Soft Mist Inhaler Research Articles

Anti-inflammatory effects of tiotropium in copd: a randomized double-blind trial

IntroductionChronic Obstructive Pulmonary Disease (COPD) is a major global health issue characterized by respiratory symptoms and exacerbations, significantly impacting mortality and quality of life. Muscarinic antagonists are known to prevent exacerbations, possibly by mitigating airway inflammation. This study evaluated the anti-inflammatory effects of tiotropium in patients with COPD by examining inflammatory protein profiles in sputum and blood, and genome-wide expression in sputum.MethodsWe conducted the prospective, double-blind, randomized-controlled ANTIOFLAM trial. Patients with COPD GOLD II and worse, aged≥40 years and with≥10 smoking pack years were included. After a 4-week wash-out period of inhaled corticosteroids (ICS) and anticholinergics, participants were randomized to 6 weeks of treatment with placebo or tiotropium (soft mist inhaler, 5 µg daily). Our primary endpoint was a decrease of sputum interleukin-6 and interleukin-8 levels in the tiotropium group when compared to the placebo group.ResultsWe evaluated samples of 33 participants (n=17 placebo and n=16 tiotropium). Changes in sputum proteins interleukin-6 and interleukin-8 were significantly higher after treatment with tiotropium when compared to placebo (p<0.05). Differential expression analysis did not reveal gene expression differences including interleukin-6 and −8.ConclusionWe did not find tiotropium to have anti-inflammatory effects in sputum or blood of patients with COPD. In contrast, we found 6 weeks of treatment with tiotropium to increase the concentration of almost all tested sputum inflammatory proteins when compared to placebo, while RNA expression levels did not change.

Environmental impact of pressurised metered dose inhalers versus dry powder and soft mist inhalers at a tertiary Melbourne hospital.

The carbon footprint of devices to deliver inhaled respiratory medications has come into focus as climate change has been identified as a worldwide emergency. Metered dose inhalers (MDIs) contain hydrofluorocarbons that have significant global warming potential compared to dry powder inhalers (DPIs) and soft mist inhalers (SMIs), which do not use a propellant gas. A 12-month pharmacy inpatient dispensing audit demonstrated that inpatient MDI use significantly outweighed that of DPIs and SMIs and accounted for approximately 99% of inhaler-related greenhouse gas emissions at our hospital.

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.

Rate of Correct Inhaler Usage and Related Factors in Elderly Patients With Chronic Obstructive Pulmonary Disease

Poor disease control in patients with chronic obstructive pulmonary disease (COPD) is associated with suboptimal inhaler use. This study was designed to explore the accuracy of inhaler use and related factors in elderly patients with COPD. A cross-sectional survey design was used to recruit patients with COPD from a medical centre in southern Taiwan who were over 65 years old and used inhalers regularly. All of the data as well as information on inhaler use accuracy were collected using a self-designed questionnaire and inhaler operation checklist. Multivariable logistic regression was used to analyse significant correlates of correct inhaler operation. The average age of the 150 participants was 75.0 years (SD = 7.5) years. Most used one type of inhaler only (86.0%). The rate of accurate inhaler operation was 40.7% (n = 61) for the sample, with dry powder inhalers associated with the highest accuracy (64%) and pressurized metered-dose inhalers associated with the lowest accuracy (1.6%). Multivariate logistic regression analysis showed that using a soft mist inhaler (adjusted odds ratio, AOR = 23.29; 95% confidence interval, 95% CI [2.84, 191.07]), using a dry powder inhaler (AOR =15.60, 95% CI [1.99, 122.26]), and higher satisfaction with the inhaler were positively and independently associated with accurate inhaler use (AOR = 1.94, 95% CI [1.09, 3.44]). Important factors related to inhaler use accuracy include inhaler type and level of patient satisfaction with their inhaler. Healthcare professionals should regularly confirm that older patients are able to use their inhalers correctly and are satisfied with their inhalers.

Effect of Nasal Inhalation on Drug Particle Deposition and Size Distribution in the Upper Airway: With Soft Mist Inhalers.

