Time Required to Rectify Inhaler Errors Among Experienced Subjects With Faulty Technique.

The inhaler is an important drug delivery system in the treatment of asthma, but inhaler technique is often inadequate. We assessed technique in children diagnosed with asthma, comparing the performance of three devices. In a cross-sectional survey, 523 children (271 boys, 252 girls, ages 5 to 12 years; mean+/-SD 7.53+/-1.79 years) demonstrated inhalation technique according to Netherlands Asthma Foundation criteria during a first visit to a primary care clinic in Abha, Saudi Arabia. Patients used the device with which they were most familiar (either pMDI, Turbuhaler or Diskus). Two hundred children (38% of total population) used a pMDI, while 323 (62% of total population) used one of the dry powder inhalers 173 (58%) the Turbuhaler and 150 (47%) the Diskus. Only 49 children (25% of the total population) completed the assessment without making a mistake. The remaining 474 (75% of the total population) performed one or more manuevers poorly. Only 80 children who used an MDI (40% of those using the device) completed 50% or more of the maneuvers correctly compared with 111 (69% of those using the device) and 100 (67% of those using the device) of those using the Turbuhaler and Diskus, respectively (P=0.001 for comparison of MDI with dry powder inhalers). Children whose mothers had intermediate school or higher education performed better than those whose mothers had less education (P=0.001). The father's education had no bearing on performance with the inhaler. The inhaler technique of most asthmatic children is poor, but technique is better in children who use a dry powder compared a metered-dose inhaler. The level of the mother's education is positively associated with better inhalation technique in the child.

Although multiple studies have documented the prevalence of poor inhaler techniques in Ethiopia, no quality improvement initiatives have been conducted to provide guidance for improving inhaler techniques and symptom control. This quality improvement project aims to assess the effect of face-to-face demonstrations and multimedia-assisted demonstrations on improving inhaler techniques and symptom control among asthmatic patients attending the Chest Referral Clinic of Tikur Anbessa Specialized Hospital. A total of 50 asthmatic participants using inhalers were recruited. Baseline asthma symptom control was assessed using the Asthma Control Test tool. Thirty of the recruited participants received face-to-face demonstrations from trained healthcare professionals while easy-to-use pictogram pamphlets and adapted videos were distributed. Inhaler techniques and asthma control were reassessed using adapted checklists and the Asthma Control Test, respectively, four weeks after the demonstrations and trainings were delivered. Finally, pre-intervention and post-intervention outcomes were analyzed and compared to quantify the impact of the implemented trainings. A total of 30 participants underwent both pre- and post-intervention assessments of inhaler techniques and Asthma Control Test scores. There was a marked improvement in the proper use of inhalers, increasing from 10.5% to 52.6% among participants using dry powder inhalers (P = 0.007) and from 7.1% to 35.7% (P = 0.011) among those using metered dose inhalers. Face-to-face demonstrations of inhaler techniques, when supported with multimedia resources, significantly improved proper inhaler use among asthmatic patients. This project demonstrated a general trend toward better symptom control as measured by the Asthma Control Test post-intervention.

Although inhaled medications are effective therapies for COPD, many patients and providers use them incorrectly. We recruited providers who prescribe inhalers or teach inhaler technique and assessed their use of metered-dose inhalers (MDIs), various dry powder inhalers (DPIs), and Respimat using predefined checklists. Then they watched tablet-based multimedia educational videos that demonstrated correct inhaler technique by a clinical pharmacist with teach-back from a patient and were re-evaluated. We also recruited patients with COPD and assessed their use of their prescribed inhalers and then retested them after 3-6 months. Baseline and follow-up respiratory symptoms were measured by the COPD Assessment Test. Fifty-eight providers and 50 subjects participated. For all providers, correct inhaler technique (reported as percentage correct steps) increased after the videos: MDI without a spacer (72% vs 97%) MDI with a spacer (72% vs 96%), formoterol DPI (50% vs 94%), mometasone DPI (43% vs 95%), tiotropium DPI (73% vs 99%), and Respimat (32% vs 93%) (before vs after, P < .001 for all comparisons). Subjects also improved their inhaler use technique after viewing the educational videos: MDI without a spacer (69% vs 92%), MDI with a spacer (73% vs 95%), and tiotropium DPI (83% vs 96%) (before vs after, P < .001 for all comparisons). The beneficial effect of this educational intervention declined slightly for subjects but was durably improved after several months. COPD Assessment Test scores did not demonstrate any change in respiratory symptoms. A tablet-based inhaler education tool improved inhaler technique for both providers and subjects. Although this intervention did show durable efficacy for improving inhaler use by patients, it did not reduce their respiratory symptoms.

