Inhaler Medication Research Articles

Fibromyalgia, mood disorders, and intense creative energy: A1AT polymorphisms are not always silent

Persons with single copies of common alpha-1-antitrypsin polymorphisms such as S and Z are often considered “silent carriers”. Published evidence however supports a complex behavioral phenotype or trait – intense creative energy (“ICE”)-associated with A1AT polymorphisms. We now confirm that phenotype and present an association of fibromyalgia syndrome (FMS) and A1AT in a consecutive series of neurological patients.This is a retrospective case control series of 3176 consecutive patients presenting to Duke University Memory Clinic (747 patients) and to regional community-based Caldwell Hospital Neurology and Memory center (2429 patients). Work-up included medical history and examination, psychological evaluation, and genetic analysis. Chronic widespread pain (CWP) or FMS were diagnosed according to clinical guidelines, mostly as secondary diagnoses. Neurological patients carrying A1AT polymorphisms were common (ca 16% prevalence) and carriers had significantly higher use of inhaler and anxiolytic medications. Patients with ICE phenotype had a significantly higher proportion of A1AT polymorphisms (42%) compared to non-ICE patients (13%). Presence of CWP or FMS was common (14–22%) with average age at presentation of 56 years old and mostly female gender (82%). Patients with CWP/FMS had again significantly higher proportion of A1AT polymorphisms (38%) compared to other neurological patients (13%). Patients with anxiety disorders, bipolar I or bipolar II disorders or PTSD also had increased proportion of A1AT polymorphisms and significant overlap with ICE and FMS phenotype. Significant reductions in CWP/FMS prevalence are seen in apolipoprotein E4 carriers and methylene tetrahydrofolate reductase (MTHFR) mutation homozygotes. Since ICE phenotype is reported as a lifelong behavioral attribute, the presumption is that A1AT carriers have fundamental differences in brain development and inflammatory response. In support of this concept is finding those persons reporting a diagnosis of juvenile rheumatoid or idiopathic arthritis (JRA, JIA) had a significantly high proportion of A1AT polymorphisms (63%), suggesting a spectrum for JRA to later FMS presentations. Likewise, persons reporting a history of attention deficit disorder (ADD) had an increased proportion of A1AT polymorphisms (26%) compared to non-ADD persons (13%). Toxic environmental exposures are common (23%) and associated with diagnoses of PSP, PPA, FTD, FTD-PD, PD and ADVD. A1AT carriers were increased in cases of toxic exposure and PSP, PPA and FTD-PD.Our findings support the ICE behavioral phenotype for A1AT polymorphism carriers and the reported association with anxiety and bipolar spectrum disorders. We now extend that phenotype to apparent vulnerability to inflammatory muscle disease in a spectrum from JRA to fibromyalgia (FMS) and specific behavioral subsets of ADD, PTSD, and specific late onset neurological syndromes (FTD-PD and PPA). High and low risk FMS subsets can be defined using A1AT, MTHFR and APOE genotyping. Clinical diagnoses associated with A1AT polymorphisms included fibromyalgia, JRA/JIA, bipolar disorder, PTSD, primary progressive aphasia and FTDPD, but not most Alzheimer Disease subtypes. These results support an extended phenotype for A1AT mutation carriers beyond liver and lung vulnerability to selective advantages: ICE phenotype and disadvantages: fibromyalgia, affective disorders, and selected late onset neurological syndromes.

Recent educational interventions for improvement of asthma medication adherence

Poor adherence to asthma medication treatment is a dilemma as it decreases the chance of achieving and maintaining a proper asthma control. Another dilemma is that there seems to be a small range of functional interventions that enhance adherence to long-term medication treatments. The aim was to review the last five years of published educational interventions for improving adherence to asthma medication. Through systematic database searches 20 articles were identified, which matched the inclusion criteria and described educational interventions to improve asthma self-management including adherence. The current review showed that addressing unintentional non-adherence in terms of incorrect inhaler technique by recurrent education improved the technique among many patients, but not among all. Phoning patients, as a means to remove medication beliefs as adherence barriers, seemed to be an effective educational strategy, shown as increased adherence. Involving patients in treatment decisions and individualising or tailoring educational support also seemed to have favourable effect on adherence. To conclude, addressing specific adherence barriers such as poor inhaler technique or medication beliefs could favour adherence. To change adherence behavior, the current review proposes that educational adherence support should be a collaborative effort between the patient and the health-care professional based on each individual patient's needs and patient factors, including elements such as personality traits.

