Dose Inhaler Research Articles

Molecular Dynamic Simulation Approach to Predict the Compatibility of Formulation Components of Salbutamol Sulfate Metered Dose Inhaler Free off Ethanol

More than 50 years since the first introduction of metered dose inhaler (MDI) by Riker laboratories 1956. The major development in MDI manufacturing was the transformation from chloroflouro carbon (CFC) to hydroflouro alkane (HFA) which required a new engineering design to the MDI components and reformulation of existing MDI to fit the new propellant. Evolution of MDI formulation was challenging due to the low solubility profile of most excipients in HFA propellants and the limitation of generally recognized as safe (GRAS) excipients that could be delivered to the lung. The main purpose of this study was to develop a new salbutamol sulfate (SS) MDI using PEG400(1%) w/w as suitable alternative co-solvents to ethanol (10%)w/w. PVP-k30(0.001-0.0001%) w/w and Brij72(0.001-0.005-0.01%) were used separately as suggested stabilizer. In silico molecular dynamic (MD) simulation was carried out to investigate the compatibility of new excipients with SS and PEG400 before adding the HFA134a. Differential scanning calorimeter(DSC) was also run to evaluate the compatibility between formulations components that passed the visual observation test. Content per actuation was also used to estimate the developing formulation at accelerated stability conditions (40°C/75%RH).(N=10). MD simulation results demonstrated the compatibility of PVP-k30(0.0001%) w/w with other formulation's components before adding HFA134a propellant(small or negative value for and ). MD simulation results were also confirmed by DSC thermograms which indicate the compatibility between PVP-k30 based formulation due to a small change in endothermic maximum melting point compared with Brij 72 based formulation.Content per actuation of PVP-k30(0.0001%)w/w based formulation passed the accelerated stability test and there is a significant effect of stabilizer type and concentration on the emitted dose (p-value >0.05). This work confirms that MD simulations could save time and reduce the cost of experiments during the early stage of reformulation process of MDI.

A computational study of droplet-spray formation from pressurized metered dose inhalers with applications to drug deposition in a human lung-airway model

Orally administered drugs using portable devices, such as pressurized metered dose inhalers (pMDIs), can alleviate the symptoms of various respiratory diseases. The basic non-isothermal fluid-particle dynamics of pMDIs have been simulated, including computer model validations and different inhalation techniques, using the Ventolin HFA from GlaxoSmithKline (UK) as a representative application. Specifically, the evolution of thermal droplet sprays has been realistically simulated and experimentally validated, employing the open-source computational fluid dynamics (CFD) toolbox OpenFOAM. The segmental droplet temperature results show elevated temperatures for higher inhalation flow rates because of stronger convective flow around the evaporating droplets. The general problems of high, wasteful oropharyngeal deposition and cold impacting droplets were tackled by devising a new ‘pulsed injection’ strategy in which the spray was broken into pulses with a time delay between them. This new methodology indicated up to a 20% increase in useful lung deposition beyond the oropharynx over conventional drug administration methods. In addition, compared to the conventional single injection approach, the segmental variations in temperature of the deposited aerosols show an increase in temperature of around 10% and 7% for the 30 LPM and 60 LPM cases up to segment 4 for pulsed injection. An increase of 23% and 13% for the 30 LPM and 60 LPM cases were observed for segments 5–7 for pulsed injection. Also, a reduction in inertia of the droplets at 30 LPM, where the spray was broken into eight pulses with 100 ms delay between them, resulted in higher residence times and an increase in temperature of over 35°C.Copyright © 2023 American Association for Aerosol Research

A Novel Trans-Tracheostomal Retrograde Inhalation Technique Increases Subglottic Drug Deposition Compared to Traditional Trans-Oral Inhalation.

