A comprehensive evaluation of online inhaler use techniques for obstructive airway disease.

BACKGROUND: Pulmonary inhaler therapy is a core treatment modality for >600 million individuals affected by obstructive airways disease globally. Poor inhaler technique is associated with reduced disease control and increased health care utilization; however, many patients rely on the internet as a technical resource. This study assesses the content and quality of online resources describing inhaler techniques. METHODS: A Google search was conducted in April 2023 capturing the top 5 search results for 12 common inhaler devices. Websites were compared to product monographs for preparation/first use, inhalational technique, and post-usage/device care. They were also assessed using accepted quality metrics (GQS, DISCERN, JAMA Benchmark scores) and clinically relevant aspects based on the literature and consensus statements. RESULTS: Websites regularly excluded critical steps important for proper inhaler technique. They performed best on information related directly to inhalation technique (average median score 78%), whereas steps related to preparation/first use (58%) or post-usage/device care (50%) were less frequently addressed. Median GQS, DISCERN, and JAMA Benchmark scores were 3 [IQR 3-4], 3 [IQR 2-4], and 1 [IQR 1-3], respectively. Clinically relevant factors were only addressed in about one-fifth of websites with no websites addressing smoking cessation, environmental considerations, or risk factors for poor technique. CONCLUSIONS: This study highlights gaps in online resources describing inhaler technique, particularly related to preparation/first use and post-usage/device care steps. Clinically relevant factors were rarely addressed across websites. Improvements in these areas could lead to enhanced inhaler technique and clinical outcomes.

A novel thiol-saccharide mucolytic for the treatment of muco-obstructive lung diseases.

BACKGROUND: Mucin disulfide cross-links mediate pathologic mucus formation in muco-obstructive lung diseases. MUC-031, a novel thiol-modified carbohydrate compound, cleaves disulfides to cause mucolysis. The aim of this study was to determine the mucolytic and therapeutic effects of MUC-031 in sputum from patients with cystic fibrosis (CF) and mice with muco-obstructive lung disease (ßENaC-Tg mice). METHODS: We compared the mucolytic efficacy of MUC-031 and existing mucolytics (N-acetylcysteine (NAC) and recombinant human deoxyribonuclease I (rhDNase)) using rheology to measure the elastic modulus (G') of CF sputum, and we tested effects of MUC-031 on airway mucus plugging, inflammation and survival in ßENaC-Tg mice to determine its mucolytic efficacy in vivo. RESULTS: In CF sputum, compared to the effects of rhDNase and NAC, MUC-031 caused a larger decrease in sputum G', was faster in decreasing sputum G' by 50% and caused mucolysis of a larger proportion of sputum samples within 15 min of drug addition. Compared to vehicle control, three treatments with MUC-031 in 1 day in adult ßENaC-Tg mice decreased airway mucus content (16.8±3.2 versus 7.5±1.2 nL·mm-2, p<0.01) and bronchoalveolar lavage cells (73 833±6930 versus 47 679±7736 cells·mL-1, p<0.05). Twice-daily treatment with MUC-031 for 2 weeks also caused decreases in these outcomes in adult and neonatal ßENaC-Tg mice and reduced mortality from 37% in vehicle-treated ßENaC-Tg neonates to 21% in those treated with MUC-031 (p<0.05). CONCLUSION: MUC-031 is a potent and fast-acting mucolytic that decreases airway mucus plugging, lessens airway inflammation and improves survival in ßENaC-Tg mice. These data provide rationale for human trials of MUC-031 in muco-obstructive lung diseases.

Repeated bronchoscopy in health and obstructive lung disease: is the airway microbiome stable?