Teaching inhaler use in chronic obstructive pulmonary disease patients

To review barriers to the successful use of inhalers in patients with chronic obstructive pulmonary disease (COPD), and the role of the nurse practitioner (NP) in facilitating optimum inhaler use. Review of the national and international scientific literature. Pharmacologic treatment of COPD patients comprises mainly inhaled medications. Incorrect use of inhalers is very common in these individuals. Some of the consequences of poor inhaler technique include reduced therapeutic dosing, medication adherence, and disease stability, which can lead to increased morbidity, decreased quality of life, and a high burden on the healthcare system. Knowledgeable evaluation and frequent reassessment of inhaler use coupled with education of patients, caregivers, and healthcare professionals can significantly improve the benefits COPD patients derive from inhaled therapy. Patient education is vital for correct use of inhalers and to ensure the effectiveness of inhaled medications. The NP has a critical role in assessing potential barriers to successful learning by the patient and improving inhaler technique and medication management. The NP can also facilitate success with inhaled medications by providing up-to-date inhaler education for other healthcare team members, who may then act as patient educators.

Inhaler device selection: Special considerations in elderly patients with chronic obstructive pulmonary disease

Special considerations in the selection of medication inhaler devices for elderly patients with chronic obstructive pulmonary disease (COPD) in the ambulatory care setting are reviewed. Substantial deficiencies in inhaler device technique and medication adherence are evident in patients with COPD, leading to suboptimal health outcomes. As the prevalence of COPD rises with age, elderly patients pose special challenges with regard to inhaler device selection. In elderly patients with sufficient cognitive function, manual dexterity, and hand strength, the most influential factors in inhaler selection are cost reimbursement, device availability, device convenience, and patient preference. Cost reimbursement may be a deciding factor in device selection, as nearly all elderly patients are Medicare beneficiaries. Nebulizers provide a cost-effective alternative to pressurized metered-dose inhaler (pMDI) and dry powder inhaler (DPI) devices. DPI device availability is limited to "controller" medications, while pMDI devices and nebulizers provide complete symptomatic coverage. Multiple-dose DPIs offer the convenience of rapid medication administration, ease of handling, and integral dose counters. Given the availability and expenses of medication devices, ambulatory patients may prefer combining the convenience of a hand-held inhaler (i.e., pMDI) as a rescue medication during the active hours of midday with the cost savings of a nebulized controller medication in the morning and at night. In elderly patients with sufficient cognitive function, manual dexterity, and hand strength, the most important factors in inhaler device selection are cost reimbursement issues, device availability, device convenience, and patient preference. Pharmacist knowledge of appropriate inhaler technique, competent patient education and demonstration, and follow-up assessment are instrumental in optimizing device competency and medication adherence.

Challenges and advances in the development of inhalable drug formulations for cystic fibrosis lung disease

Introduction: Cystic fibrosis (CF) is a multisystem genetic disorder, which usually results in significant respiratory dysfunction. At present there is no cure for CF, but advances in pharmacotherapy have gradually increased the life expectancy of CF patients. As many drugs used in the therapy of CF are delivered by inhalation, the demand for effective and convenient inhalational CF drug formulations will grow as CF patients live longer. Knowledge of the current limitations in inhalational CF drug delivery is critical in identifying new opportunities and designing rational delivery strategies.Areas covered: This review discusses current and emerging therapeutic agents for CF therapy, selected physiological challenges to effective inhalational medication delivery, and various approaches to overcoming these challenges. The reader will find an integrated view of the known inhalational drug delivery challenges and the rationales for recent investigational inhalational drug formulations.Expert opinion: An ideal drug/gene delivery system to CF airways should overcome the tenacious sputum, which presents physical, chemical and biological barriers to effective transport of therapeutic agents to the targets and various cellular challenges.

Fundamentals of Anaesthesia, 3rd Edition.

