Influence of Aerosol Mask Design on Fugitive Aerosol Concentrations During Nebulization.

BACKGROUND: Secondhand exposure to fugitive aerosols may cause airway diseases in health providers. We hypothesized that redesigning aerosol masks to be closed-featured would reduce the fugitive aerosol concentrations during nebulization. This study aimed to evaluate the influence of a mask designed for a jet nebulizer on the concentration of fugitive aerosols and delivered doses. METHODS: An adult intubation manikin was attached to a lung simulator to mimic normal and distressed adult breathing patterns. The jet nebulizer delivered salbutamol as an aerosol tracer. The nebulizer was attached to 3 aerosol face masks: an aerosol mask, a modified non-rebreathing mask (NRM, with no vent holes), and an AerosoLess mask. An aerosol particle sizer measured aerosol concentrations at parallel distances of 0.8 m and 2.2 m and a frontal distance of 1.8 m from the manikin. The drug dose delivered distal to the manikin's airway was collected, eluted, and analyzed using a spectrophotometer at a 276 nm wavelength. RESULTS: With a normal breathing pattern, the trends of aerosol concentrations were higher with an NRM followed by an aerosol mask and AerosoLess mask (P < .001) at 0.8 m; however, the concentrations were higher with an aerosol mask followed by NRM and AerosoLess mask at 1.8 m (P < .001) and 2.2 m (P < .001). With a distressed breathing pattern, the aerosol concentrations were higher with an aerosol mask followed by an NRM and AerosoLess mask at 0.8 m, 1.8 m (P < .001), and 2.2 m (P = .005). The delivered drug dose was significantly higher with AerosoLess mask with a normal breathing pattern and with an aerosol mask with a distressed breathing pattern. CONCLUSIONS: Mask design influences fugitive aerosol concentrations in the environment, and a filtered mask reduces the concentration of aerosols at 3 different distances and with 2 breathing patterns.

Multidrug Aerosol Delivery During Mechanical Ventilation.

Background: In the critically ill, pulmonary vasodilators are often provided off label to intubated patients using continuous nebulization. If additional aerosol therapies such as bronchodilators or antibiotics are needed, vasodilator therapy may be interrupted. This study assesses aerosol systems designed for simultaneous delivery of two aerosols using continuous nebulization and bolus injection without interruption or circuit disconnection. Methods: One i-AIRE dual-port breath-enhanced jet nebulizer (BEJN) or two Aerogen® Solo vibrating mesh nebulizers (VMNs) were installed on the dry side of the humidifier. VMN were stacked; one for infusion and the second for bolus drug delivery. The BEJN was powered by air at 3.5 L/min, 50 psig. Radiolabeled saline was infused at 5 and 10 mL/h with radiolabeled 3 and 6 mL bolus injections at 30 and 120 minutes, respectively. Two adult breathing patterns (duty cycle 0.13 and 0.34) were tested with an infusion time of 4 hours. Inhaled mass (IM) expressed as % of initial syringe activity (IM%/min) was monitored in real time with a ratemeter. All delivered radioaerosol was collected on a filter at the airway opening. Transients in aerosol delivery were measured by calibrated ratemeter. Results: IM%/h during continuous infusion was linear and predictable, mean ± standard deviation (SD): 2.12 ± 1.45%/h, 2.47 ± 0.863%/h for BEJN and VMN, respectively. BEJN functioned without incident. VMN continuous aerosol delivery stopped spontaneously in 3 of 8 runs (38%); bolus delivery stopped spontaneously in 3 of 16 runs (19%). Tapping restarted VMN function during continuous and bolus delivery runs. Bolus delivery IM% (mean ± SD): 20.90% ± 7.01%, 30.40% ± 11.10% for BEJN and VMN, respectively. Conclusion: Simultaneous continuous and bolus nebulization without circuit disconnection is possible for both jet and mesh technology. Monitoring of VMN devices may be necessary in case of spontaneous interruption of nebulization.

Influence of Mechanical Ventilation Modes on the Efficacy of Nebulized Bronchodilators in the Treatment of Intubated Adult Patients with Obstructive Pulmonary Disease.

