Comparative study of the inhalation parameters of COPD patients through NEXThaler® and Ellipta® dry powder inhalers.

The deposition of dry powder aerosol drugs depends on the inhalation parameters of the patients through the inhaler. These data are not directly measured in clinical practice. Their prediction based on the routinely measured spirometric data could help in choosing the appropriate device and optimizing the therapy. The aim of this study was to perform inhalation experiments to find correlations between inhalation parameters of COPD patients through two DPI devices and their native spirometric data, gender, age and disease severity. Another goal was to establish relationships between peak inspiratory flows through NEXThaler® and Ellipta® inhalers and their statistical determinants. Breathing parameters of 113 COPD patients were measured by normal spirometry and while inhaling through the two DPIs. Statistical analysis of the measured data was performed. The average values of peak inspiratory flow through the devices (PIFdev) were 68.4 L/min and 78.0 L/min for NEXThaler® and Ellipta®, respectively. PIFdev values were significantly higher for males than for females, but differences upon age, BMI and disease severity group were not significant. PIFdev values correlated best with their native spirometric counterparts (PIF) and linear relationships between them were revealed. Current results may be used in the future to predict the success of inhalation of COPD patients through DPI devices, which may help in the inhaler choice. By choosing the appropriate device-drug pair for each patient the lung dose can be increased and the efficiency of the therapy improved. Further results of the clinical study will be the subject of a next publication.

Effects of Different Inspiratory Muscle Training Protocols on Exercise Capacity, Respiratory Muscle Strength, and Health-Related Quality of Life in Patients with Hypertension.

Aim: This study aimed to explore how varying inspiratory muscle training workloads affect exercise capacity, health-related quality of life (HrQoL), depression, peripheral and respiratory muscle strength, pulmonary function, dyspnea, fatigue, and physical activity levels in hypertension (HT) patients. Methods: A randomized, controlled three-arm study. Forty-five patients (58.37 ± 8.53 y, 7F/38M) with HT received IMT (7 days/8 weeks) by POWERbreathe® Classic LR device and were randomized to control group (CG, 10% maximal inspiratory pressure (MIP), n: 15), low-load group (LLG, 30% MIP), and high-load group (HLG, %50 MIP). Exercise capacity, HrQoL, depression, peripheral and respiratory muscle strength, pulmonary function, fatigue, physical activity level, dyspnea, and sleep quality were evaluated before and after the training. Results: Exercise capacity, physical functioning, peripheral muscle strength, and resting dyspnea were statistically significantly improved in HLG and LLG after the training compared to CG (p < 0.05). Similar improvements in perception of depression, fatigue, and sleep quality were seen within and between the groups (p > 0.05). Statistically significant differences were found within all the groups in terms of MIP and PEF values of respiratory functions (p < 0.05). The superior improvement in the physical activity level was found in the HLG (p < 0.05). Discussion. High-load IMT was particularly effective in increasing physical activity level, peripheral muscle strength, exercise capacity, and improved HrQoL. Low-load IMT was effective in reducing dyspnea and improving respiratory function. Device-guided breathing exercises decreased blood pressure, improved sleep quality, and strengthened respiratory muscles. IMT, an efficient method, is suggested for inclusion in rehabilitation programs due to its capacity to increase physical activity, exercise capacity, and peripheral muscle strength, enhance HrQoL and respiratory function, and alleviate dyspnea. Also, the efficacy of IMT should be investigated with different training protocols such as endurance IMT or functional IMT in HT patients.

Critical roles of airway smooth muscle in mediating deep-inspiration-induced bronchodilation: a big stretch?

BACKGROUND: Deep inspiration (DI) has been shown to induce bronchodilation and bronchoprotection in bronchochallenged healthy subjects, but not in asthmatics. Strain-induced relaxation of airway smooth muscle (ASM) is considered one of the factors responsible for these effects. Other factors include the release or redistribution of pulmonary surfactant, alteration in mucus plugs, and changes in airway heterogeneity. MAIN BODY: The present review is focused on the DI effect on ASM function, based on recent findings from ex vivo sheep lung experiments showing a large change in airway diameter during a DI. The amount of stretch on the airways, when applied to isolated airway rings in vitro, caused a substantial decrease in ASM contractility that takes many minutes to recover. When challenged with a bronchoconstrictor, the increase in pulmonary resistance in the ex vivo ovine lungs is mostly due to the increase in airway resistance. CONCLUSIONS: Although non-ASM related factors cannot be excluded, the large strain on the airways associated with a DI substantially reduces ASM contractility and thus can account for most of the bronchodilatory and bronchoprotective effects of DI.