Subglottic stenosis represents a challenging clinical condition in otolaryngology. Although patients often experience improvement following endoscopic surgery, recurrence rates remain high. Pursuing measures to maintain surgical results and prevent recurrence is thus necessary. Steroids therapy is considered effective in preventing restenosis. Currently, however, the ability of trans-oral steroid inhalation to reach and affect the stenotic subglottic area in a tracheotomized patient is largely negligible. In the present study, we describe a novel trans-tracheostomal retrograde inhalation technique to increase corticosteroid deposition in the subglottic area. We detail our preliminary clinical outcomes in four patients treated with trans-tracheostomal corticosteroid inhalation via a metered dose inhaler (MDI) following surgery. Concurrently, we leverage computational fluid-particle dynamics (CFPD) simulations in an extra-thoracic 3D airway model to gain insight on possible advantages of such a technique over traditional trans-oral inhalation in augmenting aerosol deposition in the stenotic subglottic region. Our numerical simulations show that for an arbitrary inhaled dose (aerosols spanning 1-12 µm), the deposition (mass) fraction in the subglottis is over 30 times higher in the retrograde trans-tracheostomal technique compared to the trans-oral inhalation technique (3.63% vs. 0.11%). Importantly, while a major portion of inhaled aerosols (66.43%) in the trans-oral inhalation maneuver are transported distally past the trachea, the vast majority of aerosols (85.10%) exit through the mouth during trans-tracheostomal inhalation, thereby avoiding undesired deposition in the broader lungs. Overall, the proposed trans-tracheostomal retrograde inhalation technique increases aerosol deposition rates in the subglottis with minor lower-airway deposition compared to the trans-oral inhalation technique. This novel technique could play an important role in preventing restenosis of the subglottis.

Study of glycopyrrolate dry powder behavior in new single dose inhalers under generic product development

With increasing environmental pollution and tendency to smoking, the number of patients suffering from chronic obstructive pulmonary disease is increasing and a demand for generic products for the treatment of chronic obstructive pulmonary disease (COPD) is growing. The long process of generic formulation development can be accelerated by using an inhaler with suitable fluid dynamics features. This paper presents a study of a newly patented single-dose Memmatec Mora® inhaler in two versions: with grid openings 1.0 (A) and 0.5 mm (B), using Seebri Breezhaler® as a reference product. The studies were conducted with inhalation powders containing 44μg glycopyrronium bromide placed in a capsule. The manuscript presents studies during the selection of a generic inhaler within the course of inhalation powder development by a pharmaceutical company. The fluid dynamics features of the inhalers and the dose delivered were determined. The aerodynamic particle size distribution (APSD) and the inhalable dose were tested using a cascade impactor. The delivery dose for the Breezhaler, Mora A and Mora B inhalers for a volumetric flow of 100 L×min-1 was 38.5, 40.5 40.3μg, respectively. Fine particle fraction of the inhalers tested was 22.3, 24.6 25.5μg, respectively. Results of the study indicate that increase of the glycopyrronium bromide inhalation dose can be achieved not only by changes in the manufacturing technology of inhalation powder, hard capsule technology or addition of best quality raw materials, but also by the use of a properly selected inhaler with specific fluid dynamics features.

Internal radiation exposure from TENORM for workers conducting cleaning activities on equipment used at geothermal energy plant.

Geothermal energy is predicted to be one of the most important renewable energy sources in the near future. In geothermal energy plants, the secondary products such as the scale containing naturally occurring radioactive material (NORM) and adhering to the surface of equipment produce radiation fields. The workers who maintain and clean such equipment are at a risk to be exposed by the technically enhanced NORM (TENORM). To estimate the risks of radiation exposure to the workers, we assessed internal doses resulting from the cleaning activities on 150 heat exchanging boards used at a geothermal energy plant, focusing on 222Rn, 226Ra, 210Pb, 228Ra and 228Th. The experiment was performed with the subjects of workers and office workers as control, supplying prepared foods and drinks. Using the analytical results of 210Pb, 226Ra, 228Ra, and 228Th in the excretions of subjects, committed effect doses were determined. The annual internal dose for the workers with protective clothing due to the cleaning activities on removing scale, assuming the cleaning activities requires 170h (standard monthly working time) a year, was obtained as 26μSv/y and the total dose including 222Rn inhalation dose was calculated as 323 μSv/y. The additional dose for the cleaning workers was less than the dose limit of 20000 μSv/y for radiation workers, even less than for general population (1000 μSv/y) recommended by International Commission on Radiological Protection (ICRP). However, the elevated inhalation dose for workers conducting cleaning activities may present a health hazard to workers if they deal with excessive materials containing TENORM, work for excessive time or are under inappropriate safety measures.

