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      Influence of inhaler technique on asthma and COPD control: a multicenter experience

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          The successful management of asthma and chronic obstructive pulmonary disease (COPD) mostly depends on adherence to inhalation drug therapy, the usage of which is commonly associated with many difficulties in real life. Improvement of patients’ adherence to inhalation technique could lead to a better outcome in the treatment of asthma and COPD.


          The aim of this study was to assess the utility of inhalation technique in clinical and functional control of asthma and COPD during a 3-month follow-up.


          A total of 312 patients with asthma or COPD who used dry powder Turbuhaler were enrolled in this observational study. During three visits (once a month), training in seven-step inhalation technique was given and it was practically demonstrated. Correctness of patients’ usage of inhaler was assessed in three visits by scoring each of the seven steps during administration of inhaler dose. Assessment of disease control was done at each visit and evaluated as: fully controlled, partially controlled, or uncontrolled. Patients’ subjective perception of the simplicity of inhalation technique, disease control, and quality of life were assessed by using specially designed questionnaires.


          Significant improvement in inhalation technique was achieved after the third visit compared to the first one, as measured by the seven-step inhaler usage score (5.94 and 6.82, respectively; P<0.001). Improvement of disease control significantly increased from visit 1 to visit 2 (53.9% and 74.5%, respectively; P<0.001) and from visit 2 to visit 3 (74.5% and 77%, respectively; P<0.001). Patients’ subjective assessment of symptoms and quality of life significantly improved from visit 1 to visit 3 ( P<0.001).


          Adherence to inhalation therapy is one of the key factors of successful respiratory disease treatment. Therefore, health care professionals should insist on educational programs aimed at improving patients’ inhalation technique with different devices, resulting in better long-term disease control and improved quality of life.

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          Most cited references 24

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          Global and regional estimates of COPD prevalence: Systematic review and meta–analysis

          Background The burden of chronic obstructive pulmonary disease (COPD) across many world regions is high. We aim to estimate COPD prevalence and number of disease cases for the years 1990 and 2010 across world regions based on the best available evidence in publicly accessible scientific databases. Methods We conducted a systematic search of Medline, EMBASE and Global Health for original, population–based studies providing spirometry–based prevalence rates of COPD across the world from January 1990 to December 2014. Random effects meta–analysis was conducted on extracted crude prevalence rates of COPD, with overall summaries of the meta–estimates (and confidence intervals) reported separately for World Health Organization (WHO) regions, the World Bank's income categories and settings (urban and rural). We developed a meta–regression epidemiological model that we used to estimate the prevalence of COPD in people aged 30 years or more. Findings Our search returned 37 472 publications. A total of 123 studies based on a spirometry–defined prevalence were retained for the review. From the meta–regression epidemiological model, we estimated about 227.3 million COPD cases in the year 1990 among people aged 30 years or more, corresponding to a global prevalence of 10.7% (95% confidence interval (CI) 7.3%–14.0%) in this age group. The number of COPD cases increased to 384 million in 2010, with a global prevalence of 11.7% (8.4%–15.0%). This increase of 68.9% was mainly driven by global demographic changes. Across WHO regions, the highest prevalence was estimated in the Americas (13.3% in 1990 and 15.2% in 2010), and the lowest in South East Asia (7.9% in 1990 and 9.7% in 2010). The percentage increase in COPD cases between 1990 and 2010 was the highest in the Eastern Mediterranean region (118.7%), followed by the African region (102.1%), while the European region recorded the lowest increase (22.5%). In 1990, we estimated about 120.9 million COPD cases among urban dwellers (prevalence of 13.2%) and 106.3 million cases among rural dwellers (prevalence of 8.8%). In 2010, there were more than 230 million COPD cases among urban dwellers (prevalence of 13.6%) and 153.7 million among rural dwellers (prevalence of 9.7%). The overall prevalence in men aged 30 years or more was 14.3% (95% CI 13.3%–15.3%) compared to 7.6% (95% CI 7.0%–8.2%) in women. Conclusions Our findings suggest a high and growing prevalence of COPD, both globally and regionally. There is a paucity of studies in Africa, South East Asia and the Eastern Mediterranean region. There is a need for governments, policy makers and international organizations to consider strengthening collaborations to address COPD globally.
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            Medication non-adherence in the elderly: how big is the problem?

