哮喘患者正确使用定量气雾剂相关因素分析

皮质激素和支气管扩张药的吸入治疗在哮喘防治上占据重要地位,尤其是吸入皮质激素已作为治疗哮喘的首选药物被全球公认.定量型气雾剂(MDI)为实施吸入治疗最为普遍的装置.欲使药物能达到最佳疗效,患者正确掌握MDI的使用方法就成为了关键.为此,我们调查了1999年6月至2003年1月在我院门诊就诊及住院的100例哮喘患者的MDI使用情况,分析影响MDI使用正确率的相关因素及常见的MDI使用出错形式,从而更有效地对哮喘患者MDI使用进行针对性指导,使吸入治疗达到应有的疗效.     

哮喘病人定量雾化吸入器使用方法的护理干预

[目的]探讨哮喘病人定量雾化吸入器(MDI)使用方法护理干预的效果.[方法]选取MDI使用时间1年以上的哮喘病人60例,随机分为实验组和对照组各30例,调查其MDI使用的正确率、测定其肺功能并进行生活质量评分,对实验组进行MDI使用的护理干预,对照组不予干预,12个月后再次进行上述指标的评估.[结果]两组12个月后MDI使用的及格率比较差异有统计学意义,实验组入组时与12个月后肺功能、生活质量评分比较均有统计学意义(P<0.01或P<0.05).[结论]MDI使用方法的护理干预能够显著改善哮喘病人肺通气功能和提高其生活质量,是提高哮喘控制水平的有效手段.     

回授法对支气管哮喘患者吸入技术的影响

目的 探讨回授法对支气管哮喘患者吸入技术的影响,为回授法的推广及支气管哮喘患者吸入技术的改善提供参考依据.方法 选取我院呼吸科2013年1月至2014年12月收治的支气管哮喘患者60例,按照随机数字表法分为观察组和对照组各30例,均接受吸入技术讲解,观察组患者加用回授法.比较两组患者吸入技术的掌握程度.结果 两组患者干预4周后健康知识、健康信念、健康行为、健康技能及健康素养总分均显著提高,观察组变化更为明显,差异有统计学意义(P<0.05).两组患者吸入装置打开错误、上药错误发生率比较,差异均无统计学意义(P>0.05);观察组患者呼气错误、吸药错误、屏气错误、漱口错误发生率均显著低于对照组,差异有统计学意义(P<0.05).结论 回授法能够显著提高支气管哮喘患者吸入技术及健康素养、降低吸入操作的错误率,有望提高患者临床症状控制效果,值得推广应用.     

哮喘病人定量雾化吸入器使用方法的护理干预

[目的]探讨哮喘病人定量雾化吸入器（MDI）使用方法护理干预的效果。[方法]选取MDI使用时间1年以上的哮喘病人60例，随机分为实验组和对照组各30例，调查其MDI使用的正确率、测定其肺功能并进行生活质量评分，对实验组进行MDI使用的护理干预，对照组不予干预，12个月后再次进行上述指标的评估。[结果]两组12个月后MDI使用的及格率比较差异有统计学意义，实验组入组时与12个月后肺功能、生活质量评分比较均有统计学意义（P〈0.01或P〈0.05）。[结论]MDI使用方法的护理干预能够显著改善哮喘病人肺通气功能和提高其生活质量，是提高哮喘控制水平的有效手段。     

吸入技术对哮喘控制水平的影响

【目的】探讨哮喘患者通过健康教育对吸入技术的掌握程度对其控制水平的影响。【方法】61例哮喘患者通过3个月健康教育，按照对吸入装置使用评分，≥4分为甲组32例和〈4分为乙组29例，甲组对吸入技术能很好的掌握，乙组不能完全正确掌握吸入技术。观察治疗前后两组患者使用定量气雾吸入器（MDI）、都保或准纳器操作的全过程并对步骤进行评分。比较两组患者治疗前后吸入剂使用评分，肺功能指标和哮喘生存质量评估表（AQLQ）评分。【结果】甲组患者3个月后使用MDI、都保和准纳器评分及合格率较治疗前明显增加（P〈0．05）。两组患者3个月后FEV1占预计值％和PEF占预计值％均明显增加，与治疗前比较有统计学意义（P〈0．05）。甲组患者3个月后肺功能指标改善更显著，与乙组治疗后比较有统计学意义（P〈0．05）。甲组患者3个月后AQLQ各项指标评分较乙组明显增加（P〈0．05或P〈0．01）。甲组3个月后AQLQ各项指标评分较治疗前明显增加（P〈0．05）。【结论】哮喘患者通过健康教育，提高了对吸入技术的正确掌握，从而改善患者的肺功能和生存质量，改善哮喘控制水平，是哮喘防治中重要的一部分。     

