Metered-dose Research Articles

Small Airways Disease Affects Aerosol Deposition in Children with Severe Asthma: A Functional Respiratory Imaging Study.

Background: Small airways disease (SAD) in severe asthma (SA) is associated with high disease burden. Effective treatment of SAD could improve disease control. Reduced end-expiratory flows (forced expiratory flow [FEF]25-75 and FEF75) are considered sensitive indicators of SAD. Inhaled medication should be delivered to the smaller peripheral airways to treat SAD effectively. Aerosol deposition is affected by structural airway changes. Little is known about the effect of SAD on aerosol delivery to the smaller peripheral airways. Functional respiratory imaging (FRI) is a validated technique using 3D reconstructed chest computed tomography (CT) and computational fluid dynamics to predict aerosol deposition in the airways. Aim: This study aims to compare central and peripheral (= small airways) deposition between children with SA and SAD and children with SA without SAD, with different inhaler devices and inhalation profiles. Methods: FRI was used to predict the deposition of beclomethasone/formoterol dry powder inhaler (DPI), beclomethasone/formoterol pressurized metered dose inhaler with valved holding chamber (pMDI/VHC), and salbutamol pMDI/VHC for different device-specific inhalation profiles in chest-CT of 20 children with SA (10 with and 10 without SAD). SAD was defined as FEF25-75 and FEF75 z-score < -1.645 and forced vital capacity (FVC) z-score > -1.645. No SAD was defined as forced expiratory volume (FEV)1, FEF25-75, FEF75, and FVC z-score > -1.645. The intrathoracic, central, and peripheral airways depositions were determined. Primary outcome was difference in central-to-peripheral (C:P) deposition ratio between children with SAD and without SAD. Results: Central deposition was significantly higher (∼3.5%) and peripheral deposition was lower (2.9%) for all inhaler devices and inhalation profiles in children with SAD compared with children without SAD. As a result C:P ratios were significantly higher for all inhaler devices and inhalation profiles, except for beclomethasone administered through DPI (p = .073), in children with SAD compared with children without SAD. Conclusion: Children with SA and SAD have higher C:P ratios, that is, higher central and lower peripheral aerosol deposition, than children without SAD. The intrathoracic, central, and peripheral deposition of beclomethasone/formoterol using DPI was lower than using pMDI/VHC.

Examining factors associated with poor metered-dose inhaler technique in a cohort of bronx patients with uncontrolled asthma

Objective Most studies investigating at-risk groups for poor inhaler technique (PT) have been in adolescents. However, evidence suggests older age correlates with PT. This study aimed to correlate patient characteristics with PT in an adult asthma cohort in the Bronx. Methods We categorized 237 patients with uncontrolled asthma by demonstration of good inhaler technique (GT) (n = 112) or PT (n = 58) at their initial visit. Independent variables included age, sex, ethnicity, language, insurance status, BMI, depression severity, and socioeconomic data. Two logistic regression models were created to assess odds of PT among independent variables at initial visit and odds of improvement in technique at follow-up. Results At the initial visit, patients with PT had a mean age of 53.74 (±13.54) versus 45.12 (±13.26) among those with GT (p= <0.001). The PT group also had a lower percentage of patients with private insurance (52.53% versus 71.15%, p = 0.037). When controlling for language, ethnicity, insurance status, and educational attainment, the odds of PT increased with age (OR, 1.051; CI, 1.017-1.087, p = 0.003) and BMI (OR, 1.065; CI, 1.010-1.123, p = 0.020). Males had lower odds of PT (OR, 0.379; CI, 0.144-0.997; p = 0.049). While insurance status did not affect odds of PT, Medicaid users had lower odds of improving technique (OR, 0.184; CI, 0.040-0.854; p = 0.031). Conclusions At baseline, individuals with PT were younger and more likely to be on a public health insurance plan. Increasing age, increasing BMI, and female sex were associated with higher odds of PT at the baseline visit, but were not associated with improvements in technique.

