Usability of inhaler devices: a parameter currently misused

Inhalation represents the most convenient route for delivering respiratory drugs. Delivery systems showed a huge technological progress and several pocket inhalers had been engineered over the last decades for clinical use. Despite the growing technological efforts aimed to simplify the inhalation procedures and optimize the therapeutic outcomes, the effectiveness of drug inhalation through inhalers still represents a major challenge in respiratory medicine. Patients may actually incur in different types of critical errors when using all inhalers and are not capable to inhale throughout all devices equally well. Therefore, the choice of the most suitable and convenient device to prescribe still is a critical issue in real life. Usability is the only comprehensive parameter consenting the effective and objective assessment of pocket inhalers' performance, and allowing their objective comparison and ranking. Unpredictable discrepancies are in fact easily detectable between inhalers (even belonging to the same class) in terms of Usability, independently of the patient's awareness. The reasons were described and discussed for each class of inhalers presently available. Usability is a multidimensional parameter that is much more multifaceted and complex than usually presumed. Usability takes origin from the integrated, balanced and objective assessment of the role played by several factors from different domains, such as: factors related to patient's beliefs, to patients' behavioural components, to device engineering and to the overall cost. Usability is the key parameter for assessing and optimizing the appropriateness of any inhalation treatment through whatever device. Usability would also represent a key investigational instrument for supporting the future development of -innovative and more performing inhaler devices objectively.

Trend of Bronchial Hyperresponsiveness to Methacholine as a Cost Predictor of Mild-to-Moderate Asthma: A Twelve-Month Survey in Teenagers

Bronchial asthma is characterized by variable airflow obstruction, airway inflammation, and bronchial hyperresponsiveness (BHR) to non-specific stimuli. The role of underlying airway inflammation and of related long-lasting BHR has been suboptimally investigated in teenagers with mild-to-moderate asthma, as has the corresponding economic impact over time. The aim of the present study was to calculate the cost of mild-to-moderate atopic asthma in teenagers arising from their degree of persisting BHR over a twelve-month period.

METHODS

Patients aged 12-18 years with mild-to-moderate symptoms treated with fluticasone fumarate/vilanterol 92/22 mcg daily were retrospectively followed for 12 months. Usual spirometric parameters, BHR to methacholine (MCh), and resource consumption (visits, hospitalizations, systemic steroids and/or antibiotics courses, school days off) were assessed at recruitment (the index date) and after 6 and 12 months. Adherence to treatment was also calculated. The cost of asthma was calculated based on Italian tariffs and published papers. The trend over time in BHR and the association between response to MCh and total cost were investigated by using regression models adjusted for repeated measures.

RESULTS

106 teenagers (53 males, age 15.9 ± 1.6 years) were investigated. The annual cost of asthma proved significantly related to the BHR trend: every increment of a factor 10 in the response to MCh was associated with a saving of EUR 184.90 (95% CI -305.89 to -63.90). BHR was progressively optimized after 6 and 12 months in relation to the patients' compliance to treatment (≥70% of prescribed inhalation doses).

CONCLUSIONS

the usual spirometric parameters are largely insufficient to reflect the effects of underlying persistent inflammation in milder forms of asthma in teenagers. In terms of clinical governance, the periodic assessment of non-specific BHR is the appropriate procedure from this point of view. Non-specific BHR proves a reliable procedure for predicting and monitoring the economic impact of mild-to-moderate asthma in teenagers over time.

Editorial for "Asthma and Its Impact in Adolescents" Special Issue

Bronchial asthma is a chronic disease related to the atopic condition in most cases but also to other factors (such as infectious diseases; social, economic, environmental, and occupational conditions; exposure to biological irritants; and/or chemical aggressions) [...].

Nebivolol: an effective option against long-lasting dyspnoea following COVID-19 pneumonia - a pivotal double-blind, cross-over controlled study

Background

Pulmonary microvascular occlusions can aggravate SARS-CoV-2 pneumonia and result in a variable decrease in capillary blood volume (Vc). Dyspnoea may persist for several weeks after hospital discharge in many patients who have "radiologically recovered" from COVID-19 pneumonia. Dyspnoea is frequently "unexplained" in these cases because abnormalities in lung vasculature are understudied. Furthermore, even when they are identified, therapeutic options are still lacking in clinical practice, with nitric oxide (NO) supplementation being used only for severe respiratory failure in the hospital setting. Nebivolol is the only selective β¹ adrenoceptor antagonist capable of inducing nitric oxide-mediated vasodilation by stimulating endothelial NO synthase via β₃ agonism. The purpose of this study was to compare the effect of nebivolol versus placebo in patients who had low Vc and complained of dyspnoea for several weeks after COVID-19 pneumonia.

Methods

Patients of both genders, aged ≥18 years, non-smokers, who had a CT scan that revealed no COVID-related parenchymal lesions but still complaining of dyspnoea 12-16 weeks after hospital discharge, were recruited. Spirometrical volumes, blood haemoglobin, SpO₂, simultaneous diffusing capacity for carbon monoxide (CO) and NO (DL_CO and DL_NO, respectively), DL_NO/DL_CO ratio, Vc and exhaled NO (eNO) were measured together with their dyspnoea score (DS), heart frequency (HF), and blood arterial pressure (BAP). Data were collected before and one week after both placebo (P) and nebivolol (N) (2.5 mg od) double-blind cross-over administered at a two-week interval. Data were statistically compared, and p<0.05 assumed as statistically significant.

Results

Eight patients (3 males) were investigated. In baseline, their mean DS was 2.5±0.6 SD, despite the normality of lung volumes. DL_CO and DL_NO mean values were lower than predicted, while mean DL_NO/DL_CO ratio was higher. Mean Vc proved substantially reduced. Placebo did not modify any variable (all p=ns) while N improved DLco and Vc significantly (+8.5%, p<0.04 and +17.7%, p<0.003, respectively). eNO also was significantly increased (+17.6%, p<0.002). Only N lowered the dyspnoea score (-76%, p<0.001). Systolic and diastolic BAP were slightly lowered (-7.5%, p<0.02 and -5.1%, p<0.04, respectively), together with HF (-16.8%, p<0.03).

Conclusions

The simultaneous assessment of DL_NO, DL_CO, DL_NO/DL_CO ratio, and Vc confirmed that long-lasting dyspnoea is related to hidden abnormalities in the lung capillary vasculature. These abnormalities can persist even after the complete resolution of parenchymal lesions regardless of the normality of lung volumes. Nebivolol, but not placebo, improves DS and Vc significantly. The mechanism suggested is the NO-mediated vasodilation via the β3 adrenoceptor stimulation of endothelial NO synthase. This hypothesis is supported by the substantial increase of eNO only assessed after nebivolol. As the nebivolol tolerability in these post-COVID normotensive patients was very good, the therapeutic use of nebivolol against residual and symptomatic signs of long-COVID can be suggested in out-patients.

Long-lasting dyspnoea in patients otherwise clinically and radiologically recovered from COVID pneumonia: a probe for checking persisting disorders in capillary lung volume as a cause

Background

During SARS-CoV-2 infection, diffuse alveolar damage and pulmonary microvascular abnormalities are critical events that result in gas exchange disorders of varying severity and duration. The only measure of carbon monoxide (CO) diffusing capacity (DL_CO) is unable to distinguish the alveolar from the vascular side of present and residual diffusive abnormalities, and measure of nitric oxide (NO) diffusing capacity (DL_NO) is also recommended. Dyspnoea, despite being understudied, persists in a significant proportion of patients for several weeks after hospital discharge. The goal of this study was to look into the underlying cause of long-term dyspnoea in patients who were "clinically and radiologically recovered" from COVID pneumonia by assessing DL_CO and DL_NO at the same time.

Methods

Patients of both genders, aged ≥18 years, who had a CT scan showing complete resolution of COVID-related parenchymal lesions were recruited consecutively. Spirometrical volumes, blood haemoglobin, SpO₂, DL_CO, DL_NO and capillary blood volume (Vc) were measured. Data from patients without dyspnoea (group A) and from patients still claiming dyspnoea after 12-16 weeks from their hospital discharge (group B) were statistically compared.

Results

Forty patients were recruited: 19 in group A and 21 in group B. Groups were comparable for their general characteristics and spirometrical volumes, that were in the normal range. Mean values for DL_CO, DL_NO and Vc were significantly and substantially lower than predicted only in patients of group B (p<0.011; p<0.0036; p<0.02; p<0.001, respectively). The DL_NO/ DL_CO ratio was higher in group B (p<0.001) and inversely correlated to Vc values (-0.3636).

Conclusions

The single-breath, simultaneous measurement of DL_CO, DL_NO, and Vc demonstrated that problems with blood gas exchange can persist even after parenchymal lesions have healed completely. Regardless of the normality of spirometric volumes, there was a significant reduction in lung capillary blood volume. In these patients, the cause of long-term dyspnoea may be related to hidden abnormalities in the vascular side of diffusive function. In the near future, novel therapeutic approaches against residual and symptomatic signs of long-COVID are possible.

The Effect of Maintenance Treatment with Erdosteine on Exacerbation Treatment and Health Status in Patients with COPD: A Post-Hoc Analysis of the RESTORE Dataset

Purpose

To explore the effect of erdosteine on COPD exacerbations, health-related quality of life (HRQoL), and subjectively assessed COPD severity.

Patients and methods

This post-hoc analysis of the RESTORE study included participants with COPD and spirometrically moderate (GOLD 2; post-bronchodilator forced expiratory volume in 1 second [FEV₁] 50‒79% predicted; n = 254), or severe airflow limitation (GOLD 3; post-bronchodilator FEV₁ 30‒49% predicted; n = 191) who received erdosteine 300 mg twice daily or placebo added to usual maintenance therapy for 12 months. Antibiotic and oral corticosteroid use was determined together with patient-reported HRQoL (St George’s Respiratory Questionnaire, SGRQ). Patient and physician subjective COPD severity scores (scale 0‒4) were rated at baseline, 6 and 12 months. Data were analyzed using descriptive statistics for exacerbation severity, COPD severity, and treatment group. Comparisons between treatment groups used Student’s t-tests or ANCOVA as appropriate.

Results

Among GOLD 2 patients, 43 of 126 erdosteine-treated patients exacerbated (7 moderate-to-severe exacerbations), compared to 62 of 128 placebo-treated patients (14 moderate-to-severe exacerbations). Among those with moderate-to-severe exacerbations, erdosteine-treated patients had a shorter mean duration of corticosteroid treatment (11.4 days vs 13.3 days for placebo, P = 0.043), and fewer patients required antibiotic treatment with/without oral corticosteroids (71.4% vs 85.8% for placebo, P < 0.001). Erdosteine-treated GOLD 2 patients who exacerbated showed significant improvements from baseline in SGRQ total scores and subjective disease severity scores (patient- and physician-rated), compared with placebo-treated patients regardless of exacerbation severity. Among GOLD 3 patients, there were no significant differences between treatment groups on any of these measures.

Conclusion

Adding erdosteine to the usual maintenance therapy of COPD patients with moderate airflow limitation reduced the number of exacerbations, the duration of treatment with corticosteroids and the episodes requiring treatment with antibiotics. Additionally, treatment with erdosteine improved HRQoL and patient-reported disease severity.

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Comparison of Consistency, Feasibility, and Convenience of a Novel Compact System for Assessing Lung Volumes and Carbon Monoxide Diffusing Capacity versus Whole Body Plethysmography

Background

The MiniBox+™ is an innovative technique for assessing lung volumes (LVs) and the diffusing capacity of the lung for carbon monoxide (DLco). Differently from the equipment needed for whole body plethysmography (WBP), the MiniBox+ is a small, transportable instrument, which derives total lung capacity (TLC) during tidal breathing by analyzing gas pressures and airflows immediately preceding and immediately following airway occlusions.

Aim

To compare the consistency and the feasibility of LV and DLco measurements between the two instruments in different lung function disorders, and their cost of execution.

