Use Of Inhaled Medications Research Articles

Pharmacist Interventions for Inhaled Medication Use in Chronic Obstructive Pulmonary Disease (COPD).

Pharmacists are ideally situated and trained to educate and advocate for the proper use of inhaled medications among patients in the community. Proper inhaler technique is an important way to prevent exacerbations and manage the symptoms associated with chronic pulmonary diseases. The American Lung Association estimates almost 6 million people 65 years of age or older had a diagnosis of chronic obstructive pulmonary disease (COPD) in 2020 in the United States. However, published reports have found that less than 20% of older people with COPD use inhalers correctly. As inhalers are the primary route of administration for medications used to treat chronic airway diseases such as COPD, pharmacist-led education can help overcome the widespread lack of knowledge regarding proper inhaler use.

Emotion regulation among adults with asthma: Links with short-acting inhaler medication overuse and utilization of acute medical care

Objective Existing research suggests that emotion plays an important role in airway inflammation and asthma symptom control. The objective of this study was to determine whether difficulties regulating emotion were associated with overuse of short-acting inhaled medications and acute medical care usage in adults with asthma. Methods The sample included 401 adults with asthma recruited from an online panel of adults with chronic respiratory disease. Sequential binary logistic regression models were used to examine the associations of emotion regulation with short-acting inhaled medication use and acute medical care use, controlling for patient characteristics and comorbid mental health conditions. Results Greater difficulties with emotion regulation were significantly associated with greater odds of short-acting inhaler medication overuse (p < 0.001), emergency department visits (p < 0.001), and hospitalizations (p = 0.001). Conclusions Emotion dysregulation may play an important role in asthma management. Evidence-based interventions to reduce difficulties in emotion regulation may help improve problematic patterns of short-acting medication overuse and acute service use. The current findings should be interpreted in the context of several limitations, including the use of self-report measures. Future research should use electronic medical records or metered dose inhalers to objectively assess short-acting inhaler overuse and acute medical care use.

Relationship between symptoms and results on spirometry in adults seen in non-tertiary public health facilities presenting with preserved ratio impaired spirometry.

Preserved ratio impaired spirometry (PRISm), defined by reduced forced expiratory volume in 1 second (FEV1) without meeting criteria for airway obstruction, is often encountered in clinical practice. The management of this heterogeneous condition in individuals with chronic respiratory symptoms is challenging, especially under limited diagnostic resources. Since 2020, all consecutive patients referred for spirometry at our institution have been invited to participate in our registry. Other than spirometry, no other physiological lung function testing is available in this public health service. Therefore, we reviewed our databank with the aim of assessing: i) the proportion of symptomatic patients aged 18 years or older referred for spirometry presenting with PRISm; ii) the rate of inhaled medication used in this group, suggesting a referral diagnosis of obstructive airway disease (OAD); and iii) the relationship between symptoms and results on spirometry in PRISM compared to a group with obstruction matched by FEV1. To this end, the COPD Assessment Test (CAT) and the Asthma Control Test (ACT) were conjointly responded to by 1032 participants, irrespective of the clinical suspicion. We found that 22% had PRISM, of whom 200 were paired with obstruction by FEV1 (68±10% of predicted). The CAT and ACT results were well-correlated in both groups (r=-0.727 and -0,698, respectively; p<0.001) and used to measure symptoms. Participants in the final sample (n=400) were aged 62±13 years; 70% were ever smokers; and 55% reported household exposure to biomass smoke (at least 5 years). The CAT responses were in the range of moderate symptoms (17±9) and ACT borderline for uncontrolled symptoms (19±5). The main differences were higher body mass index (33±7 versus 29±7 kg/m2; p<0.001) and proportion of females (72 versus 49%; p<0.001) in PRISm compared to obstruction. This group had lower exposure to tobacco (65 versus 76% of ever-smokers) but greater exposure to biomass smoke (61 versus 49%) (p<0.05 for all). The rate of inhaled medication use was as high in PRISm as in obstruction (80%). Notwithstanding matched FEV1, we found less prominent signs of airway disease in PRISM: marginally reduced FEV1/forced vital capacity (FVC) ratio (94±8% of predicted); higher expiratory flow between 25% and 75% of vital capacity, despite presumed lower lung volumes (lower FVC); and lower rate of bronchial hyperresponsiveness. In an identical multivariate model, FEV1 predicted symptoms of obstruction only. In conclusion, these data raise suspicion of a substantial rate of misclassification of individuals with PRISM as having OAD in healthcare facilities with constraints on diagnostic resources.

