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PubMed2004

The course of inhalation profiles during an exacerbation of obstructive lung disease.

BACKGROUND: Acute exacerbations of asthma and chronic obstructive pulmonary disease (COPD) are associated with increased airflow Limitation, hyperinflation and respiratory muscle fatigue. It is unclear, whether patients are able to perform adequate inhalations through various inhalation devices with different orfices during an exacerbation. The aim of this study was to examine the evolution of inhalation profiles of patients inhaling through Diskus, Turbuhaler, pressurized metered dose inhaler (pMDI) and Volumatic and consequently the appropriateness of using the various devices during an exacerbation. MEASUREMENTS: 15 hospitalized patients participated in this randomized comparison of inhalation profiles through the four placebo-devices. For each device, triplicate inhalation profiles were recorded during day 1-9 of admission and in stable phase (day 50). RESULTS: The mean percentage of patients performing optimum inhalation profiles was 100% for Diskus, 60% for Turbuhaler, 14% for pMDI and 87% for Volumatic over the interval of day 1-9 and day 50. Patients with an inspiratory muscle strength (MIP) of less than 6kPa were generally unable to generate the optimum flow through the Turbuhaler (>60 l/min). CONCLUSION: The Diskus and Volumatic can be used effectively in the acute phase of an exacerbation of asthma or COPD. The Turbuhaler could be optimally used after the fifth day of convalescence. The pMDI is rather unsuitable during an exacerbation.

Acute Disease↗
PubMed2004

Combined corticosteroid and long acting beta-agonist in one inhaler for chronic obstructive pulmonary disease.

BACKGROUND: Long-acting beta-agonists and inhaled corticosteroids have both been recommended in guidelines for the treatment of chronic obstructive pulmonary disease. Their co-administration in a combined inhaler is intended to facilitate adherence to medication regimens, and to improve efficacy. OBJECTIVES: To assess the efficacy of combined inhaled corticosteroid and long-acting beta-agonist preparations, compared to placebo or the individual components, in the treatment of adults with chronic obstructive pulmonary disease. SEARCH STRATEGY: We searched the Cochrane Airways Group chronic obstructive pulmonary disease (COPD) trials register. Date of last search April 2004. SELECTION CRITERIA: Studies were included if they were randomised and double-blind. Studies could compare a combined inhaled corticosteroids and long-acting beta-agonist preparation with either component preparation or placebo. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. The primary outcome was exacerbations. MAIN RESULTS: Six randomised trials with 4118 participants were included. Two different combination preparations (fluticasone/salmeterol and budesonide/formoterol) were used. Combination treatment was more effective than placebo for mean exacerbation rates, quality of life and lung function. No trials were found comparing the combination of drugs in a single inhaler with the same drugs both given in separate inhalers. Exacerbations: Fluticasone/salmeterol did not significantly reduce exacerbations compared with either of its component treatments in one large study. There was no significant difference when budesonide/formoterol was compared with budesonide. Budesonide/formoterol was more effective than formoterol in reducing exacerbations (Rate ratio: 0.78 [0.68 to 0.90], two studies). A pooled analysis of both combination therapies indicated that exacerbations were less frequent when compared with either placebo or long-acting beta-agonist (versus placebo Rate ratio: 0.76 [0.68, 0.84], three studies, versus beta-agonist, Rate ratio: 0.85 [0.77, 0.95], three studies), but not when compared with steroid. The clinical impact of this effect depends on the frequency of exacerbations experienced by patients. One full exacerbation was prevented for every two to four years of treatment in the type of patients included in the trials. Quality of Life: There were conflicting findings in quality of life and symptoms when fluticasone/salmeterol was compared with inhaled steroids alone (three studies). There was no significant difference between fluticasone/salmeterol and long-acting beta-agonist in quality of life scores (three studies). Budesonide/formoterol improved symptoms when compared with budesonide but not with formoterol. There were conflicting findings in quality of life scores when budesonide/formoterol was compared with component inhaled corticosteroid or beta-agonist. These may be accounted for by different study design. Lung Function: Treatment with either combination led to small, significant differences in lung function compared with component steroid medication. Fluticasone/salmeterol led to small improvements in FEV1 compared with salmeterol, but budesonide/formoterol treatment did not increase FEV1 significantly when compared with formoterol. REVIEWERS' CONCLUSIONS: Compared with placebo, combination therapy led to clinically meaningful differences in quality of life, symptoms and exacerbations. However, there were conflicting results when the different combination therapies were compared with the mono-components alone. In order to draw firmer conclusions about the effects of combination therapy in a single inhaler more data are necessary, including the assessment of the comparative effects with separate administration of the two drugs in double-dummy trials.

