Sex differences and determinants of anxiety symptoms in patients with COPD initiating pulmonary rehabilitation.

BACKGROUND: Anxiety is common in patients with chronic obstructive pulmonary disease (COPD). However, there is little evidence available regarding gender differences, and severity of dyspnea in relation to anxiety in patients with COPD. AIMS: We examined gender differences and the association of dyspnea with anxiety in a cohort of patients with COPD prior to entering a pulmonary rehabilitation (PR) program. METHOD: We analyzed data from a prospective cohort of COPD patients who attended PR from 2013 to 2019 in Lytham, Lancashire, UK. Patients were aged 40 years or older with a post-bronchodilation forced expiratory volume in 1 s (FEV1) less than 80 % of the predicted normal value and FEV1/FVC (forced vital capacity) ratio less than 0.7. We assessed quality of life (QoL) using the Saint George's Respiratory Questionnaire (SGRQ), anxiety using the Anxiety Inventory for Respiratory disease (AIR), dyspnea using the modified Medical Research Council (mMRC) scale, and exercise capacity using the Incremental Shuttle Walk Test (ISWT). RESULTS: Nine hundred ninety-three patients with COPD (mean age = 71 years, FEV1/FVC = 58 % predicted, 51 % male) entered the PR program. Of these, 348 (35 %) had anxiety symptoms (AIR ≥8); of these 165 (47 %) were male and 183 (53 %) female, (χ2 = 3.33, p = 0.06). On logistic multivariate analysis, the following variables were independently associated with elevated anxiety: younger age (p < 0.001), female sex (p = 0.03), higher SGRQ-total score (p < 0.001) and high FEV1/FVC (p < 0.002). Dyspnea was associated with anxiety r = 0.25, p < 0.001. CONCLUSION: Over a third of COPD patients had clinically relevant anxiety symptoms with a higher prevalence in women than men. Anxiety was associated with younger age, female gender, and impaired QoL. Early recognition and treatment of anxiety in patients with COPD is worthy of consideration for those attending PR, especially women.

Response to omalizumab using patient enrichment criteria from trials of novel biologics in asthma.

BACKGROUND: Recent efficacy studies of asthma biologics have included highly enriched patient populations. Using a similar approach, we examined factors that predict response to omalizumab to facilitate selection of patients most likely to derive the greatest clinical benefit from therapy. METHODS: Data from two phase III clinical trials of omalizumab in patients with allergic asthma were examined. Differences in rates of asthma exacerbations between omalizumab and placebo groups during the 16-week inhaled corticosteroid (ICS) dose-stable phase were evaluated with respect to baseline blood eosinophil counts (eosinophils <300/µL [low] vs ≥300/µL [high]) and baseline markers of asthma severity (emergency asthma treatment in prior year, asthma hospitalization in prior year, forced expiratory volume in 1 second [FEV1 ; FEV1 <65% vs ≥65% predicted], inhaled beclomethasone dipropionate dose [<600 vs ≥600 µg/day], and long-acting beta-agonist [LABA] use [yes/no]). RESULTS: Adults/adolescents (N = 1071) were randomized to receive either omalizumab (n = 542) or placebo (n = 529). In the 16-week ICS dose-stable phase, rates of exacerbations requiring ≥3 days of systemic corticosteroid treatment were 0.066 and 0.147 with omalizumab and placebo, respectively, representing a relative rate reduction in omalizumab-treated patients of 55% (95% CI, 32%-70%; P = .002). For patients with eosinophils ≥300/µL or with more severe asthma, this rate reduction was significantly more pronounced. CONCLUSION: In patients with allergic asthma, baseline blood eosinophil levels and/or clinical markers of asthma severity predict response to omalizumab.

Revisiting Type 2-high and Type 2-low airway inflammation in asthma: current knowledge and therapeutic implications.