OBJECTIVE: Little is known concerning the stability of the lower airway microbiome. We have compared the microbiota identified by repeated bronchoscopy in healthy subjects and patients with ostructive lung diseaseases (OLD). METHODS: 21 healthy controls and 41 patients with OLD completed two bronchoscopies. In addition to negative controls (NCS) and oral wash (OW) samples, we gathered protected bronchoalveolar lavage in two fractions (PBAL1 and PBAL2) and protected specimen brushes (PSB). After DNA extraction, we amplified the V3V4 region of the 16S rRNA gene, and performed paired-end sequencing (Illumina MiSeq). Initial bioinformatic processing was carried out in the QIIME-2 pipeline, identifying amplicon sequence variants (ASVs) with the DADA2 algorithm. Potentially contaminating ASVs were identified and removed using the decontam package in R and the sequenced NCS. RESULTS: A final table of 551 ASVs consisted of 19 × 106 sequences. Alpha diversity was lower in the second exam for OW samples, and borderline lower for PBAL1, with larger differences in subjects not having received intercurrent antibiotics. Permutational tests of beta diversity indicated that within-individual changes were significantly lower than between-individual changes. A non-parametric trend test showed that differences in composition between the two exams (beta diversity) were largest in the PSBs, and that these differences followed a pattern of PSB > PBAL2 > PBAL1 > OW. Time between procedures was not associated with increased diversity. CONCLUSION: The airways microbiota varied between examinations. However, there is compositional microbiota stability within a person, beyond that of chance, supporting the notion of a transient airways microbiota with a possibly more stable individual core microbiome.

Prevalence and quality of care among patients using medication targeting obstructive lung disease: a cross-sectional study in the five regions of Greenland.

The aim of this study was to estimate the age- and gender-specific prevalence and quality of care among patients using medication targeting obstructive lung disease in the five regions of Greenland. The study was designed as a cross-sectional study. Data on patients using medication targeting obstructive lung disease was obtained from the electronically medical record used in Greenland. The prevalence was calculated using the population of Greenland as background population. The quality of care was determined using indicators proposed by international literature and the Steno Diabetes Center Greenland guidelines. The total prevalence of patients using medication targeting obstructive lung disease was 7.5%. The prevalence was significantly higher among women compared to men and differed significantly between the five regions. Smoking status, blood pressure and spirometry were registered within one/two years for 29.8%/43.2%, 29.2%/41.1% and 15.9%/26.0% of the patients, respectively. Regional differences were observed for all indicators.The use of medication targeting obstructive lung disease is common in Greenland. Yet, the quality of care was low and interventions improving the quality of care is recommended.

Aerosol delivery systems for treating obstructive airway diseases during the SARS-CoV-2 pandemic.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes CoronaVirus Disease 2019 (COVID-19), has resulted in a worldwide pandemic and currently represents a major public health crisis. It has caused outbreaks of illness through person-to-person transmission of the virus mainly via close contacts, and droplets produced by an infected person's cough or sneeze. Aerosolised inhaled therapy is the mainstay for treating obstructive airway diseases at home and in healthcare settings, but there is heightened particular concern about the potential risk for transmission of SARS-CoV-2 in the form of aerosolised respiratory droplets during the nebulised treatment of patients with COVID-19. As a consequence of this concern, the use of hand-held inhalers, especially pressurised metered dose inhalers, has risen considerably as an alternative to nebulisers, and this switch has led to inadequate supplies of inhalers in some countries. However, there is no evidence supporting an increased risk of viral transmission during nebulisation in COVID-19 patients. Furthermore, some patients may be unable to adequately use their new device and may not benefit fully from the switch to treatment via hand-held inhalers. Thus, there is no compelling reason to alter aerosol delivery devices for patients with established nebuliser-based regimens. The purpose of this paper is to discuss the current evidence and understanding of the use of aerosolised inhaled therapies during the SARS-CoV-2 pandemic and to provide some guidance on the measures to be taken to minimise the risk of transmitting infection, if any, during aerosol therapies.

Competence in metered-dose inhaler technique among healthcare workers of three general hospitals in Mexico: it is not good after all these years.

