Clinical recommendations for dry powder inhaler use in the management of COPD in primary care

Marika  Leving; Sinthia Bosnic-Anticevich; Joyce  van Cooten; Jaime Correia de Sousa; Biljana Cvetkovski; Richard Dekhuijzen; Lars  Dijk; Marina  Garcia Pardo; Asparuh Gardev; Radosław  Gawlik; Iris  van der Ham; Ymke  Janse; Federico Lavorini; Tiago  Maricoto; Jiska Meijer; Boyd Metz; David Price; Miguel Román-Rodríguez; Kirsten Schuttel; Nilouq  Stoker; Ioanna Tsiligianni; Omar Usmani; Omar Usmani; Janwillem Kocks

doi:10.1038/s41533-022-00318-3

Clinical recommendations for dry powder inhaler use in the management of COPD in primary care

Marika Leving, Sinthia Bosnic-Anticevich, Joyce van Cooten, Jaime Correia de Sousa, Biljana Cvetkovski, Richard Dekhuijzen, Lars Dijk, Marina Garcia Pardo, Asparuh Gardev, Radosław Gawlik, Iris van der Ham, Ymke Janse, Federico Lavorini, Tiago Maricoto, Jiska Meijer, Boyd Metz, David Price, Miguel Román-Rodríguez, Kirsten Schuttel, Nilouq StokerIoanna Tsiligianni, Omar Usmani, Omar Usmani, Janwillem Kocks^* (Corresponding Author)

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

4 Citations (Scopus)

2 Downloads (Pure)

Abstract

Over 1400 patients using dry powder inhalers (DPIs) to deliver COPD maintenance therapies were recruited across Europe and Australia. Their peak inspiratory flow (PIF) was measured, inhaler technique was observed, and adherence to treatment assessed. From relating the findings with patient health status, and thereby identifying critical errors, key clinical recommendations for primary care clinicians were determined, namely – measure PIF before prescribing a DPI to ensure inhalation manoeuvre ability is well-matched with the device.
Some patients could benefit from inhalation training whereas others should have their DPI changed for one better suited to their inspiratory ability or alternatively be prescribed an active device (such as a soft mist inhaler or pressurized metered dose inhaler). Observing the inhalation technique was valuable however this misses sub-optimal PIF (approaching one fourth of patients with a satisfactory observed manoeuvre had a suboptimal PIF for their DPI). Assess adherence as deliberate non-adherence can point to a mismatch between a
patient and their inhaler (deliberate non-adherence was significantly associated with PIFs below the minimum for the DPI). In-person observation of inhalation technique was found to be inferior to video rating based on device-specific checklists. Where video assessments are not possible, observation training for healthcare professionals would therefore be valuable particularly to improve the ability to identify the critical errors associated with health status namely ‘teeth and lips sealed around mouthpiece’, ‘breathe in’ and ‘breathing out calmly
after inhalation’. However, it is recommended that observation alone should not replace PIF measurement in the DPI selection process.

Original language	English
Article number	59
Number of pages	8
Journal	npj Primary Care Respiratory Medicine
Volume	32
DOIs	https://doi.org/10.1038/s41533-022-00318-3
Publication status	Published - 27 Dec 2022

