Comparative Study of Inhaler Device Handling Technique and Risk Factors for Critical Inhaler Errors in Korean COPD Patients

Prospective Randomized Study on Switching Triple Inhaler Therapy in COPD from Multiple Inhaler Devices to a Single Inhaler Device in a Chinese Population

Background

Triple therapy with inhaled corticosteroids and dual bronchodilator therapy is recommended for chronic obstructive pulmonary disease (COPD) patients who have exacerbations and eosinophilia. It can be administered by single inhaler triple therapy (SITT) or by multiple inhaler triple therapy (MITT). There is a lack of evidence of the benefits of SITT over MITT in the Chinese population, especially on switching from existing MITT to SITT.

Methods

A total of 70 Chinese patients with COPD were recruited in this open-label, double-arm clinical trial to investigate the number of critical inhaler errors, the modified Medical Research Council (mMRC) dyspnea scale, the Medication Adherence Report Scale for Asthma (MARS-A) score, and a satisfaction score upon switching from MITT to SITT.

Results

The mean number of critical inhaler errors was 0.4±1.0 in the SITT group and 1.1±1.8 in the MITT group( p=0.038) at the first visit; and 0.2±0.6 in the SITT group and 0.8±1.1 in the MITT group (p=0.007) at the second visit. The mean change in MARS-A from baseline to first visit was +3.76±7.48 in the SITT group and -1.27±7.76 in the MITT group (p-value 0.008). A total of 22 (59.5%) and 8 (24.2%) of the patients in the SITT and the MITT group respectively, had an increase in MARS-A score from baseline to first visit, with an adjusted odds ratio of 6.23 (95% confidence interval=1.63-23.77, p=0.007), favoring SITT. There was no significant difference in the change in the mMRC dyspnea scale and the satisfaction score between the 2 groups.

Conclusion

Switching from MITT to SITT in Chinese COPD patients may have the benefits of having fewer critical inhaler errors and a higher MARS-A score.

A 7-point evidence-based care discharge protocol for patients hospitalized for exacerbation of COPD: consensus strategy and expert recommendation

Acute exacerbations of COPD (ECOPD) are an important event in the life of a COPD patient as it causes significant deterioration of physical, mental, and social health, hastens disease progression, increases the risk of dying and causes a huge economic loss. Preventing ECOPD is therefore one of the most important goals in the management of COPD. Before the patient is discharged after hospitalization for ECOPD, it is crucial to offer an evidence-based care bundle protocol that will help minimize the future risk of readmissions and death. To develop the content of this quality care bundle, an Expert Working Group was formed, which performed a systematic review of literature, brainstormed, and debated on key clinical issues before arriving at a consensus strategy that could help physicians achieve this goal. A 7-point consensus strategy was prepared, which included: (1) enhancing awareness and seriousness of ECOPD, (2) identifying patients at risk for future exacerbations, (3) optimizing pharmacologic treatment of COPD, (4) identifying and treating comorbidities, (5) preventing bacterial and viral infections, (6) pulmonary rehabilitation, and (7) palliative care. Physicians may find this 7-point care bundle useful to minimize the risk of future exacerbations and reduce morbidity and mortality.

Recalibrating Perceptions and Attitudes Toward Nebulizers versus Inhalers for Maintenance Therapy in COPD: Past as Prologue

Aerosol therapy administered via handheld inhaler or nebulizer device has long been standard for the treatment of chronic obstructive pulmonary disease (COPD), both for maintenance therapy and for management of acute exacerbations. Of the 2 options for drug delivery, inhaler devices are the most widely used for ambulatory patients with COPD as they are small, portable, and convenient and offer an array of medication options. They are, however, prone to suboptimal inhalation technique and use errors, which decrease the amount of medication delivered, compromise efficacy, and adversely affect clinical outcomes. Nebulizers are less often employed for aerosol delivery than inhalers, particularly in the home environment. Considered bulky and expensive, nebulizers have historically had limited medication options compared with inhalers. Nonetheless, nebulizers may be preferred over inhalers in specific patient populations, such as in patients with poor lung function, lack of hand-breath coordination, or cognitive impairment. Furthermore, technological advances and development of new nebulizer-compatible medications are shifting the benefit equation for nebulizers versus inhalers in a way that merits reconsideration of the role of nebulizers in the maintenance treatment of COPD. Using the available literature, this state-of-the-art review critically evaluates the benefits and limitations of aerosol therapy delivery via inhaler or nebulizer for patients with COPD; describes the factors that may influence the benefit equation, including current advances in nebulizer technology and future developments; and provides insights on implementation of nebulizer therapy in clinical practice.

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

Purpose

The use of inhaled bronchodilators is the mainstay of treatment for patients with chronic obstructive pulmonary disease (COPD). Although the soft mist inhaler (SMI) was developed to overcome the disadvantages of pressurized metered dose and drug powder inhalers, misuse during handling has been frequently observed in many studies. However, few studies have focused on SMI misuse among patients with COPD. Thus, we aimed to assess and identify the risk factors associated with SMI misuse among patients with COPD.

