspiratory flow parameters were extracted: time to peak inspiratory flow through inhaler (PIFinh), time at which peak inspiratory flow occurs (tPIFinh), total inhalation time (T), and inhaled volume during maneuver (V). Results and Conclusions: There are significant relationships between spirometric indices and parameters of inhalation through a low-resistance, cyclohaler-type DPI (assessed by single-factor analysis of Spearman's rank correlation coefficient). Multiple regression models were constructed, predicting inspiratory flow parameters (including spirometric indices, demographic parameters, and inhaler's usage history as determinants). The exhalation halfway to RV before inhalation did not affect significantly PIFinh and tPIFinh (and, thus, initial flow dynamics) in asthma patients. T and V parameters were then significantly decreased, but seemed sufficient for successful DPI performance. Both exhalation to RV and incomplete exhalation halfway to RV preceding inhalation allow for effective usage of low-resistance DPI. [ABSTRACT FROM AUTHOR]

Introduction: New training devices have been introduced to help in inhaler counseling by addressing the inspiratory flow through the metered-dose inhaler (MDI), which is the most important problem of the MDI inhalation technique. This study aims to compare the effects of MDI traditional verbal counseling and advanced counseling using training devices with a smartphone application in pediatric asthmatic patients. Methods: A total of 201 pediatric asthmatic subjects (8–18 years) were divided into two groups: a verbal counseling group, who received only MDI verbal counseling training (n = 101), and an advanced counseling group who received counseling using a training device (Flo-Tone with Trainhaler smartphone application) in addition to the traditional MDI verbal counseling (n = 100). Every patient in the two groups attended three counseling visits, 1 month apart. At each visit, pulmonary functions [peak expiratory flow (PEF), forced expiratory volume in 1 s (FEV1) as % of predicted] were measured. Also, patients were asked to perform their normal inhalation technique using their MDI, and mistakes were detected and recorded by the investigator. Then, patients were trained on the correct steps of the MDI inhalation technique using either verbal counseling or advanced counseling depending on their study group. In the advanced group, the Flo-Tone was connected to the mouthpiece of the MDI to blow a whistle while the patient inhaled from the MDI. That whistle was detected by the Trainhaler smartphone application and the duration of inhalation determined by the application was recorded. Results: Both groups showed a gradual significant decrease (p < 0.05) in the total mean number of MDI inhalation technique mistakes from the second visit of counseling, and the improvement continued in the third visit, with a lower number of mistakes in the advanced group especially in inhaling at a slow rate until the lungs are a full step. Also, the advanced counseling group showed a gradual significant increase (p < 0.05) in lung function (PEF and FEV1% of predicted) from the second visit of counseling, particularly (FEV1% predicted) results which showed a greater and more rapid overall improvement in the advanced group compared to the limited overall improvements that occurred in the control group, while significant improvement (p < 0.05) of lung function was obtained at the third visit in the verbal counseling group. In the advanced group, the number of seconds measured by the smartphone application, which represents the duration of inhalation, increased significantly (p < 0.05) in the second and third visits. Conclusions: The addition of training devices and smartphone applications to traditional verbal counseling of MDI inhalation technique in asthmatic children resulted in significant improvements in lung function (especially in FEV1% of predicted results), and duration of inhalation, and progressive decreases in the average number of MDI inhalation techniques errors compared to the verbal counseling group. [ABSTRACT FROM AUTHOR]

