Inhaler Devices Research Articles

The Impact of an Educational Intervention on the Skill of Community Pharmacists in the Use of a Pressurized Metered-dose Inhaler: A Covert Simulated Patient Approach in Pakistan

Introduction: Metered-dose inhalers are the most widely prescribed and dispensed inhaler devices worldwide for the management of asthma. The present study aimed to access the impact of educational intervention on the competency of community pharmacists of Islamabad, Pakistan regarding the pressurized metered-dose inhaler (MDI) technique. Materials and Methods: The intervention involved educating pharmacists practically through placebo inhalers and theoretically through literature brochures; based upon the “National Asthma Education and Preventive Program” inhaler technique. A total of 100 pharmacists were recruited from the rural and urban sectors of Islamabad. A covert simulated patient approach was used to evaluate the inhaler technique of pharmacists. Type of pharmacy, education status of pharmacists and the influence of already received training on the use of inhaler devices were the factors that demonstrated a significant positive association with the competency of pharmacists. Results: McNemar test was applied for pre and post-intervention intragroup comparisons to further access categorical variables. A p-values <0.05 were considered statistically significant. The competency of pharmacists increased significantly from 24% before intervention to 33% after intervention (p<0.001). Conclusion: Originally, the inhaler technique competency of the majority of pharmacy professionals was observed to be inappropriate. However, the educational intervention proved to be effective in substantially enhancing the skill of community pharmacists regarding the MDI technique.

Efficacy and Safety of Methoxyflurane for Treatment of Acute Traumatic Pain by EMTs during Alpine Rescue Operations: The “PainDrop” Trial

Background: Treatment of acute traumatic pain is a core task for mountain rescue services. Intravenous access, however, is often difficult, and the vast majority of missions are carried out without a physician at the scene. The spectrum of analgesics available for use by non-physician personnel is limited. Inhaled analgesics, such as methoxyflurane, might prove useful, but currently no data exist on their application by non-physicians in the alpine setting. Methods: This prospective observational alpine field study was conducted over a period of 15 months. Patients suffering traumatic injuries with moderate to severe pain (pain score ≥ 5) after downhill bike accidents in the Tyrol mountains (1,362 m to 2,666 m above sea level) were enrolled. Teams of four mountain rescue service members, one of them a trained EMT, treated the patients with 3 ml of methoxyflurane by inhaler. We measured efficacy as reduction in pain from baseline to 15 minutes after treatment on a numerical rating scale. Safety was assessed by change in vital signs or occurrence of side-effects. Sample-size calculations were based on the efficacy outcome and yielded a need for 20 patients at a power of 0.8. Results: From June 29, 2020 to September 30, 2021, a total of 20 patients (two females; mean age 37 years) were included. The mean initial pain score was 7.2 (SD 1.0) points. After 15 minutes, pain was significantly reduced by a mean of 2.9 (SD 1.4) points. No major adverse events or relevant changes in vital signs were observed. Conclusion: The use of methoxyflurane by EMTs during alpine rescue operations in our study proved to be safe and efficient. We observed no reduction in the efficacy of the inhaler device at moderate altitude.

Same lung deposited dose in dog dosing a fine and coarse aerosol indicates no difference in intranasal filtration