BACKGROUND: Little has been reported in terms of clinical outcomes to confirm the benefits of nebulized bronchodilators during mechanical ventilation (MV). Electrical Impedance Tomography (EIT) could be a valuable method to elucidate this gap. OBJECTIVE: The purpose of this study is to evaluate the impact of nebulized bronchodilators during invasive MV with EIT by comparing three ventilation modes on the overall and regional lung ventilation and aeration in critically ill patients with obstructive pulmonary disease. METHOD: A blind clinical trial in which eligible patients underwent nebulization with salbutamol sulfate (5 mg/1 mL) and ipratropium bromide (0.5 mg/2 mL) in the ventilation mode they were receiving. EIT evaluation was performed before and after the intervention. A joint and stratified analysis into ventilation mode groups was performed, with p < 0.05. RESULTS: Five of nineteen procedures occurred in controlled MV mode, seven in assisted mode and seven in spontaneous mode. In the intra-group analysis, the nebulization increased total ventilation in controlled (p = 0.04 and ⅆ = 2) and spontaneous (p = 0.01 and ⅆ = 1.5) MV modes. There was an increase in the dependent pulmonary region in assisted mode (p = 0.01 and ⅆ = 0.3) and in spontaneous mode (p = 0.02 and ⅆ = 1.6). There was no difference in the intergroup analysis. CONCLUSIONS: Nebulized bronchodilators reduce the aeration of non-dependent pulmonary regions and increase overall lung ventilation but there was no difference between the ventilation modes. As a limitation, it is important to note that the muscular effort in PSV and A/C PCV modes influences the impedance variation, and consequently the aeration and ventilation values. Thus, future studies are needed to evaluate this effort as well as the time on ventilator, time in UCI and other variables.

Inhaler technique in a pediatric emergency department: Impact of an education intervention among healthcare professionals.

BACKGROUND: Inhaler technique (IT) knowledge among healthcare providers is poor. The aim was to improve Pediatric Emergency Department (PED) healthcare providers' IT technique by carrying out an education intervention and sustain it for 6 months. METHODS: Open-label, quasi-experimental, prospective, and unicentric study. Healthcare professionals working at the PED were enrolled. The study was developed in three phases: baseline evaluation and education intervention (P1) and reevaluation 1 month (P2) and 6 months (P3) after the education intervention. Participants fulfilled an eight-question theoretical test. Practical skills were evaluated by demonstrating IT in all three phases. The education intervention consisted in a verbal explanation of IT followed by a demonstration of IT with metered-dose inhaler using a mannequin. RESULTS: A total of 84 healthcare providers (medical residents, nurses, and nursing assistants) were involved. In the theoretical questionnaire, the mean score at baseline was 4.4/8 (SD 1.7) improving to 6.3/8 (SD 1.2) in P2 and 6.47/8 (SD 1.1) in P3. In the IT evaluation for children <7 years old, the score improved from 5.7/7 (SD 1.3) to 6.5/7 in P2 and 6.7/7 in P3 (p < 0.001). For children >7 years old, the mean score of IT at baseline was 3.1/10 (SD 4), which improved to 7.4/10 (SD 3) and 8.2/10 in P2 and P3, respectively (p < 0.001). Only professional category influenced results at baseline. CONCLUSION: Healthcare providers' theoretical knowledge and practical skills on IT are low. The education intervention performed is a useful strategy to ameliorate IT among healthcare providers.

Eficacia de una intervención educativa en el manejo de un dispositivo de inhalación entre profesionales de enfermería de un servicio de urgencias / Efficacy of an educational intervention in the management of an inhalation device among nursing professionals of an emergency department

Objetivo: Explorar los errores más frecuentes de la técnica inhalatoria (pilar para el tratamiento farmacológico de las exacerbaciones de asma y/o enfermedad pulmonar obstructiva crónica) en enfermeras de un servicio de urgencias, y evaluar la eficacia de una intervención educativa. Métodos: Estudio cuasiexperimental prospectivo, realizado en un hospital de Argentina durante 2019. Para la evaluación de enfermeras se utilizaron los pasos del Consenso Separ-Alat. La intervención educativa consistió en explicación oral y demostración visual de la técnica inhalatoria. Se realizó análisis de datos pareados, y se calcularon las frecuencias absolutas y relativas con sus respectivos intervalos de confianza de 95%. Resultados: Se incluyó una muestra consecutiva de 72 enfermeros, de los cuales el 95,83% (IC 95% 88,30-99,13) cometieron al menos un error en la evaluación basal. Los errores más frecuentes fueron la falta de indicación al paciente de espirar previo a la inhalación (83,72%), el olvido de retirar la aerocámara y repetir los pasos antes de la segunda dosis (81,40%). Tras la evaluación inmediata después de recibir la intervención educativa, el 74,42% (IC 95% 58,83-86,49) corrigió la técnica. Sin embargo, al mes el 53,49% (23/43; IC 95% 37,66-68,86) realizaba la técnica correctamente. Conclusiones: La intervención educativa puede ser eficaz para subsanar errores en esta práctica, aunque sus efectos tienden a extinguirse con el tiempo. Por ende, consideramos relevante la educación periódica y sistemática para mantener una técnica de inhalación correcta entre los profesionales.(AU)

