Evaluation of the preference, satisfaction and correct use of Breezhaler® and Respimat® inhalers in patients with chronic obstructive pulmonary disease - INHALATOR study

Prevalence and Factors Affecting Appropriate Inhaler Use in Elderly Patients with Chronic Obstructive Pulmonary Disease: A Prospective Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) mainly affects individuals aged 60 and older. The proper use of inhalers is crucial for managing COPD. This study aimed to evaluate the prevalence and factors affecting the appropriate use of inhalers among elderly patients with COPD.

METHODS

We enrolled 91 elderly patients with COPD admitted to the Department of Respiratory, University Medical Center HCMC between October 2020 and May 2021. Patients who were capable of using the inhaler would have their inhaler usage recorded through video footage. Two respiratory experts carefully analyzed 133 video-recorded demonstrations for evaluation purposes.

RESULTS

18.7% of the patients demonstrated the correct inhaler technique. Pressurized metered dose inhaler (pMDI) and Turbuhaler had the lowest documented correct usage rates (11.9% and 10.0%, respectively). Two critical steps, namely "holding breath for about five seconds or as long as comfortable" and "breathing out gently," were commonly performed incorrectly when using pMDI, Respimat, Breezhaler, or Turbuhaler. Multivariable logistic regression analysis showed that lower mMRC scores (AOR = 5.3, CI 1.1-25.5, p = 0.037) and receiving inhaler instruction within the past three months (AOR = 5.2, CI 1.3-20.1, p = 0.017) were associated with increased odds of using the inhaler correctly.

CONCLUSIONS

Our study found that less than 20% of elderly patients with COPD use inhalers correctly. Common errors include inadequate breath-holding and gentle exhalation. mMRC scores and recent inhaler instruction were predictors of proper use. These findings can aid clinicians in improving inhaler management for elderly patients with COPD.

Inhaler use in chronic obstructive pulmonary disease patients: a meta-analysis†

Objective: To evaluate errors in the use of inhalation techniques in patients with chronic obstructive pulmonary disease (COPD), and to provide evidence for improving the effectiveness of drugs.

Methods: A meta-analysis was performed after searching for literature at PubMed, Embase, Web of Science, Cochrane Library, CINAHL, China National Knowledge Infrastructure (CNKI), WanFang, VIP, and SionMed databases which were published from January 2011 to October 2020, addressing errors in the use of inhalation technologies for the treatment of COPD. After reviewing the literature, extracting pertinent information, and evaluating the risk of bias for the included studies, statistical analysis was performed using Stata 15.1.

Results: Thirteen papers (12 in English and 1 in Chinese), representing 2527 patients, met the search criteria and were included in the meta-analysis. The results showed that the combined effect size of COPD patients making at least one operational error was 76% (95% CI: 0.69–0.83). The error rate varied with inhaler type; the combined effect size error for powered inhalers was 66% (95% CI: 0.57, 0.74), 67% (95% CI. 0.57, 0.77) for metered-dose inhalers (MDI), and 51% (95% CI: 0.38, 0.64) for soft mist inhalers (SMI).

Conclusions: More than 75% of patients with COPD were unable to consistently use inhalers correctly, with the highest error rate for MDI. Therefore, health care providers must continue to educate patients on proper use of inhaler, ensuring their correct use and reducing the risk of acute COPD exacerbations.

The history, current state and perspectives of aerosol therapy

Nebulization is a very effective method of drug administration. This technique has been popular since ancient times when inhalation of plants rich in tropane alkaloids with spasmolytic and analgesic effects was widely used. Undoubtedly, the invention of anasthesia in the 19th century had an influence on the development of this technique. It resulted in the search for devices that facilitated anasthesia such as pulveriser or hydronium. From the second half of the 21st century, when the first DPI and MDI inhalers were launched, the constant development of aerosol therapy has been noticed. This is due to the fact that nebulization, compared with other means of medicinal substance application (such as oral and intravenous routes of administration), is safer and it exhibits a positive dose/efficacy ratio connected to the reduction of the dose. It enables drugs administration through the lung and possesses very fast onset action. Therefore, various drugs prescribed in respiratory diseases (such as corticosteroids, β-agonists, anticholinergics) are present on the market in a form of an aerosol.