Recommendations for Reducing the Environmental Impact of Inhalers in Portugal: Consensus Document

This consensus document addresses the reduction of the environmental impact of inhalers in Portugal. It was prepared by the Portuguese Council for Health and the Environment and the societies representing the specialties that account for these drugs' largest volume of prescriptions, namely the Portuguese Society of Pulmonology, the Portuguese Society of Allergology and Clinical Immunology, the Portuguese Society of Pediatrics, the Portuguese Society of Internal Medicine, the Portuguese Association of General and Family Medicine and also a patient association, the Respira Association. The document acknowledges the significant impact of pressurized metered-dose inhalers on greenhouse gas emissions and highlights the need to transition to more sustainable alternatives. The carbon footprint of pressurized metered-dose inhalers and dry powder inhalers in Portugal was calculated, and the level of awareness among prescribing physicians on this topic was also estimated. Finally, recommendations were developed to accelerate the reduction of the ecological footprint of inhalers.

LP-33 Environmental modeling of trifluoroacetic acid (TFA) from pressurized metered-dose inhalers releasing HFO-1234ze(E)

LP-33 Environmental modeling of trifluoroacetic acid (TFA) from pressurized metered-dose inhalers releasing HFO-1234ze(E)

Comparison of Systemic Exposure Between Epinephrine Delivered via Metered-Dose Inhalation and Intramuscular Injection.

Background: Primatene® MIST, an epinephrine metered-dose inhaler (MDI), has long been questioned by some medical professionals for asthma treatment despite having been approved by the Food and Drug Administration. One of the primary reasons for their concerns stemmed from potential cardiovascular complications following epinephrine administration. However, the majority of documented cardiovascular complications seemed to occur following the injection route of the epinephrine. The aim of this study was to evaluate the systemic exposure of epinephrine delivered through different administration routes and to understand its relationship with cardiovascular effects. Since albuterol inhalers are commonly recommended for asthma, albuterol was also studied as a comparator drug. Method: A randomized, evaluator-blinded, three-arm crossover study was conducted in 28 healthy adult subjects to compare the profiles of systemic exposure for epinephrine delivered by MDI versus epinephrine intramuscular (IM) injection and albuterol MDI. Serially sampled plasma epinephrine and albuterol levels were measured and compared between treatment groups. Safety was assessed by adverse events, serial vital signs, electrocardiograms (ECGs), and clinical laboratory tests obtained at each crossover dosing visit. Results: Systemic exogenous drug exposure for inhaled epinephrine MDI (39 pg/mL × hour) was ∼9 times lower than that of epinephrine IM (435 pg/mL × hour) and 122 times lower than that of albuterol MDI (3453 pg/mL × hour) after dose normalization. The Cmax in epinephrine MDI (345 pg/mL) was approximately half of that of epinephrine IM (816 pg/mL) and that of albuterol MDI (681 pg/mL). Plasma drug concentrations for epinephrine MDI dropped rapidly to baseline (∼0.6 hour), while epinephrine IM took ∼8 hours, and albuterol MDI required more than 24 hours. Epinephrine MDI and albuterol MDI resulted in minimal, clinically insignificant changes in vital signs and ECGs, whereas epinephrine IM led to mild transient increases in systolic blood pressure, heart rate, and corrected QT interval. Conclusion: Epinephrine MDI (Primatene MIST) had ∼9 times lower systemic drug exposure (SDE) than that of epinephrine IM and ∼122 times lower than that of albuterol MDI. The lower SDE of inhaled epinephrine also correlated with reassuring safety findings, with no significant cardiovascular adverse effects found, compared with transient effects seen after IM epinephrine. Clinical trial registration number: NCT04207840.