Objetive: To explore the most frequent errors of the inhalation technique (main topic for the pharmacological treatment of exacerbations of asthma and/or chronic obstructive pulmonary disease) in the nursing staff of an emergency department, and to evaluate the efficacy of an educational intervention. Methods: Prospective quasi-experimental study, carried out in a hospital in Argentina during 2019. For the evaluation of the nursing staff, the steps of the Separ-Alat Consensus were used. The educational intervention consisted of oral explanation and visual demonstration of the inhalation technique. Paired data analysis was performed, and absolute and relative frequencies were calculated with their respective 95% confidence intervals. Results: A consecutive sample of 72 nurses was included, of which 95.83% (95% CI 88.30-99.13) made at least one error in the baseline assessment. The most frequent errors were the lack of indication to the patient to exhale prior to inhalation (83.72%), forgetting to remove the air chamber and repeat the steps before the second dose (81.40%). After immediate evaluation after receiving the educational intervention, 74.42% (95% CI 58.83-86.49) corrected the technique. However, at one month, 53.49% (23/43; 95% CI 37.66-68.86) performed the technique correctly. Conclusions: The educational intervention could be effective in correcting errors in this practice, although its effects tend to fade over time. Therefore, we consider periodic and systematic education relevant to maintain a correct inhalation technique among professionals.(AU)

Identificación y adquisición de dispositivos de entrenamiento para mejorar la técnica de administración en una farmacia comunitaria / Identification and procurement of training devices to improve dispensing technique in a community pharmacy

JUSTIFICACIÓN: el asma y la EPOC son dos patologías muy prevalentes y con una alta tasa de mortalidad. El tratamiento de ambas suele incluir medicación que tiene que ser administrada vía inhalada, mediante dispositivos en los que su manejo es complejo. Esto genera un mal control de la enfermedad y altas tasas de no adherencia, lo que agrava aún más el problema. La educación sanitaria, se convierte en un factor trascendental en el abordaje de esta patología respiratoria, y el farmacéutico comunitario en una figura clave en su difusión. Si el paciente no domina la técnica de inhalación, es muy útil disponer de dispositivos de inhalación no medicamentosos, para poder ofrecer una educación sanitaria de calidad. OBJETIVOS: identificar dispositivos de inhalación comercializados, averiguar si el laboratorio comercializador dispone de simuladores para entrenamiento de los pacientes en su manejo y adquirirlos para su uso en una farmacia comunitaria como herramienta de educación sanitaria. MATERIAL Y MÉTODOS: revisión bibliográfica para conocer los dispositivos autorizados y los laboratorios comercializadores. Se empleó la base de datos del consejo Botplus, y se consultó páginas de sociedades científicas así como guías clínicas. Se contacta con los laboratorios y se solicita los dispositivos. RESULTADOS/DISCUSIÓN: se localizaron once tipos de dispositivos de inhalación (Relvar®, Handihaler®, Accuhaler®, cartuchos a presión, Genuair®, Turbuhaler®, Respimat®, Nexthaler®, Modulite®, Breezhaler® y Spiromax®) comercializados por seis laboratorios farmacéuticos GlaxoSmithKline (GSK), AstraZeneca, Boehringer Ingelheim, Chiesi, Novartis y TEVA. Cinco laboratorios si contestaron, pero solo tres mandaron los dispositivos. (AU)

Efficacy of an educational intervention in the management of an inhalation device among nursing professionals of an emergency department.

OBJECTIVE: To explore the most frequent errors of the inhalation technique (main topic for the pharmacological treatment of exacerbations of asthma and/or chronic obstructive pulmonary disease) in the nursing staff of an emergency department, and to evaluate the efficacy of an educational intervention. METHODS: Prospective quasi-experimental study, carried out in a hospital in Argentina during 2019. For the evaluation of the nursing staff, the steps of the Separ-Alat Consensus were used. The educational intervention consisted of oral explanation and visual demonstration of the inhalation technique. Paired data analysis was performed, and absolute and relative frequencies were calculated with their respective 95% confidence intervals. RESULTS: A consecutive sample of 72 nurses was included, of which 95.83% (95%CI 88.30-99.13) made at least one error in the baseline assessment. The most frequent errors were the lack of indication to the patient to exhale prior to inhalation (83.72%), forgetting to remove the air chamber and repeat the steps before the second dose (81.40%). After immediate evaluation after receiving the educational intervention, 74.42% (95%CI 58.83-86.49) corrected the technique. However, at one month, 53.49% (23/43; 95%CI 37.66-68.86) performed the technique correctly. CONCLUSIONS: The educational intervention could be effective in correcting errors in this practice, although its effects tend to fade over time. Therefore, we consider periodic and systematic education relevant to maintain a correct inhalation technique among professionals.

Chronic obstructive pulmonary disease patients' experience using Trelegy as compared with other inhalers.