INTRODUCTION: Inhaled medication is the cornerstone of pharmacological treatment for chronic respiratory diseases. Therefore, it is important to use a metered-dose inhaler (MDI) correctly to get the appropriate dosage and benefit from the drug. Health-care workers (HCW) are responsible for teaching the correct MDI technique. Unfortunately, numerous studies consistently show that HCW have poor MDI technique. This study aimed to evaluate the current knowledge of MDI technique in HCW working in three general hospitals. MATERIAL AND METHODS: A hospital-based, cross-sectional descriptive study was conducted in three general hospitals in Aguascalientes, México. Three surveyors simultaneously scored through a 14 dichotomic questions list as bad, regular, good, and very good MDI technique. Data were analyzed with SPSS version 16. Statistical analyses were performed using chi-square test or unpaired t-tests. An analysis of one-way ANOVA was used for comparison of three independent general hospitals. Values of p < 0.05 were considered to indicate statistical significance. RESULTS: A total of 244 HCWs were surveyed: 78.3% were nurses whereas 21.3% were physicians. The inter-observer concor-dance analysis among observers was 0.97. We observed that 32.4% (79) performed a bad technique, 51.6% (126) a regular technique, 13.5% (33) a good one, and 2.5% HCW (6) a very good technique. No difference between gender, labor category, schedule, service, age, seniority, and education degree between the three hospitals was observed. The most common mistakes were "insufficient expiration prior to activation of the device", and "the distance the inhaler was placed for inhalation" (83 and 84% respectively). CONCLUSION: We observed that a high percentage of HCW do not follow the MDI technique correctly, being this percentage even higher than the reported in other studies. These observations suggest the urgent need to establish frequent training programs for the correct use of MDI.

Therapeutic effect of nebulized hypertonic saline for muco-obstructive lung diseases: a systematic review and meta-analysis with trial sequential analysis.

Overproduction of mucus and impaired clearance play important roles in the pathogenesis of muco-obstructive lung diseases (MOLDs). This study aims to evaluate the therapeutic effect and safety of nebulized hypertonic saline (HS) on MOLDs. Five electronic databases including PubMed, Excerpt Medica Database (EMBASE), Cochrane Central Register of Controlled Trials, ClinicalTrials.gov and International Standard Randomized Controlled Trial Number Register were searched until June 2019. Randomized controlled trials or randomized controlled crossover trials which investigated the therapeutic effect of HS versus non-HS for MOLDs were included. Twenty-one studies met the eligibility criteria. For cystic fibrosis (CF), although the forced expiratory volume in the first second and forced vital capacity did not improve significantly (mean difference (MD) -0.48, 95% CI -3.72 to 2.76), (MD 1.85, 95% CI -4.31 to 8.01), respectively), the clearance capability of lung and quality of life (QOL) improved significantly in the HS group ((standard mean difference 0.44, 95% CI 0.02 to 0.87), (MD -0.64, 95% CI -)1.14, to 0.13), respectively). However, the results of trial sequential analysis showed the evidence needed more researches to support. The effect of nebulized HS on non-CF bronchiectasis, chronic obstructive pulmonary disease, and primary ciliary dyskinesia also need more evidence to conclude, since current studies are limited and results are inconsistent. Most adverse events of nebulized HS were mild and transient. In summary, the current available evidence suggests that nebulized HS may increase the QOL in CF, but there was no significant improvement in lung function. However, it is not possible to draw firm conclusions for other MOLDs due to limited data.

Research advances on selective phosphatidylinositol 3 kinase δ (PI3Kδ) inhibitors.

PI3Kδ in B cells mediates antigen receptor signaling and promote neutrophil chemotaxis. The activation of PI3Kδ can cause mast cell maturation and degranulation, myeloid cell dysfunction, and cytokine release. As a key signal molecule, PI3Kδ interacts with the lipid binding domain of a variety of cellular proteins as a secondary messenger, ultimately affecting a series of significant cellular pathways in disease pathology. Therefore, many research organizations and pharmaceutical companies have studied it to develop effectively selective PI3Kδ inhibitors as therapeutics. This review summarizes research advances in varying chemical classes of selective PI3Kδ inhibitors and the structure-activity relationship, and it mainly focuses on the propeller- versus flat-type class of inhibitors.

Phosphodiesterase isoforms and cAMP compartments in the development of new therapies for obstructive pulmonary diseases.

