Asthma and chronic obstructive pulmonary disease inhalers: Techniques for proper use.

BACKGROUND: Asthma and chronic obstructive pulmonary disease (COPD) affect millions of Americans. Inhalers are necessary to manage these diseases, but physicians and patients often struggle to use them correctly. OBJECTIVE: To simplify inhaler use for patients and physicians. METHODS: This article compares the various inhalers used to treat asthma and COPD, their techniques for use, and the steps necessary to prime the inhaler if required. The authors provide a suggested standardized technique for the use of metered-dose inhalers, dry powder inhalers, and soft-mist inhalers to provide for a more universal approach for the use of these medications and summarizes how each product is to be used per the U.S. Food and Drug Administration approved package insert. RESULTS AND CONCLUSIONS: The simplified techniques proposed in this article for the use of metered-dose inhalers, dry powder inhalers, and soft mist inhalers used to treat asthma and COPD may limit inhaler misuse and aid in proper medication delivery and treatment.

Assessing the determinants of the potential for cost-effectiveness over time: the empirical case of COPD.

OBJECTIVES: The objective of this study was to assess the potential for cost-effectiveness of new technologies for chronic obstructive pulmonary disease (COPD) over the period from 2001 to 2010. METHODS: Lung function outcomes and drug prices were observed for a UK COPD population over the period from 2001 to 2010. Cost-effectiveness was assessed at regular intervals on the basis of an established cost-effectiveness model, and the maximum price a technology providing cure could achieve under the current cost-effectiveness rules was estimated. RESULTS: The results of this study show that although the scope for clinical improvement in COPD was still considerable, during the 10 years studied, the potential for cost-effectiveness at each point in time was dependent on momentary market characteristics, such as the changing price of comparators and improvements in clinical effectiveness. As a result, the analysis demonstrates that the future cost-effectiveness of a technology in development depends on the manner pricing and clinical effectiveness evolve throughout time. CONCLUSIONS: Because any predictions will be short-lived and dependent on a number of uncertain factors, we conclude that producing accurate forecasts on the potential for cost-effectiveness of new therapies earlier during the development process is especially difficult under the current static cost-effectiveness framework.

Use of ozone-depleting substances; removal of essential-use designation (flunisolide, etc.). Final rule.

The Food and Drug Administration (FDA), after consultation with the Environmental Protection Agency (EPA), is amending FDA's regulation on the use of ozone-depleting substances (ODSs) in self-pressurized containers to remove the essential-use designations for flunisolide, triamcinolone, metaproterenol, pirbuterol, albuterol and ipratropium in combination, cromolyn, and nedocromil used in oral pressurized metered-dose inhalers (MDIs). The Clean Air Act requires FDA, in consultation with the EPA, to determine whether an FDA-regulated product that releases an ODS is an essential use of the ODS. FDA has concluded that there are no substantial technical barriers to formulating flunisolide, triamcinolone, metaproterenol, pirbuterol, albuterol and ipratropium in combination, cromolyn, and nedocromil as products that do not release ODSs, and therefore they will no longer be essential uses of ODSs as of the effective dates of this rule. MDIs for these active moieties containing an ODS may not be marketed after the relevant effective date.

The future of bronchodilation: looking for new classes of bronchodilators.

Available bronchodilators can satisfy many of the needs of patients suffering from airway disorders, but they often do not relieve symptoms and their long-term use raises safety concerns. Therefore, there is interest in developing new classes that could help to overcome the limits that characterise the existing classes.At least nine potential new classes of bronchodilators have been identified: 1) selective phosphodiesterase inhibitors; 2) bitter-taste receptor agonists; 3) E-prostanoid receptor 4 agonists; 4) Rho kinase inhibitors; 5) calcilytics; 6) agonists of peroxisome proliferator-activated receptor-γ; 7) agonists of relaxin receptor 1; 8) soluble guanylyl cyclase activators; and 9) pepducins. They are under consideration, but they are mostly in a preclinical phase and, consequently, we still do not know which classes will actually be developed for clinical use and whether it will be proven that a possible clinical benefit outweighs the impact of any adverse effect.It is likely that if developed, these new classes may be a useful addition to, rather than a substitution of, the bronchodilator therapy currently used, in order to achieve further optimisation of bronchodilation.

