The correct use of inhalation devices is an inclusion criterion for all studies comparing inhaled treatments. In real life, however, patients may make many errors with their usual inhalation device, which may negate the benefits observed in clinical trials. Our study was undertaken to compare inhalation device handling in real life. A total of 3811 patients treated for at least 1 month with an inhalation device (Aerolizer, Autohaler, Diskus, pressurized metered dose inhaler (pMDI), or Turbuhaler) were included in this observational study performed in primary care in France between February 1st and July 14th, 2002. General practitioners had to assess patient handling of their usual inhaler device with the help of a checklist established for each inhaler model, from the package leaflet. Seventy-six percent of patients made at least one error with pMDI compared to 49-55% with breath-actuated inhalers. Errors compromising treatment efficacy were made by 11-12% of patients treated with Aerolizer, Autohaler, or Diskus compared to 28% and 32% of patients treated with pMDI and Turbuhaler, respectively. Overestimation of good inhalation by general practitioners was maximal for Turbuhaler (24%), and lowest for Autohaler and pMDI (6%). Ninety percent of general practitioners felt that participation in the study would improve error detection. These results suggest that there are differences in the handling of inhaler devices in real life in primary care that are not taken into account in controlled studies. There is a need for continued education of prescribers and users in the proper use of these devices to improve treatment efficacy.

Background: Early life development may influence subsequent respiratory morbidity. The impact of factors determined in childhood on adult lung function, decline in lung function and chronic obstructive pulmonary disease (COPD) was investigated. Methods: European Community Respiratory Health Survey participants aged 20-45 years randomly selected from general populations in 29 centres underwent spirometry in 1991-3 (n = 13 359) and 9 years later (n = 7738). Associations of early life factors with adult forced expiratory volume in 1 s (FEV 1 ), FEV 1 decline and COPD (FEV 1 /FVC ratio ,70% and FEV 1 ,80% predicted) were analysed with generalised estimating equation models and random effects linear models. Results: Maternal asthma, paternal asthma, childhood asthma, maternal smoking and childhood respiratory infections were significantly associated with lower FEV 1 and defined as ''childhood disadvantage factors''; 40% had one or more childhood disadvantage factors which were associated with lower FEV 1 (men: adjusted difference 95 ml (95% CI 67 to 124); women: adjusted difference 60 ml (95% CI 40 to 80)). FEV 1 decreased with increasing number of childhood disadvantage factors (>3 factors, men: 274 ml (95% CI 154 to 395), women: 208 ml (95% CI 124 to 292)). Childhood disadvantage was associated with a larger FEV 1 decline (1 factor: 2.0 ml (95% CI 0.4 to 3.6) per year; 2 factors: 3.8 ml (95% CI 1.0 to 6.6); >3 factors: 2.2 ml (95% CI 24.8 to 9.2)). COPD increased with increasing childhood disadvantage (1 factor, men: OR 1.7 (95% CI 1.1 to 2.6), women: OR 1.6 (95% CI 1.01 to 2.6); >3 factors, men: OR 6.3 (95% CI 2.4 to 17), women: OR 7.2 (95% CI 2.8 to 19)). These findings were consistent between centres and when subjects with asthma were excluded. Conclusions: People with early life disadvantage have permanently lower lung function, no catch-up with age but a slightly larger decline in lung function and a substantially increased COPD risk. The impact of childhood disadvantage was as large as that of heavy smoking. Increased focus on the early life environment may contribute to the prevention of COPD.Early life environment is most important for the development of asthma and atopy, 1-3 but there has been less focus on early life origins of chronic obstructive pulmonary disease (COPD).1 4-6 The development of the bronchial tree is completed in terms of numbers of terminal bronchioles by the first trimester of pregnancy.7 The final number of alveoli is established by the age of 2 years. 7 8 Thereafter, growth and functional development of the bronchial tree and the alveoli continue until a plateau phase is reached by the end of adolescence in women 9 and in the mid-20s in men. 10 11 It seems plausible that this period of development and growth of the lungs might be important for lung function and the development of COPD later in life. 5While smoking is a very important determinant for adult lung function and COPD, there is a wide variation in adult lung function that is not related to smoking 12 and that could ...

Chronic obstructive pulmonary disease (COPD) is responsible for early mortality, high death rates and significant cost to health systems. The projection for 2020 indicates that COPD will be the third leading cause of death worldwide (from sixth in 1990) and fifth leading cause of years lost through early mortality or handicap (disability-adjusted life years) (12th in 1990). Active smoking remains the main risk factor, but other factors are becoming better known, such as occupational factors, infections and the role of air pollution. Prevalence of COPD varies according to country, age and sex. This disease is also associated with significant comorbidities. COPD is a disorder that includes various phenotypes, the continuum of which remains under debate. The major challenge in the coming years will be to prevent onset of smoking along with early detection of the disease in the general population.

Acute exacerbations of chronic obstructive pulmonary disease (COPD) can be prevented by inhaled treatment. Errors in inhaler handling, not taken into account in clinical trials, could impact drug delivery and minimise treatment benefit. We aimed to assess real-life inhaler device handling in COPD patients and its association with COPD exacerbations.To this end, 212 general practitioners and 50 pulmonologists assessed the handling of 3393 devices used for continuous treatment of COPD in 2935 patients. Handling errors were observed in over 50% of handlings, regardless of the device used. Critical errors compromising drug delivery were respectively made in 15.4%, 21.2%, 29.3%, 43.8%, 46.9% and 32.1% of inhalation assessment tests with Breezhaler® (n=876), Diskus® (n=452), Handihaler® (n=598), pressurised metered-dose inhaler (pMDI) (n=422), Respimat® (n=625) and Turbuhaler® (n=420).The proportion of patients requiring hospitalisation or emergency room visits in the past 3 months for severe COPD exacerbation was 3.3% (95% CI 2.0-4.5) in the absence of error and 6.9% (95% CI 5.3-8.5) in the presence of critical error (OR 1.86, 95% CI 1.14-3.04, p<0.05).Handling errors of inhaler devices are underestimated in real life and are associated with an increased rate of severe COPD exacerbation. Training in inhaler use is an integral part of COPD management.