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Basic components of a nebulizer. Adapted, with permission, from Newman SP. Aerosol generators and delivery systems. Respir Care. 1991; 36:939-51.
Source publication
Special considerations in the selection of medication inhaler devices for elderly patients with chronic obstructive pulmonary disease (COPD) in the ambulatory care setting are reviewed.
Substantial deficiencies in inhaler device technique and medication adherence are evident in patients with COPD, leading to suboptimal health outcomes. As the preva...
Context in source publication
Context 1
... The jet nebulizer consists of a medication reservoir linked by tub- ing to a battery-or ac-powered com- pressor, which forces pressurized gas through the tubing and into contact with the medication reservoir. The liquid medication is mixed with the compressed gas to form droplets; a stream of droplets rises in the nebu- lizer to a baffle that aerosolizes the droplets for inhalation (Figure 3). 53,54 The disadvantages of both jet and ultrasonic nebulizers include the long duration of administration, Care. ...
Citations
... The investigators observed that most videos addressed required steps for optimal technique; however, omitted several critical steps which could translate to inadequate delivery of medication to the lungs and thus increased risk of suboptimal disease control [11]. In addition to standardized inhaler technique, there are several important clinically relevant educational factors to consider such as requirements related to manual dexterity, cognitive impairment, cost and environmental considerations [3,4,[22][23][24][25][26]. It is unclear whether online resources adequately address these important considerations. ...
... Our group developed a list of clinically relevant factors related to inhaler use based on literature review and chronic lung disease guidelines and consensus statements [3,4,6,[8][9][10][22][23][24][25][26][35][36][37][38][39][40]. These were based on aspects that are considered clinically important with respect to proper inhaler technique, which are typically addressed during interactions with healthcare professionals (Supplemental Table 4). ...
... We evaluated websites for clinically relevant factors that were developed based on the literature and review of clinical guidelines [3,4,6,[8][9][10][22][23][24][25][26][35][36][37][38][39][40]. Surprisingly no websites mentioned risk factors for poor technique of dry powder inhalers or smoking cessation. ...
... However, it can also occur due to hypoxemia or depression. 22 In addition, patients should check the dosage of the preparation before use. This study found that 22% of preparations were not dose checked by geriatric patients. ...
... This is important to make sure the patient has inhaled the medicine. 22 Agility and strength play an important role in inhaler handling. DPI is a preparation that does not require hand-breath coordination as in MDI. ...
... -pMDIs, DPIs), require high treatment doses, or have multiple comorbidities [6,7]. Nebulizers overcome some of the limitations of pMDIs and DPIs, such as user error, and better deliver the drug allowing a greater margin of user error to still receive a therapeutic dose [6,8,9]. However, up to 50% of patients on nebulizer therapy experience practical difficulties with their nebulizer or do not receive proper instruction on its use [10,11]. ...
Background
Transition from hospital to home is a vulnerable period for patients with COPD exacerbations, with a high risk for readmission and mortality. Twenty percent of patients with an initial hospitalization for a COPD exacerbation are readmitted to a hospital within 30 days, costing the health care system over $15 billion annually. While nebulizer therapy directed at some high-risk COPD patients may improve the transition from hospital to home, patient and social factors are likely to contribute to difficulties with their use. Current literature describing the COPD patient’s experience with utilizing nebulizer therapy, particularly during care transitions, is limited. Therefore, the objective of this study was to explore underlying COPD patient and social factors contributing to practical difficulties with nebulizer use at the care transition from hospital to home.
Methods
This was a qualitative study conducted between September 2020 and June 2022. Patients were included if they were ≥ 40 years old, had a current diagnosis of COPD, had an inpatient admission at a hospital, and were discharged directly to home with nebulizer therapy. Semi-structured, one-on-one interviews with patients were conducted covering a broad range of patient and social factors and their relationships with nebulizer use and readmission. Interviews were recorded and transcribed verbatim. A thematic analysis was performed using a mixed inductive and deductive approach.
Results
Twenty-one interviews were conducted, and subjects had a mean age of 64 ± 8.4 years, 62% were female, and 76% were White. The predominant interview themes were health care system interactions and medication management. The interviews highlighted that discharge counseling methods and depth of counseling from hospitals were inconsistent and were not always patient-friendly. They also suggested that patients could appropriately identify, set up, and utilize their nebulizer treatment without difficulties, but additional patient education is required for nebulizer clean up and maintenance.
Conclusions
Our interviews suggest that there is room for improvement within the health care system for providing consistent, effective discharge counseling. Also, COPD patients discharged from a hospital on nebulizer therapy can access and understand their treatment but require additional education for nebulizer clean up and maintenance.