Inhaled indacaterol/glycopyrronium/mometasone furoate fixed-dose combination in moderate-to-severe asthma

INTRODUCTION

Fixed-dose long-acting beta2-agonist (LABA)/inhaled corticosteroid (ICS) combinations and add-on therapies as needed are the mainstay for maintenance therapy in asthma. However, more than 40% of patients have an inadequately controlled disease. The development of triple fixed-dose combinations consisting of long-acting muscarinic antagonist (LAMA)/LABA/ICS has paved the way for a new approach to reach therapeutic goals of an optimal control of symptoms and an effective prevention of future exacerbations.

AREAS COVERED

A search was conducted on PubMed (MEDLINE), using the MeSH terms [asthma] + [indacaterol] + [glycopyrronium] +[mometasone furoate] + [treatment], until October 2021. Original data from clinical trials, prospective and retrospective studies and reviews were selected. Clinical studies with IND/MF/GLY (Enerzair Breezhaler) are summarized, and its place in current asthma therapy is examined.

EXPERT OPINION

Triple therapy has been shown to be an effective and safe therapeutic option for asthma patients who remain uncontrolled despite ICS/LABA combination. The recently approved single-inhaler indacaterol/glycopyrronium/mometasone fixed dose combination has demonstrated to significantly reduce exacerbations, improve FEV₁, symptoms and quality of life compared to ICS/LABA, including, salmeterol/fluticasone combination. Moreover, once-daily dosing may improve adherence.

Effectiveness of inhalation technique assessment service for patients with Respimat® inhaler

OBJECTIVES

The objective of this study was to examine how Inhalation Technique Assessment Service (ITAS) by community pharmacies affect patients' inhalation techniques when using the Respimat® soft mist inhaler. The inhaler was simultaneously updated into a reusable inhaler. The study focused on the Respimat® inhaler because its use is known to be challenging for patients.

METHODS

The study was performed as a pre-post design in 33 community pharmacies (CPs) in Finland. Patients' inhalation technique was assessed before ITAS (baseline) and immediately after ITAS (follow-up 1). Follow-up 2 was performed when the patient came to the pharmacy for a refill (1-3 months after the baseline and the follow-up 1). A Respimat specific twenty item checklist was used to assess inhalation technique. The checklist included 1) preparation steps before the first use of the Respimat® inhaler (8 items) and 2) daily use steps of the Respimat® inhaler (12 items). After ITAS, the patients received a brief questionnaire to assess their asthma/COPD history.

RESULTS

A total of 228 patients were enrolled at the first visit (mean age 67.8 years, 61.0% female, 85.5% had previous Respimat® use experience) and 42 of them attended the follow-up 2, 1-3 months later (mean age 70.1 years, 69.0% female, 92.9% had previous Respimat® use experience. The median number of the steps performed correctly increased from 17/20 at the baseline to all the 20 steps at the follow-up 1 (p < 0.001). At the baseline, 27.6% of the patients (n = 228) performed all preparation steps correctly, while 87.3% at the follow-up 1 and 71.4% at the follow-up 2. The percentage of the patients with acceptable inhalation technique (all critical daily use steps correct) increased from 69.7% at the baseline to 93.0% at the follow-up 1 (p < 0.001). The corresponding figure at the follow-up 2 was 69.0%. At the baseline, 30.3% of patients had optimal inhalation technique (all daily use steps correct). At the follow-up 1 corresponding figure was 85.1%, and 54.8% at the follow-up 2.

CONCLUSIONS

A pharmacist-led intervention significantly improved asthma and COPD patients' inhalation technique with the Respimat® inhaler. Significant improvements were found in the daily use steps and the preparation steps before the first use.

