On the Feasibility of Rugose Lipid Microparticles in Pressurized Metered Dose Inhalers with Established and New Propellants.

Pressurized metered dose inhalers (pMDIs) require optimized formulations to provide stable, consistent lung delivery. This study investigates the feasibility of novel rugose lipid particles (RLPs) as potential drug carriers in pMDI formulations. The physical stability of RLPs was assessed in three different propellants: the established HFA-134a and HFA-227ea and the new low global-warming-potential (GWP) propellant HFO-1234ze. A feedstock containing DSPC and calcium chloride was prepared without pore forming agent to spray dry two RLP batches at inlet temperatures of 55 °C (RLP55) and 75 °C (RLP75). RLPs performance in pMDI formulations was compared to two reference samples that exhibit significantly different performance when suspended in propellants: well-established engineered porous particles and particles containing 80% trehalose and 20% leucine (80T20L). An accelerated stability study at 40 °C and relative humidity of 7% ± 5% was conducted over 3 months. At different time points, a shadowgraphic imaging technique was used to evaluate the colloidal stability of particles in pMDIs. Field emission electron microscopy with energy dispersive X-ray spectroscopy was used to evaluate the morphology and elemental composition of particles extracted from the pMDIs. After 2 weeks, all 80T20L formulations rapidly aggregated upon agitation and exhibited significantly inferior colloidal stability compared to the other samples. In comparison, both the RLP55 and RLP75 formulations, regardless of the propellant used, retained their rugose structure and demonstrated excellent suspension stability comparable with the engineered porous particles. The studied RLPs demonstrate great potential for use in pMDI formulations with HFA propellants and the next-generation low-GWP propellant HFO-1234ze.

Environmentally sustainable opportunities for health systems: metered-dose inhaler prescribing, dispensing, usage, and waste at The Ottawa Hospital.

BACKGROUND: The carbon footprint of Canada's health sector is among the worst in the world, responsible for 4·6% of Canada's total greenhouse gas emissions. A quarter of emissions from Canada's health sector are linked to pharmaceuticals, including metered dose inhalers (MDIs). MDIs use propellants, such as hydrofluorocarbons, which act as greenhouse gas emissions and contribute to the health-care sector's overall carbon footprint. The objective of this study was to describe MDI prescribing, dispensing, usage, and waste patterns at The Ottawa Hospital (Ottawa, ON, Canada). Secondary objectives included estimating the monetary and carbon cost of current practice and the potential benefits and costs of switching to the more environmentally friendly dry powder inhalers. METHODS: In this retrospective point-prevalence cohort study, we identified 100 consecutive patients from medical and surgical services at both campuses of The Ottawa Hospital from health records discharged from medical and surgical services and who were prescribed at least one MDI during their admission. Medical records were reviewed and data related to demographics, MDI prescribing, dispensing, usage, and wastage were collected using a pre-piloted electronic case report form. Financial cost was calculated using local costing estimates and carbon cost was calculated using published estimates. FINDINGS: Between Jan 1, 2023, and June 1, 2023, we collected data for 100 eligible patients, of whom 60 (60%) were female and 90 (90%) were admitted to hospital medicine wards (10% from surgical wards). The median length of stay was 7 (range 1-47) days. The most common inpatient diagnoses were respiratory tract infections in 43 (43%) of 100 patients and chronic obstructive pulmonary disease exacerbations in 28 (28%) of 100 patients. The median number of MDIs prescribed during a patients stay was two (range one to 15) and the median number dispensed was one (range one to seven). For formulary options of MDIs, of the 200 (range 30-1400) actuations dispensed per patient, 8% were used, representing 92% wastage. During the audit, 315 MDIs were dispensed in total, of which 97 were not used at all. INTERPRETATION: MDIs are significant contributors to the carbon footprint attributed to pharmaceutical use in hospitals. This study suggests that 90% of MDI doses are wasted, showing that there is substantial room for improvement. FUNDING: None.

Overcoming the Low-Stability Bottleneck in the Clinical Translation of Liposomal Pressurized Metered-Dose Inhalers: A Shell Stabilization Strategy Inspired by Biomineralization.