Adrenergic beta-Agonists↗
PubMed1990

Use of different inhalation devices in children.

Many studies in which patient's inhaler use technique has been studied have shown that one of the major problems patients have, in using an inhaler correctly, is that of poor coordination of inhaler actuation with inspiration. We have studied a new breath-actuated inhaler ("Autohaler" 3M Riker) which is designed to ensure correct coordination automatically. This study involves 100 children (aged 3-10 years) and includes both normal children and asthmatic patients. None of these children have previous experience using any type of inhaler. Each child is taught to use the "Autohaler" containing a placebo only. A video film is employed in order to standardize the teaching technique. Once the child is able to operate the new inhaler correctly, he or she inspires through an "Autohaler" unit specially modified so that the inspiratory flow rate and the volume of air inhaled is measured by a pneumotachograph in series with the inhaler. The time point, within the inspiratory cycle, at which the inhaler is triggered is also recorded. The majority of children older than 7 years were able to use the "Autohaler" after a few minutes instruction. Therefore, this is a valuable alternative in this age group.

Asthma↗
PubMed2006

Anti-inflammatory effects of inhaled nitric oxide are optimized at lower oxygen concentration in experimental Klebsiella pneumoniae pneumonia.

OBJECTIVE AND DESIGN: To evaluate whether antiinflammatory effects of inhaled nitric oxide (NO) in experimental Klebsiella pneumoniae pneumonia may be affected by oxygen levels in association with cytokine response and NO synthase (NOS) activity. SUBJECTS AND TREATMENT: Healthy adult rats were intratracheally instilled with live Klebsiella pneumoniae to induce pneumonia (P) or with sterile saline as a control (C) group. Group C was allocated to room air (CA) and inhaled NO (CNO, NO = 20 parts per million) groups. Group P was divided into 6 groups (n = 8 - 10) exposed to room air (PA), inhaled NO (PNO), low oxygen (40%, PLO), inhaled NO and low oxygen (PLONO), high oxygen (100%, PHO), and inhaled NO and high oxygen (98%, PHONO). After 24 h exposure, intraalveolar cells, expression of proinflammatory cytokines, nuclear transcription factor (NF-kappaB), myeloperoxidase (MPO) and NOS activities, characteristic of lung inflammatory mechanisms, were measured. RESULTS: All the pneumonia groups had pneumonia whereas CA and CNO had no or mild lung inflammation. Compared to the PA, significantly decreased recruitment of alveolar neutrophils was found in the PNO, along with lower NF-kappaB and MPO activity, tumor necrosis factor-alpha (TNF-alpha) and intercellular adhesion molecule-1 (ICAM-1). Similar trends were found between the PLONO and PLO in alleviation of lung inflammation. However, PHONO significantly enhanced recruitment of alveolar neutrophils and pulmonary MPO activity associated with increased TNF-alpha. Inhaled NO improved bacterial clearance, reduced total proteins in alveoli, and ICAM-1 expression irrespective of oxygen levels. Inhaled NO and/or low and high oxygen partially restored constitutive NOS activity whereas high oxygen or together with inhaled NO depressed inducible NOS activity. CONCLUSIONS: The overall beneficial effects of inhaled NO in anti-inflammation in the mature lungs with K. pneumoniae pneumonia are in favor of a combination with lower level of oxygen, which warrants clinical verification in the treatment of lung inflammatory injury.

Animals↗
PubMed1996

[NO inhalation in heart surgery procedures: relevance for right heart function?].

