Which factors affect the choice of the inhaler in chronic obstructive respiratory diseases?

doi:10.1016/j.pupt.2015.02.006

Pulmonary Pharmacology & Therapeutics

Volume 31, April 2015, Pages 63-67

https://doi.org/10.1016/j.pupt.2015.02.006 Get rights and content

Abstract

Inhalation is the preferred route of drug administration in chronic respiratory diseases because it optimises delivery of the active compounds to the targeted site and minimises side effects from systemic distribution. The choice of a device should be made after careful evaluation of the patient's clinical condition (degree of airway obstruction, comorbidities), as well as their ability to coordinate the inhalation manoeuvre and to generate sufficient inspiratory flow. These patient factors must be aligned with the specific advantages and limitations of each inhaler when making this important choice. Finally, adherence to treatment is not the responsibility of the patient alone, but should be shared also by clinicians. Clinicians have access to a wide selection of pressurised metered dose inhalers (pMDIs) and dry powder inhalers (DPIs) that can be used effectively when matched to the needs of individual patients; this should be perceived as an opportunity rather than a limitation.

Introduction

Chronic diseases require regular treatment. This applies to asthma and chronic obstructive pulmonary disease (COPD), the most common chronic respiratory conditions, which are characterised by persistent airway inflammation and bronchial obstruction. Inhalation is the preferred route of administration when treating respiratory obstructive diseases, because it optimises the delivery of active compounds to the targeted site, while minimising side effects. In this context, the inhaler plays a crucial role in the management of chronic respiratory diseases. The choice of the device can be as important as the choice of the drug. In real-life clinical settings, physicians often discuss on the properties of various drugs with their colleagues and patients, in order to agree on the best possible choice for the patient, whereas little consideration is given to the properties of different inhalers. We believe that priority should be given to the choice of the appropriate device, based on patient needs and expectations, followed by the choice of the drug, based on the disease and its severity. A consensus statement by the task force of the European Respiratory Society (ERS) and the International Society for Aerosols in Medicine (ISAM) provides clear recommendations for choosing the best aerosol delivery device based on a patient's actuation–inhalation coordination, level of inspiratory flow, and other clinical conditions [1]. For example, some inhalers require strong inspiratory force, which may not be possible in emergency situations or in children and elderly.

Ideally, patients should use one device for all of their inhaled therapies; obviously, this is not always possible. We believe that differences in efficacy among devices become trivial in case of correct inhalation technique, as supported by evidence-based guidelines from the American College of Chest Physicians/American College of Asthma, Allergy, and Immunology [2]. The key issue is patient training and verification of the inhalation technique. The issue remains of whether the drug is able to reach the targeted site with each device. The current review article aims at comparing the available inhaler devices to assess their advantages and limitations in chronic obstructive diseases. The role of the devices with regard to adherence to treatment will be also addressed.

Section snippets

Role of the inhaler in the management of chronic obstructive respiratory diseases

The goal of therapy is to obtain optimal control of symptoms and, ideally, to alter the natural course of the disease by delivering the correct drug dosage to the site of structural and functional alterations. To achieve this, two conditions must be met: 1) the aerosol formulation must deposit along the bronchial tree, and 2) drug deposition must provide functional and clinical benefits. Both conditions are closely related to the type of device used. Treatment effectiveness is also determined

Key points in managing treatment by inhaled medications

Despite the clinical importance of inhaled therapy, current guidelines seem to lack a consensus on recommendations for devices. Less than 3% of the official documents for management of asthma and COPD focus on device-related issues. Guidelines are generally vague and not always evidence-based regarding criteria for choosing inhaler devices, especially for adults, thus allowing clinically irrelevant factors to influence the choice.

