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Matuszak M, Ochowiak M, Włodarczak S, Krupińska A, Doligalski M. State-of-the-Art Review of The Application and Development of Various Methods of Aerosol Therapy. Int J Pharm 2021; 614:121432. [PMID: 34971755 DOI: 10.1016/j.ijpharm.2021.121432] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 12/09/2021] [Accepted: 12/23/2021] [Indexed: 12/23/2022]
Abstract
Aerosol therapy is a rapidly developing field of science. Due to a number of advantages, the administration of drugs to the body with the use of aerosol therapy is becoming more and more popular. Spraying drugs into the patient's lungs has a significant advantage over other methods of administering drugs to the body, including injection and oral methods. In order to conduct proper and effective aerosol therapy, it is necessary to become familiar with the basic principles and applications of aerosol therapy under various conditions. The effectiveness of inhalation depends on many factors, but most of all on: the physicochemical properties of the sprayed system, the design of the medical inhaler and its correct application, the dynamics of inhalation (i.e. the frequency of breathing and the volume of inhaled air). It is worth emphasizing that respiratory system diseases are one of the most frequently occurring and fastest growing diseases in the world. Accordingly, in recent years, a significant increase in the number of new spraying devices and pharmaceutical drugs for spraying has appeared on the market. It should also be remembered that the process of spraying a liquid is a complicated and complex process, and its efficiency is very often characterized by the use of micro- and macro parameters (including average droplet diameters or the spectrum of droplet diameter distribution). In order to determine the effectiveness of the atomization process and in the delivery of drugs to the patient's respiratory tract, the analysis of the size of the generated aerosol droplets is most often performed. Based on the proposed literature review, it has been shown that many papers dealt with the issues related to aerosol therapy, the selection of an appropriate spraying device, the possibility of modifying the spraying devices in order to increase the effectiveness of inhalation, and the possibility of occurrence of certain discrepancies resulting from the use of various measurement methods to determine the characteristics of the generated aerosol. The literature review presented in the paper was prepared in order to better understand the spraying process. Moreover, it can be helpful in choosing the right medical inhaler for a given liquid with specific rheological properties. The experimental data contained in this study are of great cognitive importance and may be of interest to entities involved in pharmaceutical product engineering (in particular in the case of the production of drugs containing liquids with complex rheological properties).
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Affiliation(s)
- M Matuszak
- Faculty of Chemical Technology, Poznan University of Technology, Institute of Chemical Technology and Engineering, 4 Berdychowo Street, 60-965 Poznan, Poland.
| | - M Ochowiak
- Faculty of Chemical Technology, Poznan University of Technology, Institute of Chemical Technology and Engineering, 4 Berdychowo Street, 60-965 Poznan, Poland
| | - S Włodarczak
- Faculty of Chemical Technology, Poznan University of Technology, Institute of Chemical Technology and Engineering, 4 Berdychowo Street, 60-965 Poznan, Poland
| | - A Krupińska
- Faculty of Chemical Technology, Poznan University of Technology, Institute of Chemical Technology and Engineering, 4 Berdychowo Street, 60-965 Poznan, Poland
| | - M Doligalski
- Faculty of Computer, Electrical and Control Engineering, University of Zielona Góra, 4a Szafrana Street, 65-516 Zielona Góra, Poland
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Ding B, Siddiqui S, DePietro M, Petersson G, Martin UJ. Inhaler usability of a pressurized metered dose inhaler and a soft mist inhaler in patients with COPD: A simulated-use study. Chron Respir Dis 2018; 16:1479972318787914. [PMID: 30016880 PMCID: PMC6302969 DOI: 10.1177/1479972318787914] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The objective of this study was to evaluate task performance and handling errors
with soft mist inhalers (SMIs) or pressurized metered-dose inhalers (pMDIs)
among patients with chronic obstructive pulmonary disease (COPD) experienced
with, but not recently trained in, using these devices. This exploratory,
noninterventional, simulated-use study (D5970R00004) assessed handling/usability
of SMIs and pMDIs in inhaler-experienced patients with COPD (40–78 years;
diagnosis ≥6 months). Patients received a device and instruction-for-use leaflet
but no training and were recorded while performing tasks required for checking
the device, priming, and dosing. Errors that could substantially affect the
lung-delivered dose were considered critical. Sixteen of 61 patients (52% male)
had used SMIs and 55 had used pMDIs. Thirty-one patients received an SMI and 30
a pMDI. Overall, 79% made ≥5 performance errors (SMI 94%; pMDI 63%) and 49% made
≥5 critical errors (SMI 68%; pMDI 30%). All patients made ≥1 error; three (all
pMDI) made no critical errors. Regardless of the device used and previous
inhaler experience, patient-centered training, education, and continuous
retraining on correct inhaler use should be key aspects of routine patient care
in COPD.