... line in lung function over time. Smokingrelated COPD typically worsens at a faster rate compared to other forms of COPD. The French studies show smokers with COPD are more likely to experience frequent exacerbations, which are episodes of increased symptoms and respiratory distress. These exacerbations can be severe and may require hospitalization.[Barrons, R. et al., 2011] ...
COPD is a progressive respiratory condition characterized by airflow limitation and breathing difficulties, primarily involving chronic bronchitis and emphysema. The paper highlights the importance of bronchodilators in managing COPD by improving lung function, reducing symptoms, and enhancing quality of life. Due to that, our study presented a cross-sectional study that analyses and assesses the outcomes of 100 patients with chronic obstructive pulmonary disease (COPD) and their relationship to bronchodilators in different hospitals in Iraq. Als the study also assessed the impact of bronchodilators on the quality of life of COPD patients using the St. George's Respiratory Questionnaire (SGRQ-C) which our study depended on bronchodilators are medications commonly used to treat COPD patients by relaxing the muscles in the airways, allowing for improved airflow and easier breathing. Combination therapy (bronchodilators) with other medication classes, such as inhaled corticosteroids, is often used for the comprehensive management of COPD. The study found that combination therapy with bronchodilators and inhaled corticosteroids showed better outcomes in terms of symptom control and preventing exacerbations. Our results enrolled that combination therapy with bronchodilators and inhaled corticosteroids showed better outcomes in terms of symptom control and preventing exacerbations. In addition, the use of inhaled corticosteroids (ICS) in early-group patients was associated with lower symptoms, such as shortness of breath and headache, compared to patients who in late-group patients. According to the results, our study showed that bronchodilators improved lung function, reduced symptoms, and enhanced the quality of life of COPD patients.
... The elderly population is vulnerable and is more likely to acquire cognitive or physical disorders affecting their ability to learn and maintain necessary skills [20][21][22]. Although previous research uncovered the causes behind increased inhaler misuse in elderly patients, there has not been a comprehensive analysis of the proportion and types of mistakes made with different inhalers [8,23,24]. Therefore, the study aimed at identifying the accuracy of inhaler usage among patients with COPD of more than 60 under multiple expert reviews. Additionally, the study revealed the most critical inhaler usage steps prone to mistakes and factors that increase the likelihood of correct inhaler usage in elder adults with COPD. ...
Background:
Chronic obstructive pulmonary disease (COPD) mainly affects individuals aged 60 and older. The proper use of inhalers is crucial for managing COPD. This study aimed to evaluate the prevalence and factors affecting the appropriate use of inhalers among elderly patients with COPD.
Methods:
We enrolled 91 elderly patients with COPD admitted to the Department of Respiratory, University Medical Center HCMC between October 2020 and May 2021. Patients who were capable of using the inhaler would have their inhaler usage recorded through video footage. Two respiratory experts carefully analyzed 133 video-recorded demonstrations for evaluation purposes.
Results:
18.7% of the patients demonstrated the correct inhaler technique. Pressurized metered dose inhaler (pMDI) and Turbuhaler had the lowest documented correct usage rates (11.9% and 10.0%, respectively). Two critical steps, namely "holding breath for about five seconds or as long as comfortable" and "breathing out gently," were commonly performed incorrectly when using pMDI, Respimat, Breezhaler, or Turbuhaler. Multivariable logistic regression analysis showed that lower mMRC scores (AOR = 5.3, CI 1.1-25.5, p = 0.037) and receiving inhaler instruction within the past three months (AOR = 5.2, CI 1.3-20.1, p = 0.017) were associated with increased odds of using the inhaler correctly.
Conclusions:
Our study found that less than 20% of elderly patients with COPD use inhalers correctly. Common errors include inadequate breath-holding and gentle exhalation. mMRC scores and recent inhaler instruction were predictors of proper use. These findings can aid clinicians in improving inhaler management for elderly patients with COPD.
... The subject's age is critical for the rational choice of inhaler devices [85]. Numerous older adults have trouble using inhalers because of physical and cognitive changes, the prevalence of arthritis or joint discomfort, as well as neuromuscular diseases such as Parkinson's disease or issues following a stroke [86]. ...