The ABCD of COPD For Patients.

Chronic obstructive pulmonary disease is a chronic condition that requires the engagement of our patients in lifestyle changes and pharmacological treatment. Although there are guidelines on many aspects of chronic obstructive pulmonary disease management, the challenge of engaging our patients persists. We propose a simple mnemonic that we hope will make it easier for patients and clinicians to achieve this goal together.

A doença pulmonar obstrutiva crónica é uma patologia crónica cujo tratamento depende do envolvimento dos doentes em mudanças de estilo de vida e tratamento farmacológico. Embora existam recomendações clínicas no tratamento da doença pulmonar obstrutiva crónica, o desafio em envolver os doentes persiste. Propomos uma mnemónica simples que esperamos contribuir para alcançar esse objetivo comum a médicos e doentes.

Cold, cough, allergy, bronchodilator, and antiasthmatic drug products for over-the-counter human use; partial final rule for combination drug products containing a bronchodilator. Final rule.

The Food and Drug Administration (FDA) is issuing a final rule establishing that cough-cold combination drug products containing any oral bronchodilator active ingredient in combination with any analgesic(s) or analgesic-antipyretic(s), anticholinergic, antihistamine, oral antitussive, or stimulant active ingredient are not generally recognized as safe and effective and are misbranded for over-the-counter (OTC) use. FDA is issuing this final rule after receiving no public comments on the agency's proposed nonmonograph status of these specific combination drug products, which was issued in the form of a tentative final monograph for OTC cough-cold combination drug products. This final rule is part of the ongoing review of OTC drug products conducted by FDA.

Cold, cough, allergy, bronchodilator, and antiasthmatic drug products for over-the-counter human use; final monograph for combination drug products. Final rule.

The Food and Drug Administration (FDA) is issuing a final rule in the form of a final monograph that establishes conditions under which over-the-counter (OTC) cold, cough, allergy, bronchodilator, and antiasthmatic (cough-cold) combination drug products are generally recognized as safe and effective and not misbranded as part of its ongoing review of OTC drug products. FDA is issuing this final rule after considering public comments on the agency's proposed regulation (tentative final monograph) and new data and information on OTC cough- cold combination drug products that have come to the agency's attention.

Pharmacological approaches to stable chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) causes disabling, slowly progressive breathlessness on exertion, chronic cough and sputum production. Its natural history is punctuated by increasingly frequent exacerbations which in turn accelerate disease progression and reduce a patient's quality of life. COPD has previously been ignored in the mistaken belief that nothing could be done. There are now a number of therapies that can be used to reduce symptoms and prevent exacerbations. In turn this reduces disability, improves the patient's health-related quality of life and has the potential to reduce costs to the health service and to society.

Chronic obstructive pulmonary disease: current comprehensive care for emphysema and bronchitis.

Chronic obstructive pulmonary disease (COPD) is the fifth leading cause of mortality in the United States. Most clients are initially seen when symptomatic and significant lung damage has already occurred; most cases are preventable. There is no cure for COPD, but lifestyle changes (especially smoking cessation) and proper treatment can significantly impact quality of life. The diagnostic tools most commonly used include chest x-ray, arterial blood gases, and pulmonary function tests. Pharmacologic interventions include steroids, bronchodilators, mucolytics, and an armamentarium of antibiotics, which must be selected with careful discretion. Because the prognosis of COPD may be guarded, the practitioner is obligated to provide information on advance directives. A sensitive approach, holistic perspective, consistent follow-up, and clinical astuteness are essential ingredients in the management of clients with COPD.