Assessing sterility techniques in bronchodilator responsiveness testing by practicing allergists in North America

BackgroundThe American Thoracic Society (ATS) has published general guidelines for sterility when testing for bronchodilator responsiveness. However, the extent to which practicing allergists implement sterility measures is currently unknown. ObjectiveThis study aims to understand the adherence to ATS guidelines for sterility among practicing allergists. MethodsA questionnaire was approved and distributed by the American Academy of Allergy, Asthma, and Immunology (AAAAI) in 2015 to all its members. Anonymous responses were recorded and tabulated after a 3-week period. ResultsOut of 6800 surveys sent to AAAAI members, 496 allergists participated in the survey (response rate 7.3%). Metered dose inhalers (MDI) with a spacer and nebulizers were the most common bronchodilator administration techniques as indicated by 59.35% and 58.52% of responses, respectively. While 69.25% of allergists consider their bronchodilator administration techniques to be sterile, 14.05% did not consider their administration technique to be sterile, and 16.70% were unsure. For maintaining sterility, 38.75% of responses indicated using a new disposable attachment for reused inhalers, 18.71% of responses indicated using a new inhaler for each patient, and 9.13% reported wiping inhalers with a cleaning agent. ConclusionsNearly a third of allergists practiced either unsterile measures or were unsure. To increase adherence to sterility measures among North American allergists, promoting guideline awareness and proposing updated guidelines focused on the most common bronchodilator administration techniques is essential.

Metered-Dose Inhaler Versus Nebulizer Treatment for Acute Asthma Exacerbation: A Process Evaluation.

Background: The prevalence of childhood asthma in the United States is 6.5%. During the COVID-19 pandemic, a Federally Qualified Health Center (FQHC) implemented metered-dose inhalers (MDIs) with spacers instead of nebulized albuterol to reduce aerosolization of pathogens and reduce costs. Objective: The objective of the study is to assess the safety, efficacy, and efficiency of a change to the asthma exacerbation protocol at an urban FQHC. Methods: A retrospective chart review compared nebulized albuterol versus an MDI with a spacer in pediatric patients experiencing asthma exacerbation. The evaluation aimed to measure (a) the 30-day return to care in either the emergency department (ED) or clinic, (b) the total number of treatments administered, and (c) the documented use of an oral steroid with albuterol treatments. Results: Return to clinic was the only statistically significant variable. Zero MDI patients returned, whereas 61% of those nebulized returned within 30 days (p < .00001). Conclusions: Albuterol MDI with a spacer was more effective than a nebulizer in reducing follow-up visits to the clinic and was effective at reducing ED visits within 30 days. Implications for Nursing: Treating asthma exacerbations in the primary care clinic with an MDI is effective and reduces cost and airborne exposure.

Dry Powder Inhaler Use in Primary School Aged Children with Asthma: A Systematic Review

ObjectiveAsthma is the most common chronic disease in children. Dry powder inhalers (DPI) are effective for medication delivery in adults and adolescents, and provide a lower environmental footprint and more portability when compared to metered dose inhaler (MDI) with spacer. They require specific technique, and it is necessary to ascertain whether they can be used in younger age groups. We aimed to assess evidence regarding whether primary school aged (5–11 years) children can use DPI with adequate technique both during stable and acute asthma.DesignOvid MEDLINE, Embase and PubMed were searched for studies assessing DPI use in children aged 5–11 years with asthma or wheeze. Results of studies were synthesised by study design and outcome measure.ResultsThirty-eight studies were identified for analysis. These were analysed in three groups: (1) 25 studies assessing children's ability to use DPI by peak inspiratory flow measurement, (2) 10 studies assessing children's ability to use DPI by physician assessment, and (3) three studies measuring efficacy of DPI compared to gold standard (MDI with spacer). Five studies included children during acute exacerbations.ConclusionThe majority of primary school aged children have the ability to use a DPI with adequate training, support and practice. Some younger children may have difficulties, and clinician assessment and ongoing review is crucial in determining which children are likely to benefit from a DPI. Consistent correct use and adherence remains a challenge, but this is also an issue with MDI plus spacer and does not appear to be significantly worse with DPI. Evidence of the use of DPI during acute illness is limited, and more studies are required in this setting.