Bibliographical note

Acknowledgements
The study sponsor was the General Practitioners Research Institute; data collection and analysis were performed by General Practitioners Research Institute. Boehringer Ingelheim was the funding and scientific partner. The members of the PIFotal study group would like to acknowledge Dr. Jaco Voorham from Data to Insights Research Solutions for his assistance with the statistical analyses, Dr Wilma Zijlema for her assistance with the review, drafting and editing of the paper, and Dr. Hans Wouters for his contribution to the project administration in the initial phase of the project. They would also like to thank all contributing researchers: Maria João Barbosa, Ana Margarida Cruz, Liliana Silva, Duarte Araújo, Eurico Silva, Daniel Castro, João Ramires, Ana Fernandes, Catarina Carvalho, Raquel Castro, Jerzy Zientek, Ewa Pasko, Witold Drzastwa, Tomasz Kachel, Kornelia Ciekalska, Krzysztof Wytrychowski, Bernard Panaszek, Krzysztof Kowal, Ebian Brill, Willemien Feenstra, Geert Struik, Hans Schuurman, Mariette van Oostrum, Hennie Holwerda Meekma, Boudewijn Dierick, George Amofa, Esther Kuipers, Lennard Ringnalda, Boris Tyndall, Mark Drenth, Peter Mast, Hilbert Talsma, Raoul Wolfs, Cobie Hoogeboom, Hanneke van Andel, Paul Stoutenberg, Nancy van de Laak, Tessa Hillaert, Laura Holtzer, Natascha Fehrmann, Anniek Makkinga – Maassen van den Brink, Annemarie Hilbink, Erik Feenstra, Murat Tek, Sabrina Burer, Jan van Ginkel, Rinze Boersma, Alyssa Bonger, Miguel Roman Rodriguez, Marina García Pardo, Alejandra Valero Suau, Laura López Velasco, Cecilia Amato, Francisco Palmer Simó, Alberto Abenza, Rosa Llull Vila, Bartolomé Llompart Van Belzen, Silvia Jimeno Martínez, Francesc Moranta Ribas, Margarita Perelló Oliver, Yolanda Gómez López, Patricia Ibañez Gómez, María Nieves Mendieta Lagos, Laura Bueno López, Virginia María Mirabal Sánchez, Ana Delia Rodríguez Delgado, Nils Fischer, Alicia González Sansó, Nayra Ramírez Mendoza, Valeria Gazzaneo, Paula Merced Guillama Rodríguez, Virginia Naranjo Guerrero, Jose Angel Suarez Caballero, Isidoro Souto Bethencourt, Juan R. Dominguez Beatell, Elena Vanesa Rojas Manrique, Maria Jose Sanz Orejas, Cary Perez Lorenzo, Jesús Antonio Pérez Jiménez, Silvia Lara Afonso Trujillo, Bartolomé Dominguez Del Río Boada, Stavroula Papageorgakopoulou, Eleytheria Vakouti, Claire Gkatzoudi, Thodoris Krasanakis, Dimitris Kounalakis , Izoldi Bouloukaki , Nikolaos Tsakountakis, Emmanouela Chronaki, Katherine Mary Borg and Kamila Abutalieva for their time and efforts to perform the study measurements and complete patient inclusion, even in the challenging times of the pandemic. Finally, they would like to thank the participants who generously gave their time to participate in the study.

Data Availability Statement

The datasets generated during and/or analysed during the current study are available from the corresponding author (JK) on request.

Keywords

Chronic airways disease
primary care
respiratory medicine
dry power inhalers

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Cite this

Leving, M., Bosnic-Anticevich, S., van Cooten, J., Correia de Sousa, J., Cvetkovski, B., Dekhuijzen, R., Dijk, L., Garcia Pardo, M., Gardev, A., Gawlik, R., van der Ham, I., Janse, Y., Lavorini, F., Maricoto, T., Meijer, J., Metz, B., Price, D., Román-Rodríguez, M., Schuttel, K., ... Kocks, J. (2022). Clinical recommendations for dry powder inhaler use in the management of COPD in primary care. npj Primary Care Respiratory Medicine, 32, Article 59. https://doi.org/10.1038/s41533-022-00318-3

Leving, M, Bosnic-Anticevich, S, van Cooten, J, Correia de Sousa, J, Cvetkovski, B, Dekhuijzen, R, Dijk, L, Garcia Pardo, M, Gardev, A, Gawlik, R, van der Ham, I, Janse, Y, Lavorini, F, Maricoto, T, Meijer, J, Metz, B, Price, D, Román-Rodríguez, M, Schuttel, K, Stoker, N, Tsiligianni, I, Usmani, O, Usmani, O & Kocks, J 2022, 'Clinical recommendations for dry powder inhaler use in the management of COPD in primary care', npj Primary Care Respiratory Medicine, vol. 32, 59. https://doi.org/10.1038/s41533-022-00318-3

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title = "Clinical recommendations for dry powder inhaler use in the management of COPD in primary care",