[Short-term effect of tiotropium in COPD patients being treated with a beta2 agonist]. / Efeito de curto prazo do tiotrópio nos portadores de DPOC em tratamento com beta2-agonista.

OBJECTIVE: To evaluate the short-term impact of tiotropium in patients with severe or very severe COPD who complain of dyspnea despite being currently treated with other bronchodilators. METHODS: A prospective study including patients with severe or very severe COPD and complaining of dyspnea at rest or on minimal exertion. Every 15 days, the bronchodilator treatment regimen was altered, from salmeterol to tiotropium to salmeterol+tiotropium. At the end of each regimen, pulmonary function tests and the six-minute walk test (6MWT) were performed. The degree of dyspnea and the ability to perform activities of daily living were also assessed. To evaluate patient ability to perform activities of daily living, we employed the London Chest Activity of Daily Living (LCADL), validated for use in Brazil. RESULTS: We evaluated 52 patients, 30 of whom completed the study. The use of tiotropium in isolation resulted in significant improvement in dyspnea at baseline (mean Medical Research Council scale score reduced from 3.0 to 2.5) and at the end of 6MWT (mean Borg scale score reduced from 6.1 to 4.5), and the differences were significant (p < 0.05 for both). The use of the salmeterol+tiotropium combination resulted in a significant (81 mL) increase in FEV1 and a 5.7 point improvement in the LCADL score. CONCLUSIONS: The introduction of tiotropium into the treatment of patients with severe or very severe COPD and using long-acting beta2 agonists improves pulmonary function and provides symptomatic relief, as perceived by patients in the short term. These results, obtained under real life treatment conditions, support the use of the salmeterol+tiotropium combination in specific treatment protocols for these patients.

Efeito de curto prazo do tiotrópio nos portadores de DPOC em tratamento com B2-agonista / Short-term effect of tiotropium in COPD patients being treated with a B2 agonist

OBJETIVO: Avaliar o impacto de curto prazo do uso de tiotrópio em pacientes com DPOC grave e muito grave com queixas de dispneia apesar do tratamento com outros broncodilatadores. MÉTODOS: Estudo prospectivo incluindo pacientes com DPOC grave ou muito grave, com queixa de dispneia de pequenos esforços ou ao repouso. A cada 15 dias, o tratamento broncodilatador foi modificado: salmeterol, tiotrópio e associação salmeterol+tiotrópio. Ao final de cada regime, foram realizados testes de função pulmonar e teste de caminhada de seis minutos (TC6). Também foram avaliados o grau de dispneia e a capacidade de realização de atividades de vida diária. Para a avaliação das atividades de vida diária, foi utilizada a escala London Chest Activity of Daily Living (LCADL) validado para uso no Brasil. RESULTADOS: Foram avaliados 52 pacientes. Desses, 30 completaram o estudo. A introdução de tiotrópio como monoterapia resultou em uma melhora significativa (p < 0,05) da dispneia basal (média do escore da escala do Medical Research Council de 3,0 para 2,5) e ao final do TC6 (média do escore da escala de Borg de 6,1 para 4,5), e as diferenças foram significativas (p < 0,05 para ambos). O uso da associação salmeterol+tiotrópio resultou em um aumento significativo médio de 81 mL no VEF1 e na melhora de 5,7 pontos no escore da escala LCADL. CONCLUSÕES: A introdução de tiotrópio no tratamento de pacientes com DPOC grave a muito grave em uso de β2-agonistas de longa duração causa melhora na função pulmonar e alivio sintomático perceptível pelos pacientes a curto prazo. Esses resultados, obtidos em regime de atendimento de vida real, dão suporte ao uso da associação salmeterol+tiotrópio em protocolos de assistência específicos a esses pacientes.