Delivery of drugs to the lungs is commonly achieved using nasal and/or oral breathing-assisted techniques. The route of inhalation can substantially change the fate of inhaled droplets. The Respimat® Soft Mist™ Inhaler (SMI) is a commercially available efficient inhaler with 40-60% effectiveness. In the present study, we used computational fluid dynamics (CFD) with a custom setup to investigate the effect of a combined oral/nasal inhalation route on the SMI's regional droplet deposition, size distribution, and flow field. Our setup used a modified induction port (MIP) to mimic nasal inhalation inside the human respiratory tract. Six different oral/nasal flow rate ratios inside the MIP were applied (total flow rate of 30l/min). An overall good agreement was achieved between simulation outcomes and in vitro results. Our results confirmed that the combined inhalation route affects the flow field, altering the MIP's droplet deposition and size distribution. The lowest depositional loss, mainly in the mouth area, was observed at oral/nasal flow rate ratios of O/N = 1 and O/N = 2 with 3% and 7.7% values, respectively. Droplets with a 2-5µm diameter range showed the highest droplet mass inside the MIP at all combined flow rates. We observed less intense vortexes followed by a lower level of turbulent kinetic energy at the oral/nasal ratio of 1. Increasing the relative humidity (RH) at oral/nasal flow rate ratios of 0.07, 1, and 14 led to an increase in droplet deposition at the outlet of the MIP.

Storage stability of lysostaphin solution and its pulmonary delivery

Methicillin-resistant Staphylococcus aureus (MRSA) has become a leading causative pathogen of nosocomial pneumonia with an alarming in-hospital mortality rate of 30%. Last resort antibiotic, vancomycin, has been increasingly used to treat MRSA infections, but the rapid emergence of vancomycin-resistant strains urges the development of alternative treatment strategies against MRSA-associated pneumonia. The bacteriolytic enzyme, lysostaphin, targeting the cell wall peptidoglycan of S. aureus, has been considered as a promising alternative for MRSA infections. Its proteinaceous nature is likely benefit from direct delivery to the lungs, but the challenges for successful pulmonary delivery of lysostaphin lying on a suitable inhalation device and a formulation with sufficient storage stability. In this study, the applicability of a vibrating mesh nebulizer (Aerogen Solo®) and a soft mist inhaler (Respimat®) was investigated. Both devices were capable of aerosolizing lysostaphin solution into inhalable droplets and caused minimum antibacterial activity loss. In addition, lysostaphin stabilized with phosphate-buffered saline and 0.1% Tween 80 was proved to have acceptable stability for at least 12 months when stored at 4 °C. These promising data encourage further clinical development of lysostaphin for management of MRSA-associated lung infections.Graphical abstractLysostaphin had insignificant activity loss after aerosol generation by a vibrating mesh nebulizer and a soft mist inhaler.Most of the lysostaphin aerosols generated by the vibrating mesh nebulizer and soft mist inhaler are inhalable.The vibrating mesh nebulizer and soft mist inhaler are suitable device for pulmonary delivery of lysostaphin.

Aerosol Plumes of Inhalers Used in COPD.

The selection of inhaler device is of critical importance in chronic obstructive pulmonary disease (COPD) as the interaction between a patient's inhalation profile and the aerosol characteristics of an inhaler can affect drug delivery and lung deposition. This study assessed the in vitro aerosol characteristics of inhaler devices approved for the treatment of COPD, including a soft mist inhaler (SMI), pressurized metered-dose inhalers (pMDIs), and dry powder inhalers (DPIs). High-speed video recording was used to visualize and measure aerosol velocity and spray duration for nine different inhalers (one SMI, three pMDIs, and five DPIs), each containing dual or triple fixed-dose combinations of long-acting muscarinic receptor antagonists and long-acting β2-agonists, with or without an inhaled corticosteroid. Measurements were taken in triplicate at experimental flow rates of 30, 60, and 90 l/min. Optimal flow rates were defined based on pharmacopoeial testing requirements: 30 l/min for pMDIs and SMIs, and the rate achieving a 4-kPa pressure drop against internal inhaler resistance for DPIs. Comparison of aerosol plumes was based on the experimental flow rates closest to the optimal flow rates. The Respimat SMI had the slowest plume velocity (0.99 m/s) and longest spray duration (1447 ms) compared with pMDIs (velocity: 3.65-5.09 m/s; duration: 227-270 ms) and DPIs (velocity: 1.43-4.60 m/s; duration: 60-757 ms). With increasing flow rates, SMI aerosol duration was unaffected, but velocity increased (maximum 2.63 m/s), pMDI aerosol velocity and duration were unaffected, and DPI aerosol velocity tended to increase, with a more variable impact on duration. Aerosol characteristics (velocity and duration of aerosol plume) vary by inhaler type. Plume velocity was lower and spray duration longer for the SMI compared with pMDIs and DPIs. Increasing experimental flow rate was associated with faster plume velocity for DPIs and the SMI, with no or variable impact on plume duration, whereas pMDI aerosol velocity and duration were unaffected by increasing flow rate.