Currently, several types of inhalable liposomes have been developed. Among them, liposomal pressurized metered-dose inhalers (pMDIs) have gained much attention due to their cost-effectiveness, patient compliance, and accurate dosages. However, the clinical application of liposomal pMDIs has been hindered by the low stability, i.e., the tendency of the aggregation of the liposome lipid bilayer in hydrophobic propellant medium and brittleness under high mechanical forces. Biomineralization is an evolutionary mechanism that organisms use to resist harsh external environments in nature, providing mechanical support and protection effects. Inspired by such a concept, this paper proposes a shell stabilization strategy (SSS) to solve the problem of the low stability of liposomal pMDIs. Depending on the shell material used, the SSS can be classified into biomineralization (biomineralized using calcium, silicon, manganese, titanium, gadolinium, etc.) biomineralization-like (composite with protein), and layer-by-layer (LbL) assembly (multiple shells structured with diverse materials). This work evaluated the potential of this strategy by reviewing studies on the formation of shells deposited on liposomes or similar structures. It also covered useful synthesis strategies and active molecules/functional groups for modification. We aimed to put forward new insights to promote the stability of liposomal pMDIs and shed some light on the clinical translation of relevant products.

Development of a self-microemulsifying drug delivery system to deliver delamanid via a pressurized metered dose inhaler for treatment of multi-drug resistant pulmonary tuberculosis.

Tuberculosis (TB) is a serious health issue that contributes to millions of deaths throughout the world and increases the threat of serious pulmonary infections in patients with respiratory illness. Delamanid is a novel drug approved in 2014 to deal with multi-drug resistant TB (MDR-TB). Despite its high efficiency in TB treatment, delamanid poses delivery challenges due to poor water solubility leading to inadequate absorption upon oral administration. This study involves the development of novel formulation-based pressurized metered dose inhalers (pMDIs) containing self-microemulsifying mixtures of delamanid for efficient delivery to the lungs. To identify the appropriate self-microemulsifying formulations, ternary diagrams were plotted using different combinations of surfactant to co-surfactant ratios (1:1, 2:1, and 3:1). The combinations used Cremophor RH40, Poly Ethylene Glycol 400 (PEG 400), and peppermint oil, and those that showed the maximum microemulsion region and rapid and stable emulsification were selected for further characterization. The diluted self-microemulsifying mixtures underwent evaluation of dose uniformity, droplet size, zeta potential, and transmission electron microscopy. The selected formulations exhibited uniform delivery of the dose throughout the canister life, along with droplet sizes and zeta potentials that ranged from 24.74 to 88.99 nm and - 19.27 to - 10.00 mV, respectively. The aerosol performance of each self-microemulsifying drug delivery system (SMEDDS)-pMDI was assessed using the Next Generation Impactor, which indicated their capability to deliver the drug to the deeper areas of the lungs. In vitro cytotoxicity testing on A549 and NCI-H358 cells revealed no significant signs of toxicity up to a concentration of 1.56 µg/mL. The antimycobacterial activity of the formulations was evaluated against Mycobacterium bovis using flow cytometry analysis, which showed complete inhibition by day 5 with a minimum bactericidal concentration of 0.313 µg/mL. Moreover, the cellular uptake studies showed efficient delivery of the formulations inside macrophage cells, which indicated the potential for intracellular antimycobacterial activity. These findings demonstrated the potential of the Delamanid-SMEDDS-pMDI for efficient pulmonary delivery of delamanid to improve its effectiveness in the treatment of multi-drug resistant pulmonary TB.

Medicaciones inhaladas y cámaras de inhalación para el asma infantil. Red española de grupos de trabajo sobre asma en pediatría (REGAP) / Inhaled medications and inhalation chambers for childhood asthma. Spanish network of working groups on asthma in pediatrics (REGAP)