Methods

Consecutive patients of both genders with obstructive and restrictive respiratory disorders were randomly recruited. LVs and DLco were measured by a randomized sequence. The failure risk, number of attempts to achieve the first reliable measurement, corresponding time spent, and costs per patient were compared.

Results

A total of 134 patients were enrolled: 42 asthmatics (32.1%), and 47 patients with obstructive (35.1%) and 44 with restrictive respiratory disorders (32.8%). The overall failure risk was 19.4% for WBP and 8.2% for the MiniBox+ (risk ratio=0.417, 95% CI 0.242 to 0.72). LVs and DLco values proved equal with both techniques, regardless of the patients’ age, sex, schooling level, and initial lung disorder. Number of attempts and total time spent in achieving the first reliable measurement were significantly lower with the MiniBox+. Mean cost per patient was €87.58 with WBP and €75.11 with the MiniBox+, with a mean saving of €12.33 (95% CI 5.93 to 18.73), mainly due to the saving in productivity loss.

Conclusion

LV and DLco measurements with the MiniBox+ were highly consistent with those obtained with WBP. The MiniBox+ proved easier to use (lower failure risk) and more convenient (lower execution costs) than WBP.

The contribution of patients' lung function to the inspiratory airflow rate achievable through a DPIs' simulator reproducing different intrinsic resistance rates

Background

The performance of DPIs depends on several physiological (patient-dependent) and technological (device-dependent) factors. The inspiratory airflow rate is the only active force generated and operating in the system for inducing the required pressure drop and eliciting the resistance-induced turbulence needed to disaggregate the powder through the device. The present study aimed to investigate in the most prevalent respiratory disorders whether and at what extent the inspiratory airflow rate achievable when inhaling through a DPIs’ simulator reproducing different intrinsic resistance regimens (low, mid, and high resistance) is affected by peculiar changes in lung function and/or can be predicted by any specific lung function parameter.

Methods

The inspiratory airflow rate was assessed in randomized order by the In-Check DIAL G16 at low, mid, and high resistance regimens in a sample of consecutive subjects at recruitment. Independent predictors of the probability to achieve the expected inhalation airflow rate were investigated by means of a multivariate logistic regression model, specific to the disease.

Results

A total of 114 subjects were recruited (asthmatics n=30; COPD n=50, restrictive patients n=16, and normal subjects n=18). The mean values of the expected inspiratory airflow rate achieved proved significantly different within the groups (p<0.0001), independently of sex and age. In asthmatics and in COPD patients, the mid-resistance regimen proved highly associated with the highest mean values of airflow rates obtained. Low- and high-resistance regimens were significantly less likely to consent to achieve the expected level of inspiratory airflow rate (OR<1 in all comparisons). Restrictive patients performed the lowest airflow rates at the low-resistance regimen (p<0.01). Unlike FEV¹, RV in asthmatics (OR=1.008); RV and I_Raw in COPD (OR=0.587 and OR=0.901, respectively), and FIF and TLC in restrictive patients (OR=1.041, and OR=0.962, respectively) proved the only sensitive predictors of the inspiratory airflow rate achievable at the different resistive regimens.

Conclusions

The intrinsic resistive regimen of DPIs can play a critical role. The patients’ lung function profile also affects the extent of their inhalation airflow rate. Some specific lung function parameters (such as: FIF; RV; I_Raw; TLC, but not FEV₁) may be regarded as specific predictors in real-life. In order to optimize the DPI choice, further to the device’s technology, also the current patients’ lung function should be properly investigated and carefully assessed.

Prevalence and clinical features of most frequent phenotypes in the Italian COPD population: the CLIMA Study

Background

Chronic obstructive pulmonary disease (COPD) is a complex, progressive respiratory condition characterized by heterogeneous clinical presentations (phenotypes). The aim of this study was to assess the prevalence of the main COPD phenotypes and match of each phenotype to the most fitting clinical and lung function profile.

Methods

the CLIMA (Clinical Phenotypes in Actual Clinical Practice) study was an observational, cross-sectional investigation involving twenty-four sites evenly distributed throughout Italy. Patients were tentatively grouped based on their history and claimed prevailing symptoms at recruitment: chronic cough (CB, suggesting chronic bronchitis); dyspnoea (possible emphysema components, E); recurrent wheezing (presuming asthma components, A). Variables collected were: anagraphics; smoking habit; history of asthma; claim of >1 exacerbations in the previous year; blood eosinophil count; total blood IgE and alpha¹ anti-trypsin (α¹-AT) levels; complete lung function, and the chest X-ray report. mMRC, CAT, BCS, EQ5d-5L were also used. The association between variables and phenotypes were checked by Chi-square test and multinomial logistic regression.

Results

The CB phenotype was prevalent (48.3%), followed by the E and the A phenotypes (38.8% and 12.8%, respectively). When dyspnoea was the prevailing symptom, the probability of belonging to the COPD-E phenotype was 3.40 times higher. Recurrent wheezing was mostly related to the COPD-A phenotype. Lung function proved more preserved in the COPD-CB phenotype. Smoke; n. exacerbations/year; VR, and BODE index were positively correlated with the COPD-E phenotype, while SpO₂, FEV₁/FVC, FEV₁/VC, and FEV₁ reversibility were negatively correlated. Lower DLco values were highly probative for the COPD-E phenotype (p<0.001). Conversely, smoke, wheezing, plasma eosinophils, FEV₁ reversibility, and DLco were positively correlated with the COPD-A phenotype. The probability of belonging to the COPD-A phenotype raised by 2.71 times for any increase of one unit in % plasma eosinophils (p<0.001). Also multiparametrical scores contributed to discriminate the three phenotypes.

Conclusion

The recognition of the main phenotypes of COPD can be effectively pursued by means of a few clinical and instrumental parameters, easy to obtain also in current daily practice. The phenotypical approach is crucial in the management of COPD as it allows to individualize the therapeutic strategy and to obtain more effective clinical outcomes.

Standard spirometry to assess emphysema in patients with chronic obstructive pulmonary disease: the Emphysema Severity Index (ESI)

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a generic term identifying a condition characterized by variable changes in peripheral airways and lung parenchyma. Standard spirometry cannot discriminate the relative role of conductive airways inflammatory changes from destructive parenchymal emphysema changes. The aim of this study was to quantify the emphysema component in COPD by a simple parameter (the Emphysema Severity Index - ESI), previously proved to reflect CT-assessed emphysema.

METHODS

ESI was obtained by fitting the descending limb of MEFV curves by a fully automated procedure providing a 0 to 10 score of emphysema severity. ESI was computed in COPD patients enrolled in the CLIMA Study.

RESULTS

The vast majority of ESI values ranged from 0 to 4, compatible with no-to-mild/moderate emphysema component. A limited proportion of patients showed ESI values >4, compatible with severe-to-very severe emphysema. ESI values were greatly dispersed within each GOLD class indicating that GOLD classification cannot discriminate emphysema and conductive airways changes in patients with similar airflow limitation. ESI and diffusing capacity (DLCO) were significantly correlated (p<0.001). However, the great dispersion in their correlation suggests that ESI and DLCO reflect partially different anatomo-functional determinants in COPD.

CONCLUSIONS

Airflow limitation has heterogenous determinants in COPD. Inflammatory and destructive changes may combine in CT densitometric alterations that cannot be detected by standard spirometry. ESI computation from spirometric data helps to define the prevailing pathogenetic mechanism underlying the measured airflow limitation. ESI could be a reliable advancement to select large samples of patients in clinical or epidemiological trials, and to compare different pharmacological treatments.

The Global Usability Score Short-Form for the simplified assessment of dry powder inhalers (DPIs) usability

Background

The choice of the Dry Powder Inhaler (DPI) to prescribe is a critical issue. The estimation of DPIs usability depends on the objective assessment of several indices related to both subjective and objective determinants. The Global Usability Score (GUS) Questionnaire is a comprehensive tool usable for checking, comparing, and ranking inhalers' usability objectively in real life, but it takes some time to fill.

Aim

The aim of this study was to favour the quicker check of DPIs usability in clinical practice by means of a simplified short-form GUS (S-GUS) Questionnaire, while maintaining the high specificity and sensitivity of the original, extended version of the Questionnaire (O-GUS questionnaire).

Methods

The usability of the six most prescribed DPIs was assessed in 222 patients with persistent airway obstruction and needing long-term inhalation treatments. LASSO regression and multicollinearity test were used to select the subset of questions of the O-GUS questionnaire, with the highest information power. Each item was then scored using the corresponding coefficient in the linear regression (normalized at 50 as the O-GUS score). Agreement between the original and the short-form questionnaire was evaluated using the Cohen's kappa statistic (κ). The overall S-GUS values obtained for each DPI were then compared to those from the O-GUS, in the same patients, using a Bayesian indirect comparison (IC) model.

Results

After the statistical selection of the items mostly contributing to the overall score, the novel S-GUS questionnaire consists of twelve items only. Nine items are related to patients' opinion before DPIs handling, and three to the nurse's assessment after DPIs practicality. O-GUS and S-GUS score were strongly correlated (R²=0.9843, p<0.0001) and the usability score calculated for each DPI by means of the O- and of S- GUS overlapped almost completely (κ=84.5%, 95% CI 81.3% to 89.2%). Furthermore, S-GUS was much faster to complete than O-GUS (mean time 6.1 vs 23.4 minutes, p<0.001). Estimates of S-GUS, obtained from the IC model, allowed to propose a simple classification of usability: "good" by GUS values >25; "pretty good" by values ≤25≥15, and "insufficient" by values <15.

Conclusions

The S-GUS proves as much specific and suitable as the extended O-GUS questionnaire in measuring DPIs usability, while maintaining the same high sensitivity. As the time required for its use is quite shorter, S-GUS is also particularly suitable and helpful in current clinical practice.

XII AIST 2018 Conference: “The thousand faces of cough: clinical and therapeutic updates”

This paper summarizes the presentations submitted for publication of the 12th AIST National Congress (Associazione Italiana Studio Tosse/Italian Association for Cough Study) entitled “The thousand facets of cough. A clinical and therapeutic update”, which occurred last February 2nd-3rd, 2018 in Bologna (Italy). It summarizes the contributions from leading experts of the sector, who, as in the previous editions, also this year have analyzed a problem too often underestimated which still has many dark sides as regards both the diagnosis and the therapy of cough. The Scientific Committee has chosen topics that had less space in previous editions and these are topical subjects representing a concrete opportunity for learning and comparison of opinions, as well as indispensable elements for the correct management of the symptoms. Hereby we report the abstracts of the works submitted for publication in this Meeting report. The main topics have covered Cough relationship with nerve vagus, ATP, air pollution, GERD, imaging, COPD, pediatric and therapy. Of particular interest it is the preliminary data on cough hydration ratio that shows a highly significant correlation between dehydration and cough.