Older adults have a higher prevalence of chronic obstructive pulmonary disease (COPD), which will likely increase substantially in the coming decades owing to aging populations and increased long-term exposure to risk factors for this disease. COPD in older adults is characterized by low-grade chronic systemic inflammation, known as inflamm-aging. It contributes substantially to age-associated pulmonary changes that are clinically expressed by reduced lung function, poor health status, and limitations in activities of daily living. In addition, inflamm-aging has been associated with the onset of many comorbidities commonly encountered in COPD. Furthermore, physiologic changes that are often seen with aging can influence the optimal treatment of older patients with COPD. Therefore, variables such as pharmacokinetics, pharmacodynamics, polypharmacy, comorbidities, adverse drug responses, drug interactions, method of administration, and social and economic issues that impact nutrition and adherence to therapy must be carefully evaluated when prescribing medication to these patients because each of them alone or together may affect the outcome of treatment. Current COPD medications focus mainly on alleviating COPD-related symptoms, so alternative treatment approaches that target the disease progression are being investigated. Considering the importance of inflamm-aging, new anti-inflammatory molecules are being evaluated, focusing on inhibiting the recruitment and activation of inflammatory cells, blocking mediators of inflammation thought to be important in the recruitment or activation of these inflammatory cells or released by these cells. Potential therapies that may slow the aging processes by acting on cellular senescence, blocking the processes that cause it (senostatics), eliminating senescent cells (senolytics), or targeting the ongoing oxidative stress seen with aging need to be evaluated.
... As the device-handling plays a critical role in the success of inhalation therapy, many factors influencing patient conduct can be investigated (15)(16)(17). Sufficient peak inspiratory flow (PIF) is crucial using DPI devices, which might be difficult to generate for patients with severe COPD (18). Appropriate handling of pMDI and SMI devices demand the precision from patients regarding the timing of actuation and inspiration, adequate breath-hold time, correct posture and device position, and sufficient inspiratory volumes (16). ...
Introduction
Inhalation therapy is a cornerstone of treating patients with chronic obstructive pulmonary disease (COPD). Inhaler devices might influence the effectiveness of inhalation therapy. We aimed to model and compare the deposition of acting agents of an open and a fixed dose combination (FDC) triple therapy and examine their repeatability.
Methods
We recruited control subjects (Controls, n = 17) and patients with stable COPD (S-COPD, n = 13) and those during an acute exacerbation (AE-COPD, n = 12). Standard spirometry was followed by through-device inhalation maneuvers using a pressurized metered dose inhaler (pMDI) and a soft mist inhaler (SMI) to calculate deposition of fixed dose and open triple combination therapies by numerical modeling. Through-device inspiratory vital capacity (IVCd) and peak inspiratory flow (PIFd), as well as inhalation time (tin) and breath hold time (tbh) were used to calculate pulmonary (PD) and extrathoracic deposition (ETD) values. Deposition was calculated from two different inhalation maneuvers.
Results
There was no difference in forced expiratory volume in 1 s (FEV1) between patients (S-COPD: 42 ± 5% vs. AE-COPD: 35 ± 5% predicted). Spiriva® Respimat® showed significantly higher PD and lower ETD values in all COPD patients and Controls compared with the two pMDIs. For Foster® pMDI and Trimbow® pMDI similar PD were observed in Controls, while ETD between Controls and AE-COPD patients did significantly differ. There was no difference between COPD groups regarding the repeatability of calculated deposition values. Ranking the different inhalers by differences between the two deposition values calculated from separate maneuvers, Respimat® produced the smallest inter-measurement differences for PD.
Discussion
Our study is the first to model and compare PD using pMDIs and an SMI as triple combination in COPD. In conclusion, switching from FDC to open triple therapy in cases when adherence to devices is maintanined may contribute to better therapeutic effectiveness in individual cases using low resistance inhalers.
... Various factors have been reported to be associated with incorrect use of inhalers. These include use of multiple devices, older age, low educational level, reduced manual dexterity and strength, lack of previous inhaler instructions, and cognitive impairment [2,3,[6][7][8]. ...
... Previous studies have reported that cognitive impairment, which is commonly observed in older adults, is significantly associated with incorrect use of inhalers and reduced ability to retain proper inhalation techniques [3,6,7,[9][10][11]. Reportedly, cognitive impairment (Mini-Mental State Examination [MMSE] score < 24) is associated with incorrect use of inhalers in older adults [6,[10][11][12]. ...
Background
Maintaining correct inhaler technique is crucial in the management of chronic obstructive pulmonary disease (COPD). We aimed to investigate the inhaler technique in patients with COPD, to compare it immediately after and at 1 month after training, and to identify the predictors of incorrect inhaler use at 1 month after training.
Methods
This prospective study was conducted at the COPD clinic of Siriraj Hospital (Bangkok, Thailand). Patients demonstrating improper inhaler use were trained face-to-face by pharmacists. Inhaler technique was re-assessed immediately after and at 1 month after training. The Montreal Cognitive Assessment (MoCA) score, pulmonary function tests, 6-min walk distance (6 MWD), modified Medical Research Council scale score, and COPD Assessment Test (CAT) score were evaluated.