El asma, la enfermedad crónica más prevalente en la edad pediátrica, continúa planteando desafíos en su manejo y tratamiento1. Guías nacionales e internacionales destacan la importancia de la educación terapéutica (ET) para lograr el control de esta enfermedad2,3. Esta educación implica la transmisión de conocimientos y habilidades al paciente y su familia, mejorando la adherencia a la medicación, corrigiendo errores en la técnica de inhalación y ajustando el tratamiento según las características individuales de cada paciente4,5. Es esencial que la ET sea progresiva, gradual e individualizada, y que esté presente en todos los niveles asistenciales. La formación en ET de profesionales sanitarios es crucial, especialmente para los pediatras, quienes además deben conocer la extensa variabilidad de medicamentos e inhaladores disponibles y sus indicaciones para cada edad6. Para abordar esta necesidad, el Grupo red española de grupos de trabajo sobre asma en pediatría (REGAP) ha revisado exhaustivamente los inhaladores actualmente disponibles en España para el tratamiento del asma en la edad pediátrica. La revisión incluye una revisión de los distintos sistemas de inhalación y los distintos fármacos inhalados, utilizados para el tratamiento del asma en la edad pediátrica. Esta revisión se actualizará anualmente, incluyendo información sobre fármacos, dispositivos, cámaras de inhalación, indicaciones y financiación. El Grupo REGAP espera que estas tablas sean una valiosa ayuda para los pediatras en su práctica clínica diaria y constituyen una eficaz herramienta de ET.(AU)

Asthma, the most prevalent chronic disease in pediatric age, continues to pose challenges in its management and treatment. National and international guidelines emphasize the importance of therapeutic education (TE) to achieve disease control. TE involves imparting knowledge and skills to the patient and their family, enhancing medication adherence, rectifying errors in inhalation technique, and tailoring treatment based on individual patient characteristics. It is essential for TE to be progressive, gradual, and personalized, spanning all levels of care. Training healthcare professionals in TE is crucial, particularly for pediatricians, who must also be aware of the extensive variability of available meds and inhalers and their respective age-specific indications. Addressing this need, the REGAP Group extensively reviewed inhalers currently available in Spain for pediatric asthma treatment. The review encompassed different inhalation systems and inhaled drugs used for pediatric asthma treatment. This review will be updated annually, providing information on medications, devices, inhalation chambers, indications, and financiation. The REGAP Group hopes that these tables will be a valuable help for pediatricians in their daily clinical practice and serve as an effective TE tool.(AU)

Enhancing Inhalation Drug Delivery: A Comparative Study and Design Optimization of a Novel Valved Holding Chamber.

This paper presents an innovative approach to the design optimization of valved holding chambers (VHCs), crucial devices for aerosol drug delivery. We present the design of an optimal cylindrical VHC body and introduce a novel valve based on particle impaction theory. The research combines computational simulations and physical experiments to assess the performance of various VHCs, with a special focus on the deposition patterns of medication particles within these devices. The methodology incorporates both experimental and simulation approaches to validate the reliability of the simulation. Emphasis is placed on the deposition patterns observed on the VHC walls and the classification of fine and large particles for salbutamol sulfate particles. The study reveals the superior efficacy of our valve design in separating particles compared to commercially available VHCs. In standard conditions, our valve design allows over 95% of particles under 7 µm to pass through while effectively filtering those larger than 8 µm. The optimized body design accomplishes a 60% particle mass flow fraction at the outlet and an average particle size reduction of 58.5%. When compared numerically in terms of size reduction, the optimal design outperforms the two commercially available VHCs selected. This study provides valuable insights into the optimization of VHC design, offering significant potential for improved aerosol drug delivery. Our findings demonstrate a new path forward for future studies, aiming to further optimize the design and performance of VHCs for enhanced pulmonary drug delivery.

Demystifying Dry Powder Inhaler Resistance with Relevance to Optimal Patient Care.

The selection of an inhaler device is a key component of respiratory disease management. However, there is a lack of clarity surrounding inhaler resistance and how it impacts inhaler selection. The most common inhaler types are dry powder inhalers (DPIs) that have internal resistance and pressurised metered dose inhalers (pMDIs) that use propellants to deliver the drug dose to the airways. Inhaler resistance varies across the DPIs available on the market, depending largely on the design geometry of the device but also partially on formulation parameters. Factors influencing inhaler choice include measures such as flow rate or pressure drop as well as inhaler technique and patient preference, both of which can lead to improved adherence and outcomes. For optimal disease outcomes, device selection should be individualised, inhaler technique optimised and patient preference considered. By addressing the common clinically relevant questions, this paper aims to demystify how DPI resistance should guide the selection of the right device for the right patient.

