Inhaler Technique Research Articles

Real-World Use of Inhaled COPD Medications: the Good, the Bad, the Ugly.

Patients with chronic obstructive pulmonary disease (COPD) rely primarily on inhaled medications to control and treat symptoms. Although the medications delivered by inhaler devices are often quite efficacious when delivered to the lung, the real-world effectiveness of these inhaler devices often falls short. Barriers to effective inhaler use include inhaler misuse and cost-related nonadherence. Inhaler misuse can be reduced with appropriate education which leads to improved outcomes. Education can be provided in multiple settings by a wide array of clinicians and clinical team members including pharmacists, respiratory therapists, nurses, physicians, advanced practice nurses, physician assistants, and community health workers, among others. However, despite decades of research and existing effective strategies across settings and types of educators, overall not much progress has been made with respect to effective inhaler technique among populations of patients with COPD in nearly half a century. Similarly, cost-related nonadherence is a long-standing and critical barrier to effective control of COPD, with limited improvements, especially until very recently. This perspective reviews the current promising directions for inhaler-based therapies, ongoing challenges, and critical issues requiring urgent attention.

ФІКСОВАНА КОМБІНАЦІЯ ЕКСТРАМІЛКОДИСПЕРСНОГО БЕКЛОМЕТАЗОНУ ДИПРОПІОНАТУ ТА ФОРМОТЕРОЛУ — НОВІ МОЖЛИВОСТІ В ПОКРАЩЕННІ КОНТРОЛЮ АСТМИ

Despite the great work done in recent years on the dissemination and implementation of asthma recommendations, the level of control of the disease in the world and in Europe remains unsatisfactory in a significant percentage of patients. Factors associated with the treatment failure in patients with obstructive lung diseases are not only the low adherence to the prescribed drug therapy, incorrect use of the device (poor inhalation technique), insufficient communication between the physician and the patient, inadequate drug treatment. There are other factors associated with the disease: asthma and COPD are inflammatory disorders of the entire bronchial tree, including the peripheral airways. Their involvement may remain functionally and clinically silent until signs of air trapping and hyperinflation become apparent, resulting in a lack of symptom control despite conventional treatment. Inflammatory and functional changes in the small airways (<2 mm in diameter) contribute significantly to the pathogenesis of asthma in terms of bronchoconstriction and hyperreactivity. Today, the awareness of their role in the development of asthma is increasing and they are considered as a potential target for therapy aimed at achieving and maintaining optimal disease control. The determination of the role of the distal parts of the respiratory tract predicted the need for the development of a new generation inhalers that could generate aerosols with extra-fine particles of drugs for more effective penetration of the aerosol to the periphery of the lungs. The recent appearance of inhaled extra-fine particles inhaled drugs allows for a more uniform distribution of the active substance throughout the respiratory tract, including the peripheral airways. These drugs are more effective and require a lower nominal dose to achieve the same effect on lung function and symptoms compared to equipotent doses of non-extra-fine aerosols. Extra-fine fixed combination of beclomethasone dipropionate and formoterol 100/6 mcg (FOSTER) was the first registered metered dose inhaler for the MART regimen in asthma. Key words: asthma, distal airways, inhalers, asthma control, exacerbation.

Assessment of Inhaler Technique of Healthcare Workers in Port Harcourt, Nigeria

Introduction: Pressurized metered dose inhalers (pMDIs) are important in asthma management, however, their therapeutic effectiveness is dependent on correct use, as a poor technique would result in suboptimal drug delivery to the lungs. It is, therefore, necessary for healthcare professionals to know and teach proper pMDI techniques, to improve the outcomes in asthma management. Aim: The aim of the study was to assess pMDI technique instructions given by healthcare workers to patients with bronchial asthma. Method: This was a cross-sectional study done amongst healthcare workers who attended the 2022 World Asthma Day Workshop in Port Harcourt. An interviewer-administered questionnaire was used to obtain information on the demographic characteristics of participants. A model station was set up for the healthcare workers to give simulated health instructions to patients on the use of the provided pMDI. The correct identification of a pMDI and the stepwise pMDI training instructions of each participant were observed and scored according to the National Heart, Lung and Blood Institute protocol. Result: Sixty participants were recruited for the study.Ninety-eight per cent of the participants correctly identified a pMDI. However,88.3% gave less than 60% of the instructions required for proper demonstration of the inhaler technique. Conclusion: The study demonstrated poor pMDI technique among Health workers in Port Harcourt, Rivers State, Nigeria.