A Duarte-de-Araújo,1–3 P Teixeira,1,2 V Hespanhol,4,5 J Correia-de-Sousa1,2,61Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal; 2ICVS/3B’s, PT Government Associate Laboratory, Braga/Guimarães, Portugal; 3Respiratory Department, H. Sª Oliveira, Guimarães, Portugal; 4Department of Pneumology, Centro Hospitalar de S. João, Porto, Portugal; 5Faculty of Medicine (FMUP), University of Porto, Porto, Portugal; 6Horizonte Family Health Unit, Matosinhos, PortugalBackground and objectives: Inhalers mishandling remain an important clinical issue worldwide. The aim of this study was to evaluate inhalation technique in stable COPD out-patients. The variables under study were type of inhaler device (ID), patients’ preference for an inhaler, number of IDs used by each patient, beliefs about inhaler medication and some demographic, clinical and functional patients’ characteristics. We aim to assess how they are related to inhalation technique.Methods: A cross-sectional study was conducted in a hospital outpatient respiratory care. COPD patients over 40 years old, diagnosed according to GOLD criteria, and using IDs were included consecutively. The Beliefs about Medicines Questionnaire (BMQ), a demographic and a clinical survey were applied. The number of IDs used by each patient and the patients’ preference for some IDs were recorded. Patients were asked to demonstrate the use of their prescribed inhalation devices, and inhaler technique was assessed by using previously defined checklists, including essential steps and critical errors. A statistics analysis was then performed.Results: We studied 300 subjects performing a total of 521 inhalation manoeuvers with 10 different IDs. At least one step incorrectly performed was found in 48.2% of demonstrations and in 29.9% critical errors were observed. Misuse was related to priming/loading in 6.9%, to inhalation manoeuver in 13.1% and to both in 10%. There was a statistically significant association between critical errors and type of ID (P

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Background: Asthma and chronic obstructive lung disease (COPD) together constitute a huge burden on healthcare all around the world. Treatment of these patients is largely dependent on the way the inhalation devices are used. This study aimed at measuring the impact of rectification of inhalation technique on quality of life and severity of obstruction in patients with asthma and COPD. Materials and Methods: A total of 45 asthma (partly controlled) and 38 patients with COPD (categories B and C) were enrolled after applying optimal exclusion criteria. These patients underwent Asthma Control Test (ACT)/COPD Assessment Test (CAT) questionnaire as a measure of quality of life and forced expiratory volume in one second (FEV1) as a measure of severity of obstruction at 0 and 4 weeks, respectively. Results: In asthmatics, the mean FEV1 improved from 2.0 to 2.15 L after 4 weeks of technique correction (P < 0.001). In addition, the mean ACT scores improved from 18.0 to 20.75 (P < 0.001). In patients with COPD, the mean FEV1 improved slightly from 1.54 to 1.56 L after 4 weeks of technique correction (P = 0.28). In addition, the mean CAT scores improved from 21.86 to 19.83 (P < 0.001). Conclusion: Demonstration of correct inhalation technique should be an indispensible part of the treatment prescription of patients with obstructive airway disease. This simple and important task can be undertaken at the level of primary care physicians in a community-based setting to improve patient compliance.

Abstract Background The burden of asthma and COPD among patients is high and people affected are frequently hospitalized due to exacerbations. There are numerous reasons for the lack of disease control in asthma and COPD patients. It is associated with non-adherence to guidelines on the part of the health care provider and with poor inhalation technique and/or non-adherence to the prescribed treatment plan by the patient. This study aims to present data on inhaler technique and its impact on quality of life (QoL) and symptom control in a typical population of patients with chronic lung disease from a randomized controlled trial on medication adherence. Methods For this cross-sectional analysis, 165 asthma and COPD patients were analyzed. Correct application of inhaler devices was tested using pre-defined checklists for each inhaler type. QoL and symptom control were investigated using COPD Assessment Test (CAT) and Asthma Control Test (ACT). Spirometry was used to measure forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). Results Overall, incorrect inhalation technique ranged from 0 to 53% depending on the type of inhaler. COPD patients with incorrect device application had a higher CAT sum score compared to those with a correct device application (P = .02). Moreover, COPD patients with incorrect device application were more likely to suffer from cough (P = .03) and were more breathless while walking uphill or a flight of stairs (P = .02). While there was no significance found in asthma patients, COPD patients who used their devices correctly had a significantly better mean FEV1% predicted at baseline compared to those who applied their devices incorrectly (P = .04). Conclusions Correct inhalation of prescribed medication is associated with improved health status and lung function. These findings should encourage health professionals to provide instructions on correct inhalation technique and to regularly re-evaluate the patients’ inhalation technique. Trial registration ClinicalTrials.gov: NCT0238672, Registered 14 February 2014.