Rush Medical College, Rush University Medical Center, Chicago, Illinois. bryan.williams@yahoo.comEdited by Tim Smith, M.D., F.R.C.A., Colin Pinnock, M.B.B.S., F.R.C.A., Ted Lin, M.B.B.S., F.R.C.A. Cambridge, Cambridge University Press, 2009. Pages: 956. Price: $141.99.While reviewing Fundamentals of Anaesthesia , I could not help but find myself reading with a British accent. The third edition of this book represents an update of the publication geared toward trainees who sit for part 1 of the Fellowship of the Royal College of Anesthetists (FRCA) examination, taken in the first or second year of training. During the training program, the trainee anesthetist takes an examination in two parts (primary and final).The editors are contributors to the FRCA examination; in the preface, editor Tim Smith indicates the desire to provide a textbook specifically designed around and correlated closely with the syllabus for the primary FRCA examination. This text accomplishes this goal by its organization and content, which promote reading and comprehension targeted specifically for that examination. The text includes the competency-based training framework for the examination in the newly created Appendix. All the chapters have been revised, and an update on preoperative assessment is included.The third edition is organized into four color-coded sections. The first section (Clinical Anaesthesia) begins with preoperative, intraoperative, and postoperative management. It includes a new chapter on resuscitation, with the European Resuscitation Council and the British Difficult Airway Society algorithms. Other chapters include information about clinical anatomy, regional anesthesia, and special patient circumstances. The second section (Physiology) is comprehensive, covering physiologic aspects of all major organ systems and including topics such as cellular physiology, physiology of the nervous system, and the newly added pain physiology. Pharmacology is the third section, beginning with physical chemistry and including enteral, intravenous, and inhalation medications. The section concludes with clinical trial design and evaluation, which are often overlooked in a text this size. The fourth section (Physics, Clinical Measurement, and Statistics) uniquely presents chapters on mathematics, including calculus, vectors, ultrasonography, and magnetic resonance imaging. The section also includes chapters on clinical measurement, anesthetic equipment, and statistics. The Appendix concludes the book, which includes the primary FRCA syllabus. The subjects of physiology, pharmacology, and physics are well represented in the text, correlating to the examination syllabus.The content of each chapter is clearly summarized on a title page into headings and subheadings. There are 650 black-and-white illustrations throughout the textbook. Although the text is geared toward the FRCA examination, it does provide relevant information for those not taking the examination. However, compared with an equivalent text, Clinical Anesthesiology, Fourth Edition , edited by G. Edward Morgan, Jr, Maged Mikhail, and Michael Murray, Fundamentals of Anaesthesia's layout may appear nonlinear in that topics (e.g ., obstetrics and obstetric anesthesia) may course over several chapters, requiring the reader to review several chapters for completeness on a topic. Although the layout of the topics may appear nonlinear, the intended reader is the trainee taking the FRCA examination, Fundamentals of Anaesthesia faithfully adheres to this goal in the organizational schema, and the Appendix facilitates quick cross-references.Fundamentals of Anaesthesia is highly practical, is an excellent learning text for training clinicians, and warrants its popularity among anesthesiology trainees in the United Kingdom system. The textbook is unique by cross-referencing most, if not all, of the topics contained on the licensing examination. It is a valuable reference text that provides anesthesia practitioners with essential information covering basic science, physics, and pharmacology. The individual chapters certainly serve as excellent sources of information, but the strength of the text lies in the reliability and fidelity to the FRCA syllabus. Useful chapters not present in most training books include those about applied physics, basic statistics, clinical trials, and physical chemistry; in fact, I most enjoyed reading these chapters. These chapters and the book as a whole serve as excellent sources of information for the trainee in the United Kingdom system and abroad. Finally, the information contained in Fundamentals of Anaesthesia , with its cross-reference section, provides convenience for the busy practitioner.Rush Medical College, Rush University Medical Center, Chicago, Illinois. bryan. williams@yahoo.com

Relationships between repeated instruction on inhalation therapy, medication adherence, and health status in chronic obstructive pulmonary disease

