The role of inspiratory flow in selection and use of inhaled therapy for patients with chronic obstructive pulmonary disease

Mahler, Donald A.

doi:10.1016/j.rmed.2019.105857

Cited by 51 publications

(57 citation statements)

References 53 publications

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“…The inhalation manoeuvre, that is, inhalation flow rate and duration, is a potential source of critical errors. The checklist used in this study for each device model included a step evaluating if the inhalation manoeuvre was demonstrated as described in the patient information leaflets, for example, hard and fast for DPIs and slow and steady for the Respimat, as recommended 23 , and performed in the previous studies 15,16,18,19,22 . Thus, the inhalation manoeuvre was evaluated visually, using a similar procedure as in usual primary care, or at respiratory wards or outpatient clinics.…”

Section: Discussionmentioning

confidence: 99%

Critical inhaler technique errors in Swedish patients with COPD: a cross-sectional study analysing video-recorded demonstrations

Sulku

Bröms

Högman

et al. 2021

npj Prim. Care Respir. Med.

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A correct use of inhaler devices is essential in chronic obstructive pulmonary disease (COPD) treatment. Critical errors were studied by analysing 659 video-recorded demonstrations of inhaler technique from 364 COPD patients using six different inhaler device models. The majority of the included patients used two (55%) or more (20%) device models. Overall, 66% of the patients made ≥1 critical error with at least one device model. The corresponding numbers for patients using 1, 2 and ≥3 device models were 43%, 70% and 86%, respectively. The only factor associated with making ≥1 critical error was simultaneous use of two (adjusted odds ratios (aOR) 3.17, 95% confidence interval (95% CI) 1.81, 5.64) or three or more (aOR 8.97, 95% CI 3.93, 22.1) device models. In conclusion, the proportion of patients making critical errors in inhaler technique was substantial, particularly in those using several different device models. To obtain optimal COPD treatment, it is important to assess a patient’s inhaler technique and to minimise the number of inhaler device models.

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Section: Discussionmentioning

confidence: 99%

Critical inhaler technique errors in Swedish patients with COPD: a cross-sectional study analysing video-recorded demonstrations

Sulku

Bröms

Högman

et al. 2021

npj Prim. Care Respir. Med.

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“…Although the PIFs considered adequate for each type of ID vary according to the source consulted, for this study we used the PIFs proposed by Mahler et al [6] at 30-60 L/min for pMDIs, ≤30 L/min for pMDIs with chamber, 15-50 L/min for SMIs, 60 L/min for low and medium resistance DPIs (R1 to R4), and 30 L/min for high resistance DPIs (R5). For patients with more than one prescribed ID, their PIF was considered adequate when their inhalation capacity fell within the ranges for all their prescribed inhalers.…”

Section: Measurement Toolsmentioning

confidence: 99%

“…It has been shown that the reduced inspiratory flow of these patients influences the effectiveness of the drugs being administered and this has relevant clinical consequences [5]. Thus, assessing the inspiratory flow of patients may be important in the choice of ID they should be prescribed [6]. Unfortunately, despite the relevance of this data, inspiratory flow is currently not often measured or standardized as part of the healthcare provided to patients with COPD, in part because comfortable, validated devices for this purpose are not routinely available.…”

Section: Introductionmentioning

confidence: 99%

Evaluation of Suboptimal Peak Inspiratory Flow in Patients with Stable COPD

Represas-Represas

Aballe-Santos

Fernández-García³

et al. 2020

JCM

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Objective: Although the importance of assessing inspiratory flow in the selection of treatments for chronic obstructive pulmonary disease (COPD) is understood, evaluation of this factor is not yet widespread or standardized. The objective of the present work was to evaluate the peak inspiratory flow (PIF) of patients with COPD and to explore the variables associated with a suboptimal PIF. Methods: An observational, cross-sectional study was carried out at specialized nursing consultations over a period of 6 months. We collected clinical data as well as data on symptoms, treatment adherence, and patient satisfaction with their inhalers via questionnaires. PIF was determined using the In-Check Dial G16® device (Clement Clarke International, Ltd., Harlow, UK). In each case, the PIF was considered suboptimal when it was off-target for any of the prescribed inhalers. The association with suboptimal PIF was evaluated using multivariate logistic regression and the results were expressed as the odds ratio (OR) with 95% confidence interval (CI). Results: A total of 122 COPD patients were included in this study, of whom 34 (27.9%) had suboptimal PIF. A total of 229 inhalers were tested, of which 186 (81.2%) were dry powder devices. The multivariate analysis found an association between suboptimal PIF and age (OR = 1.072; 95% CI (1.019, 1.128); p = 0.007) and forced vital capacity (OR = 0.961; 95% CI (0.933, 0.989); p = 0.006). Conclusions: About a third of patients in complex specialized COPD care have suboptimal PIFs, which is related to age and forced vital capacity.