Introduction: Trelegy is a combination inhaler that is often reported to offer benefits over multiple inhalers. We compared Trelegy use with multiple inhalers for adherence, symptoms, medication beliefs, and medication attitudes. Methods: This cross-sectional survey of 58 patients compared the patient's experience with Trelegy (n = 18) versus any other inhaler (n = 40). Outcome variables consisted of Test of the Adherence to Inhalers scale, the Chronic obstructive pulmonary disease Assessment Test (CAT) scale, attitude items from the St. George's Respiratory Questionnaire, the Beliefs about Medicines Questionnaire (BMQ)-necessity subscale, and the BMQ-concerns subscale. Results: We found that patients using Trelegy had greater CAT symptoms (M = 19.8, SD = 7.75) in comparison with the any other inhaler group (M = 15.7, SD = 11.10; P = 0.04). We did not find any difference between the groups for adherence or any of the medication attitudes or beliefs. CAT score was positively correlated with the number of months patients were on their current inhaler (r s = 0.29, P < 0.05) and their use of a rescue inhaler (r s = 0.42, P < 0.01). Patients with more concern about their medications were negatively correlated with the use of a rescue inhaler (r s = -0.31, P < 0.05). Discussion: We found that patients using Trelegy had greater symptoms in comparison with the any other inhaler group, but did not differ for adherence, medication attitudes, or medication beliefs. Conclusion: We recommend that clinicians should regularly re-evaluate their Trelegy recommendations, as Trelegy use may not be the best therapy for certain patients. Also, a study with a larger sample size can be beneficial to confirm these findings.

Aerosol therapy during mechanical ventilation in intensive care units: A questionnaire-based survey of 2203 ICU medical staff in China.

Background: To describe the current status of aerosol therapy during mechanical ventilation (MV) and the practice, knowledge, and beliefs about aerosol therapy in physicians working in the intensive care unit (ICU) in China. Methods: A physician self-administered questionnaire-based cross-sectional survey was carried out from January 2019 to July 2019. An electronic questionnaire was designed, and physicians who worked regularly in ICUs across several hospitals were contacted through WeChat. Answers to all questions and the general characteristics of physicians who answered the questionnaire were collected and analyzed. Results: A total of 2203 medical staff who regularly worked in the ICUs completed this questionnaire (9.0% missing data); 87.7% of the participants were doctors. Most respondents claimed that they often administered aerosolization therapy. Ultrasonic atomizer (50.7%) and jet nebulizer (48.6%) were the most commonly used atomization devices. Bronchodilators (65.8%) and steroids (66.3%) were the most frequently aerosolized drugs during MV. During nebulization, ventilator settings were never changed by 32.7% of respondents. Only 49.1% of respondents knew the appropriate place for a nebulizer. Further, 62.7% of respondents using heated humidifiers reported turning them off during nebulization. Specific knowledge about droplet size and nebulization yield was poor. Respondents from tertiary hospitals and those with higher technical title or work experience tended to have better accuracy than those from primary hospitals or with lower technical titles (P < 0.050). Conclusions: Aerosol therapy was commonly used during MV, and the most frequent drugs were bronchodilators and steroids. Scientific knowledge about the optimal implementation of aerosol therapy during MV seemed deficient.

Association between beta-2 adrenergic receptor variants and clinical outcomes in children and adolescents with acute asthma

ABSTRACT Objective To investigate whether different genotypes of p.Arg16Gly, p.Gln27Glu, p.Arg19Cys and p.Thr164Ile variants interfere in response to treatment in children and adolescents with moderate to severe acute asthma. Methods This sample comprised patients aged 2 to 17 years with a history of at least two wheezing episodes and current moderate to severe asthma exacerbation. All patients received multiple doses of albuterol and ipratropium bromide delivered via pressurized metered-dose inhaler with holding chamber and systemic corticosteroids. Hospital admission was defined as the primary outcome. Secondary outcomes were changes in forced expiratory volume in the first second after 1 hour of treatment, and for outpatients, length of stay in the emergency room. Variants were genotyped by sequencing. Results A total of 60 patients were evaluated. Hospital admission rates were significantly higher in carriers of the genotype AA relative to those with genotype AG or GG, within the p.Arg16Gly variant (p=0.03, test χ2, alpha=0.05). Secondary outcomes did not differ between genotypes. Conclusion Hospital admission rates were significantly higher among carriers of the genotype AA within the p.Arg16Gly variant. Trial registration: ClinicalTrials.gov: NCT01323010

Environmental impact of inhaler devices on respiratory care: a narrative review / Impacto ambiental dos dispositivos inalatórios nos cuidados respiratórios: uma revisão narrativa

ABSTRACT Climate change is a huge and present threat to human health. This article aims to deepen the knowledge about the environmental impact of inhaler devices on their carbon footprint for patients and health professionals, providing information that allows a better choice of the type of device to be prescribed for the treatment of asthma and COPD. This narrative and nonsystematic review was carried out by searching databases (PubMed, Google Scholar, SciELO, and EMBASE) for articles published between 2017 and 2022, written in Portuguese or in English, using the search words "inhalation device" OR "environmental." The review showed that global warming cannot be addressed by focusing only on inhaler devices. However, the devices that we use to treat respiratory diseases such as asthma and COPD, which are diseases that are aggravated by climate change, are also causing that change. Therefore, health professionals, patient organizations, and industries should take a lead in health policies to offer affordable alternatives to inhalers containing hydrofluoroalkane.