Experience of clinicians with dual bronchodilator therapy in COPD (EXPAND) in Nepal

Introduction: Combination of bronchodilators, particularly long-acting muscarinic antagonists (LAMAs) and long-acting β2 agonists (LABAs) have become the mainstay of pharmacological therapy for COPD. COPD is now a common non communicable disease in Nepal. Objective: The study evaluated the current perception and experience of the clinicians in Nepal on diagnosis and management of COPD with focus on use of dual bronchodilator therapy. Method: This cross-sectional, observational survey evaluated experiences of clinicians (n=96; pulmonologist-13, physician-57, general practitioner-26) in Nepal on diagnosis, management trends, and current perceptions on the use of dual bronchodilator therapy in COPD management. Result: 93% of clinicians were practising in an urban setting for an average of 10 years and an average of 35% of their patients are of COPD. 61% of clinicians use mMRC with (34%) or without (27%) CAT score. 92% of clinicians perceived that most of their patients had 1 (32%) or >1 (59%) exacerbation/year. 54% of clinicians performed spirometry on all their patients with suspected COPD. 49% of clinicians measured blood EOS in their patients with severe COPD before adding ICS. 93% of clinicians preferred dual therapy (separate inhalers or a combination) for their COPD patients, but 83% of clinicians preferred LABA + LAMA in a single inhaler over inhalers given separately. 57% of clinicians preferred LABA + LAMA and 82% preferred the Tiotropium + Formoterol combination. 81% of clinicians stepped up or stepped down their treatment. 56% of patients were taking LABA + LAMA + ICS and 55% of clinicians co-prescribed ICS + LABA with LABA + LAMA. 80% of clinicians checked the inhalation technique at every visit and an average of 54% of their COPD patients were adherent (>80%) to the prescribed inhalation therapy. 78% of clinicians felt that dryness of mouth was the most common side effect of LABA + LAMA. 94% of clinicians believed that managing COPD better could improve cardiovascular outcomes in their patients with coexistent COPD. Conclusion: In the EXPAND survey, Formoterol + Tiotropium was preferred by most clinicians in Nepal amongst the LABA + LAMA combination. There is a good scope for improvement in the utilization of tools like spirometry, mMRC, CAT, and blood EOS in the daily practice of clinicians in Nepal.

The ADEM project: implementation of ‘Good medicines use conversation’ for COPD-patients, embedded in multidisciplinary context.

COPD is a chronic, progressive disease, for which a multidisciplinary approach is crucial. Appropriate follow-up is crucial to improve the quality of life of COPD-patients and reduce associated healthcare costs. 
 A ‘Good medicines use conversation’ COPD is a pharmaceutical care intervention, conducted by the community pharmacist, consisting of a tailored-made education of the COPD-patient on the disease and its treatment. Scientific research (PHARMACOP-trial) has shown that this intervention significantly improves therapy adherence and inhalation technique and reduces exacerbation rates and associated hospitalizations. 
 The aim of the ADEM implementation project was to investigate the needs for a sustainable implementation of this intervention.
 The ADEM project was conducted in Flemish-Brabant (Belgium), with the integrated care region ‘Leuven Cares’ as a separate entity. 
 All participating pharmacies (9 in region Flemish-Brabant and 8 in region ‘Leuven Cares’) received a support package consisting of: 1) a three-part online training about COPD and a visual COPD-atlas; 2) a population management-tool (a query to identify COPD-patients in the pharmacy, resulting in a list of COPD-patients with a ‘score’ per patient as an initial proxy for patient prioritization); and 3) local interdisciplinary meetings (LIM) to discuss and promote the intervention. Pharmacist of the region Caring Leuven additionally received individual care plans, providing an overview of the healthcare status of each COPD-patient, and an individual coaching session.
 Semi-structured interviews were conducted with 8 participating pharmacists (4 region Flemish-Brabant, 4 region ‘Leuven Cares’). Thematic analysis was performed.
 