Selection of the right inhaler is important to ensure that patients with respiratory diseases get the most benefit from their treatment. Dry powder inhalers and pressurised metered dose inhalers are the most common inhaler types. Pressurised metered dose inhalers use propellants to deliver the drug to the lungs. In contrast, dry powder inhalers deliver the drug to the lungs by having internal resistance. This restricts the flow of air through the inhaler. As the patient inhales through the inhaler, the resistance against the air flow generates the power to separate the drug molecules and carry them to the lungs. While there are many factors to be considered for inhaler selection, there is often confusion around how resistance should guide selection of inhaler. With low-resistance devices, patients must inhale faster to generate the power to separate the drug molecules, which may be difficult in patients with poor lung function. With high-resistance devices, patients do not need to inhale as fast to separate the drug, and most patients can effectively use the inhaler. This article addresses the common clinically relevant questions to clarify how the internal resistance of the inhaler should be used to help guide the selection of the right device for the right patient.

Biocompatibility Considerations for Orally Inhaled and Nasal Drug Products and Other Drug--Device Combination Products.

Biocompatibility considerations have historically been important for orally inhaled and nasal drug products (OINDPs) and other drug-device combination products, because finished device components and packaging in these products are often in direct contact with formulation and the patient. The International Pharmaceutical Aerosol Consortium on Regulation and Science (IPAC-RS) discusses, in this article, the current regulatory landscape associated with biocompatibility and how biocompatibility is typically assessed for OINDPs, including risk management considerations and navigation of regulatory requirements. The article also describes current challenges related to alignment of regulatory expectations, particularly for drug-device combination products, and proposes some questions and topics for further discussion with regulatory agencies and other stakeholders to help advance alignment. To further illustrate current challenges and industry approaches to meeting biocompatibility requirements, we also present results of an IPAC-RS benchmarking survey and case studies.

Simultaneous UPLC Assay for Oxitropium Bromide and Formoterol Fumarate Dihydrate in Pressurized Metered Dose Inhaler Products for Chronic Obstructive Pulmonary Disease.

BACKROUND: Oxitropium bromide (OB) and formoterol fumarate dihydrate (FFD) are inhaler molecules that are widely used in the treatment of chronic lung diseases. OBJECTIVE: The goal of this work was to create a reversed phase-ultra performance liquid chromatography (RP-UPLC) technique for assay and identification of OB and FFD, as well as identification and estimate of its associated compounds in pressurized metered dose inhaler product (pMDI). METHOD: Separation of oxitropium and formoterol peaks were enhanced on a C18 (50 × 2.1 mm × 1.7 µm) UPLC column with ethylene-bridged-hybrid technology, The mobile phase consists of buffer (0.07 M KH2PO4) and acetonitrile (80:20, v/v). The detector wavelength of 210 nm, flow rate of pump 0.6 mL/min, and oven temperature for column were set at 25°C. The injection volume was 10 µL. The method run time was 2 min. The mobile phase was used as the solvent. RESULTS: Retention times (RTs) were 0.5 min for OB and 1.0 min for FFD. The assay analysis was linear range for all analytes within the range for concentrations 0.03-14.8 µg/mL of OB, 0.01-0.88 µg/mL of FFD. LOD values and LOQ values 0.009 and 0.026 µg/mL for OB and 0.003 and 0.009 µg/mL for FFD, respectively. Recoveries were obtained at 96.3% for OB and 97.2% for FFD. Precisions values were (as RSD, %) ≤1.5%. CONCLUSIONS: With the UPLC method developed and validated according to the current ICH guidelines, it is possible to simultaneously detect OB and FFD of assay analysis in pMDI products accurately, precisely and selectively, independent of the matrix effect. HIGHLIGHTS: The present method is the first method in the literature based on the UPLC method for this purpose. The UPLC method is a time-saving method, it provides a faster and cheaper technique than the high performance liquid chromatography (HPLC) method.