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Affiliation(s)
- Bo Ding
- 1 AstraZeneca Gothenburg, Mölndal, Sweden
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Abstract
Current guidelines recommend inhaled pharmacologic therapy as the preferred route of administration for treating COPD. Bronchodilators (β2-agonists and antimuscarinics) are the mainstay of pharmacologic therapy in patients with COPD, with long-acting agents recommended for patients with moderate to severe symptoms or those who are at a higher risk for COPD exacerbations. Dry powder inhalers and pressurized metered dose inhalers are the most commonly used drug delivery devices, but they may be inadequate in various clinical scenarios (eg, the elderly, the cognitively impaired, and hospitalized patients). As more drugs become available in solution formulations, patients with COPD and their caregivers are becoming increasingly satisfied with nebulized drug delivery, which provides benefits similar to drugs delivered by handheld inhalers in both symptom relief and improved quality of life. This article reviews recent innovations in nebulized drug delivery and the important role of nebulized therapy in the treatment of COPD.
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Affiliation(s)
- Donald P Tashkin
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Carvalho TC, McConville JT. The function and performance of aqueous aerosol devices for inhalation therapy. ACTA ACUST UNITED AC 2016; 68:556-78. [PMID: 27061412 DOI: 10.1111/jphp.12541] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 02/05/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In this review paper, we explore the interaction between the functioning mechanism of different nebulizers and the physicochemical properties of the formulations for several types of devices, namely jet, ultrasonic and vibrating-mesh nebulizers; colliding and extruded jets; electrohydrodynamic mechanism; surface acoustic wave microfluidic atomization; and capillary aerosol generation. KEY FINDINGS Nebulization is the transformation of bulk liquids into droplets. For inhalation therapy, nebulizers are widely used to aerosolize aqueous systems, such as solutions and suspensions. The interaction between the functioning mechanism of different nebulizers and the physicochemical properties of the formulations plays a significant role in the performance of aerosol generation appropriate for pulmonary delivery. Certain types of nebulizers have consistently presented temperature increase during the nebulization event. Therefore, careful consideration should be given when evaluating thermo-labile drugs, such as protein therapeutics. We also present the general approaches for characterization of nebulizer formulations. SUMMARY In conclusion, the interplay between the dosage form (i.e. aqueous systems) and the specific type of device for aerosol generation determines the effectiveness of drug delivery in nebulization therapies, thus requiring extensive understanding and characterization.