 All elements of the support package were positively evaluated by the participating pharmacists. The population management tool seemed to support pharmacists in planning, interpreting and prioritizing care for COPD-patients. A follow-up study is needed to further investigate the tool and to what extent population management contributes to a more qualitative and effective pharmaceutical care. 
 COVID-19, lack of personnel, lack of reimbursement and lack of time were identified as limiting factors for the implementation of the protocol-based COPD-intervention. Cooperation with the GP was indicated by the majority as minimal and insufficient. Therefore, LIM’s were evaluated as very important to inform GP’s about the pharmaceutical intervention and make local agreements about the multidisciplinary approach of COPD.
 The findings of this study are in line with the available evidence on the implementation of new services in pharmacies. Many pharmacists have the intrinsic motivation to offer extended pharmaceutical care, but current practices often do not allow this. Population management appeared to be a major factor that can be used to facilitate the implementation. By considering the needs of the local population, pharmacists can work in a more targeted way and prioritize the pharmaceutical services they offer. Given the group of chronically ill people in Belgium is expected to grow in the coming years due to the increasing ageing of the population, there will be an increasing demand for specialized interventions and advice from the pharmacist. It is therefore necessary to provide a sufficient framework for these services, bearing in mind the needs of the local population and the requirement for a pragmatic approach in the pharmacy. 

Development and Implementation of an Integrated Pharmaceutical Care Program for patients with COPD in a Rehabilitation Hospital.

Background: Chronic obstructive pulmonary disease (COPD) is a progressive disease associated with airflow limitation and prolonged respiratory problems. The treatment requires an interdisciplinary approach with a holistic view of the patient. A cornerstone of the treatment consists of inhalation therapy. Inhalation errors are abundant and medication adherence towards inhalation therapy is low. We aimed (1) to develop a standardized pharmaceutical care protocol for hospitalized patients with COPD and (2) to evaluate the effect and feasibility of protocol implementation.
 Methods: This study took place at the rehabilitation hospital Koningin Elisabeth Instituut (RH-KEI) in Oostduinkerke, Belgium from January 2021 to April 2022. The protocol was based on the PHARMACOP protocol, tailored to the specific setting using in-depth interviews with all HCPs involved in the pharmaceutical care of patients with COPD (physicians, pharmacists, pharmacy technicians, nurses, physiotherapists and an occupational therapist). The finalized protocol consisted of six additional patient contacts (3 evaluation moments, 2 educational moments and 1 evaluation moment two weeks after discharge), mainly between the hospital pharmacist and the patients. Consequently, from January 2022 to April 2022, adult patients with COPD were included to follow the complete protocol. Patient outcomes were evaluated using standardized questionnaires (i.e. mMRC, BMQ, CAT, EQ-D and EQ-VAS). The feasibility was assessed during a focus group discussion with all involved HCPs and a patient survey after discharge.
 Results: Before the start of the study, the hospital pharmacist in RH-KEI had no patient contact and there were no (recurrent) training sessions about inhaler use. The in-depth interviews elucidated that most involved health care providers (HCPs) had insufficient knowledge of the correct use of inhalers. This is however needed as 37% of included patients made at least one critical inhalation error at hospitalization. The adapted PHARMACOP protocol was tested in 13 patients, after which a significant improvement was noted in mMRC (p = 0.047), BMQ concerns (p = 0.011) and CAT score (p = 0.002). A trend towards improvement was noted in the EQ-5D and EQ-VAS score (resp. p = 0.065, p = 0.590). Finally, mean inhalation technique scores had significantly improved (p = 0.003). Transferring information to primary care HCPs seemed difficult as only a third of patients had handed over their discharge letter to their community pharmacist. The in-hospital HCPs concluded that the protocol was feasible for implementation with some adjustments, such as a more prominent role of the (hospital) pharmacist, the possibility to tailor the program to the patient and a set timing for interdisciplinary (patient) discussions. 
 Conclusion: An interdisciplinary pharmaceutical care program can improve outcomes in patients with COPD. Additional attention should be given to the inclusion of primary care HCPs to guarantee continuity of care concerning inhalation therapy for COPD management.