UNLABELLED: The right ventricle is more jeopardized by a cardiopulmonary bypass than the left one. Impaired right ventricular performance may profit from an afterload reduction. A selective reduction in pulmonary artery pressure (PAP) or pulmonary vascular resistance (PVR) without impairment of the systemic circulation seems to be possible by inhalation of nitric oxide (NO). Therefore in the present study we looked for influences of NO inhalation on PAP, PVR and right heart parameters immediately after weaning from the bypass. The dependence of endothelial function on age, preoperative heart function and extracorporeal circulation is well established. The relevance of such parameters on NO inhalation was also investigated. METHODS: After ethical approval and informed consent were obtained, 20 patients with moderately increased PAP were included in the study. Ten patients inhaled NO at a concentration of 30 ppm; the other group served as a control group. Measurement points were 10 min after the end of extracorporeal circulation (baseline), 3, 10, and 20 min after the start, as well as 10 min after the end of NO inhalation. NO was injected near the tube into the tubing system during inspiration; dosage and monitoring of the concentration were achieved by means of a chemiluminometer. Measured parameters consisted of PAP, PVR, right ventricular ejection fraction and volumes, systemic blood pressure and resistance, central venous pressure, pulmonary capillary wedge pressure, and oxygenation parameters (paO2, pvO2, paCO2). RESULTS: The decrease in PAP (from 29.7 +/- 3.9 to a minimal 25.4 +/- 4.3 mm Hg, P < 0.005) and in PVR (from 169.4 +/- 51.9 to a minimal 116.3 +/- 60.9 dyn.s.cm-5, P.0.05) did not improve right heart function. A similar significant increase in SVR was observed in the NO group and in the control group. Age, haemodynamic parameters or duration of the ischaemic phase of the cardiopulmonary bypass did not influence the course of PAP or PVR. Changes in PAP (from 30.0 +/- 4.0 to a minimal 26.7 +/- 3.6 mm Hg, P < 0.05) and PVR (from 149.0 +/- 41.5 to a minimal 125.2 +/- 51.5 dyn.s.cm-5, in the control group were not statistically different from those in the NO group. Indicators of intoxication like an increase in NO2 or methaemoglobin concentrations or changes in compliance or resistance were not observed. CONCLUSIONS: Patients with moderate pulmonary hypertension did not profit from NO inhalation immediately after weaning from the cardiopulmonary bypass. The decreases in PAP and PVR found in the NO or control group did not improve right-heart function. When the NO and control group were compared, specific effects of NO inhalation on PAP and PVR must be questioned. This could perhaps be explained by data from animal experiments, which found high endogenous NO levels in situations with elevated cytokine levels. Cytokines are increased after extracorporeal circulation. Oxygenation was not impaired by inhalation of relatively high concentrations of NO. For all investigations with NO inhalation not preceded by steady-state conditions, a control group is recommended.

Aged↗
PubMed2003

The effects of one-week fluticasone propionate inhalation therapy for Tc-99m DTPA radioaerosol distribution in asthma of children: a preliminary report.

This study evaluated the effects of fluticasone propionate inhalation therapy for the distribution pattern of Tc-99m DTPA radioaerosols in 10 children with asthma. The homogeneous degree of depositing Tc-99m DTPA radioaerosol was evaluated using a modified standard score system over the bilateral lungs. The baseline scores were calculated from Tc-99m DTPA radioaerosol inhalation lung scintigraphy before inhalation therapy (100 microg fluticasone propionate two times daily for one week), and the scores were recalculated after inhalation therapy to evaluate the effects of one-week of fluticasone propionate inhalation therapy for Tc-99m DTPA radioaerosol distribution patterns. After one week of fluticasone propionate inhalation therapy, the scores were decreased in all of the 10 children, which may mean that the bronchial constriction degree due to asthma is decreased. In addition, there was a significantly statistical difference in the scores before and after one-week fluticasone propionate inhalation therapy (p < 0.05). In conclusion, one-week fluticasone propionate inhalation therapy could significantly improve the bronchial constriction due to asthma in children based on the evidence of Tc-99m DTPA radioaerosol inhalation lung scintigraphic findings.

Androstadienes↗
PubMed1980

Comparison of plasma histamine and cyclic nucleotides after antigen and methacholine inhalation in man.