Inhaler technique in asthma and COPD: challenges and unmet knowledge that can contribute to suboptimal use in real life

Introduction: Inhalers are the most commonly used devices for lung drug delivery in asthma and COPD. Inhaler use offers several advantages but requires the user's proper mastery. The issue of inhaler technique is very important as inhaler misuse remains common in real life regardless of the inhaler used and is associated with poor disease control.Areas covered:This narrative review analyses the key-steps of inhaler mastery and the significance of the errors of use for the main devices. There are uncertainties on many tasks of inhaler use and on those variations from recommended steps that are considered as critical errors.Expert opinion: Despite technological advancements, an easy-to-use device is not yet available. Whatever the chosen inhaler, health care givers' proper practical education with the opportunity of feedback learning has a key-role for improving inhaler technique, but is time-consuming, and remains limited to few successful experiences. Newer digital technologies will be applied to the field of inhaler education, but the lack of knowledge on many practical aspects of inhaler technique might be a limit for its extensive implementation. Possibly digital innovation might substantially contribute to reduce inhaler misuse only if clinicians, manufacturers, and subjects will cooperate together on this issue.

Technical Evaluation of Soft Mist Inhaler Use in Patients with Chronic Obstructive Pulmonary Disease: A Cross-Sectional Study

Background

Proper inhaler technique is highly relevant to the effective management of chronic obstructive pulmonary disease (COPD). The tiotropium bromide spray (TBS) (Spiriva^® Respimat^®) is a soft mist inhaler (SMI) preferred by patients to pressurized metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs) because of its convenience in use. However, the technique of using TBS inhaler in the real world is unclear.

Objective

To evaluate techniques in using TBS inhaler and investigate the association between the patient characteristics and the correct use of TBS inhaler.

Methods

This cross-sectional study enrolled 74 COPD patients who used TBS inhaler device for more than 3 months. The sociodemographic and clinical characteristics of the patients were recorded. The technique of using TBS inhaler was evaluated step by step. Incorrect use was defined as the patient’s inability to complete the key steps in the inhalation manoeuvre. The percentage of incorrect use was compared between the groups. Risk factors related to incorrect use were analyzed by logistic regression analysis.

Results

Of the 74 participants, only 2 (2.7%) patients completed all the steps correctly, and 48 (64.9%) patients misused the key steps in the inhalation manoeuvre. Incorrect preparation of the TBS inhaler for the first use was the most frequently misused step, accounting for 77.0%. Factors associated with misuse of TBS inhaler included the educational background (p=0.010), living state (p=0.031) and COPD assessment test (CAT) score (p=0.005) of the patients. Additionally, logistic regression analysis showed that the COPD duration was significantly associated with the incorrect use (p=0.019). Compared with patients with a higher educational background, patients with an elementary school background [OR 11652.99, CI: 22.72–5975697.72], junior high school background [OR 7187.78, CI: 16.41–3146787] and high school background [OR 1563, CI: 4.27–572329.67] were more likely to misuse TBS inhaler. Patients living with their spouses alone were also more likely to commit errors in using TBS inhaler as compared with those living with their children [OR 12.29, CI of 1.14–1.96]. Clinical factors like the COPD symptoms were relative to the technical use of the device. Better technique was accompanied by a lower CAT score [OR 1.49, CI of 1.14–1.96].

Conclusion

The incorrect use of TBS inhaler was common in COPD patients. Healthcare providers should not only teach the patients about the drug preparation but help them use the inhaler correctly. Special attention should be paid to patients with a short COPD duration and a low educational background and those who live without the company of their children. Proper use of TBS inhaler can significantly improve the symptom control of COPD patients.

Inhaler device feature preferences among patients with obstructive lung diseases: A systematic review and meta-analysis

BACKGROUND

Bronchodilators administered through inhalation devices are the mainstay treatment for patients with obstructive lung diseases. Patients do not view devices as interchangeable. This systematic review and meta-analysis examined device feature preferences among patients with obstructive lung diseases treated with handheld inhalers.