RESUMO As mudanças climáticas são uma ameaça enorme e presente para a saúde humana. Este artigo visa aprofundar o conhecimento sobre o impacto ambiental dos dispositivos inalatórios na pegada de carbono para pacientes e profissionais de saúde, fornecendo informações que permitem uma melhor escolha do tipo de dispositivo a ser prescrito para o tratamento da asma e da DPOC. Esta revisão narrativa e não sistemática foi realizada por meio de busca nas bases de dados PubMed, Google Acadêmico, SciELO e EMBASE de artigos publicados entre 2017 e 2022, escritos em português ou inglês, utilizando as palavras de busca "inhalation device" OR "environmental". A revisão mostrou que o aquecimento global não pode ser abordado com foco em dispositivos inalatórios apenas. No entanto, os dispositivos que utilizamos para tratar doenças respiratórias como asma e DPOC, que são doenças agravadas pelas mudanças climáticas, também estão causando essa mudança. Portanto, profissionais de saúde, organizações de pacientes e indústrias devem assumir a liderança nas políticas de saúde para oferecer alternativas acessíveis aos inaladores contendo hidrofluoralcano.

Safety and efficacy of autologous non-hematopoietic enriched stem cell nebulization in COVID-19 patients: a randomized clinical trial, Abu Dhabi 2020.

BACKGROUND: The novel SARS-CoV-2 has caused the coronavirus disease 2019 (COVID-19) pandemic. Currently, with insufficient worldwide vaccination rates, identifying treatment solutions to reduce the impact of the virus is urgently needed. METHOD: An adaptive, multicentric, open-label, and randomized controlled phase I/II clinical trial entitled the "SENTAD-COVID Study" was conducted by the Abu Dhabi Stem Cells Center under exceptional conditional approval by the Emirates Institutional Review Board (IRB) for COVID-19 Research Committee from April 4th to July 31st, 2020, using an autologous peripheral blood non-hematopoietic enriched stem cell cocktail (PB-NHESC-C) administered by compressor (jet) nebulization as a complement to standard care therapy. The primary endpoints include safety and efficacy assessments, adverse events, the mortality rate within 28 days, and the time to clinical improvement as measured by a 2-point reduction on a seven-category ordinal scale or discharge from the hospital whichever occurred first. RESULTS: The study included a total of 139 randomized COVID-19 patients, with 69 in the experimental group and 70 in the control group (standard care). Overall survival was 94.20% for the cocktail-treated group vs. 90.27% for the control group. Adverse events were reported in 50 (72.46%) patients receiving PB-NHESC-C and 51 (72.85%) in the control group (p = 0.9590), with signs and symptoms commonly found in COVID-19. After the first 9 days of the intervention, 67.3% of cocktail-treated patients recovered and were released from hospitals compared to 53.1% (RR = 0.84; 95% CI, 0.56-1.28) in the control group. Improvement, i.e., at least a 2-point reduction in the severity scale, was more frequently observed in cocktail-treated patients (42.0%) than in controls (17.0%) (RR = 0.69; 95% CI, 0.56-0.88). CONCLUSIONS: Cocktail treatment improved clinical outcomes without increasing adverse events. Thus, the nebulization of PB-NHESC-C was safe and effective for treatment in most of these patients. TRIAL REGISTRATION: ClinicalTrials.gov. NCT04473170. It was retrospectively registered on July 16th, 2020.

A New Trick for an Old Dog: L-Epinephrine Delivered Continuously in the Vapor Phase.