Indoor radon survey in Whitehorse, Canada, and dose assessment

Radon-222 (222Rn) and its decay products are the primary sources of a population’s exposure to background ionizing radiation. Radon decay products are the leading cause of lung cancer for non-smokers and the second leading cause of lung cancer after smoking for smokers. A community-driven long-term radon survey was completed in 232 residential homes in different subdivisions of Whitehorse, the capital of the Yukon, during the heating season from November to April in 2016–2017 and in 2017–2018. Radon concentrations were measured in living rooms and bedrooms on ground floors. The arithmetic and geometric means of indoor radon activity concentrations in different subdivisions of Whitehorse ranged from 52 ± 0.6 Bq m−3 and 37 ± 2.3 Bq m−3 in the Downtown area of Whitehorse to 993.0 ± 55.0 Bq m−3 and 726.2 ± 2.4 Bq m−3 in Wolf Creek. Underlying geology and glacial surfaces may partly explain these variations of indoor radon concentrations in subdivisions of Whitehorse. A total of 78 homes (34.0%) had radon concentrations higher than 100 Bq m−3, 47 homes (20.5%) had concentrations higher than 200 Bq m−3 and 33 homes (14.4%) had concentrations higher than 300 Bq m−3. The indoor radon contribution to the annual effective inhalation dose to residents ranged from 3.0 mSv in the Downtown area to 51.0 mSv in Wolf Creek. The estimated annual average dose to adults in Whitehorse, Yukon, is higher than the world’s average annual effective dose of 1.3 mSv due to the inhalation of indoor radon. The annual radon inhalation effective dose was assessed using radon measurements taken during winter; hence the assessed dose may be overestimated. Cost-efficient mitigation methods are available to reduce radon in existing buildings and to prevent radon entry into new buildings.

Investigation of 220Rn and its Progeny Distribution in a Test Chamber

Introduction: Due to the widespread belief that 220Rn's levels are minimal due to its shorter half life and that its contribution to the overall inhalation dose is neglected in the presence of other important natural radiation sources, data for 220Rn in indoor and industrial environments are few.
 Objectives: To find the distribution of radon, thoron and their progeny levels with wall and floor distances.
 Methods: The experimental methodology is as per the standard protocol provided by the Environmental Assessment Division, Department of Atomic Energy, Bhabha Atomic Research Centre, Government of India, Mumbai for radon groups working in the country. Measurements of radiation levels and the concentrations of radionuclides in the environment are accomplished employing appropriate nuclear instruments. The radon, thoron and their progeny levels were determined using Solid State Nuclear Track Detectors and the tracks formed in these films were counted by Spark Counter detailed methods are discussed elsewhere.
 Results At the room's walls, ceiling, and floors, 220Rn concentrations were highest and rapidly decreased as one moved away from them. Indoors, the concentration of 220Rn progeny is independent of the distance between walls. Research on 220Rn diffusion from each wall of the construction materials used and factors affecting the levels of 220Rn progeny in homes are two examples of the extensive and continuous study needed to estimate the dosage due to 220Rn and its offspring.
 Conclusions: The assessment of public exposure to natural radiation, particularly the exposure from 220Rn and its offspring, has to be conducted more thoroughly across the country.

Thinking "Green" When Treating "Pink Puffers" and "Blue Bloaters"-Reducing Carbon Footprint When Prescribing Inhalers.

The impact of man-made climate change is already affecting millions of people worldwide. The health care sector in the US is a relevant contributor, accounting for about 8 to 10% of national greenhouse gas emissions. This special communicationdescribes the harmful impact of propellant gases in metered dose inhalers (MDI) on the climate and summarizes and discusses current knowledge and recommendations from European countries. Dry powder inhalers (DPI) are a good alternative to MDIs and are available for all inhaler drug classes recommended in current asthma and COPD guidelines. Changing an MDI to PDI can significantly reduce carbon footprints. The majority of the US population is willing to do more to protect the climate. Primary care providers can engage in this by addressing the impacts of drug therapy on climate change in medical decision making.