OBJECTIVE: To evaluate the short-term impact of tiotropium in patients with severe or very severe COPD who complain of dyspnea despite being currently treated with other bronchodilators. METHODS: A prospective study including patients with severe or very severe COPD and complaining of dyspnea at rest or on minimal exertion. Every 15 days, the bronchodilator treatment regimen was altered, from salmeterol to tiotropium to salmeterol+tiotropium. At the end of each regimen, pulmonary function tests and the six-minute walk test (6MWT) were performed. The degree of dyspnea and the ability to perform activities of daily living were also assessed. To evaluate patient ability to perform activities of daily living, we employed the London Chest Activity of Daily Living (LCADL), validated for use in Brazil. RESULTS: We evaluated 52 patients, 30 of whom completed the study. The use of tiotropium in isolation resulted in significant improvement in dyspnea at baseline (mean Medical Research Council scale score reduced from 3.0 to 2.5) and at the end of 6MWT (mean Borg scale score reduced from 6.1 to 4.5), and the differences were significant (p < 0.05 for both). The use of the salmeterol+tiotropium combination resulted in a significant (81 mL) increase in FEV1 and a 5.7 point improvement in the LCADL score. CONCLUSIONS: The introduction of tiotropium into the treatment of patients with severe or very severe COPD and using long-acting β2 agonists improves pulmonary function and provides symptomatic relief, as perceived by patients in the short term. These results, obtained under real life treatment conditions, support the use of the salmeterol+tiotropium combination in specific treatment protocols for these patients.

Postoperative administration of aerosolized medications: Part I--The basics.

Based on the content of this article, the reader should be able to (1) describe the advantages and disadvantages of instituting drug delivery using the inhalation route; (2) verbalize factors that impact on aerosol deposition within the lung; (3) list the various types of aerosol-generating devices; (4) describe the benefits of incorporating a spacer device with the metered dose inhaler; and (5) identify and be familiar with the major categories of aerosolizable agents.

Nonantimicrobial aspects of therapy.

Current therapy for chronic obstructive pulmonary disease is symptomatic, and no treatments prevent the progression of the disease. Stopping smoking is the only effective approach, and this may be facilitated by nicotine replacement and bupropion. Treatment with short- and long-acting inhaled beta2-agonists and anticholinergics are the mainstay of therapy. Inhaled corticosteroids have no impact on disease progression, and the small reduction in exacerbations may not justify the potential systemic side effects. Supplementary oxygen therapy is indicated for acute exacerbations and chronic hypoxia. Other treatments, including mucolytics, vaccines, and respiratory stimulants are of little value. Nonpharmacological measures that are useful include pulmonary rehabilitation, exercise, good nutrition, and, in selected cases, surgery. Several new classes of drug are now in development, including mediator antagonists (leukotriene B4, interleukin-8 antagonists, and anti-oxidants) and nonsteroid anti-inflammatory drugs, of which phosphodiesterase-4 inhibitors look the most promising. There is a pressing need for a better understanding of the underlying disease process to develop more logical therapies.

Management of acute asthma in childhood.

In children, acute asthma is one of the most common reasons for admission to hospital. Morbidity and mortality from asthma are unnecessarily high. It is essential that all those caring for asthma patients can accurately assess and treat an acute exacerbation of asthma.

The pharmacological treatment of voice disorders.

The increasing diversity of purpose-built, synthetic and biogenetically engineered pharmaceuticals has led to a revival of interest in the pharmacological possibilities for the treatment of voice disorders. Where dysphonias arise as a part of a pathophysiological process, the pharmacological treatment of either the pathology or its associated symptoms may improve dysphonic voicing patterns. The treatment of symptoms such as cough and vocal fatigue are discussed together with treatment of allergic and other causes of inflammation or stiffening of the vocal tract. The pharmacological logical treatment of dysphonia due to defective neuromuscular control in dyskinetic and dystonic conditions is also discussed. Dysphonic voicing patterns are commonly multifactorial, and the author wishes to highlight problems encountered when attempting to adjust the performance of the vocal tract: imprecise targeting of the pathophysiological problems either by the physician or by the drug employed, and the systemic and attendant side-effects of drugs which may be thought to be appropriate.