PurposeAdherence to inhalation therapy is a critical determinant of the success of chronic obstructive pulmonary disease (COPD) management. However, in practice, nonadherence to inhalation therapy is very common in COPD patients. The effects of adherence to inhalation therapy in COPD have not been fully studied, and less is known about the relationship between medication adherence and quality of life in COPD. Our aim is to assess the factors that contribute to adherence to inhalation therapy and examine their correlation with quality of life.Patients and methodsA cross-sectional analysis of 88 COPD patients was performed using a self-reported adherence questionnaire with responses on a 5-point Likert scale.ResultsOf the 88 patients who were potential participants, 55 (63%) responded with usable information. The only significant factor associated with the overall mean adherence score was receiving repeated instruction about inhalation techniques (P = 0.032). Of the 55 respondents, 22 (40.0%) were given repeated verbal instruction and/or demonstrations of inhalation technique by a respiratory physician. Significant correlations were found between the overall mean adherence score and the health-related quality of life score (St George’s Respiratory Questionnaire: total, r = −0.35, P = 0.023; symptoms, r = −0.43, P = 0.002; impacts, r = −0.35, P = 0.011). Furthermore, patients with repeated instruction showed better quality of life scores than those who did not receive instruction (total, P = 0.030; symptoms, P = 0.038; impacts, P = 0.019).ConclusionsRepeated instruction for inhalation techniques may contribute to adherence to therapeutic regimens, which relates to better health status in COPD.

Löffler syndrome caused by extensive cutaneous larva migrans: A case report and review of the literature

In rare cases, cutaneous larva migrans may be complicated by Löffler syndrome. This syndrome is thought to result from a type I hypersensitivity reaction related to the pulmonary larval migration phase of various parasites. It is characterized by migratory pulmonary eosinophilic infiltrates and peripheral eosinophilia, with malaise, fever, and cough. Our patient was successfully treated with ivermectin, a corticosteroid cream, and inhalation medication in an early phase, which prevented complications. We present the details of this case and review the literature.

Predictors of Incorrect Inhalation Technique in Patients with Asthma or COPD: A Study Using a Validated Videotaped Scoring Method

Inadequate technique reduces the effects of inhalation medication. Errors in inhalation technique have been reported to range up to 85%. Not only various patients' characteristics but also the device has an effect on correct inhalation technique. The purpose of this study was to determine the effect of patients' characteristics and type of inhaler device on inhalation technique in patient with asthma or chronic obstructive pulmonary disease (COPD). A validated scoring method was used that consisted of triple viewing of video-recorded inhalations, using device-specific checklists. The following patient characteristics were investigated: gender, age, education level, diagnosis, treatment by a pulmonary physician, previously received inhalation instruction, exacerbation frequency, knowledge, self-management competence, pulmonary function, and use of multiple inhaler devices. Chi-square statistics were used for univariate associations between potential determinants and correctness of inhalation technique. Relevant determinants were entered into a multivariate logistic regression model. Moreover, inhalation technique errors were examined for six inhaler devices: three prefilled dry powder inhalers, one single-dose dry powder inhaler, a pressurized metered-dose inhaler (pMDI) and a pMDI with a spacer. Overall, 40% of the patients made at least one essential mistake in their inhalation technique. Patients who never received inhalation instruction and patients who used more than one inhaler device made significantly more errors (odds ratio both 2.2). Comparison between devices showed that a correct inhalation technique most likely occurred with the use of prefilled dry powder devices. Incorrect inhalation technique is common among asthma and COPD patients in a pulmonary outpatient clinic. Our study suggests that the use of prefilled dry powder inhalers as well as inhalation instruction increases correct inhalation technique. Simultaneous use of different types of inhalation devices has to be discouraged.

Partnership‐based nursing practice for people with chronic obstructive pulmonary disease and their families: influences on health‐related quality of life and hospital admissions

To evaluate the outcome of a coherent nursing practice in the form of partnership that addresses the complexity of living with chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease is a wide-ranging and progressive chronic disease that not only requires relentless attentiveness of the persons having the disease but also the families involved. Particular consideration is called for in health care for those with an advanced and complicated stage of the disease. The nursing practice, grounded in the theoretical framework of 'partnership as practice', is participatory comprehensive, long-term and dynamic to individual patient-family needs. Retrospective and prospective pretest-post-test intervention study. Methods. Eleven men and 39 women participated (n = 50). Mean age was 66 years. The majority (n = 36) had severe chronic obstructive pulmonary disease (GOLD stage III and IV). Actual study period was six months (T2). Hospital admission data were collected six months prior to (T1) and six months after that period (T3), a total of 18 months. Hospital admission rate and days spent in hospital because of chronic obstructive pulmonary disease were significantly reduced. Disease-specific health-related quality of life measured by St. George's Respiratory Questionnaire improved significantly. For those with clinical anxiety and depression, both decreased significantly. Of those who were underweight, body mass index improved significantly. Abstinence from smoking changed non-significantly. Capability in the use of inhaler medications improved. These results are in contrast to previous studies on outpatient nursing care for people with chronic obstructive pulmonary disease. The participatory nature of partnership with dialogue as central and which was uniquely implemented in this study might be of particular relevance for individuals and families living with chronic obstructive pulmonary disease. Complex and comprehensive health needs of people with chronic obstructive pulmonary disease and their families may be effectively addressed in partnership centred on dialogue together with efficient intra-and interdisciplinary collaboration.

