Turbutest in the training of asthmatic Turbuhaler users

Evaluation of Suboptimal Peak Inspiratory Flow in Patients with Stable COPD

Objective: Although the importance of assessing inspiratory flow in the selection of treatments for chronic obstructive pulmonary disease (COPD) is understood, evaluation of this factor is not yet widespread or standardized. The objective of the present work was to evaluate the peak inspiratory flow (PIF) of patients with COPD and to explore the variables associated with a suboptimal PIF. Methods: An observational, cross-sectional study was carried out at specialized nursing consultations over a period of 6 months. We collected clinical data as well as data on symptoms, treatment adherence, and patient satisfaction with their inhalers via questionnaires. PIF was determined using the In-Check Dial G16^® device (Clement Clarke International, Ltd., Harlow, UK). In each case, the PIF was considered suboptimal when it was off-target for any of the prescribed inhalers. The association with suboptimal PIF was evaluated using multivariate logistic regression and the results were expressed as the odds ratio (OR) with 95% confidence interval (CI). Results: A total of 122 COPD patients were included in this study, of whom 34 (27.9%) had suboptimal PIF. A total of 229 inhalers were tested, of which 186 (81.2%) were dry powder devices. The multivariate analysis found an association between suboptimal PIF and age (OR = 1.072; 95% CI (1.019, 1.128); p = 0.007) and forced vital capacity (OR = 0.961; 95% CI (0.933, 0.989); p = 0.006). Conclusions: About a third of patients in complex specialized COPD care have suboptimal PIFs, which is related to age and forced vital capacity.

A review of the effects of medication delivery systems on treatment adherence in children with asthma

BACKGROUND

A patient's adherence to an appropriate treatment regimen is necessary to minimize morbidity and mortality associated with childhood asthma. Many factors influence the success of treatment adherence.

OBJECTIVE

The goal of this article was to examine the effect of the mode of medication delivery on the success of treatment adherence in children with asthma.

METHODS

Relevant clinical studies were identified through a MEDLINE search of articles published from 1966 to 2002, using the search terms adherence, aerosol, asthma, children, compliance, dry powder inhaler, metered-dose inhaler, nebulizer, and pediatric.

RESULTS

A relationship seems to exist between treatment adherence and the type of medication delivery system used in childhood asthma. The highest rates of adherence appear to be associated with oral medications.

CONCLUSIONS

Clinicians should consider the mode of medication delivery as 1 factor that can influence the success of treatment adherence.

Reduced Peak Inspiratory Effort through the Diskus((R)) and the Turbuhaler((R)) due to Mishandling is Common in Clinical Practice

OBJECTIVES

A minimum peak inspiratory flow (PIF) through dry powder inhalers (DPIs) is required for effective drug delivery to the lungs. Some patients are unable to generate the minimally effective PIF through the DPI. However, little information is available about the 'real life' prevalence of reduced peak inspiratory effort through the Diskus((R)) and the Turbuhaler((R)) as a result of mishandling

METHODS

We investigated peak inhalation effort through the Diskus((R)) and the Turbuhaler((R)) by both direct observation and the In-Check Dial((R)), a portable PIF meter, in a large sample of patients consecutively referred to our laboratory who were familiar with these devices. Patients with reduced peak inspiratory effort repeated the PIF measurement after a session of instruction on the need for more forceful effort through the device.

RESULTS

We studied 644 patients (mean age 62 years, 42% female). Of these, 62% had chronic obstructive pulmonary disease and 35% had asthma. The mean baseline forced expiratory volume in 1 second was 53% of predicted. 502 patients were using the Diskus((R)) and 185 the Turbuhaler((R)). Overall, 106 patients (16.5%) showed weak inhalation by direct observation at baseline. Of 44 subjects with weak inhalation through the Turbuhaler((R)), 34 (77%) demonstrated a PIF <30 L/min. Post-counselling, only four patients did not achieve a PIF of at least 30 L/min (p < 0.01). Of 62 subjects with weak inhalation through the Diskus((R)), 37 (60%) had a PIF <30 L/min. Post-counselling, all these subjects achieved a PIF of at least 30 L/min (p < 0.001).

CONCLUSION

A significant number of patients show a reduced peak inspiratory effort through the Diskus((R)) and the Turbuhaler((R)) in real life. Our results indicate that the cause of this deficiency is often mishandling of the device because, after a brief session of instruction on the need for more forceful inhalation, most patients obtained an acceptable PIF rate. A PIF meter may identify patients with inadequately weak inhalation and offer useful feedback for obtaining the best inspiratory effort.

The Diskus: a review of its position among dry powder inhaler devices

The use of dry powder inhalers (DPIs) to administer treatments for respiratory diseases has increased significantly in recent years. There is now a wide range of DPIs available that vary considerably in design, required operational techniques, output characteristics and drug delivery across a range of inhalation patterns. Different patient populations may find individual types of DPI easier to use correctly than others and selecting the right DPI for particular patient requirements will improve compliance with therapy. For example, some DPIs offer a greater resistance against inspirational flow rate than others which affects the total emitted dose and also fine particle mass of the aerosol released. An individual patient may therefore receive different amounts of drug when inhaling from different DPIs. Therefore, it is important that the prescriber is fully aware of the characteristics of the different types of DPI, so that he or she can prescribe the device that is most appropriate to an individual patient's needs. This review explores the characteristics of currently available DPIs and evaluates their efficacy and patient acceptability. The differences in output characteristics, ease of use and patient preferences between available devices is shown to affect treatment efficacy and patient compliance with therapy. Changing the DPI prescribed to a patient to a cheaper or generic device may therefore adversely affect disease control and thereby increase the cost of treatment.