Health effects of air pollution on respiratory symptoms: A longitudinal study using digital health sensors

Previous studies of air pollution and respiratory disease often relied on aggregated or lagged acute respiratory disease outcome measures, such as emergency department (ED) visits or hospitalizations, which may lack temporal and spatial resolution. This study investigated the association between daily air pollution exposure and respiratory symptoms among participants with asthma and chronic obstructive pulmonary disease (COPD), using a unique dataset passively collected by digital sensors monitoring inhaled medication use. The aggregated dataset comprised 456,779 short-acting beta-agonist (SABA) puffs across 3,386 people with asthma or COPD, between 2012 and 2019, across the state of California. Each rescue use was assigned space–time air pollution values of nitrogen dioxide (NO2), fine particulate matter with diameter ≤ 2.5 µm (PM2.5) and ozone (O3), derived from highly spatially resolved air pollution surfaces generated for the state of California. Statistical analyses were conducted using linear mixed models and random forest machine learning. Results indicate that daily air pollution exposure is positively associated with an increase in daily SABA use, for individual pollutants and simultaneous exposure to multiple pollutants. The advanced linear mixed model found that a 10-ppb increase in NO2, a 10 μg m−3 increase in PM2.5, and a 30-ppb increase in O3 were respectively associated with incidence rate ratios of SABA use of 1.025 (95 % CI: 1.013–1.038), 1.054 (95 % CI: 1.041–1.068), and 1.161 (95 % CI: 1.127–1.233), equivalent to a respective 2.5 %, 5.4 % and 16 % increase in SABA puffs over the mean. The random forest machine learning approach showed similar results.This study highlights the potential of digital health sensors to provide valuable insights into the daily health impacts of environmental exposures, offering a novel approach to epidemiological research that goes beyond residential address. Further investigation is warranted to explore potential causal relationships and to inform public health strategies for respiratory disease management.

Bidirectional relationship between chronic obstructive pulmonary disease and oral disease

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that has various comorbid conditions and systemic complications. One of the complications is dental and oral disease, which can occur through systemic inflammatory mechanisms and the long-term side effects of inhaled drugs. Dental and oral diseases can also cause COPD progression, increase the risk of exacerbations, and affect the patient's quality of life. Some mechanisms that may play a role include aspiration of oral pathogens, aspiration of inflammatory proteins, and systemic inflammation. Dysbiosis of the lung microbiome can result from dental and oral conditions, increasing the risk of COPD and pulmonary infections. The association between COPD and oral disease includes the presence of systemic inflammatory conditions, the risk factor of smoking, and the indirect effects of inhaled medication use. Comprehensive management of COPD patients regarding dental and oral health is needed, which includes prevention of dental and oral disease, routine assessment of dental and oral health, provision of specific dental therapy, and personalized treatment in selecting COPD therapy.

Errors and Adherence to Inhaled Medications in Chinese Adults with COPD.