Childhood asthma complications, management, and environmental triggers

Childhood asthma, which is a chronic respiratory condition, presents challenges in terms of its complications, management, and identification of environmental triggers. This review of existing literature explores the complexities surrounding asthma. It delves into complications, strategies for managing the condition, and the crucial role that environmental factors play in worsening it. Uncontrolled asthma in children has far-reaching consequences as it affects lung function, physical activity levels, and overall quality of life. Early recognition and addressing of these complications are essential to minimize long-term effects. The management of childhood asthma has evolved to focus on treatment plans, with corticosteroids being a key component. For cases, advanced therapeutic options like biologics are available. Indoor and outdoor environmental triggers have an impact on asthma exacerbations, making targeted preventive measures necessary. Education plays a role by providing caregivers and children with asthma action plans as well as proper inhaler technique guidance. Regular follow-up visits ensure assessment and adjustment of treatment plans while fostering a relationship between healthcare providers and families. Comprehensive care for childhood asthma involves an approach that includes pediatricians, pulmonologists, allergists, and respiratory therapists. The triad of interventions, environmental modifications, and educational strategies forms an encompassing framework for the management of asthma. This review highlights how crucial it is to tackle childhood asthma issues. By doing so, we can improve outcomes. Promote the overall well-being of children who are affected by this condition.

Optimization of Inhalation Technique Knowledge in the Pharmacies of Matosinhos Municipality, Portugal: An Intervention Project.

The therapeutic approach to the most common respiratory diseases, asthma and chronic obstructive pulmonary disease (COPD), involves the use of inhalation devices. Its use is essential, but incorrect use is frequent, and learning and reviewing the technique is necessary for the adequate management of these diseases. This study aims to increase the knowledge of health professionals from pharmacies in the municipality of Matosinhos, Portugal, about the correct inhalation technique. The project developed from May 2022 to June 2023 was based on a training session for pharmacy professionals that took place after professionals completed a questionnaire and after evaluating each participant's inhalation technique by the authorsusing a checklist. Both were reapplied three months after the first evaluation. Fifteen pharmacies in Matosinhos, Portugal, were invited, of which eight agreed to participate, with a total of 16 health professionals (30.8% of professionals in these pharmacies). We found that professionals questioned and taught users more times about the inhalation technique and that a greater number of professionals considered they knew how to correctly perform the inhalation technique in the second assessment. It was also possible to verify statistically significant differences (p<0.001) between the mean of correct steps in the inhalation technique between the first and second assessments. There was also an improvement in the qualitative analysis of errors in the inhalation technique. In the first assessment, the inhalation devices with the lowest percentage of correct steps were Forspiro® and Respimat®. In the second evaluation, the Diskus® and Ellipta® devices obtained 100% correct steps, with the K-haler® being the device with the lowest percentage. This study confirms the effectiveness of continuous training for health professionals and the importance of multidisciplinary cooperation in teaching inhalation techniques. Other studies are needed to complement these results, particularly with representative samples of the general population, or assessing the impact of this intervention in patients with respiratory diseases.

Does mixing inhaler devices lead to unchecked inhaler technique errors in patients with COPD? Findings from the cross-sectional observational MISMATCH study

BackgroundPatients with chronic obstructive pulmonary disease (COPD) may be prescribed multiple inhalers that require different techniques for optimal performance. Mixing devices has been associated with poorer COPD outcomes suggesting that...

Educational Interventions in Immigrants for Asthma and COPD: A Systematic Review.