Results
Sixty-six patients with COPD who demonstrated at least one critical error during the use of any controller inhaler were enrolled. The mean age was 73.0 ± 9.0 years, and 75.8% patients had moderate/severe COPD. Immediately after training, all patients used dry powder inhalers correctly and 88.1% used pressurized metered-dose inhalers correctly. At 1 month, the number of patients demonstrating the correct technique decreased across all devices. Multivariable analysis revealed that MoCA score ≤ 16 was independently associated with a critical error at 1 month after training (adjusted odds ratio: 12.7, 95% confidence interval: 1.8–88.2, p = 0.010). At 1 month, CAT score (11.4 ± 8.9 vs. 8.4 ± 5.5, p = 0.018) and 6 MWD (351 ± 93 m vs. 372 ± 92 m, p = 0.009) had significantly improved in patients demonstrating the correct technique, and CAT score met the minimal clinically important difference.
Conclusions
Face-to-face training by pharmacists improved patient performance. However, the number of patients following proper technique had decreased at 1 month after training. Cognitive impairment (MoCA score ≤ 16) independently predicted the ability of COPD patients to maintain proper inhaler technique. Assessment of cognitive function combined with technical re-assessment and repeated training should improve COPD management.
... The various advantages of DPI are having fast dose delivery [27]. Compared to the liquid dosage forms it has high stability [28]. It has less chance of formulation issues [29]. ...
... Advancement in research in context with DPI showed the several advantages of it and also opens several other areas for its applications. Fast dose delivery, free from the propellant, high dose carrying capacity, high stability, free from inhalation and actuation coordination, easy to handle, more reliable, and reproducible are the key advantages associated with them [27][28][29][30][31][32]49]. Conveniently, DPI can be classified based on dose frequency as single dose device (BreezHaler® and HandiHaler®) and multi-dose device (Ellipta® and Turbuhaler®) [38]. ...
A Dry Powder Inhaler (DPI) is a technique as well as a device used to inhale formulation which is in the form of dry powder, and is inhaled through the nose or mouth. It was developed for the purpose of treating conditions like chronic obstructive pulmonary disease (COPD), Asthma, and even cystic fibrosis etc. The aim of the review is to discuss the different methods of preparation of dry powders along with the characterization of DPI. Here we present the outline of different methods like supercritical fluid extraction (SCF), spray drying, and milling. The review focussed on various devices including single and multi-dose devices used in the DPI. It also highlights on recent advances in the DPI including nano particulate system, siRNA-based medication, liposomes, and pro-liposomes based delivery. In COVID-19 silver nanoparticles-based DPIs provide very prominent results in the infected lungs. Moreover, this review states that the AI-based DPI development provides and improvement in the bioavailability and effectiveness of the drug along with the role of artificial neural networks (ANN). The study also showed that nasally administered drugs (nose to brain) can easily cross the blood-brain barrier (BBB) and enter the central nervous system (CNS) through the olfactory and trigeminal pathway which provides effective CNS concentrations at lower dosage. It is suggested that DPIs not only target respiratory complications but also treat CNS complications too. This review provides support and guides the researcher in the recent development and evaluation of DPI.
... inhalation, [3,6] an important aspect in patient satisfaction. [7] Although nebulization is prescribed by the clinician, paramedics play a critical role in administering treatment to the patient. ...
... [8] Nasal inhalation can filter drug particles, reducing bronchodilator response to nearly half which further reduces lung deposition; inhaling through the mouth, especially with the facemask, is therefore important. [5][6][7]9,10] In the survey, 46% paramedics provided facemask to all patients requiring nebulization. Sixty-seven percentages clinicians instructed on drug and dosage followed by cleaning (50%), nebulization frequency (43%), selection of facemask/ mouthpiece (38%), and nebulization time (31%). ...
Aims: The aim of the study was to access the knowledge and practice of student nurses toward nebulization therapy. Introduction: Nebulization is an important tool in the treatment of respiratory conditions. Nurses are primary health-care providers for using the nebulizers in a hospital setting. The examination of nurse’s knowledge and performance regarding the nebulizer therapy is of almost importance for proper nebulization. Methodology: The pre-experimental research design was conducted in this study. The total sample was 60 in this study. Purposive sample technique was used. The target population is student nurses. The area of setting is Government Medical College Hospital of Ambikapur (c.g.). Result: The data show that analysis of the knowledge score pre-test mean score was 9.75, mean percentage score was 1.66% and SD was 2.71, analysis of post-test knowledge mean score was 14.51, mean percentage 2% and SD was 1.76, and standard error was 0.412, paired “t” value was 6.85 that was found to significant at 0.05 level. Practice score and pre-test mean score was 13.08, mean percentage score was 54.5%, and SD was 2.37, analysis of post-test knowledge mean score was 17.08, mean percentage 71.16 and SD was1.42, and standard error was 0.35, paired “t” value was 11.42 that was found to significant at 0.05 level. Conclusion: After the detailed analysis, this study leads to following conclusion that is more effective in improving knowledge and practice on regarding nebulization therapy