Inhaler is the most preferable device to deliver medication in order to treat asthma and Chronic Obstructive Pulmonary Disease (COPD). Incorrect usage of inhaler influences the clinical effectiveness of the delivered drug. A pilot study was conducted to determine the appropriateness of inhaler handling technique among asthma and COPD patients. As many as 92 subjects whom diagnosed with asthma and COPD, aged between 18 to 64 years old were observed in this cross-sectional study. Consenting subjects on inhaler, who attended medical out patients clinic at a primary health care unit in Selangor, Malaysia were asked to demonstrate on how they use the inhaler while an inhaler administration checklist were used to assess each patients inhaler technique. Data was analysed using descriptive statistical methods. Of total 92 patients, a total of 155 devices were used. Only 4 out of 92 patients correctly handles the device (4.3%). In average, a patient made approximately >4 mistakes during pMDI inhalation and >2 mistakes during DPI inhalation. The most common mistake found among pMDI, Turbuhaler and Accuhaler users were unable to hold the breath for approximately 5 seconds in which comprise of ≥80% patients. In conclusion, majority of asthma and COPD patients use their inhaler inaccurately. Patients prescribed by inhalation medications should have routine assessment of their inhaler technique at every visit and corrected if found to be poor.

Objective: Inhalation therapy is one of the key pillars in the treatment of chronic obstructive diseases, such as asthma and COPD (Chronic obstructive pulmonary disease); however, wide number of errors occur with high frequency in the inhalation manoeuvres among these patient. This review discuss the main errors made with inhalation devices, factors associated with poor IT (inhalation technique), their consequences and possible solutions. Data sources: To do this, we performed a search of any publications available in PubMed between the years 2000 and 2019, using the key words: asthma, COPD, obstructive lung disease, inhalers, misuse and errors. Study selections: After a review of the titles and abstracts by the working group, the articles chosen were considered the most relevant in providing evidence of the problems and establishing solutions in the inhalation treatment of asthma and COPD. Results: There are several publications that associated the errors in the inhalation technique with a poor prognosis both of asthma and COPD. Most authors generally agree in that a poor IT is associated with poor control of the symptoms. Conclusions: It is essential to review the IT in all our patients with asthma and COPD due to the high socio‐economic impact that it involves; an effort must be made to homogenise the evaluation of IT, so that it helps to transmit a clear message to the patients, as well as to the health professionals on what is and what is not a correct manoeuvre. [ABSTRACT FROM AUTHOR]

Objective: In patients with asthma and chronic obstructive pulmonary disease (COPD), disease control is still suboptimal—incorrect inhalation technique and medication non‐adherence are two important reasons for this outcome. Pharmacists' interventions have been shown to have a positive effect on the clinical outcomes of asthma and COPD. Quantitative assessment of the efficacy of pharmacist‐led interventions, mainly on inhalation techniques and medication adherence, is needed. Evidence for different interventions is not totally conclusive, and no results of theory‐based adherence promotion interventions for asthma and COPD have been published. The objective of our study is to evaluate the effect of pharmacist‐led interventions on asthma and COPD management, focusing mainly on inhalation technique and medication adherence, and whether the content of interventions (categorized based on Information‐Motivation‐Behavioural skills (IMB) model) affects the effectiveness and whether the IMB model is worthy of clinical promotion and application in adults with asthma or COPD. Methods: The PubMed, EMBASE, The Cochrane Library, Web of Science and ClinicalTrials.gov databases were searched for randomized controlled trials that involved pharmacist‐led interventions among patients with asthma or COPD. We used database‐specific vocabulary (eg, Medical Subject Headings) and free text terms expanding from 'asthma', 'COPD' and 'pharmacist' to identify relevant articles. Two reviewers independently selected the studies, assessed the risk of bias and extracted the data. The meta‐analysis was performed in Review Manager 5.3 provided by the Cochrane Collaboration. PROSPERO registration number: CRD42019144793. Results and discussion: Thirteen studies were eligible for qualitative analysis, and 12 studies were included in the meta‐analysis. Pharmacist‐led interventions showed a positive effect on medication adherence (1.34 [95% CI 1.18‐1.53], P <.0001) and inhalation technique (1.85 [95% CI 1.57‐2.17], P <.00001) in COPD and asthma patients. In the subgroup meta‐analysis, significant medication adherence improvement was found only in COPD patients (1.41 [1.24‐1.61], P <.0001). The subgroup meta‐analysis also noted that interventions that included all three Information‐Motivation‐Behavioural skills (IMB) constructs had a significant improvement in medication adherence (1.41 [1.24‐1.61], P <.0001). Subgroup meta‐analysis conducted between different diseases, different intervention contents, and different measure tools did not significantly change the heterogeneity. What is new and conclusion: Pharmacist‐led interventions can improve inhalation technique in adult asthma and COPD patients. Significant improvement in medication adherence was found only in COPD patients. The effect among asthmatic patients requires further study. Interventions based on the IMB model may be worthy of clinical promotion and application. More future research is needed to establish solid evidence base for effective interventions and uniform measurement of medication adherence. [ABSTRACT FROM AUTHOR]