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“…The three handheld inhalation devices used in the treatment of COPD are dry powder inhalers (DPIs), pressurized metered-dose inhalers (pMDIs) and soft mist inhalers (SMIs). 5,6 The delivery and deposition of medication in the lungs by these devices is affected by both inhaler characteristics and patient-related factors, such as peak inspiratory flow (PIF). 6,7 DPIs, for example, require a PIF of >60 L/minute (low to medium-high resistance devices) 6,[8][9][10] to overcome the inhaler's internal resistance and separate the medicine from its carrier particles.…”

Section: Introductionmentioning

confidence: 99%

“…5,6 The delivery and deposition of medication in the lungs by these devices is affected by both inhaler characteristics and patient-related factors, such as peak inspiratory flow (PIF). 6,7 DPIs, for example, require a PIF of >60 L/minute (low to medium-high resistance devices) 6,[8][9][10] to overcome the inhaler's internal resistance and separate the medicine from its carrier particles. [11][12][13][14] Duarte et al reported that as many as one in five ambulatory patients with COPD have suboptimal PIF.…”

Section: Introductionmentioning

confidence: 99%

TRONARTO: A Randomized, Placebo-Controlled Study of Tiotropium/Olodaterol Delivered via Soft Mist Inhaler in COPD Patients Stratified by Peak Inspiratory Flow

Mahler

Ludwig-Sengpiel²,

Ferguson³

et al. 2021

COPD

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Background: Inhaled bronchodilator therapy is currently the mainstay of treatment for patients with chronic obstructive pulmonary disease (COPD). Some inhalers require patients to achieve certain inhalation efforts either to activate the device or to deliver medication to the site of action. For dry powder inhalers, low peak inspiratory flow (PIF) can result in poor medication delivery but the clinical significance of this is not well understood. Methods: TRONARTO was a 4-week, randomized, double-blind, placebo-controlled, multicenter, parallel-group study which stratified patients with moderate-to-severe COPD according to their PIF against medium-low resistance at screening. Patients were randomized to receive tiotropium/olodaterol (5 μg/5 μg) or matched placebo delivered via the Respimat ® Soft Mist™ inhaler (SMI). After 4 weeks of treatment, we assessed change from baseline in forced expiratory volume in 1 second (FEV 1 ) area under the curve 0-3 hours (FEV 1 AUC 0-3h ) and trough FEV 1 . Results: Overall, 213 patients were randomized, of whom 106 received tiotropium/olodaterol (PIF <60 L/min, 55; PIF ≥60 L/min, 51) and 107 received placebo (PIF <60 L/min, 55; PIF ≥60 L/min, 52). For FEV 1 AUC 0-3h , the adjusted mean change from baseline versus placebo was 336 mL (95% confidence interval [CI] 246-425 mL; P<0.0001) in the PIF <60 L/min group and 321 mL (95% CI 233-409 mL; P<0.0001) in the PIF ≥60 L/min group. For trough FEV 1 , the adjusted mean change from baseline versus placebo was 201 mL (95% CI 117-286 mL; P<0.0001) in the PIF <60 L/min group and 217 mL (95% CI 135-299 mL; P<0.0001) in the PIF ≥60 L/min group. Conclusion:In the TRONARTO study, which included patients with moderate-to-severe COPD and varying inspiratory flow abilities, treatment with tiotropium/olodaterol resulted in significant lung function improvements versus placebo. This SMI can be used irrespective of the PIF that a patient can generate.

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The role of inspiratory flow in selection and use of inhaled therapy for patients with chronic obstructive pulmonary disease

Cited by 51 publications

References 53 publications

Critical inhaler technique errors in Swedish patients with COPD: a cross-sectional study analysing video-recorded demonstrations

Critical inhaler technique errors in Swedish patients with COPD: a cross-sectional study analysing video-recorded demonstrations

Evaluation of Suboptimal Peak Inspiratory Flow in Patients with Stable COPD

TRONARTO: A Randomized, Placebo-Controlled Study of Tiotropium/Olodaterol Delivered via Soft Mist Inhaler in COPD Patients Stratified by Peak Inspiratory Flow

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