STUDY APPRAISAL AND SYNTHESIS METHODS

PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were searched to identify publications between 2010 and 2019 that met the following criteria:A manual search extended the study period from 2001 to 2019. Random-effects models were used to generate pooled mean effect sizes and 95% confidence intervals (CIs) for preferred device features. Heterogeneity was measured by the I statistic.

RESULTS

Nineteen studies (n = 11,256) were included in this meta-analysis. Average age ranged from 50.4 to 74.3 years. The majority of patients were male (57%) and had chronic obstructive pulmonary disease (92%).Patients preferred the following device features: CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS:: Adults with obstructive lung diseases preferred small inhaler devices that were portable, durable, perceived as easy to use, and fast in medication administration. Healthcare providers should give due consideration to the patient's device feature preferences when developing a treatment plan that prescribes an inhalation device.

The Respimat® Soft Mist Inhaler: Implications of Drug Delivery Characteristics for Patients

Successful treatment for respiratory diseases relies on effective delivery of medication to the lungs using an inhalation device. Different inhalers have distinct characteristics affecting drug administration and patient adherence, which can impact clinical outcomes. We report on the development of the Respimat^® soft mist inhaler (SMI) and compare key attributes with metered-dose inhalers (MDIs) and dry powder inhalers (DPIs). The Respimat SMI, a pocket-sized device generating a single-breath, inhalable aerosol, was designed to enhance drug delivery to the lungs, reduce the requirements for patient coordination and inspiratory effort, and improve the patients’ experience and ease of use. The drug deposition profile with Respimat SMI is favorable compared with MDIs and DPIs, with higher drug deposition to the lung and peripheral airways. The slow velocity and long spray duration of the Respimat SMI aerosol also aid patient coordination. Clinical equivalence has been demonstrated for maintenance treatment of chronic obstructive pulmonary disease using once-daily tiotropium between Respimat SMI (5 µg) and HandiHaler DPI (18 µg). In comparative studies, patients preferred Respimat SMI to MDIs and DPIs; they reported that Respimat SMI was easy to use and felt the inhaled dose was delivered. The Respimat SMI, designed to generate a slow-moving and fine mist, is easy to use and effectively delivers drug treatment to the lungs. The patient-centered design of Respimat SMI improved patient satisfaction, and may help to promote long-term adherence and improve clinical outcomes with asthma and chronic obstructive pulmonary disease.

Device use errors with soft mist inhalers: A global systematic literature review and meta-analysis

Inhaled bronchodilators are the cornerstone of treatment for chronic obstructive pulmonary disease (COPD). Soft mist inhalers (SMIs) are devices that deliver bronchodilators. Although correct device use is paramount to successful medication delivery, patient errors are common. This global systematic literature review and meta-analysis examined device use errors with SMIs among patients with obstructive lung diseases. PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were searched to identify studies published between 2010 and 2019 that met the following inclusion criteria: (a) English language; (b) a diagnosis of COPD, bronchitis, or emphysema; and (c) reported device use errors among adults receiving long-acting bronchodilator treatment with Respimat® SMI (i.e. Spiriva®, Stiolto®, Spiolto®, and Striverdi®). Descriptive statistics examined sociodemographics, clinical characteristics, and device use errors. Meta-analysis techniques were employed with random-effects models to generate pooled mean effect sizes and 95% confidence intervals (CIs) for overall and step-by-step errors. The I2 statistic measured heterogeneity. Twelve studies (n = 1288 patients) were included in this meta-analysis. Eighty-eight percent of patients had COPD, and most had moderate/very severe airflow limitation (Global Initiative for Chronic Obstructive Lung Disease spirometric stages II to IV). Aggregate results revealed that 58.9% (95% CI: 42.4-75.5; I2 = 92.8%) of patients made ≥1 device use errors. Among 11 studies with step-by-step data, the most common errors were failure to (1) exhale completely and away from the device (47.8% (95% CI: 33.6-62.0)); (2) hold breath for up to 10 seconds (30.6% (95% CI: 17.5-43.7)); (3) take a slow, deep breath while pressing the dose release button (27.9% (95% CI: 14.5-41.2)); (4) hold the inhaler upright (22.6% (95% CI: 6.2-39.0)); and (5) turn the base toward the arrows until it clicked (17.6% (95% CI: 3.0-32.2)). Device use errors occurred in about 6 of 10 patients who used SMIs. An individualized approach to inhalation device selection and ongoing training and monitoring of device use are important in optimizing bronchodilator treatment.