A dual methodology employing ion-pair chromatography and built-in UV spectrophotometry for quantifying recently approved combination of mometasone and indacaterol in a novel combined metered dose inhaler: assessing the greenness, carbon footprint, blueness, and whiteness

Developing analytical techniques that align with green and sustainable chemistry principles is crucial in today's scientific landscape. This work introduces two innovative approaches for the simultaneous quantification of indacaterol (IND) and mometasone (MOM), a recently approved combination therapy for chronic obstructive pulmonary disease. These methods—rapid isocratic ion pair chromatography (IPC) and UV–visible spectrophotometry—demonstrate improved environmental sustainability, cost-effectiveness, and versatility compared to existing techniques. The optimized 4-min IPC method achieved excellent resolution (retention times 2.18 ± 0.1 min for IND and 3.95 ± 0.1 min for MOM), peak symmetry, and sensitivity. It utilizes a low-cost ion pair mobile phase of acetonitrile and acidified water containing 0.025% sodium dodecyl sulfate (50:50% v/v), making it suitable for laboratories with standard chromatographic instruments. The spectrophotometric approach offers two procedures: first derivative and ratio derivative methods. These serve as simplified, low-cost alternatives for resource-limited laboratories without access to advanced instruments. Both techniques feature simplified protocols that minimize extraction and fractionation steps. Comprehensive validation confirmed outstanding accuracy (98–102%) and precision (%2 <). Sustainability assessments using ComplexGAPI, AGREE, carbon footprint, BAGI, and RGB12 tools demonstrated enhanced environmental performance compared to existing methods. The IPC and spectrophotometry methods achieved greenness scores of 0.81 and 0.85, respectively, surpassing the 0.63–0.67 range of reported techniques. Additionally, they showed lower carbon footprints of 0.035 and 0.022 kg CO2 equivalent emissions per sample, compared to 0.079–0.092 kg for conventional procedures. The application of novel "blueness" and "whiteness" concepts using BAGI and RGB12 algorithms further confirmed superior sustainability, with scores of 87.5 & 90 for blueness and 88.1 & 89.8 for whiteness. Successfully applied to quantify IND and MOM in combined capsules, this work provides a model for eco-friendly pharmaceutical analysis that maintains high analytical reliability while improving sustainability metrics.

Thoughtful prescription of inhaled medication has the potential to reduce inhaler-related greenhouse gas emissions by 85%

IntroductionBoth physicians and patients are increasingly aware of the environmental impacts of medication. The shift of treatment paradigm towards MART-treatment (Maintenance and Reliever Therapy) in asthma affects the treatment-related emissions....

Prevalence and Management of Chronic Obstructive Pulmonary Disease in the Gulf Countries with a Focus on Inhaled Pharmacotherapy.

Background: Chronic obstructive pulmonary disease (COPD) is a preventable, progressive disease and the third leading cause of death worldwide. The epidemiological data of COPD from Gulf countries are very limited, as it remains underdiagnosed and underestimated. Risk factors for COPD include tobacco cigarette smoking, water pipe smoking (Shisha), exposure to air pollutants, occupational dusts, fumes, and chemicals. Inadequate treatment of COPD leads to worsening of disease. The 2024 GOLD guidelines recommend use of inhaled bronchodilators, corticosteroids, and adjunct therapies for treatment and management of COPD patients based on an individual assessment of the severity of symptoms and risk of exacerbations. This article reviews COPD pharmacotherapy in the Gulf countries and explores the role of nebulization in the management of COPD in this region. Methods: To review the COPD pharmacotherapy in the Gulf Countries, literature search was conducted using PubMed, Medline, Cochrane Systematic Reviews, and Google Scholar databases (before December 2022), using search terms such as COPD, nebulization, inhalers/inhalation, aerosols, and Gulf countries. Relevant articles from the reference list of identified studies were reviewed. Consensus statements, expert opinion, and other published review articles were included. Results: In the Gulf countries, pressurized metered-dose inhalers (pMDIs), dry powder inhalers (DPIs), soft mist inhalers, and nebulizers are used for drug delivery to COPD patients. pMDIs and DPIs are most prone to errors in technique and other common device handling errors. Nebulization is another mode of inhalation drug delivery, which is beneficial in certain patient populations such as the elderly and patients with cognitive impairment, motor or neuromuscular disorders, and other comorbidities. Conclusion: There is no major difference between Gulf countries and rest of the world in the approach to management of COPD. Nebulizers should be considered for patients who have difficulties in accessing or using MDIs and DPIs, irrespective of geographical location.