Looking at a pressurised metered dose inhaler (pMDI), for

Drug deposition according to device selection

pMDIs are the most widely used devices. Their correct use requires coordination between inhalation and device actuation. Incorrect technique can limit the effectiveness in daily clinical practice; lack of coordination can occur with pMDIs and represents almost half of all errors [4]. This can lead to ineffective drug delivery to the lungs with excess deposition in the oropharynx. To overcome this limitation, the use of a spacer with pMDIs is often recommended, especially for patients with known

Comparing devices for chronic obstructive pulmonary diseases

The first area to explore when comparing different inhaler devices is the particle size range of the emitted dose. Aerosol particle/droplet size is one of the most important factors influencing the deposition of medications in the airways. A particle size of 2–5 μm has the greatest potential to be deposited throughout the bronchial tree. Indeed, smaller particles deposit into the alveoli, where there is no smooth muscle and where systemic absorption is increased [8]. Particles >5 μm tend to

Patient adherence in the management of chronic obstructive respiratory diseases

Patients play a major role in determining the success or failure of treatment. “Adherence” must be distinguished from “compliance”, the difference being in the patient's willingness to accept therapy [25]: the “non-compliant” patient simply ignores prescriptions. Adherent patients take medications as prescribed, whereas “non-adherent” patients fail to do so despite their willingness and acceptance of therapy. The unwitting non-adherence that occurs when a patient does not know the proper

Conclusions

Meta-analyses and systematic reviews [2], [3], [30] indicate that all inhalers can be effective and can achieve a similar therapeutic effect when patients use the inhalation technique recommended by the manufacturer, although different doses may be required. These observations are often documented in randomised controlled trials, where patients receive more inhaler-technique training and counselling on the importance of adherence than do patients in routine clinical practice. Real-life

Acknowledgements

English language editing and styling assistance was provided by Edra LSWR, Elsevier, and funded by AstraZeneca.