Effective dose (ingestion and inhalation) due to radon from tap water samples in children at primary schools in Najaf city, Iraq

Abstract This study focuses on the evolution of radon concentrations in tap water samples of primary schools in Najaf city using a RAD-7 detector. Annual effective doses in children were calculated. A Geographic Information System technique was used for the mapping of radon concentrations, annual effective dose (AED) for ingestion, and inhalation. It was found that the average value of AED due to radon ingestion was 0.236 ± 0.020 μSv/year, while that due to radon ingestion was 0.015 ± 0.0001 nSv/year. Moreover, the range in value of the total AED in μSv/year was 0.015–1.171, with an average value of 0.236 ± 0.020. Radon concentrations in most samples of water comply with the world-wide limits that are approved by WHO and ICRP which state that safe limits (0.5 and 0.4 Bq/L), respectively. Furthermore, all results of the total AED due to radon ingestion and inhalation assessment from radon concentrations in tap water samples collected from the primary schools in Najaf city when used as drinking water were within the global limitations of the WHO. One may conclude that from the results of the AED in children (7–12 years), there is no danger of radon concentrations in the case of human consumption.

Estimation of Inhalation and Ingestion Dose Due to Radon Concentration in Drinking Water Samples of Shankaraghatta Forest Environment, Karnataka, India

Objectives: To estimate inhalation and ingestion doses due to radon concentration in rural areas of Shankaraghatta forest environment, India. Methods: In this study, the risk due to radon concentration in underground drinking water samples of the Shankaraghatta region has been estimated using emanometry technique. The 44 drinking water samples were collected from different water sources in sample bottles (500 ml) and were carefully sealed to ensure there is no air gap and were analysed within 24 hours by radon bubbler technique using a Lucas cell. Findings: The radon (222Rn) concentration in underground and surface water samples of the entire region varies from 1.10  0.25 Bq l􀀀1 to 30.67  5.10 Bq l􀀀1 with an average value of 13.10  2.2 Bq l􀀀1, is higher than the USEPA proposed maximum contamination threshold of 11Bql􀀀1.The Annual Effective Dose Equivalent (AEDE) ranges from 3.86 mSv y􀀀1 to 83.80 mSv y􀀀1 with an average value of 36.35mSv y􀀀1, which is slightly higher than the global average value. Novelty: The present work focuses on the public health of the study area where such estimation was not carried out. The estimated annual effective, inhalation and ingestion doses due to radon in underground drinking water samples are found to be substantially below the 100 mSvy􀀀1recommended by WHO and EC. Hence, public of the study area won’t receive any serious health hazard due to radon in drinking water and the water is fit for drinking without any additional treatment. Keywords: Radon Concentration; Underground and Surface water; Emanometry Technique

How to engineer aerosol particle properties and biopharmaceutical performance of propellant inhalers

Given the environmental compulsion to reformulate pressurised metered dose inhalers (pMDI) using new propellants with lower global warming potential, this study investigated how non-volatile excipients can be used to engineer aerosol particle microphysics and drug release. The dynamics of change in particle size, wetting and physical state were measured for single particles (glycerol/ethanol/beclomethasone dipropionate; BDP) in the aerosol phase at different relative humidity (RH) using an electrodynamic balance. BDP dissolution rates were compared for aerosols from pMDI containing different ratios of BDP:glycerol or BDP:isopropyl myristate (IPM). In 45 % RH, ethanol loss was followed by evaporation of condensed water to generate spherical particles with solid inclusions or compact irregular-shaped solid particles, according to the presence or absence of glycerol. In RH > 95 %, condensed water did not evaporate and BDP formed solid inclusions in water/glycerol or water droplets. Varying the non-volatile component, 0–50 % w/w, in pMDI resulted in a concentration-dependent 4–8-fold reduction in BDP dissolution rate. These findings demonstrate that non-volatile excipients provide a means of engineering aerosol properties and, modifying the rate of drug release from aerosol medicines. We also demonstrated differences between particles formed in vitro in ambient humidity versus higher humidity, more like that encountered during oral inhalation.