Asthma and COPD are prevalent respiratory conditions among immigrants, yet many individuals in this population do not effectively utilize available therapies, resulting in exacerbations and limitations in their daily lives. This systematic review seeks to describe asthma/COPD educational interventions specifically tailored for immigrant patients and assess their variability and outcomes, with the ultimate goal of improving self-management and achieving better asthma or COPD control in this population. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. A comprehensive literature search was conducted using four electronic databases (CINAHL, PubMed, Embase and PsycInfo). Articles were included if they focused on asthma or COPD interventions conducted in immigrant populations. The Mixed Methods Appraisal Tool was used to assess the quality of included articles. Out of the initial 1173 articles identified, 812 were assessed for eligibility. Six articles met the inclusion criteria for educational interventions targeting immigrants with asthma or COPD. These studies explored the effectiveness of interventions on various immigrant populations using different methodologies including group discussion of photographs and classroom-based interventions. The interventions varied in terms of settings, educational materials, and delivery methods. Positive outcomes were observed in areas such as knowledge, understanding of instructions, and inhaler technique. However, the included studies had limitations in assessing the impact on asthma and COPD self-management and sustainability. More research is needed on asthma and COPD management in immigrants. The interventions included in this review had positive effects on outcomes like inhaler technique and asthma knowledge. However, due to variability in outcome measures, it is difficult to directly compare the interventions. Future studies should include diverse immigrant populations, consider the specific migration status of the immigrants, long-term sustainability of the intervention and use culturally tailored approaches to improve respiratory health in this population.

Achieving mastery in inhaler technique: An evaluation of training provided to general practice healthcare professionals

Abstract Introduction A local scoping questionnaire on previous training and confidence demonstrating inhaler technique in general practice (GP) healthcare professionals (HCP), identified that despite frequent consultations with patients with respiratory disease, 43% reported being self-taught on inhalers. In addition, the proportion of HCPs who reported confidence for demonstrating inhaler technique was low, approximately 60% for pressurised metered dose inhalers (pMDI), and 35-50% for the dry powder inhalers (DPIs) Ellipta, Easyhaler, and NEXThaler. Aim To evaluate the impact of an expert-led face-to-face inhaler technique workshop on HCP confidence and skills. Methods GP HCPs at seven Primary Care Networks (PCN) within Leeds Integrated Care Board (ICB) were invited to attend a multidisciplinary pilot inhaler training session in September 2022, led by a Consultant Respiratory Pharmacist and three facilitators. Inhaler technique was assessed at baseline and after education on the theory and practical issues of inhaler technique for the four most prescribed devices locally (Ellipta, Easyhaler, pMDI, NEXThaler). Inhaler technique was assessed using a seven-step checklist and scored as Optimal (no errors), Satisfactory (no critical errors, but some minor errors) or Unsatisfactory (at least 1 critical error).1 Each facilitator was allocated one inhaler device type and assessed all attendees with that same device. Attendees were asked to complete a post-training evaluation questionnaire, which asked about understanding of inhaler technique and confidence in demonstrating it. Data were subjected to descriptive statistical analysis. This evaluation of educational provision did not require ethical approval. Results Data was available for 23 of the 24 participants who completed the full session. Inhaler technique improved across all four devices post-training. The proportion of HCPs with satisfactory or optimal inhaler technique improved by 87% for Ellipta (from 4% to 91%), 65% for Nexthaler (from 22% to 87%), 17% for pMDI (from 0% to 17%) and 65% for Easyhaler (from 0% to 65%). The most common critical error made using pMDI, even after training, was inhaling too fast, whilst the most common critical error for Ellipta, Easyhaler and Nexthaler devices was not tilting the chin up prior to inhalation. This improved after training. 22 attendees completed a post-training session evaluation form. An improvement in understanding of correct inhaler technique was reported by 89% of HCPs, and 100% agreed they felt more confident demonstrating inhaler technique to patients. Discussion/Conclusion Evaluation of our expert-led inhaler technique training showed that HCPs were more likely to feel confident and achieve mastery in inhaler technique using DPIs than pMDI. Despite pMDIs being the device HCPs felt most confident using prior to training, this was the device HCPs performed poorly in. Post-training, many attendees described that to use a pMDI they inhale slowly and steadily, but on demonstration continued to inhale quickly and deeply, highlighting the difficulty in changing ingrained incorrect practice. Whilst understanding on how to use pMDIs correctly probably improved, it is likely that more practice is required. Consideration should be given to regular repeat training sessions, and the setting of these (in person, remote or eLearning) should be assessed in wider rollout of this initiative.