Nebulizers are used by the great majority of cystic fibrosis patients for delivery of cornerstone treatments. Inhalation technique and adequate disinfection and maintenance are important for optimizing medication delivery. In this study, inhalation technique and nebulizer disinfection/maintenance were assessed in cystic fibrosis patients by direct observation in clinic and completion of a scoring sheet. A total of 108 patients were recruited. The maximum inhalation technique score was attained by 30.5% and adequate inhalation technique score by 74.08% of patients. The inhalation technique score was best with the vibrating mesh nebulizer (p = 0.038), while patient age and number of nebulized medications did not affect ITS significantly (p > 0.05). Nebulizer disinfection/maintenance score was excellent in only 31.48%. Most families kept the nebulizer clean and used appropriate disinfection method, but only half of them replaced the nebulizer and nebulizer cup at the recommended time intervals. Nebulizer disinfection/maintenance score was positively affected by a number of nebulized medications and negatively by years of equipment use (p = 0.009 and p = 0.001, respectively). Even though inhalation technique and disinfection/maintenance practices were found to be adequate in a large proportion of cases, there is still a need for regular review and education. The type of nebulizer was associated with improved inhalation technique, but more data are required before making specific recommendations. [ABSTRACT FROM AUTHOR]

Background: The ability of patients to take, correctly and regularly, aerosol treatments is a key for good control of asthma and chronic obstructive pulmonary disease. Devices that help to improve inhalation technique could train the patient to take their medication properly, reducing risk of exacerbations. In this study we evaluate a new device that by recording real-time respiratory flow into the valved holding chamber (VHC) mouthpiece, could be used to improve patient technique. Methods and Results: Using computational fluid dynamics analysis we demonstrated that compared to a mouthpiece with no flow probe, the presence of a probe modifies the flow profile and velocity regardless of the probe shape or position. During flow measurement using a SDP610 pressure sensor (Sensirion, Switzerland), all probes can accurately record adult and child respiratory patterns. Resistance was determined from the back pressure generated by the VHC with or without probes; and resistance was not impacted by the probes. Aerodynamic particle size distribution and drug delivery measurement were assessed using the United States Pharmacopeia throat model (Copley Scientific, UK), next generation impactor (NGI; Copley Scientific), and a breath simulator (BRS200; Copley Scientific). To test different formulations, these experiments were performed with fluticasone propionate (Flixotide®; GSK, UK), salbutamol (Ventolin®; GSK), and beclomethasone dipropionate (BDP) (QvarSpray®; GSK). Depending on the molecule or the probe configuration, we noticed a decrease of the emitted doses, fine particle deposition, mass median aerodynamic diameter, but no significant change in the mass of drug delivered. A decrease in the fine particle fraction (FPF) was observed in most testing conditions. However, a slight increase was noticed for two conformations with BDP (round and close [Rc] and diamond and far [Df]) and salbutamol (Rc and round and far [Rf]). Conclusion: By inserting a flow probe directly into the mouthpiece of a VHC we could perform real-time analysis of respiratory flow during the VHC use without disturbing drug delivery, or increasing resistance. [ABSTRACT FROM AUTHOR]

The aim was to evaluate the inhalation technique among COPD patients using pressurized metered dose inhaler and determinants of incorrect inhalation technique. In this hospital based cross-sectional study, total 92 COPD patients were enrolled. Basic socio-demographic information was collected. The inhalation technique was visually observed and scored on checklist. Statistical Analysis Used: Chi-square test and Fisher exact test. Among the 92 patients observed, 69 (75.0%) were males. The mean age of the patients was 45.8 ± 1.4 years. Correct technique was observed in only 22 (23.9%) patients step at which maximum number of patients committed mistake was exhalation 65.2% followed by breath holding 45.7% and multiple actuations were seen in 44.5%. It was found that substantial errors were made in the inhalation technique hence proper training and follow-up of the patients is required to achieve the desired effects of the inhaled medications. [ABSTRACT FROM AUTHOR]