社区护理干预对老年患者吸入治疗依从性的影响

目的探讨社区护理干预对老年支气管哮喘和慢性阻塞性肺病(COPD)患者吸入治疗依从性的影响。方法对上海市嘉定区102例确诊为支气管哮喘或COPD、年龄≥65岁的老年患者吸入治疗的依从性进行问卷调查。根据调查所了解的原因进行护理干预(进行疾病健康教育,包括正确使用吸入装置的重要性、各类吸入性药物的作用及不良反应、坚持吸入治疗的重要性和注意点、常见不良反应的处理和吸入方法)及吸入方法现场演示宣教(使用图示说明、PPT演示和实物讲解),宣教1次,随后每个月上门随访1次,观察周期为3个月,比较护理干预前后老年患者吸入治疗的依从性。结果 102例老年患者干预前不能坚持吸入治疗者为81例(79.4%),经护理干预后在坚持吸入治疗,正确开、关药物装置,正确吸入药物和屏气、正确漱口及三步骤均使用正确方面均明显高于干预前(均P<0.01)。结论社区护理干预可以显著提高老年支气管哮喘和COPD患者的吸入治疗的依从性。     

支气管哮喘患者吸入糖皮质激素治疗依从性的研究

目的 调查门诊成人支气管哮喘患者吸入糖皮质激素治疗的依从状况,并探讨其影响因素.方法 采用便利抽样方法,选取北京市某三级甲等医院呼吸科门诊就诊的167例成人哮喘患者.用一般资料调查表、哮喘用药依从性量表和哮喘知识问卷分别测评患者的一般资料、吸入糖皮质激素治疗的依从性和哮喘知识水平;让患者采用吸入装置模型演示糖皮质激素的吸入方法,依据吸入技术的6个步骤判断患者的吸入方法是否正确.采用二元logistic回归对吸入糖皮质激素治疗依从性的影响因素进行统计分析.结果 哮喘患者吸入糖皮质激素治疗依从性好的比例为37.7％.logistic回归结果显示,疾病严重程度[OR =0.61,95％CI(0.44,0.86),P=0.01]、哮喘知识[OR=1.12,95％CI(1.01,1.25),P=0.03]及吸入技术[OR=2.94,95％CI(1.36,6.36),P＜0.01]对哮喘患者吸入糖皮质激素治疗依从性的影响有显著性差异.结论 门诊成人哮喘患者吸入糖皮质激素治疗的依从性不佳.疾病严重程度、哮喘知识及吸入技术影响患者吸入糖皮质激素治疗的依从性.     

雾化吸入护理干预对哮喘患儿治疗舒适度及病情康复的影响

目的：探讨雾化吸入护理干预对哮喘患儿治疗舒适度及病情康复的影响。方法采用随机分层法将我院在2012年8月至2013年12月行氧驱动雾化吸入治疗的100例哮喘患儿分为对照组（ n＝50,治疗过程中予以常规护理）和观察组（ n＝50,在常规护理基础上加入吸入宣教、体位指导以及心理、饮食等方面的雾化吸入护理干预）,比较两组患者治疗舒适度及病情康复情况的差异。结果观察组患者护理干预后雾化意愿、喘息症状改善、睡眠质量、舒适程度等方面评分显著优于对照组,比较差异显著（ P＜0.05）;观察组患儿肺弹性阻力、气道阻力、气促缓解时间、哮鸣音消失时间以及平均住院时间等病情康复指标显著优于对照组,比较差异具有统计学意义（ P＜0.05）。结论对氧泵雾化吸入治疗的哮喘患儿予以护理干预,能有效提高治疗舒适度,改善哮喘症状,促进病情康复。     