Effectiveness of a Maintenance and Reliever Digihaler System in Asthma: 24-Week Randomized Study (CONNECT2)

BACKGROUNDDigital health tools have been shown to help address challenges in asthma control, including inhaler technique, treatment adherence and short-acting beta2-agonist overuse. The maintenance and reliever Digihaler System (DS) comprises two Digihaler inhalers (fluticasone propionate/salmeterol and albuterol) with an associated patient App and web-based Dashboard. Clinicians can review patients’ inhaler use and Digihaler inhalation parameter data to support clinical decision-making. OBJECTIVECONNECT2 evaluated asthma control in participants using the DS versus standard-of-care (SoC) maintenance and reliever inhalers. METHODSParticipants (≥13 years) with uncontrolled asthma (Asthma Control Test [ACT] score <19) were randomized 4:3 (open-label) to the DS (n = 210) or SoC (n = 181) for 24 weeks. The primary endpoint was the proportion of patients achieving well-controlled asthma (i.e., an ACT score ≥20 or increase from baseline of ≥3 units at Week 24). RESULTSThere was an 88.7% probability that participants using the DS would have greater odds of achieving improvement in asthma control compared with SoC after 24 weeks. Mean odds ratio (95% credible interval) for DS versus SoC was 1.35 (0.846–2.038), indicating a 35% higher odds of improved asthma control with the DS. The DS group had more clinician-participant interactions versus SoC, mainly addressing poor inhaler technique. DS participants’ maintenance treatment adherence was good (Month 1: 79.2%; Month 6: 68.6%); reliever use decreased by 38.2% versus baseline. App and Dashboard usability were rated ‘good’. CONCLUSIONThe positive results in asthma control in this study after 24 weeks demonstrate the effectiveness of the DS in asthma management.

How does community pharmacy support patients living with asthma?

Abstract Introduction Asthma is a chronic respiratory condition that is currently an increasing issue worldwide. Particularly in the United Kingdom, 185 people are admitted to hospital because of an attack and 3 people die daily despite the National Healthcare Service (NHS) spending £1 billion on asthma care.1 Community pharmacies are taking on a more clinical role in the NHS but the extent of their role in primary care, specifically regarding helping patients living with asthma is unknown. Aim This study aimed to identify how community pharmacists reduced the general practitioners (GPs) workload by helping patients living with asthma. Methods The study used a 30-question survey to collect data from community pharmacists in North-East London boroughs (n=206 pharmacies). The survey consisted of both closed and open-ended questions, exploring the asthma interventions pharmacists conducted and the impact this had on patients, as well as the medication or devices that patients were struggling with the most and how confident pharmacists felt about all aspects of asthma. The paper-based survey was handed to each responsible pharmacist for completion. Data was input into SPSS for analysis. The study received ethical approval from Kingston University. Results Participants found the New Medicines Service to be the most helpful service (4.4/5) for patients living with asthma, followed by influenza vaccine (4/5), Community Pharmacy Consultation Service (CPCS) (3.8/5) and inhaler technique checks (3.8/5). The percentage of referrals to the GP that resulted from these services were 0-20% of patients in an average week. The most frequently referred medication was salbutamol (56.5%) due to its overuse or exacerbation of symptoms with Clenil® (15.2%) the second most referred medicine due to side-effects such as a sore throat. The most frequent inhaler device dispensed was the metered dose inhalers (94%), however the most troublesome inhalers were dry powder inhalers (50.8%) due to patient’s poor inhalation capacity, dexterity, inability to load the capsules and poor knowledge. Overall, pharmacists were confident in their ability to help asthma patients, however, younger pharmacists were less likely to check inhaler technique at every dispensing (p=0.016), more likely to check it only upon patient request (p=0.042) and were more likely to refer patients to the GP after consultations. Contrastingly, nearly all participants (93.2%) found their training for asthma and its services to be sufficient, with 62.5% using centre for pharmacy postgraduate education as their training provider. Discussion/Conclusion The results suggest that most of the time pharmacists were well trained, addressed patients concerns adequately and were able to support with adherence and usage of inhalers.2 It was clear that pharmacists do play an active role in the lives of asthma patients through the services they conduct. Their training allows pharmacists to be confident when carrying out these services so that majority of patient’s concerns are addressed within the pharmacy and only a few require GP referral. It may be beneficial to carry out technique checks more frequently, conduct asthma reviews within the pharmacy and provide additional resources to newly qualified pharmacists to aid their confidence in helping asthma patients.