A novel inhalation exposure system was developed with the aim to increase the efficiency of pharmacokinetic (PK) evaluations of inhaled drugs in a large species such as the dog. It enables collecting PK data for multiple drug candidates in a single experiment by simultaneous administration of the drugs to the same animal. This facilitates a direct PK comparison of the same lung dose of different drugs using the same blood samples, which can be considered to be a refinement measure from an animal research perspective. The system design was inspired by a clinical precision dosing dosimeter systems, which enhance dosing precision by synchronizing the aerosol delivery from the jet nebulizer with the inhalation to maximize the inhaled fraction of the nebulized dose.The performance of the novel system was validated in an in-vivo study, which included a comparison of the same nebulized dose delivered as a fine and a coarse aerosol. The drugs selected for this study were developed for local treatment of the lung via inhalation and were known to have low oral bioavailability due to being extremely poorly soluble and therefore expected to also have low nasal bioavailability. This would result in systemic exposure derived primarily from pulmonary absorption, which facilitated the PK assessment applied to determine the lung deposited dose.The jet nebulizer selected to generate a fine aerosol was designed for alveolar lung deposition and approved by U.S. Food and Drug Administration for lung ventilation imaging, and the nebulizer selected to generate a coarse aerosol was a standard nebulizer. The drugs were wet milled to a particle size considerably smaller than the nebulized droplets and the dispersed drug particles were therefore homogenously distributed in the droplet size distribution.Higher initial plasma concentrations were observed for the fine aerosol. This was expected, as the smaller droplets should deposit more efficiently in the peripheral regions of the lung, which consequently should lead to a faster absorption compared with the coarse aerosol from the standard nebulizer that should deposit more centrally. The fact that this could be observed supports that the novel system is an excellent tool in PK evaluations.Our study indicated that there was no difference in the systemic exposure between the fine and the coarse aerosol for the same nebulized dose, and thus the lung deposition was also the same. The considerable difference in the nebulized size distribution within the range relevant for available inhalation devices resulted in a negligible difference in intranasal filtration. The fraction of the nebulized dose that deposited in the lung was observed to be high in this study (mean of 21–30% and about 50% for one dog with a distinguished slow and deep breathing), which supports that the intranasal filtration was low. That a high fraction of the nebulized dose deposited in the lung indicates that an enhanced dosing precision was obtained with the novel system. The similar achieved lung doses of all three drugs, shows that the simultaneous administration of multiple drugs worked well.That the intranasal filtration was low is an important finding considering that devices for oropharyngeal delivery in dogs are applied in order to eliminate intranasal filtration. Oropharyngeal dosing is more invasive compared with oronasal dosing and avoiding utilizing that method can be considered a refinement measure from an animal research perspective.

Detailed evaluation of drug powder deposition in swirl-type dry powder inhalers

Based on numerical simulations by the Euler/Lagrange approach in combination with the RNG-k-ε turbulence model flow field and particle transport through inhaler devices are studied. Since one major problem in inhaler performance and drug powder release is their deposition on the inhaler walls this issue is analysed in more detail. For computing fine particle motion through the stationary flow field all relevant particle forces and turbulent dispersion are considered. A potential deposition of fine particles is governed by two elementary processes, namely the transport of the fine drug particles towards the walls and their possible wall adhesion. Wall impingement of particles is induced by fluid transport and particle inertia as well as turbulence and for very fine particles also Brownian random motion. The possibility of particle sticking on the inhaler walls is modelled by considering the van der Waals adhesion force. Based on an energy balance for an oblique elastic-plastic wall impingement, a critical impact velocity is derived below which the particles are depositing. This approach accounts for the mechanical properties of wall and particle materials. First, the performance of different deposition models was analysed and the results were compared with literature experiments. The local and global deposition of particles in the considered swirl-type inhalers is determined in dependence of particle size, stationary flow rates (between15 l/min and 90 l/min) and particle release location. The range of particle sizes considered is between 0.05 μm and 10 μm, representing a typical spectrum for fine drug powders in use. Additionally, the spatial distribution of the deposits within the two inhaler types is evaluated for allowing inhaler optimisation and the predicted emitted fraction of fine particles is compared with experimental observations.

Formulation and Evaluation of Dry Powder Inhaler

Abstract: This review focuses on the dry powder inhaler (DPI) formulation and development process. Most DPI formulations consist of micronized drug blended with larger carrier particles, which enhance flow, reduce aggregation, and aid in dispersion. A combination of intrinsic physicochemical properties, particle size, shape, surface area, and morphology affects the forces of interaction and aerodynamic properties, which in turn determine fluidization, dispersion, delivery to the lungs, and deposition in the peripheral airways. When a DPI is actuated, the formulation is fluidized and enters the patient’s airways. Under the influence of inspiratory airflow, the drug particles separate from the carrier particles and are carried deep into the lungs, while the larger carrier particles impact on the oropharyngeal surfaces and are cleared. If the cohesive forces acting on the powder are too strong, the shear of the airflow may not be sufficient to separate the drug from the carrier particles, which results in low deposition efficiency. This review thus demonstrates that the successful delivery of dry powder aerosols to the lung requires careful consideration of the powder production process, formulation and inhaler device. The developments and improvements towards high dose powder pulmonary drug delivery are summarized and discussed here. It also throws light on the invention and improvement of novel inhaler devices as well as the further development of formulation principles and new powder engineering methods.