Inhaled L-epinephrine is a known treatment of severe croup and postextubation upper airway obstruction. L-epinephrine can be delivered continuously in the vapor phase, but the indications, safety, and efficacy of this novel practice have yet to be evaluated. Theoretical risks are tachycardia, hypertension, and dysrhythmias. The study objective was to describe patient characteristics and vital sign changes related to continuous vaporized L-epinephrine use in critically ill children with the hypothesis that it can be practically and safely administered to children with subglottic edema and lower airway obstruction. DESIGN: Retrospective cohort study. SETTING: PICU and cardiothoracic ICU in a tertiary academic children's hospital. PATIENTS: Patients age 0-21 years treated with continuous vaporized L-epinephrine from 2013 to 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Continuous vaporized L-epinephrine was administered 140 times to 129 subjects via a high-flow nasal oxygen device. The median age was 10.6 months (1.3; interquartile range, 4.8-17.1 mo). The most common indications were lower respiratory tract obstruction (45%), postextubation subglottic edema (31%), and croup (16%). Eighty-eight percent had no escalation of respiratory support within 24 hours of initiation of continuous vaporized L-epinephrine, 5% progressed to require endotracheal intubation, and 3% were reintubated within 24 hours of initiation of continuous vaporized L-epinephrine following an extubation attempt. After starting continuous vaporized L-epinephrine, 85% of subjects had a decrease in heart rate and 80% had a decrease in respiratory rate. Six subjects had an increase in heart rate, and eight had an increase in blood pressure of more than 20% from baseline. These subjects did not receive interventions specific to these vital sign changes, including discontinuation of continuous vaporized L-epinephrine. CONCLUSIONS: Continuous vaporized L-epinephrine was safely administered to critically ill children with most subjects demonstrating a decrease in heart rate, blood pressure, and respiratory rate.

[Assessment of general practitioners' knowledge of inhalers]. / Évaluation des connaissances des médecins généralistes sur les inhalateurs. Les médecins généralistes savent-ils utiliser les inhalateurs qu'ils prescrivent dans le traitement de l'asthme ?

INTRODUCTION: Inhaled drug delivery is the cornerstone treatment for asthma. General practitioners (GPs) have a key role for educating patient about how to use their inhalers. The purpose of this study was to find out whether GPs know how to use the inhalers they usually prescribe. METHOD: This was a descriptive and analytical cross-sectional study among GPs from the Paris metropolitan area. GPs had to choose the inhalers they usually prescribe and then demonstrate their use. The technique of use was assessed using a scale specific to each type of inhaler. Overall success was defined by the use of prescribed inhalers without critical errors. RESULTS: Thirty-seven GPs were recruited between July 2018 and July 2019. Nineteen GPs (51.4%) were able to use the inhalers they prescribed without critical errors. The success rate without critical error was better with the pressurized metered dose inhalers with spacer than with other inhalers. The overall success rate was better among GPs who had previously used an inhaler on a personal basis (OR 7.58 95%CI [1.86, 37.02]) or who had prescribed only one type of inhaler (OR 4,8 95%CI [1.21, 22.41]). CONCLUSION: Half of the GPs in our study did not know how to use the inhalers they prescribe and therefore may have difficulty educating their patients.

Nivel de adhesión y prevalencia a inhaladores en pacientes ambulatorios con Asma y Enfermedad Pulmonar Obstructiva Crónica / Level of inhaler adhesion and prevalence in outpatients with Asthma and Chronic Obstructive Pulmonary Disease

INTRODUCCIÓN. Para el tratamiento farmacoterapéutico de enfermedades respi-ratorias, el uso de herramientas para abordar la vía inhalatoria es de elección por su mayor eficacia y menos efectos secundarios; registrar su adhesión y prevalencia es importante. OBJETIVO. Determinar el nivel y la prevalencia de adhesión al uso de inhaladores en pacientes con Asma y Enfermedad Pulmonar Obstructiva Cróni-ca. MATERIALES Y MÉTODOS. Estudio analítico transversal. Población de 215 y muestra de 121 Historias Clínicas. Se aplicó el Test de Adhesión a Inhaladores, que consistió en dos cuestionarios complementarios: el de 10 ítems, que valoró el nivel de adhesión, y el de 12 que identificó el tipo de incumplimiento en pacientes de Consulta Externa de la Unidad Técnica de Neumología del Hospital de Especialidades Carlos Andrade Marín, periodo julio 2018 - enero 2019. La tabulación y análisis de datos se realizó con el programa Excel. RESULTADOS. La prevalencia de mala adhesión en asmáticos fue de 83,33% y en Enfermedad Pulmonar Obstructiva Crónica 13,33%. En cuanto al sexo, la prevalencia de mala adhesión fue de 15,28% en hombres y de 40,82% en mujeres, con una p<0,05. No se encontró diferencia significativa respecto a los niveles de instrucción. CONCLUSIÓN. La prevalencia de mala adhesión al uso de inhaladores en pacientes con Asma y Enfermedad Pulmonar Obstructiva Crónica fue alta sobre todo en los asmáticos.