Demographic and Asthma-Related Characteristics of Asthmatics Using Pressurized Metered Dose Inhalers and Dry Powder Inhalers.

Background: Asthma controller medications can be delivered via pressurized metered dose inhaler (pMDI) or dry powder inhaler (DPI) devices. Objective: This study aimed to evaluate the frequency of exacerbations and satisfaction rate with device use in asthmatics using pMDIs or DPIs. Methods: A multicenter, cross-sectional study was conducted in adults who used pMDIs or DPIs with correct inhaler technique and good adherence for asthma treatment. Demographic and asthma-related characteristics of the subjects and data regarding device satisfaction were collected through a face-to-face interview in the outpatient clinic. Rates of pMDI and DPI users and the data were compared between the two groups. Results: The study included 338 patients (mean age: 48.6 ± 14.5 years, 253 [74.9%] women). Among participants, 96 (28.4%) were using pMDI and 242 (71.6%) were using DPI. The age of patients using pMDI were significantly lower compared with DPI users. No significant difference was observed in terms of device satisfaction and clinical outcomes of asthma between pMDI and DPI users with good inhaler technique and good adherence. Conclusion: More asthmatics use DPIs, however, pMDIs are used in younger asthmatic patients. No significant difference in terms of device satisfaction and clinical outcomes of asthma was observed between pMDI and DPI users.

Impact of nebulization versus metered-dose inhaler utilization on viral particle dispersion in patients with COVID-19.

Conflicting guidance exists regarding the characterization of nebulization as an aerosol-generating procedure and subsequent risk of transmission of SARS-CoV-2 to healthcare workers. This study sought to address whether SARS-CoV-2 viral load distribution was impacted by bronchodilator delivery via nebulizer versus metered-dose inhaler (MDI). Adults infected with COVID-19 were enrolled and received a single dose of albuterol sulfate nebulized solution (2.5mg/3mL via breath-actuated nebulizer with filtered mouthpiece) or albuterol sulfate hydrofluoroalkane inhalation aerosol (90µg/actuation; two puffs via MDI with spacer) in a randomized crossover sequence. Air and surfaces were sampled at predefined locations within patients' hospital rooms to assess SARS-CoV-2 dispersion over three periods (baseline, MDI, and nebulizer). Eleven patients received crossover therapy. Six patients had detectable SARS-CoV-2 RNA during one treatment period (n = 3 each for MDI and nebulizer) and one during both treatment periods. No viral RNA was found in the rooms of four (36.4%) patients. Overall, few environmental samples (17/397; 4.3%) contained detectable viral RNA, with no meaningful differences in positivity rate across periods; RNA genome copy numbers were low in positive samples. No correlation between dispersion and patient clinical status or environmental parameters was observed. In this first prospective trial evaluating viral load distribution following use of nebulizer versus MDI in hospitalized patients with COVID-19, low environmental contamination was found regardless of administration method. Findings support the use of either device when needed to treat patients with COVID-19.