Protective Abilities of an Inhaled DPI Formulation Based on Sodium Hyaluronate against Environmental Hazards Targeting the Upper Respiratory Tract

The exposure of lung epithelium to environmental hazards is linked to several chronic respiratory diseases. We assessed the ability of an inhaled dry powder (DPI) medical device product (PolmonYDEFENCE/DYFESATM, SOFAR SpA, Trezzano Rosa, Italy), using a formulation of sodium hyaluronate (Na-Hya) as the key ingredient as a defensive barrier to protect the upper respiratory tract. Specifically, it was evaluated if the presence of the barrier formed by sodium hyaluronate present on the cells, reducing direct contact of the urban dust (UD) with the surface of cells can protect them in an indirect manner by the inflammatory and oxidative process started in the presence of the UD. Cytotoxicity and the protection capability against the oxidative stress of the product were tested in vitro using Calu-3 cells exposure to UD as a trigger for oxidative stress. Inflammation and wound healing were assessed using an air-liquid interface (ALI) culture model of the Calu-3 cells. Deposition studies of the formulation were conducted using a modified Anderson cascade impactor (ACI) and the monodose PillHaler® dry powder inhaler (DPI) device, Na-Hya was detected and quantified using high-performance-liquid-chromatography (HPLC). Solubilised PolmonYDEFENCE/DYFESATM gives protection against oxidative stress in Calu-3 cells in the short term (2 h) without any cytotoxic effects. ALI culture experiments, testing the barrier-forming (non-solubilised) capabilities of PolmonYDEFENCE/DYFESATM, showed that the barrier layer reduced inflammation triggered by UD and the time for wound closure compared to Na-Hya alone. Deposition experiments using the ACI and the PillHaler® DPI device showed that the majority of the product was deposited in the upper part of the respiratory tract. Finally, the protective effect of the product was efficacious for up to 24 h without affecting mucus production. We demonstrated the potential of PolmonYDEFENCE/DYFESATM as a preventative barrier against UD, which may aid in protecting the upper respiratory tract against environmental hazards and help with chronic respiratory diseases.

A CFD Investigation on the Aerosol Drug Delivery in the Mouth–Throat Airway Using a Pressurized Metered-Dose Inhaler Device

Inhalation therapy involving a pressurized metered-dose inhaler (pMDI) is one of the most commonly used and effective treatment methods for patients with asthma. The purpose of this study was to develop a computational fluid dynamics (CFD) model to characterize aerosol flow issued from a pMDI into a simulated mouth–throat geometry. The effects of air flow rate and cone angle were analyzed in detail. The behaviour of the multiphase flow initiated at the inhaler actuation nozzle and extended through the mouth–throat airway was simulated based on the Eulerian-Lagrangian discrete phase model, with the k-ω model applied for turbulency. We validated our model against published experimental measurements and cover the hydrodynamic aspect of the study. The recirculation we observed at the 90° bend inside the mouth–throat airway resulted in the selective retention of larger diameter particles, and the fluid flow patterns were correlated with drug deposition behaviour. Enhancing air flow rates up to three times reduced the aerodynamic particle diameters to 20%. We also observed that, as cone angle increased, mouth deposition increased; an 8° cone angle was the best angle for the lowest mouth–throat deposition.

Afatinib liposomal dry powder inhaler: Targeted pulmonary delivery of EGFR inhibitor for the management of lung cancer

The present research work aims to prepare a liposomal dry powder inhaler (LDPI) of afatinib dimaleate for the treatment of non-small cell lung cancer through pulmonary delivery. The influence of formulation independent variables, lipid concentration (X1, mol%) and organic phase (X2, mL), on dependent variables, entrapment efficiency (%) and particle size (nm), were investigated using a three-level factorial design. The optimized drug encapsulated PEGylated liposomal batch of 2 mL prepared by ethanol injection method was further scaled up to 25 mL, to enable lyophilization used to convert liposomal dispersion into LDPI. Scale-up batch of liposomes was found to have an average particle size of 181.2 ± 5.0 nm, % entrapment efficiency of 75.31 ± 2.70%, and zeta potential of 9.65 ± 0.31 mV. LDPI manufactured with trehalose as a cryoprotectant and l-leucine as an antiadherent offered porous particles with smooth morphologies that improved aerodynamic efficiency. The prepared LDPI formulation exhibited 9.639 ± 1.369 μm of particle size distribution, 72.56 ± 1.04% drug content, and good flow properties. In vitro lung deposition study implied that particles could reach the deeper region of the lung with more than 85% dose emission from an inhaler device. In vitro drug release study revealed that the drug release profile in pH 7.4 buffer was lower than in pH 5.5 and pH 6.5 buffers, demonstrating the stability of LDPI in lung fluid. Cytotoxicity study utilizing A549 adenocarcinoma cell line uncovered the greater potential of liposomal formulation in inhibiting tumor cell growth as compared to plain drug solution. The cellular uptake across adenocarcinoma cells exhibited more intracellular uptake of fluorescein isothiocyanate (FITC) encapsulated afatinib liposomal formulation than plain FITC dye. Thus, the optimized LDPI can offer an excellent approach for managing lung cancer through site-specific delivery.