Inhaler Costs and Medication Nonadherence Among Seniors With Chronic Pulmonary Disease

Chronic pulmonary diseases (CPDs) such as asthma and COPD are associated with particularly high rates of cost-related medication nonadherence (CRN), but the degree to which inhaler costs contribute to this is not known. Here, we examine the relationship between inhaler-specific out-of-pocket costs and CRN in CPD. Using data obtained in 2006 in a national stratified random sample (N = 16,072) of community-dwelling Medicare beneficiaries aged >or= 65 years, we used logistic regression to examine the relationship between inhaled medications, various types of out-of-pocket costs, and CRN in persons with CPD. The prevalence of CRN in Medicare recipients with CPD using inhalers was 31%. In multivariate models, the odds that respondents with CPD using inhalers would report CRN was 1.43 (95% CI, 1.21-1.69) compared with respondents without CPD who were not using inhalers. Adjustment for out-of-pocket inhaler costs-but not adjustment for total medication costs or non-inhaler costs-eliminated this excess risk of CRN (OR, 0.95; 95% CI, 0.71-1.28). Patients paying > $20 per month for inhalers were at significantly higher risk for CRN compared with those who had no out-of-pocket inhaler costs. Individuals with CPD and high out-of-pocket inhaler costs are at increased risk for CRN relative to individuals on other medications. Physicians should be aware that inhalers can pose a particularly high risk of medication nonadherence for some patients.

Customizing Inhaled Therapy to Meet the Needs of COPD Patients

Chronic obstructive pulmonary disease (COPD) is a progressive disease characterized by airflow limitation resulting from emphysema and chronic bronchitis. Inhaled therapy is the major therapeutic approach for treating COPD. Multiple inhaler medications are available in the United States and are delivered by a variety of different devices: metered-dose inhalers, dry powdered inhalers, and nebulizers. Each inhaler device has unique requirements for use that must be correctly performed by the patient for successful drug delivery. Patients with COPD represent a medically diverse population, with each patient having distinct characteristics, such as lung function, comorbidities, cognitive functions, hand strength, and lifestyle. These characteristics impact the patient's ability to properly use specific inhaler devices and therefore affect adherence to therapy, therapeutic outcomes, and quality of life. It is estimated that between 28% to 68% of patients do not use metered-dose inhalers or dry powder inhalers correctly. Worsening symptoms or increased frequency of exacerbations may not always indicate disease progression but may indicate a patient's inability to use their inhaler device properly. This review discusses the patient- and device-specific factors to be considered when choosing an inhaled therapy, which will be concordant with the patient's medical needs, preferences, and lifestyle. The review also considers how the ideas underlying the patient-centered medical home model can be incorporated into the choice and use of inhaler device for a given patient with COPD to improve treatment outcomes.

Prevalence of gastroesophageal reflux disease in patients with asthma and chronic obstructive pulmonary disease

It is speculated that the prevalence of gastroesophageal reflux disease (GERD) might increase with asthma or chronic obstructive pulmonary disease (COPD). The aim of the present study was to evaluate the prevalence of GERD in patients with asthma and COPD in an area representative of developing countries. A validated GERD questionnaire was conducted face-to-face with 308 consecutive asthma (240 women) and 133 COPD (35 women) patients in the tertiary referral pulmonary outpatient clinic, and 694 controls from the research area. Detailed histories of patients and pulmonary function tests were also recorded. The prevalence of GERD (heartburn/regurgitation once a week or more) was 25.4%, 17.0%, 19.4% and occasional symptoms (less than weekly) were 21.2%, 16.3% and 27.0% of patients with asthma, COPD and controls, respectively. The prevalence was higher in the asthma group compared with the controls and the COPD group. No significant difference was found between the COPD group and the controls. Heartburn started following pulmonary disease in 24.1% of the asthma group, and 26.4% of the COPD group. The majority of additional symptoms were significantly higher in asthmatics compared with the controls. No difference was found in the consumption of pulmonary medications in asthmatic patients in groups with different symptom frequency. Heartburn was increased 13.8% by the consumption of inhaler medications. These results implicate that the prevalence of GERD in asthma and COPD are lower than in published reports in a tertiary referral center. These differences might be related to the characteristics of developing countries, increased consumption of powerful medications in GERD and pulmonary diseases, or methodological flaws in earlier studies.