Adherence to inhaled medications is key to chronic obstructive pulmonary disease (COPD) control and management. To assess errors and adherence to inhalation therapy in COPD patients, and identify potential factors associated with poor adherence. This cross-sectional study was conducted from October 1, 2022, to November 30, 2022, in 24 hospital outpatient departments in different cities of Hunan Province, China. Adherence to inhaled medications was measured using the 10-item Test of Adherence Inventory, and the results were expressed using both descriptive and inferential statistics. A total of 2218 clinically confirmed adult COPD patients completed the questionnaires, and 1423 patients with more than a 3-month history of inhalation therapy were analyzed. This study found that 61.3% of patients made one or more use errors. Not holding the breath after inhalation or holding the breath for less than 3s had the highest reporting rate (30.7%). A considerable proportion of patients (66.6%) demonstrated suboptimal adherence to inhaled medications. Patients who resided in rural areas (OR 1.45, 95% CI 1.12-1.88), used dual therapy (OR 1.47, 95% CI 1.05-2.05), and exhibited common use errors (OR 3.02, 95% CI 2.39-3.82) were more likely to present suboptimal adherence. Patients with CAT (Chronic Obstructive Pulmonary Disease Assessment Test) score < 10 (OR 0.73, 95% CI 0.56-0.94), a junior high school education and above (OR 0.73, 95% CI 0.57-0.94), and duration of inhaled medication use > 3years (OR 0.63, 95% CI 0.47-0.83) were associated with better adherence. Suboptimal adherence to inhaled medications and many inhalation therapy errors were identified among COPD patients. Common use errors in inhaled medications, CAT score, and education background were predictive of and influenced adherence to inhaled medications. It is necessary to strengthen training in Chinese patients about inhaler use and follow-up intensively with patients throughout treatment, especially for patients with risk factors.

Risk factors for poorer respiratory outcomes in adolescents and young adults born preterm

RationaleThe respiratory outcomes for adult survivors of preterm birth in the postsurfactant era are wide-ranging with prognostic factors, especially those encountered after the neonatal period, poorly understood.ObjectivesTo obtain comprehensive ‘peak’...

Disability Retirement After First Admission with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Danish Nationwide Registry Cohort Study Using a Retrospective Follow-Up Design.

IntroductionMany chronic obstructive pulmonary disease (COPD) patients below retirement age are outside the workforce. The existing knowledge about association between acute exacerbation of COPD (AECOPD) and disability retirement is limited.AimThe aim of this study is to explore disability retirement in COPD patients 3 years following first-ever AECOPD.MethodsThis retrospective registry-based follow-up cohort study design is based on nationwide Danish registry data. Patients admitted to the hospital for the first time between 1999 and 2017 with AECOPD and age between 35 and 59 years, active in the workforce, were included in the study. Socio-demographics, comorbidities and inhaled medication use were explored. COPD patients’ hazard ratio of disability retirement during 3-year follow-up was calculated. Cox regression was used to examine the effects of covariates on disability retirement.ResultsA total of 4032 patients were included in the study. During follow-up, 17.2% (692/4032) experienced disability retirement from the workforce. Factors associated with disability retirement were expressed as hazard ratio (95% confidence intervals): Higher age (ref. age 46–50: Age 51–55, 1.42, (1.12–1.81); age 56–59, 1.37 (1.08–1.74)); living alone (1.34 (1.14–1.56)); number of comorbidities for 1, 2, and 3 comorbidities (1.36 (1.14–1.62), 1.57 (1.19–2.07), 1.77 (1.20–2.60)); emphysema (2.01 (1.44–2.79)); depression (1.60 (1.12–2.28)); cardiac comorbidity (1.38 (1.07–1.78)); triple inhalation therapy (2.76 (2.20–3.47)); ICS + LAMA or ICS + LABA treatment (1.82 (1.48–2.23)); and ICS treatment (1.49 (1.17–1.90)). Higher educational level was associated with a significantly reduced risk of disability retirement, medium, short higher and long higher educational level, relative to low education level (0.78 (0.67–0.91), 0.63 (0.48–0.83) and 0.27 (0.12–0.60)).ConclusionPatients vulnerable to disability retirement are patients with markers of severe COPD, comorbidities, and social vulnerability.

Asthma-like symptom or "cystic fibrosis asthma"?