Do patients think that dry powder inhalers can be used interchangeably?

As recognised in management guidelines, patients are the most important group of people in any prescribing decision. Despite their importance, few studies have asked what patients think about being switched between different inhalers. This paper reports two such studies, one involving interviews of a sample of patients and the other consisting of a quantitative survey of patients across five countries. In the qualitative study, four of the five patients interviewed reported that they would be confused, worried and unhappy about a switch in their dry powder inhaler and would revisit their physician to be shown how to use the inhaler or to ask for a new prescription for their old inhaler. In the quantitative survey of 499 patients with asthma, more than half (51%) were opposed to their current dry powder inhaler being replaced by a substitute device, with 83% reporting concerns. There was considerable concern about training in use of the new device and confusion about the need for change. Almost a quarter of patients (23%) would want training, and 23% of patients thought they would need information about the new inhaler. From limited information, it appears that patients would be concerned about switching of their existing dry powder inhaler for another, with the potential for confusion, need for additional consultations and need for training in the new device.

Can patients use all dry powder inhalers equally well?

If patients are unable to use their inhaler, drug delivery may be unsatisfactory and the patients may fail to benefit from the prescribed medication. It is important to consider whether patients can use all dry powder inhalers equally well. Changing a patient from a dry powder inhaler used well to one that the patient is unable to operate effectively could compromise asthma control. The many marketed dry powder inhalers reflect differences in design decisions that could affect lung deposition. Studies using different dry powder inhalers have confirmed that different lung deposition patterns are observed. Furthermore, there may be considerable individual variability in lung deposition. Differences in lung deposition patterns could have clinical effects. Studies may show similar clinical effectiveness with two inhalers, because most products are used at the plateau phase of the dose-response curve, although there may be differences in the adverse event profile. The ideal inhaler does not yet exist. Different dry powder inhalers show some but not all features of the ideal inhaler; hence, patients may prefer some aspects of one inhaler while favouring a different inhaler for other features. The individual balance of features will govern the overall preference for one inhaler over others. The method for operation of dry powder inhalers varies. Ease of use is seen as an important consideration when selecting an inhaler device, which should be evaluated in real-life studies using unselected patient populations. In conclusion, the evidence suggests that patients cannot use all dry powder inhalers equally well.

The inhalers of the future? A review of dry powder devices on the market today

International agreements to ban the use of environmentally damaging chlorofluorocarbons (CFCs) have signalled an end to the traditional CFC-propelled pressurised metered dose inhaler (pMDI) which has long been the mainstay of topical asthma therapy. The need for acceptable and cost-effective replacement inhalers, combined with opportunities to develop generic formulations of patent-expired drugs, has fueled a lively response from the pharmaceutical industry. Improvements in pMDI design and reformulation with propellants such as hydrofluoroalkanes may offer significant advantages over CFC-pMDIs and prolong the widespread use of pressurised drug delivery systems for many years to come. In the longer term, however, another likely candidate for success in providing economical, efficient and acceptable inhaled therapies is the breath-actuated, multiple-dose dry powder inhaler (DPI). This review concentrates on the multiple-dose DPIs available within Europe today.

The inhalation manager: a new computer-based device to assess inhalation technique and drug delivery to the patient

The rational choice of an inhalation device is a cornerstone in the effective management of asthma and COPD. In this publication, we describe the development of a new system, the Inhalation Manager, which, for the first time, offers the possibility to assess the entire inhalation maneuver of patients using original devices under everyday conditions. So far the Inhalation Manager allows the measurement of inspiratory maneuvers of patients through placebo inhalation devices of the most common breath-actuated CFC-free inhalers in the market for the three main glucocorticosteroids Budesonide [Turbohaler (TH), dry powder inhaler (DPI)], Beclomethasone dipropionate [Autohaler (AH), breath-actuated pressurized metered dose inhaler (pMDI)], and Fluticasone propionate [Diskus (DI), DPI] by means of a pneumotachometer. In addition, it allows allocation of the individual maneuver to the expected drug delivery values (mass output and particle size distribution) of these three devices. In a field trial, the inhalation technique of 628 (TH), 794 (AH), and 795 (DI) patients, respectively, was tested in 72 pulmonologist practices with the Inhalation Manager. For patients in the 18-59-year-old group, the Inhalation Manager detected the following percentages needing improvement: 1.5% for the Autohaler device, 16.7% for the Diskus, and 38.9% for the Turbohaler. In the 60-99-year-old group, percentages needing improvement were 1.5%, 31.5%, and 66.1% for the Autohaler, Diskus, and Turbohaler, respectively. Therefore, the Inhalation Manager could become an essential tool in asthma management by finding the most suitable inhaler for an individual patient and by training the optimal inhalation technique.