Background Inhalation therapy is the cornerstone for asthma management, and it has been reported by several studies that a correct inhalation technique is required for achievement of proper disease control. Objective This study attempted to assess the inhaler technique in Egyptian children with asthma, identify the factors affecting improper technique, and evaluate the effect of educational intervention in improving the technique and asthma control. Patients and methods This pre–post clinical trial included a random sample of 350 asthmatic children aged 2–12 years, following up at the Allergy Clinic, Faculty of Medicine, Cairo University. They were diagnosed as having asthma according to GINA guidelines and were on inhaled corticosteroids using metered-dose inhaler (MDI) or dry-powder inhaler (DPI) for at least 3 months. Children’s inhalation technique was observed and assessed by the study researcher formerly, and then educational intervention was given, which was then followed by reassessment during the next follow-up visit, and the patient’s level of control was determined during each visit. The study was carried out from 30 June to 31 December 2018. Results Longer duration of inhaler use, regular follow-up, maternal education, and receiving education from a qualified trainer were significantly associated with a proper educational technique (P Conclusion Repeated education, checking, and correction of the inhaler steps are required to reach a proper reliable inhalation technique and better asthma control.

The factors that influence product development depend, amongst other things, on the type of product, the economic situation, the state of the art technology and various social and cultural trends. In modern era, often not the specs and costs are the decisive factors for purchasing a product, but aspects like design and brand personality. One of the reasons for this is the abundance of products of the same type for the same purpose. In fact, this is the current situation for dry powder inhalers (DPIs) although the self-congruity concept seems more applicable to the doctors who prescribe the inhalers than to the patients who are using them. For the early DPIs from the 1960s and 1970s the driving factor for development was the necessity of having an alternative for cholofluorocarbon (CFC) containing metered dose inhalers (MDIs). An important factor affecting their design could have been the desire to improve pulmonary drug delivery compared to that from MDIs, but unfortunately this oportunity was missed. Instead, available technology like hard gelatin capsules and adhesive ('ordered') mixtures were used and lung deposition remained more or less the same as from MDIs (only approx. 10% of the dose). After the capsule (and multi-dose reservoir) DPIs became more widely accepted and patents on inhaled drugs expired, consulting groups and generic manufacturers became more and more involved in the emerging DPI market, purely on an economic basis. This does not mean that there have not been developments yet aiming at improvement of the therapy with DPIs and various future applications may give a new boost to using new technology for dry powder inhalation.

Sub-optimal chronic obstructive pulmonary disease (COPD) management has been found largely due to patients’ medication non-adherence and incorrect inhaler technique. This study aimed to examine inhaler use technique and medication adherence among Vietnamese COPD patients as well as potential associated factors. A cross-sectional study involving 70 COPD exacerbators was conducted. Inhaler technique and adherence were evaluated by the 10-item and 12-item Test of Adherence to Inhaler (TAI). Data on the history of COPD, home prescription of inhalers and duration of hospitalization were also collected. Generalized linear regression models were used to determine the associated factors with inhaler use and medication adherence. The results showed that the proportion of patients with good inhaler technique was 22.7% for metered-dose inhalers (MDI), 30.4% for dry powder inhalers (DPI) and 31.8% for soft-mist inhalers (SMI). Full exhalation was the most common mistake. The rates of non-compliance patterns were: “ignorant” (77.1%), “sporadic” (58.6%), and “deliberate” (55.7%). Worse dyspnea, greater health condition impairment, and an increased frequency of exacerbations and hospitalizations were found to be associated negatively with correct inhaler use and treatment adherence. Instructions to COPD patients about using inhalers should focus on correct inhaler technique and adherence even when feeling healthy.