The diagnosis of asthma is still a difficult problem in cystic fibrosis. There is no consensus on how to define "CF asthma". The aim of this study was to determine the role of bronchodilator response and laboratory evidence of allergy in "CF asthma". Patients aged ≥6 years with evaluated bronchodilator response and characteristics of atopy were included in the study. Patients diagnosed with Allergic Bronchopulmonary Aspergillosis or pulmonary exacerbation were excluded. A total of 204 CF patients were evaluated, and 40 who met the criteria were included. Asthma had been diagnosed in ten patients. A positive bronchodilator response was present in 47.3% of the patients tested. Aeroallergen sensitization was present in 52.5% of the patients. While the frequency of recurrent/history of wheezing, family history of atopy and elevated total immunoglobulin E were similar (p> 0.05), the frequencies of inhaled medication use and coexistence of asthma were statistically higher in the group with positive allergen sensitization (p<0.05). The frequencies of positive bronchodilator response (77.7% versus 37.9%) and a family history of asthma/atopy (40% versus. 23%) were found to be similar in CF asthma and CF. There were significant increases in total IgE and allergen-specific IgE and an increase in the frequency of aeroallergen sensitization in CF asthma compared to CF (p<0.05). Although not routinely used in the evaluation of patients, allergen specific-IgE and skin prick test for aeroallergen sensitization may be used as an adjunctive test in patients with suspected clinical findings. The recognition of CF asthma may facilitate the development of targeted therapies.

Inhaled Medication Use in Smokers With Normal Spirometry.

The objective of our study was to identify variables associated with inhaled medication use in smokers with normal spirometry (GOLD-0) and to examine the association of inhaled medication use with development of exacerbations and obstructive spirometry in the future. We performed a retrospective multivariable analysis of GOLD-0 subjects identified in data from the COPDGene study to examine factors associated with medication use. Five categories were identified: (1) no medications, (2) short-acting bronchodilator, (3) long-acting bronchodilator; long-acting muscarinic antagonists and/or long-acting β agonist, (4) inhaled corticosteroids (ICS) with or without long-acting bronchodilator, and (5) dual bronchodilator with ICS. Sensitivity analysis was performed excluding subjects with history of asthma. We also evaluated whether long-acting inhaled medication use was associated with exacerbations and obstructive spirometry at the follow-up visit 5 y after enrollment. Of 4,303 GOLD-0 subjects within the analysis, 541 of them (12.6%) received inhaled medications. Of these, 259 (6%) were using long-acting inhaled medications and 282 (6.6%) were taking short-acting bronchodilator. Female sex (odds ratio [OR] 1.47, P = .003), numerous medical comorbidities, radiographic emphysema (OR 2.22, P = .02), chronic bronchitis (OR 1.77, P < .001), dyspnea (OR 2.24, P < .001), asthma history (OR 15.56, P < .001), prior exacerbation (OR 8.45, P < .001), and 6-min walk distance (OR 0.9, P < .001) were associated with medication use. Minimal changes were noted in a sensitivity analysis. Additionally, inhaled medications were associated with increased total (incidence rate ratio 2.83, P < .001) and severe respiratory exacerbations (incidence rate ratio 3.64, P < .001) and presence of obstructive spirometry (OR 2.83, P = .002) at follow-up. Respiratory symptoms, history of asthma, and radiographic emphysema were associated with inhaled medication use in smokers with normal spirometry. These individuals were more likely to develop obstructive spirometry, which suggests that health care providers may be able to identify obstructive lung disease prior to meeting the current criteria for COPD.

Improving lung cancer risk stratification leveraging whole transcriptome RNA sequencing and machine learning across multiple cohorts