Radiotoxicity and health risk assessment of 222Rn in groundwater using statistical and Monte Carlo simulation approaches

Water is an important natural resource to humans, and itsquality has been a big concern from time immemorial. Water is polluted by the increasing activities of man. Pollutants of major concern include naturally occurring radioactive materials (NORM), heavy and potentially toxic metals, which are ubiquitous in the environment. Naturally occurring radionuclides such as 222Rn are the major precursors of lung and other types of cancer in humans. Exposure to radon in drinking water in excess of 300 pCi/L is treated as a radiological risk, while toxic metals in excess of the World Health Organization (WHO) maximum permissible levels in drinking water are considered both environmental and health risks to humans. A total of 34 groundwater samples were collected in the Akoko area of Ondo State, Nigeria for 222Rn activity concentration determination. The water samples were collected using standard techniques. RAD7 solid-state-detector was utilized for the 222Rn measurements. The results show the activity concentration of 222Rn ranging from 76 pCi/L to 3593 pCi/L with a mean value of 705 ± 76 pCi/L. Inhalation and ingestion doses from 222Rn dissolved in groundwater were evaluated for the infants, children, and adult populations in the study area. Radiological risks were evaluated through statistical and Monte Carlos simulation methods. It can be concluded from this study that there exists a likelihood of radiation-induced health risks due to inhalation of 222Rn from the sampled water.

Urine concentrations of vilanterol and its metabolites, GSK932009 and GW630200, after inhalation of therapeutic and supratherapeutic doses.

The 2023 Prohibited List issued by the World Anti-Doping Agency (WADA) permits athletes to inhale the beta2 -agonist vilanterol at a standard dose of 25 μg daily. However, given limited data on urine pharmacokinetics, vilanterol has no urinary threshold or decision limit to discriminate therapeutic from supratherapeutic use. We investigated urine concentrations of vilanterol and its main metabolites GSK932009 and GW630200 over 0-72 h following inhalation of therapeutic (25 μg) or supratherapeutic (100 μg) doses and repeat-dose administration for 7 days of 25 or 100 μg·day-1 in 25 trained men and women. Vilanterol administration was followed by 1 h of exercise. GW630200 urine concentrations were low and insufficient for threshold purposes, and while GSK932009 had higher urine concentrations, it could not discriminate between therapeutic and supratherapeutic use. Mean (range) maximum urine concentrations of parent vilanterol were 1.2 (0.2-4.1) and 6.2 (1.4-14.3)ng·ml-1 for single-dose 25 and 100 μg vilanterol, respectively, and 2.0 (0.3-4.8) and 22.4 (6.4-42.1)ng·ml-1 for repeat-dose 25 and 100 μg·day-1 vilanterol. In 333 samples collected 6 h post-administration and considering WADA TD2022DL, a 3.1 ng·ml-1 vilanterol cut-off showed 30% sensitivity in detecting supratherapeutic use at 100 μg versus therapeutic use at 25 μg. Considering inter- and intra-individual variability and guard bands in doping analysis, a 6 ng·ml-1 decision limit, which could be shifted upwards in samples with specific gravity >1.018, appears sufficiently high to minimize risk of samples exceeding the decision limit after therapeutic use of vilanterol, while demonstrating the ability to detect supratherapeutic use at 100 μg.

Assessing of low-tech solutions for aerosol delivery: Comparative performance study of manufactured versus homemade spacers

PurposeThis study aims to evaluate the performance of low-cost homemade spacers compared with manufactured valved holding chambers (VHCs) for fluticasone propionate delivery via a pMDI (pressurized Metered Dose Inhaler). MethodsThe Total Emitted Dose (TED) and particle size distribution were measured for pMDI alone or connected to the different spacers, according to CAN/CSA-Z264.1-02 standard. Two types of low-cost alternative and manufactured spacers were investigated: 500 mL plastic bottle and 553 mL aluminium can; non-antistatic plastic VHCs and aluminium antistatic VHCs. ResultsThe TED of homemade plastic bottle vs plastic VHC were similar in the 20–23% range. In contrast, the TED of homemade aluminium can was higher compared to aluminium VHC (83% vs 68%). The Fine Particle Fraction (FPF) was similar for the two plastic-based spacers (in the 12.68–17.60% range), although it was greater for the aluminium can compared to aluminium VHC (51% vs 42%). However, all spacers have limited large particles fraction, mainly deposited in the oropharyngeal tract, potentially decreasing side effects. ConclusionWe demonstrated that low-tech solutions as homemade spacers have at least similar performances to VHC medical devices composed of same material (aluminium or plastic). Thus, low-cost homemade spacers represent alternatives in case of emergency and without VHCs nearby.