The second messenger molecule 3'5'-cyclic adenosine monophosphate (cAMP) imparts several beneficial effects in lung diseases such as asthma, chronic obstructive pulmonary disease (COPD) and idiopathic pulmonary fibrosis (IPF). While cAMP is bronchodilatory in asthma and COPD, it also displays anti-fibrotic properties that limit fibrosis. Phosphodiesterases (PDEs) metabolize cAMP and thus regulate cAMP signaling. While some existing therapies inhibit PDEs, there are only broad family specific inhibitors. The understanding of cAMP signaling compartments, some centered around lipid rafts/caveolae, has led to interest in defining how specific PDE isoforms maintain these signaling microdomains. The possible altered expression of PDEs, and thus abnormal cAMP signaling, in obstructive lung diseases has been poorly explored. We propose that inhibition of specific PDE isoforms can improve therapy of obstructive lung diseases by amplifying specific cAMP signals in discreet microdomains.

The need for physiological phenotyping to develop new drugs for airways disease.

Asthma and COPD make up the majority of obstructive airways diseases (OADs), which affects ∼11 % of the population. The main drugs used to treat OADs have not changed in the past five decades, with advancements mainly comprising variations on existing treatments. The recent biologics are beneficial to only specific subsets of patients. Part of this may lie in our inability to adequately characterise the tremendous heterogeneity in every aspect of OAD. The field is currently moving towards the concept of personalised medicine, based on a focus on treatable traits that are objective, measurable and modifiable. We propose extending this concept via the use of emerging clinical tools for comprehensive physiological phenotyping. We describe, based on published data, the evidence for the use of functional imaging, gas washout techniques and oscillometry, as well as potential future applications, to more comprehensively assess and predict treatment response in OADs. In this way, we hope to demonstrate how physiological phenotyping tools will improve the way in which drugs are prescribed, but most importantly, will facilitate development of new drugs for OADs.

Kinase inhibitors in the treatment of obstructive pulmonary diseases.

Chronic pulmonary diseases, including chronic obstructive pulmonary disease (COPD) and asthma, are major causes of death and reduced quality of life. Characteristic of chronic pulmonary disease is excessive lung inflammation that occurs in response to exposure to inhaled irritants, chemicals, and allergens. Chronic inflammation leads to remodeling of the airways that includes excess mucus secretion, proliferation of smooth muscle cells, increased deposition of extracellular matrix proteins and fibrosis. Protein kinases have been implicated in mediating inflammatory signals and airway remodeling associated with reduced lung function in chronic pulmonary disease. This review will highlight the role of protein kinases in the lung during chronic inflammation and examine opportunities to use protein kinase inhibitors for the treatment of chronic pulmonary diseases.

Lung function in adults and future burden of obstructive lung diseases in a long-term follow-up.

Spirometry is recommended in symptomatic smokers to identify obstructive lung diseases. However, it is unknown whether there are certain characteristics that can be used to identify the individual risk of developing obstructive lung diseases. The aim of this study was to examine the association between lung function in adults and burden of lung diseases throughout 27 years of follow-up. We performed a cohort study among individuals aged 30-49 years at baseline (1991). Spirometry measurements were divided into three groups: (1) FEV1/FVC < 70, (2) FEV1/FVC: 70-75, (3) FEV1/FVC > 75 (reference). Using negative binominal regression, the burden of lung diseases was measured by contacts to general practice, hospitalisations, redeemed respiratory medicine and socioeconomic parameters between 1991 and 2017. A total of 905 citizens were included; mean age of 40.3 years, 47.5% were males and 51.2% were smokers at baseline. The group with an FEV1/FVC: 70-75 received more respiratory medicine (IRR = 3.37 (95% CI: 2.69-4.23)), had lower income (IRR = 0.96 (95% CI: 0.93-0.98)), and had more contacts to general practice (IRR = 1.14 (95% CI: 1.07-1.21)) and hospitals for lung diseases (IRR = 2.39 (95% CI: 1.96-5.85)) compared to the reference group. We found an association between lung function and the future burden of lung diseases throughout 27 years of follow-up. In particular, adults with an FEV1/FVC: 70-75 need extra attention in the case finding.