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Affiliation(s)
- Thiago C Carvalho
- Bristol-Myers Squibb, Drug Product Science & Technology, New Brunswick, NJ, USA
| | - Jason T McConville
- Department of Pharmaceutical Sciences, University of New Mexico, Albuquerque, NM, USA
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Panos RJ. Efficacy and safety of eco-friendly inhalers: focus on combination ipratropium bromide and albuterol in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2013; 8:221-30. [PMID: 23658481 PMCID: PMC3643287 DOI: 10.2147/copd.s31246] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality and its treatment is critical to improve quality of life, reduce symptoms, and diminish the frequency of COPD exacerbations. Due to the harmful environmental effects of pressurized metered-dose inhalers (pMDIs) containing chlorofluorocarbons (CFCs), newer systems for delivering respiratory medications have been developed. Methods A search of the literature in the PubMed database was undertaken using the keywords “COPD,” “albuterol,” “ipratropium bromide,” and “Respimat® Soft Mist Inhaler™”; pertinent references within the identified citations were included. The environmental effect of CFC-pMDIs, the invention of the Respimat® Soft Mist Inhaler™ (SMI) (Boehringer Ingelheim, Ingelheim, Germany), and its use to deliver the combination of albuterol and ipratropium bromide for the treatment of COPD were reviewed. Results The adverse environmental effects of CFC-pMDIs stimulated the invention of novel delivery systems including the Respimat SMI. This review presents its development, internal mechanism, and use to deliver the combination of albuterol and ipratropium bromide. Conclusion CFC-pMDIs contributed to the depletion of the ozone layer and the surge in disorders caused by harmful ultraviolet B radiation. The banning of CFCs spurred the development of novel delivery systems for respiratory medications. The Respimat SMI is an innovative device that produces a vapor of inhalable droplets with reduced velocity and prolonged aerosol duration that enhance deposition within the lower airway and is associated with improved patient satisfaction. Clinical trials have demonstrated that the Respimat SMI can achieve effects equivalent to pMDIs but with lower medication doses. The long-term safety and efficacy remain to be determined. The Respimat SMI delivery device is a novel, efficient, and well-received system for the delivery of aerosolized albuterol and ipratropium bromide to patients with COPD; however, the presence of longer-acting, less frequently dosed respiratory medications provide patients and providers with other therapeutic options.
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Affiliation(s)
- Ralph J Panos
- Pulmonary, Critical Care, and Sleep Medicine Division, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH 45220, USA.
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Vincken W, Bantje T, Middle MV, Gerken F, Moonen D. Long-Term Efficacy and Safety of Ipratropium Bromide plus Fenoterol via Respimat((R)) Soft Misttrade mark Inhaler (SMI) versus a Pressurised Metered-Dose Inhaler in Asthma. Clin Drug Investig 2012; 24:17-28. [PMID: 17516687 DOI: 10.2165/00044011-200424010-00003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Respimat((R)) Soft Misttrade mark Inhaler (SMI) is a novel, propellant-free device that significantly increases lung deposition compared with pressurised metered-dose inhalers (pMDIs). The aim of this study was to compare the efficacy and safety of ipratropium bromide/fenoterol hydrobromide (IB/FEN; Berodual((R))) delivered via Respimat((R)) SMI and via a chlorofluorocarbon (CFC)-driven pMDI (CFC-MDI) in patients with asthma. DESIGN Multicentre, randomised, double-blind, placebo-controlled, parallel- group study. PATIENTS 631 patients (18-65 years old) with stable asthma. INTERVENTIONS After a 2-week run-in period (IB/FEN 20mug/50mug via CFC-MDI, two actuations four times a day), patients were randomised to 12 weeks' treatment with one of five treatments: IB/FEN 10mug/25mug, 20mug/50mug or placebo via Respimat((R)) SMI (one actuation four times a day), or IB/FEN 20mug/50mug or placebo via CFC-MDI (two actuations four times a day). The main efficacy measure was lung function (assessed on days 1, 29, 57 and 85); safety was assessed by monitoring adverse events. RESULTS Bronchodilator responses to IB/FEN were much greater than those to placebo (mean peak increases in forced expiratory volume in 1 second [FEV(1)] on day 85: 0.498-0.521L, active treatment; 0.215 and 0.240L, placebo). According to the primary endpoint, i.e. the average change in FEV(1) from test-day baseline over the 6 hours after dosing on day 85, neither IB/FEN dosage via Respimat((R)) SMI was inferior to IB/FEN via pMDI (p < 0.001). Non-inferiority of the two Respimat((R)) SMI dosages was supported by analyses of other lung function measures, e.g. average change in FEV(1) from test-day baseline over the 6 hours after dosing on the other 3 test days, and peak FEV(1) on all test days. Overall, the safety profile of IB/FEN via Respimat((R)) SMI was comparable to that via CFC-MDI. CONCLUSION IB/FEN from Respimat((R)) SMI is as effective and safe as from CFC-MDI and enables a 2- to 4-fold daily dose reduction of IB/FEN.