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One additional educational session in inhaler use to patients with COPD in primary health care – A controlled clinical trial
2022, Patient Education and Counseling
Citation Excerpt :
According to GOLD, the patient’s ability, preferences [1], and characteristics [45] are highly relevant when choosing a device [1]. Examples of important patient characteristics include the degree of airway obstruction and comorbidities [45], age, peak inspiratory flow, inhalation volume, sex, education, and physical or cognitive impairment [46]. It is essential to include patients in the treatment decision and to make the device selection as tailored as possible [47].
To investigate whether one additional educational session about inhaler use, delivered to patients with COPD in primary healthcare, could affect the patients’ skills in inhaler use. Specifically, to study the effects on errors related to handling the device, to inhalation technique, and to both.
This nonrandomized controlled clinical trial included 64 patients who used devices and made errors. COPD nurses assessed inhaler use using a checklist and educated patients. Intervention group received one additional educational session after two weeks.
At baseline, patients in the IG had more devices (n = 2,1) compared to patients in the CG (n = 1,6) (p = 0.003). No other statistically significant differences were seen at baseline. At follow-up, intervention group showed a lower proportion of patients who made errors related to handling the device (p = 0.006). No differences were seen in the other categories.
One additional educational session in inhaler use for patients with COPD was effective in reducing the proportion of patients making errors related to handling of their devices.
Practice implications:
Categorization of errors might help healthcare professionals to assess the suitability of patients’ devices, tailor patient education, and thus improve patient health.
Therapeutic adherence in chronic obstructive pulmonary disease: A literature review
2019, Revue des Maladies Respiratoires
Peu d’études ont porté sur l’adhésion thérapeutique des patients atteints de bronchopneumopathie chronique obstructive (BPCO) en France alors que l’impact en termes de morbi-mortalité est présent. Cette revue de littérature visait à mieux comprendre l’adhésion dans son ensemble et identifier les effets de la non-adhésion afin d’optimiser la prise en charge des patients.
Un algorithme de recherche a été conçu afin d’identifier toutes les publications sur l’adhésion thérapeutique dans la BPCO de 2010 à 2017, en anglais et en français. Les bases de données utilisées étaient MEDLINE, ScienceDirect, BDSP, Cochrane et CAIRN.
Sur 1553 articles identifiés, 94 ont été retenus (65 études observationnelles, 11 études interventionnelles et 18 revues ou synthèses générales). Les études observationnelles portaient sur les facteurs prédictifs de l’adhésion/la non-adhésion et leurs conséquences. Les études interventionnelles évaluaient l’efficacité d’interventions visant à améliorer l’adhésion.
Malgré d’importants progrès thérapeutiques, les problèmes de fond de la prise en charge de la BPCO persistent. Si l’offre de traitements s’est élargie ces dernières années, beaucoup d’efforts restent à faire pour simplifier les posologies, améliorer la prise de ces traitements et motiver les patients à y adhérer. Cette revue a aussi souligné le besoin d’une meilleure communication médecin–patient.
In France, only a small number of studies have focused on therapeutic adherence in patients with chronic obstructive pulmonary disease COPD) despite its impact in terms of multimorbidity. The objective of this literature review was a better understanding of adherence as a whole, and the identification of the effects of non-adherence, in order to optimise patient management.
A search algorithm was developed to identify all publications on therapeutic adherence in COPD published between 2010 and 2017, in English and in French. The databases used were MEDLINE, ScienceDirect, BDSP, Cochrane and CAIRN.
Of the 1551 articles initially identified, 94 were included in the review (65 observational studies, 11 interventional studies and 18 reviews or general overviews). Observational studies considered the predictive factors for adherence/non-adherence, and their consequences. Interventional studies evaluated the efficacy of interventions designed to improve adherence.
Despite major therapeutic progress, the essential problems of COPD management remain. While the treatment armamentarium has expanded in recent years, there is still a great deal of work to be done in simplifying treatment regimens, improving the administration of these treatments and motivating patients to be compliant with them. This review also highlights the need for better physician–patient communication.
The Role of Fixed-Dose Dual Bronchodilator Therapy in Treating COPD
2018, American Journal of Medicine
Citation Excerpt :
Recommendations for device selection in current guidelines are limited. As device suitability depends on several factors (eg, inhalation technique, coordination, inspiratory flow; Table 3),11,59,60 an algorithm has been developed to help identify the most suitable inhaler type for a given patient (Figure 2).61 A device should be chosen after careful evaluation of the patient's clinical condition, as well as patient preference.
The incidence of chronic obstructive pulmonary disease (COPD) is rising in the United States, and the disease represents a significant source of morbidity and mortality. Primary care providers face many challenges in COPD diagnosis and treatment, as different clinical phenotypes require personalized treatment approaches. Patient adherence and inhaler technique also contribute to treatment outcomes. Around 48% of primary care providers are unaware of guidelines and recommendations for COPD diagnosis and treatment, which may lead to misdiagnosis or undertreatment of COPD symptoms. Inadequately treated COPD can impair patients' quality of life and ability to perform everyday activities. Long-acting bronchodilator therapy is the cornerstone treatment for patients with COPD; combinations of bronchodilators of different pharmacological classes have shown improved efficacy vs monotherapy. We review the rationale behind fixed-dose dual bronchodilator therapy, evidence for the 4 currently Food and Drug Administration-approved long-acting anticholinergic bronchodilators/long-acting β₂-agonists fixed combinations, patient suitability for the available inhaler devices, and practical guidance to optimize personalized care for patients with COPD.
Factors affecting the selection of an inhaler device for COPD and the ideal device for different patient profiles. Results of EPOCA Delphi consensus