Risk Factors Associated with Misuse of Soft Mist Inhaler in Patients with Chronic Obstructive Pulmonary Disease.

The use of inhaled bronchodilators is the mainstay of treatment for patients with chronic obstructive pulmonary disease (COPD). Although the soft mist inhaler (SMI) was developed to overcome the disadvantages of pressurized metered dose and drug powder inhalers, misuse during handling has been frequently observed in many studies. However, few studies have focused on SMI misuse among patients with COPD. Thus, we aimed to assess and identify the risk factors associated with SMI misuse among patients with COPD. In this prospective, observational, cross-sectional study, we enrolled patients with COPD who were undergoing SMI treatment between January 2018 and March 2020. An advanced nurse practitioner assessed the participants' handling of the device by using a check list. Among 159 participants, 136 (85.5%) reported inhaler misuse. Duration of COPD and COPD assessment test (CAT) scores were positively associated with inhaler misuse; adherence and education level were negatively associated with inhaler misuse. In the multivariable analysis, a low educational level (less than high school), high CAT score (≥ 10), and short duration of COPD (≤ 2 years) were identified as risk factors for SMI misuse. SMI misuse remains common among patients with COPD. Therefore, clinicians should pay close attention to their patients using SMIs, especially in the early period after the diagnosis of COPD.

Tiotropium bromide in the treatment of chronic obstructive pulmonary disease

The aim of this review was to analyze current information on tiotropium bromide as one of the LAMAs. Tiotropium was chronologically the first LAMA in clinical practice. It is administered using a dry powder inhaler or an aerosol inhaler (Respimat soft mist inhaler). Due to the long bronchodilator effect, tiotropium can be inhaled once a day. The drug has a significant effect on functional respiratory parameters, reduces lung hyperinflation, improves exercise tolerance and quality of life. Tiotropium is superior to short-acting bronchodilators and long-acting β2-agonists (LABAs) and is comparable to other LAMAs, as well as combinations of LABAs and inhaled corticosteroids in the prevention of COPD exacerbations. Tiotropium bromide has a favorable safety profile. Generic tiotropium drug products, including Respium®, are currently available in the Russian Federation. A clinical trial confirmed the non-inferiority and safety of generic tiotropium drug compared to the original branded product.Conclusion. Tiotropium is an effective and safe medication for the maintenance treatment of COPD and for reducing COPD exacerbations. The generic tiotropium drug products widen the range of effective inhaled medications available to physicians.

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)

Accuracy of Inhaler Use in COPD Patients and Factors Affecting It

Background: An inhaler is a type of dosage form used in the treatment of chronic obstructive pulmonary disease (COPD). The inhaler has a unique technique for use; however, the percentage of accuracy in inhaler use is still low. Proper inhaler use is expected to improve quality of life and decrease the occurrence of exacerbations. This study aimed to observe the percentage of accuracy in using inhalers and the factors that influence it.Method: This study was conducted with a cross-sectional design on COPD patients in two different hospitals. Primary data were collected using a questionnaire. The accuracy of inhaler use was assessed using a checklist.Results: The total number of patients in this study was 110, with an average age of 62 years. Patients were given single inhaler therapy, which included Dry Powder Inhalers (DPI) for 34 patients with 70.7% accuracy, Pressurized Metered-Dose Inhalers (pMDI) for 9 persons with 45.74% accuracy, and Soft Mist Inhalers (SMI) for one person with 66.67% accuracy. Furthermore, patients who used a combination of pMDI and DPI inhalers had an accuracy value of 68.53%, while a combination of pMDI and SMI had an accuracy value of 72.72%. The stage with the lowest level of accuracy in the pMDI-type inhaler used alone was exhaling before the inhaler was supplied.Conclusion: According to the findings, the accuracy of inhaler use in COPD patients is still relatively low. Furthermore, gender is a factor that has a statistically significant relationship with inhaler accuracy.

Clinical Implications of Peak Inspiratory Flow in COPD: Post Hoc Analyses of the TRONARTO Study.