Serial determinations of plasma histamine and cyclic nucleotides (adenosine monophosphate [AMP] and guanosine monophosphate [GMP]) were performed after inhalation of antigen and methacholine in four groups of subjects. In the first group, consisting of six antigen-sensitive subjects exhibiting bronchospasm after inhalation of ragweed or grass antigen, plasma histamine was elevated within 2 min and persisted for 30 min after inhalation of antigen. Peak histamine levels were between 18 to 80 ng/ml. In the second group, consisting of four nonatopic subjects, neither bronchospasm nor histamine was observed, despite inhalation of the same or 10-fold increased concentrations of antigen. In the third group, consisting of six subjects (three atopic and three nonatopic) exhibiting bronchospasm after inhalation of 2.5 to 10 mg of methacholine, sustained increases of histamine began at 1 min and persisted for 60 min after inhalation of methacholine. In the fourth group, seven subjects (two atopic, five nonatopic) without demonstrable bronchospasm despite inhalation of 2.5- to 10-fold increased doses of methacholine, no histamine was detected in the plasma at any time after inhalation of methacholine. Serial measurements of cyclic nucleotides showed no consistent changes in serum levels of cyclic AMP or cyclic GMP following inhalation challenge. We conclude that serum levels of histamine but not cyclic nucleotides change during bronchospasm induced by either antigen or methacholine.

Adult↗
PubMed2004

An evaluation of the acidogenic potential of asthma inhalers.

AIM: The aims of the present study were firstly to investigate the inherent pH and titratable acidity of commercially available paediatric asthma inhalers in the United Kingdom and secondly to assess their in vivo acidogenic potential (saliva pH and plaque pH (PpH) tests) in a group of healthy adult volunteers. MATERIALS AND METHODS: Manually actuated metered dose inhaler (MDI) and dry powder inhaler (DPI) formulations of all available preventor (glucocorticoids, disodium chromoglycate), reliever (beta(2) agonists) and combination asthma medication were investigated. The inherent pH and titratable acidity of 18 inhalers were determined and analysed using t-tests, ANOVA and post hoc Tukey's tests. Following this the oral pH responses after inhaler use were assessed in 14 healthy adult volunteers (complying with the FNDH criteria, 1985) who participated in a random blind study to determine both the salivary pH (SpH) and plaque pH following inhaler use. Non-parametric tests of significance (Mann-Whitney and Wilcoxon Signed-Ranked Tests) were used to analyse pH responses according to vehicle of delivery (MDI/DPI), lactose content and generic drug. RESULTS: The inherent pH of the DPIs (n=8, mean pH=5.06) was significantly lower (P<0.005) than that of the MDIs (n=10, mean pH=6.45) and the titratable acidity of the lactose-based DPIs was twice that of the non-lactose-based DPIs (P<0.000). Lactose-based DPIs produced significantly lower salivary pH and plaque pH readings, greater maximum pH drops from baseline pH and larger areas below baseline pH in comparison with that of all other inhalers tested (P<0.05). All inhalers, however, failed to depress plaque pH below pH 6. CONCLUSIONS: Although none of the inhalers were able to demonstrate an acidogenic response below the "critical" pH, the substantial pH drops observed with the lactose-based DPIs may be an important consideration for enamel demineralisation.

Adrenergic beta-Agonists↗
PubMed2007

The Predicting Response to Inhaled Corticosteroid Efficacy (PRICE) trial.

BACKGROUND: Although guidelines recommend anti-inflammatory therapy for persistent asthma, recent studies suggest that 25% to 35% of patients with asthma may not improve lung function with inhaled corticosteroids. OBJECTIVE: To evaluate potential biomarkers of predicting short-term (6-week) response to inhaled corticosteroid with subsequent evaluation of responders and nonresponders to asthma control over a longer interval (16 additional weeks). METHODS: Eighty-three subjects with asthma off steroid were enrolled in this multicenter study. Biomarkers and asthma characteristics were evaluated as predictors of inhaled corticosteroid response over a 6-week trial for changes in FEV(1) and methacholine PC(20). After this, an additional 4-month trial evaluated asthma control. RESULTS: Although multiple baseline predictors had significant correlations with improvements for short-term inhaled steroid success, the only strong correlations (r >or= +/- 0.6) were albuterol reversibility (r = 0.83; P < .001), FEV(1)/forced vital capacity (r = -0.75; P < .001), and FEV(1) % predicted (r = -0.71; P < .001). Dividing the subjects in the short-term inhaled steroid trial into responders (>5% FEV(1) improvement) and nonresponders (<or=5%) determined the longer-term need for steroids. For the nonresponders, asthma control remained unchanged whether inhaled corticosteroids were continued or were substituted with a placebo (P = .99). The good short-term responders maintained asthma control longer-term only if maintained on inhaled steroids (P = .007). CONCLUSION: The short-term response to inhaled corticosteroids with regard to FEV(1) improvement predicts long-term asthma control. CLINICAL IMPLICATIONS: The decision to use long-term inhaled steroids could be based on a short-term trial. Different therapeutic strategies would need to be established for nonresponders.