Detection of Asthma Inhaler Use via Terahertz Spectroscopy.

Inhaled medications are commonplace for administering bronchodilators, anticholinergics, and corticosteroids. While they have a defined legitimate use, they are also used in sporting events as performance-enhancing drugs. These performance enhancers can be acquired via both legal (i.e., at a pharmacy through over-the-counter medications or through a prescription) and illicit (i.e., black market and foreign pharmacies) means, thus making monitoring procurement impossible. While urine tests can detect these pharmacological agents hours after they have been inhaled, there is a significant lag time before they are observed in urine. Direct detection of these inhaled agents is complicated and requires a multiplexed approach due to the sheer number of inhaled pharmacological agents. Therefore, detection of propellants, which carry the drug into the lungs, provides a simpler path forward toward detection of broad pharmacological agents. In this paper, we demonstrate the first use of terahertz spectroscopy (THz) to detect inhaled medications in human subjects. Notably, we were able to detect and quantitate the propellant, HFA-134a, in breath up to 30 min after using an asthma inhaler, enabling the use of a point-of-care device to monitor exhaled breath for the presence of propellants. We also demonstrate via simulations that the same approach can be leveraged to detect and identify next-generation propellants, specifically HFA-152a. As a result, we provide evidence that a single point-of-care THz sensor can detect when individuals have used pressure-mediated dose inhalers (pMDIs) without further modification of the hardware.

Age-dependent potential health risk assessment due to radioactive radon-222 in the environs of highly populated Durgapur industrial zone and nearby Bakreswar hot spring, India.

It is well known that exposure to a high concentration of radon-222 causes severe health effects, including cancer. The present article includes a survey on radon-222 in the water bodies of the city Durgapur [non-geothermal area] and nearby Bakreswar hot spring [geothermal province], India. The possible sources of radon from natural radionuclides and industries have been discussed in the article. Durgapur is a densely populated [~ 3680 persons/km2] industrial city with a population of 0.57 million. On the other hand, many tourists and pilgrims usually visit Bakreswar throughout the year. Age-dependent potential health risk assessments of the dwellers at Durgapur and Bakreswar due to radon exposure were performed for the first time. The present work is the first attempt to estimate the mean ingestion /and inhalation dose per annum, total effective dose [TED] per annum and the health risk assessment for cancer in adults, children and infants due to radon exposure at Durgapur and Bakreswar. In some cases, the values of TED exceed the permissible limit of 100 micro Sievert per year [µSv/y] as recommended by EUC and WHO. The radiation profile maps relating to radon concentration and associated contour maps of health risk factors [HRF] for the adults, children and infants were also prepared for the first time. Some areas were identified as high-risk zones, and the dwellers are prone to a high risk of cancer. The article also proposed several techniques to reduce radon in water and buildings. The authors also recommended banning some water sources to protect people from radon risk. This study will help scientists, policymakers, industrialists, farmers, government agencies and public health departments.

210Po in the Environment: Reassessment of Dose to Humans

Significant efforts have been made by the International Commission on Radiological Protection (ICRP) to establish a reliable basis of equivalent and effective doses due to radionuclides. The ICRP over years has been updating the dose coefficients to include recent developments and make it more realistic. This perspective highlights some issues that warrant updating the methodology used for estimating 210Po dose to humans. The need to underpin these dose coefficients with ever-increasing literature has encouraged us to share the observation on the significant loss of 210Po due to seafood cooking, considering the loss due to cooking warrants changing the factor for the dose from seafood ingestion. Most dose assessment approaches use whole-body concentration, while most 210Po is present in the liver and digestive system that often are not part of the edible portion. The other factor is the extremely high 210Po concentration in aerosols as a result of coal and oil-fired power plants, forest fires, and volcanic activities, especially in the inhalable fraction. The 210Po/210Pb concentration ratio in the Gulf was observed to be between 1.6 and 1.9 in contrast to the 0.1 ratio observed in non-impacted areas. This reassessment of the inhalation dose is also relevant globally due to increasing incidences of forest fires where a much higher than 0.1 210Po/210Pb ratio is expected and will result in a significant inhalation dose.