Aim of the work — to evaluate the effectiveness of inhalation technique when using different types of inhalers (dry powder inhalers — Turbuhaler, Diskus), metered-dose inhalers, breath-actuated inhalers — Easyhaler). Materials and methods. 45 patients aged 6–17 years underwent the evaluation of inhalation technique accuracy with the use of In-Check-Dial — apparatus, which imitates the airway resistance that should be overcome during inspiration through different inhaler types, and measure inspiration velocity. Incidence of mistakes was studied in different age groups. Results. 80 % of children aged 6–7 years made mistakes while using Turbuhaler, 73.3 % — metered-dose inhaler, 60 % — Easyhaler. There were no mistakes in patients making inhalation by means of Diskhaler. 100 % of children aged 12–14 years incorrectly used metered-dose inhaler. Easyhaler was incorrectly used in 66.6 % of cases, Diskhaler — in 26.6 %. Among elder group, incidence of mistakes when making inhalations through Turbuhaler was lower — 40 % in 12–14-year-old group and 25 % — in 15–17-year-old (р < 0.05). Children of 15–17 years old are able to use Turbuhaler and Diskus (mistakes in 33.3 and 46.6 %, respectively). At the same time, none of the patients have done the correct inhalation by means of metered-dose inhaler, 93.3 % of the patients have mistakes when using Easyhaler. Conclusions. The incidence of mistakes depends on the age and inhaler type and reaches 26–100 %. Minimal quantity of mistakes is seen for Diskus (in all age groups), maxi­mal — for metered-dose inhaler. For the purpose of optimal inhaler choice in a child with bronchial asthma, it is advisable to measure the inspiratory flow with the help of In-Check-Dial before therapy administration.

Objective The objective of this study was to evaluate errors in the use of metered-dose inhalers (MDIs) among patients diagnosed with asthma or chronic obstructive pulmonary disease (COPD). Additionally, we aimed to assess improvements following corrective interventions. Settings and design This cross-sectional study was done by simple random sampling. Methods and materials This study was done at a tertiary care center in South India in an outpatient department and ward for tuberculosis and chest disease to find out the right way to use an MDI and investigate the reasons why people with asthma and COPD don't use it correctly. There were a total of 12 steps. The patient was given an empty canister to try the inhalation technique and was scored one point for every correct step and zero for every incorrect step, for a total of 12 steps. Following the demonstration, an educator used a variety of tools, including verbal communication, pictorial demonstrations, and practical demonstrations, to correct the mistakes. After education was provided, post-interventional data was collected. Results During pre-intervention of the 12 steps out of the 183 participants, step one had 183 correct participants (100%), step two had 104 correct participants (56.83%), step three had 129 correct participants (70.49%), step four had 71 correct participants (38.79%), step five had 167 correct participants (91.25%), step six had 123 correct participants (67.21%), step seven had 132 correct participants (72.13%), step eight had 81 correct participants (43.71%), step nine had 123 correct participants (67.21%), step 10 had 108 correct participants (59.01%), step 11 had 128 correct participants (69.94%), and step 12 had 175 correct participants (95.62%). During the post-intervention of the 12 steps, out of the 183 participants, step one remained at 183 correct participants (100%), step two increased to 149 correct participants (81.42%), step three to step seven increased to 183 correct participants (100%), step eight increased to 142 correct participants (77.59%), step nine increased to 174 correct participants (95.08%), step 10 increased to 177 correct participants (96.72%), step 11 increased to 143 correct participants (78.14%) and step 12 increased to 177 correct participants (96.72%). Conclusion This study highlights the prevalent errors in the use of metered-dose inhalers (MDIs) among patients diagnosed with asthma or chronic obstructive pulmonary disease (COPD). The results demonstrate significant improvements in the MDI technique. Following educational interventions such as verbal communication, pictorial demonstrations, and practical exercises, patients were able to correct their inhaler technique effectively and emphasized the importance of patient education and counseling to ensure the maintenance of correct usage over time., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, A et al.)