abstract = "Over 1400 patients using dry powder inhalers (DPIs) to deliver COPD maintenance therapies were recruited across Europe and Australia. Their peak inspiratory flow (PIF) was measured, inhaler technique was observed, and adherence to treatment assessed. From relating the findings with patient health status, and thereby identifying critical errors, key clinical recommendations for primary care clinicians were determined, namely – measure PIF before prescribing a DPI to ensure inhalation manoeuvre ability is well-matched with the device.Some patients could benefit from inhalation training whereas others should have their DPI changed for one better suited to their inspiratory ability or alternatively be prescribed an active device (such as a soft mist inhaler or pressurized metered dose inhaler). Observing the inhalation technique was valuable however this misses sub-optimal PIF (approaching one fourth of patients with a satisfactory observed manoeuvre had a suboptimal PIF for their DPI). Assess adherence as deliberate non-adherence can point to a mismatch between apatient and their inhaler (deliberate non-adherence was significantly associated with PIFs below the minimum for the DPI). In-person observation of inhalation technique was found to be inferior to video rating based on device-specific checklists. Where video assessments are not possible, observation training for healthcare professionals would therefore be valuable particularly to improve the ability to identify the critical errors associated with health status namely {\textquoteleft}teeth and lips sealed around mouthpiece{\textquoteright}, {\textquoteleft}breathe in{\textquoteright} and {\textquoteleft}breathing out calmlyafter inhalation{\textquoteright}. However, it is recommended that observation alone should not replace PIF measurement in the DPI selection process. ",

keywords = "Chronic airways disease, primary care, respiratory medicine, dry power inhalers",

author = "Marika Leving and Sinthia Bosnic-Anticevich and {van Cooten}, Joyce and {Correia de Sousa}, Jaime and Biljana Cvetkovski and Richard Dekhuijzen and Lars Dijk and {Garcia Pardo}, Marina and Asparuh Gardev and Rados{\l}aw Gawlik and {van der Ham}, Iris and Ymke Janse and Federico Lavorini and Tiago Maricoto and Jiska Meijer and Boyd Metz and David Price and Miguel Rom{\'a}n-Rodr{\'i}guez and Kirsten Schuttel and Nilouq Stoker and Ioanna Tsiligianni and Omar Usmani and Omar Usmani and Janwillem Kocks",

note = "Acknowledgements The study sponsor was the General Practitioners Research Institute; data collection and analysis were performed by General Practitioners Research Institute. Boehringer Ingelheim was the funding and scientific partner. The members of the PIFotal study group would like to acknowledge Dr. Jaco Voorham from Data to Insights Research Solutions for his assistance with the statistical analyses, Dr Wilma Zijlema for her assistance with the review, drafting and editing of the paper, and Dr. Hans Wouters for his contribution to the project administration in the initial phase of the project. They would also like to thank all contributing researchers: Maria Jo{\~a}o Barbosa, Ana Margarida Cruz, Liliana Silva, Duarte Ara{\'u}jo, Eurico Silva, Daniel Castro, Jo{\~a}o Ramires, Ana Fernandes, Catarina Carvalho, Raquel Castro, Jerzy Zientek, Ewa Pasko, Witold Drzastwa, Tomasz Kachel, Kornelia Ciekalska, Krzysztof Wytrychowski, Bernard Panaszek, Krzysztof Kowal, Ebian Brill, Willemien Feenstra, Geert Struik, Hans Schuurman, Mariette van Oostrum, Hennie Holwerda Meekma, Boudewijn Dierick, George Amofa, Esther Kuipers, Lennard Ringnalda, Boris Tyndall, Mark Drenth, Peter Mast, Hilbert Talsma, Raoul Wolfs, Cobie Hoogeboom, Hanneke van Andel, Paul Stoutenberg, Nancy van de Laak, Tessa Hillaert, Laura Holtzer, Natascha Fehrmann, Anniek Makkinga – Maassen van den Brink, Annemarie Hilbink, Erik Feenstra, Murat Tek, Sabrina Burer, Jan van Ginkel, Rinze Boersma, Alyssa Bonger, Miguel Roman Rodriguez, Marina Garc{\'i}a Pardo, Alejandra Valero Suau, Laura L{\'o}pez Velasco, Cecilia Amato, Francisco Palmer Sim{\'o}, Alberto Abenza, Rosa Llull Vila, Bartolom{\'e} Llompart Van Belzen, Silvia Jimeno Mart{\'i}nez, Francesc Moranta Ribas, Margarita Perell{\'o} Oliver, Yolanda G{\'o}mez L{\'o}pez, Patricia Iba{\~n}ez G{\'o}mez, Mar{\'i}a Nieves Mendieta Lagos, Laura Bueno L{\'o}pez, Virginia Mar{\'i}a Mirabal S{\'a}nchez, Ana Delia Rodr{\'i}guez Delgado, Nils Fischer, Alicia Gonz{\'a}lez Sans{\'o}, Nayra Ram{\'i}rez Mendoza, Valeria Gazzaneo, Paula Merced Guillama Rodr{\'i}guez, Virginia Naranjo Guerrero, Jose Angel Suarez Caballero, Isidoro Souto Bethencourt, Juan R. Dominguez Beatell, Elena Vanesa Rojas Manrique, Maria Jose Sanz Orejas, Cary Perez Lorenzo, Jes{\'u}s Antonio P{\'e}rez Jim{\'e}nez, Silvia Lara Afonso Trujillo, Bartolom{\'e} Dominguez Del R{\'i}o Boada, Stavroula Papageorgakopoulou, Eleytheria Vakouti, Claire Gkatzoudi, Thodoris Krasanakis, Dimitris Kounalakis , Izoldi Bouloukaki , Nikolaos Tsakountakis, Emmanouela Chronaki, Katherine Mary Borg and Kamila Abutalieva for their time and efforts to perform the study measurements and complete patient inclusion, even in the challenging times of the pandemic. Finally, they would like to thank the participants who generously gave their time to participate in the study.",