Evolution of Web-Based Training Videos Provided by the German Respiratory League for the Correct Inhalation Technique

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

Kuru Toz İnhalerlerinde Tasarım Hatası ve Çözümü

In this study, the design errors of dry powder inhaler devices that have been used for many years, and their solutions depending on these errors were investigated. For this study, the most recommended inhaler devices by doctors, and the most frequently used by patients are provided. The effective use of the device and the problems that arise during its use have been observed on many patients, and a newly designed inhaler device has been developed considering the emerging problems. Observations have revealed hesitations for patients to switch to the newly designed device due to old habits. However, in the studies conducted on patients who switched to the new design device, it is seen that there is a serious time reduction in the treatment processes if the device is used correctly.

Assessing adherence to inhaled therapies in asthma and the emergence of electronic monitoring devices.

Infrequent use of inhaled corticosteroids (ICS) and/or over-reliance of short-acting β-agonists (SABA) are recognised as key contributors to increased morbidity and mortality in asthma. The most frequent measures of ICS adherence and SABA use rely on patient-reported questionnaires or prescription refill records, neither of which are considered sufficiently reliable. Technological advancements in the development of electronic monitoring of inhaler devices allow for monitoring of use, as well as recording of and feedback on inhaler technique for some devices. Most electronic monitoring devices (EMDs) are paired with a smartphone application, allowing patients to set reminders and display both preventer and reliever use over time. This allows identification of intentional and unintentional ICS non-adherence as well as frequency of SABA use. This information assists clinicians in distinguishing difficult-to-control from severe asthma. Although additional evidence is required to assess the impact of EMDs on clinical outcome measures such as exacerbation rate, the introduction of EMDs into the asthma armoury is a significant step forward in asthma care with the potential to improve asthma-related outcomes.

Allergic sensitization and obstructive airway diseases among an adult rural population in Nepal

Background: The relevance of the obstructive lung diseases asthma and COPD and IgE-mediated allergy in Nepal is still poorly characterized.
 Method: In a cross-sectional study in rural Nepal 199 persons were characterized with a questionnaire, skin prick tests, spirometry and total IgE concentration in serum.
 Results: About 20% of the women and 50% of the men were current smokers. Half of the study population used biomass fuel at home to cook or to heat and 70% of the study participants experienced dust-exposure at work or at home. 50% of the women and 30% of the men had a history of COPD, while 57% of the women and 53% of the men had symptoms of respiratory allergy. 18% of the women and 16% of the men used inhaler devices. 62% of the women and 66% of the men had a total IgE concentration in serum >100 IU/mL. About 30% of the women had a FEV1 < 80% and about 10 % had a FEV1 < 40%, also 30% of the men had a FEV1 <80% but none of the men had a FEV1 <40%. The FEV1/VC ratio was smaller than 70% in 13 % of the women and 14,6% of the men. We observed a significant inverse correlation between serum IgE with FEV1. 14% of study participants had positive prick test for house dust mite, 5% were positive for cat dander and 3% were positive for mugwort.
 Conclusion: In summary this study shows an relevant burden of obstructive pulmonary disorders and IgE-mediated allergy in a rural Nepalese population.

Patents And Regulatory Exclusivities On Inhalers For Asthma And COPD, 1986-2020.

Inhalers are the mainstay of treatment for asthma and chronic obstructive pulmonary disease (COPD). These products face limited generic competition in the US and remain expensive. To better understand the strategies that brand-name inhaler manufacturers have employed to preserve their market dominance, we analyzed all patents and regulatory exclusivities granted to inhalers approved by the Food and Drug Administration between 1986 and 2020. Of the sixty-two inhalers approved, fifty-three were brand-name products, and these brand-name products had a median of sixteen years of protection from generic competition. Only one inhaler contained an ingredient with a new mechanism of action. More than half of all patents were on the inhaler devices, not the active ingredients or other aspects of these drug-device combinations. Manufacturers augmented periods of brand-name market exclusivity by moving active ingredients from one inhaler device into another ("device hops"). The median time from approval of an originator product to the last-to-expire patent or regulatory exclusivity of branded follow-ons was twenty-eight years (across device hops on fourteen originator products). Regulatory and patent reform is critical to ensure that the rewards bestowed on brand-name inhaler manufacturers better reflect the added clinical benefit of new products.