家长参与下互动式护理模式对小儿哮喘吸入剂治疗效果的影响

目的 探讨家长参与下互动式护理模式对小儿哮喘吸入剂治疗效果的影响。方法 纳入 2019 年 1 月至 2021 年 1 月支气管 哮喘患儿 74 例作为研究对象。随机分为对照组和干预组,每组各 37 例。对照组予以常规吸入剂用药指导,干预组予以家长参 与下互动式护理模式。观察对比两组吸入剂使用相关知识掌握情况、哮喘吸入剂不正确使用情况和满意度。结果 干预组吸入 剂使用相关知识掌握情况优于对照组,差异有统计学意义（P＜0.05）。干预组吸入剂不正确使用率（2.70%）低于对照组（18.92%）, 差异有统计学意义（P＜0.05）。干预组的护理满意度为 100.00%,显著高于对照组的 86.49%（P＜0.05）。结论 家长参与下互 动式护理模式可以促进吸入剂使用相关知识掌握,促进小儿哮喘吸入剂的正确使用,提高护理满意度高,值得推广。     

长期护理干预对门诊哮喘患者的影响

目的 评价门诊哮喘患者长期护理干预效果,提高管理质量.方法 将应用联合治疗方案且同意接受长期护理管理的128例门诊慢性持续期哮喘患者分为常规干预(A)组63例和加强干预(B)组65例.对2组患者遵医嘱行为(复诊、服药依从性)、退出率、急性加重、临床完全控制率及良好控制率等指标进行对比.结果 2组完成了4次常规随访的患者约9,12个月时的完全控制率和约4,9,12个月的良好控制率比较无显著差异.加强干预组中依从性差的患者例数、患者退出率及重度急性加重的例数均明显低于常规干预组.常规干预组第4次复诊率较第2次复诊率明显下降.讨论哮喘患者随着病情的控制,疗程的延长,自我监控力度易松懈,产生懒惰性,对医务人员的依赖性增加.护士应及时掌握患者动态变化,根据个体在不同阶段的特点,适当增加相应护理干预,强化患者遵医行为,可控制哮喘发作,提高患者生活质量.     

Handling of inhaler devices in actual pulmonary practice: metered-dose inhaler versus dry powder inhalers

BACKGROUND: Handling of inhaler devices such as pressurized metered-dose inhalers (MDIs) and dry-powder inhalers (DPIs) in actual pulmonary practice is not well studied. OBJECTIVE: The aim of this study was to evaluate patients' proper handling of inhaler devices during actual pulmonary practice. METHODS: Prospective observational evaluations were conducted at 3 pulmonary clinics in Jordan, from February 2006 until August 2006. MDI (without spacer), Turbuhaler, Diskus, and Aerolizer devices were studied. Incorrect handling was defined as improper technique in any of the predefined essential steps. RESULTS: Patients (n = 300) were recruited and 525 inhaler-device handling technique evaluations were completed. Diskus inhaler had the lowest rate of incorrect handling (7/103, 6.8%) and MDI had the highest rate of incorrect handling (144/193, 74.6%). Turbuhaler and Aerolizer were handled incorrectly by 63/146 (43.2%) and 14/83 (16.9%) patients, respectively. DPI had a lower rate of incorrect handling, when compared with the MDI (p < 0.001). Among the DPI devices, the Diskus had the lowest rate of incorrect handling (p < 0.031). CONCLUSIONS: In actual pulmonary clinical practice the majority of patients were unable to use MDI correctly, whereas correct handling of DPI devices was variable. Regular checking of inhalation technique and proper teaching by health care providers is crucial for optimum use of most inhaler devices.     

Clinical assessment of a new breath-actuated inhaler

Up to 50 per cent of patients cannot use a conventional metered-dose inhaler (MDI) efficiently and therefore obtain less than optimum benefit. Seventy adults with no previous experience of inhalers were asked to demonstrate their inhaler techniques after reading written instructions for an MDI and for a new breath-actuated inhaler. The breath-actuated inhaler was found to be easier to use and was preferred to the MDI.     