An evaluation of the use of inhalers in asthma and chronic obstructive pulmonary disease

ObjectivesInhaled therapy is the treatment of choice for obstructive lung diseases such as asthma and chronic obstructive pulmonary disease (COPD). However, the maximum benefit from such therapy depends on the correct use of inhaler devices. In this study, our primary aim was to evaluate inhaler techniques in patients with asthma and COPD in order to identify common errors. In addition, we investigated the effect of various parameters on the rate of inhaler misuse. MethodsWe enrolled a total of 300 asthma/COPD patients, who presented at the Chest Diseases and Family Medicine Outpatient Clinics of a tertiary hospital located in Ankara, Turkey. We used a face-to-face survey that included questions about sociodemographic features and inhaler therapy. Subsequently, we requested patients to demonstrate how they use their inhalers and assessed their inhalation technique according to checklists. ResultsOf the 300 patients, 70.2% used their inhaler drugs incorrectly. The rate of misuse among metered dose inhaler (MDI) users was significantly higher than those using dry powder inhalers (DPIs) (77.6% vs 64%; p = 0.002). When DPI devices were analyzed, the rates of misuse were significantly higher in Handihaler users (p = 0.012) and Diskus inhaler users (p = 0.009) when compared to Sanohaler users. Gender, type of disease (asthma/COPD), duration of inhaler use, and duration of illness had no impact on the rate of misuse. However, an advanced age (>60 years old), a level of education lower than high school, and the use of MDI were all identified as factors associated with misuse. The most common mistake was ‘failing to breath out before inhalation’ for all types of devices (for MDI: 66.7%, and for DPI: 71.1–82.8%). ConclusionsThe rate of inhaler drug misuse was high. The identification of factors associated with misuse could provide information to implement appropriate actions to reduce the rates of misuse.

Sustaining Long-term Asthma Outcomes at a Community and Tertiary Care Pediatric Hospital.

Implementing asthma Clinical Practice Guidelines (CPG) have been shown to improve length of stay (LOS) and readmission rates on a short-term basis at both tertiary care and community hospital settings. Whether these outcomes are sustained long term is not known. The goal of this study was to measure the long-term impact of CPG implementation at both tertiary and community sites in 1 hospital system. A retrospective study was conducted using the Pediatric Health Information System database. LOS and 7- and 14-day emergency department (ED) revisit and readmission rates from 2009 to 2020 were compared pre and post implementation of asthma CPG in 2012 at both sites. Implementation involved electronic order sets, early metered dose inhaler introduction, and empowering respiratory therapists to wean per the bronchodilator weaning protocol. Interrupted time series and statistical process control charts were used to assess CPG impact. Implementation of asthma CPG was associated with significant reductions in the variability of LOS without impacting ED revisit or readmission rates at both the tertiary and community sites. Secular trends in the interrupted time series did not demonstrate significant impact of CPG on LOS. However, the overall trend toward decreased LOS that started before CPG implementation was sustained for 7 years after CPG implementation. Early metered dose inhaler introduction, respiratory therapist-driven bronchodilator weaning, and electronic order sets at both the community and tertiary care site led to a significant reduction in the variation of LOS, without impacting ED revisit or readmission rate.

Disposal Methods of Used Pressurized Metered Dose Inhalers and Spacers by Families of Children With Asthma

The choice of disposal method of used pressurized metered dose inhalers and spacers by families of children with asthma were evaluated by a questionnaire. The disposal methods used for inhalers and spacers by the 120 children enrolled included giving to plastic/metal waste collectors (28.3% and 33.3%), burning (15.8% and 8.3%), general waste (9.2% and 6%), burial (5.8% and 2.4%), hospital waste (1.7% and 1.2%), rivers (0.8% and 1.2%) and open dumping (0.8% and 0%), respectively. Further, 37.5% of inhalers and 47.6% of spacers were awaiting disposal after use, and were stored at home.