Influenza and influenza-like syndromes: the subjects’ beliefs, the attitude to prevention and treatment, and the impact in Italian general population

Background: Influenza and influenza-like syndromes (I-LSs) are infectious diseases occurring on a seasonal basis which can lead to upper (URTI) and lower respiratory tract illness (LRTI) of different severity. The approach to these disorders is unfortunately not uniform. Aim of the study was to investigate real-life people beliefs, the attitude to  their prevention and treatment, and their impact in general population. Methods: A cross-sectional survey via Computer Assisted Telephone Interview (CATI) was carried out using a specific questionnaire investigating influenza episode rates, subjects behavior in case of influenza and I-LSs, and prescribed therapy. Results: 1,202 subjects completed the questionnaire: median age was 46, 49% male, 20% active smokers. 57% of respondents experienced at least one episode of influenza or I-LS in the previous 12 months; episodes were usually homemanaged, shorter than 2 weeks and more frequent in fall and winter (73% of the total). GP resulted the first health-care option (56%); almost 3% of respondents referred to the emergency room, and hospitalization occurred in 1%. Mucolytics resulted the most prescribed drugs (55%) followed by antibiotics and aerosol therapy (37–38%). Even if more than 70% of subjects considered vaccination essential, only 14% received influenza vaccination yearly and almost 60% had never received vaccination. Approximately 36% of respondents regarded homeopathy (namely Oscillococcinum) as an helpful alternative because of perceived as safer. Conclusions: Seasonal prevalence of I-LSs and influenza partially overlap. As virus identification is not a common procedure in daily practice, only a clinical discrimination is possible. Antibiotic prescription is still too high and largely inappropriate. Influenza vaccination is strongly encouraged, but different strategies are also used. Other approaches are receiving increasing attention in general population, and subjects’ willingness to spend out-of-pocket for effective remedies is also increasing. The discrepancy between subjects’ beliefs and health care actions likely reflects the insufficiency of institutional preventive strategies. In general, the approach to influenza and I-LSs appear variable and highly dependent of subjects’ and their GPs’ cultural beliefs.

Effect of Erdosteine on COPD Exacerbations in COPD Patients with Moderate Airflow Limitation

Background

The RESTORE study, a multi-national randomized, placebo-controlled study, showed that erdosteine - a muco-active antioxidant that modulates bacterial adhesiveness - reduced the rate and duration of exacerbations in moderate and severe COPD with a history of exacerbations. How much benefit patients with less severe disease experience when taking this drug remains unclear.

Methods

This post hoc analysis of the 254 RESTORE participants with spirometrically-defined moderate COPD (post-bronchodilator forced expiratory volume in 1 second [FEV₁] 50‒79% predicted) examined exacerbation rate and duration, time to first exacerbation, and exacerbation-free time. Data were analyzed using descriptive statistics and comparisons between treatment groups used Wilcoxon rank-sum tests, Mann-Whitney U-tests, or log rank tests.

Results

Patients with moderate COPD received erdosteine 300 mg twice daily (n=126) or placebo (n=128) added to usual COPD therapy for 12 months. During this time, there were 53 exacerbations in the erdosteine group and 74 in the placebo group, with 42.1% and 57.8% of patients, respectively, experiencing an exacerbation. There was a 47% reduction in the mean exacerbation rate with erdosteine compared to placebo (0.27 vs 0.51 exacerbations per-patient per-year, respectively, P=0.003), and a 58.3% reduction in the mild exacerbation rate (0.23 vs 0.53 mild exacerbations per-patient per-year, P=0.001). Mean duration of exacerbations was 26% shorter in erdosteine-treated patients (9.1 vs 12.3 days for placebo, P=0.022), with significant reductions in the duration of mild and moderate-to-severe exacerbations. Mean time to first exacerbation was prolonged by 7.7% (182 days for erdosteine vs 169 days for placebo, P<0.001) and the mean exacerbation-free time was increased by 51 days (279 days for erdosteine vs 228 days for placebo; P<0.001).

Conclusion

These results indicate that adding erdosteine to usual COPD maintenance therapy reduces the number of mild, and duration of all, exacerbations in patients with moderate COPD and a history of exacerbations.

Correction to: Patients’ usability of seven most used dry-powder inhalers in COPD

Correction to: Multidiscip RespirMed (2019) 14:30 https://doi.org/10.1186/s40248-019-0192-5After publication of the Original research article [1] it was brought to our attention that the sentence at the bottom of the section entitled Discussion (pag 6 of 9, just below Fig. 4) must be corrected as follows: “In real life, DPIs are highly prescribed in Italian COPD patients being their prescription usually independent of their known basic characteristics and technical differences, such as the different number of main actions required for their actuation (7 for Breezhaler, 4 for Turbohaler, and 3 for the remaining devices),” and their intrinsic resistance, ranging from 0.017 kPa0.5 L/min to 0.039 kPa0 .5 L/min [28, 29].

Patients' usability of seven most used dry-powder inhalers in COPD

Introduction: Inhalation devices affect both the effectiveness and the therapeutic outcomes in persistent airway obstruction, and the effects are largely independent of the drug(s) assumed. Usability is a complex and comprehensive indicator of inhalation devices’ performance. The Global Usability Score (GUS) Questionnaire is an investigational tool designed to assess objectively the patients’-related and unrelated domains of devices’ usability. Methods: The GUS questionnaire was administered to all consecutive COPD patients referring for three months to the Lung Unit of CEMS Specialist Centre (Verona, Italy). The usability of seven Dry Powder Inhalers (DPIs) indicated as appropriate in COPD was tested and compared: Breezhaler, Diskus, Ellipta, Genuair, Nexthaler, Spiromax, and Turbohaler. Patients were divided in two groups, checked separately, according to their DPIs previous experience. A Bayesian Indirect Comparison (IC) model was built to assess “global usability” ranking. Results: A total of 103 patients were investigated: 74 patients already instructed in DPI use and 29 naive to DPIs. IC analysis proved Ellipta as the device characterized by the highest usability, while Breezhaler the device with the lowest usability in both groups of COPD patients (both with probability > 90%). Moreover, Turbohaler ranked second according to the Bayesian pooling, followed by Diskus, Spiromax, Nexthaler, and Genuair in patients already instructed in DPI use, while the ranking order was not as much well defined in naïve patients, likely due to their too small sample. Conclusions: Usability is a multifaceted indicator that contributes to assess the factual DPIs’ convenience in real life. DPIs are characterized by different levels of real-life usability, which can be checked, compared and ranked by means of the GUS score.

Patients' usability of seven most used dry-powder inhalers in COPD

Introduction

Inhalation devices affect both the effectiveness and the therapeutic outcomes in persistent airway obstruction, and the effects are largely independent of the drug(s) assumed. Usability is a complex and comprehensive indicator of inhalation devices’ performance. The Global Usability Score (GUS) Questionnaire is an investigational tool designed to assess objectively the patients’-related and unrelated domains of devices’ usability.

Methods

The GUS questionnaire was administered to all consecutive COPD patients referring for three months to the Lung Unit of CEMS Specialist Centre (Verona, Italy). The usability of seven Dry Powder Inhalers (DPIs) indicated as appropriate in COPD was tested and compared: Breezhaler, Diskus, Ellipta, Genuair, Nexthaler, Spiromax, and Turbohaler. Patients were divided in two groups, checked separately, according to their DPIs previous experience. A Bayesian Indirect Comparison (IC) model was built to assess “global usability” ranking.

Results

A total of 103 patients were investigated: 74 patients already instructed in DPI use and 29 naive to DPIs. IC analysis proved Ellipta as the device characterized by the highest usability, while Breezhaler the device with the lowest usability in both groups of COPD patients (both with probability > 90%). Moreover, Turbohaler ranked second according to the Bayesian pooling, followed by Diskus, Spiromax, Nexthaler, and Genuair in patients already instructed in DPI use, while the ranking order was not as much well defined in naïve patients, likely due to their too small sample.

Conclusions

Usability is a multifaceted indicator that contributes to assess the factual DPIs’ convenience in real life. DPIs are characterized by different levels of real-life usability, which can be checked, compared and ranked by means of the GUS score.

Electronic supplementary material

The online version of this article (10.1186/s40248-019-0192-5) contains supplementary material, which is available to authorized users.

Acute cough in Italian children: parents' beliefs, approach to treatment, and the family impact

Background

Acute cough is the most common symptom among children in primary care, but the impact of cough episodes was never investigated in Italian families.

Methods

A cross-sectional telephone survey was conducted on a representative sample of Italian families, randomly selected from general population; a specific and validated questionnaire was used.

Results

The sample (604 calls) was uniform by geographical distribution, and by children age and gender. Mean cough episode was 3.1/year, they were short lasting (only 4.7% > 2 weeks). Independent predictors of children cough episodes were parents’ active smoking habit and work (p < 0.05). The mean nursery/school absenteeism was mostly < 7 days, but of a 7–15-day duration in near 30% of cases. The pediatrician was contacted immediately only by 25% of parents and a second consultation (mostly a lung physician) usually occurred after 2–3 weeks of cough. Meanwhile, home/pharmacist suggested remedies were adopted in 50–70% of cases. Usual prescriptions were mucolytics (85.8%), antitussive agents (55.6%), non-steroideal anti-inflammatory drugs (33.8%), antibiotics (regularly or episodically 80%), and corticosteroids (systemic steroids in less than 50%, but via aerosol in more than 80% of cases). Moreover, pediatricians claimed to use homeopathic drugs regularly or episodically in almost 50%. The respondents’ willingness to spend out-of-pocket for an “effective remedy” against cough was of € 20 (>€ 30 in 18.4% of cases).

Conclusions

Parents’ actions against cough episodes were variable, depending on their beliefs, smoking habit, and occupational status. The parents’ perceived efficacy of usual prescriptions is poor, and their willingness to pay out-of-pocket for an “effective remedy” against cough is high. The interest for alternative treatments is not negligible in these circumstances.

Electronic supplementary material

The online version of this article (10.1186/s40248-019-0180-9) contains supplementary material, which is available to authorized users.

Acute cough in Italian children: parents’ beliefs, approach to treatment, and the family impact

Background: Acute cough is the most common symptom among children in primary care, but the impact of cough episodes was never investigated in Italian families. Methods: A cross-sectional telephone survey was conducted on a representative sample of Italian families, randomly selected from general population; a specific and validated questionnaire was used. Results: The sample (604 calls) was uniformby geographical distribution, and by children age and gender. Mean cough episode was 3.1/year, they were short lasting (only 4.7% > 2 weeks). Independent predictors of children cough episodes were parents’ active smoking habit and work (p < 0.05). The mean nursery/school absenteeism was mostly < 7 days, but of a 7–15-day duration in near 30% of cases. The pediatrician was contacted immediately only by 25% of parents and a second consultation (mostly a lung physician) usually occurred after 2–3 weeks of cough. Meanwhile, home/pharmacist suggested remedies were adopted in 50–70% of cases. Usual prescriptions were mucolytics (85.8%), antitussive agents (55.6%), non-steroideal anti-inflammatory drugs (33.8%), antibiotics (regularly or episodically 80%), and corticosteroids (systemic steroids in less than 50%, but via aerosol in more than 80% of cases). Moreover, pediatricians claimed to use homeopathic drugs regularly or episodically in almost 50%. The respondents’ willingness to spend out-of-pocket for an “effective remedy” against cough was of € 20 (>€ 30 in 18.4% of cases). Conclusions: Parents’ actions against cough episodes were variable, depending on their beliefs, smoking habit, and occupational status. The parents’ perceived efficacy of usual prescriptions is poor, and their willingness to pay out-ofpocket for an “effective remedy” against cough is high. The interest for alternative treatments is not negligible in these circumstances.

Fluticasone furoate/vilanterol 92/22 µg once a day: a 12-month study on outcomes in mild to moderate asthma

Background:

Fluticasone furoate/vilanterol (FF/V) is an effective long-acting β2 agonist/inhaled corticosteroid combination for managing persistent bronchial asthma. The aim of the study was to assess the outcomes achievable in patients with mild to moderate asthma receiving FF/V 92/22 µg once daily for 12 months.

Methods:

Data were automatically and anonymously obtained from the institutional database: forced expiratory volume in 1 s predicted values; the exacerbation and hospitalization rates; days of hospitalization; general practitioner (GP) or specialist visits; days of inactivity; courses of systemic steroids or antibiotics were recorded at baseline and after 3, 6 and 12 months of treatment. The overall adherence to treatment was also calculated. Analysis of variance was used for checking the trends of variables. The improvement in lung function was significant (p < 0.001) and time dependent. The mean (±standard error) exacerbation rate per patient changed from 1.05 (±0.16) at baseline to 0.28 (±0.07) after 3 months, 0.33 (±0.08) after 6 months and 0.18 (±0.08) after 12 months (p < 0.001). The mean hospitalization rate per patient changed from 0.30 (±0.07) at baseline to 0.08 (±0.04) after 3 months, 0.10 (±0.05) after 6 months and 0.03 (±0.03) after 12 months (p < 0.001). Also mean duration of hospitalization and days of inactivity were reduced over time (p < 0.001). GP visits were also reduced, together with specialist visits (both p < 0.001). Steroid and antibiotic courses dropped significantly (p < 0.001 and p < 0.001, respectively). Moreover, changes in all outcomes considered proved time dependent, particularly over the second semester. Finally, over time, adherence to treatment was high.