Adult↗
PubMed1994

Acute effects of inhaled nitric oxide in children with severe hypoxemic respiratory failure.

To determine the physiologic effects of inhaled nitric oxide (NO) on oxygenation and hemodynamics in children with severe hypoxemic respiratory failure, we studied the acute response to inhaled NO during mechanical ventilation in 17 pediatric patients. Diagnoses included adult respiratory distress syndrome (ARDS) (10 patients), bronchopulmonary dysplasia with viral pneumonitis (6 patients), and acute pneumonitis, caused by respiratory syncytial virus, without chronic lung disease (1 patient). Gas exchange and hemodynamic measurements were compared before and during exposure to inhaled NO (20 ppm) without changing ventilator settings for 30 minutes. Hemodynamic variables, including pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac index, were measured in 10 patients with ARDS. Inhaled NO acutely improved oxygenation in 15 of 17 patients; mean arterial oxygen tension increased from 58 +/- 13 mm Hg (baseline) to 86 +/- 25 mm Hg after 30 minutes (p < 0.01). Inhaled NO lowered mean pulmonary artery pressure (42 +/- 6 mm Hg at baseline to 31 +/- 6 mm Hg; p < 0.01) and intrapulmonary shunt (39% +/- 7% vs 32% +/- 7%; p < 0.01) without changing systemic arterial pressure or pulmonary capillary wedge pressure. Cardiac index increased by 14% (p < 0.01). Fifteen patients were subsequently treated with low-dose inhaled NO (3 to 10 ppm) for 1 to 24 days; 5 (50%) of 10 patients with ARDS and 7 (100%) of the 7 non-ARDS patients survived. We conclude that inhaled NO acutely improves oxygenation and lowers pulmonary vascular resistance without causing adverse hemodynamic effects in severe hypoxemic respiratory failure in pediatric patients. Inhaled NO may be a useful adjuvant therapy in children with acute hypoxemic respiratory failure, including infants with bronchopulmonary dysplasia, but whether prolonged low-dose inhalational NO therapy can reduce morbidity or improve survival rates remains unknown.

Adolescent↗
PubMed2003

Current in vivo and in vitro screens for inhalant allergy.

Screening for inhalant allergy requires the use of a rapid, accurate, cost-effective methodology for the detection of the presence or absence of allergic responsiveness. In vivo and in vitro methods have been demonstrated to be sensitive and specific in the diagnosis of inhalant allergy, even with panels as small as seven or eight antigens. There is good concurrence between skin testing techniques and various serum measures of specific IgE, and both methods can be used effectively for screening inhalant allergy, although per-test costs for in vitro methods remain higher than comparable costs for skin testing [28]. Although the rapidity of both methods is acceptable, skin testing allows immediate observation and interpretation of test results, whereas all in vitro methods involve serum processing that delays results for hours to days. In general, both in vitro methods and epicutaneous testing with a device such as the Multi-Test II offer the clinician effective techniques in screening for inhalant allergy. Each technique has benefit and can be used in both primary care practices and in specialists' offices. The choice of the primary technique to be used for screening depends on the type of practice, the practice's familiarity with skin testing, the geographic region, and the relevant payer mix. A review of the relevant research on allergy screening suggests that the number of antigens used should be in the range of 8 to 12 and should include representative allergens from all the significant classes for the specific geographic [table: see text] region. This screen would probably contain one or two grasses, weeds, and trees, two or three molds, cat allergen, and one dust mite allergen. A sample panel is demonstrated in Box 6. It is important to recognize that the diagnosis and treatment of inhalant allergy is a fluid process. In patients who have negative allergy screens but for whom suspicion of inhalant allergy remains high, additional testing with ID techniques is sometimes indicated. This procedure might be suggested in patients for whom there is a high suspicion of mold allergy or who have unusual inhalant exposures. These individuals may represent a failure of the screening process and require additional testing. In these unusual cases, the judgment of the otolaryngic allergist is critical in guiding this further diagnostic work-up. The use of screening procedures for the diagnosis of inhalant allergy provides a rapid, accurate, and cost-effective method for evaluating patients with a history suggestive of allergic disease. Research suggests that a screening panel has strong clinometric properties and has both sensitivity and specificity in excess of 95%. It is statistically unlikely that a patient with negative findings to an allergy screen will demonstrate clinically significant inhalant allergy.