Does mixing inhaler devices lead to unchecked inhaler technique errors in patients with COPD? Findings from the cross-sectional observational MISMATCH study.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) may be prescribed multiple inhalers that require different techniques for optimal performance. Mixing devices has been associated with poorer COPD outcomes suggesting that it leads to inappropriate inhaler technique. However, empirical evidence is lacking. AIMS: Compare the nature and frequency of dry powder inhaler (DPI) technique errors in patients with COPD using (1) a single DPI or (2) mixed-devices (a DPI and pressurised metered dose inhaler (pMDI)). METHODS: Data from the PIFotal study-a cross-sectional study on Peak Inspiratory Flow in patients with COPD using a DPI as maintenance therapy, capturing data from 1434 patients on demographic characteristics, COPD health status and inhaler technique-were used to select 291 patients using mixed-devices. Frequency matching based on country of residence and DPI device type was used to select 291 patients using a DPI-only for comparison. Predetermined checklists were used for the evaluation of DPI video recordings and complemented with additional errors that were observed in ≥10%. Error proportions were calculated for the (1) individual and total number of errors, (2) number of critical errors and (3) number of pMDI-related errors. RESULTS: The study sample contained 582 patients (mean (SD) age 69.6 (9.4) years, 47.1% female). DPI technique errors were common, but not significantly different between the groups. The majority of patients made at least one critical error (DPI-only: 90.7% vs mixed-devices: 92.8%). Proportions of total, 'pMDI-related' and critical errors did not significantly differ between the groups. CONCLUSION: The nature and frequency of inhaler technique errors did not substantially differ between patients prescribed with a single DPI and mixed-devices. Currently, 'pMDI-related errors' in DPI use are not accounted for in existing checklists. TRIAL REGISTRATION NUMBER: ENCEPP/EUPAS48776.

Canister valve and actuator deposition in metered dose inhalers formulated with low-GWP propellants.

A challenge in pressurised metered-dose inhaler (pMDI) formulation design is management of adhesion of the drug to the canister wall, valve and actuator internal components and surfaces. Wall-material interactions differ between transparent vials used for visual inspection and metal canister pMDI systems. This is of particular concern for low greenhouse warming potential (GWP) formulations where propellant chemistry and solubility with many drugs are not well understood. In this study, we demonstrate a novel application of X-ray fluorescence spectroscopy using synchrotron radiation to assay the contents of surrogate solution and suspension pMDI formulations of potassium iodide and barium sulphate in propellants HFA134a, HFA152a and HFO1234ze(E) using aluminium canisters and standard components. Preliminary results indicate that through unit life drug distribution in the canister valve closure region and actuator can vary significantly with new propellants. For solution formulations HFO1234ze(E) propellant shows the greatest increase in local deposition inside the canister valve closure region as compared to HFA134a and HFA152a, with correspondingly reduced actuator deposition. This is likely driven by chemistry changes. For suspension formulations HFA152a shows the greatest differences, due to its low specific gravity. These changes must be taken into consideration in the development of products utilising low-GWP propellants.

[Chinese expert consensus on standardized inhaler device application in stable chronic airway diseases (2023)].