BackgroundBronchoscopy for suspected lung cancer has low diagnostic sensitivity, rendering many inconclusive results. The Bronchial Genomic Classifier (BGC) was developed to help with patient management by identifying those with low risk of lung cancer when bronchoscopy is inconclusive. The BGC was trained and validated on patients in the Airway Epithelial Gene Expression in the Diagnosis of Lung Cancer (AEGIS) trials. A modern patient cohort, the BGC Registry, showed differences in key clinical factors from the AEGIS cohorts, with less smoking history, smaller nodules and older age. Additionally, we discovered interfering factors (inhaled medication and sample collection timing) that impacted gene expressions and potentially disguised genomic cancer signals.MethodsIn this study, we leveraged multiple cohorts and next generation sequencing technology to develop a robust Genomic Sequencing Classifier (GSC). To address demographic composition shift and interfering factors, we synergized three algorithmic strategies: 1) ensemble of clinical dominant and genomic dominant models; 2) development of hierarchical regression models where the main effects from clinical variables were regressed out prior to the genomic impact being fitted in the model; and 3) targeted placement of genomic and clinical interaction terms to stabilize the effect of interfering factors. The final GSC model uses 1232 genes and four clinical covariates – age, pack-years, inhaled medication use, and specimen collection timing.ResultsIn the validation set (N = 412), the GSC down-classified low and intermediate pre-test risk subjects to very low and low post-test risk with a specificity of 45% (95% CI 37–53%) and a sensitivity of 91% (95%CI 81–97%), resulting in a negative predictive value of 95% (95% CI 89–98%). Twelve percent of intermediate pre-test risk subjects were up-classified to high post-test risk with a positive predictive value of 65% (95%CI 44–82%), and 27% of high pre-test risk subjects were up-classified to very high post-test risk with a positive predictive value of 91% (95% CI 78–97%).ConclusionsThe GSC overcame the impact of interfering factors and achieved consistent performance across multiple cohorts. It demonstrated diagnostic accuracy in both down- and up-classification of cancer risk, providing physicians actionable information for many patients with inconclusive bronchoscopy.

Alignment of Inhaled Chronic Obstructive Pulmonary Disease Therapies with Published Strategies. Analysis of the Global Initiative for Chronic Obstructive Lung Disease Recommendations in SPIROMICS.

Despite awareness of chronic obstructive pulmonary disease (COPD) treatment recommendations, uptake is poor. The Subpopulations and Intermediate Outcome Measures in COPD Study (SPIROMICS) spans 2010-2016, providing an opportunity to assess integration of 2011 Global Initiative for Obstructive Lung Disease (GOLD) treatment strategies over time in a large observational cohort study. To evaluate how COPD treatment aligns with 2011 GOLD strategies and determine factors associated with failure to align with recommendations. Information on inhaled medication use collected via questionnaire annually for 4 years was compiled into therapeutic classes (long-acting antimuscarinic agent, long-acting β-agonist, inhaled corticosteroids [ICS], and combinations thereof). Medications were not modified by SPIROMICS investigators. 2011 GOLD COPD categories A, B, C, and D were assigned. Alignment of inhaler regimen with first-/second-line GOLD recommendations was determined, stratifying into recommendation aligned or nonaligned. Recommendation-nonaligned participants were further stratified into overuse and underuse categories. Of 1,721 participants with COPD, at baseline, 52% of regimens aligned with GOLD recommendations. Among participants with nonaligned regimens, 46% reported underuse, predominately owing to lack of long-acting inhalers in GOLD category D. Of the 54% reporting overuse, 95% were treated with nonindicated ICS-containing regimens. Among 431 participants with 4 years of follow-up data, recommendation alignment did not change over time. When we compared 2011 and 2017 recommendations, we found that 47% did not align with either set of recommendations, whereas 35% were in alignment with both recommendations. Among SPIROMICS participants with COPD, nearly 50% reported inhaler regimens that did not align with GOLD recommendations. Nonalignment was driven largely by overuse of ICS regimens in milder disease and lack of long-acting inhalers in severe disease.

Results of a Pulmonologist Survey Regarding Knowledge and Practices With Inhalation Devices for COPD.