Background: We examined the effect of physical position on peak inspiratory flow (PIF) in patients with chronic obstructive pulmonary disease (COPD) using dry-powder inhalers (DPIs) with low‑medium internal resistance (R2) and/or high internal resistance (R5)., Methods: This prospective study in stable, ambulatory patients with spirometry-confirmed COPD evaluated the effect of 3 physical positions on maximal PIF achieved. Participants had PIFs of 30-90L/min (R5) or 60-90L/min (R2 DPIs) using the In-Check™ DIAL. PIF was measured in triplicate randomly in 3 positions that patients might be in while using their inhaler (standing, sitting, and semi-upright [supine position with the head of the bed at 45°, neck flexed forward]) against prescribed DPI resistance (R2/R5/both). Correlations between PIF and percentage decline in PIF between positions and differences in participant characteristics with >10% versus ≤10% PIF decline standing to semi-upright were calculated., Results: A total of 76 participants (mean age, 65.2 years) had positional measurements; 59% reported seated DPI use at home. The mean (standard deviation) PIF standing, sitting, and semi-upright was 80.7 (13.4), 77.8 (14.3), and 74.0 (14.5) L/min, respectively, for R2 and 51.1 (9.52), 48.6 (9.84), and 45.8 (7.69) L/min, respectively, for R5 DPIs. PIF semi-upright was significantly lower than sitting and standing (R2; P < 0.0001) and standing (R5; P = 0.002). Approximately half of the participants had >10% decline in PIF from standing to semi-upright. Patient characteristics exceeding the 0.10 absolute standardized difference threshold with the decline in PIF for both the R2 and R5 DPIs were waist-to-hip ratio, modified Medical Research Council dyspnea score, and postbronchodilator percentage predicted forced vital capacity and PIF by spirometry., Conclusions: PIF was significantly affected by physical position regardless of DPI resistance. PIF was highest when standing and lowest when semi-upright. We recommend that patients with COPD stand while using an R2 or R5 DPI. Where unfeasible, the position should be sitting rather than semi-upright. ClinicalTrials.gov identifier NCT04168775., (JCOPDF © 2024.)

Inhaled therapies are the cornerstone of treatment in asthma and chronic obstructive pulmonary disease, and there are a multitude of devices available. There is, however, a distinct lack of evidence-based guidance for healthcare providers on how to choose an appropriate inhaler. This review aims to summarise recent updates on topics related to inhaler choice, and to offer practical considerations for healthcare providers regarding currently marketed devices. The importance of choosing the right inhaler for the right patient is discussed, and the relative merits of dry powder inhalers, pressurised metered dose inhalers, breath-actuated pressurised metered dose inhalers, spacers and soft mist inhalers are considered. Compiling the latest studies in the devices therapy area, this review focuses on the most common types of handling errors, as well as the comparative rates of incorrect inhalation technique between devices. The impact of device-specific handling errors on inhaler performance is also discussed, and the characteristics that can impair optimal drug delivery, such as inhalation flow rate, inhalation volume and particle size, are compared between devices. The impact of patient perceptions, behaviours and problems with inhalation technique is analysed, and the need for appropriate patient education is also highlighted. The continued development of technology in inhaler design and the need to standardise study assessment, endpoints and patient populations are identified as future research needs. The reviews of this paper are available via the supplemental material section. [ABSTRACT FROM AUTHOR]