Humans↗
PubMed2003

[Do our asthma patients still use inhalers incorrectly?].

AIM: To determine how skilled our patients with asthma are in performing different steps in the use of different inhalation devices, and to identify variables that may influence correct inhalation technique (IT). DESIGN: Descriptive, cross-sectional study. SETTING: An urban primary care center. PARTICIPANTS: 141 patients with asthma. MAIN OUTCOME MEASURES: Performance of a practical test to evaluate each step in IT for different devices according to SEPAR-semFYC guidelines. One point was scored for each step that was performed correctly, and the technique was considered correct if the total score was >9. The main outcome variable was the percentage of patients who performed the IT correctly. RESULTS: About three-fourths of the participants (77.3%) were women; mean age was 56.08 +/- 18.99 years. Inhalation technique was incorrect in 53.9% of the patients (51.06% of those who used a pressurized canister inhaler, 59.1% of those who used a PCI+spacer, 38.5% of those who used a Turbuhaler, and 37.5% of those who used an Accuhaler). The highest error rates were seen in exhaling completely before beginning the inhalation (63.78%), holding the breath after inhalation for as long as possible (65.94%), and breathing out slowly after the inhalation (64.86%). Better IT was seen in younger patients with higher levels of education (P=.007). There were no statistically significant differences in the rest of the variables. CONCLUSIONS: A large percentage of patients performed inhalations incorrectly. We cannot conclude that any given device is superior. The variables related with correct IT were age and level of education. Greater health education efforts are needed to teach patients how to use inhalation systems correctly.

Asthma↗
PubMed1998

Asthma-related prescribing patterns with four different corticosteroid inhaler devices.

Four types of corticosteroid inhaler devices are available in New Zealand for first-line treatment of asthma, including two aerosol systems [Autohaler (3M Healthcare Ltd, Loughborough, U.K.; 3M Pharmaceuticals (Australia Pty Ltd, Sydney, Australia) and MDI (Glaxo Wellcome PLC, Ware, U.K.)] and two dry powder systems [Diskhaler (Glaxo Wellcome) and Turbuhaler (Astra AB, Sodertalje, Sweden)]. Rates of asthma-related health care consumption and treatment outcomes associated with use of the different inhalers are unknown. In this retrospective survey, asthma-related primary health care consultation and prescription patterns were compared in a large general practice population for each corticosteroid inhaler device prescribed as first-line treatment. An electronic search of a computerized clinical database yielded the medical records of 5704 patients with physician-diagnosed asthma who were prescribed either the Autohaler, Diskhaler, MDI or Turbuhaler as their sole corticosteroid inhaler device in the previous 12 months. The mean daily inhaled corticosteroid dose was lowest for the Autohaler (569 micrograms day-1; 95% CI: 538-605), followed by the Diskhlaer (638 micrograms day-1; 95% CI: 609-670) and MDI (665 micrograms day-1; 95% CI: 638-673), and was highest for the Turbuhaler (990 micrograms day-1; 95% CI: 954-1029, P < 0.001). A relatively high proportion of patients aged 19-49 years in the Turbuhaler and Diskhaler groups (29% and 23%, respectively) received at least one inhaled corticosteroid prescription including a daily dose greater than 1500 micrograms compared with the MDI group (4%). In the Diskhaler group the mean daily inhaled corticosteroid dose prescribed for adult patients was similar to that for the Turbuhaler group (904 micrograms day-1 and 1058 micrograms day-1, respectively). These data suggest that in New Zealand the dry powder corticosteroid inhaler devices are prescribed for adults at significantly higher doses than the aerosol inhaler devices. Clinical databases of this type yield valuable information on drug utilization in large patient populations and usefully assess clinical prescribing practices.

Adolescent↗
PubMed2002

Does introduction of new "easy to use" inhalational devices improve medical personnel's knowledge of their proper use?