COPD guidelines advise on inhaled medication use, yet no advice is offered on when to use and which type of patient could benefit from a specific delivery device. We investigated pulmonologists' perception of their knowledge and practices with delivery devices for COPD management. An online survey was designed by a steering committee of American Thoracic Society clinicians and scientists and conducted by a national market research firm between January 7 and 29, 2016. Two hundred and five respondents completed the survey. Nearly 80% of the respondents believed that they were very knowledgeable in COPD management and the use of medications; 68% believed that they were knowledgeable about preventing exacerbations. Ninety-eight percent of the respondents stated that they were at least somewhat knowledgeable about devices. Many respondents (70%) stated that small-volume nebulizers were more effective than dry powder inhalers and pressurized metered-dose inhalers in the management of COPD exacerbations, and 63% believed that these were more effective in severe COPD (modified Medical Research Council dyspnea scale grade 4). Only 54% of the respondents discussed device options with their patients. Physician screening for physical or cognitive impairments that could impact device choices was 53% and 16%, respectively. Seventy percent of the respondents discussed device use, whereas 9% discussed cleaning and storage during a patient's first visit. Few respondents were very knowledgeable in teaching patients how to use devices (43%) and, specifically, how to use (32%) or clean and/or maintain (20%) small-volume nebulizers. Most respondents were confident in their knowledge about treating COPD. Fewer respondents were confident about the use and maintenance of inhalation devices, and most respondents desired to learn more about inhalation devices.

Asthma-like symptoms, diagnostic tests, and asthma medication use in children and adolescents: a population-based nationwide survey

Objective: This study aimed to estimate the prevalence of asthma-like symptoms, current asthma (CA), asthma diagnostic tests, and inhaled medication use in a nationwide pediatric population (<18 years). Methods: Pediatric-specific data from a cross-sectional, population-based telephone survey (INAsma study) in Portugal were analyzed. CA was defined as lifetime asthma and (1) wheezing, (2) waking with breathlessness, or (3) asthma attack in the previous 12 months, and/or (4) taking asthma medication at the time of the interview. Results: In total, 716 children were included. The prevalence of asthma-like symptoms was 39.4% [95% confidence interval (95% CI): 35.7–43.3]. The most common symptoms were waking with cough (30.9%) and wheezing (19.1%). The prevalence of CA was 8.4% (95% CI: 6.6–10.7). Among children with CA, 79.9% and 52.9% reported prior allergy testing and pulmonary function testing (PFT), respectively. Inhaled medication use in the previous 12 months was reported by 67.6% (reliever inhalers, 40.1%; controller inhalers, 41.5%). Those who only used inhaled reliever medications experienced more asthma attacks [odds ratio (OR): 2.69]. Significantly fewer children with CA living in rural areas than those living in urban areas had undergone PFT or used inhaled medication (OR: 0.06 for PFT, 0.20 for medication]. Conclusions: The prevalence of CA in the Portuguese pediatric population was 8.4%. Only half of children with CA had ever undergone PFT; more than half did not use controller inhalers, and those who only used reliever inhalers reported more asthma attacks. These findings suggest that asthma management has been substandard, mainly in rural areas.

The Association of Weight With the Detection of Airflow Obstruction and Inhaled Treatment Among Patients With a Clinical Diagnosis of COPD

BACKGROUND:Most patients with a clinical diagnosis of COPD have not had spirometry to confirm airflow obstruction (AFO). Overweight and obese patients report more dyspnea than normal weight patients, which may be falsely attributed to AFO. We sought to determine whether overweight and obese patients who received a clinical diagnosis of COPD were more likely to receive a misdiagnosis (ie, lack of AFO on spirometry) and be subsequently treated with inhaled medications.METHODS:The cohort comprised US veterans with COPD (International Classification of Diseases, 9th Revision, code; inhaled medication use; or both) and spirometry measurements from one of three Pacific Northwest Veterans Administration Medical Centers. The measured exposures were overweight and obesity (defined by BMI categories). Outcomes were (1) AFO on spirometry and (2) escalation or deescalation of inhaled therapies from 3 months before spirometry to 9 to 12 months after spirometry. We used multivariable logistic regression with calculation of adjusted proportions for all analyses.RESULTS:Fifty-two percent of 5,493 veterans who had received a clinical diagnosis of COPD had AFO. The adjusted proportion of patients with AFO decreased as BMI increased (P< .01 for trend). Among patients without AFO, those who were overweight and obese were less likely to remain off medications or to have therapy deescalated (adjusted proportions: normal weight, 0.69 [95% CI, 0.64-0.73]; overweight, 0.62 [95% CI, 0.58-0.65;P= .014]; obese, 0.60 [95% CI, 0.57-0.63;P= .001]).CONCLUSIONS:Overweight and obese patients are more likely to be given a misdiagnosis of COPD and not have their inhaled medications deescalated after spirometry demonstrated no AFO. Providers may be missing potential opportunities to recognize and treat other causes of dyspnea in these patients.