INTRODUCTION. For respiratory diseases and their pharmacotherapeutic treatment, the use of tools to address the inhalation route is chosen due to its greater efficacy and fewer secondary effects; then record the adherence and prevalence is important. OBJECTIVE. To determine both level and prevalence of adherence to the use of inhalers in patients with Asthma and Chronic Obstructive Pulmonary Disease. MATE-RIALS AND METHODS. Cross-sectional analytical study. Population of 215 and sam-ple of 121 patients. The Inhaler Adherence Test was applied, which consisted of two complementary questionnaires: a 10-item questionnaire, which assessed the level of adherence, and a 12-item questionnaire that identified the type of non-compliance in patients of the Pneumology Technical Unit of the Hospital de Especialidades Carlos Andrade Marín, period July 2018 - January 2019. The tabulation and data analysis was performed with Microsoft Excel program. RESULTS. The prevalence of poor ad-herence in asthmatics was 83.33% and in Chronic Obstructive Pulmonary Disease was 13.3%. Regarding gender, the prevalence of poor adherence was 15.28% in men and 40.82% in women, with a p <0.05. No significant differences were found regarding the levels of instruction. CONCLUSION. The prevalence of poor adherence to the use of inhalers in patients with Asthma and Chronic Obstructive Pulmonary Disease was high, especially in asthmatics

CARE: an observational study of adherence to home nebulizer therapy among children with asthma.

BACKGROUND: The prevalence of pediatric asthma in China is approximately 3%, and asthma remains poorly controlled in many of these patients. This study assessed the rate of adherence to home nebulizer treatment in paediatric patients in China. METHODS: The CARE study was a 12-week, multicentre, prospective, observational study across 12 tertiary hospitals in China. Patients were aged 0-14 years, clinically diagnosed with asthma and prescribed home nebulizer inhaled corticosteroid (ICS) therapy for ⩾3 months. The primary endpoint was electronically monitored treatment adherence. Patients attended onsite visits at 0, 4, 8 and 12 weeks to assess asthma control, severity and treatment adherence (recorded by electronic monitoring devices and caregivers). RESULTS: The full analysis set included 510 patients. Median treatment adherence reported by electronic monitoring devices was 69.9%, and median caregiver-reported adherence was 77.9%. The proportion of patients with well-controlled asthma increased from 12.0% at baseline to 77.5% at visit 4. Increased time between asthma diagnosis and study enrolment was a significant predictor for better adherence [coefficient: 0.01, p = 0.0138; 95% confidence interval (CI): 0.00, 0.01] and asthma control (odds ratio = 1.001, p = 0.0498; 95% CI: 1.000, 1.002). Negative attitude to treatment by the caregiver was associated with poorer asthma control. CONCLUSIONS: Adherence to home nebulization, a widely used treatment for asthma, was high among Chinese pediatric patients. Asthma control improved with increasing treatment duration. These results suggest that home nebulization of ICS is an effective and recommendable long-term treatment for paediatric patients with asthma.Trial registrationClinicalTrials.gov identifier: NCT03156998The reviews of this paper are available via the supplemental material section.

Tolerability and efficacy of two doses of aerosolized albuterol in ventilated infants with BPD: A randomized controlled crossover trial.

RATIONALE: Aerosolized albuterol is widely used, but its tolerability and efficacy in infants with severe bronchopulmonary dysplasia (sBPD) is not well established. OBJECTIVES: To compare the tolerability and efficacy of two dose levels of aerosolized albuterol to saline placebo in infants with sBPD. METHODS: Single-center, multiple-crossover trial in 24 ventilated very preterm infants with sBPD. Albuterol (1.25 mg, 2.5 mg) and 3 ml of normal saline were administered every 4 h during separate 24-h treatment periods assigned in random order with a 6-h washout phase between periods. The primary outcome was the absolute change (post and pretherapy) in expiratory flow at 75% of exhalation (EF75). Secondary endpoints were changes in ventilator parameters, vital signs, and heart arrhythmia. RESULTS: Average within subject EF75 values improved with each therapy: saline placebo ( + 0.45 L/min ± 2.5, p = .04), 1.25 mg of albuterol ( + 0.70 L/min ± 2.4, p < .001), and 2.5 mg of albuterol ( + 0.38 L/min ± 2.4, p = .06). However, 1.25 mg of albuterol (0.26 L/min; 95% CI -0.19, 0.72) and 2.5 mg (-0.10 L/min; 95% CI -0.77, 0.57) produced similar changes in EF75 when compared to saline. All secondary outcomes were similar between saline and 1.25 mg of albuterol. Peak inspiratory pressure needed to deliver goal tidal volumes (7.5% relative decrease, 95% CI 2.6, 12.3) and heart rate (6.5% increase, 95% CI 2.2, 10.8) differed significantly between albuterol 2.5 mg and saline. CONCLUSION: Albuterol at 1.25 mg and 2.5 mg, compared to aerosolized saline, did not affect EF75 in infants with sBPD receiving invasive ventilation. Greater improvement in peak inspiratory pressures with albuterol 2.5 mg suggests benefit, but close heart monitoring may be indicated.

Mask Use with Spacers/Valved Holding Chambers and Metered Dose Inhalers among Children with Asthma.