In patients with COPD, inhalation ability should be assessed when considering inhaler choice. To evaluate whether the soft mist inhaler (SMI) is suitable for COPD patients irrespective of inhalation ability, the TRONARTO study investigated the efficacy of dual long-acting bronchodilator therapy delivered via the Respimat® SMI on lung function in patients with COPD stratified by inhalation ability. Tiotropium/olodaterol delivered via the SMI was effective both in patients with peak inspiratory flow (PIF) <60L/min and PIF ≥60L/min, measured against medium-low resistance. This congress compilation summarizes post hoc analyses from the TRONARTO study presented at the annual American Thoracic Society 2022 and European Respiratory Society 2022 meetings. These analyses evaluated PIF in over 200 patients, with PIF measurements taken daily at home for 4weeks, and in the clinic at baseline, Weeks 2 and 4. Overall, 57.9% of patients had a PIF range (difference between lowest and highest PIF measurements) <20 L/min (12.4% of patients had PIF range <10 L/min). At-home PIF range decreased over the study period, suggesting that inhaler training/repeated PIF measurements may help to make patients' inspiratory effort more consistent. Some patient characteristics correlated with lower PIF (female gender, shorter stature, more severe disease, worse airflow obstruction) and lower PIF range (more severe disease). PIF measurements differed between medium-low and high-resistance settings, highlighting the importance of measuring PIF at the resistance of a patient's inhaler. PIF correlated poorly with spirometry measurements. As indicated in COPD management guidelines, choice of inhaler is essential to optimize pharmacologic therapies for COPD. Poor inspiratory ability should be viewed as a treatable trait that can help to inform inhaler choice. Inhaler training and consideration of PIF (if patients use a dry powder inhaler) can reduce patient-to-inhaler mismatch, with potential consequences for health status and exacerbation risk.

Abstracts from The Aerosol Society Drug Delivery to the Lungs 33.

Abstracts from The Aerosol Society Drug Delivery to the Lungs 33.

Respiratory Care Management of COPD Exacerbations.

A COPD exacerbation is characterized by an increase in symptoms such as dyspnea, cough, and sputum production that worsens over a period of 2 weeks. Exacerbations are common. Respiratory therapists and physicians in an acute care setting often treat these patients. Targeted O2 therapy improves outcomes and should be titrated to an SpO2 of 88-92%. Arterial blood gases remain the standard approach to assessing gas exchange in patients with COPD exacerbation. The limitations of arterial blood gas surrogates (pulse oximetry, capnography, transcutaneous monitoring, peripheral venous blood gases) should be appreciated so that they can be used wisely. Inhaled short-acting bronchodilators can be provided by nebulizer (jet or mesh), pressurized metered-dose inhaler (pMDI), pMDI with spacer or valved holding chamber, soft mist inhaler, or dry powder inhaler. The available evidence for the use of heliox for COPD exacerbation is weak. Noninvasive ventilation (NIV) is standard therapy for patients who present with COPD exacerbation and is supported by clinical practice guidelines. Robust high-level evidence with patient important outcomes is lacking for the use of high-flow nasal cannula in patients with COPD exacerbation. Management of auto-PEEP is the priority in mechanically ventilated patients with COPD. This is achieved by reducing airway resistance and decreasing minute ventilation. Trigger asynchrony and cycle asynchrony are addressed to improve patient-ventilator interaction. Patients with COPD should be extubated to NIV. Additional high-level evidence is needed before widespread use of extracorporeal CO2 removal. Care coordination can improve the effectiveness of care for patients with COPD exacerbation. Evidence-based practices improve outcomes in patients with COPD exacerbation.