Inspiratory and Expiratory Computed Tomography Imaging Clusters Reflect Functional Characteristics in Chronic Obstructive Pulmonary Disease.

Purpose: Disease probability measure (DPM) is a useful voxel-wise imaging assessment of gas-trapping and emphysematous lesions in patients with chronic obstructive pulmonary disease (COPD). To elucidate the progression of COPD, we performed a cluster analysis using the following DPM parameters: normal (DPMNormal), gas-trapping (DPMGasTrap), and emphysematous lesions (DPMEmph). Our findings revealed the characteristics of each cluster and the 3-year disease progression using imaging parameters. Patients and Methods: Inspiratory and expiratory chest computed tomography (CT) images of 131 patients with COPD were examined, of which 84 were followed up for 3 years. The percentage of low attenuation volume (LAV%) and the square root of the wall area of a hypothetical airway with an internal perimeter of 10 mm (√Aaw at Pi10) were quantitatively measured using inspiratory chest CT. A hierarchical cluster analysis was performed using the DPM parameters at baseline. Five clusters were named according to the dominant DPM parameters: normal (NL), normal-GasTrap (NL-GT), GasTrap (GT), GasTrap-Emphysema (GT-EM), and Emphysema (EM). Results: Women were predominantly diagnosed with GT. Forced expiratory volume in 1 s gradually decreased in the following order: NL, NL-GT, GT, GT-EM, and EM. DPMEmph correlated well with LAV%. Four clusters other than NL showed significantly higher values of √Aaw at Pi10 than NL; however, no significant differences were observed among them. In all clusters, DPMEmph increased after 3 years. DPMNormal only increased in the GT cluster. Conclusion: Clusters using DPM parameters may reflect the characteristics of COPD and help understand the pathophysiology of the disease.

Un caso de neumotórax espontáneo por inhalación de pegante de policloropreno / A case of spontaneous pneumothorax due to inhalation of polychloroprene glue

El uso de inhalantes como drogas de abuso es una práctica de fácil acceso en menores y jóvenes tanto en países de bajos ingresos como en los de altos ingresos. Dentro de las complicaciones que se pueden presentar se encuentra el neumotórax espontáneo, que se ha relacionado tanto con el daño en el parénquima pulmonar producido por la sustancia y con la técnica de inhalación y/o exposición generando barotrauma. Se presenta un reporte de caso de un hombre joven que inhaló pegante y desarrolló un neumotórax espontáneo completo del pulmón izquierdo. Requirió intervención quirúrgica con colocación de sonda a tórax y su evolución fue satisfactoria. Esta complicación se ha reportado en la literatura con mayor frecuencia en hombres y con el uso de cocaína. Sólo se identificó otro caso similar en el contexto de inhalación de pegante con tolueno en sus componentes. Debido a los pocos reportes encontrados respecto al uso de sustancias inhalantes y al tolueno, es importante resaltar el hallazgo a fin de contribuir al inicio de futuras investigaciones a mayor escala. (AU)

Inhalants as drugs of abuse is an accessible practice in minors and young people in low-income countries as well as high-income ones. Spontaneous pneumothorax is a possible complication, which has been related both to damage of the lung parenchyma produced by the substance and inhalation and/or exposure technique making barotrauma. A case report of young man who inhaled glue with toluene and developed a complete spontaneous pneumothorax of the left lung is presented. He required surgical intervention with placement of a chest tube and his evolution was satisfactory. This complication has been reported in the literature more frequently in men and with the use of cocaine. Only one other similar case report was identified in the context of inhalation of glue with toluene in its components. Due to the few reports found regarding use of inhalant substances and toluene, it is important to highlight the finding to contribute to the initiation of future research on a larger scale. (AU)

Training the equine respiratory muscles: Ultrasonographic measurement of muscle size.