Evaluation of impact of adherence to inhaled therapy and critical mistakes in inhalation technique on clinical outcomes in patients with obstructive airway diseases in India

Adherence to inhaled therapy is more relevant in respiratory diseases because, to achieve therapeutic efficacy, it is necessary that the patient adhere to the recommended therapy as well as use their inhalers correctly with appropriate inhalation technique.This was a prospective, observational study that included 126 patients &amp;#62;18 years of age of all genders, diagnosed with an obstructive airway disease, and prescribed inhaler medication. Adherence was assessed using the Test of Adherence to Inhalers (TAI) questionnaire, and inhaler device technique was assessed every 3 months. At the end of one year, outcome data like the number of exacerbations, the number of admissions, including critical-care admissions, the number of days of hospitalization, adverse events, and their associations were analyzed.Poor adherence to inhaled therapy was found in 40.48% of patients, with the majority of patients (69.05%) having an unwitting or ignorant pattern of non- adherence. Out of 75 patients using MDI (Metered Dose Inhaler), 34.67% had critical mistakes in technique, and out of 51 patients using Rotahaler, 23.53% had critical mistakes in technique. There was no significant relationship between level of adherence and critical mistakes with gender, BMI category, or past history of smoking. Patients with poor adherence and those with critical mistakes in inhalation technique had poor health outcomes.This study highlights the role of adherence and identifies barriers responsible for non-adherence to inhaled therapy. Identifying the behaviors responsible for non-adherence and counseling the patients on the correct inhalation technique can improve the health outcomes of chronic respiratory diseases.

Correlation Between Dynamic Spray Plume and Drug Deposition of Solution-Based Pressurized Metered-Dose Inhalers.

Background: The lack of visual dynamic spray characterization has made the understanding of the physical processes governing atomization and drug particle formation difficult. This study aimed to investigate the changes in the spray plume morphology and aerodynamic particle size of solution-based pressurized metered-dose inhalers (pMDIs) under different conditions to achieve better drug deposition. Methods: Solution-based pMDIs were studied, and the effects of various factors, such as propellant concentration, orifice diameters, and atomization chamber volume, on drug deposition were examined by analyzing the characteristics of spray plume and aerodynamic particle size. Results: Reducing the actuator orifice and spray area led to a concentrated spray plume and increased duration and speed. Moreover, the aerodynamic particle sizes D50 and D90 decreased, whereas D10 remained relatively unchanged. Decreasing the atomization chamber volume of the actuator led to reduced spray area and an increased duration but a decreased plume velocity. D90 exhibited a decreasing trend, whereas D10 and D50 remained relatively unchanged. Reducing the propellant concentration in the prescription, the spray area and the plume velocity first decreased and then increased. The duration initially increased and then decreased. The values of D50 and D90 showed an initial decreasing followed by an increasing trend, whereas D10 remained relatively unchanged. Conclusions: During the development process, attention should be paid to the changes in the spray area, spray angle, duration, and speed of the spray plume. This study recommended analyzing the characteristics of the spray plume and combining the data of two or more aerodynamic particle size detection methods to verify the deposition in vitro to achieve rapid screening and obtain high lung deposition invivo.

In Vitro Evaluation of Colistin Conjugated with Chitosan-Capped Gold Nanoparticles as a Possible Formulation Applied in a Metered-Dose Inhaler.