Asthma is a complex respiratory disorder characterized by marked heterogeneity in individual patient disease triggers and response to therapy. Several asthma phenotypes have now been identified, each defined by a unique interaction between genetic and environmental factors, including inflammatory, clinical and trigger-related phenotypes. Endotypes further describe the functional or pathophysiologic mechanisms underlying the patient's disease. type 2-driven asthma is an emerging nomenclature for a common subtype of asthma and is characterized by the release of signature cytokines IL-4, IL-5 and IL-13 from cells of both the innate and adaptive immune systems. A number of well-recognized biomarkers have been linked to mechanisms involved in type 2 airway inflammation, including fractional exhaled nitric oxide, serum IgE, periostin, and blood and sputum eosinophils. These type 2 cytokines are targets for pharmaceutical intervention, and a number of therapeutic options are under clinical investigation for the management of patients with uncontrolled severe asthma. Anticipating and understanding the heterogeneity of asthma and subsequent improved characterization of different phenotypes and endotypes must guide the selection of treatment to meet individual patients' needs.

New perspectives regarding ß(2) -adrenoceptor ligands in the treatment of asthma.

In the last two decades several significant changes have been proposed in the receptor theory that describes how ligands can interact with G protein-coupled receptors (GPCRs). Here we briefly summarize the evolution of receptor theory and detail recent prominent advances. These include: (i) the existence of spontaneously active GPCRs that are capable of signalling even though they are unoccupied by any ligand; (ii) the discovery of ligands that can inactivate these spontaneously active receptors; (iii) the notion that a ligand may simultaneously activate more than one GPCR signalling pathway; and (iv) the notion that certain ligands may be able to preferentially direct receptor signalling to a specific pathway. Because the data supporting these receptor theory ideas are derived primarily from studies using artificial expression systems, the physiological relevance of these new paradigms remains in question. As a potential example of how these new perspectives in receptor theory relate to drug actions and clinical outcomes, we discuss their relevance to the recent controversy regarding the chronic use of ß(2) -adrenoceptor agonists in the treatment of asthma.

Arformoterol and salmeterol in the treatment of chronic obstructive pulmonary disease: a one year evaluation of safety and tolerance.

INTRODUCTION: Concerns have been raised regarding the safety of extended use of long-acting beta2-agonists (LABAs). The safety of arformoterol (50 microg QD), and salmeterol (42 microg BID), was assessed over 12 months in subjects with COPD. The study also examined the occurrence of tolerance with these agents, i.e. whether improvement in airway function diminished or frequency of exacerbations increased with 12-months of use. METHODS: Subjects with COPD (mean FEV1 1.2 L, ~41% predicted) were enrolled in the study and randomized to receive nebulized arformoterol 50 microg QD (n = 528) or salmeterol 42 microg BID (MDI; n = 265) in a prospective, multicenter, open-label, 12-month trial. The frequency of adverse events, COPD exacerbations, and use of short-acting bronchodilator agents were assessed throughout the study period. Pulmonary function was also examined. RESULTS: Among treated subjects, the frequency of adverse events was similar for those taking arformoterol (90.5%) and salmeterol (88.3%). Tremor was more frequent among subjects treated with arformoterol (13.4%) than those treated with salmeterol (1.1%). The frequency of COPD exacerbations did not increase over 12 months for arformoterol and salmeterol (weeks 0-13: 15.7% and 11.7%, respectively; weeks 39-52: 10.0% and 9.4%, respectively). Supplemental ipratropium bromide and rescue racemic albuterol use decreased for both groups by 0.8 to 1.5 actuations/day, decreases that remained stable throughout the 52-week study. Mean predose (trough) FEV1 improved for arformoterol and salmeterol at week 13 (7.1% +/- 17.0 and 7.6% +/- 17.8, respectively) and the improvement continued at week 52 (5.9% and 6.2%, respectively). Mean peak percent predicted postdose FEV1 over the course of the 52-week study declined by about 2% for both treatments, but throughout was higher for arformoterol than for salmeterol. CONCLUSION: In this trial, both arformoterol 50 microg QD and salmeterol 42 microg BID were well tolerated in patients with COPD. Both LABAs produced effective bronchodilation and their use was not associated with the development of clinically meaningful tolerance over a 1-year treatment period.