Conclusions:

The once-daily inhalation of combined FF/V 92/22 µg optimized systematically the exacerbation and hospitalization rates in mild to moderate asthma, together with all other outcomes over time. The effectiveness of FF/V 92/22 µg once daily proved to be time dependent over the period of the study.

Cost-effectiveness of the COPD Patient Management European Trial home-based disease management program

Purpose

Efficient management of COPD represents an international challenge. Effective management strategies within the means of limited health care budgets are urgently required. This analysis aimed to evaluate the cost-effectiveness of a home-based disease management (DM) intervention vs usual management (UM) in patients from the COPD Patient Management European Trial (COMET).

Methods

Cost-effectiveness was evaluated in 319 intention-to-treat patients over 12 months in COMET. The analysis captured unplanned all-cause hospitalization days, mortality, and quality-adjusted life expectancy. Costs were evaluated from a National Health Service perspective for France, Germany, and Spain, and in a pooled analysis, and were expressed in 2015 Euros (EUR). Quality of life was assessed using the 15D health-related quality-of-life instrument and mapped to utility scores.

Results

Home-based DM was associated with improved mortality and quality-adjusted life expectancy. DM and UM were associated with equivalent direct costs (DM reduced costs by EUR −37 per patient per year) in the pooled analysis. DM was associated with lower costs in France (EUR −806 per patient per year) and Spain (EUR −51 per patient per year), but higher costs in Germany (EUR 391 per patient per year). Evaluation of cost per death avoided and cost per quality-adjusted life year (QALY) gained showed that DM was dominant (more QALYs and cost saving) in France and Spain, and cost-effective in Germany vs UM. Nonparametric bootstrapping analysis, assuming a willingness-to-pay threshold of EUR 20,000 per QALY gained, indicated that the probability of home-based DM being cost-effective vs UM was 87.7% in France, 81.5% in Spain, and 75.9% in Germany.

Conclusion

Home-based DM improved clinical outcomes at equivalent cost vs UM in France and Spain, and in the pooled analysis. DM was cost-effective in Germany with an incremental cost-effectiveness ratio of EUR 2,541 per QALY gained. The COMET home-based DM intervention could represent an attractive alternative to UM for European health care payers.

COPD: The Annual Cost-Of-Illness during the Last Two Decades in Italy, and Its Mortality Predictivity Power

Chronic obstructive pulmonary disease (COPD) is a progressive pathological condition characterized by a huge epidemiological and socioeconomic impact worldwide. In Italy, the actual annual cost of COPD was assessed for the first time in 2002: the mean cost per patient per year was €1801 and ranged from €1500 to €3912, depending on COPD severity. In 2008, the mean annual cost per patient was €2723.7, ranging from €1830.6 in mild COPD up to €5451.7 in severe COPD. In 2015, it was €3291, which is 20.8% and 82.7% higher compared to the costs estimated in 2008 and 2002, respectively. In all these studies, the major cost component was direct costs, in particular hospitalization costs due to exacerbations, which corresponded to 59.9% of the total cost and 67.2% of direct costs, respectively. When the annual healthcare expenditure per patient is related to the length of survival by means of the PRO-BODE Index (PBI, which is the implementation of the well-known BODE Index with costs due to annual exacerbations and/or hospitalizations), the annual cost of care proved much more strictly and inversely proportional to patients' survival at three years, with the highest regression coefficient (r = -0.58) of all the multidimensional indices presently available, including the BODE Index (r = -021). In Italy, even though tobacco smoking has progressively declined by up to 21% in the general population, the economic impact of COPD has shown relentless progression over the last two decades, confirming that the present national health system organization is still insufficient for facing the issue of chronic diseases, in particular COPD, effectively. The periodic assessment of costs is an effective instrument for care providers in predicting COPD mortality, and for decision makers for updating and planning their social, economic, and political strategies.

XII AIST 2018 Conference: “The thousand faces of cough: clinical and therapeutic updates”

This paper summarizes the presentations submitted for publication of the 12^th AIST National Congress (Associazione Italiana Studio Tosse/Italian Association for Cough Study) entitled “The thousand facets of cough. A clinical and therapeutic update”, which occurred last February 2^nd-3^rd, 2018 in Bologna (Italy). It summarizes the contributions from leading experts of the sector, who, as in the previous editions, also this year have analyzed a problem too often underestimated which still has many dark sides as regards both the diagnosis and the therapy of cough. The Scientific Committee has chosen topics that had less space in previous editions and these are topical subjects representing a concrete opportunity for learning and comparison of opinions, as well as indispensable elements for the correct management of the symptoms.

Hereby we report the abstracts of the works submitted for publication in this Meeting report.

The main topics have covered Cough relationship with nerve vagus, ATP, air pollution, GERD, imaging, COPD, pediatric and therapy. Of particular interest it is the preliminary data on cough hydration ratio that shows a highly significant correlation between dehydration and cough.

Cost of acute cough in Italian children

Objectives

Acute cough is the most common symptom among children in primary care, but the economic impact of cough episodes has never been investigated in Italian families.

Materials and methods

A cross-sectional telephone survey was conducted on a representative sample of Italian families, randomly selected from general population. Collected data were analyzed to evaluate the economic impact of cough episodes according to, first, Italian Family Perspective and, second, National Health System Perspective (NHS-P). The costs considered in the analysis were the cost of drugs used (antibiotics, corticosteroids, antitussive drugs, and aerosol therapy) and the cost of child care during nursery/school absenteeism.

Results

Six hundred four valid questionnaires were analyzed: mean age of children is 7 years (SD=3.3) and that of parents is 40 years (SD=6.2). Mean rate of cough episodes was 3.15/year, and in general, they were short lasting (94.6%, <2 weeks). Nursery/school absenteeism was mostly <7 days (63.2%), but almost 30% of respondents declared 7–15 days. The respondents’ willingness to spend out-of-pocket for an “effective remedy” against cough was an average of €20 (>€30 in 19.7% of cases). The overall economic impact on Italian families was estimated as €1,204 (SD=€88); it resulted in a cost per cough episode equal to €337, mainly due to nursery/school absenteeism (94.6%), whereas pharmaceutical expenditure was marginal (5.4%).

Conclusion

Cough episodes are acute (lasting <1 week, mainly) but frequent, causing a considerable socioeconomic impact. The pharmaceutical costs are in line with parents’ willingness to pay but these costs result negligible when compared to those related to school absenteeism, generally not perceived by parents.

Correction to: Fluticasone furoate/Vilanterol 92/22 μg once-a-day vs Beclomethasone dipropionate/Formoterol 100/6 μg b.I.D.: a 12-month comparison of outcomes in mild-to-moderate asthma

Correction to: Multidisciplinary Respiratory Medicine (2018) 13:18 DOI: 10.1186/s40248-018-0131-x After publication of the Original research article [1] it was brought to our attention that the sentence at pag 6 (between Fig. 3 and Fig. 4)) must be corrected as follows: “The mean duration of inactivity was 2.88 (0.63) at baseline; 1.53 (0.27) after 3; 1.40 (0.27) after 6, and 1.45 days (0.58) after twelve months (Anova: p = 0.11) in group A, while the corresponding duration in group B was 3.35 (0.63) at baseline; 0.60 (0.19) after 3; 1.10 (0.21) after 6, and 0.83 days (0.39) after 12 months (Anova; p <0.001), respectively.” In addition at pag. 7 Fig. 5 entitled “Changes in mean duration of inactivity/p. over 12 months” must be substituted with the new Fig. 5 because there is a mistake regarding anova p = 0.11 and consequently in the whole image. This Correction shows the revised Fig. 5. The original article has been updated.

Fluticasone furoate/Vilanterol 92/22 μg once-a-day vs Beclomethasone dipropionate/Formoterol 100/6 μg b.I.D.: a 12-month comparison of outcomes in mild-to-moderate asthma

Background: Bronchial asthma is an inflammatory disease of the airways. Beclomethasone dipropionate/Formoterol (BDP/F) and Fluticasone furoate/Vilanterol (FF/V) are two of the most effective LABA/ICS combinations for managing persistent bronchial asthma. Aim of the study was to compare the outcomes achieved in mild-tomoderate asthma patients assuming BDP/F 100/6 μg b.i.d. (Group A) or FF/V 92/22 μg once-daily (Group B) for 12-months. No head-to-head long-term comparison is available at present. Methods: Data were automatically and anonymously obtained from the institutional database: FEV1% predicted values; the exacerbation and hospitalization rates; days of hospitalization; GP and/or specialist visits; days of inactivity; courses of systemic steroids and/or antibiotics were recorded at baseline and after 3, 6 and 12 months of both treatments. The overall adherence to treatments was also calculated. The propensity score method was used for matching and comparing the two cohorts of patients; Anova and Wilcoxon tests were used for checking the trends and time-to-time comparisons over the period; statistical significance was accepted for p < 0.05. Results: The PS-matching process returned a cohort of 40 group A patients matched with 40 patients of group B, fully comparable for demographics, clinical characteristics, and comorbidities. The improvement in lung function was significant in both groups (p < 0.001), even if it was significantly higher and time-dependent in group B. The mean (±SE) exacerbation rate/patient changed from 0.63 (±0.13) at baseline to 0.53 (±0.12) after three; to 0.58 (±0.13) after six, and to 0.60 (±0.18) after twelve months in group A (p = ns), while from of 1.05 (±0.16) at baseline, to 0.28 (±0.07) after three; to 0.33 (±0.08) after six, and to 0.18 (±0.08) after twelve months in group B (p < 0.001), respectively. The mean hospitalization rate/patient changed from 0.25 ± 0.07 at baseline to 0.15 (±0.06) after three; to 0.08 (±0.04) after six, and to 0.13 (±0.05) after twelve months in group A (p = ns), while from 0.30 (±0.07) at baseline to 0.08 (±0.04) after three; to 0.10 (±0.05) after six, and to 0.03 (±0.03) after twelve months in group B (p < 0.001), respectively. Also mean duration of hospitalization and days of inactivity were in favour of FF/V treatment over time (in both cases p < 0.001). GP’s visits were reduced by both treatments (p < 0.007 in group A and p < 0.001 in group B, respectively, while Specialist’s visits only dropped during FF/V (p < 0.001). Steroid and antibiotic courses were significantly reduced by both treatments, even if more systematically in group B (p < 0.001 vs p < 0.007, and p < 0.001 vs p < 0.044, respectively). Moreover, changes in all outcomes considered proved time-dependent during the FF/V treatment only, particularly over the second semester. Finally, the overtime adherence to treatment was higher by 22 days during FF/V . Conclusions: Both the ICS/LABA combinations proved effective, even if characterized by different patterns of effectiveness either in terms of lung function and of long-term clinical outcomes. Only the once-daily inhalation of combined FF/V 92/22 μg once-daily optimized systematically the exacerbation and hospitalization rates in mild-tomoderate asthma, together with all other outcomes over time. The effectiveness of FF/V 92/22 once-daily μg proved progressive and time-dependent over the twelve-month period of the study, and associated to a higher adherence to treatment.

Influenza and influenza-like syndromes: the subjects' beliefs, the attitude to prevention and treatment, and the impact in Italian general population

Background

Influenza and influenza-like syndromes (I-LSs) are infectious diseases occurring on a seasonal basis which can lead to upper (URTI) and lower respiratory tract illness (LRTI) of different severity. The approach to these disorders is unfortunately not uniform. Aim of the study was to investigate real-life people beliefs, the attitude to their prevention and treatment, and their impact in general population.