Endothelial Activation, Innate Immune Activation, and Inflammation Are Associated With Postbronchodilator Airflow Limitation and Obstruction Among Adolescents Living With HIV.

BACKGROUND: Chronic inflammation, innate immune activation, T-cell imbalance and endothelial activation have been linked with lung diseases. We sought to determine whether markers of these pathophysiologic pathways were associated with spirometry and chest computed tomography (CT) abnormalities among adolescents living with HIV (ALWH). SETTING: Coptic Hope Center for Infectious Diseases in Nairobi, Kenya. METHODS: We performed a cross-sectional study of ALWH (10-19 years old). Participants underwent chest CT, spirometry, and venipuncture for serum biomarkers. We also collected demographic, anthropometric, T-cell subset, antiretroviral therapy, and exposure data. We compared characteristics and biomarkers by airflow obstruction [postbronchodilator FEV1/FVC z-score (zFEV1/FVC) < -1.64]. We used multivariable linear regression to determine associations of log10-transformed biomarkers and chest CT abnormalities with lower postbronchodilator zFEV1/FVC (airflow limitation). We performed exploratory principal components analysis on biomarkers, and determined associations of factors with postbronchodilator zFEV1/FVC and chest CT abnormalities. RESULTS: Of 47 participants with acceptable quality spirometry, 21 (45%) were female, median age was 13 years and 96% had perinatally-acquired HIV. Median CD4 was 672 cells/µL. Overall, 28% had airflow obstruction and 78% had a chest CT abnormality; airflow obstruction was associated with mosaic attenuation (P = 0.001). Higher endothelial activation (sVCAM-1, sICAM-1), inflammation and innate immune activation (serum amyloid-A, sTREM-1, sCD163), and T-cell imbalance (lower CD4/CD8) markers were associated with airflow limitation. Factors comprising endothelial and innate immune activation were associated with airflow limitation. CONCLUSIONS: Endothelial activation, innate immune activation, T-cell imbalance, and chronic inflammation are associated with airflow limitation and obstruction, providing insights into chronic lung disease pathophysiology among ALWH.

Intratracheal GLP-1 receptor agonist treatment up-regulates mucin via p38 and exacerbates emphysematous phenotype in mucus hypersecretory obstructive lung diseases.

Glucagon-like peptide-1 (GLP-1) is a gastrointestinal hormone that stimulates glucose-mediated insulin production by pancreatic beta cells. It is also associated with protective effects in multiple tissues. GLP-1 receptor is highly expressed in pulmonary tissue, hinting possible pulmonary delivery of GLP-1 drugs. However, little is known about the role of GLP-1 signaling in the lung, especially in mucus hypersecretory obstructive lung diseases. Here, we showed that treatment with exendin-4, a clinically available GLP-1 receptor agonist, up-regulates mucin expression in normal airway epithelial cells and in the lung of normal mice, indicating mucus stimulatory effect of GLP-1 under physiological condition. Exendin-4 also increased mucin expression in in vitro cellular and in vivo murine models of obstructive lung diseases via the activation of p38 MAP kinase. Notably, mucin induction in vivo exacerbated key pulmonary abnormalities including emphysematous phenotypes, implying that GLP-1 signaling in the lung is detrimental under pulmonary obstructive condition. Another GLP-1 receptor agonist liraglutide had similar induction of mucin. Together, our studies not only demonstrate novel physiological and pathological roles of GLP-1 in the lung but may also caution against the clinical use of inhaled GLP-1 receptor agonists in the patients with obstructive lung diseases.

Regional lung deflation with increased airway volume underlies the functional response to bronchodilators in chronic obstructive pulmonary disease.