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Affiliation(s)
- Walter Vincken
- Academic Hospital, University of Brussels (AZVUB), Brussels, Belgium
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Ram FSF, Carvallho CR, White J. Clinical effectiveness of the Respimat inhaler device in managing chronic obstructive pulmonary disease: evidence when compared with other handheld inhaler devices. Int J Chron Obstruct Pulmon Dis 2011; 6:129-39. [PMID: 21468167 PMCID: PMC3064421 DOI: 10.2147/copd.s8092] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Indexed: 11/23/2022] Open
Abstract
Objectives: Medication for the management of chronic obstructive pulmonary disease (COPD) may be delivered by a number of different inhaler devices. This study was undertaken to determine the clinical effectiveness of the Respimat® handheld inhaler device compared with other handheld inhaler devices for the delivery of medication in stable COPD. Methodology: A systematic review of high-quality randomized controlled clinical trials comparing Respimat with other inhaler devices using the same medication was performed. Studies were searched for in the Cochrane Central Register of Controlled Trials as well as other relevant electronic databases. Manufacturers of inhaled COPD medication were also contacted for potential trials. Results: Seven studies of high methodological quality with 3813 participants were included in the review. Three trials used Handihaler® as the comparator inhaler, three used a chlorofluorocarbon metered-dose inhaler (CFC-MDI), and one trial used a hydroflouroalkane (HFA)-MDI. When Respimat was compared with Handihaler, the following reported outcomes were not significantly different: trough forced expiratory volume in 1 second (FEV1) (weighted mean difference [WMD] 0.01 L; P = 0.14), trough forced vital capacity (FVC) (WMD 0.001 L: P = 0.88), peak FEV1 (WMD 0.01 L: P = 0.08), peak FVC (WMD 0.01 L: P = 0.55), morning peak expiratory flow rate (PEFR) (WMD 5.06 L/min: P = 0.08), and evening PEFR (WMD 4.39 L/min: P = 0.15). Furthermore, there were no differences when Respimat was compared with Handihaler for risk of exacerbations (relative risk [RR] 0.94: P = 0.81), dry mouth (RR 1.57: P = 0.34), or nasopharyngitis (RR 1.42: P = 0.22). For Respimat compared with CFC-MDI, the only outcome for which data were available for meta-analysis was exacerbations, which were not significantly different (RR 1.20: P = 0.12). In addition, five trials with 2136 patients showed that there was no difference in risk of exacerbations or nasopharyngitis when Respimat was compared with all other handheld inhaler devices (RR 1.18: P = 0.13 and RR 1.33: P = 0.19, respectively). None of the clinical outcome measures reported was significantly different when the same, higher, or lower doses of medication were used in the inhaler devices being compared. Unfortunately, none of the included trials reported mortality as an outcome measure. Conclusions: Evidence from high-quality trials published to date suggests that the Respimat inhaler does not provide any additional clinical benefit to that provided by other inhaler devices in the management of COPD. Although in vitro studies have reported differences between the Respimat inhaler device and other handheld devices, we found no difference in any clinical outcome measures, including lung function and adverse events. Although recent reports have highlighted concerns of increased mortality with the Respimat inhaler device, none of the included trials reported mortality as an outcome. Only a small number of trials reported data that could be used in this systematic review, and a limited number of studies have been published that compare Respimat with other inhaler devices using the same drug and strength. Therefore, further trials comparing Respimat with other handheld inhaler devices using the same drug and dose are required before firm conclusions can be drawn. The concern with increased mortality with Respimat use should be investigated urgently.
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Affiliation(s)
- Felix S F Ram
- School of Health and Social Services, Massey University, Auckland, New Zealand.