Long-term safety of nebulized formoterol: results of a twelve-month open-label clinical trial.

UNLABELLED: Formoterol fumarate is a long-acting beta2-agonist that is an effective bronchodilator for the maintenance management of patients with chronic obstructive pulmonary disease. The safety profile of the newly developed nebulized formoterol was evaluated over a twelve-month period in an open-label, active-control study. After completing a twelve-week double-blind double-dummy period, 569 subjects with chronic obstructive pulmonary disease entered an open-label extension study and received twice-daily 20 microg formoterol fumarate inhalation solution for nebulization (FFIS) or 12 microg formoterol fumarate dry powder inhalation (FA) for 52 weeks. Most of the FFIS-treated subjects (86%) completed at least six months of open-label treatment with over 90% compliance, comparable to the FA group (88%). RESULTS: of safety monitoring for adverse events, laboratory values, and cardiac changes were similar between treatment groups. Three hundred forty (73%) of FFIS-treated subjects and 83 (78%) of FA-treated subjects experienced an adverse event over the course of the study, the majority of which were mild to moderate and considered unrelated to treatment. COPD exacerbation occurred in 15.8% of FFIS-treated and 17.9% of FA-treated subjects. Deaths, serious adverse events, and discontinuations for adverse events occurred in 1.3, 16.2, and 5.4% of the nebulized group versus 1.9, 17.9, and 7.5% of the inhaled group, respectively. There were no clinically important changes from baseline in laboratory tests, including serum potassium and glucose, or vital signs and no treatment-related increases in cardiac arrhythmias, heart rate, or QTc prolongation. We conclude that nebulized formoterol fumarate twice daily is well tolerated over long-term treatment in moderate-to-severe COPD subjects and has a similar safety profile to the DPI formulation.

The bronchodilator response to salmeterol is maintained with regular, long-term use in patients with COPD.

Long-acting beta(2)-agonists (LABAs) are recommended in the management of patients with chronic obstructive pulmonary disease (COPD). Previous studies have demonstrated that the LABA, salmeterol, improves lung function, symptoms and quality of life in patients with COPD. In this study, we have performed additional analyses of the combined data from two previous double-blind, placebo-controlled, parallel studies of salmeterol (50 microg, b.i.d) in patients with COPD. The new analyses reveal that the significant improvements seen in pre-dose and 2-h post-dose forced expiratory volume in 1 s (FEV(1)) compared to placebo, occur early in the treatment period, and are sustained for at least 24 weeks. Moreover, improvements in peak expiratory flow rate occur as early as Day 1, and are sustained throughout the 24-week period. Additional analyses of 12-h FEV(1) data also show that salmeterol is associated with an increase in the area under the curve at Week 12 compared with Day 1, adding further support to evidence that it results in a sustained bronchodilator response, with no evidence of tolerance.

Accidental hypothermia.

Individuals at extremes of age and those who have certain underlying medical conditions are at greatest risk for hypothermia. Hypothermia may occur during any season of the year and in any climate. Prompt recognition of hypothermia and early institution of the rewarming techniques are imperative for a successful outcome with minimal complications. Several rewarming techniques are available and the decision to use any of them depends on the degree of hypothermia, the condition of the patient, and the rewarming rate possible with the technique chosen.

Effect of exposure to low levels of ozone on the response to inhaled allergen in allergic asthmatic patients.