BACKGROUND: Lack of basic inhaler skills by medical personnel has been documented by numerous studies. Consequently, training of patients in correct inhalational technique suffers. Newer dry powder inhalers such as Turbuhaler (budesonide, Astra USA, Westborough, MA) and Diskus (salmeterol, GlaxoSmithKline, Research Triangle Park, NC) have some advantages over conventional metereddose inhalers (MDIs) including easier technique of usage. They have been recently marketed with the hope of overcoming this problem. OBJECTIVE: To determine whether introduction of newer "easy to use" dry powder inhalers such as budesonide (Turbuhaler) and salmeterol (Diskus) would result in improvement in medical personnel's knowledge of their proper use. METHODS: In and around a community-based teaching hospital, interviews were conducted in March 2000 of 50 assorted randomly selected medical personnel. They included 10 respiratory therapists, 10 registered nurses, 10 medical residents, 10 primary care physicians, and 10 pharmacists. Objective evaluation was made of their skills demonstration and knowledge scores for usage of MDIs, budesonide, and salmeterol. RESULTS: Mean percentage demonstration scores of different medical personnel for all three devices taken together: respiratory therapist (81.6%), primary care physicians (77.7%), pharmacists (57.7%), registered nurses (54.4%), and medical residents (53.8%). Mean percentage demonstration scores of different inhalers for all medical personnel taken together: MDI (80.9%), salmeterol (64.2%), budesonide (49.9%). Mean percentage knowledge score of all three inhalational devices taken together for respiratory therapist was the best at 76.6%. Registered nurses performed the worst with a score of 52.0%. Mean percentage knowledge scores: MDI (78%), salmeterol (63.2%), and budesonide (52.4%). A repeated measures two-way analysis of variance demonstrated that differences in both demonstration and knowledge scores between inhaler types and between medical personnel were all highly statistically significant (P < 0.0001). CONCLUSIONS: Demonstration skills and knowledge scores for use of both budedsonide and salmeterol were substantially lower than that for MDI for all medical personnel. Medical personnel responsible for teaching the correct use of inhalational devices are lacking in basic knowledge and user skills. This likely contributes to patient's poor technique when using these devices.

Adult↗
PubMed2001

Patients' opinions of CFC-free inhaler changeover in primary care.

OBJECTIVE: To determine patient's opinions regarding the changeover from CFC containing to CFC-free salbutamol. DESIGN: Patients receiving metered dose salbutamol inhaler therapy were identified and verbal consent was obtained before a semi-structured interview was performed. Setting An outpatient respiratory clinic within a busy teaching hospita. MAIN OUTCOME MEASURES: Knowledge of CFC-free inhaler therapy and acceptance of change. RESULTS: A total of 28 patients were identified of whom only eight (29%) had been changed to a CFC-free product. Six of these (75%) had received counselling from their GP or pharmacist regarding the change. Differences were reported by all of the patients who had been changed to a CFC-free inhaler with comments including difference in taste (6 patients), difference in feel (6), less effective (1) and more effective (1). Three patients preferred the CFC-free inhaler to their previous therapy. Although 13 out of the 20 patients who had not received a CFC-free inhaler stated they were happy with the potential changeover, 10 (80%) has concerns relating to effectiveness. CONCLUSION: The majority of patients still receiving CFC inhalers were aware that the production of CFC-containing products had been restricted although they were unaware of the imminent changes that would take place regarding their inhaler therapy. However, the small sample size recruited in this study may mean that the results are unrepresentative of the CFC-free implementation process in the Grampian Health Board area as a whole. Nonetheless, in view of the differences experienced by patients who received CFC-free inhalers and the concerns stated about potential lack of efficacy by patients about to be changed over, it is essential that healthcare professionals provide advice on CFC-free inhalers to all patients.

Air Pollutants↗
PubMed1992

Biochemical toxicology and disposition of Therminol 66 heat transfer fluid after inhalation or after dietary administration to male Sprague-Dawley rats.

