Assessment of key influences on asthma inhaler device selection.

AIM: To identify factors that influenced trained asthma practice nurses' inhaler device selection and the relative importance they placed on these factors in clinical practice. METHOD: Questionnaires were sent to 1,500 randomly selected, trained asthma nurses working in primary care. A second, open-ended questionnaire was sent to 300 of these nurses. RESULTS: The response rate was 38% (573) for the first questionnaire and 21% (64) for the second questionnaire. Patient-related factors had the greatest influence on device selection. Other important factors were ease of inhaler use, the patient's lifestyle and inspiratory flow. Less important considerations were device availability, the size, shape and colour of the inhaler and recommendations from others. CONCLUSION: Many factors influence device selection. Nurses considered some of the factors identified as important when selecting a device, but not others. Nurses should be aware of potential influences on device selection and should consider their professional accountability in all patient interactions.

Delay in the Provision of Medication by a Pharmacy Outside the Respiratory Outpatient Department.

Respiratory medicine physicians prescribe many different kinds of medications depending on patient's condition. To examine an outside pharmacy's ability to meet the demand of our respiratory prescription services, we developed a questionnaire for all the patients who came to our outpatient department from November 1, 2015 to January 31, 2016. A total of 298 of 330 patients answered the questionnaire. Overall, 169 patients mainly went to the pharmacy near our hospital, whereas 64 patients mainly went to another pharmacy. Specifically, 23 of 219 patients who answered the question "When you went to the pharmacy with prescription, have you ever been not immediately given medication?", were not immediately given medication by the pharmacy. The results show that the other pharmacy significantly delayed medication compared with the one near our hospital. Interestingly, there were many types of inhaler cases that were out of stock in both pharmacies. Also, we found that 9 of 11 patients who were not provided medication on the spot acquired the medication within 1 or 2 d. Further, 10 of 20 patients who were not provided medication on the spot were only able to obtain the medication once. We did not observe any changes in patients' physical condition due to the delay in medication.

Availability and consumption status of CFC and non-CFC inhalers for asthma and chronic obstructive pulmonary diseases in Thailand.

In response to the Montreal Protocol and the calls for global early-bird CFC phase-out before 2010, the demand and supply status of both CFC and non-CFC inhalers for prevention and treatment of asthma and COPD in Thailand were evaluated to determine how soon the country would be able to discontinue CFC MDIs with least impacts to both consumers and importers. Availability and supply of the inhalers were collected from registration and importation database of the Thai FDA. Demand and product cost were obtained from the local importers and from IMS, Thailand. Available inhaled products comprise of 39% CFC MDIs, 28% DPIs, 20% solutions for nebulizers and 13% HFA MDls, respectively. All 31 brands of portable hand-held inhalers, comprising 16 CFC MDIs, 6 HFA MDIs and 9 DPIs, are imported, only solutions for nebulization are locally manufactured. Salbutamol is mostly prescribed MDI, its consumption is over 50% of all. The transition to non-CFC alternatives (HFA MDIs and DPIs) has become evidence since 2000. After being informed about the demand and supply of the inhalers, in 2005, Thai FDA has announced its CFC phase-out policy and encouraged importation of HFA alternatives by facilitating the registration and approval process. When the most prescribing CFC MDls, salbutamol, is completely replaced with non-CFC form in 2006, Thailand would be able to reduce considerable amount of CFCs into our atmosphere.

If we prescribe it, will it come? Access to asthma equipment for Medicaid-insured children and adults in the Bronx, NY.