BACKGROUND: Limited information exists regarding changes in the size of respiratory and locomotor muscles in response to exercise training in the Thoroughbred racehorse. OBJECTIVES: To describe and compare the responses of the respiratory and locomotor muscles to conventional exercise training and inspiratory muscle training (IMT). STUDY DESIGN: Prospective randomised controlled trial. METHODS: Thoroughbred racehorses, in training for competition in National Hunt races, were recruited from two training establishments. Ultrasonographic images were obtained for selected muscles of the upper airway, diaphragm, accessory respiratory, and locomotor systems and their sizes measured. Examinations were performed at three timepoints: (A) when unfit, (B) following 12 weeks of conventional exercise training and (C) following 10-12 weeks continued training at race fitness. In addition, horses at yard 1 performed IMT, between timepoint B and C, and were randomly assigned into high-load (treatment) or low-load (control) group. Repeated measures models were constructed to compare the change in muscle measurements over time, and to investigate the effects of yard, previous airway surgery and IMT on the change in ultrasonographic size measurements obtained. RESULTS: Upper airway muscle size increased in response to conventional race training between timepoints A-C, and B-C. Diaphragm size increased in response to conventional exercise training between timepoints A and B. The diaphragm size of horses that undertook high-load IMT was either maintained or increased, whereas diaphragm size decreased in horses that undertook low-load IMT or no IMT between timepoints B and C. A significant interaction between gluteal muscle size and airway surgery status was observed, with greater gluteal muscle thicknesses measured in horses that had not previously undergone airway surgery (left gluteal 3.9%, p < 0.001; right 4.5%, p = 0.04). MAIN LIMITATIONS: Low number of horses underwent IMT. CONCLUSIONS: Respiratory and locomotor muscles increase in size in response to conventional exercise training, with a further change in diaphragm size in response to inspiratory muscle training.

Training the equine respiratory muscles: Inspiratory muscle strength.

BACKGROUND: Little is known about the response of the equine respiratory muscles to training. OBJECTIVES: To measure an index of inspiratory muscle strength (IMSi) before and after a period of conventional exercise training (phase 1) and inspiratory muscle training (IMT), comparing high-load (treatment) and low-load (control) groups (phase 2). STUDY DESIGN: Prospective randomised controlled trial. METHODS: Phase 1: Twenty National Hunt Thoroughbred racehorses performed an inspiratory muscle strength test (IMST) twice on two occasions; when unfit at timepoint A (July), and when race fit at timepoint B (October). Phase 2: Thirty-five Thoroughbred racehorses at race fitness were randomly assigned into a high-load (treatment, n = 20) or low-load (control, n = 15) IMT group. The high-load group followed an IMT protocol that gradually increased the inspiratory pressure applied every 4 days. The low-load group underwent sham IMT with a low training load. The IMT was performed 5 days/week for 10 weeks. The IMST was performed twice on two occasions, timepoint B (October) and timepoint C (January). Conventional exercise training and racing continued during the study period. The peak IMSi values obtained from the different groups at timepoints A, B and C were compared using a Wilcoxon Signed Rank Test. RESULTS: Phase 1: There was a significant increase in IMSi from timepoint A: 22.5 cmH2 O (21-25) to timepoint B: 26 cmH2 O (24-30) (p = 0.015). Phase 2: From timepoint B to C there was a significant increase in IMSi for the high-load group 34 cmH2 O (28-36) (p = 0.001) but not the low-load group 26 cmH2 O (24-30) (p = 0.929). The peak IMSi at timepoint C was significantly higher for the high-load than low-load group (p = 0.019). MAIN LIMITATIONS: Single centre study with only National Hunt horses undergoing race-training included. CONCLUSIONS: In horses undergoing race training there is a significant increase in IMSi in response to conventional exercise training and high-load IMT.

The Effects of Respiratory Muscle Training on Resting-State Brain Activity and Thoracic Mobility in Healthy Subjects: A Randomized Controlled Trial.