A Pharmacoeconomic Study of Respiratory Medications for Hospice Patients with End-Stage Respiratory Disease.

Background: End-stage respiratory disease and compromised clinical status can hinder patients' ability to use inhalers for effective symptom management. Nebulized and oral medications offer an alternative drug delivery method that may provide therapeutic benefits and reduce medication expenditure. Objectives: Primary research objectives were to determine the cost per patient per claim per day for inhaler devices, nebulized medications, or oral corticosteroids and to estimate the monetary waste generated by using inhalers at the end of life. Design: A retrospective pharmacoeconomic analysis of claims adjudicated by a national hospice-centric pharmacy benefit manager between January 1, 2017, and December 31, 2019. Setting/Subjects: A total of 37,935 adult patients (aged ≥18 years) admitted to hospice with a primary diagnosis of end-stage respiratory disease in the United States were included in the study. Results: A total of 295,451 claims for inhalers, nebulized medications, and oral corticosteroids were analyzed. The mean costs per patient per claim per day were $10.64 for inhalers, $3.28 for nebulized medications, and $1.02 for oral corticosteroids. These costs were significantly different from each other (all p values <0.001). Total monetary waste resulting from unused inhaler doses was $1,040,669, with 21.0%, 13.1%, and 7.3% of patients having claims for inhalers within 30, 14, and 7 days of discharge, respectively. Conclusions: Inhaler use near the end of life generates a significant amount of monetary waste. Using a combination of nebulized and oral medications could reduce health care costs. Nebulized medications may generate less waste since providers can tailor the dispensed supply to the patient's needs rather than using the standard one-month supply of inhaler devices.

Inhalation Devices and Pulmonary Drug Delivery

Inhaled drug delivery is mainly used to treat pulmonary airway disorders by transporting the drug directly to its targeted location for action. This decreases the dose required to exert a therapeutic effect and minimizes any potential adverse effects. Direct drug delivery to air passages facilitates a faster onset of action; it also minimizes irritation to the stomach, which frequently occurs with oral medications, and prevents the exposure of drugs to pre-systemic metabolism that takes place in the intestine and liver. In addition to that, the lung is regarded as a route for transporting medications throughout the entire body’s blood circulation. The type of medication and the device used to deliver it are both important elements in carrying the drug to its target in the lungs. Different types of inhalation methods are used in inhaled delivery. They differ in the dose delivered, inhalation technique, and other factors. This paper will discuss these factors in more detail.

FIDEPOC: Consensus on Inspiratory Flow and Lung Deposition as Key Decision Factors in COPD Inhaled Therapy.

PurposeThe pharmacological treatment of chronic obstructive pulmonary disease (COPD) is largely based on inhaled bronchodilators. Inspiratory flow and lung deposition are key parameters to be considered in inhaled therapy; however, the relationship between these two parameters, the patient specificities, and the suitability of the inhaler type for COPD management has not been fully addressed. The present study follows a Delphi Panel methodology to find expert consensus on the role of inspiratory flow and lung deposition as key decision factors in COPD inhaled therapy.MethodsA two-round Delphi Panel, consisting of 38 statements (items) and completed by 57 Spanish pulmonologists, was carried out to measure the experts’ consensus degree with each item.ResultsA high degree of consensus was reached on most of the items consulted, among these inspiratory flow or inspiratory capacity should be periodically considered when choosing an inhalation device and to ensure the suitability of the inhaler used; the outflow velocity and particle size of the different devices should be considered to ensure adequate lung deposition; an active device (pressurized metered-dose inhalers (pMDI) or soft mist inhalers (SMI)) should be used in patients with low inspiratory flow to achieve adequate lung deposition; and, the use of dry powder inhalers (DPI) should be re-evaluated in patients with severe obstruction and severe exacerbations.ConclusionThis study shows the relevance of inspiratory flow and the degree of particle deposition in the lung in the choice of an inhalation device for COPD management, as well as the convenience of an SMI type device in cases of low inspiratory flow. Moreover, it highlights the scarcity of information on the specific features of inhalation devices in COPD guidelines.