Methods

A cross-sectional survey via Computer Assisted Telephone Interview (CATI) was carried out using a specific questionnaire investigating influenza episode rates, subjects behavior in case of influenza and I-LSs, and prescribed therapy.

Results

1,202 subjects completed the questionnaire: median age was 46, 49% male, 20% active smokers. 57% of respondents experienced at least one episode of influenza or I-LS in the previous 12 months; episodes were usually home-managed, shorter than 2 weeks and more frequent in fall and winter (73% of the total). GP resulted the first health-care option (56%); almost 3% of respondents referred to the emergency room, and hospitalization occurred in 1%. Mucolytics resulted the most prescribed drugs (55%) followed by antibiotics and aerosol therapy (37-38%). Even if more than 70% of subjects considered vaccination essential, only 14% received influenza vaccination yearly and almost 60% had never received vaccination. Approximately 36% of respondents regarded homeopathy (namely Oscillococcinum) as an helpful alternative because of perceived as safer.

Conclusions

Seasonal prevalence of I-LSs and influenza partially overlap. As virus identification is not a common procedure in daily practice, only a clinical discrimination is possible. Antibiotic prescription is still too high and largely inappropriate. Influenza vaccination is strongly encouraged, but different strategies are also used. Other approaches are receiving increasing attention in general population, and subjects' willingness to spend out-of-pocket for effective remedies is also increasing. The discrepancy between subjects' beliefs and health care actions likely reflects the insufficiency of institutional preventive strategies. In general, the approach to influenza and I-LSs appear variable and highly dependent of subjects' and their GPs' cultural beliefs.

COMET: a multicomponent home-based disease-management programme versus routine care in severe COPD

The COPD Patient Management European Trial (COMET) investigated the efficacy and safety of a home-based COPD disease management intervention for severe COPD patients.

The study was an international open-design clinical trial in COPD patients (forced expiratory volume in 1 s <50% of predicted value) randomised 1:1 to the disease management intervention or to the usual management practices at the study centre. The disease management intervention included a self-management programme, home telemonitoring, care coordination and medical management. The primary end-point was the number of unplanned all-cause hospitalisation days in the intention-to-treat (ITT) population. Secondary end-points included acute care hospitalisation days, BODE (body mass index, airflow obstruction, dyspnoea and exercise) index and exacerbations. Safety end-points included adverse events and deaths.

For the 157 (disease management) and 162 (usual management) patients eligible for ITT analyses, all-cause hospitalisation days per year (mean±sd) were 17.4±35.4 and 22.6±41.8, respectively (mean difference −5.3, 95% CI −13.7 to −3.1; p=0.16). The disease management group had fewer per-protocol acute care hospitalisation days per year (p=0.047), a lower BODE index (p=0.01) and a lower mortality rate (1.9% versus 14.2%; p<0.001), with no difference in exacerbation frequency. Patient profiles and hospitalisation practices varied substantially across countries.

The COMET disease management intervention did not significantly reduce unplanned all-cause hospitalisation days, but reduced acute care hospitalisation days and mortality in severe COPD patients.

COPD management as a model for all chronic respiratory conditions: report of the 4th Consensus Conference in Respiratory Medicine

Background

Non-communicable diseases (NCDs) kill 40 million people each year. The management of chronic respiratory NCDs such as chronic obstructive pulmonary disease (COPD) is particularly critical in Italy, where they are widespread and represent a heavy burden on healthcare resources. It is thus important to redefine the role and responsibility of respiratory specialists and their scientific societies, together with that of the whole healthcare system, in order to create a sustainable management of COPD, which could become a model for other chronic respiratory conditions.

Methods

These issues were divided into four main topics (Training, Organization, Responsibilities, and Sustainability) and discussed at a Consensus Conference promoted by the Research Center of the Italian Respiratory Society held in Rome, Italy, 3–4 November 2016.

Results and conclusions

Regarding training, important inadequacies emerged regarding specialist training - both the duration of practical training courses and teaching about chronic diseases like COPD. A better integration between university and teaching hospitals would improve the quality of specialization. A better organizational integration between hospital and specialists/general practitioners (GPs) in the local community is essential to improve the diagnostic and therapeutic pathways for chronic respiratory patients. Improving the care pathways is the joint responsibility of respiratory specialists, GPs, patients and their caregivers, and the healthcare system. The sustainability of the entire system depends on a better organization of the diagnostic-therapeutic pathways, in which also other stakeholders such as pharmacists and pharmaceutical companies can play an important role.

Effect of erdosteine on the rate and duration of COPD exacerbations: the RESTORE study

Oxidative stress contributes to chronic obstructive pulmonary disease (COPD) exacerbations and antioxidants can decrease exacerbation rates, although we lack data about the effect of such drugs on exacerbation duration.

The RESTORE (Reducing Exacerbations and Symptoms by Treatment with ORal Erdosteine in COPD) study was a prospective randomised, double-blind, placebo-controlled study, enrolling patients aged 40–80 years with Global Initiative for Chronic Obstructive Lung Disease stage II/III. Patients received erdosteine 300 mg twice daily or placebo added to usual COPD therapy for 12 months. The primary outcome was the number of acute exacerbations during the study.

In the pre-specified intention-to-treat population of 445 patients (74% male; mean age 64.8 years, forced expiratory volume in 1 s 51.8% predicted) erdosteine reduced the exacerbation rate by 19.4% (0.91 versus. 1.13 exacerbations·patient⁻¹·year⁻¹ for erdosteine and placebo, respectively; p=0.01), due to an effect on mild events; the reduction in the rate of mild exacerbations was 57.1% (0.23 versus 0.54 exacerbations·patient⁻¹·year⁻¹ for erdosteine and placebo, respectively; p=0.002). No significant difference was observed in the rate of moderate and severe exacerbations (0.68 versus 0.59 exacerbations·patient⁻¹·year⁻¹ for erdosteine and placebo, respectively; p=0.054) despite a trend in favour of the comparison group. Erdosteine decreased the exacerbation duration irrespective of event severity by 24.6% (9.55 versus 12.63 days for erdosteine and placebo, respectively; p=0.023). Erdosteine significantly improved subject and physician subjective severity scores (p=0.022 and p=0.048, respectively), and reduced the use of reliever medication (p<0.001), but did not affect the St George's Respiratory Questionnaire score or the time to first exacerbation.

In patients with COPD, erdosteine can reduce both the rate and duration of exacerbations. The percentage of patients with adverse events was similar in both the placebo and erdosteine treatment groups.

RESTORE study: erdosteine reduces both rate and duration of COPD exacerbations with a placebo-like safety profilehttp://ow.ly/BbGI30dRdEt

Instant velocity and consistency of emitted cloud change by the different levels of canister filling with Metered Dose Inhalers (MDIs), but not with Soft Mist Inhalers (SMIs): a bench study

Background: Inhalation is the preferred route for respiratory drug delivery, but several factors contribute to the variability of the respirable dose fraction. Instant velocity and the dynamic characteristics of the droplet cloud represent crucial factors. Aim was to measure and compare the instant velocity and the consistency of emitted cloud from five different MDIs (A - Salbutamol sulphate 100mcg, GSK; B - Salbutamol sulphate 100mcg, Valeas; C - Salmeterol xinafoate/Fluticasone propionate 25/125mcg, GSK; D - Formoterol fumarate/Bechlomethasone propionate 6/100mcg, Chiesi; E - Formoterol fumarate/Fluticasone dipropionate 5/125mcg, Mundipharma) and one SMI (Tiotropium bromide 5mcg, Boehringer Ingelheim), at different distance from the nozzle and canister filling. Methods: Measurements were made at 90, 50, and 10% of canister filling, and at 5, 10, and 20 cm from the nozzle, for a total of 972 puffs. A high speed video photography protocol was adopted and high speed cameras (1.200 frames/ sec.) were used. Data were acquired by means of specialized softwares. Temperature, humidity, and vibrations occurrence were strictly controlled during measurements. Statistics: Anova and p < 0.05 were accepted as the minimum significance level. Results: MDIs generated different Instant velocities: MDI B generated the highest, while MDI A the lowest. As expected, velocity decreased in proportion to the distance from the nozzle. Except with MDI C, instant velocity decreased significantly over the first 50% of canister emptying, but dropped by >33% at 90% of emptying with all other MDIs (p < 0–037; p < 0.001; p < 0.005, and p < 0.001, respectively). Instant velocity was extremely lower (p < 0.001) and constant for all levels of canister filling (p = ns) with SMI. All MDIs had a very fast jet phase, ranging 0.01–0.03 s at 10 cm, and 0.03–0.05 s at 20 cm from the nozzle, without any significant difference from each other (p= ns). MDIs generated a cloud similarly tight (p = ns) at 10 and 20 cm from the nozzle, while it was extremely wider and constant with the SMI (p = 0–001). Also the cloud turbulence was minimized during the SMI emission. Discussion and Conclusions: MDIs are characterized by a substantial variability in both their instant velocity and consistency of the emitted cloud at different levels of canister filling. SMI generates a much slower soft mist cloud which is constantly homogeneous and independent of canister emptying. These peculiarities assessed at bench are suggesting a higher dose consistency and a much more effective therapeutic performance also in real life.

Instant velocity and consistency of emitted cloud change by the different levels of canister filling with Metered Dose Inhalers (MDIs), but not with Soft Mist Inhalers (SMIs): a bench study

Background

Inhalation is the preferred route for respiratory drug delivery, but several factors contribute to the variability of the respirable dose fraction. Instant velocity and the dynamic characteristics of the droplet cloud represent crucial factors. Aim was to measure and compare the instant velocity and the consistency of emitted cloud from five different MDIs (A - Salbutamol sulphate 100mcg, GSK; B - Salbutamol sulphate 100mcg, Valeas; C - Salmeterol xinafoate/Fluticasone propionate 25/125mcg, GSK; D - Formoterol fumarate/Bechlomethasone propionate 6/100mcg, Chiesi; E - Formoterol fumarate/Fluticasone dipropionate 5/125mcg, Mundipharma) and one SMI (Tiotropium bromide 5mcg, Boehringer Ingelheim), at different distance from the nozzle and canister filling.

Methods

Measurements were made at 90, 50, and 10% of canister filling, and at 5, 10, and 20 cm from the nozzle, for a total of 972 puffs. A high speed video photography protocol was adopted and high speed cameras (1.200 frames/sec.) were used. Data were acquired by means of specialized softwares. Temperature, humidity, and vibrations occurrence were strictly controlled during measurements. Statistics: Anova and p < 0.05 were accepted as the minimum significance level.

Results

MDIs generated different Instant velocities: MDI B generated the highest, while MDI A the lowest. As expected, velocity decreased in proportion to the distance from the nozzle. Except with MDI C, instant velocity decreased significantly over the first 50% of canister emptying, but dropped by >33% at 90% of emptying with all other MDIs (p < 0–037; p < 0.001; p < 0.005, and p < 0.001, respectively). Instant velocity was extremely lower (p < 0.001) and constant for all levels of canister filling (p = ns) with SMI. All MDIs had a very fast jet phase, ranging 0.01–0.03 s at 10 cm, and 0.03–0.05 s at 20 cm from the nozzle, without any significant difference from each other (p = ns). MDIs generated a cloud similarly tight (p = ns) at 10 and 20 cm from the nozzle, while it was extremely wider and constant with the SMI (p = 0–001). Also the cloud turbulence was minimized during the SMI emission.

Discussion and Conclusions

MDIs are characterized by a substantial variability in both their instant velocity and consistency of the emitted cloud at different levels of canister filling. SMI generates a much slower soft mist cloud which is constantly homogeneous and independent of canister emptying. These peculiarities assessed at bench are suggesting a higher dose consistency and a much more effective therapeutic performance also in real life.