The objectives of this study were to determine the disposition of Therminol 66 in rats and to determine the effects of this heat-transfer fluid on liver and kidney microsomal drug-metabolizing enzymes. Therminol 66 was administered to male Sprague-Dawley rats at various doses as either a single oral administration at 0, 100, or 300 mg/kg, or as a single 6-h inhalation exposure at 0 or 350 mg/m3. Animals were killed 48 h after gavage or after termination of inhalation exposure. Additional groups of animals were exposed to Therminol 66 via the diet at 0, 100, 500, or 5000 ppm for 14 d, or via repeated inhalation exposure at 0, 25, 250, or 1200 mg/m3 for 6 h/d for 14 d. These exposure scenarios represent approximately equivalent doses of Therminol 66 by the different routes of administration. No change in body weight was observed after acute oral or inhalation exposure, and little change in body weight was observed in animals administered Therminol 66 via the diet except at the highest dose. There was no change in kidney weight, and liver weights were increased only at the higher doses of Therminol 66. The body weight gain of animals exposed to Therminol 66 via inhalation decreased in a dose-dependent manner over the 2-wk exposure period. Results from the disposition study indicated that Therminol 66 did not appear to accumulate in the tissues examined and did not appear to be extensively absorbed after a single oral dose of 300 mg/kg. The whole-body elimination half-life was approximately 14 h and occurred primarily via the feces. There was no significant induction of hepatic aryl hydrocarbon hydroxylase (AHH) activity after single oral or inhalation exposures to Therminol 66. Ethoxycoumarin O-deethylase (ECOD) was significantly induced only in animals exposed to 350 mg/m3 via inhalation. Repeated dietary and inhalation exposures resulted in AHH and ECOD induction only at the highest doses, and the kidney appeared to be less sensitive than the liver. Animals exposed via inhalation demonstrated a greater hepatic inductive effect than did animals exposed via the diet, which may be due to absorption differences.(ABSTRACT TRUNCATED AT 400 WORDS)

7-Alkoxycoumarin O-Dealkylase↗
PubMed2001

On the use of dry powder inhalers in situations perceived as constrained.

Dose delivery from dry powder inhalers (DPIs) are dependent on the inhalation effort of the patient. Some patient groups, including asthmatic children, patients with acute asthma, and patients with advanced chronic obstructive pulmonary disease (COPD) are perceived as having problems in readily inhaling from a DPI in an efficient way; this opinion is based on alleged low inhalation flows. A review of the literature however shows that these groups can use a DPI in an efficient way and gain good clinical effect from its use. Particularly, it has been shown that children can generate a good peak inhalation flow through a DPI, albeit a lower inhaled volume. Similarly, patients with acute asthma can use a DPI in an efficient way, even reaching a better clinical effect with the DPI than with a pressurized metered dose inhaler with a spacer. Finally, it was shown that patients with severe COPD can generate the inhalation flows needed to generate an efficient drug aerosol from a DPI. Collectively, the discussed patient groups seem to perform as well as other subjects when it comes to their ability to generate an adequate inhalation flow through a DPI.

Adult↗
PubMed1997

Effect of intermittent cigarette smoke inhalation on tibial lengthening: experimental study on rabbits.

We investigated the effect of intermittent cigarette smoke inhalation on the bone healing of tibial lengthening in rabbits. Thirty-eight male rabbits were divided into two groups of 19 animals each. The first group went through intermittent cigarette smoke inhalation, and the second group did not go through intermittent cigarette smoke inhalation. Each animal's right tibia was lengthened 5 mm using an uniplanar lengthening device. Five animals of each group were killed at 4, 6, and 8 weeks postoperatively for biomechanical testing, and one animal of each group was killed at 2, 4, 6, and 8 weeks postoperatively for histologic study. Using the contralateral nonoperated tibia as an internal control, we found that torsional strength of the lengthened tibia of the smoke inhalation group was decreased significantly compared with the non-smoke inhalation group. The mean percent of maximal torque at 4, 6, and 8 weeks were 22.0, 66.3, and 78.6%, respectively, in the smoke inhalation group, whereas the mean percent of maximal torque were 48.0, 84.1, and 90.8% %, respectively, in non-smoke inhalation group (one-tailed t test, p < 0.01, p < 0.01, and p < 0.05 at 4, 6, and 8 weeks, respectively). Our histologic observations revealed that the granulation tissue resorption, bone formation, and remodeling were delayed in smoke inhalation group. The results of this study suggest that intermittent inhalation of cigarette smoke delays, but does not prevent, the bone healing in tibial lengthening.

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