The incidence of chronic airway diseases in China has been increasing every year, resulting in a high burden of disease. Inhalation therapy is widely used as a basic first-line treatment for such diseases. However, inappropriate selection of inhalation devices and usage methods is common, leading to poor disease control and prognosis, as well as a waste of medical resources. In order to facilitate the reasonable selection and appropriate use of inhaler devices, improve the efficacy of inhalation therapy, and increase patient compliance, the Inhalation Therapy and Respiratory Rehabilitation Group, Respiratory Equipment Committee of China Association of Medical Equipment, and Chinese Chronic Obstructive Pulmonary Disease Coalition organized experts to revise the Chinese expert consensus on standardized inhaler device application in stable chronic respiratory disease patients (2019 Edition) based on the latest evidence-based medical evidence and clinical diagnosis and treatment experience.Chronic airway diseases can affect the anatomical and physiological structure of the respiratory tract, which can affect the inhalation and delivery of drugs. In order to achieve the maximum effect of inhaled drugs, it is necessary for the drugs to be completely released from the device and to be deposited in the peripheral airways. Therefore, inhaler devices, patients, and medical staff can have a significant impact on the effectiveness of inhalation administration. The effectiveness of inhalation administration is influenced by several factors related to the inhaler device itself, including active or passive release, aerosol characteristics, and internal device resistance. For patients, the inhalation ability, the correct use of inhaler devices (inhalation technique), and regular and quantitative inhalation (treatment compliance) are essential to achieve the desired therapeutic effect. Medical staff can influence the efficacy and compliance of patients through proper assessment of their inhalation capacity and preferences, knowledge of different inhaler device characteristics, rational selection of inhaler devices, training in inhalation techniques, and guidance on inhaler device replacement. Standardized education can help minimize operational errors and improve patients' ability to use inhaler devices effectively. In addition, deep inspiratory volume, prolonged breath-hold time, airway clearance, and reduction of upper airway curvature and resistance can further improve the efficacy of inhaled drugs. The choice of inhalation device should be based on the patient's inspiratory flow rate, hand-lung coordination ability, device operation ability, and preference.The revised consensus version provides a clear understanding of the characteristics and operating principles of different types of inhaler devices, including pressurized metered-dose inhaler (pMDI), dry powder inhaler (DPI), soft mist inhaler (SMI), and small-volume nebulizers (SVN). The consensus categorizes pMDI as traditional pMDI (solution type, suspension type, and co-suspension type), extra-fine pMDI, and breath-actuated pMDI; and DPI into capsule, reservoir, and blister types. The inhalation device is evaluated based on three dimensions: drug delivery, device operation, and other characteristics. The indicators to assess drug delivery characteristics include lung deposition, oropharyngeal deposition, aerosol duration, aerosol plume velocities, MMAD, fine particle fractions, and dose repeatability. The indicators used to assess the operational device characteristics include inspiratory flow rate requirements, hand-breath coordination requirements, inspiratory synchronous drive, pre-use shaking, and operational steps. Other characteristic indicators include avoidance of humidity exposure, storage environment requirements, propellant, carrying convenience, counter, cleaning, and medication type. The consensus provides a detailed introduction to the personalized selection, switching, education, and follow-up of inhaler devices.1. Establishing a Chinese consensus on the individualized selection of inhaler devices for patients based on the characteristics of different devices includes the following steps:(1) Testing the patient's hand-breath coordination using an active release inhaler device (recommended: a short-acting bronchodilator inhaler). If the device is being used for the first time or is not being used correctly, it should be re-tested after instruction.(2) Testing the patient's peak inspiratory flow rates and whether they can consistently inhale at an inspiratory flow rate of 30 L/min for 3 seconds (an alternative assessment method is to continue eating yoghurt through a straw).(3) Assessing the need for non-invasive ventilation in patients with poor hand-breath coordination.(4) Based on the evaluation results, the recommendations for different inhaler devices are as follows:① Patients with good hand-breath coordination and the ability to inhale consistently at an inspiratory flow rate of 30 L/min (or more) for more than 3 seconds can use any inhaler device; ② Patients with poor hand-breath coordination who can achieve a peak inspiratory flow rate of 30L/min can use DPI or an active release device with a Spacer; ③ Patients with good hand-breath coordination, a peak inspiratory flow rate less than 30 L/min, and a constant inspiratory flow for more than 3 seconds can use SMI or an active release device with a Spacer; ④ Patients with poor hand-breath coordination, a peak inspiratory flow rate less than 30 L/min, and a constant inspiratory flow for more than 3 seconds can use SMI and an active release device with a Spacer; ⑤ Patients with a peak inspiratory flow rate less than 30 L/min and a constant inspiratory flow for less than 3 seconds can use an active release device with a Spacer; ⑥ Patients who require non-invasive ventilation can use an active release device and nebulizers(Active release devices include pMDI and SMI).2. Switching inhaler devices:The need to switch inhaler devices should be clear, and there are indications for switching:(1) inhaled drugs has been changed or added because of the patient's condition, requiring delivery by another inhaler device.(2) the patient was unable to use the inhaler device correctly after several training attempts.(3) patients were dissatisfied with the inhaler device and had poor adherence.(4) the patient used the device correctly, but the therapeutic effect was unsatisfactory.Once the decision to switch the inhaler device has been made, the following steps should be taken:(1) explain the necessity of switching the inhaler device.(2) retrain the patient in the use of the new inhaler device.(3) intensify follow-up to obtain patient feedback on the use of the new device and to check inhalation technique, drug consumption and efficacy.3. Education on inhalation technique:It is crucial to educate patients on proper inhalation technique. Teaching patients how to use inhaler devices in a standardized way is an important measure to ensure that they use the devices correctly. This helps to improve the accuracy of inhaler device operation, patient adherence, disease control, and reduce disease burden. Relying solely on the instructions provided with the inhaler device is not sufficient to adequately educate patients, and patients' inhalation technique may unintentionally change over time, resulting in decreased efficacy. Inhalation technique should be regularly reviewed and corrected at each visit.4. Follow-up of inhalation therapy:Follow-up management is a crucial part of maximizing patient efficacy, including assessing efficacy, correcting operation techniques, and promoting adherence.5. Other:When patients with chronic airway diseases are at risk of respiratory epidemic infectious diseases, the use of inhaler devices should strictly comply with the requirements for the prevention and control of such diseases.