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doi = "10.1038/s41533-022-00318-3",

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T1 - Clinical recommendations for dry powder inhaler use in the management of COPD in primary care

AU - Leving, Marika

AU - Bosnic-Anticevich, Sinthia

AU - van Cooten, Joyce

AU - Correia de Sousa, Jaime

AU - Cvetkovski, Biljana

AU - Dekhuijzen, Richard

AU - Dijk, Lars

AU - Garcia Pardo, Marina

AU - Gardev, Asparuh

AU - Gawlik, Radosław

AU - van der Ham, Iris

AU - Janse, Ymke

AU - Lavorini, Federico

AU - Maricoto, Tiago

AU - Meijer, Jiska

AU - Metz, Boyd

AU - Price, David

AU - Román-Rodríguez, Miguel

AU - Schuttel, Kirsten

AU - Stoker, Nilouq

AU - Tsiligianni, Ioanna

AU - Usmani, Omar

AU - Kocks, Janwillem

N1 - Acknowledgements The study sponsor was the General Practitioners Research Institute; data collection and analysis were performed by General Practitioners Research Institute. Boehringer Ingelheim was the funding and scientific partner. The members of the PIFotal study group would like to acknowledge Dr. Jaco Voorham from Data to Insights Research Solutions for his assistance with the statistical analyses, Dr Wilma Zijlema for her assistance with the review, drafting and editing of the paper, and Dr. Hans Wouters for his contribution to the project administration in the initial phase of the project. They would also like to thank all contributing researchers: Maria João Barbosa, Ana Margarida Cruz, Liliana Silva, Duarte Araújo, Eurico Silva, Daniel Castro, João Ramires, Ana Fernandes, Catarina Carvalho, Raquel Castro, Jerzy Zientek, Ewa Pasko, Witold Drzastwa, Tomasz Kachel, Kornelia Ciekalska, Krzysztof Wytrychowski, Bernard Panaszek, Krzysztof Kowal, Ebian Brill, Willemien Feenstra, Geert Struik, Hans Schuurman, Mariette van Oostrum, Hennie Holwerda Meekma, Boudewijn Dierick, George Amofa, Esther Kuipers, Lennard Ringnalda, Boris Tyndall, Mark Drenth, Peter Mast, Hilbert Talsma, Raoul Wolfs, Cobie Hoogeboom, Hanneke van Andel, Paul Stoutenberg, Nancy van de Laak, Tessa Hillaert, Laura Holtzer, Natascha Fehrmann, Anniek Makkinga – Maassen van den Brink, Annemarie Hilbink, Erik Feenstra, Murat Tek, Sabrina Burer, Jan van Ginkel, Rinze Boersma, Alyssa Bonger, Miguel Roman Rodriguez, Marina García Pardo, Alejandra Valero Suau, Laura López Velasco, Cecilia Amato, Francisco Palmer Simó, Alberto Abenza, Rosa Llull Vila, Bartolomé Llompart Van Belzen, Silvia Jimeno Martínez, Francesc Moranta Ribas, Margarita Perelló Oliver, Yolanda Gómez López, Patricia Ibañez Gómez, María Nieves Mendieta Lagos, Laura Bueno López, Virginia María Mirabal Sánchez, Ana Delia Rodríguez Delgado, Nils Fischer, Alicia González Sansó, Nayra Ramírez Mendoza, Valeria Gazzaneo, Paula Merced Guillama Rodríguez, Virginia Naranjo Guerrero, Jose Angel Suarez Caballero, Isidoro Souto Bethencourt, Juan R. Dominguez Beatell, Elena Vanesa Rojas Manrique, Maria Jose Sanz Orejas, Cary Perez Lorenzo, Jesús Antonio Pérez Jiménez, Silvia Lara Afonso Trujillo, Bartolomé Dominguez Del Río Boada, Stavroula Papageorgakopoulou, Eleytheria Vakouti, Claire Gkatzoudi, Thodoris Krasanakis, Dimitris Kounalakis , Izoldi Bouloukaki , Nikolaos Tsakountakis, Emmanouela Chronaki, Katherine Mary Borg and Kamila Abutalieva for their time and efforts to perform the study measurements and complete patient inclusion, even in the challenging times of the pandemic. Finally, they would like to thank the participants who generously gave their time to participate in the study.