BACKGROUND: Although inspiratory muscle training (IMT) is an effective intervention for improving breath perception, brain mechanisms have not been studied yet. PURPOSE: To examine the effects of IMT on insula and default mode network (DMN) using resting-state functional MRI (RS-fMRI). STUDY TYPE: Prospective. POPULATION: A total of 26 healthy participants were randomly assigned to two groups as IMT group (n = 14) and sham IMT groups (n = 12). FIELD STRENGTH/SEQUENCE: A 3-T, three-dimensional T2* gradient-echo echo planar imaging sequence for RS-fMRI was obtained. ASSESSMENT: The intervention group received IMT at 60% and sham group received at 15% of maximal inspiratory pressure (MIP) for 8 weeks. Pulmonary and respiratory muscle function, and breathing patterns were measured. Groups underwent RS-fMRI before and after the treatment. STATISTICAL TESTS: Statistical tests were two-tailed P < 0.05 was considered statistically significant. Student's t test was used to compare the groups. One-sample t-test for each group was used to reveal pattern of functional connectivity. A statistical threshold of P < 0.001 uncorrected value was set at voxel level. We used False discovery rate (FDR)-corrected P < 0.05 cluster level. RESULTS: The IMT group showed more prominent alterations in insula and DMN connectivity than sham group. The MIP was significantly different after IMT. Respiratory rate (P = 0.344), inspiratory time (P = 0.222), expiratory time (P = 1.000), and inspiratory time/total breath time (P = 0.572) of respiratory patterns showed no significant change after IMT. All DMN components showed decreased, while insula showed increased activation significantly. DATA CONCLUSION: Differences in brain activity and connectivity may reflect improved ventilatory perception with IMT with a possible role in regulating breathing pattern by processing interoceptive signals. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 4.

Effects of Inspiratory Muscle Training on Clinical Predictors of Respiratory Muscle Strength and Lung Function in Burned Patients with Inhalation Injury.

Chronic airway illness is a well-documented inhalation injury side effect. Many pulmonary function impairments persisted for several months after lung parenchymal injury. Thus, the purpose of this study was to investigate the effects of inspiratory muscle training on respiratory muscle strength and pulmonary function (PFT) in patients who had suffered an inhalation injury. This study included male patients with inhalation injuries aged 20-35 years. Patients were chosen at random and assigned to an exercise group, which received inspiratory muscle training and routine chest physiotherapy, including early ambulation, coughing, and deep breathing, three times weekly for 4 weeks, and the control group, which only received routine chest physiotherapy. All participants were assessed for PFT and respiratory muscle strength at enrollment and the end of the study. The statistical analysis for outcome variables between both groups revealed no significant differences before treatment (P > .05) of forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), maximal inspiratory pressure, and maximal expiratory pressure. According to the findings of this study, including IMT as part of a physical therapy program led to significant gains (P ˂ .05) in FVC and FEV1. However, after treatment, there was not a substantial difference found in either the MIP or the MEP between the groups. The exercise group performed better in terms of FVC, FEV1, MIP, and MEP after receiving treatment, according to these significant and non-significant differences.

Mechanical mechanism to induce inspiratory flow limitation in obstructive sleep apnea patients revealed from in-vitro studies.

Inspiratory flow limitation means that when the flowrate reaches a certain value, it no longer increases, or even decreases, which is called negative effort dependence flow limitation, even if the inspiration effort is increased. This occurs often in obstructive sleep apnea patients, but its mechanism remains unclear. To reveal the mechanism of inspiratory flow limitation, we constructed a unique partially collapsible in-vitro upper airway model of obstructive sleep apnea patients to observe the change of airway resistance with inspiratory driving pressure. The important findings demonstrate that with the increase of inspiratory effort, the driving pressure increases faster than the airway resistance in the early stages, and then the reverse occurs as the airway becomes narrower. The airway collapse caused by the transmural pressure can lead to a rapid increase in downstream resistance with the increase of inspiratory effort, which is the key reason causing the flow reduction and the formation of typical negative effort dependence flow limitation. The mechanical mechanism revealed in this study will lead to fully new insights into the study and treatment of obstructive sleep apnea.

Sex differences in blood pressure and inactive limb blood flow responses during dynamic leg exercise with increased inspiratory muscle work.

We hypothesized that, compared with young males, young females have a smaller decrease in blood flow to the inactive limb, accompanied by a smaller increase in arterial blood pressure, during dynamic exercise with increased inspiratory muscle work. Young males and females performed dynamic knee-extension and -flexion exercises for 10 min (spontaneous breathing for 5 min and voluntary hyperpnoea with or without inspiratory resistance for 5 min). Mean arterial blood pressure (MAP) and mean blood flow (MBF) in the brachial artery were continuously measured by means of finger photoplethysmography and Doppler ultrasound, respectively. No sex differences were found in the ΔMAP and ΔMBF (Δ: from baseline) during exercise without inspiratory resistance. In contrast, the ΔMAP during exercise with inspiratory resistive breathing was greater (P < 0.05) in males (+31.3 ± 2.1 mmHg, mean ± SE) than females (+18.9 ± 3.2 mmHg). The MBF during exercise with inspiratory resistance did not change in males (-4.4 ± 10.6 mL/min), whereas it significantly increased in females (+25.2 ± 15.4 mL/min). These results suggest that an attenuated inspiratory muscle-induced metaboreflex in young females affects blood flow distribution during submaximal dynamic leg exercise.