Adequate use of asthma inhalation medication in children: more involvement of the parents seems useful

BackgroundAsthma and other chronic airway diseases can be effectively treated by inhaler therapy. Inhaler therapy depends on appropriate use of the inhaler. This study evaluates the knowledge among Dutch children and their parents regarding asthma inhaler therapy and appropriateness of its use.FindingsFive general practices selected all children aged 0 to 12 years on asthma inhalation medication. Children demonstrated inhaler use and were interviewed with their parents.46 subjects were enrolled; mean age 5.5 years (SD 3.4) years; 26 (57%) were boys. Of the children using one inhaler only, 70% used the inhaler as indicated and of those using more than one inhaler 46%. On average 2.6 mistakes were made during demonstration of the technique, and 2 mistakes were reported in the interview. In total, 87% of the parents decided when and how the inhaler had to be used. Spacer cleaning was performed correctly by 49%; 26% reported a correct way of assessing how many doses were remaining.ConclusionDutch children make essential mistakes related to inhaler use that are easy to avoid. We recommend a better explanation and demonstration of the technique, and recommend involvement of the parents during instruction.

Effectiveness of pharmacist intervention for asthma control improvement

Education on optimal medication use is an essential strategy to improve asthma control. The current authors investigated whether pharmacist interventions, focused on appropriate use of asthma medication and tailor-made to the patient's current asthma control, would improve asthma control in adult patients. A 6-month randomised, controlled, parallel-group trial was conducted in 66 community pharmacies in Belgium. Patients were randomly assigned to receive usual pharmacist care (n = 94) or a pre-defined pharmacist intervention (n = 107). This intervention mainly focused on improving inhalation technique and medication adherence. Primary outcome was the level of asthma control, as assessed by the Asthma Control Test (ACT). Mean ACT scores did not change from baseline for both study groups. However, a pre-defined subgroup analysis of patients having insufficiently controlled asthma at baseline showed that the intervention had significantly increased the ACT score after 6 months compared with usual care. The intervention also reduced, for the complete study group, reliever medication use and the frequency of night-time awakenings due to asthma. Inhalation technique and adherence to controller medication were significantly better in the intervention group. In conclusion, pragmatic community pharmacy-based programmes can significantly improve therapeutic outcomes in adult asthma patients.

Reliability in the Assessment of Videotaped Inhalation Technique

Inhalation medication is essential in the treatment of asthma and chronic obstructive pulmonary disease (COPD) patients. Incorrect inhalation technique reduces the effects of medication and has been reported to range from 22% to 95% from optimal. The objective of this study was to determine inter- and intraobserver reliability in inhalation technique assessment. For interobserver reliability three observers scored after three times viewing a total of 49 video recorded inhalation demonstrations using device-specific checklists and mutually agreed scoring rules. Intraobserver reliability was assessed for two observers after 8 months by scoring inhalation demonstrations a second time. Both inter- and intraobserver reliability were expressed by mean percent agreement and mean Kappa scores. All inhaler devices revealed a high mean percent agreement and a substantial or almost perfect Kappa scoring for both inter- and intraobserver reliability. Only one item, "exhale to residual volume," showed poor intraobserver reliability. Assessment of video recorded inhalation technique using device-specific checklists, triple viewing, and mutual agreed scoring rules is reliable. This method enables blind observation of inhalation technique.