2018, Pulmonary Pharmacology and Therapeutics
Citation Excerpt :
Therefore, the selection of the most adequate inhalation device that takes into account the characteristics of the individual patient may result in improved adherence and better clinical outcomes. The importance of factors such as age, cognitive status, visual acuity, manual dexterity, manual strength and ability to coordinate have been highlighted in previous extensive reviews [9] and a practical approach to the selection of the best device for each type of patient has been proposed [10,24]; however, the opinion of respiratory specialists about the relevance of the characteristics of the inhalation devices and their preferred choices for different types of COPD patients have only seldom been investigated [25,26]. As a result of this Delphi consensus, we previously reported the perception of specialists about the requirements of an inhalation device to be used for the treatment of COPD.
This study aimed to identify the relevant factors for the choice of an inhaler device by physicians and the selection of the most important characteristics of a device according to different characteristics of patients with COPD.
In this two-round Delphi survey, 96 Spanish COPD-expert pulmonologists completed an internet-based, self-administered questionnaire, which consisted of a first part with 19 items related to the prioritization of the drug or the device, the experience, ability and preference of the patient, and the experience and preferences of the healthcare professional. For each item, responses were grouped into three categories based on a 9-point Likert-type scale, calculating the response frequency and the degree of consensus. The second part included 18 items related to the inhalation devices with the aim to identify the main characteristics of a device for 8 different profiles of patients with COPD.
Experts considered that the selection of a device was relevant when choosing the treatment for COPD patients, although 62.5% of them prioritised the selection of the drug over the device. The experience of the patient (89.6%) and his/her ability to handle the device (97.9%), together with coordination (96.9%), ability to learn (87.5%) and adherence to therapy (84.4%) were the main aspects considered in the selection of inhalation device. The panel identified Respimat^® as the most adequate device for patients with either low inspiratory flow or severely impaired lung function and Spiromax^® for patients with either impaired fine motor skills or older than 70 years.
Selection of the inhalation device is recognized by specialists as a strategic therapeutic decision and should be based on the characteristics of the individual patient. Some devices may be more adequate for different patient profiles.
Treatment of stable COPD
2017, Archivos de Bronconeumologia
Inhalation devices, delivery systems, and patient technique
2016, Annals of Allergy, Asthma and Immunology
Citation Excerpt :
Differences in efficacy and safety are affected by the potency of the molecule; pharmacokinetic properties of the ICS, such as bioavailability and elimination; particle size and distribution; constancy of dosing, which is influenced by the intrinsic airflow resistance of the inhaler; and patient characteristics, including differences in breathing patterns, airway caliber, and patient technique.1,2 Typically, little consideration is given to the properties of different inhalers and formulations,3 and clinical guidelines for asthma do not offer much guidance on how these properties ought to affect treatment choices.4 The purpose of this article is to help improve the selection of ICS for asthma, including consideration of the effects of inhalation devices and user technique on efficacy, safety, and adherence.
In real-life clinical settings, physicians often consider the properties of various inhaled corticosteroids (ICSs), but typically little consideration is given to the properties of different inhalers and formulations.
To discuss the effects of inhalation devices and user technique on efficacy, safety, and adherence with the aim of improving asthma management.
Relevant publications were selected to augment discussion.
There are many types of devices available, each with advantages, disadvantages, ease of use, and rate of misuse. Aerosol particle size influences the deposition pattern of a drug in the lungs, and the optimal particle size range is 1 to 5 μm. Retrospective reviews suggest that smaller particles (1–2 μm) could provide improved asthma control, but randomized, prospective studies are needed. Multiple studies have demonstrated high misuse rates in patients for pressurized metered-dose inhalers and dry powder inhalers. Because of this, repeated education should include physical demonstrations of using the device, checking the patient's technique, correcting the technique, and rechecking the technique. This also means that dedicated, trained staff and placebo devices should be available for instructing patients. Furthermore, the device should be selected to be cost effective and to fit the patient's preference and ability to use it correctly to enhance compliance. Asthma management guidelines and algorithms are available to guide the clinician.
The choice of inhaler device should depend on cost effectiveness and the patient's preference and ability to use it correctly. Patient inhaler technique should be checked and, if necessary, corrected and rechecked, with retraining if needed, at every opportunity.

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ReviewWhich factors affect the choice of the inhaler in chronic obstructive respiratory diseases?

Abstract

Introduction

Section snippets

Role of the inhaler in the management of chronic obstructive respiratory diseases

Key points in managing treatment by inhaled medications

Drug deposition according to device selection

Comparing devices for chronic obstructive pulmonary diseases

Patient adherence in the management of chronic obstructive respiratory diseases

Conclusions

Acknowledgements

Chest

Int J Pharm

Pulm Pharmacol Ther

Ann Allergy Asthma Immunol

Int J Pharm

Respir Med

Immunol Allergy Clin N Am

BMC Pulm Med

Chest

What the pulmonary specialist should know about the new inhalation therapies

Eur Respir J

Pediatric aerosol therapy: new devices and new drugs

Respir Care

Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability

Eur Respir J

Multiple inhalers confuse asthma patients

Eur Respir J

Development of respimat soft mist inhaler and its clinical utility in respiratory disorders

Med Devices Auckl

Anatomy and physiology in delivery: can we define our targets?

Alergy

Review
Which factors affect the choice of the inhaler in chronic obstructive respiratory diseases?