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Henriet AC, Marchand-Adam S, Mankikian J, Diot P. [Respimat®, first Soft Mist™ inhaler: new perspectives in the management of COPD]. Rev Mal Respir 2010; 27:1141-9. [PMID: 21163393 DOI: 10.1016/j.rmr.2010.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Accepted: 09/16/2010] [Indexed: 10/18/2022]
Abstract
INTRODUCTION In COPD, inhaler choice should be based on the likelihood that the patient will be able to use the device correctly in order to favour adherence and compliance, and therefore treatment efficacy. SATE OF THE ART: Performances of usual inhalers are limited by the necessity of a good coordination of patient inspiration and inhaler activation (pressurized metered dose inhalers), or a sufficient inspiratory flow (dry powder inhalers). Respimat®, the first "Soft Mist™ inhaler" (SMI), releases the drug solution as a low and sustained soft mist, so that lung deposition is both improved and reproducible. PERSPECTIVES In clinical studies, Respimat® has been shown to allow equivalent bronchodilator response and tolerability to metered dose or dry powder inhalers, but with lower doses of active drugs. Furthermore, studies assessing inhaler preference in COPD showed that patients preferred Respimat® to usual inhalers. CONCLUSION Respimat® SMI offers new perspectives for the management of chronic respiratory diseases, particularly in newly diagnosed or poorly compliant patients.
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Affiliation(s)
- A-C Henriet
- Inserm U618, Service de Pneumologie, Hôpital Bretonneau, CHU de Tours, 2 Boulevard Tonnellé, 37044 Tours, France
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Vincken W. Clinical efficacy and safety of the combination of ipratropium bromide and fenoterol inhaled via the Respimat Soft Mist inhaler for relief of airflow obstruction. Expert Rev Respir Med 2010; 2:11-26. [PMID: 20477218 DOI: 10.1586/17476348.2.1.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bronchodilators are key drugs in symptomatic as well as maintenance treatment of obstructive lung diseases such as chronic obstructive pulmonary disease and asthma. The short-acting anticholinergic ipratropium bromide and the short-acting beta(2)-adrenergic receptor agonist fenoterol hydrobromide have been available for combined use both as a pressurized metered-dose inhaler and as a solution for nebulization. Their combination at half the dose in the novel device, the Respimat Soft Mist inhaler (RMT), has been shown to provide therapeutic equivalence to their combination into a conventional pressurized metered-dose inhaler, both in terms of efficacy and safety in patients with chronic obstructive pulmonary disease or asthma, both adults and children. Dose reduction with the RMT has been made possible due to the physical characteristics of the aerosol cloud emitted from the RMT, facilitating correct inhalation and ensuring higher pulmonary deposition of the aerosolized bronchodilators. Post-marketing studies using validated questionnaires confirm a high level of satisfaction with the performance and convenience of the RMT device, a large majority of patients preferring the RMT to other inhaler systems.
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Affiliation(s)
- Walter Vincken
- University Hospital Brussels (UZ Brussel), Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium.
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One hundred years of respiratory medicine chronic obstructive pulmonary disease (COPD)—Republished article. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.rmedu.2007.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Events of the past decade have stimulated development of new drug formulations and delivery devices that have improved the efficiency, ease of use, and environmental impact of inhaled drug therapy. Respimat® Soft Mist™ Inhaler is a novel, multidose, propellant-free, hand-held, liquid inhaler that represents a new category of inhaler devices. The aerosol cloud generated by Respimat contains a higher fraction of fine particles than most pressurized metered dose inhalers (pMDIs) and dry powder inhalers (DPIs), and the aerosol spray exits the inhaler more slowly and for a longer duration than with pMDIs. This translates into higher lung drug deposition and lower oropharyngeal deposition, making it possible to give lower nominal doses of delivered drugs without lowering efficacy. In clinical trials in patients with COPD, bronchodilator drugs delivered from Respimat were equally effective at half of the dose delivered from a pMDI. In one study of inhaler preference, Respimat was preferred over the pMDI by patients with COPD and other obstructive lung diseases. Respimat is a valuable addition to the range of inhaler devices available to the patient with COPD.
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Affiliation(s)
- Paula Anderson
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, Central Arkansas Veterans Healthcare System, 4301 W. Markham, Slot 555, Little Rock, AR 72205, USA.