CONTEXT: Asthma is a major cause of morbidity in the United States. Self-management of asthma requires access to appropriate equipment. Clinical experience in an inner-city practice suggests that families encounter difficulties in filling prescriptions for spacers/holding chambers, peak flow (PF) meters, and nebulizer machines. OBJECTIVES: To determine whether Bronx, NY, pharmacies (1) carry spacers/holding chambers, PF meters, and nebulizer machines; (2) accept Medicaid insurance for them; and (3) perceive barriers to reimbursement by Medicaid for this equipment. DESIGN AND SETTING: Structured telephone survey of 100 Bronx pharmacies randomly selected from the 1999 telephone directory. PARTICIPANTS: Ninety-eight pharmacists and 2 pharmacy technicians in 100 different pharmacies. MAIN OUTCOME MEASURES: Pharmacists' reports of equipment availability, Medicaid acceptance, and reasons for not carrying equipment or accepting Medicaid. RESULTS: Overall equipment availability was as follows: spacers (68%), spacers with masks (57%), adult PF meters (40%), child-range PF meters (24%), and nebulizer machines (56%). For Medicaid recipients, equipment was less available: spacers (45%), spacers with masks (35%), adult PF meters (27%), child-range PF meters (17%), and nebulizer machines (33%). Surveyed pharmacists reported misconceptions about requirements for Medicaid reimbursement, which included the following: that Durable Medical Equipment permits are required (64% spacers and 33% PF meters), that special forms are needed (17% PF meters), or that this equipment is not covered by Medicaid (14% spacers and 8% PF meters). Of the 100 surveyed pharmacists, 32 reported difficulties with Medicaid reimbursement and 41 had never tried to receive reimbursement. CONCLUSIONS: These results suggest that (1) access to spacers/holding chambers, PF meters, and nebulizers for Medicaid-insured families is severely limited in Bronx pharmacies; (2) misunderstandings regarding Medicaid reimbursement policies are common; and (3) interventions to increase the proportion of pharmacies that dispense equipment are needed.

Development and evaluation of a pulsed nebulizer with predictable dosing characteristics.

A metered dose nebulizer assembly with the capability for repeatable doses is described, comprising a commercial disposable nebulizer and a timing circuit to control the duration of air supply. Data on performance of the nebulizer apparatus under typical operating conditions are presented, using cromolyn sodium as a model compound. Repeat doses from the apparatus typically show less than 10% relative standard deviation.

An easy-to-use dry-powder inhaler.

The mometasone furoate dry-powder inhaler is a novel device designed to support compliance by delivering a topical corticosteroid in a simple three-step operation. This breath-actuated inhaler uses a stabilized agglomerate formulation to measure and deliver accurate, uniform, and precise doses of drug over a range of inspiratory flow rates. Laboratory and clinical data have shown that the design produced a simple, clinically effective inhaler for the treatment of adults and children 12 years of age and older with mild, moderate, or severe persistent asthma.

What is new in asthma: new dry powder inhalers.

Asthma affects an estimated 4.8 million children. The pressurized metered-dose inhaler (pMDI), despite problems associated with its use and concern that most of these inhalers contain ozone-damaging chlorofluorocarbons (CFCs), is currently the device most frequently used to deliver inhaled medication. Concerns regarding pMDIs that contain CFCs have led to further development of alternative delivery devices, including CFC-free pMDIs, breath-actuated devices, and dry powder inhalers (DPIs). Advantages and disadvantages of these devices are discussed briefly, with emphasis on the new DPIs. A brief overview of their safety, efficacy, and acceptance by patients is presented. DPIs have the potential to become important devices for administration of inhaled medication in pediatric asthma management.

Association between availability of non-prescription beta 2 agonist inhalers and undertreatment of asthma.