Chronic Obstructive Pulmonary Disease – Recent Updates

Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of death and disability globally as well as in Bangladesh. Continuing research is essential to combat the threat posed by rising prevalence of COPD. Here we present recent updates in the field of COPD research. The revised definition of COPD emphasizes COPD as a heterogeneous disease affecting the bronchi, bronchioles, alveoli and pulmonary vasculature. The traditional view of COPD as a smoker’s disease with a late onset has been replaced by the new concept of COPD etiotypes, which recognizes the contribution of developmental, genetic, environmental, infective and idiopathic contributions to COPD. Vaping has also been proposed as a risk factor for COPD. Two precursors to COPD – pre-COPD and PRISm – have also been proposed to highlight the opportunity of early detection and management. Clinical classification of COPD has been updated to the simplified ABE approach. New recommendations for treatment prioritize the initial use of a fixed dose LABA+LAMA combination. A more judicious use of ICS in COPD patients is recommended, in those with specific indications (exacerbation-prone, high eosinophil counts, or concomitant asthma). In this population, single-inhaler triple-therapy of LABALAMA- ICS has replaced previous recommendations of LABA-ICS. A strong emphasis has been placed on appropriate, individualized choice of inhaler device and training on technique for each patient. Interventional pulmonology and minimally invasive surgery also have a growing role in management of selected patients. Small airways disease is a key cause of morbidity in COPD. Newer diagnostic techniques, such as impulse oscillometry, and novel drug formulations (extra-fine particles, cosuspension forms, soft mist inhalers) are under study. The monoclonal antibody dupilumab has also shown promise in reducing COPD exacerbation. Finally, COPD is a multisystem disease and any management plan must include steps to identify and treat associated co-morbidities. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 197

Optimization of formulation and atomization of lipid nanoparticles for the inhalation of mRNA

Lipid nanoparticles (LNPs) have demonstrated efficacy and safety for mRNA vaccine administration by intramuscular injection; however, the pulmonary delivery of mRNA encapsulated LNPs remains challenging. The atomization process of LNPs will cause shear stress due to dispersed air, air jets, ultrasonication, vibrating mesh etc., leading to the agglomeration or leakage of LNPs, which can be detrimental to transcellular transport and endosomal escape. In this study, the LNP formulation, atomization methods and buffer system were optimized to maintain the LNP stability and mRNA efficiency during the atomization process. Firstly, a suitable LNP formulation for atomization was optimized based on the in vitro results, and the optimized LNP formulation was AX4, DSPC, cholesterol and DMG-PEG2K at a 35/16/46.5/2.5 (%) molar ratio. Subsequently, different atomization methods were compared to find the most suitable method to deliver mRNA-LNP solution. Soft mist inhaler (SMI) was found to be the best for pulmonary delivery of mRNA encapsulated LNPs. The physico-chemical properties such as size and entrapment efficiency (EE) of the LNPs were further improved by adjusting the buffer system with trehalose. Lastly, the in vivo fluorescence imaging of mice demonstrated that SMI with proper LNPs design and buffer system hold promise for inhaled mRNA-LNP therapies.

Modeling of pulmonary deposition of agents of open and fixed dose triple combination therapies through two different low-resistance inhalers in COPD: a pilot study.

Inhalation therapy is a cornerstone of treating patients with chronic obstructive pulmonary disease (COPD). Inhaler devices might influence the effectiveness of inhalation therapy. We aimed to model and compare the deposition of acting agents of an open and a fixed dose combination (FDC) triple therapy and examine their repeatability. We recruited control subjects (Controls, n = 17) and patients with stable COPD (S-COPD, n = 13) and those during an acute exacerbation (AE-COPD, n = 12). Standard spirometry was followed by through-device inhalation maneuvers using a pressurized metered dose inhaler (pMDI) and a soft mist inhaler (SMI) to calculate deposition of fixed dose and open triple combination therapies by numerical modeling. Through-device inspiratory vital capacity (IVCd) and peak inspiratory flow (PIFd), as well as inhalation time (tin) and breath hold time (tbh) were used to calculate pulmonary (PD) and extrathoracic deposition (ETD) values. Deposition was calculated from two different inhalation maneuvers. There was no difference in forced expiratory volume in 1 s (FEV1) between patients (S-COPD: 42 ± 5% vs. AE-COPD: 35 ± 5% predicted). Spiriva® Respimat® showed significantly higher PD and lower ETD values in all COPD patients and Controls compared with the two pMDIs. For Foster® pMDI and Trimbow® pMDI similar PD were observed in Controls, while ETD between Controls and AE-COPD patients did significantly differ. There was no difference between COPD groups regarding the repeatability of calculated deposition values. Ranking the different inhalers by differences between the two deposition values calculated from separate maneuvers, Respimat® produced the smallest inter-measurement differences for PD. Our study is the first to model and compare PD using pMDIs and an SMI as triple combination in COPD. In conclusion, switching from FDC to open triple therapy in cases when adherence to devices is maintanined may contribute to better therapeutic effectiveness in individual cases using low resistance inhalers.