Changes in critical inhaler technique errors in inhaled COPD treatment – A one-year follow-up study in Sweden

BackgroundCritical inhaler technique errors have been associated with lower treatment efficacy in chronic obstructive pulmonary disease (COPD). We aimed to assess and follow-up critical inhaler technique errors, and to investigate their association with COPD symptoms and exacerbations. MethodsCOPD-diagnosed primary and secondary care outpatients (n = 310) demonstrated inhaler technique with inhaler devices they were currently using. Critical errors in opening, positioning and loading the inhaler device, and exhalation through dry-powder inhalers were assessed and corrected, and the assessment was repeated one year later. COPD Assessment Test, the modified Medical Research Council dyspnoea scale and history of exacerbations were collected at both visits. ResultsThe proportion of patients making ≥1 critical inhaler technique error was lower at follow-up in the total population (46% vs 37%, p = 0.01) and among patients with unchanged device models (46% vs 35%, p = 0.02), but not among patients with a new inhaler device model (46% vs 41%, p = 0.56). Not positioning the device correctly was the most common critical error at both visits (30% and 22%). Seventy-four percent of the patients had unchanged COPD treatment from baseline to follow-up. Treatment escalation, de-escalation, and switch was observed in 14%, 11%, and 1% of the patients, respectively. No association was found between critical errors and COPD symptoms or exacerbations. ConclusionsAssessment and correction of inhaler technique was associated with a decrease in critical inhaler technique errors. This effect was most pronounced in patients using the same device models throughout the follow-up period.

Mobile device: a useful tool to teach inhaler devices to healthcare professionals

BackgroundProper inhaler device usage is paramount for control of underlying obstructive airway disease. Hence, education to healthcare professionals who will eventually educate patients need to be done effectively. We developed an application for mobile devices for education on six medical inhaler devices, the metered-dose inhaler (MDI), Turbuhaler, Accuhaler, Breezhaler, Ellipta and Respimat, and studied if there were any difference between the application and the manufacturer’s instructions on inhaler technique. The aim of this study is to see if inhaler education via a mobile phone app is comparable to manual instruction for health care professions.MethodsParticipants, who were nursing students, were randomized to learn the inhaler devices via the manufacturer’s instruction guide or a mobile device app designed specifically for education on inhaler devices.ResultsThere were 45 participants in each group. 78% of them were females with a median age of 21 (IQR 3). 67% used an Apple mobile device and the remainder used an Android device. The mobile device showed better total improvement points for the Turbuhaler device (262 vs 287 points; P = 0.02). Participants learning from the manufacturer’s guide had a significantly higher total improvement points in the Breezhaler (370 vs 327 points; P < 0.01) and Ellipta (214 vs 174 points; P < 0.01) device. Both interventions showed improvement in total scores for demonstrating the correct usage of all inhaler devices. MDI has the least number of correct steps for both interventions. The participants’ reported their mean (SD) self-rated knowledge was significantly higher for those using the app for all devices as compared to those that did not (4.33 (0.68) vs 4.73 (0.42); P = < 0.01). Self-reported confidence level was found to be higher in the mobile app group, but this was not statistically significant. The app was well received and scored of 4.42 of 5 with regards to its quality.ConclusionUsing a mobile inhaler app is just as effective to teach inhaler device techniques to healthcare professionals and is likely a more convenient, versatile and important adjunct to learning.Trial registrationNational Healthcare Group Ethics Board (2018/00960).

ОТДЕЛЬНЫЕ АСПЕКТЫ ЛЕЧЕНИЯ ПАЦИЕНТОВ С ВПЕРВЫЕ ВЫЯВЛЕННЫМ ТУБЕРКУЛЕЗОМ ЛЕГКИХ С МНОЖЕСТВЕННОЙ ЛЕКАРСТВЕННОЙ УСТОЙЧИВОСТЬЮ В СОЧЕТАНИИ И ХРОНИЧЕСКОЙ ОБСТРУКТИВНОЙ БОЛЕЗНЬЮ ЛЕГКИХ: В ФОКУСЕ ИНГАЛЯЦИОННЫЕ ГЛЮКОКОРТИКОСТЕРОИДЫ