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Abstract
Chronic obstructive pulmonary disease (COPD) is an increasing health problem and one of the leading causes of morbidity and mortality worldwide, but knowledge about its pathogenesis has increased substantially in recent years. The disease results from interaction between individual risk factors (like enzymatic deficiencies) and environmental exposures to noxious agents, like cigarette smoking, occupational dusts, air pollution and infections in childhood. The main mechanisms that may contribute to airflow limitation in COPD are fixed narrowing of small airways, emphysema and luminal obstruction with mucus secretions. COPD is characterised by a chronic inflammatory process in the pulmonary tissue, with a pattern different from bronchial asthma, associated with extrapulmonary effects and is considered now a complex, systemic disease. Optimal therapeutic targeting of COPD depends on a clear understanding of the precise mechanisms of these complex processes and on early and correct evaluation of disease severity. A combination of pharmacological and non-pharmacological approaches is used to treat COPD. Bronchodilators are the mainstay of COPD treatment and can be combined with inhaled corticosteroids for greater efficacy and fewer side effects. The use of LTOT for hypoxemic patients has resulted in increased survival, and expanded drug therapy options have effectively improved dyspnoea and quality of life. Recent studies have documented the benefits of pulmonary rehabilitation. In addition, non-invasive mechanical ventilation offers new alternatives for patients with acute or chronic failure.
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Affiliation(s)
- Mario Cazzola
- Department of Internal Medicine, Unit of Respiratory Diseases, University of Rome Tor Vergata, Rome, Italy.
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Kilfeather SA, Ponitz HH, Beck E, Schmidt P, Lee A, Bowen I, Hesse C. Improved delivery of ipratropium bromide/fenoterol from Respimat® Soft MistTM Inhaler in patients with COPD. Respir Med 2004; 98:387-97. [PMID: 15139567 DOI: 10.1016/j.rmed.2003.12.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We performed a multicentre, randomised, double-blind (within-device), placebo- and active-controlled, parallel-group study to compare the efficacy and safety of ipratropium bromide plus fenoterol hydrobromide (IB/FEN; Berodual) delivered via the novel, propellant-free Respimat Soft Mist Inhaler (SMI) and from a chlorofluorocarbon (CFC)-metered-dose inhaler (MDI) in moderate-to-severe chronic obstructive pulmonary disease (COPD) patients. After 2-weeks' run-in (CFC-MDI [IB 20 microg/FEN 50 microg per actuation] two actuations q.i.d. [MDI 40/100]), 892 patients were randomised to Respimat SMI containing IB 10 microg/FEN 25 microg (Respimat SMI 10/25), IB 20 microg/FEN 50 microg (Respimat SMI 20/50) or placebo (one actuation q.i.d.), or a CFC-MDI containing IB 20 microg/FEN 50 microg (MDI 40/100) or placebo (two actuations q.i.d.) for 12 weeks. Analysis of the primary endpoint (change in forced expiratory volume in 1 s [FEV1] in the first 60 min after dosing [area under the curve; AUC0-1h]) on day 85 showed that the efficacy of Respimat SMI 20/50 (but not Respimat SMI 10/25) was not inferior to that of MDI 40/100. The safety profile of Respimat SMI was comparable to CFC-MDI. Switching from MDI 40/100 to Respimat SMI was well tolerated. Respimat SMI enables a 50% reduction of the nominal inhaled dose of IB/FEN in COPD patients while offering similar therapeutic efficacy and safety to the CFC-MDI.
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Affiliation(s)
- S A Kilfeather
- Aeirtec Research Unit, Aeirtec Ltd., Bioscience Building, Times Square, Newcastle Upon Tyne, UK.