BACKGROUND: A significant percentage of patients with asthma and COPD do not use their inhalers properly. The aim of this study was to evaluate the impact of a single session of inhalation technique training on the frequency of inhalation errors and the course of asthma and COPD. METHODS: This randomized controlled trial included adults who had been diagnosed with and treated for asthma or COPD with at least one inhaler use daily on a regular basis. All subjects were followed for 6 months, at which time their inhalation technique was assessed and an individual inhalation training (study group) or a sham procedure (control group) was applied. The number of mishandlings was calculated as the ratio of the number of errors to the number of inhalers used by an individual subject. The effect of training was evaluated after 3 months and again after 6 months. RESULTS: 50 subjects with asthma and 50 subjects with COPD were enrolled. Only 20% of subjects made no critical errors before the intervention. Subjects who were trained in the proper inhalation technique made fewer errors after 3 months (32 of 50 vs 20 of 50). The relative risk was 1.63 (95% CI 1.1-2.4, P = .01) and the number needed to treat was 3.9 (95% CI 2.2-15). Despite the improvement in the inhalation technique, we found no reduction in the number of asthma/COPD exacerbations, symptom severity, or the quality of life. After 3 consecutive months, the efficacy of the intervention decreased, and only 66% of the former responders maintained the lower ratio of errors per inhaler. After 6 months, there was no difference in the number of subjects with better inhalation technique between intervention (24 of 50) and control group (27 of 50) (P = .62). CONCLUSIONS: Although a single inhalation training leads to a reduction in the number of errors made during inhalation, it does not influence the course of asthma and COPD. The positive effect of a single inhalation technique training is temporary. (ClinicalTrials.gov registration NCT02131454.) [ABSTRACT FROM AUTHOR]

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Sinthia Bosnic-Anticevich,1 Henry Chrystyn,2 Richard W Costello,3,4 Myrna B Dolovich,5 Monica J Fletcher,6 Federico Lavorini,7 Roberto Rodríguez-Roisin,8 Dermot Ryan,9,10 Simon Wan Yau Ming,2 David B Price2,11 1Woolcock Institute of Medical Research, School of Medical Sciences, University of Sydney and Sydney Local Health District, Sydney, NSW, Australia; 2Observational and Pragmatic Research Institute Pte Ltd, Singapore; 3RCSI Medicine, Royal College of Surgeons, 4RCSI Education & Research Centre, Beaumont Hospital, Beaumont, Dublin, Ireland; 5Department of Medicine, Respirology, McMaster University, ON, Canada; 6Education for Health, Warwick, UK; 7Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy; 8Respiratory Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; 9Optimum Patient Care, Cambridge, 10Centre for Population Health Sciences, University of Edinburgh, Edinburgh, 11Academic Primary Care, University of Aberdeen, Aberdeen, UK Background: Patients with COPD may be prescribed multiple inhalers as part of their treatment regimen, which require different inhalation techniques. Previous literature has shown that the effectiveness of inhaled treatment can be adversely affected by incorrect inhaler technique. Prescribing a range of device types could worsen this problem, leading to poorer outcomes in COPD patients, but the impact is not yet known. Aims: To compare clinical outcomes of COPD patients who use devices requiring similar inhalation technique with those who use devices with mixed techniques. Methods: A matched cohort design was used, with 2 years of data from the Optimum Patient Care Research Database. Matching variables were established from a baseline year of follow-up data, and two cohorts were formed: a “similar-devices cohort” and a “mixed-devices cohort”. COPD-related events were recorded during an outcome year of follow-up. The primary outcome measure was an incidence rate ratio (IRR) comparing the rate of exacerbations between study cohorts. A secondary outcome compared average daily use of short-acting beta agonist (SABA). Results: The final study sample contained 8,225 patients in each cohort (mean age 67 [SD, 10], 57% males, 37% current smokers). Patients in the similar-devices cohort had a lower rate of exacerbations compared with those in the mixed-devices cohort (adjusted IRR 0.82, 95% confidence interval [CI] 0.80–0.84) and were less likely to be in a higher-dose SABA group (adjusted proportional odds ratio 0.54, 95% CI 0.51–0.57). Conclusion: COPD patients who were prescribed one or more additional inhaler devices requiring similar inhalation techniques to their previous device(s) showed better outcomes than those who were prescribed devices requiring different techniques. Keywords: chronic obstructive pulmonary disease, inhalation technique, exacerbations, inhaler devices, observational, matched cohort