STUDY OBJECTIVES: In a previous study published by our group, six out of nine subjects with mild allergic asthma were shown to have an enhanced response to allergen challenge following a 1-h exposure in an 0.8-m3 exposure chamber (modified from a body plethysmograph) to an average of 120 parts per billion (ppb) ozone at rest. Other studies failed to confirm this effect. In the present study, using a similar design, we reexamined this effect using a larger group of asthmatics and a larger chamber allowing minimal fluctuations in ozone levels during exposures. DESIGN: Prospective, randomized single-blinded crossover study. SETTING: Pulmonary function laboratory equipped with an exposure chamber. SUBJECTS: Fifteen subjects had mild allergic asthma; 9 men and 6 women; the mean (SD) age was 32.5 (10) years; FEV1 was 3.4 (0.8) L; baseline methacholine provocation concentration causing a 20% fall in FEV1 was (PC20) 3.28 (4.1) mg/mL. INTERVENTIONS: Each participant was exposed, at rest, on 1 day to filtered air and on another day to ozone (mean level=120 ppb) in a larger exposure chamber than the one used in our first study with less variability in ozone level (110 to 130 vs 85 to 175 ppb) using a random, single-blinded design. After each exposure, the subject was challenged with allergen (nine with grass pollen extract and six with ragweed extract) and allergen PC15 was measured. RESULTS: Ozone preexposure did not affect allergen PC15 when compared with clean air preexposure (allergen PC15 dilution 1/114 vs 1/119, respectively). Ozone vs air preexposure resulted in an allergen PC15 that was lower in five subjects, higher in six, and unchanged (within one doubling dose) in four. CONCLUSIONS: At this low level with less variability and lower peaks than our previous study, ozone had no significant effect on airway allergen responsiveness.

Acute respiratory distress syndrome. Inhaled nitric oxide.

There is enough evidence to support the short-term beneficial effects and safety of administering inhaled NO to ARDS patients. This effect may be potentiated when inhaled NO is administered in conjunction with other therapies. The full spectrum of effects of inhaled NO remains to be elucidated. Long-term benefit in terms of mortality and duration of mechanical ventilation has not been demonstrated; more randomized trials probing these effects are needed.

Vasodilators in mechanical ventilation.

Vasodilators that affect the pulmonary vasculature are appealing adjuncts in many cardiopulmonary conditions that require mechanical ventilation such as ARDS, COPD, PPHN, and cardiothoracic surgery. The adverse systemic effects of parenteral PGE1 and parenteral prostacyclin limit their usefulness in critically ill patients. Liposomal PGE1 has few systemic effects, but thus far has not resulted in a significant clinical benefit in patients with ARDS. Inhaled NO and aerosolized prostacyclin offer the advantage of selective pulmonary vasodilation with minimal systemic effects. Both agents decrease PAP and in many clinical situations improve oxygenation; however, the physiologic effects of inhaled NO and aerosolized prostacyclin have not convincingly led to improved clinical outcomes. Currently, use of vasodilators in mechanically ventilated patients remains investigational.

Ventilation of patients with asthma and obstructive lung disease.

Mechanical ventilation in a patient with obstructive airway disease may be a lifesaving measure; however, it may also be associated with significant morbidity and mortality. It is important for a physician to be familiar with the potential complications of mechanical ventilation in this group of patients and to know how to avoid them by carefully applying safe ventilator strategies. The cornerstone of such strategies is to minimize minute ventilation, maximize time for expiration, and avoid hyperinflation of the lung. Several bedside parameters (iPEEP, VEI, Pplat) that reflect presence of gas trapping and potential hyperinflation may be measured. In addition to mechanical ventilation, management should include inhaled bronchodilators and systemic corticosteroid therapies. In the event controlled hypoventilation is necessary, sedation with or without the use of muscle relaxants may be required. Unconventional therapies such as the use of Heliox, magnesium sulfate, ketamine, and inhalational anesthetics may be attempted in severe cases that do not respond to conventional management. With appropriate use of ventilator strategies, a reduction in the mortality and morbidity of patients with obstructive airway disease requiring mechanical ventilation has recently been noted.

Factors associated with emergency department dependence of patients with asthma.