Prospective evAluatIon foR inhalation devices in Greek patients with COPD and asthma: The PAIR study

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) and asthma remain a major health burden. Adherence to inhaled therapy is critical in order to optimize treatment effectiveness. Properly designed questionnaires can assess patients' satisfaction with their inhaler devices.

PATIENTS AND METHODS

A total of 766 patients with COPD, asthma or Asthma-COPD Overlap (ACO) were initially enrolled. During their first visit, patients were classified into three groups (Diskus™, Elpenhaler®, Turbuhaler®). Patients completed the FSI-10 questionnaire on Day 0 and Day 60. Test-retest reliability was evaluated.

RESULTS

A total of 705 patients completed the study. FSI-10 questionnaire had good test-retest reliability (Total Intraclass Correlation Coefficient: 0.86). All dry powder inhaler (DPIs) yielded satisfactory results. Median score of FSI-10 questionnaire in first visit (FSI-10-I) was significantly higher for patients receiving Elpenhaler® (45, 95% CI: 44 to 46) than patients receiving Diskus™ (42, 95% CI: 41 to 43) and Turbuhaler® (42, 95% CI: 41 to 43) (p < 0.001). Accordingly, median score of FSI-10 questionnaire in the final visit (FSI-10-II) was significantly higher for patients receiving Elpenhaler® (46, 95% CI: 45 to 47) than patients receiving Diskus™ (42, 95% CI: 41 to 43) and Turbuhaler® (43, 95% CI: 42 to 44) (p < 0.001).

CONCLUSION

FSI-10 questionnaire had good test-retest reliability and thus can be used in the follow-up of patients with COPD, asthma and ACO. All DPIs were highly acceptable among all study groups. Elpenhaler® achieved significantly higher ratings than Diskus™ and Turbuhaler® in FSI-10 score and presented higher preference among patients with obstructive lung diseases.

Study to Evaluate Satisfaction with the Inhalation Device Used by Patients with Asthma or Chronic Obstructive Pulmonary Disease and the Association with Adherence and Disease Control

Background: Adherence to pharmacological treatment is a fundamental factor in the control of chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD). Poor disease control is associated with increased morbidity and mortality and higher health costs. Methods: A multicenter, observational cross-sectional study was performed. Four hundred patients with a diagnosis of asthma or COPD were recruited from 18 Spanish hospitals. A total of 15 different inhalation devices used in the treatment of these diseases and grouped depending on their characteristics were analyzed. Patients underwent a clinical interview, and questionnaires were completed on inhaler adherence, satisfaction, and disease control. Results: Satisfaction was lower when adherence was intermediate or poor than when it was good (good vs. intermediate p = 0.035; poor vs. good p = 0.009). Multivariate analyses of feeling of satisfaction with inhaler (FSI) showed statistically significant effects for the level of adherence and academic degree in both chronic respiratory diseases and for the Asthma Control Test in the case of asthma, but not for COPD. Conclusions: High degree of satisfaction with the inhalers was observed in asthma and COPD patients, with no difference among device types. A positive association was found between satisfaction and both adherence and the degree of disease control in asthma, but not in COPD. Nevertheless, further investigations are needed to better clarify these associations.