Assessment of inhalation technique in patients with bronchial asthma and chronic obstructive pulmonary disease

Investigate inhalation techniques using different inhalers types and their effect on the course of disease. This cross-sectional study included 110 patients with asthma, chronic obstructive pulmonary disease using the inhaler at least one month. Inhaler errors performed during demonstration were evaluated for each patient and entered in the check-lists. We also collected information about co-morbidities, education, mMRC dyspnea score, rate of exacerbations, and performed spirometry. 80.9% of patients used metered-dose inhaler, 20.9% - single-dose and 21.8% - multiple-dose dry powder inhaler, 22.7% - soft-mist inhaler. Inhaler errors were made by 80.9% patients. The mean number of mistakes in metered-dose inhaler use was 2±1.6, single-dose powder inhaler -1.5±1.3, multiple-dose dry powder inhaler - 1.25±1.4, soft-mist inhaler - 0.68±0.7 (р=0.003). Age, diagnosis, duration of disease, education level, inhalers usage by relatives have no influence on the inhalation technique. A number of errors was related to female gender (р=0.007) and usage of more than 2 inhalers (r=0.3, p=0.002), previous instruction about inhalation technique (r=0.3, p=0.001). On the other hand, there were correlations between the number of errors and degree of bronchial obstruction, asthma control, severity of dyspnea by mMRC score, exacerbation rate. Patients with bronchoobstructive diseases perform many inhaler errors, that substantially influences the severity and course of asthma and chronic obstructive pulmonary disease.

From the infant to the geriatric patient-Strategies for inhalation therapy in asthma and chronic obstructive pulmonary disease.

Inhalation therapy represents the standard of care in children, adolescents as well as in young, middle-aged and geriatric adults with asthma or chronic obstructive pulmonary disease. However, there are only few recommendations for the choice of inhalation devices, which consider both, age-specific limitations in young and geriatric patients. Transition concepts are lacking. In this narrative review, the available device technologies and the evidence for age-specific problems are discussed. Pressurized metered-dose inhalers may be favoured in patients who fulfill all cognitive, coordinative and manual power requirements. Breath-actuated metered-dose inhalers, soft-mist inhalers or the use of add-on devices such as spacers, face masks and valved holding chambers may be suitable for patients with mild to moderate impairments of these variables. In these cases, available resources of personal assistance by educated family members or caregivers should be used to allow metered-dose inhaler therapy. Dry powder inhalers may be reserved for patients with a sufficient peak inspiratory flow and good cognitive and manual abilities. Nebulizers may be indicated in persons who are either unwilling or unable to use handheld inhaler devices. After initiation of a specific inhalation therapy, close monitoring is essential to reduce handling mistakes. An algorithm is developed that considers age and relevant comorbidities to support the decision-making process for the choice of an inhaler device.

Reducing carbon footprint by switching to reusable soft-mist inhalers.

Inhalation therapy is the cornerstone of COPD, together with non-pharmacological treatments. Long-acting muscarinic antagonists (LAMAs), alone or in combination with long-acting β-agonists (LABAs), are commonly used. Pressurised metered-dose inhalers (pMDIs), dry powder inhalers (DPIs) and soft-mist inhalers (SMIs) are used, each with different carbon footprints. This study aimed to assess the carbon footprint of hypothetically replacing LAMA or LAMA/LABA inhalers with an SMI, Respimat Reusable, within the same therapeutic class. An environmental impact model was established to assess the change in carbon footprint of replacing pMDIs/DPIs with Respimat Reusable within the same therapeutic class (LAMA or LAMA/LABA) across 12 European countries and the USA over 5 years. Inhaler use for country and disease-specific populations was derived from international prescribing data and the associated carbon footprint (CO2 equivalents (CO2e)) was identified from published sources. Over 5 years and across all countries, replacing LAMA inhalers with Spiriva Respimat Reusable reduced CO2e emissions by 13.3-50.9%, saving 93-6228 tonnes of CO2e in the different countries studied. Replacing LAMA/LABA inhalers with Spiolto Respimat Reusable reduced CO2e emissions by 9.5-92.6%, saving 31-50 843 tonnes of CO2e. In scenario analyses, which included total replacement of DPIs/pMDIs, consistent CO2e savings were estimated. Sensitivity analyses showed that results were sensitive to changes in several parameters including varying assumptions around reusability of inhalers and potential CO2e impact. Replacement of pMDIs and DPIs with Respimat Reusable within the same therapeutic class would result in substantial reductions in CO2e emissions.