Survey on attitudes of Italian pediatricians toward cough

CONTEXT

Children's cough is a daily concern for most pediatricians. The management of both acute and chronic cough requires a systematic and comprehensive approach. Despite the approved protocols for management, the pediatric assessment of cough and the corresponding prescribing attitude frequently do not fit these protocols, which can be affected by parental suggestions - sometimes substantially.

OBJECTIVE

The objective of this study was to investigate both the perception and the behavior of a representative sample of Italian pediatricians toward cough in real life.

METHODS

A specific questionnaire consisting of 18 questions was prepared. The questionnaire was completed by 300 pediatricians (all members of PAIDOSS: Italian National Observatory on Health of Childhood and Adolescence) who represented ~300,000 children.

RESULTS

A vast majority of children have cough throughout the year (99.3% of respondents have cough during autumn/winter and 64.7% in spring/summer). Allergic disease is the most frequent suspected cause of chronic cough in children (53%), and this is supported by the high demand for consultations: 73% seek the opinion of allergologists, 62% of otorhinolaryngologists and only 33% of pulmonologists. The majority of pediatricians (92%) reported that they prescribe therapy in acute cough regardless of cough guidelines. Moreover, the survey pointed out the abuse of aerosol therapy (26% in acute cough and 38% in chronic cough) and of antibiotics prescription (22% in acute cough and 42% in chronic cough).

CONCLUSION

Our survey suggests that some Italian pediatricians' therapeutic attitudes should be substantially improved in order to achieve better management of cough in children and to minimize the burden of cough.

Cost of persistent asthma in Italy

Background

Asthma is a common disease of the airways with a significant burden for the society and for patients’ quality of life. The Social Impact of Respiratory Integrated Outcomes (SIRIO) study estimated a mean cost of 1,177.40 € per patient/year in Italy, in 2007. The aim of the present study was to update the cost of persistent asthma patients in Italy.

Methods

An observational, retrospective, bottom-up analysis was carried out starting from the data base operating in the Lung Unit of the Specialist Medical Centre (CEMS), Verona (Italy), over the period June 2013-December 2015. Patients’ data were recorded over the 12 ± 2 months before the enrollment and during 12 ± 2 months of follow-up. The prospective was the Italian National Health Service and the broad Italian society. Clinical data were measured in terms of forced expiratory volume in 1 s (FEV₁%) and number of relapses. Healthcare resources (namely; number of hospitalizations and/or ER admissions; number of visits; drug use and duration, and indirect costs) were recorded.

Results

The cohort consisted of 817 patients with persistent asthma of different severity. They had a 42.96% male prevalence; a mean (±SE) age of 49.06 (±0.64) years; a mean 87.47% (±0.81) FEV₁% pred. in baseline, and 69.16% of subjects had comorbidities. The mean (±SE) number of relapses was 0.91 (±0.09) per patient/year before the enrolment. After 12 months, FEV₁% significantly improved by +6.31% (±0.45) from the corresponding baseline value (p  < 0.001). The number of relapses decreased of −0.46 (±0.09) (p  < 0.001). The estimated total annual cost per asthmatic patient was 1,183.14 € (±65.79 €) during the 12 months before the enrolment, and 1,290.89 € (±68.74 €) throughout the follow-up. The increase was mostly due to the significantly increased duration of therapeutic strategies. The costs of hospitalization, general practitioner and rescue medications were significantly decreased.

Conclusions

The periodic update of cost analysis is a key to monitor the trend of main asthma outcomes and related expenditure over time. It allows to plan the most convenient actions in terms of prevention strategies and effective interventions, with the aim of optimizing the healthcare resources consumption and maximizing the impact on clinical outcomes and patients’ quality of life. The role of an appropriate pharmacological strategy still proves crucial in minimizing asthma morbidity and the corresponding socio-economic impact.

Cost of persistent asthma in Italy

Background: Asthma is a common disease of the airways with a significant burden for the society and for patients’ quality of life. The Social Impact of Respiratory Integrated Outcomes (SIRIO) study estimated a mean cost of 1,177.40 € per patient/year in Italy, in 2007. The aim of the present study was to update the cost of persistent asthma patients in Italy. Methods: An observational, retrospective, bottom-up analysis was carried out starting from the data base operating in the Lung Unit of the Specialist Medical Centre (CEMS), Verona (Italy), over the period June 2013-December 2015. Patients’ data were recorded over the 12 ± 2 months before the enrollment and during 12 ± 2 months of follow-up. The prospective was the Italian National Health Service and the broad Italian society. Clinical data were measured in terms of forced expiratory volume in 1 s (FEV1%) and number of relapses. Healthcare resources (namely; number of hospitalizations and/or ER admissions; number of visits; drug use and duration, and indirect costs) were recorded. Results: The cohort consisted of 817 patients with persistent asthma of different severity. They had a 42.96% male prevalence; a mean (±SE) age of 49.06 (±0.64) years; a mean 87.47% (±0.81) FEV1% pred. in baseline, and 69.16% of subjects had comorbidities. The mean (±SE) number of relapses was 0.91 (±0.09) per patient/year before the enrolment. After 12 months, FEV1% significantly improved by +6.31% (±0.45) from the corresponding baseline value (p < 0.001). The number of relapses decreased of −0.46 (±0.09) (p < 0.001). The estimated total annual cost per asthmatic patient was 1,183.14 € (±65.79 €) during the 12 months before the enrolment, and 1,290.89 € (±68.74 €) throughout the follow-up. The increase was mostly due to the significantly increased duration of therapeutic strategies. The costs of hospitalization, general practitioner and rescue medications were significantly decreased. Conclusions: The periodic update of cost analysis is a key to monitor the trend of main asthma outcomes and related expenditure over time. It allows to plan the most convenient actions in terms of prevention strategies and effective interventions, with the aim of optimizing the healthcare resources consumption and maximizing the impact on clinical outcomes and patients’ quality of life. The role of an appropriate pharmacological strategy still proves crucial in minimizing asthma morbidity and the corresponding socio-economic impact.

Cough: impact, beliefs, and expectations from a national survey

Background: Cough is one of the most common discomforts affecting general population, which can disrupt subjects’ quality of life due to its physical, social, and psychological effects. Aim of the study was to investigate the impact of cough and related beliefs of general population. Methods: A cross-sectional telephone survey was carried out by means of a specific, validated questionnaire on a representative sample of Italian general population. All the interviews were carried out according to the Computer Assisted Telephone Interview (CATI) methodology by expert, professional interviewers. Distributions of all answers were calculated in the overall sample. Results: A total of 1,251 subjects (mean age: 49 years; females 44.2 %) completed the interviews. The overall number of telephone calls was 5362, and the corresponding redemption rate was 1/4.3 (23.%). The sample was representative of national population in terms of geographical distribution, age, gender, and smoking habit. The majority of respondents was convinced that cough is merely a symptom of several different diseases, but 46.4 % of respondents affirmed that cough should be regarded as “a disease” per se. Only 29. 1 % of subjects say that they usually do not complain of any cough over the year, while 18.4 % reported ≥ 3 episodes of cough/year. These episodes have a duration ranging 10–30 days in 19.9 % of subjects, and > 30 days in 6.9 % of subjects. The majority of respondents is worried about their cough only after 1 week, but 76.9 % of subjects is much more worried if cough affects a child. After a few days of cough, 23.1 % of subjects use domestic remedies; 20.9 % ask their pharmacist, and 33.4 % their doctor, being GPs (69.6 %) and lung physicians (16.2 %) the most asked professionals. The occurrence of bronchitis, pneumonia, upper airway infections, and allergic troubles are the most feared events. The majority of respondents are convinced that antibiotics and steroids should not be regarded as the gold standard for treating persistent cough (61.2 and 58.2 %, respectively), while anti-tussive drugs and aerosols in general are regarded as the most effective strategies (69.1 and 74. 1 %, respectively). Moreover, 33.8 % of the sample is in favour of homeopathic drugs, while 23.2 % had already used an homeopathic anti-tussive syrup, and 27.6 % of subjects are really interested in using the homeopathic approach. The willingness to pay for an effective anti-tussive remedy was: 46.3 % up to 10 €; 27.8 % up to 20 €, and 13.3 % more than 20 €. Conclusions: Cough confirms its high impact in Italy, and a substantial proportion of individuals regards cough as “a disease”. Only one out of three Italians refers to their doctor, but when cough is already persistent. Cough in children is much more feared than in adults. The majority of Italians have a proper and conservative position versus both antibiotic and the systemic steroid uses against cough. The Italian attitude to aerosol therapy confirms very high. Differently from the cough guidelines, anti-tussive drugs are highly valued among Italian people. The attitude and the interest to homeopathic anti-tussive remedies proves high. Finally, the willingness to pay for an effective anti-tussive remedy is quite high in Italy.

Erdosteine reduces the exercise-induced oxidative stress in patients with severe COPD: Results of a placebo-controlled trial

BACKGROUND

Erdosteine (ER), a multimechanism, mucoactive agent with anti-oxidant and anti-inflammatory properties, has been shown to improve lung function, decrease plasma reactive oxygen species (ROS), and 8-isoprostane levels in patients with chronic obstructive pulmonary disease (COPD).

AIM

To assess vs. placebo the effect of ER on the exercise-induced oxidative stress by measuring and comparing the release of pro-inflammatory mediators in severe COPD patients.

METHODS

The double blind, placebo controlled study was carried out in 24 severe (GOLD Class III) COPD patients, aged >40 yr, randomized to receive either oral ER (600 mg/day, 8 males, mean age 70.5 yr) or placebo (9 males, mean age 70.8 yr) for 10 days. All patients performed a 6-min walking test (6MWT) before and after both treatments.

RESULTS

Mean ROS plasma levels increased significantly, but equally, in each group following the baseline 6MWT (p = ns). At the end of both treatments, a significant difference in mean plasma ROS increase from baseline became clear between the ER (+14.6% ± 2.7) and the placebo group (+24.4% ± 3.8) after the second 6MWT (p < 0.025). A similar significant trend was proved for the mean 8-isoprostane increase, which changed from baseline by +14.1% ± 2.6 in the ER, and by +26.3 ± 2.9 in the placebo group, respectively, after the second 6MWT (p < 0.006).

CONCLUSIONS

Data from the present study are suggesting that ER is effective in reducing the release of inflammatory mediators due to the exercise-induced oxidative stress in severe COPD patients.

Dry-powder inhalers in patients with persistent airflow limitation: usability and preference

BACKGROUND

Inhalation devices represent per sé critical factors because they can affect the therapeutic outcomes independently of the drug used. The role of patients' usability and preference (PUP) for Dry Powder Inhalers (DPIs) is high indeed because they can influence the extent of the adherence to treatment and the therapeutic outcomes. Aim of the study was to assess and compare the PUP of three different DPIs in out-patients with persistent airflow limitation due to asthma or COPD.

METHODS

The PUP of three different DPIs (Breezhaler; Genuair; Handihaler) were investigated by means of the Handling Questionnaire in out-patients with persistent airflow limitation needing an inhalation therapy. Patients had to report their preference before and after the nurse's instruction on the handling of each device. The nurse had also to note the critical steps during the patient's procedure for actuation; to count the number of attempts needed for actuating the device properly, and to measure the time (in sec.) required for these procedures. Data were collected up to three attempts per device.

STATISTICS

Welch test was used for normal distributed variables, while the Wilcoxon test for not normal distributed variables. The χ (2) test and the ANOVA test were also used. Univariate and multivariate regressions were also performed in order to investigate the effect of patients' characteristics and of technical differences of each device on their proper use.