BACKGROUND: Dependence on crisis-oriented care rather than continuous ambulatory care for asthma is thought to contribute to asthma morbidity and mortality. We contrasted the characteristics of patients who depend on emergency department (ED) care for the management of their asthma exacerbations to the characteristics of patients employing self-management plans in an ambulatory setting. METHODS: In prospective fashion, we used a structured interview and charted information to survey two cohorts of patients suffering from an acute exacerbation of asthma; those seen in a hospital ED (n = 80) and those seen in an ambulatory asthma care facility (Asthma Center [AC]) (n = 40) at the same hospital. We looked for differences in socioeconomic characteristics, asthma severity, asthma knowledge, and asthma self-management skills between groups. RESULTS: There were no significant differences in mean age (SD) (ED vs AC: 36.65 [13.8] vs 40 [13.8] years) or female to male ratio (ED vs AC: 2/1 vs 2.5/1) between the two groups. There were no major differences in ethnic origin, educational status, marital status, smoking history, employment status, number of children in the household, possession of an extended health insurance plan, sick leave benefits, and child care availability between the two groups. Patients seeking ED care were more likely to have resided in the city for < 5 years (34% vs 8%; p < 0.05), and more likely to be living alone (35% vs 15%; p < 0.05). Significantly more patients from the ED group had a below average gross annual income (55% vs 3%; p < 0.05). There were several significant differences between groups in their knowledge of asthma and its therapy. Most striking, 79% of AC patients reported having a predetermined crisis plan vs just 23% of ED patients (p < 0.001). Although measurements of airflow (percent predicted FEV1) were significantly lower in the ED group than the AC group (mean, 50% vs 78.4%; p < 0.001), other indexes reflecting the degree of asthma severity over the long term such as past use of oral steroids, history of hospitalization, or ICU admission for asthma and the mean total days of disability within the preceding year were not significantly different between the two groups. Most of the ED patients had more than one previous visit to the ED for asthma exacerbation within the preceding year while most exacerbations of AC patients had been treated in the ambulatory care setting. Only 17% of ED patients initiated or increased inhaled or oral steroids before seeking medical care vs 89% of AC patients (p < 0.001). CONCLUSION: We conclude that a subgroup of asthmatics depends primarily on crisis-oriented care for the management of asthma. These patients are more likely to have lower income, to live alone, and to have resided at their current address for less time than patients seeking less urgent ambulatory care. Moreover, such patients are less knowledgeable about asthma and its management and are less likely to have a predetermined crisis plan.

The accuracy of a handheld portable spirometer.

BACKGROUND: Objective measurement of lung function is considered essential in the management of patients with asthma and COPD. Many primary care practitioners lack the means necessary to obtain these measurements conveniently. To meet this need, electronic spirometers, offering portability, ease of operation, and timesaving readout options have been introduced. We compared the accuracy of a typical pneumotachograph-based device with a conventional volume displacement spirometer. METHODS: We compared indexes of pulmonary function (FVC, FEV1, mean forced expiratory flow during the middle half of FVC, [FEF25-75%], and peak expiratory flow rate [PEFR]) measured by the handheld device with those measured by a conventional spirometer in 75 white subjects (33 men, 42 women) with a median age of 43 years (22 to 77 years) who were either healthy or were referred to the pulmonary function laboratory of a large tertiary care teaching hospital. The order of the instrument tested first was randomized and the patients were blinded to which instrument was being studied. RESULTS: There was a linear relationship between instruments for all indexes measured (r = 0.97, 0.98, 0.94, 0.94 for FVC, FEV1, FEF25-75%, and PEFR, respectively, for all p < 0.001). The random error (precision) was within 5% only for FEV1. The mean of the differences between the values obtained using both instruments (the bias) +/- limits of agreement (+/- 2 SD) were 0.06 +/- 0.56 L for FVC (p = NS), 0.2 +/- 0.44 L for FEV1 (p < 0.05), 0.61 +/- 1.26 L/s for FEF25-75% (p < 0.05), and 0.44 +/- 1.9 L/s for PEFR (p < 0.05). CONCLUSION: Our data suggest that measurements obtained using the pneumotachograph device are closely related to those obtained by volume displacement spirometry and that the handheld device may be useful in clinical practice. However, because the limits of agreement are wide and the difference between the two instrument measurements are significant for FEV1, FEF25-75%, and PEFR, the bias between them is not consistent nor is it insignificant. Therefore, the measurements made with the two types of machine cannot be used interchangeably.