Inhaler misuse is highly prevalent and associated with high morbidity and costs. For metered dose inhalers, proper use can be supported with devices such as spacers/valved holding chambers (VHCs) and masks to effectively deliver inhaled medication to the lungs. However, guidelines are vague about which children with asthma should use spacers/VHCs with masks to deliver medication from metered dose inhalers as well as when they should transition to spacers/VHCs with mouthpieces. In this paper, we provide a focused review of the evidence for mask use, highlighting unclear and conflicting information in guidelines and studies. We synthesize the differences in recommendations and practice. Based on these findings, we call for future research to determine the appropriate age and necessary skills for transitioning children from using metered dose inhalers with spacers/VHCs and masks to using spacers/VHCs and mouthpieces. Guidelines about mask use should be standardized to help ensure optimal medical delivery for patients, provide consistent inhaler prescriptions and education across settings, and support team-based care to help lower pediatric asthma morbidity and costs.

Factors Determining Continuous Infusion Aerosol Delivery During Mechanical Ventilation.

BACKGROUND: Continuous nebulization of prostacyclins and albuterol by infusion pump during mechanical ventilation evolved as a popular off-label treatment for severe hypoxemic respiratory failure and asthma. Most institutions use a vibrating mesh nebulizer. A new breath-enhanced jet nebulizer is a potential alternative. This study was designed to compare these devices to better define factors influencing continuous infusion aerosol delivery. Device function, ventilator settings, and infusion pump flow were studied in vitro. METHODS: Using a bench model of adult mechanical ventilation, radiolabeled saline was infused at 6 flows (1.5-12 mL/h) into test nebulizers; 4 examples of each were used in rotation to test device reproducibility. Four breathing patterns with duty cycles (percentage of inspiratory time) ranging from 0.13 to 0.34 were tested. The vibrating mesh nebulizer was installed on the "dry" side of the heated humidifier (37°C). The breath-enhanced jet nebulizer, installed on the "wet" side, was powered by air at 3.5 L/min and 50 psi. Infusion time was 1 h. Inhaled mass of aerosol was collected on a filter at the airway opening. Inhaled mass was expressed as the percentage of the initial syringe radioactivity delivered per hour. Radioactivity deposited in the circuit was measured with a gamma camera. Data were analyzed with multiple linear regression. RESULTS: Variation in inhaled mass was significantly explained by pump flow and duty cycle (R2 0.92) and not by nebulizer technology. Duty cycle effects were more apparent at higher pump flow. Vibrating mesh nebulizers failed to nebulize completely in 20% of the test runs. Mass balance indicated that vibrating mesh nebulizers deposited 15.3% in the humidifier versus 0.2% for breath-enhanced jet nebulizer. CONCLUSIONS: Aerosol delivery was determined by infusion pump flow and ventilator settings with comparable aerosol delivery between devices. The breath-enhanced jet nebulizer was more reliable than the vibrating mesh nebulizer; 10-12 mL/h was the maximum infusion flow for both nebulizer technologies.

Face Mask Leak Determines Aerosol Delivery in Noninvasive Ventilation.

BACKGROUND: Aerosol transport during noninvasive ventilation follows the flow of pressurized gas through the noninvasive ventilation circuit, vented via leak port and face mask, and inhaled by the patient. Recommendations for nebulizer placement are based on in vitro models that have focused primarily on aerosol losses via the leak port; face mask leaks have been avoided. This study tested aerosol delivery in the setting of controlled face mask leak. METHODS: Three nebulizer technologies were studied on a bench model using a lung simulator with a face mask placed onto a manikin head. Radiolabeled aerosol delivery (ie, inhaled mass) was determined by mass balance using filters and a gamma camera that tested the effects of nebulizer location and face mask leak. Low (15-20 L/min) and high (55-60 L/min) mask leaks were used to mimic realistic clinical conditions. RESULTS: Inhaled mass (% nebulizer charge) was a function of nebulizer technology (with the nebulizer at ventilator outlet position: Aerogen 22.8%, InspiRx 11.1%, and Hudson 8.1%; P = .001). The location of the nebulizer before or after the leak port was not important (P = 0.13 at low leak and P = 0.38 at high leak). Aerosol delivery was minimal with high mask leak (inhaled mass 1.5-7.0%). Aerosol losses at the leak port at low mask leak were 28-36% versus 9-24% at high mask leak. Aerosol losses via the mask leak were 16-20% at low mask leak versus 46-72% at high mask leak. Furthermore, high face mask leak led to significant deposition on the mask and face (eg, up to 50% of the nebulizer charge with the Aerogen mask). CONCLUSIONS: During noninvasive ventilation, nebulizer placement at the ventilator outlet, which is a more practical position, is effective and minimizes deposition on face and mask. Aerosol therapy should be avoided when there is high face mask leak.