RESULTS

Three hundred thirty-three consecutive out-patients (age range 55-58 years, and well matched for gender), with persistent airway limitation of different severity were investigated, suffering from bronchial asthma (n = 175) or from chronic obstructive pulmonary disease (COPD) (n = 158). In particular, 127 patients (38 %) tested the three DPIs, while 110 (33 %) tested Breezhaler and Genuair, and 96 (29 %) Breezhaler and Handihaler. More than 50 % of patients who tested all devices preferred the Genuair and perceived this device as the easiest to use. The nurse's judgement confirmed their opinion. When compared to the other two DPIs, Genuair proved the least problematic either according to the patients' judgement and to the nurse's opinion. Mean number of attempts aimed to achieving the first proper actuation was lower with Genuair than with Breezhaler and Handihaler (1.5 vs 2.5-2.6, p < 0.0001). Finally, Genuair also proved the easiest to use and the least problematic according to the nurse judgement (0.0001), the most easily learned (0.0001), and that one with a successful rate of more than 56 % at the first attempt. Breezhaler and Handihaler needed an average of about one additional attempt to be used properly (p < 0.0001), and their usability proved significantly more difficult (OR of successful rate between 0.15 and 0.17, p < 0.001). In general, older patients needed more attempts to perform their first proper inhalation; their successful rate was lower, and they needed more time to learn how to use devices properly: with Genuair these differences were minimized.

CONCLUSIONS

The possibility of grading objectively the performance of different DPIs in terms of their usability and therapeutic convenience in daily life represents a crucial operational opportunity to pursue. To note that a substantial discrepancy exists between the patients' belief "at glance" and the patients' effective usability with can be registered with some devices. From a general point of view, devices requiring less manual actions for their actuation confirmed their better usability and proper handling after less attempts. In particular, Genuair came out as the most preferred DPI also when several different aspects of preference and usability are assessed objectively and compared.

Dry-powder inhalers in patients with persistent airflow limitation: usability and preference

Background: Inhalation devices represent per sé critical factors because they can affect the therapeutic outcomes independently of the drug used. The role of patients’ usability and preference (PUP) for Dry Powder Inhalers (DPIs) is high indeed because they can influence the extent of the adherence to treatment and the therapeutic outcomes. Aim of the study was to assess and compare the PUP of three different DPIs in out-patients with persistent airflow limitation due to asthma or COPD. Methods: The PUP of three different DPIs (Breezhaler; Genuair; Handihaler) were investigated by means of the Handling Questionnaire in out-patients with persistent airflow limitation needing an inhalation therapy. Patients had to report their preference before and after the nurse’s instruction on the handling of each device. The nurse had also to note the critical steps during the patient’s procedure for actuation; to count the number of attempts needed for actuating the device properly, and to measure the time (in sec.) required for these procedures. Data were collected up to three attempts per device. Statistics: Welch test was used for normal distributed variables, while the Wilcoxon test for not normal distributed variables. The χ2 test and the ANOVA test were also used. Univariate and multivariate regressions were also performed in order to investigate the effect of patients’ characteristics and of technical differences of each device on their proper use. Results: Three hundred thirty-three consecutive out-patients (age range 55–58 years, and well matched for gender), with persistent airway limitation of different severity were investigated, suffering from bronchial asthma (n = 175) or from chronic obstructive pulmonary disease (COPD) (n = 158). In particular, 127 patients (38 %) tested the three DPIs, while 110 (33 %) tested Breezhaler and Genuair, and 96 (29 %) Breezhaler and Handihaler. More than 50 % of patients who tested all devices preferred the Genuair and perceived this device as the easiest to use. The nurse’s judgement confirmed their opinion. When compared to the other two DPIs, Genuair proved the least problematic either according to the patients’ judgement and to the nurse’s opinion. Mean number of attempts aimed to achieving the first proper actuation was lower with Genuair than with Breezhaler and Handihaler (1.5 vs 2.5–2.6, p < 0.0001). Finally, Genuair also proved the easiest to use and the least problematic according to the nurse judgement (0.0001), the most easily learned (0.0001), and that one with a successful rate of more than 56 % at the first attempt. Breezhaler and Handihaler needed an average of about one additional attempt to be used properly (p < 0.0001), and their usability proved significantly more difficult (OR of successful rate between 0.15 and 0.17, p < 0.001). In general, older patients needed more attempts to perform their first proper inhalation; their successful rate was lower, and they needed more time to learn how to use devices properly: with Genuair these differences were minimized. Conclusions: The possibility of grading objectively the performance of different DPIs in terms of their usability and therapeutic convenience in daily life represents a crucial operational opportunity to pursue. To note that a substantial discrepancy exists between the patients’ belief “at glance” and the patients’ effective usability with can be registered with some devices. From a general point of view, devices requiring less manual actions for their actuation confirmed their better usability and proper handling after less attempts. In particular, Genuair came out as the most preferred DPI also when several different aspects of preference and usability are assessed objectively and compared.

Patient Heterogeneity in Health Economic Decision Models for Chronic Obstructive Pulmonary Disease: Are Current Models Suitable to Evaluate Personalized Medicine?

OBJECTIVES

To assess how suitable current chronic obstructive pulmonary disease (COPD) cost-effectiveness models are to evaluate personalized treatment options for COPD by exploring the type of heterogeneity included in current models and by validating outcomes for subgroups of patients.

METHODS

A consortium of COPD modeling groups completed three tasks. First, they reported all patient characteristics included in the model and provided the level of detail in which the input parameters were specified. Second, groups simulated disease progression, mortality, quality-adjusted life-years (QALYs), and costs for hypothetical subgroups of patients that differed in terms of sex, age, smoking status, and lung function (forced expiratory volume in 1 second [FEV₁] % predicted). Finally, model outcomes for exacerbations and mortality for subgroups of patients were validated against published subgroup results of two large COPD trials.

RESULTS

Nine COPD modeling groups participated. Most models included sex (seven), age (nine), smoking status (six), and FEV₁% predicted (nine), mainly to specify disease progression and mortality. Trial results showed higher exacerbation rates for women (found in one model), higher mortality rates for men (two models), lower mortality for younger patients (four models), and higher exacerbation and mortality rates in patients with severe COPD (four models).

CONCLUSIONS

Most currently available COPD cost-effectiveness models are able to evaluate the cost-effectiveness of personalized treatment on the basis of sex, age, smoking, and FEV₁% predicted. Treatment in COPD is, however, more likely to be personalized on the basis of clinical parameters. Two models include several clinical patient characteristics and are therefore most suitable to evaluate personalized treatment, although some important clinical parameters are still missing.

Cultural and linguistic validation of the NHQ-2 Questionnaire: a specific instrument for assessing patient's usability of inhalation devices

Background

An increasing number of inhalation devices are presently available in the market. They are differently characterized in terms of their handling and usability, both factors which may affect the outcomes of respiratory treatment.

The assessment of the preference and the usability rate of all devices can be carried out by means of specific questionnaires. Before their use, the identification of errors due to the incorrect wording of questions included in the questionnaires, together with the trans-cultural reliability represents the main issues of their cultural and linguistic validation.

Methods and results

The New Handling Questionnaire - NHQ-2 is a novel specific questionnaire aimed to measure both the preference and the usability of all kinds of inhalation devices. The method used for its validation has been summarized in the first section of the present paper, while the results of the specific validation and translation process have been described in the second section, together with the grading of improvement achieved over the process. The comprehensibility and the reproducibility rates achieved for both the Italian and the English final versions of the NHQ-2 questionnaire were very high, such as >90 % for each question included.

Conclusions

The novel NHQ-2 questionnaire proved very high comprehensibility and reproducibility in both its Italian and English final versions. It can be proposed for the trans-cultural clinical use when the usability, and not only the patients’ preference of devices, should be assessed.

Electronic supplementary material

The online version of this article (doi:10.1186/s40248-016-0067-y) contains supplementary material, which is available to authorized users.

Cultural and linguistic validation of the NHQ-2 Questionnaire: a specific instrument for assessing patient’s usability of inhalation devices

Background: An increasing number of inhalation devices are presently available in the market. They are differently characterized in terms of their handling and usability, both factors which may affect the outcomes of respiratory treatment. The assessment of the preference and the usability rate of all devices can be carried out by means of specific questionnaires. Before their use, the identification of errors due to the incorrect wording of questions included in the questionnaires, together with the trans-cultural reliability represents the main issues of their cultural and linguistic validation. Methods and results: The New Handling Questionnaire - NHQ-2 is a novel specific questionnaire aimed to measure both the preference and the usability of all kinds of inhalation devices. The method used for its validation has been summarized in the first section of the present paper, while the results of the specific validation and translation process have been described in the second section, together with the grading of improvement achieved over the process. The comprehensibility and the reproducibility rates achieved for both the Italian and the English final versions of the NHQ-2 questionnaire were very high, such as >90 % for each question included. Conclusions: The novel NHQ-2 questionnaire proved very high comprehensibility and reproducibility in both its Italian and English final versions. It can be proposed for the trans-cultural clinical use when the usability, and not only the patients’ preference of devices, should be assessed.

Fluticasone furoate/Vilanterol 92/22 μg once-a-day vs Beclomethasone dipropionate/ Formoterol 100/6 μg b.i.d.: a 12-week cost analysis in mild-to-moderate asthma

Background: Asthma is a disease with high cost for the National Health Service. Two of the most recent LABA/ICS combinations for persistent bronchial asthma are Beclomethasone dipropionate/Formoterol (B/F) delivered via the Nexthaler device and Fluticasone furoate/Vilanterol (F/V) delivered via the Ellipta device. No comparison has been carried out yet in terms of cost analysis in asthma, to our knowledge. Aim of the present monocentric, observational, retrospective study was to calculate and compare the costs of mild-to-moderate asthma patients assuming B/F 100/6 μg b.i.d. to those of patients assuming F/V 92/22 μg once-a-day over a 12-week treatment period from the Italian National Health Service perspective. Methods: Data were obtained automatically and anonymously from the institutional database of the Lung Unit of the Specialist Medical Centre (CEMS), Verona, Italy, UNI EN ISO 9001-2008 validated. FEV1 values, number of relapses, healthcare resources as hospitalizations due to asthma relapses, days of hospitalization, general practitioner (GP), specialist visits, and days of inactivity, were recorded over the study period together with the use of extra medications (systemic steroids and antibiotics). In order to compare the outcomes achieved in both groups, the propensity score matching method was used in STATA, and statistical significance was accepted for p < 0.05. Results: Clinical data of 77 patients treated with B/F b.i.d (Group A) and of 40 patients treated with F/V 92/22 μg once-a-day (Group B) were selected. The PS-matching process, designed as matching on the baseline covariates, gender, age, FEV1 and comorbidities, returned a cohort of 40 group A patients of the entire cohort matched with 40 patients of group B, fully comparable for demographics and clinical characteristics. In the PS-matched cohort, the mean (±SE) number of relapses per patient during the follow-up was 0.53 (±0.12) in group A and 0.28 (±0.07) in group B. In group A, n = 25 (62.50 %), n = 9 (22.50 %), and n = 6 (15 %) patients had 0, 1, 2 relapses, respectively. In group B, n=29 (72.50 %), and n = 11 (27.50 %) had 0 and 1 relapse, respectively. Over the study period, the average number of hospitalizations per patient was 0.15 (±0.06), with 0.28 (±0.12) days of hospitalization in group A, and 0.08 (±0.04) with 0.08 (±0.04) days of hospitalization in group B, respectively. The difference between the two groups in terms of FEV1(L) improvement vs baseline was 0.11 in favour of group B (p = 0.007). When results were compared, the improvement in lung function obtained in group B proved significantly higher both in terms of absolute FEV1 and of FEV1 % predicted. The mean (±SE) cost of hospitalizations per patient was € 345.30 (±133.23) in group A and € 172.65 (±98.18) in group B, respectively, with a mean not significant difference of - € 172.65 in favour of group B (p = 0.9). In particular, the mean (±SE) cost for visits per patient was € 26.82 (±3.73) in group A and € 11.36 (±2.30) in group B (p = 0.002), and the mean cost for rescue medications per patient was € 35.24 (±6.93) in group A, and € 18.73 (±3.38) in group B, respectively (p = 0.05). Conclusions: Even if both ICS/LABA combinations were checked over a limited period of time, they seem characterized by a different profile in terms of effect on lung function and economic impact on mild-tomoderate asthma. The once-daily inhalation of combined Fluticasone furoate/Vilanterol 92/22 μg showed the potential for enhanced clinical outcomes and reduced costs when compared to Beclomethasone dipropionate/Formoterol 100/6 μg b.i.d.