Patient and Methods

In this prospective, observational, cross-sectional study, we enrolled patients with COPD who were undergoing SMI treatment between January 2018 and March 2020. An advanced nurse practitioner assessed the participants' handling of the device by using a check list.

Results

Among 159 participants, 136 (85.5%) reported inhaler misuse. Duration of COPD and COPD assessment test (CAT) scores were positively associated with inhaler misuse; adherence and education level were negatively associated with inhaler misuse. In the multivariable analysis, a low educational level (less than high school), high CAT score (≥ 10), and short duration of COPD (≤ 2 years) were identified as risk factors for SMI misuse.

Conclusion

SMI misuse remains common among patients with COPD. Therefore, clinicians should pay close attention to their patients using SMIs, especially in the early period after the diagnosis of COPD.

Delivery technology of inhaled therapy for asthma and COPD

Inhaled therapy is the cornerstone of the management of asthma and chronic obstructive pulmonary disease (COPD). Drugs such as bronchodilators and corticosteroids are administered directly to the airways for local effect and rapid onset of action while systemic exposure and side effects are minimized. There are four major types of inhaler devices used clinically to generate aerosols for inhalation, namely, pressurized metered-dose inhalers (pMDIs), nebulizers, Soft Mist™ inhalers (SMIs) and dry powder inhalers (DPIs). Each of them has its own unique characteristics that can target different patient groups. For instance, patients' inhaler technique is critical for pMDIs and SMIs to achieve proper drug deposition in the lung, which could be challenging for some patients. Nebulizers are designed to deliver aerosols to patients during tidal breathing, but they require electricity to operate and are less portable than other devices. DPIs are the only device that delivers aerosols in dry powder form with better stability, but they rely on patients' inspiration effort for powder dispersion, rendering them unsuitable for patients with compromised lung function. Choosing a device that can cater for the need of individual patient is paramount for effective inhaled therapy. This chapter provides an overview of inhaled therapy for the management of asthma and COPD. The operation principles, merits and limitations of different delivery technologies are examined. Looking ahead, the challenges of delivering novel therapeutics such as biologics through the pulmonary route are also discussed.

Assessment of Inhaler Satisfaction and Determinants of High Satisfaction Among Korean COPD Patients

BACKGROUND

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for chronic obstructive pulmonary disease (COPD) recommend considering patient preference when choosing an inhaler device. However, few studies have assessed both inhaler satisfaction and factors associated with high inhaler satisfaction. Therefore, we assessed inhaler satisfaction and determinants of high satisfaction in Korean COPD patients.

METHODS

COPD patients were prospectively enrolled from January 2018 to November 2019. The 308 inhalers used by the 261 participants in this study included dry powder inhalers (Turbuhaler, Breezhaler, Ellipta, Diskus, and Genuair), a soft mist inhaler (Respimat), and pressurized metered dose inhalers (pMDIs). Inhaler satisfaction was assessed by the Feeling of Satisfaction with Inhaler (FSI-10) questionnaire. High inhaler satisfaction was defined as an FSI-10 ≥ 43.

RESULTS

Among 261 COPD patients, 163 (62.5%) were highly satisfied with their inhaler device. The rates of high inhaler satisfaction for Turbuhaler, Breezhaler, Ellipta, Diskus, Genuair, Respimat, and pMDI usage were 40.0%, 67.2%, 66.7%, 50.0%, 55.6%, 63.4%, and 45.0%, respectively (P = 0.215). In univariate analyses, higher body mass index, non-current smoker, GOLD grades I and II, a modified Medical Research Council (mMRC) score < 2, lower inhaler puff burden, once daily usage of inhaler, and good inhaler adherence were associated with high inhaler satisfaction. In multivariate analyses, an mMRC score < 2, and good inhaler adherence were independently associated with high inhaler satisfaction.

CONCLUSION

High inhaler satisfaction was associated with dyspnea symptom and good inhaler adherence in COPD patients. Effective strategies are needed including appropriate inhaler device selection, consideration of patient preference, and repeated inhaler education to improve patient satisfaction of inhalers.

Impact of Sex on Proper Use of Inhaler Devices in Asthma and COPD: A Systematic Review and Meta-Analysis

Despite females being more often affected by asthma than males and the prevalence of COPD rising in females, conflicting evidence exists as to whether sex may modulate the correct inhaler technique. The aim of this study was to assess the impact of sex on the proper use of inhaler devices in asthma and COPD. A pairwise meta-analysis was performed on studies enrolling adult males and females with asthma or COPD and reporting data of patients making at least one error by inhaler device type (DPI, MDI, and SMI). The data of 6,571 patients with asthma or COPD were extracted from 12 studies. A moderate quality of evidence (GRADE +++) indicated that sex may influence the correct use of inhaler device in both asthma and COPD. The critical error rate was higher in females with asthma (OR 1.31, 95%CI 1.14−1.50) and COPD (OR 1.80, 95%CI 1.22−2.67) using DPI vs. males (p < 0.01). In addition, the use of SMI in COPD was associated with a greater rate of critical errors in females vs. males (OR 5.36, 95%CI 1.48−19.32; p < 0.05). No significant difference resulted for MDI. In conclusion, choosing the right inhaler device in agreement with sex may optimize the pharmacological treatment of asthma and COPD.