The distribution of COPD in UK general practice using the new GOLD classification.

The new Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011 document recommends a combined assessment of chronic obstructive pulmonary disease (COPD) based on current symptoms and future risk. A large database of primary-care COPD patients across the UK was used to determine COPD distribution and characteristics according to the new GOLD classification. 80 general practices provided patients with a Read code diagnosis of COPD. Electronic and hand searches of patient medical records were undertaken, optimising data capture. Data for 9219 COPD patients were collected. For the 6283 patients with both forced expiratory volume in 1 s (FEV1) and modified Medical Research Council scores (mean±sd age 69.2±10.6 years, body mass index 27.3±6.2 kg·m(-2)), GOLD 2011 group distributions were: A (low risk and fewer symptoms) 36.1%, B (low risk and more symptoms) 19.1%, C (high risk and fewer symptoms) 19.6% and D (high risk and more symptoms) 25.3%. This is in contrast with GOLD 2007 stage classification: I (mild) 17.1%, II (moderate) 52.2%, III (severe) 25.5% and IV (very severe) 5.2%. 20% of patients with FEV1 ≥50% predicted had more than two exacerbations in the previous 12 months. 70% of patients with FEV1 <50% pred had fewer than two exacerbations in the previous 12 months. This database, representative of UK primary-care COPD patients, identified greater proportions of patients in the mildest and most severe categories upon comparing 2011 versus 2007 GOLD classifications. Discordance between airflow limitation severity and exacerbation risk was observed.

Asthma patients' inability to use a pressurised metered-dose inhaler (pMDI) correctly correlates with poor asthma control as defined by the global initiative for asthma (GINA) strategy: a retrospective analysis.

BACKGROUND: In practice it is logical that inhalers are prescribed only after patients have received training and demonstrated their ability to use the device. However, many patients are unable to use their pressurised metered-dose inhaler devices (pMDIs) correctly. We assessed the relationship between asthma control and patients' ability to use their prescribed pMDIs. METHODS: Evaluation of 3,981 (46% male) primary care asthma patient reviews, which included inhaler technique and asthma control, by specialist nurses in primary care in 2009. The paper focuses on people currently prescribed pMDI devices. RESULTS: Accurate data on reliever and preventer inhaler prescriptions were available for 3,686 and 2,887 patients, respectively. In patients prescribed reliever inhalers, 2,375 (64%) and 525 (14%) were on pMDI alone or pMDI plus spacer, respectively. For those prescribed preventers, 1,976 (68%) and 171 (6%) were using a pMDI without and with a spacer, respectively. Asthma was controlled in 50% of patients reviewed. The majority of patients (60% of 3,686) were using reliever pMDIs, 13% with spacers. Incorrect pMDI use was associated with poor asthma control (p<0.0001) and more short burst systemic steroid prescriptions in the last year (p=0.038). Of patients using beclometasone (the most frequently prescribed preventer drug in our sample), significantly more of those using a breath-actuated pMDI device (p<0.0001) and a spacer (p<0.0001) were controlled compared with those on pMDIs alone. CONCLUSIONS: Patients who are able to use pMDIs correctly have better asthma control as defined by the GINA strategy document. Beclometasone via a spacer or breath-actuated device resulted in better asthma control than via a pMDI alone. Patients prescribed pMDIs should be carefully instructed in technique and have their ability to use these devices tested; those unable to use the device should be prescribed a spacer or an alternative device such as one that is breath-actuated.

Technique training does not improve the ability of most patients to use pressurised metered-dose inhalers (pMDIs).

AIMS: According to guidelines, inhaler technique should be tested in all patients, particularly those with poorly controlled asthma. We aimed to assess uncontrolled asthma patients' ability to use a pressurised metered-dose inhaler (pMDI) using the Aerosol Inhalation Monitor (AIM, © Vitalograph). METHODS: Practices invited patients for a detailed clinical review by trained asthma nurses according to practice-agreed protocols. Reviews took place from 1st April to 30th June 2008, and included checking of inhaler technique. Reasons for invitations included, time since last review, asthma control, prescriptions, adherence to medical advice. A proxy measure of control--the total number of short-acting ß2-agonist (SABA) bronchodilator inhaler canisters prescribed in the previous 12 months--was used. Data on 77 pre-determined clinical parameters (including prescribing and healthcare utilisation data) were collected. Patient-completed postal symptom questionnaires (the RCP 3 questions) were obtained in some patients. All patients using pMDIs had at least two assessments using the AIM, and where appropriate inhaler technique education was provided. RESULTS: 2123 (24% of those invited) symptomatic asthma patients were reviewed; 1291 (61%) were using pMDIs (mean age 52 years; SD 21), of whom over 80% were in BTS/SIGN Steps 2 and 3. 1092 (85.6%) of those patients using pMDIs failed the first AIM assessment. There was a significant increase in the number of patients able to use their pMDIs correctly following instruction after the second (129 to 260 of 1197 patients, p<0.01) and third (61 to 181 of 528 patients, p< 0.01) tests. However, 78.4% and 65.7% of those tested twice and three times, respectively, failed the AIM assessment despite instruction. Logistic regression analysis failed to show any effect of age and BTS step on these outcomes. CONCLUSIONS: A majority of symptomatic asthma patients in this study were unable to use pMDIs correctly. It is essential to check all patients' ability to use their prescribed inhalers regularly. Cost alone should not determine prescribing recommendations.