Studies conducted in adults have suggested that patients who use a metered-dose inhaler/holding chamber spacer (MDI/S) and dry powder inhaler (DPI) concurrently will have poorer MDI/S technique than that of patients who use MDI/S exclusively. To our knowledge, as of August 31, 2006, no studies have been performed in pediatric patients. To compare MDI/S technique scores of children using only MDI/S with scores of those using both MDI/S and DPIs. The MDI/S technique of children aged 6-17 years, with persistent asthma, recruited from a general pediatric practice population for an asthma intervention study project was scored using a standardized checklist. MDI/S scores of children who were being treated with maintenance and rescue medication delivered only by MDI/S were compared with those treated with both MDI/S (rescue) and DPI (maintenance). Scores lower than 70% were considered to be inadequate. A total of 117 patients (73 male, 44 female), aged 9.70 +/- 3.1 years (mean +/- SD), with persistent asthma, participated in the study. There were 83 children (54 male, 29 female, age 9.4 +/- 3.2 y) in the MDI/S only group and 34 (19 male, 15 female, age 10.3 +/- 2.9 y) in the MDI/S + DPI group. In the MDI/S + DPI group, Diskus was the DPI used for 32 patients, and Turbuhaler was used by 2 children. Sixteen patients had severe persistent asthma, 80 had moderate persistent asthma, and 21 had mild persistent asthma as classified by National Heart Lung and Blood Institute guidelines. No difference in sex and age demographics existed; however, there was a difference in the distribution of asthma severity between groups (ie, no patients with mild persistent asthma in the MDI/S + DPI group; p < or = 0.01). Mean score for the MDI/S only group was 86 +/- 17% and, for the MDI/S + DPI group, 90.1 +/- 12% (p = 0.15). More patients in the MDI/S group had inadequate scores (18%) compared with those in the MDI/S + DPI group (3%; p < 0.05). While DPI and MDI/S techniques are markedly different in several significant ways, concurrent use of these inhalers did not adversely affect MDI/S technique scores of pediatric patients with persistent asthma, compared with those using MDI/S alone. Patients in the MDI/S only group had an inadequate MDI/S score (<70%) more often than did patients in the MDI/S + DPI group.

Background: Inhalation has become the preferred route of drug administration compared to oral medication in managing Asthma due to its direct delivery to the airways, thus producing a faster onset of action and fewer systemic side effects at lower doses than would be required for other routes of administration. Aims and Objectives: This study aimed to evaluate the inhaler technique among children with asthma and its association with the level of asthma control and to identify factors associated with improper use of inhaler devices. Materials and Methods: This is a prospective cross-sectional study conducted at the Department of Pediatrics at B. P Koirala Institute of Health Science, university teaching Hospital in Nepal. The children with asthma were asked to use their inhaler device as usual and inhalational technique was assessed using inhaler device assessment tool and control of asthma level was assessed using the Childhood Asthma Control Test score. Results: One hundred and three asthmatic children of the age range of 4–11 years were enrolled in the study. The mean age of surveyed children was 6.3 ± 2.2 years and over half of the participants were boys (68.9%). Around 60% had moderate asthma. Among them, 50% had symptoms for &lt;3 years; only 50% of children with asthma demonstrated good technique of inhaler medication. Forty-five percent of them showed optimal asthma control. Near about a quarter of the participants showed mistakes in one step and about a fifth of the children showed mistakes at more than one step. Almost 30% of children with asthma have not obtained inhaler technique education. Factors associated with poor inhaler technique and poor asthma control were younger age and irregular follow-ups. The most common errors in the proper use of inhalers were not shaking the inhaler before use (30%) and wrong breathing techniques (30%). Conclusions: Improper inhaler technique is common among children with asthma. Children with asthma should have their inhaler technique routinely checked, during visits and should be given detailed education on proper inhalation techniques. Health education programs on asthma control are recommended in countries like Nepal to improve proper asthma inhaler device use and treatment outcomes in children with asthma.

Introduction and objectivesFluticasone propionate/salmeterol (FP/SAL), can be delivered by metered-dose inhaler (MDI) or dry powder inhaler (DPI). The choice of device may affect adherence to and effectiveness of treatment. Although...

Asthma is the most common chronic disease among children. Dry-powder inhalers (DPIs) are effective for medication delivery in adults and adolescents, and provide a lower environmental footprint and more portability than a metered dose inhaler (MDI) with a spacer. They require a 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 DPIs with adequate technique during both stable and acute asthma. Ovid MEDLINE, Embase and PubMed were searched for studies assessing DPI use among children aged 5-11 years with asthma or wheeze. Results of studies were synthesised by study design and outcome measure. 38 studies were identified for analysis. These were analysed in three groups: 1) 25 studies assessing children's ability to use DPIs by peak inspiratory flow measurement, 2) 10 studies assessing children's ability to use DPIs by physician assessment, and 3) three studies measuring the efficacy of DPIs compared with the gold standard (MDI with spacer). Five studies included children during acute exacerbations. The 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 remain as challenges, but these are also issues with an MDI plus spacer and do not appear to be significantly worse with DPIs. Evidence of the use of DPIs during acute illness is limited; more studies are required in this setting.