Inhaler Devices for Delivery of LABA/LAMA Fixed-Dose Combinations in Patients with COPD

Inhaled fixed-dose combinations (FDCs) of a long-acting β-agonist (LABA) and a long-acting muscarinic antagonist (LAMA) have become the cornerstone for the maintenance treatment of symptomatic COPD patients. In this regard, global COPD treatment guidelines have recognized the importance of inhaler devices as integral contributors to the effectiveness of LABA/LAMA FDCs and recommend regular assessment of inhaler device use by the patients in order to improve long-term clinical outcomes. Optimal disease control is also highly dependent upon patient preferences and adherence to inhaler devices. This review objectively examines and compares the major inhaler devices used to deliver different LABA/LAMA FDCs, discusses the inhaler device characteristics that determine drug deposition in the airways, real-life preference for inhaler devices, and handling of inhaler devices that impact the results of the long-term management of COPD. The introduction of new LABA/LAMA FDCs, new inhaler devices, and more clinical studies have created confusion among physicians in choosing the optimal inhaled therapy for COPD patients; in this context, this review attempts to provide an evidence-based framework for informed decision-making with a particular focus on the inhaler devices.Funding. The preparation of this manuscript was funded by Novartis Pharma AG.

Tiotropium/Olodaterol: A Review in COPD

Tiotropium/olodaterol (Stiolto® Respimat®; Spiolto® Respimat®) is an inhaled fixed-dose combination of the long-acting muscarinic antagonist tiotropium bromide (hereafter referred to as tiotropium) and the long-acting β2-adrenergic agonist olodaterol. It is available in several countries, including the USA, Japan, China and those of the EU, where it is indicated for the long-term maintenance treatment of patients with chronic obstructive pulmonary disease (COPD). The efficacy of tiotropium/olodaterol 5/5 μg/day in patients with COPD was evaluated in phase III or IV trials of 6-52 weeks' duration. Tiotropium/olodaterol improved lung function to a greater extent than each of its individual components or placebo in 12- and 52-week trials. In 6-week trials, tiotropium/olodaterol provided greater lung function benefits over 24 h than the individual components, placebo or twice-daily fluticasone propionate/salmeterol. Tiotropium/olodaterol also demonstrated beneficial effects on health-related quality of life (HR-QoL), dyspnoea, inspiratory capacity, exercise endurance and the need for rescue medication. In an 8-week open-label trial, umeclidinium/vilanterol was superior to tiotropium/olodaterol for the primary endpoint of trough forced expiratory volume in 1 s. The tolerability profile of tiotropium/olodaterol was generally similar to that of the individual components. In conclusion, tiotropium/olodaterol provides a useful option for the maintenance treatment of COPD, with the convenience of once-daily administration via a single inhaler.

Patient preference for chronic obstructive pulmonary disease (COPD) treatment inhalers: a discrete choice experiment in France

OBJECTIVES

Understanding inhaler preferences may contribute to improving adherence in COPD patients and improving long-term outcomes. This study aims to identify and quantify preferences for convenience-related inhaler attributes in French moderate-to-severe COPD patients, with discrete choice experiment (DCE) methodology.

METHODS

Attributes were defined from a literature search, clinician and patient interviews: shape, dose insertion, dose preparation, dose release, dose confirmation, dose counter and reusability. An online DCE was conducted in respondents with self-reported COPD stage 2-4 recruited through a panel. The study questionnaire included twelve choice scenarios per respondent and questions on patient characteristics, treatment and disease severity. Statistical analyses used a mixed logit regression model with random effects. Utility scores were estimated for four types of inhalers: Inhaler A - soft mist inhaler; Inhaler B - reusable soft mist inhaler; Inhaler C - multi-dose dry powder inhaler; and Inhaler D - single dose dry powder inhaler.

RESULTS

The study was completed by 153 patients (50 females); respondents were 50.4 years old on average; 13 different inhaler devices were reported. The most preferred inhaler is L-shaped, has dose preparation with capsule insertion and a dose counter, and is reusable. Inhaler profiles A and B had the highest utilities (mean of 1.2533 and 0.9578 respectively) compared to inhaler C (0.6315) and D (0.2200).

CONCLUSIONS

This study showed statistically significant results that the strongest drivers of preference in French users of inhalation devices for COPD are shape, dose counter and reusability. Convenience-related characteristics are important to patients and should be taken into account by clinicians prescribing these devices.