Dry Powder Inhalers: From Bench to Bedside.

Dry powder inhalers (DPIs) are now widely prescribed and preferred by the majority of patients. These devices have many advantages over the traditional pressurized metered-dose inhaler (pMDI) but they do have disadvantages. The characteristics of the dose emitted from a DPI are affected by the inhalation manoeuvre used by a patient. Each patient is different and the severity of their lung disease varies from mild to very severe. This affects how they use an inhaler and so determines the type of dose they inhale. An understanding of the pharmaceutical science related to DPIs is important to appreciate the relevance of how patients inhale through these devices. Also, each type of DPI has its unique dose preparation routine, and thus it is essential to follow these recommended steps because errors at this stage may result in no dose being inhaled. All issues related to the inhalation manoeuvre and dose preparation are addressed in this chapter. The importance of the inhalation technique is highlighted with a realization of inhale technique training and checking. During routine patient management, devices should not be switched nor doses increased unless the patient has demonstrated that they can and do use their DPI.

Rats chasing the dragon: A new heroin inhalation method

BackgroundDespite extensive human use of inhalation for ingesting opioids, models in rodents have mostly been limited to parenteral injection and oral dosing. Methods using electronic drug delivery systems (EDDS; “e-cigarettes”) have shown efficacy in rodent models but these do not faithfully mimic the most popular human inhalation method of heating heroin to the point of vaporization. New methodMiddle aged rats were exposed to vapor created by direct heating of heroin HCl powder in a ceramic e-cigarette type atomizer. Efficacy was determined with a warm water tail withdrawal nociception assay, rectal temperature and self-administration. ResultsTen minutes of inhalation of vaporized heroin slowed response latency in a warm water tail withdrawal assay and increased rectal temperature in male rats, in a dose-dependent manner. Similar antinociceptive effects in female rats were attenuated by the opioid antagonist naloxone (1.0 mg/kg, s.c.). Female rats made operant responses for heroin vapor in 15-minute sessions, increased their response rate when the reinforcement ratio increased from FR1 to FR5, and further increased their responding when vapor delivery was omitted. Anti-nociceptive effects of self-administered volatilized heroin were of a similar magnitude as those produced by the 10-minute non-contingent exposure. Comparison with existing methodsInhalation of directly volatilized heroin successfully produces heroin-typical effects, comparable to EDDS inhalation delivery. ConclusionsThis study shows that “chasing the dragon” methods of inhalation of heroin can be modeled successfully in the rat. Inhalation techniques may be particularly useful for longer term studies deep into the middle age of rats.

Chinese expert consensus on standardized inhaler device application in stable chronic airway diseases (2023)

Chinese expert consensus on standardized inhaler device application in stable chronic airway diseases (2023)

Errors in Metered Dose Inhaler Use Amongst Pediatric Asthma Patients.

The aim of this paper is to use easily accessible smartphones as a straightforward means for physicians to objectively check Medical Device Inhaler (MDI) technique, without the need for additional devices. Additionally, we seek to assess the frequency of inhaler technique errors and their impact on asthma control. Thirty-two children between the ages of 5 and 18 receiving asthma therapy through MDIs were included. Three surveys were administered to all participants to gauge device history, asthma control, and patient characteristics. Patient technique was scored using inhaler audio signals recorded with a smartphone. For subjects that were able, forced oscillation technique (FOT) was performed during tidal breathing conditions before and after corticosteroid administration. 81% (25/31) of participants used their MDIs incorrectly with the most common errors being rapid shallow breathing, inadequate breath-holding, and excessive actuations. Poor inhaler technique correlated with poorly controlled asthma symptoms. The use of smartphone recordings can a convenient way to evaluate technique errors and could allow patients to demonstrate and refine their technique and usage without a doctor's visit, ensuring proper technique and enhancing treatment effectiveness.