Introduction. The problem of treating tuberculosis (TB) remains relevant, due to the growth of drug-resistant forms of mycobacterium tuberculosis and an increase in the incidence of TB in persons with comorbid bronchopulmonary pathology, which requires comprehensive management of this category of patients, with mandatory drug correction of concomitant pathology. Aim. The aim of this study was to assess the effect of inhaled glucocorticosteroids (budesonide / formoterol 160 / 4.5 in an Inhaler device) on the efficacy of TB therapy in patients with newly diagnosed multidrug-resistant tuberculosis (MDR) who developed in the presence of chronic obstructive pulmonary disease (COPD). Material and methods. A simple, prospective, comparative study in accordance with the inclusion criteria included 40 patients admitted to an anti-tuberculosis dispensary with newly diagnosed MDR tuberculosis with COPD. The diagnosis of TB and COPD was confirmed using radiographic, functional and laboratory research methods. Group 1, age Me (25; 75) 55.5 (46; 58) years - 22 patients with MDR + COPD tuberculosis who, simultaneously with TB chemotherapy, received a short-acting M-anticholinergic blocker, 2 inhalations 4 times a day, group 2, age 54.5 (51; 58) years - 18 patients with MDR + COPD tuberculosis, simultaneously with TB chemotherapy received a combination of ICS with a long-acting bronchodilator (beta-2-agonist (LABA)), budesonide + formoterol 160 / 4.5 μg dose - 2 inhalations 2 times a day (in an inhaler device). Duration of observation is 9 months. Results and discussion. After 9 months of observation, closure of decay cavities in 63.6% in group 1 and 83.3% in group 2 (χ² = 0.3; p = 0.581), smear negativity in 90.9% of cases in group 1 and in 100, 0% in group 2, respectively (χ² = 0.04 p = 0.834), abacillated 63.3% and 100.0% in groups 1 and 2, respectively (χ² = 0.46; p = 0.496). Against the background of the use of ICS in the intensive phase of TB chemotherapy simultaneously with antibiotic therapy, there was a decrease in the time of abacillation and closure of decay cavities in comparison with the group that did not receive ICS. At the same time in broncholics, the use of ICS made it possible to quickly stop the broncho-obstructive syndrome, improve the quality of life and compliance with long-term anti-tuberculosis therapy. An additional nonspecific anti-inflammatory effect of ICS promoted the active resorption of infiltrative changes and the cure of a specific process, reducing the duration of the main course of treatment, including in patients with MDR. Conclusion. Patients of the anti-tuberculosis dispensary with concomitant bronchopulmonary pathology need complex treatment aimed at correcting comorbid conditions, simultaneously with chemotherapy for tuberculosis. The use of ICS in addition to long-acting bronchodilators (LABA, LDAH) in patients with COPD for the correction of broncho-obstructive syndrome in the intensive phase of TB treatment can reduce the time of smear negativity, abacillation and closure of decay cavities.

The effectiveness of large group demonstration training method on the use of pressurized metered-dose inhaler in elderly with chronic obstructive pulmonary disease.

BackgroundPressurized metered-dose inhaler (pMDI) is the most commonly used inhaler devices in community hospitals in Thailand. However, the research work on large group demonstration training method in the use of pMDI and pMDI with spacer in cases of chronic obstructive pulmonary disease (COPD) is very limited. Therefore, this study aimed to evaluate the effectiveness of this training method in elderly with COPD patients.MethodsThis prospective cross-sectional study was conducted at COPD clinic, Chiang Dao Hospital, Chiang Mai, Thailand between June 2019 and July 2019. All patients being treated in the clinic were assessed for their inhalation technique and inspiratory flow. After the initial assessment, patients were given instructions regarding the correct inhalation technique of pMDI and pMDI with spacer devices through large group demonstration. One month later, inhalation techniques and inspiratory flow were re-assessed.ResultsA total of 104 COPD patients were included, mean age 70.9±8.3 years, 51 (49.0%) male. At their first visit, 75.0% of pMDI and 81.7% of pMDI with spacer users performed at least one essential step incorrectly. After receiving large group demonstration training, there was a statistically significant increase in all devices; 26.7% vs. 56.7%, P=0.001 for correct technique, 41.7% vs. 62.7%, P=0.026 for appropriate flow, and 11.7% vs. 36.7%, P=0.001 for correct technique and flow.ConclusionsThe provision of large group training significantly increases the correct use of inhalation techniques and inspiratory flow for pMDI and pMDI with spacer in elderly with COPD.