Fluticasone furoate/Vilanterol 92/22 μg once-a-day vs Beclomethasone dipropionate/ Formoterol 100/6 μg b.i.d.: a 12-week cost analysis in mild-to-moderate asthma

Background

Asthma is a disease with high cost for the National Health Service. Two of the most recent LABA/ICS combinations for persistent bronchial asthma are Beclomethasone dipropionate/Formoterol (B/F) delivered via the Nexthaler device and Fluticasone furoate/Vilanterol (F/V) delivered via the Ellipta device. No comparison has been carried out yet in terms of cost analysis in asthma, to our knowledge. Aim of the present monocentric, observational, retrospective study was to calculate and compare the costs of mild-to-moderate asthma patients assuming B/F 100/6 μg b.i.d. to those of patients assuming F/V 92/22 μg once-a-day over a 12-week treatment period from the Italian National Health Service perspective.

Methods

Data were obtained automatically and anonymously from the institutional database of the Lung Unit of the Specialist Medical Centre (CEMS), Verona, Italy, UNI EN ISO 9001-2008 validated. FEV₁ values, number of relapses, healthcare resources as hospitalizations due to asthma relapses, days of hospitalization, general practitioner (GP), specialist visits, and days of inactivity, were recorded over the study period together with the use of extra medications (systemic steroids and antibiotics). In order to compare the outcomes achieved in both groups, the propensity score matching method was used in STATA, and statistical significance was accepted for p < 0.05.

Results

Clinical data of 77 patients treated with B/F b.i.d (Group A) and of 40 patients treated with F/V 92/22 μg once-a-day (Group B) were selected. The PS-matching process, designed as matching on the baseline covariates, gender, age, FEV₁ and comorbidities, returned a cohort of 40 group A patients of the entire cohort matched with 40 patients of group B, fully comparable for demographics and clinical characteristics. In the PS-matched cohort, the mean (±SE) number of relapses per patient during the follow-up was 0.53 (±0.12) in group A and 0.28 (±0.07) in group B. In group A, n = 25 (62.50 %), n = 9 (22.50 %), and n = 6 (15 %) patients had 0, 1, 2 relapses, respectively. In group B, n = 29 (72.50 %), and n = 11 (27.50 %) had 0 and 1 relapse, respectively. Over the study period, the average number of hospitalizations per patient was 0.15 (±0.06), with 0.28 (±0.12) days of hospitalization in group A, and 0.08 (±0.04) with 0.08 (±0.04) days of hospitalization in group B, respectively. The difference between the two groups in terms of FEV₁(L) improvement vs baseline was 0.11 in favour of group B (p = 0.007). When results were compared, the improvement in lung function obtained in group B proved significantly higher both in terms of absolute FEV₁ and of FEV₁ % predicted.

The mean (±SE) cost of hospitalizations per patient was € 345.30 (±133.23) in group A and € 172.65 (±98.18) in group B, respectively, with a mean not significant difference of - € 172.65 in favour of group B (p = 0.9). In particular, the mean (±SE) cost for visits per patient was € 26.82 (±3.73) in group A and € 11.36 (±2.30) in group B (p = 0.002), and the mean cost for rescue medications per patient was € 35.24 (±6.93) in group A, and € 18.73 (±3.38) in group B, respectively (p = 0.05).

Conclusions

Even if both ICS/LABA combinations were checked over a limited period of time, they seem characterized by a different profile in terms of effect on lung function and economic impact on mild-to-moderate asthma. The once-daily inhalation of combined Fluticasone furoate/Vilanterol 92/22 μg showed the potential for enhanced clinical outcomes and reduced costs when compared to Beclomethasone dipropionate/Formoterol 100/6 μg b.i.d.

The economic impact of educational training assessed by the Handling Questionnaire with three inhalation devices in asthma and Chronic Obstructive Pulmonary Disease patients

Background

The usability of inhalation devices depends on several factors, eg, the drug to inhale, device handling, and patients’ training. Usability is then presumed to have economic consequences.

Aim

To assess and compare the cost of patients’ training for proper usability of Breezhaler and Genuair (both dry powder inhalers) and Respimat (a soft mist inhaler) in asthma and chronic obstructive pulmonary disease (COPD) outpatients.

Methods

The acceptance and handling of the three devices were investigated by means of the Handling Questionnaire. The time spent in specific training for ensuring a proper actuation and the corresponding costs were also calculated. Linear and logistic regressions were used in order to investigate the factors influencing proper handling of the devices. A significance level of P<0.05 was accepted.

Results

According to both the patients’ and the nurse’s judgments, Genuair and Respimat were perceived as the easiest devices to use, while Breezhaler required the highest number of attempts for achieving the first proper actuation (2.6 vs 1.6; P<0.0001). The total training cost per patient (including the nurse’s time for demonstration and that for attending the patients’ maneuvers) was €1.38±€1.21. Breezhaler was found to be the most expensive as the cost per patient was €2.35±€1.26, which was three to four times higher than that of Genuair and Respimat (both devices involved a cost of <€1 per patient, with negligible differences between each other). Asthma and COPD patients showed a similar trend, with better outcomes reported for asthma patients probably due to lower age.

Conclusion

Substantial differences were found to exist in patients’ acceptability and handling of the three devices. The economic impact of specific training was also different and strictly related to the comprehension of the procedure for actuation of each device. Respimat as a soft mist inhaler and Genuair as an metered-dose inhaler proved to be the most convenient in economic terms also.

The BODECOST Index (BCI): a composite index for assessing the impact of COPD in real life

Background

Chronic Obstructive Pulmonary Disease (COPD) is a progressive condition which is characterized by a dramatic socio-economic impact.

Several indices were extensively investigated in order to asses the mortality risk in COPD, but the utilization of health care resources was never included in calculations. The aim of this study was to assess the predictive value of annual cost of care on COPD mortality at three years, and to develop a comprehensive index for easy calculation of mortality risk in real life.

Methods

COPD patients were anonymously and automatically selected from the local institutional Data Base. Selection criteria were: COPD diagnosis; both genders; age ≥ 40 years; availability of at least one complete clinical record/year, including history; clinical signs; complete lung function, therapeutic strategy, health BODE index; Charlson Comorbidity Index, and outcomes, collected at the first visit, and over the following 3-years. At the first visit, the health annual cost of care was calculated in each patient for the previous 12 months, and the survival rate was also measured over the following 3 years. The hospitalization and the exacerbation rate were implemented to the BODE index and the novel index thus obtained was called BODECOST index (BCI), ranging from 0 to 10 points. The mean cost for each BCI step was calculated and then compared to the corresponding patients’ survival duration.

Parametrical, non parametrical tests, and linear regression were used; p < 0.05 was accepted as the lower limit of significance.

Results

At the first visit, the selected 275 patients were well matched for all variables by gender. The overall mortality over the 3 year survey was 40.4 % (n = 111/275). When compared to that of BODE index (r = 0.22), the total annual cost of care and the number of exacerbations showed the highest regression value vs the survival time (r = 0.58 and r = 0.44, respectively). BCI score proved strictly proportional to both the cost of care and the survival time in our sample of COPD patients.

Discussion

BCI takes origin from the implementation of the BODE index with the two main components of the annual cost of care, such as the number of hospitalizations and of exacerbations occurring yearly in COPD patients, and their corresponding economic impact. In other words, higher the BCI score, shorter the survival and higher the cost, these trends being strictly linked.

Conclusions

BCI is a novel composite index which helps in predicting the impact of COPD at 3 years in real life, both in terms of patients’ survival and of COPD economic burden.

The BODECOST Index (BCI): a composite index for assessing the impact of COPD in real life

Background: Chronic Obstructive Pulmonary Disease (COPD) is a progressive condition which is characterized by a dramatic socio-economic impact. Several indices were extensively investigated in order to asses the mortality risk in COPD, but the utilization of health care resources was never included in calculations. The aim of this study was to assess the predictive value of annual cost of care on COPD mortality at three years, and to develop a comprehensive index for easy calculation of mortality risk in real life. Methods: COPD patients were anonymously and automatically selected from the local institutional Data Base. Selection criteria were: COPD diagnosis; both genders; age ≥ 40 years; availability of at least one complete clinical record/year, including history; clinical signs; complete lung function, therapeutic strategy, health BODE index; Charlson Comorbidity Index, and outcomes, collected at the first visit, and over the following 3-years. At the first visit, the health annual cost of care was calculated in each patient for the previous 12 months, and the survival rate was also measured over the following 3 years. The hospitalization and the exacerbation rate were implemented to the BODE index and the novel index thus obtained was called BODECOST index (BCI), ranging from 0 to 10 points. The mean cost for each BCI step was calculated and then compared to the corresponding patients’ survival duration. Parametrical, non parametrical tests, and linear regression were used; p < 0.05 was accepted as the lower limit of significance. Results: At the first visit, the selected 275 patients were well matched for all variables by gender. The overall mortality over the 3 year survey was 40.4 % (n = 111/275). When compared to that of BODE index (r = 0.22), the total annual cost of care and the number of exacerbations showed the highest regression value vs the survival time (r = 0.58 and r = 0.44, respectively). BCI score proved strictly proportional to both the cost of care and the survival time in our sample of COPD patients. Discussion: BCI takes origin from the implementation of the BODE index with the two main components of the annual cost of care, such as the number of hospitalizations and of exacerbations occurring yearly in COPD patients, and their corresponding economic impact. In other words, higher the BCI score, shorter the survival and higher the cost, these trends being strictly linked. Conclusions: BCI is a novel composite index which helps in predicting the impact of COPD at 3 years in real life, both in terms of patients’ survival and of COPD economic burden.

Acceptability and preference of three inhalation devices assessed by the Handling Questionnaire in asthma and COPD patients

BACKGROUND

The patients' criteria of preference for inhalation devices can affect the extent of their adherence to treatment and outcomes. Aim of this study was to assess and compare the patients' preference and acceptability (PPA) for Breezhaler and Genuair (both Dry Powder Inhalers), and for Respimat (a Soft Mist Inhaler) in asthma and COPD out-patients by means of the Handling Questionnaire.

METHODS

The Handling Questionnaire is a validated instrument which allows the investigation of different domains of PPA; it also takes into account the patients' age and gender, together with their previous experience with the inhalation devices and their previous education approach to them. Differences in terms of preference, acceptance and usability were assessed by linear and logistic regressions in order to evaluate factors influencing the proper actuation.

RESULTS AND DISCUSSION

Data from 333 patients were collected: Genuair and Respimat were the most liked and perceived as the easiest to use at glance by patients, but also as the least problematic according to the patients' and nurse's judgments. Mean number of attempts for achieving the first effective actuation was the highest with Breezhaler (2.6 vs 1.6; p <0.0001). Linear regressions showed that longer the explanation, higher was the number of attempts to the first proper actuation (0.58 additional attempts every 10 s increase in the first explanation, p <0.0001). Devices requiring less manoeuvres for the actuation were used properly after less attempts (0.38 increase in the number of attempts every additional manoeuvres, p <0.0001). Respimat proved to be the most indicated in COPD patients since it was the most liked and its successful rate at first attempt was the highest. Logistic regressions confirmed these data. Previous experience with DPIs and/or MDIs did not affect the patient preference and acceptability, independently whether suffering from asthma or COPD.

CONCLUSIONS

Substantial differences are existing in patient's preference and acceptability for inhalation devices, mainly related to the handling and the understanding of the different devices.