Inspiratory and leg muscle blood flows during inspiratory muscle metaboreflex activation in heart failure with preserved ejection fraction.

The purpose of this study was to determine the cardiovascular consequences elicited by activation of the inspiratory muscle metaboreflex in patients with heart failure with preserved ejection fraction (HFpEF) and controls. Patients with HFpEF (n = 15; 69 ± 10 yr; 33 ± 4 kg/m2) and controls (n = 14; 70 ± 8 yr; 28 ± 4 kg/m2) performed an inspiratory loading trial at 60% maximal inspiratory pressure (PIMAX) until task failure. Mean arterial pressure (MAP) was measured continuously. Near-infrared spectroscopy and bolus injections of indocyanine green dye were used to determine the percent change in blood flow index (%ΔBFI) from baseline to the final minute of inspiratory loading in the vastus lateralis and sternocleidomastoid muscles. Vascular resistance index (VRI) was calculated. Time to task failure was shorter in HFpEF than in controls (339 ± 197 s vs. 626 ± 403 s; P = 0.02). Compared with controls, patients with HFpEF had a greater increase from baseline in MAP (16 ± 7 vs. 10 ± 6 mmHg) and vastus lateralis VRI (76 ± 45 vs. 32 ± 19%) as well as a greater decrease in vastus lateralis %ΔBFI (-32 ± 14 vs. -17 ± 9%) (all, P < 0.05). Sternocleidomastoid %ΔBFI normalized to absolute inspiratory pressure was higher in HFpEF compared with controls (8.0 ± 5.0 vs. 4.0 ± 1.9% per cmH2O·s; P = 0.03). These data indicate that patients with HFpEF exhibit exaggerated cardiovascular responses with inspiratory muscle metaboreflex activation compared with controls.NEW & NOTEWORTHY Respiratory muscle dysfunction is thought to contribute to exercise intolerance in heart failure with preserved ejection fraction (HFpEF); however, the underlying mechanisms are unknown. In the present study, patients with HFpEF had greater increases in leg muscle vascular resistance index and greater decreases in leg muscle blood flow index compared with controls during inspiratory resistive breathing (to activate the metaboreflex). Furthermore, respiratory muscle blood flow index responses normalized to pressure generation during inspiratory resistive breathing were exaggerated in HFpEF compared with controls.

Pneumothorax/pneumomediastinum as a complication of foreign body inhalation in 3 pediatric patients: A case series.

INTRODUCTION: Foreign body inhalation (FBI) is a serious and common emergency in children. Such children present in the emergency room (ER) with cough, shortness of breath, choking, or wheezing but rarely present with pneumomediastinum. PATIENT CONCERNS: Three children aged 2 to 5 years (2 girls and 1 boy) were seen in our ER complaining of FBI. Emergency bronchoscopy removal of the inhaled foreign body was performed; however, all 3 patients developed pneumomediastinum. DIAGNOSIS: A foreign body inhalation complicated by Pneumomediastinum/pneumothorax. INTERVENTION AND OUTCOMES: All the patients underwent emergency bronchoscopy and foreign body removal. After the ER intervention, 2 children were placed in the pediatric intensive care unit, and the pneumomediastinum resolved without intervention. The third patient required an operation for chest tube placement, which was then observed in the pediatric intensive care unit, and had several chest radiography follow-ups. After 5 days, the patient exhibited clinical improvement, and the chest tube was removed. CONCLUSION: In this case series, we present 3 cases of children aged 2 to 5 years seen in our ER with a history of different types of organic FBI complicated by pneumomediastinum/pneumothorax. Pneumomediastinum/pneumothorax is a rare complication of FBI in pediatric patients. However, such complications require multidisciplinary collaboration for early diagnosis and intervention.

Blood pressure and coeliac artery blood flow responses during increased inspiratory muscle work in healthy males.