Bronchodilators, including long-acting muscarinic antagonists (LAMAs), improve airflow limitation and lung hyperinflation in patients with chronic obstructive pulmonary disease (COPD). While bronchodilators increase airway caliber and deflate the lungs, little is known about the effects of the local interaction between airway dilation and lung deflation on functional improvements resulting from bronchodilator therapy. This study aimed to explore whether lung deflation with increased airway volume in the upper and lower lung regions would produce different physiological responses to LAMA therapy. Using the clinical data of 41 patients with COPD who underwent spirometry and inspiratory computed tomography (CT) before and 1 year after LAMA treatment, we measured the 1-year change in the airway tree to lung volume percentage ratio (AWV%) for the right upper, middle, and lower lobes (RUL, RML, and RLL) and the left upper and lower lobes (LUL and LLL), and total airway count (TAC) identifiable on CT in relation to the forced expiratory volume in 1 s (FEV1 ). The results showed that LAMA treatment significantly increased the FEV1 and AWV% of the RUL, RML, RLL, LUL, and LLL. Increased AWV% in the RLL and LLL, but not in the RUL and LUL, was correlated with increased FEV1 . In the multivariate analysis, the increased AWV% in the RLL was associated with the increased FEV1 independent of the change in TAC in the RLL after treatment. This is the first study to show that the physiological improvements after bronchodilator treatment in COPD could be mainly due to the combination of regional deflation and increased airway volume of the lower lobes.

Diagnostic values of bronchodilator response versus 9-question questionnaire for asthma.

INTRODUCTION: Several studies have investigated different tools for asthma diagnosis in order to reduce the cost and improve its early recognition. The goal of this study is to establish ashort questionnaire to be used in practice for asthma screening and compare diagnostic values between this method and spirometric response to bronchodilators. MATERIAL AND METHOD: 208 patients presenting with chronic stable dyspnea (> 6 months) and definite clinical diagnosis of chronic obstructive pulmonary disease, bronchiectasis, pulmonary fibrosis or asthma, were enrolled. 9 questions out of 43 based on the literature search were selected by regression analysis. Patients were asked to complete the questionnaire and then their spirometric responses to bronchodilators were evaluated. RESULTS: Of all, 53.8% of cases were diagnosed clinically to have asthma. For establishing diagnosis of asthma, the bronchodilator test had 48.2% sensitivity, 78.1% specificity, 72% positive, 56.4% negative predictive values, 2.2 positive, 0.66 negative likeli-hood ratios, and false positive, false negative and accuracy of 21.9%, 51.8% and 62.01%, respectively. The revised 9 questions from the questionnaire had 97.3% sensitivity, 77.1% specificity, 83.2% positive, 96.1% negative predictive values, 4.24 positive, 0.03 negative likelihood ratios, 22.9% false positive, 2.7% false negative and 87.98% accuracy. CONCLUSIONS: The 9-question questionnaire had better diagnostic values in defining asthma in patients with chronic dyspnea than reversibility of airway obstruction to salbutamol and can be used as auseful screening test for diagnosis of asthma in clinical practice and for investigational purposes.

Rational particle design to overcome pulmonary barriers for obstructive lung diseases therapy.

Pulmonary delivery of active drugs has been applied for the treatment of obstructive lung diseases, including asthma, chronic obstructive pulmonary disease and cystic fibrosis, for several decades and has achieved progress in symptom management by bronchodilator inhalation. However, substantial progress in anti-inflammation, prevention of airway remodeling and disease progression is limited, since the majority of the formulation strategies focus only on particle deposition, which is insufficient for pulmonary delivery of the drugs. The lack of knowledge on lung absorption barriers in obstructive lung diseases and on pathogenesis impedes the development of functional formulations by rational design. In this review, we describe the physiological structure and biological functions of the barriers in various regions of the lung, review the pathogenesis and functional changes of barriers in obstructive lung diseases, and examine the interaction of these barriers with particles to influence drug delivery efficiency. Subsequently, we review rational particle design for overcoming lung barriers based on excipients selection, particle size and surface properties, release properties and targeting ability. Additionally, useful particle fabrication strategies and commonly used drug carriers for pulmonary delivery in obstructive lung diseases are proposed in this article.