Evaluation of an Auditory Feedback Equipped Metered Dose Inhaler

BACKGROUND: Although metered dose inhalers are one of the most frequently prescribed drug delivery systems for pulmonary disease, patients usually do not employ ideal technique when using these systems. We studied the effect of a new teaching device, the MDI Tutor (MDI Tutor Inc., Palatine, IL), on patients with unsatisfactory inhalation technique. METHODS: Twelve patients with an average of 10 years' experience with metered dose inhalers (mean age, 41 years) were evaluated by two observers. All patients had deficits in their inspiratory technique such as actuation of inhaler coordinating with the beginning of inhalation cycle, uninterrupted inhalation, and incorrect length of inspiration. Following evaluation, the patients were given metered dose inhalers equipped with a MDI Tutor prototype as well as written instructions on how to use the device most effectively. RESULTS: All patients corrected their inspiratory technique deficits. CONCLUSIONS: Equipping a metered dose inhaler with a MDI Tutor allows patients to rapidly recognize correct the errors in their inspiratory technique.     

Development of a dry powder inhaler, the Ultrahaler, containing triamcinolone acetonide using in vitro-in vivo relationships

Triamcinolone acetonide (TAA) is safe and effective corticosteroid that is marketed as an MDI (metered dose inhaler) (Azmacort) for the treatment of asthma. A novel dry powder inhaler (DPI), the Ultrahaler, has been developed to deliver Azmacort as another alternative to provide non-CFC formulation for the asthmatic patients. The Ultrahaler is breath actuated and, unlike MDI, does not require coordination of inhalation with the actuation of the device. However, with the Ultrahaler device, like any dry powder inhalation device, the challenge was the on-target and uniform delivery of the drug at the site of action (lungs) with different dose strengths. Due to the complexities of oral inhaled formulations and the topical nature of drug delivery to the lung for efficacy, the reformulation requires careful consideration and support throughout their development, using a combination of in vitro and in vivo studies. This paper describes in vitro studies and two clinical pharmacokinetic studies conducted in a sequence that helped to establish optimum doses for the Ultrahaler. In vitro data were used to guide the initial selection of doses that were then compared in vivo using a pharmacokinetic study with a charcoal block. The in vitro tests included quantifying the target-delivered dose, dose uniformity throughout the life of the device, and the particle size distribution. Particle size distribution was measured using multistage liquid impinger (MSLI) or the Andersen Cascade Impactor (ACI). For in vitro testing, TAA was measured by HPLC methods. Based on the preliminary in vitro data for the respirable fraction, dose strengths with an MDI and the Ultrahaler for the first study were determined. The in vivo assessment consisted of a four-way crossover study following oral inhalation using both MDI (75 and 225 microg/actuation, reference treatment) and comparable respirable doses in the DPI (130 and 360 microg/actuation) devices in healthy volunteers in the presence (lung deposition) and absence (lung and oropharynx deposition) of the charcoal block. Plasma TAA concentrations were determined using a radioimmunoassay (RIA) method. The in vitro data also showed dose proportionality with DPI formulation, and the doses delivered were within 13% of the target doses. A measure of dose uniformity, the relative standard deviation (%RSD) of dose, was less than 15%. Plasma TAA exposure of DPI formulations was compared with that of MDI formulations. Mean ratios (DPI/MDI) of the AUCinf were close to unity for the lower dose strength. However, for the higher dose strength, plasma exposure was higher with the Ultrahaler formulation as compared with the MDI formulation (mean AUCinf DPI/MDI ratios: 1.96). These differences seem to be due to less than proportional increases in the MDI formulation. Based on these results and using the higher dose strength of the MDI as the comparator, the new dose strengths of the Ultrahaler were chosen, ie, 100, 225, and 450 mug/actuation. Plasma TAA concentrations were measured by LC/MS/MS methods. The mean TAA concentrations and AUCinf and Cmax values increased in a dose-proportional manner with an increase in dose for the DPI formulation. The pharmacokinetic parameters showed low variability (10%-33%). Fine particle mass (in vitro testing) and TAA exposure in plasma following DPI administration were compared. Fine particle performance in vitro related well with in vivo pharmacokinetic performance (R=AUCinf-0.9998, Cmax-0.9956). In conclusion, in vitro and in vivo data were in agreement and good control over the target-dose delivery and dose proportionality could be achieved in the early stages of the development of the Ultrahaler device and were critical in guiding and ensuring the success of the reformulation efforts for Azmacort.     