Predictors of Severe Exacerbations, Poor Asthma Control, and β-Agonist Overuse for Patients with Asthma

Predictors of asthma exacerbations, poor asthma control, or extreme β-agonist overuse may be of clinical utility in the management of asthma. To investigate characteristics that predict subsequent adverse outcomes in asthma. An independent 24-week, randomized controlled trial of 303 adult patients with asthma who are at risk, which compared the efficacy of SMART (single budesonide-formoterol inhaler as maintenance and reliever therapy) with a fixed-dose regimen with salbutamol as reliever ("Standard"). Inhaled medication use was measured by electronic monitoring. Baseline characteristics that were predictors of subsequent severe asthma exacerbations, poor asthma control (Asthma Control Questionnaire -5 score ≥1.5), and "extreme" β-agonist overuse (>16 budesonide-formoterol actuations/d in SMART and >32 salbutamol actuations/d in Standard) were assessed by multivariate analyses. FEV₁ % predicted (rate ratio [RR] 1.14 [95% CI, 1.03-1.27] per 10% lower), more previous exacerbations (RR 1.15 [95% CI, 1.01-1.31]), Standard therapy (RR 1.62 [95% CI, 1.07-2.47]), and female sex (RR 2.18 [95% CI, 1.29-3.67]) were associated with future severe exacerbations. Asthma Control Questionnaire--5 (regression coefficient 0.20 [95% CI, 0.13-0.27] per 0.5 points higher) and age (regression coefficient 0.09 [95% CI, 0.01-0.17] per decade older) were associated with future poorly controlled asthma. Higher reliever use (RR 1.63 [95% CI, 1.36-1.95] per categorical score in Asthma Control Questionnaire question no. 6), Māori ethnicity (RR 2.20 [95% CI, 1.43-3.38]) and FEV₁ % predicted (RR 1.16 [95% CI, 1.03-1.31] per 10% lower) were associated with future extreme β-agonist overuse. Future severe asthma exacerbations, poor asthma control, and extreme β-agonist overuse are predicted by different baseline clinical and demographic characteristics and management approaches in at-risk asthma.

P165 The reliability and performance of electronic monitors of inhaler use in a real world asthma clinical trial

Introduction Electronic monitoring is one method to measure the use of inhaled therapy in asthma patients in clinical trials, though the reliability of these devices has been variable. Implementation of trial quality control processes and reporting on the performance of electronic monitors during patient use may help to better understand their utility and limitations. The Smartinhaler Tracker is an electronic monitor for metered dose inhalers (MDIs) that records the date, time and number of actuations to the nearest second. Objectives In a recently completed 24-week real-world randomised controlled trial of 303 asthma patients at risk of severe exacerbations, Smartinhaler Tracker electronic monitors were used to measure actual use of budesonide/formoterol and salbutamol MDI therapy with two treatment regimens. Our aim is to report on the performance of these monitors, based on the implementation of extensive pre-trial and within-trial validation protocols for their use. Methods Pre-study use checks involved two actuations of the MDI, with a further two actuations performed at least two hours later. Within-study monitor checks, performed prior to dispensing at follow-up clinic visits, included a computerised check of monitor clock function, actuation accuracy and battery life. Within-study data checks, performed after use of MDIs by participants during the trial, involved computerised checks of monitor clock function prior to data upload. Results 2678/2728 (98.2%) monitors passed pre-study use checks; 46/50 monitors failed pre-study checks either because they did not record actuations that were performed, or erroneously recorded extra actuations. 76/2642 (2.9%) monitors dispensed to participants failed within-study monitor checks; 33/76 monitors failed because the battery was not fully charged. 51/2642 (1.9%) monitors failed data upload checks, mostly as a result of fluid immersion during participant use. 93/2642 (3.5%) monitors were lost or thrown away by participants. Complete data was available from 2498/2642 (94.5%) of dispensed monitors and 2498/2549 (98.0%) of returned monitors. Conclusions The Smartinhaler Tracker is a reliable monitor for measuring MDI use in a real-world asthma clinical trial. Implementation of extensive monitor and data-checking protocols reduces data loss. The use of validated and reliable electronic monitors is the optimal method to assess patterns of inhaled medication use.