Inhaled colistin is used to treat pneumonia and respiratory infections through nebulization or dry powder inhalers. Nevertheless, the development of a metered-dose inhaler (MDI) for colistin, which could enhance patient convenience and treatment efficacy, has not yet been developed. Colistin is known for its ability to induce cellular toxicity. Gold nanoparticles (AuNPs) can potentially mitigate colistin toxicity. Therefore, this study aimed to evaluate the antimicrobial effectiveness of colistin conjugated with chitosan-capped gold nanoparticles (Col-CS-AuNPs) and their potential formulation for use with MDIs to deliver the aerosol directly to the deep lung. Fourier-transform infrared spectroscopy, nuclear magnetic resonance, and elemental analysis were used to characterize the synthesized Col-CS-AuNPs. Drug release profiles fitted with the most suitable release kinetic model were evaluated. An MDI formulation containing 100 µg of colistin per puff was prepared. The aerosol properties used to determine the MDI performance included the fine particle fraction, mass median aerodynamic diameter, and geometric standard deviation, which were evaluated using the Andersen Cascade Impactor. The delivered dose uniformity was also determined. The antimicrobial efficacy of the Col-CS-AuNP formulation in the MDI was assessed. The chitosan-capped gold nanoparticles (CS-AuNPs) and Col-CS-AuNPs had particle sizes of 44.34 ± 1.02 and 174.50 ± 4.46 nm, respectively. CS-AuNPs effectively entrapped 76.4% of colistin. Col-CS-AuNPs exhibited an initial burst release of up to 60% colistin within the first 6 h. The release mechanism was accurately described by the Korsmeyer-Peppas model, with an R2 > 0.95. The aerosol properties of the Col-CS-AuNP formulation in the MDI revealed a high fine particle fraction of 61.08%, mass median aerodynamic diameter of 2.34 µm, and geometric standard deviation of 0.21, with a delivered dose uniformity within 75-125% of the labeled claim. The Col-CS-AuNP MDI formulation completely killed Escherichia coli at 5× and 10× minimum inhibitory concentrations after 6 and 12 h of incubation, respectively. The toxicity of CS-AuNP and Col-CS-AuNP MDI formulations in upper and lower respiratory tract cell lines was lower than that of free colistin. The stability of the Col-CS-AuNP MDI formulation was maintained for at least 3 months. The Col-CS-AuNP MDI formulation effectively eradicated bacteria over a 12-h period, showing promise for advancing lung infection treatments.

Delivery of Inhaled Medication in Children: Revisiting Pharmacological and Practical Issues for Better Health Outcome

For safe and effective therapy of respiratory disorders in children, delivering the medication at the site of disease i.e. directly into the respiratory tract via aerosolized medication is critical. But, the anatomical and physiological differences in the respiratory tract of infants/children and adults make the delivery of aerosolized medication complicated. This review article gives an overview of the delivery of inhaled medication in children and discuss the pharmacological and specific clinically relevant aspects of medication delivery using nebulizers, pressurized metered dose inhalers (MDIs), and dry powder inhalers (DPIs) in children. As a physician, one should always keep in mind the various factors like properties of the device, aerosol particle, patient factors such as disease state, ventilatory pattern, and administration technique that can affect drug deposition via aerosol delivery devices.

Advances in inhaler therapy for asthma and chronic obstructive pulmonary disease: a comprehensive review of Fostair™ and Trimbow™.

The management of asthma and chronic obstructive pulmonary disease (COPD) poses considerable challenges due to the intricate nature of these respiratory conditions. Fostair™ and Trimbow™, two pressurized metered dose inhalers, have emerged as noteworthy therapeutic options for treating both asthma and COPD. Fostair combines an inhaled corticosteroid, specifically beclometasone dipropionate, with a long-acting beta2-agonist, formoterol fumarate dihydrate, offering a dual-action approach to mitigate airway inflammation and bronchoconstriction. Conversely, Trimbow integrates a tri-particulate formulation consisting of beclometasone dipropionate, formoterol fumarate dihydrate, and glycopyrronium bromide, providing a comprehensive strategy to target the pathophysiology of COPD and asthma. Recent clinical trials have underscored Trimbow's superior efficacy compared with Fostair, particularly in terms of reducing exacerbation rates and enhancing lung function. However, despite their therapeutic promise, both inhalers encounter challenges, including limited generalizability of study findings and a disparity between in vitro and human trial results. This literature review offers an in-depth analysis of Fostair and Trimbow, delving into their mechanisms of action, clinical applications, and outcomes in human studies for asthma and COPD. Additionally, the review discusses the role of combination therapy in managing respiratory diseases and underscores the necessity for further research to address existing knowledge gaps and optimize therapeutic outcomes.

Maintenance Inhalers for Asthma and COPD in Spain.