PY - 2022/12/27

Y1 - 2022/12/27

N2 - Over 1400 patients using dry powder inhalers (DPIs) to deliver COPD maintenance therapies were recruited across Europe and Australia. Their peak inspiratory flow (PIF) was measured, inhaler technique was observed, and adherence to treatment assessed. From relating the findings with patient health status, and thereby identifying critical errors, key clinical recommendations for primary care clinicians were determined, namely – measure PIF before prescribing a DPI to ensure inhalation manoeuvre ability is well-matched with the device.Some patients could benefit from inhalation training whereas others should have their DPI changed for one better suited to their inspiratory ability or alternatively be prescribed an active device (such as a soft mist inhaler or pressurized metered dose inhaler). Observing the inhalation technique was valuable however this misses sub-optimal PIF (approaching one fourth of patients with a satisfactory observed manoeuvre had a suboptimal PIF for their DPI). Assess adherence as deliberate non-adherence can point to a mismatch between apatient and their inhaler (deliberate non-adherence was significantly associated with PIFs below the minimum for the DPI). In-person observation of inhalation technique was found to be inferior to video rating based on device-specific checklists. Where video assessments are not possible, observation training for healthcare professionals would therefore be valuable particularly to improve the ability to identify the critical errors associated with health status namely ‘teeth and lips sealed around mouthpiece’, ‘breathe in’ and ‘breathing out calmlyafter inhalation’. However, it is recommended that observation alone should not replace PIF measurement in the DPI selection process.

AB - Over 1400 patients using dry powder inhalers (DPIs) to deliver COPD maintenance therapies were recruited across Europe and Australia. Their peak inspiratory flow (PIF) was measured, inhaler technique was observed, and adherence to treatment assessed. From relating the findings with patient health status, and thereby identifying critical errors, key clinical recommendations for primary care clinicians were determined, namely – measure PIF before prescribing a DPI to ensure inhalation manoeuvre ability is well-matched with the device.Some patients could benefit from inhalation training whereas others should have their DPI changed for one better suited to their inspiratory ability or alternatively be prescribed an active device (such as a soft mist inhaler or pressurized metered dose inhaler). Observing the inhalation technique was valuable however this misses sub-optimal PIF (approaching one fourth of patients with a satisfactory observed manoeuvre had a suboptimal PIF for their DPI). Assess adherence as deliberate non-adherence can point to a mismatch between apatient and their inhaler (deliberate non-adherence was significantly associated with PIFs below the minimum for the DPI). In-person observation of inhalation technique was found to be inferior to video rating based on device-specific checklists. Where video assessments are not possible, observation training for healthcare professionals would therefore be valuable particularly to improve the ability to identify the critical errors associated with health status namely ‘teeth and lips sealed around mouthpiece’, ‘breathe in’ and ‘breathing out calmlyafter inhalation’. However, it is recommended that observation alone should not replace PIF measurement in the DPI selection process.

KW - Chronic airways disease

KW - primary care

KW - respiratory medicine

KW - dry power inhalers

U2 - 10.1038/s41533-022-00318-3

DO - 10.1038/s41533-022-00318-3

M3 - Article

C2 - 36575175

SN - 2055-1010

VL - 32

JO - npj Primary Care Respiratory Medicine

JF - npj Primary Care Respiratory Medicine

M1 - 59

ER -

Clinical recommendations for dry powder inhaler use in the management of COPD in primary care

Abstract

Bibliographical note

Data Availability Statement

Keywords

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