Obesity and COPD: Associated Symptoms, Health-related Quality of Life, and Medication Use

Background: There is little data about the combined effects of COPD and obesity. We compared dyspnea, health-related quality of life (HRQoL), exacerbations, and inhaled medication use among patients who are overweight and obese to those of normal weight with COPD. Methods: We performed secondary data analysis on 364 Veterans with COPD. We categorized subjects by body mass index (BMI). We assessed dyspnea using the Medical Research Council (MRC) dyspnea scale and HRQoL using the St. George's Respiratory Questionnaire. We identified treatment for an exacerbation and inhaled medication use in the past year. We used multiple logistic and linear regression models as appropriate, with adjustment for age, COPD severity, smoking status, and co-morbidities. Results: The majority of our population was male (n = 355, 98%) and either overweight (n = 115, 32%) or obese (n = 138, 38%). Obese and overweight subjects had better lung function (obese: mean FEV1 55.4% ±19.9% predicted, overweight: mean FEV1 50.0% ±20.4% predicted) than normal weight subjects (mean FEV1 44.2% ±19.4% predicted), yet obese subjects reported increased dyspnea [adjusted OR of MRC score ≥2 = 4.91 (95% CI 1.80, 13.39], poorer HRQoL, and were prescribed more inhaled medications than normal weight subjects. There was no difference in any outcome between overweight and normal weight patients. Conclusions: Despite having less severe lung disease, obese patients reported increased dyspnea and poorer HRQoL than normal weight patients. The greater number of inhaled medications prescribed for obese patients may represent overuse. Obese patients with COPD likely need alternative strategies for symptom control in addition to those currently recommended.

Asthma symptoms and medication in the PIAMA birth cohort: Evidence for under and overtreatment

Under and overtreatment of asthma may be a serious problem especially in young children, but the evidence is scarce and no longitudinal data are available. Our aim was to investigate whether inhaled medication use in young children was in agreement with asthma symptoms at the age of 2-8 yr. Data were used from the 'Prevention and Incidence of Asthma and Mite Allergy' birth cohort, consisting of 3963 children born in the Netherlands. Between age 2 and 8 yr, children were followed up using annual postal questionnaires. Age-specific prevalences of asthma symptoms were assessed and compared with reported use of inhaled bronchodilators and/or corticosteroids. The proportion of current wheeze decreased with age. About a third of 'current wheezers' did not use any inhaled medication during the years in which symptoms were reported. At 8 yr, 30% of children with reported 'severe current asthma symptoms' were not using inhaled corticosteroids. On the other hand, up to 50% of children with inhaled corticosteroids for at least 2 yr did not report any wheezing during those 2 yr. The proportion of symptomatic children without appropriate treatment was substantial throughout childhood, even when parents reported prolonged or severe symptoms. Treatment of asymptomatic children with inhaled corticosteroids increased with age and accounted for up to a third of all inhaled steroid use at 8 yr. These findings suggest that under and overtreatment of asthma in children was common.

Effective dyspnea management strategies identified by elders with end-stage chronic obstructive pulmonary disease

The study's purpose was to identify dyspnea management strategies (DMS) perceived most effective by elders with end-stage chronic obstructive pulmonary disease (COPD). The mixed-method design also incorporated triangulation to compare results between qualitative and quantitative data. Specific DMS were selected and percentage effectiveness was rated. Four strategy categories emerged as most useful: changing activity, relaxation, inhaled medication use, and breathing pattern alteration. Gender differences in preferred DMS were revealed. All participants ( N = 30) preferred to use multiple strategies for effective dyspnea management; therefore, health care providers should consider employing individualized combinations of DMS when assisting elders with end-stage COPD during acute exacerbations of dyspnea.