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Vincken W, Dewberry H, Moonen D. Fenoterol delivery by Respimat soft mist inhaler versus CFC metered dose inhaler: cumulative dose-response study in asthma patients. J Asthma 2003; 40:721-30. [PMID: 14580004 DOI: 10.1081/jas-120023495] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Respimat (RMT) soft mist inhaler (SMI) is a novel, propellant-free alternative to chlorofluorocarbon metered-dose inhalers (CFC-MDIs). The aim of this study was to evaluate the safety and establish the equipotent dose of fenoterol delivered by RMT SMI vs. a conventional MDI. DESIGN Double-blind, randomized, crossover, comparative study between fenoterol inhaled via RMT (either 50 microg/actuation, RMT50; or 100 microg/actuation. RMT100) and MDI (100 microg/actuation; MDI100). PATIENTS AND INTERVENTIONS A total of 41 asthma patients received cumulative doses of fenoterol 600 microg (RMT50) or 1200 microg (RMT100 and MDI100) on 3 test days. MEASUREMENTS AND RESULTS The bronchodilator response (forced expiratory volume in 1 second [FEV1]) was considered therapeutically equivalent (i.e., noninferior) if the 95% confidence intervals for the difference in their mean changes from baseline were within limits of +/- 0.15L. Systemic exposure was evaluated from plasma fenoterol levels. Adverse events (AEs) were recorded. RMT50 and RMT100 produced noninferior bronchodilatation to MDI100 from 30minutes after the first dose. RMT50 showed equivalent safety and tolerability to MDI100, whereas RMT100 produced a higher incidence of AEs, a significantly greater plasma potassium reduction and a significant increase in pulse rate. Fenoterol plasma levels were twice as high with RMT100 as with RMT50 or MDI100. CONCLUSIONS; The nominal dose of fenoterol administered via RMT SMI can be at least halved to achieve equivalent efficacy, safety, and tolerability to a MDI.
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Affiliation(s)
- Walter Vincken
- Respiratory Division, Academic Hospital, University of Brussels, Brussels, Belgium.
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Ram FS, Brocklebank DM, Muers M, Wright J, Jones PW. Pressurised metered-dose inhalers versus all other hand-held inhalers devices to deliver bronchodilators for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2002; 2002:CD002170. [PMID: 11869627 PMCID: PMC8436731 DOI: 10.1002/14651858.cd002170] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Bronchodilator therapy for COPD may be delivered by a number of different inhaler devices. OBJECTIVES To determine the efficacy of pressurised metered dose inhalers (pMDI) compared to any other handheld inhaler device for the delivery of bronchodilators in non-acute COPD. SEARCH STRATEGY The Cochrane Collaboration, Asthma and Wheeze Randomised Controlled Clinical Trials register was searched for studies. The UK pharmaceutical companies who manufacture inhaled COPD medication were also contacted. SELECTION CRITERIA Two reviewers independently reviewed the results of computerised search and any potentially relevant articles were obtained in full. DATA COLLECTION AND ANALYSIS One reviewer extracted details of each trial and a second reviewer checked all extracted data. Dichotomous outcomes such as exacerbation rate were assessed using relative risk, with 95% confidence interval (CI). MAIN RESULTS Fourteen studies appeared potentially relevant but only three studies (61 patients) met the entry criteria. Two studies compared a dry powder device (Turbuhaler or Rotahaler) with a pMDI for beta2-agonist delivery, and one (36 patients cross-over design) the Respimat (soft mist device for ipratropium) vs a pMDI. For the Turbuhaler and Rotahaler, none of the reported outcome measures were significantly different. The Rotahaler study used a high and low dose of medication with or without large volume spacer. The study using the Respimat showed significant increases in FEV1 when compared to a pMDI (difference in change from base line 70 ml, 95% CI 10, 130 ml). The effect on change in FVC was of similar size. There were no differences between these two devices for any other reported outcomes. Although none of the included studies required prior patient ability to use any of the inhalers (and no study mentioned device training), it was assumed that all patients randomised into the study would have undergone training in use of the study inhalers and were capable of using those devices. REVIEWER'S CONCLUSIONS In patients with stable COPD, pMDI produced similar outcomes to a dry powder device for delivering beta2-agonists, but the very small number of studies and included patients does not permit firm conclusions to be drawn. The soft mist device for ipratropium was more effective than a pMDI, but the data come from one small study. There need to be further well designed randomised controlled trials to define the role of inhaler devices using bronchodilators in stable COPD.
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Affiliation(s)
- F S Ram
- Department of Physiological Medicine, St George's Hospital Medical School, Level 0, Jenner Wing, Cranmer Terrace, London, UK, SW17 0RE.
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