Inhalation technique assessment and evaluation for the need of pharmaceutical intervention in respiratory pathologies patients

ObjectiveTo evaluate rate and type of errors in inhalation technique of patients seen in hospitals at the observation area in the emergency department, as well as patients seen in the outpatients clinic at the primary care pharmaceutical consultation, and at the community pharmacy. MethodDescriptive observational study carried out by a hospital pharmacist, along with a primary care pharmacist and a community pharmacist. An anonymous survey was performed in order to collect different analyzed data. Each patient was asked to execute a complete demonstration on how they used their inhalers, to actively check the inhalation technique. Two checklists regarding the type of inhaler were established in order to assess said technique. Results were tabulated through Microsoft Excel® 2010 software and analyzed through R 3.5 statistical program. ResultsA total of 66 patients (42 male, 24 female; mean age 67) were recruited. Out of all patients, 48.5% used more than one inhaler, which 34.4% used different types of inhaler, and 65.6% used different systems. A total of 39 patients were under dry powder inhaler therapy, and 38 were using pressurized metered dose inhalers. The most frequent errors –both in dry powder inhalers and pressurized metered dose inhalers– were: not performing a 10 second apnea and not slowly expelling air from the lungs. Around 50% of patients needed new learning after assessing their inhalation technique, even though 88.5% had already received previous training. Older aged patients performed a worse inhalation technique. ConclusionsThere is a high rate of errors in the use of inhaled therapy, being even higher among older aged patients. The inhalation technique training by the medical staff seems inadequate, as it is crucial to raise awareness about the importance of health education for patients and their use of inhalers, to which a scheduled follow up and a technical and feedback obtained from the patient assessment is required.

Education on Inhaler Technique by Pharmacists To Improve The Quality of Life of COPD Patients: A Systematic Review and Meta-Analysis

Background: This systematic review aimed to analyze the importance of education on using inhalers by pharmacists in improving quality of life, correct inhaler use steps, and medication adherence in patients with Chronic Obstructive Pulmonary Disease (COPD).Methods: The databases used to search for articles in this systematic review include Scopus, ScienceDirect, and Pubmed. The papers submitted were published between 2009 and 2022, with the most recent search being conducted in December 2022. This review included a randomized controlled trial evaluating education on inhaler use techniques by pharmacists to improve COPD patients' quality of life in inpatient and outpatient settings. This systematic review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) writing guidelines.Results: This systematic review used six articles from five different countries. The articles involved share similar characteristics so that analysis can be carried out. The total number of research subjects included was 913 subjects. Most studies show an increase in the quality of life among COPD patients who are given education on how to use inhalers by pharmacists using print or digital media. Measurements using the St. George's Respiratory Questionnaire (SGRQ) showed a decrease in scores at the 6-month and 12-month periods (-0.75 [95% CI (-1.46 - (-.005)]. Furthermore, two articles reported that education on the technique of using inhalers by pharmacists can also increase the accuracy of using inhalers, and three articles reported increasing medication adherence.Conclusion: Interventions such as education on using inhalers by pharmacists in inpatient and outpatient settings can improve the quality of life of COPD patients, the accuracy of the steps in using inhalers, and medication adherence.

Effectiveness of clinical pharmacist intervention on medication adherence in patients with chronic obstructive pulmonary disease - A randomized controlled study

ObjectivesIn patients with chronic obstructive pulmonary disease (COPD), non-adherence remains challenging to achieve optimal disease control. Our study aimed to determine the impact of pharmacist-led educational interventions on COPD management, focusing mainly on medication adherence. MethodsWe conducted a 1-month open-labeled, randomized, controlled study at Ba Ria Hospital, Vietnam. COPD outpatients were randomly assigned to the intervention group or control group. Pharmacist-delivered education emphasized medication adherence, disease, and medication knowledge. The primary outcome was the between-group difference in medication adherence after the intervention, as assessed by the general medication adherence scale (GMAS). ResultsOf 181 recruited patients, 180 completed the follow-up. After the intervention, the results indicated a significant improvement in medication adherence rate between the two groups (90.1% vs. 66.3%, p < 0.001). Patient behavior was the most common barrier to non-adherence but was effectively reduced at the endpoint. The Modified Medical Research Council (mMRC) scale of dyspnea and inhalation technique also improved significantly in intervention patients. ConclusionsPharmacist intervention can considerably improve medication adherence and knowledge of COPD patients. Practice implicationsThis study promotes the value of clinical pharmacists in patient education to achieve better adherence and enhance population health, especially in resource-limited nations like Vietnam.