Aleksandra Dudvarski Ilic,1,2 Vladimir Zugic,1,2 Biljana Zvezdin,3,4 Ivan Kopitovic,3,4 Ivan Cekerevac,5,6 Vojislav Cupurdija,5,6 Nela Perhoc,7 Vesna Veljkovic,7 Aleksandra Barac8 1Faculty of Medicine, University of Belgrade, 2Clinic for Pulmonology, Clinical Centre of Serbia, Belgrade, 3Faculty of Medicine, University of Novi Sad, Novi Sad, 4Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica, 5Faculty of Medicine, University of Kragujevac, 6Clinic for Pulmonology, Clinical Centre Kragujevac, Kragujevac, 7Clinic for Pulmonary Diseases Knez Selo, Clinical Centre Nis, Nis, 8Faculty of Stomatology, University Academy of Business Novi Sad, Novi Sad, Serbia Background: The successful management of asthma and chronic obstructive pulmonary disease (COPD) mostly depends on adherence to inhalation drug therapy, the usage of which is commonly associated with many difficulties in real life. Improvement of patients’ adherence to inhalation technique could lead to a better outcome in the treatment of asthma and COPD.Objective: The aim of this study was to assess the utility of inhalation technique in clinical and functional control of asthma and COPD during a 3-month follow-up.Methods: A total of 312 patients with asthma or COPD who used dry powder Turbuhaler were enrolled in this observational study. During three visits (once a month), training in seven-step inhalation technique was given and it was practically demonstrated. Correctness of patients’ usage of inhaler was assessed in three visits by scoring each of the seven steps during administration of inhaler dose. Assessment of disease control was done at each visit and evaluated as: fully controlled, partially controlled, or uncontrolled. Patients’ subjective perception of the simplicity of inhalation technique, disease control, and quality of life were assessed by using specially designed questionnaires.Results: Significant improvement in inhalation technique was achieved after the third visit compared to the first one, as measured by the seven-step inhaler usage score (5.94 and 6.82, respectively; P

Josep Darbà,1 Gabriela Ramírez,2 Juan L García-Rivero,3 Sagrario Mayoralas-Alises,4 José Francisco Pascual,5 Albert Roger,6 Diego Vargas,7 Adi Bijedic8 1Department of Economics, Universitat de Barcelona, 2BCN Health Economics & Outcomes Research SL, 3Hospital Laredo, Cantabria, 4Hospital Ramón y Cajal, Madrid, 5Hospital General Universitario de Alicante, Alicante, 6Hospital Universitario Germans Trias i Pujol, Barcelona, 7Hospital de Alta Resolución el Toyo, Andalusia, 8Market Access and HEOR Department, TEVA Pharmaceutical, Madrid, Spain Objective: To assess the economic impact of the introduction of DuoResp® Spiromax® by focusing on a potential improvement in the inhalation technique to strengthen medication adherence for the treatment of moderate to severe asthmatics in Spain and five Spanish regions including Andalusia, Catalonia, Galicia, Madrid, and Valencia.Methods: A 4-year budget impact model was developed for the period 2015–2018 from the Spanish Healthcare System perspective. Budesonide–formoterol fixed-dose combination delivered by Turbuhaler® was considered to be the most appropriate comparator for assessing the budget impact with the introduction of DuoResp® Spiromax®. National and regional data on asthma prevalence were obtained from the literature. Input parameters on health care resources were obtained by consulting experts from different Spanish hospitals. Resources used included medical visits, emergency room visits, and hospitalizations. The average numbers of primary care and specialist visits per year were also gathered. Based on health care resource use per patient, the total treatment cost per patient was estimated.Results: The population with moderate to severe asthma treated with budesonide–formoterol fixed-dose combinations delivered by Turbuhaler® in 2015 was estimated to be 166,985 in Spain. Region-specific prevalence data resulted in 25,081, 12,392, 16,097, 17,829, and 15,148 patients in Andalusia, Catalonia, Galicia, Madrid, and Valencia, respectively. Based on the forecast uptake of DuoResp® Spiromax®, the total budget savings in Spain were expected to be €1.509 million over the next 4 years. Region-specific rates imply that the total savings were expected to be €229,706 in Andalusia, €90,145 in Catalonia, €188,327 in Galicia, €122,669 in Madrid, and €165,796 in Valencia over 2015–2018.Conclusion: The introduction of DuoResp® Spiromax®, which represents a potential improvement in the inhalation technique to strengthen medication adherence for the treatment of moderate to severe asthma, could represent savings for the Spanish National Health Society and five Spanish regions. Keywords: dry powder inhaler, economic evaluation, region-specific estimates, payers perspective