We conduct a 60 min practical training course in the use of bronchial asthma inhalation devices containing placebos for fifth-year undergraduate medical students and fourth-year undergraduate pharmacy students. The purpose of the training is to help students gain a better understanding of the inhalation technique and the importance of proper instruction on inhalation. In this report, we describe the practical training course and the evaluation of the metered-dose inhaler (MDI) and dry powder inhaler (DPI) by students. The course consists of 4 parts : 1. Explanation of the characteristics of different kinds of inhalation drugs and inhalation devices ; 2. Using the instructions, students practice of each step of the inhalation technique for MDI and DPI (diskhaler and diskas) inhalation devices containing placebos for patient practice ; 3. Students written evaluation of the operation of the inhalation device and instructions on it for each step assuming that the subject is an elderly patient or a younger adult patient and 4. Explanation of the need to confirm that patients have grasped the inhalation technique and the necessity of gargling after inhaling steroids. The 78 fifth-year medical students and 7 fourth-year pharmacy students who took our practical training course in 2003 said that compared to MDI and Diskhaler, Diskas was easier to operate and to provide instruction for. According to the results of a questionnaire given after the training, the students were satisfied with the practical training program on the use of inhalers for bronchial asthma.

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.

Bronchial Asthma (BA) is a chronic airway disorder with significant morbidity and mortality but due to recent advances in the field of medicine most patients with BA can have complete symptom control and live a normal life. There are various routs of drug delivery for asthma control but among them aerosol inhalation is considered the optimal route. A number of pressured Metered Dose Inhalers (MDI) &amp; Dry Powder Inhalers (DPI) are available for this purpose. However inhalation of therapeutic aerosols is not without difficulty, it requires precise instructions on the inhaler maneuvers, which is different from spontaneous normal breathing. Also, the characteristics of the inhaler device have to be suitable for the user. Available data indicate that, lack of knowledge demonstrated by health professionals &amp; patients on the inhalation maneuvers &amp; handling of inhalers resulting in a reduction of therapeutic benefit. The paper reviews the literature concerning the fundamental aspects of inhaler devices, inhalation maneuvers &amp; device selection, in an attempt to increase the knowledge of and to optimize the clinical use of therapeutic inhalers. As a result of which Asthmatics can be kept under good control. Key words: Bronchial Asthma; MDI; DPI; Inhalation technique; Rotahaler; Cozyhaler. DOI: http://dx.doi.org/10.3329/fmcj.v6i2.9212 FMCJ 2011; 6(2): 104-106

IntroductionSalmeterol/Fluticasone propionate (SFC) in the form of a dry powder inhaler (DPI) is often used in COPD, however it is also available as a metered dose inhaler (MDI). This is...

To examine the frequency of proper use of inhalation devices and influence of age and training on it. One hundred and five subjects of bronchial asthma and Chronic Obstructive Pulmonary Disease (COPD); aged between 18 to 75 y (mean ± SD; 46 ± 28.55) were studied. Subjects were enrolled over a period of three months. Data like weight, height and concomitant medications were recorded. It was an observational and questionnaire based study. Parameters were chosen to demonstrate the inhalational technique, errors committed in different steps of use & nature of medical, paramedical, nursing personals and others imparting training for use of inhaler device and time devoted for it. Of total 105 patients, 31 were using dry powdered inhalers (DPI), 50 on metered dose inhalers (MDI), and 24 on MDI with spacer devices. Among study population 83.81% were trained by healthcare professionals (doctors, nurse, pharmacists, paramedical or representatives of Pharmaceutical companies) and 16.19% are trained by general people. Among the MDI users (n=50) only 6%, 16.12% among the DPI users, 20.8%, among MDI with spacer users could use inhalers correctly. At 95% confidence limit there was significance of errors committed between DPI and MDI users (difference of SE is 2.56) and between spacer and MDI users (difference of SE 2.92). There was no difference found in regard of frequency of errors committed in taking different devices according to patient's socioeconomic, educational background and trainer. It was concluded that use of MDI with spacer most convenient method. Doctors often did not have sufficient time to train patients regarding proper technique of inhaler use. With ever increasing and widespread use of inhalers patients' education is becoming more important. Proper training will surely make these drugs more effective and cost benefit ratio more favourable.