Effectiveness of multimedia-assisted training on inhaler usage technique, which is the optimum technique?

OBJECTIVE: In this study, we aimed to investigate the most appropriate education method for patients to use their inhaler devices with the proper technique. PATIENTS AND METHODS: The study had a cross-sectional, multicenter design. 525 consecutive patients who had never used an inhaler therapy before were included in the study. Seven different types of inhalers were evaluated. 75 patients were included for each device type. For each device type, 25 patients were trained by their own physicians who personally demonstrated the use of the device [verbal education with physical demonstration (VEWPD)], 25 were given multimedia-assisted training (MAT), and 25 received both types of training together (first VEWPD followed by MAT). After the patients were trained, inhaler medications were used under the supervision of a physician. Correct use of the inhaler devices and perceptions of convenience were scored. RESULTS: For Ellipta inhaler device and Levered Diskus inhaler device, the proportion of patients using their devices properly was significantly higher in patients who were instructed with both of the methods together compared to other education groups (p = 0.011, p = 0.015). The effects of different types of training on learning in Sanohaler, Diskus inhaler, and Pressurized metered dose inhaler devices were the same. CONCLUSIONS: We could not come to a conclusion that multimedia training was more beneficial than other training. As an unexpected result, in almost all of the devices, patients who received multimedia training in combination with verbal training did not develop better learning despite being shown the use of the device twice (except Ellipta inhaler, and Levered Diskus inhaler device).

Climate aspects of dose inhalers in respitatory disorders.

Hydrofluorocarbons, the propellants used in metered dose inhalers, are powerful greenhouse gases. However, this review investigates the use of metered dose inhalers which continue to be on the rise in Denmark despite evidence that most patients are treated equally well with dry powder inhalers. If the use of metered dose inhalers in Denmark were reduced to approximately the level seen in Sweden it would lead to a reduction in CO2e comparable with the emissions from the electricity used in 16,500 typical Danish households.

Dry Powder Inhalers: From Bench to Bedside.

Dry powder inhalers (DPIs) are now widely prescribed and preferred by the majority of patients. These devices have many advantages over the traditional pressurized metered-dose inhaler (pMDI) but they do have disadvantages. The characteristics of the dose emitted from a DPI are affected by the inhalation manoeuvre used by a patient. Each patient is different and the severity of their lung disease varies from mild to very severe. This affects how they use an inhaler and so determines the type of dose they inhale. An understanding of the pharmaceutical science related to DPIs is important to appreciate the relevance of how patients inhale through these devices. Also, each type of DPI has its unique dose preparation routine, and thus it is essential to follow these recommended steps because errors at this stage may result in no dose being inhaled. All issues related to the inhalation manoeuvre and dose preparation are addressed in this chapter. The importance of the inhalation technique is highlighted with a realization of inhale technique training and checking. During routine patient management, devices should not be switched nor doses increased unless the patient has demonstrated that they can and do use their DPI.