Factors associated with health status and exacerbations in COPD maintenance therapy with dry powder inhalers

Janwillem W. H. Kocks*, Hans Wouters, Sinthia Bosnic-Anticevich, Joyce van Cooten, Jaime Correia de Sousa, Biljana Cvetkovski, Richard Dekhuijzen, Lars Dijk, Evgeni Dvortsin, Marina Garcia Pardo, Asparuh Gardev, Radosław Gawlik, Iris van Geer - Postmus, Iris van der Ham, Marten Harbers, Alberto de la Hoz, Ymke Janse, Marjan Kerkhof, Federico Lavorini, Tiago MaricotoJiska Meijer, Boyd Metz, David Price, Miguel Roman-Rodriguez, Kirsten Schuttel, Nilouq Stoker, Ioanna Tsiligianni, Omar Usmani, Marika T. Leving

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

2 Citations (Scopus)


The study aimed to determine the associations of Peak Inspiratory Flow (PIF), inhalation technique and adherence with health status and exacerbations in participants with COPD using DPI maintenance therapy. This cross-sectional multi-country observational real-world study included COPD participants aged ≥40 years using a DPI for maintenance therapy. PIF was measured three times with the In-Check DIAL G16: (1) typical PIF at resistance of participant’s inhaler, (2) maximal PIF at resistance of participant’s inhaler, (3) maximal PIF at low resistance. Suboptimal PIF (sPIF) was defined as PIF lower than required for the device. Participants completed questionnaires on health status (Clinical COPD Questionnaire (CCQ)), adherence (Test of Adherence to Inhalers (TAI)) and exacerbations. Inhalation technique was assessed by standardised evaluation of video recordings. Complete data were available from 1434 participants (50.1% female, mean age 69.2 years). GOLD stage was available for 801 participants: GOLD stage I (23.6%), II (54.9%), III (17.4%) and IV (4.1%)). Of all participants, 29% had a sPIF, and 16% were shown able to generate an optimal PIF but failed to do so. sPIF was significantly associated with worse health status (0.226 (95% CI 0.107–0.346), worse units on CCQ; p = 0.001). The errors ‘teeth and lips sealed around mouthpiece’, ‘breathe in’, and ‘breathe out calmly after inhalation’ were related to health status. Adherence was not associated with health status. After correcting for multiple testing, no significant association was found with moderate or severe exacerbations in the last 12 months. To conclude, sPIF is associated with poorer health status. This study demonstrates the importance of PIF assessment in DPI inhalation therapy. Healthcare professionals should consider selecting appropriate inhalers in cases of sPIF.

Original languageEnglish
Article number18
Number of pages10
Journalnpj Primary Care Respiratory Medicine
Issue number1
Publication statusPublished - 26 May 2022


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