OBJECTIVE: To determine whether the availability of beta 2 agonist inhalers without prescription leads to undertreatment of asthma. DESIGN: Cross sectional study of adequacy of treatment in asthmatic subjects who purchased beta 2 agonist inhalers and subjects who obtained inhalers by prescription. SETTING: Community pharmacies in New South Wales, Australia. SUBJECTS: 403 eligible consecutive asthmatic subjects aged 13 to 55 purchasing salbutamol metered dose inhalers over the counter or by prescription; 197 attended for follow up and spirometry and 139 returned 14 day symptom, peak flow, and medication diaries. MAIN OUTCOME MEASURES: Severity of asthma assessed on frequency of day time and night time wheezing, frequency of inhaler use, and peak expiratory flow rates. Adequacy of treatment according to published guidelines. RESULTS: Of the 139 patients who completed the diary 83, (60%) purchased their inhalers without prescription and 83 were undertreated. The characteristics of patients in the prescription and purchasing groups were similar. Multiple logistic regression analysis identified use of non-prescribed salbutamol as being associated with a 2.9-fold increase in the odds of undertreatment (95% confidence interval 1.3 to 6.8). Smoking increased the odds of undertreatment (3.3, 1.2 to 9.5) and use of a peak flow meter reduced the odds (0.11, 0.04 to 0.34). Adjustment for frequency of consultation made use of non-prescription salbutamol insignificant (1.4, 0.55 to 3.8). Attitudes to services provided by doctors and pharmacists were favourable and not associated with undertreatment. CONCLUSION: Over the counter purchase of salbutamol is associated with infrequent consultation with doctors and undertreatment of asthma.

The efficacy of metered-dose inhalers with a spacer device in the pediatric setting.

PURPOSE: To systematically review the published research and report on the efficacy of using a metered-dose inhaler with a spacer (MDI-S) device in a pediatric setting to treat acute exacerbations of asthma. DATA SOURCES: A literature search was conducted on the CINAHL, Medline, and Cochrane databases; additional searches were made by hand from the reference lists in each study retrieved from databases and from review articles written on the same topic. CONCLUSION: This critical appraisal of the research demonstrates the MDI-S is as effective as the nebulizer, faster in the delivery of medication, and cost-effective. IMPLICATIONS FOR PRACTICE: No significant difference between the MDI-S and nebulizer in delivering medication in an acute exacerbation of asthma was found in this analysis. The practitioner's choice of delivery methods should reflect the family's preference, the practice situation, and economic considerations.

An overview of the current asthma disease management guidance.

Asthma is a common chronic disease that carries considerable costs both to the individual and to the NHS, despite the availability of effective treatments. All nurses will encounter patients with asthma during their professional careers; therefore, a basic understanding of asthma and its management is required. Asthma responds well to treatment, yet asthma deaths still occur. The variability of asthma symptoms requires the patient to bear the responsibility of disease management from day to day. Patient education is needed if asthma is to be managed well and, while inhaler devices provide an effective delivery system, inhaler technique needs to be taught and devices used correctly if maximum benefit is to be achieved. Personal asthma action plants improve asthma control, yet are currently underused. While compliance with long-term treatment is poor and the reasons for this are complex, understanding among healthcare professionals when managing asthma.

Inhaler devices: compliance with steroid therapy.

Many people with asthma do not take their medication as prescribed. The use of inhaler devices is an important factor in patient compliance with steroid therapy. Some of the features that influence compliance are discussed and the characteristics of inhaler devices are compared.

Inhaler devices for use in asthma care.

A patient's ability to use an asthma inhaler correctly will depend on his or her age and manual dexterity. An up-to-date knowledge of the range of inhalers available on the market, and their advantages and disadvantages, will aid selection. Patients should be involved in the selection process as this will encourage compliance.

Prescription of inhalers in asthma and COPD: towards a rational, rapid and effective approach.

Inhaled medication is the cornerstone of the pharmacological treatment of patients with asthma and COPD. The major two classes of inhaled medication include corticosteroids (ICS) and bronchodilators. There is a wide diversity in molecules in both classes. Moreover, there is a wide variation in delivery systems. The correct use of inhalers is not granted and patients often incur in many mistakes when using pMDIs and DPIs, despite repeated instructions. A better matching between patient and device could be accomplished if the physician is aware of: (1) the patient characteristics (disease, severity, fluctuation in airflow obstruction, etc); (2) what class of medication is indicated; (3) where in the lung the medication should be delivered; and, (4) how this can be best achieved by a given device in this specific patient. We focus on the prescription of pMDIs and DPIs at the GP office or at the outpatient clinic of the hospital, and we propose an evidence based approach enabling the caregiver to make a rational choice in only a few minutes by just considering the following four simple questions: Who?, What? Where? and How? (the so-called 3W-H approach).