Treatment Persistence and Compliance with Medications for Chronic Obstructive Pulmonary Disease

Inhaled beta-agonist, anticholinergic and glucocorticoid medications are used to treat asthma and chronic obstructive pulmonary disease (COPD). The present study assessed the patterns of persistence with the above mentioned inhaled medications. Prescription claims data from the Ontario Drug Benefit Program were analyzed to assess persistence (time to discontinuation) and compliance (percentage of days with doses available divided by days to last refill) of patients prescribed inhaled medications. Patients were grouped as naive (no inhaled medication in the previous year) or experienced (previous or current treatment), and by age (18 to 65 years of age and older than 65 years of age). Medications included ipratropium, ipratropium plus salbutamol, formoterol, formoterol plus budesonide, salmeterol, salmeterol plus fluticasone, and tiotropium. The database included 31,368 patients (4888 naive and 26,480 experienced) who were prescribed at least one of these medications. Fifteen per cent to 63% of patients continued on the index drug for more than six months, which decreased to 7% to 53% at 12 months, and 5% to 47% at 18 months. At 12 months, patients taking tiotropium had significantly longer persistence compared with other therapies (53% versus 7% to 30%; all P<0.0001), and fewer switches to alternative medications. Most naive patients had significantly shorter treatment persistence than experienced patients for all drugs (all P<0.0001), including tiotropium (27% versus 55%, P<0.0001). Compliance rates were similar for all drugs (ie, 76% to 94%) but were highest for tiotropium. These data demonstrated that persistence with inhaled treatment was low overall, but patients treated with tiotropium remained on therapy significantly longer than when treated with other medications, and patients naive to inhaled treatment had shorter treatment persistence than experienced patients.

The Effect of Repeated Education using a Computerized Scoring System for the Proper Use of Inhalation Medicine

연구배경: 기관지천식과 만성폐쇄성폐질환과 같은 만성기도질환의 여러 가지 치료법 중 흡입제가 가장 효과적 방법이지만 상당수 환자에서 부정확하게 흡입제를 사용하고 있고, 순응도 또한 낮은 편이다. 저자들은 흡입제의 정확한 사용과 치료 순응도를 높이고자 전산화 흡입제 상담 서비스 프로그램을 개발하여 흡입제 사용에 대한 반복적 교육과 평가를 시행하여 흡입제의 사용 능력 및 치료 순응도에 미치는 효과를 알아보았다. 방법: 만성기도질환 환자를 대상으로 저자들이 개발한 전산화 흡입제 상담 서비스 프로그램을 실시하였다. 2회 이상 방문한 환자를 대상으로 흡입제의 사용능력을 9개 항목에 따라 교육과 함께 평가를 하였으며, 교육 전후 질병의 이해와 약물의 순응도를 알아보았다. 결과: 흡입제 사용 능력이 교육 전후, 1차와 2차, 2차와 3차 방문사이에 유의하게 향상되었다(p＜0.05). 자신의 질환에 대한 이해도는 1차 방문에서 70.7%, 2차 방문에서는 78.7%, 3차 방문에서는 78.9%로 증가하였다. 순응도는 2차 방문에서 70.1%, 3차 방문에서는 81.8%로 향상되었다. 결론: 저자들이 개발한 전산화 흡입제 상담 서비스 프로그램은 만성기도질환 환자에서 흡입제 사용능력 및 순응도, 질병에 대한 이해도를 향상시킬 수 있었다.

Incorrect Application Technique of Metered Dose Inhalers by Internal Medicine Residents: Impact of Exposure to a Practical Situation

We evaluated residents regarding maintenance treatment of asthma and the technique for using metered dose inhalers. Methods. Residents were asked to prescribe a treatment for a patient with poorly controlled persistent asthma and to demonstrate the use of metered dose inhaler (MDI) medication. Results. 76% of 239 residents correctly identified the medication indicated for the case; only 30% of them adequately performed the inhalation technique (49% from HCFMUSP vs. 19% from other institutions; p < 0.001). Conclusions. The results demonstrate that, when seeing a typical patient with uncontrolled persistent asthma, most residents are able to correctly identify the drugs indicated for treatment but not adequately instruct the MDI technique use.

MDI Inhalers: Do Nursing Home Support Staff Have Correct Technique?

Many elderly patients in nursing homes in the United States use metered-dose inhaler (MDI) medications for a variety of lung diseases. We wondered how much the nursing support staff knew about correct MDI inhaler technique. Thirty-eight nursing home support staff were asked to demonstrate correct use of a placebo MDI inhaler on themselves. The staff completed an average of 6.9 steps out of 8 correctly. The most common error demonstrated was the staff did not hold their breath for 10 seconds at full inspiration after inhaling the medication. The results suggest that the support staff have incorrect MDI inhaler technique.