             Carmel Hughes (2003)
            Adherence to medication is one of the most intriguing and complex behaviours demonstrated by patients. Non-adherence to a therapeutic regimen may result in negative outcomes for patients and may be compounded in populations with multiple morbidities which require multiple drug therapy. Such a population is exemplified by the elderly. However, non-adherence may not be more prevalent in older patients and there is no consensus in the literature that age is a predictor of poor adherence. Indeed, older patients may deliberately choose not to adhere to medication (intentional non-adherence) to avoid adverse effects. Furthermore, many of the studies on adherence lack commonality in terms of how adherence is measured, the definition of an 'older' patient and the range of disease states which have been examined. Adherence may also be affected by access to medications which may be restricted by the use of formularies or insurance programmes. However, non-adherence may represent a greater risk in older people resulting in poor disease control which may be compounded with multiple morbidity and polypharmacy. A range of strategies have been implemented to try and improve adherence in this patient population. The use of forgiving drugs (those which have a prescribed dosage interval that is 50% or less the duration of drug action) may facilitate occasional lapses in drug-taking. Drug holidays (deliberate, supervised non-adherence for a fixed period of time) have been used in Parkinson's disease to reduce adverse effects. Once-daily scheduling of drug administration may offer a pragmatic approach to optimising drug therapy in some patients; this may be supplemented through the use of compliance aids. What is increasingly apparent, however, is that the role of the patient (irrespective of age) is critical in decision-making about medication, together with communication between patients and healthcare professionals. This has been articulated through the concept of concordance which has been described as a therapeutic alliance between the patient and healthcare professional. In addition, interventions employed to improve adherence must be multifaceted, and together with practical approaches (reducing unnecessary drugs and simplifying dosage regimens), the patient perspective must be considered. Good adherence should be seen as a means of achieving a satisfactory therapeutic result and not as an end in itself.
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              Inhalatory therapy training: a priority challenge for the physician.

               Andrea Melani (2007)
              Patients with asthma and COPD commonly use inhaled drugs. The 3 types of currently available devices for inhaled therapy (Metered-dose inhaler, dry powder inhaler, and nebulizer) are clinically equivalent. However, since many different inhalers are available for inhaled therapy, the choice of the delivery device is important for optimizing the results of aerosol therapy. Traditional press-and-breathe Metered Dose Inhalers (pMDIs) have recently improved their ecological appeal, can be used in every clinical and environmental situation, their dosing is convenient and highly reproducible, but their efficient delivery remains highly technique dependent. Poor inhalation technique can be minimised by the use of add-on valved holding chambers, which are seldom used in the clinical practice possibly because they are cumbersome. Breath Actuated devices (BAIs), such as Dry Powder Inhalers (DPIs), which are environmental-friendly, safe, effective, reliable, portable and self-contained, overcome problems of handbreath co-ordination associated with pMDIs usage, but their use is also undermined by common errors of inhalation technique in real life. Nebulizers are cumbersome and time-comsuming for use and maintenance, but their use needs less cooperation than inhalers. Although nebulizer practice is not always evidence-based, some patients, mainly elderly prefer nebulizers for regular long-term usage. Despite the introduction of newer devices, clear advantages of a particular delivery system over other inhalers in terms of compliance, preference, and cost-effectiveness are not currently available. The objective of an ideal and easy-to use inhaler is far from reality. Patient education is the critical factor in the use and misuse of delivery devices and effectiveness of aerosol therapy. The choice of the device has to be tailored according to the patient's needs, situation, and preference. Whatever the chosen inhaler, education from health caregivers has a key-role for improving inhaler technique and compliance. Differences among delivery devices represent another challenge to patient use and caregiver instruction.

                Author and article information

                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                06 October 2016
                : 11
                : 2509-2517
                [1 ]Faculty of Medicine, University of Belgrade
                [2 ]Clinic for Pulmonology, Clinical Centre of Serbia, Belgrade
                [3 ]Faculty of Medicine, University of Novi Sad, Novi Sad
                [4 ]Institute for Pulmonary Diseases of Vojvodina, Sremska Kamenica
                [5 ]Faculty of Medicine, University of Kragujevac
                [6 ]Clinic for Pulmonology, Clinical Centre Kragujevac, Kragujevac
                [7 ]Clinic for Pulmonary Diseases Knez Selo, Clinical Centre Nis, Nis
                [8 ]Faculty of Stomatology, University Academy of Business Novi Sad, Novi Sad, Serbia
                Author notes
                Correspondence: Aleksandra Dudvarski Ilic, Clinic for Pulmonology, Clinical Center of Serbia, Koste Todorovica 2, Belgrade 11000, Serbia, Email sanjadudvarski@
                © 2016 Dudvarski Ilic et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research

                Respiratory medicine

                turbuhaler, adherence, inhalation technique, asthma, copd


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