Dose-related decrease in bone density among asthmatic patients treated with inhaled corticosteroids.

BACKGROUND: Inhaled corticosteroids are being prescribed more commonly and in higher doses than previously in the management of asthma. Although these topically active compounds have less potential for systemic impact than oral steroids, biochemical markers suggest that they are not devoid of systemic side effects. We conducted this study to investigate the effect of commonly prescribed doses of inhaled steroids on bone density. METHODS: We studied 36 patients with asthma. Those in group A (n = 18) had been taking inhaled beclomethasone dipropionate or budesonide in a dosage of 800 micrograms or more per day for at least 1 year. Those in group B (n = 18) had used only bronchodilator therapy. Adrenal function was assessed by morning serum cortisol level and by short adrenocorticotropic hormone stimulation test. Bone turnover was assessed by measurement of serum osteocalcin, alkaline phosphatase, and urinary pyridinium cross-links. Bone mineral density was measured by dual-energy x-ray absorptiometry with a Hologic QDR-1000 densitometer (Hologic Inc., Waltham, Mass.). RESULTS: Group A, mean age (SD) = 36.6 (8.4) years, had used inhaled corticosteroids at a mean dose of 1323 micrograms/day (range, 800 to 2000 micrograms/day) for a median duration of 24 months. Group B, mean age (SD) = 33.4 (8.1) years, had not been taking any form of steroid. Four patients from group A had suppressed morning serum cortisol; three of these had abnormal adrenocorticotropic hormone stimulation test results. All patients in group B had normal baseline adrenal function and an appropriate response to adrenocorticotropic hormone. Mean serum osteocalcin level in group A was significantly lower than that in group B (8.8 vs 14.2 ng/ml, p = 0.0003). Bone density measurements showed parallel changes: in group A the mean Z score (SD) of the femoral neck was -0.78 (1.02), significantly below predicted normal values (p = 0.0025). Mean Z scores of the lumbar spine and of femoral Ward's triangle were not significantly reduced. In group B the mean Z scores of the lumbar spine, femoral neck, and femoral Ward's triangle were all within normal limits. In group A the dose duration of inhaled corticosteroid therapy corrected for body mass index correlated negatively with bone density and adrenal function measurements. CONCLUSION: We conclude that the regular use of conventional doses of inhaled corticosteroids by patients with asthma can suppress adrenal function and decrease bone density in a dose-related fashion.

Health-care utilization after near-fatal asthma.

Near-fatal asthma has been repeatedly associated with an increased risk of premature death. Despite a higher risk, death after near-fatal asthma remains infrequent. Few studies have examined the long-term outcome of those who experience a near-fatal event but do not succumb to asthma. We therefore contacted patients who had an episode of near-fatal asthma 5 to 10 years earlier and documented their use of health-care services for asthma. Each index case was compared with two age-matched controls who had been hospitalized for severe but not near-fatal asthma within 2 years of the index case admission. Thirty-seven index cases and 74 control subjects were assessed. Demographics did not distinguish the two groups. Availability of primary care physicians and asthma specialists were similar. There was no difference in the frequency of hospitalizations, emergency room visits, or visits to physicians for asthma between the two groups. ICU admissions were extremely infrequent. Although the mean number of ICU admissions per subject were similar in the year preceding our contact (0.03 +/- 0.16 in each group), there was a trend toward ICU admissions occurring more often in the near-fatal group (0.62 +/- 1.67 vs 0.31 +/- 0.91 admissions/subject). Days away from work were more frequent in the control group (3.5 +/- 5.5 vs 1.6 +/- 3.3 d/yr) including days away from work in the year preceding our contact (8.9 +/- 43 vs 1.8 +/- 6.1 d). The data suggests that with regards to characteristics and health-care utilization, it may not be possible to distinguish people with near-fatal asthma from those who are hospitalized without a near-fatal event.