This study aimed to describe the use of pressurized metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs) in Spanish subjects in terms of sociodemographic, clinical, and functional characteristics in subjects with asthma or COPD on maintenance treatment with inhaled therapy. This was a retrospective, descriptive, national, multi-center, and observational study using a database with 1.8 million patients from hospitals and primary care centers as a secondary information source. The sample included 24,102 subjects with asthma on maintenance therapy (26.0% with pMDI, 55% with DPI, and 19.0% with a combination of DPI + pMDI inhalers) and 12,858 subjects with COPD on maintenance therapy (26% with pMDI; 39% with DPI; and 35% with a combination of pMDI + DPI inhalers, mostly extemporary triple therapy). In proportion, subjects ≥ 75 y old used more pMDI than DPI, while younger subjects (40-64 y old) used more DPI. An inhalation chamber was prescribed in 51.0% of subjects with asthma and 47.2% of subjects with COPD treated with pMDI. The use of an inhalation chamber increases with the degree of air-flow limitation by disease and age. In subjects with comorbidities, pMDI inhaler use increased in those ≥ 75 y old for subjects with asthma and subjects with COPD. Switching from pMDI to DPI and vice versa was relatively common: 25% of subjects with asthma and 21.6% of subjects with COPD treated with pMDI had switched from DPI in the previous year. On the contrary, 14.1% and 11.4% of subjects with asthma and subjects with COPD, respectively, treated with DPI had switched from pMDI the last year. The use of pMDI or DPI can vary according to age, both in asthma and COPD. Switching from pMDI to DPI and vice versa is relatively common. Despite the availability of dual- and triple-therapy inhalers on the market, a considerable number of subjects were treated with multiple devices.

Improvement in Inhaler Techniques After Training and Counseling in Patients With Chronic Obstructive Pulmonary Disease or Asthma.

Background Chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD) and asthma significantly impair quality of life and impose a substantial burden on healthcare systems. Proper inhalation technique is important for effective management of these diseases, yet remains poorly performed by many patients. This study evaluated the impact of structured counseling and training sessions on inhaler use among patients with COPD and asthma, aiming to enhance technique correctness and disease control. Methodology This cross-sectional study analyzed 150 patients with asthma and COPD who fulfilled the inclusion criteria for inhalation techniques. Patients were counseled regarding the proper seven-step inhalation technique for each inhaler type [metered-dose inhaler (MDI), MDI with spacer, and dry powder inhaler (DPI)] through practical demonstration at baseline visits. Correct use of inhalers was assessed by a predefined checklist for each inhaler device at the baseline visit and after three months. The correctness of the inhalation technique was evaluated by scoring each of the seven steps. The disease control assessment was done using the COPD assessment test (CAT) and asthma control test (ACT) at the baseline visit and after three months. Results In this study of 150 patients, there were 97 (64.7%) males and 53 (35.3%) females. In total, 67 (44.7%) were diagnosed with asthma and 83 (55.3%) with COPD. The mean age was 45.33 ± 12.62 years. Post-counseling improvements in inhaler technique were marked, with MDI users enhancing their technique score from an average of 4.4 to 6.1, MDI with spacer from 4.56 to 6.26, and DPI from 4.92 to 6.24 (p < 0.001 for all). Disease control also showed significant gains; CAT scores decreased for MDI users from 23.4 to 20.5, MDI with spacer from 23.92 to 20.96, and DPI from 24.89 to 21.96. Concurrently, ACT scores increased for MDI users from 16.4 to 18.0 (p = 0.002), MDI with spacer from 17.29 to 19.04, and DPI from 16.42 to 18.37 (p < 0.001 for both), reflecting substantive advances in managing COPD and asthma symptoms. Furthermore, patients with primary education exhibited a significant boost in technique mastery post-counseling (p < 0.001), underscoring the potential of well-crafted counseling to transcend educational barriers in promoting effective inhaler use. Conclusions Post-counseling, inhaler technique improved significantly across all types, with MDI with spacer users demonstrating the most progress. Technique scores increased notably (p < 0.001), and disease control scores for COPD and asthma, measured by CAT and ACT, also showed significant improvements (p < 0.001). Remarkably, primary education level participants exhibited substantial technique gains post-intervention, emphasizing the effectiveness of counseling irrespective of initial educational status in enhancing inhaler use and disease management.