NEW FINDINGS: What is the central question of this study? Increased work of breathing and the accumulation of metabolites have neural and cardiovascular consequences through a respiratory muscle-induced metaboreflex. The influence of the respiratory muscle-induced metaboreflex on splanchnic blood flow in humans remains unknown. What is the main finding and its importance? Coeliac artery blood flow decreased gradually during inspiratory resistive breathing, accompanied by a progressive increase in arterial blood pressure. It is possible that the respiratory muscle-induced metaboreflex contributes to splanchnic blood flow regulation. ABSTRACT: The purpose of this study was to clarify the effect of increasing inspiratory muscle work on coeliac artery blood flow. Eleven healthy young males completed the study. The subjects performed voluntary hyperventilation with or without inspiratory resistance (loading or non-loading trial; tidal volume of 40% of vital capacity and breathing frequency of 20 breaths/min). The loading trial was conducted with inspiratory resistance (40% of maximal inspiratory pressure) and was terminated when the subjects could no longer maintain the target tidal volume or breathing frequency. The non-loading trial was conducted without inspiratory resistance and was of the same duration as the loading trial. Arterial blood pressure was recorded using finger photoplethysmography, and coeliac artery blood flow was measured using Doppler ultrasound. Mean arterial blood pressure increased gradually during the loading trial (mean ± SD; from 89.0 ± 10.8 to 103.9 ± 17.3 mmHg) but not in the non-loading trial (from 88.7 ± 5.9 to 90.4 ± 9.9 mmHg). Coeliac artery blood flow and coeliac vascular conductance decreased gradually during the loading trial (from 601.2 ± 155.7 to 482.6 ± 149.5 mL/min and from 6.9 ± 2.2 to 4.8 ± 1.7 mL/min/mmHg, respectively) but were unchanged in the non-loading trial (from 630.7 ± 157.1 to 635.6 ± 195.7 mL/min and from 7.1 ± 1.8 to 7.2 ± 2.9 mL/min/mmHg, respectively). These results show that increasing inspiratory muscle work affects splanchnic blood flow regulation, and we suggest that this might be mediated by the inspiratory muscle-induced metaboreflex.

Proyecto revisa. Servicio Revisión del Uso del medicamento (RUM). En busca del inhalador perfecto / Project reviews. Review of Medicines Use (RUM) Service. In search of the perfect inhaler

PRESENTACIÓN DEL CASO: varón, 75 años, fumador, diagnosticado de EPOC por médico privado y con visita reciente al Sistema Nacional de Salud (SNS). Tratamiento:-Beclometasona 250mcg Inhalador Cartucho Presurizado (ICP) 1-0- 1 (médico privado)-Bromuro de ipratropio 20mcg ICP 1-1-1 (médico privado)-Salbutamol 100mcg ICP (a demanda) (médico privado)-Fluticasona/Umeclidinio/Vilanterol Ellipta® 92/55/22 (neumólogo SNS)-Prednisona 10mg, 5mg, 2.5mg. Pauta descendente (neumólogo SNS)-Omeprazol 20mg 1-0-0 (centro de salud)-Calcio Carbonato/Colecalciferol 1-0-0 (centro de salud)-Soludronate Semanal 70mg – 1 semanal (centro de salud). Utiliza el tratamiento del médico privado muchos años. Acude a la farmacia tras consulta con el neumólogo del SNS, posterior a varias visitas a urgencias por problemas respiratorios. Refiere confusión con los inhaladores. Le invitamos al servicio RUM. EVALUACIÓN: trae cuatro inhaladores, prescritos por distintos médicos. En su última visita con el neumólogo, éste sugirió dejar la Beclometasona y el Bromuro de ipratropio, y utilizar solamente Fluticasona/Umeclidinio/Vilanterol Ellipta® y Salbutamol. Confiesa no aclararse con el Fluticasona/Umeclidinio/Vilanterol Ellipta® y usar los tres inhaladores según cree conveniente, usando cada vez menos Fluticasona/Umeclidinio/Vilanterol Ellipta®. Comprobamos la técnica de inhalación con In-check Dial®, observando que su condición respiratoria no le permite hacer una inspiración adecuada para Fluticasona/Umeclidinio/Vilanterol Ellipta®. INTERVENCIÓN: considerando que la Beclometasona y el Bromuro de ipratropio no tenían el efecto deseado y que el paciente no podía usar correctamente Fluticasona/Umeclidinio/Vilanterol Ellipta®, derivamos al médico de familia, con informe para que el neumólogo reconsidere el tratamiento. Damos indicaciones sobre técnica inhalatoria, para intentar mejorar la adherencia al nuevo inhalador hasta la nueva revisión médica. (AU)