Adverse effects of inhaled corticosteroids.

Inhaled corticosteroids are considered by many to be the anti-inflammatory therapy of choice in adult asthma, given their remarkable efficacy and apparent safety. They are presently being prescribed to more patients, at larger doses, and for longer periods of time than ever before. Oropharyngeal candidiasis and dysphonia are the most commonly recognized adverse effects of therapy, but these topical phenomena cause no significant morbidity and are easily managed. By contrast, there is now increasing concern about the potential systemic effects of inhaled corticosteroids. These putative effects may include adrenal suppression, bone loss, skin thinning, increased cataract formation, decreased linear growth in children, metabolic changes, and behavioral abnormalities. Changes in adrenal function have been noted in patients using medications such as beclomethasone dipropionate and budesonide in doses exceeding 1,500 micrograms/day. The clinical relevance of these changes has yet to be clarified. Several short-term and cross-sectional studies have also revealed changes in biochemical markers of bone turnover and retrospective studies have found reduced bone density in asthmatics treated regularly with inhaled steroids. Long-term prospective studies assessing bone density changes remain to be done. Although much controversy exists, there is no unequivocal evidence that conventional doses of inhaled steroids significantly retard bone growth in children. Reports on skin changes, increased cataract formation, and behavioral changes are difficult to interpret because of several confounding factors. Although inhaled steroids should, at the present time, continue to be a recommended therapeutic option to all patients with symptomatic asthma, they should always be used in the lowest dosage compatible with disease control.

Medical personnel's knowledge of and ability to use inhaling devices. Metered-dose inhalers, spacing chambers, and breath-actuated dry powder inhalers.

BACKGROUND: Current treatment strategies for asthma and chronic obstructive pulmonary disease (COPD) emphasize the inhalation route, yet patients often misuse metered-dose inhalers (MDI). To address this problem, patient education by medical personnel has been recommended and a variety of alternate inhaler devices have been developed. METHODS: We surveyed medical personnel to assess their knowledge of and ability to use three widely used inhaler devices; MDI, MDI with a spacing chamber (Aerochamber, Trudell Medical, Canada), and a breath-actuated multidose dry powder inhaler (Turbuhaler, Astra Pharmacy, Inc., Conada). Thirty respiratory therapists (RT), 30 registered nurses (RN), and 30 medical house staff physicians (MD) were asked to demonstrate the use of each device using placebo inhalers and to answer 11 clinically relevant questions related to the use and maintenance of the tested devices. RESULTS: The RT's percent mean knowledge score (67 +/- 5 percent) was significantly higher than those achieved by either the RNs (39 +/- 7 percent) or the MDs (48 +/- 7 percent) (for all p < 0.0001). Similarly, percent mean demonstration scores for each device were significantly higher for RTs than either RN or MD groups; for MDI, 97 +/- 3 percent versus 82 +/- 13 percent and 69 +/- 24 percent, respectively (p < 0.0001); for the Aerochamber, 98 +/- 2 percent versus 78 +/- 20 percent and 57 +/- 31 percent (p < 0.0001); and for the Turbuhaler, 60 +/- 30 percent versus 12 +/- 23 percent and 21 +/- 30 percent (p < 0.0001). Knowledge of and practical skills with the devices were roughly proportional to the length of time the device had been in clinical use, Turbuhaler demonstration scores being lower than either MDI or Aerochamber scores (p = 0.05 and p = 0.09, respectively). More RTs (77 percent) had received formal instruction on the use of devices at school than either RNs (30 percent) or MDS (43 percent) (p < 0.05). CONCLUSION: We conclude that (1) many medical personnel responsible for monitoring and instructing patients in optimal inhaler use lack rudimentary skills with these devices, (2) nurses and physicians seldom receive formal training in the use of inhaling devices, and (3) newer inhaling devices designed to obviate problems of technique are at present less likely to be used well by medical personnel soon after their introduction.