Do patients prefer dry powder inhalers or metered-dose inhalers? A retrospective, combined analysis

Background: Efficacy and safety data from clinical trials of inhalers have been pooled and reported in previous studies. However, data on the patient acceptability of delivery devices were not fully reported. Acceptability of inhaler devices may be an important factor in patient compliance with regular maintenance therapy.Objective: The purpose of this retrospective, combined analysis was to assess acceptability data as an outcome variable in 3 double-blind, double-dummy studies comparing a dry powder inhaler (DPI) with a metered-dose inhaler (MDI) for delivery of beclomethasone dipropionate (BDP) to adult and pediatric patients with asthma.Methods: Studies used in this analysis were conducted in adult and pediatric patients with asthma to assess the efficacy, safety, and acceptability of either DPI or MDI (with a spacer if considered appropriate by the investigator) as a BDP delivery method after an open-label run-in period of 2 to 4 weeks, during which all patients received BDP by MDI.Results: End-of-study questionnaires were completed by 94% of randomized patients (339/362). All 3 studies demonstrated statistical therapeutic equivalence and tolerability of the 2 devices. Patients assessed the acceptability of the DPI and the MDI after ≤12 weeks of clinical use. Overall, significantly more patients found the DPI (67%) easier to use compared with the MDI (22%; P < 0.01). The DPI dose counter was rated useful by 82% of patients, and significantly more patients preferred the DPI (63%) to the MDI (28%; P < 0.01).Conclusions: This analysis of combined study data demonstrates that different delivery formats may have a marked effect on patient acceptability, and that patients in these studies preferred the delivery format of the DPI to that of the MDI, making compliance more likely.     

Practical problems with aerosol therapy in COPD

Inhaled aerosol drugs commonly used by patients with chronic obstructive pulmonary disease include short-acting and long-acting bronchodilators, as well as corticosteroids. These agents are available in a variety of inhaler devices, which include metered-dose inhalers (MDI), breath-actuated MDIs, nebulizers, and, currently, 5 different models of dry powder inhaler (DPI). There is evidence to suggest that multiple inhaler types cause confusion among patients and increase errors in patient use. Problems with MDIs include failure to coordinate inhalation with actuation of the MDI, inadequate breath-hold, and inappropriately fast inspiratory flow. Lack of a dose counter makes determining the number of remaining doses in an MDI problematic. Patient misuse of MDIs is compounded by lack of knowledge of correct use among health-care professionals. Several factors often seen with elderly patients have been identified as predictive of incorrect use of MDIs. These include mental-state scores, hand strength, and ideomotor dyspraxia. Holding chambers and spacers are partially intended to reduce the need for inhalation-actuation coordination with MDI use. However, such add-on devices can be subject to incorrect assembly. Possible delays between MDI actuation and inhalation, rapid inspiration, chamber electrostatic charge, and firing multiple puffs into the chamber can all reduce the availability of inhaled drug. Because they are breath-actuated, DPIs remove the need for inhalation-actuation synchrony, but there is evidence that patient errors in use of DPIs may be similar to those with MDIs. One of the biggest problems is loading and priming the DPI for use, and this may be due to the fact that every DPI model in current use is different. Medical personnel's knowledge of correct DPI use has also been shown to be lacking. The optimum inhalation profiles are different for the various DPIs, but, generally, chronic obstructive pulmonary disease patients have been shown to achieve a minimum therapeutic dose, although the inhaled amount may be suboptimal. A limitation of DPIs that have multidose powder reservoirs (eg, the Turbuhaler) is ambient humidity, which can reduce the released dose. Small-volume nebulizers are limited by bulk, treatment time, and variable performance, but are easy for patients to use. Important features identified by patients for an ideal inhaler are ease of use during an attack, dose counter, and general ease of use and learning. A breath-actuated-pMDI, such as the Autohaler, ranked at the top of inhaler preference in a study of 100 patients with airflow obstruction, compared to DPIs and MDIs. Short of a universal simple inhaler, patient and caregiver education remains the best solution to correct patient errors in use.     

Dry powder ipratropium bromide is as safe and effective as metered-dose inhaler formulation: a cumulative dose-response study in chronic obstructive pulmonary disease patients.

A multi-center, open, randomized, 2-way crossover study was conducted with chronic obstructive pulmonary disease (COPD) patients to compare the safety and efficacy of cumulative doses of ipratropium bromide administered from a pressurized metered-dose inhaler (MDI) or from a breath-activated dry powder inhaler (DPI). Enrolled in the study were 39 patients with moderate to severe COPD and who showed a > or= 15% increase in baseline forced expiratory volume in the first second (FEV(1)) after 80 microg of ipratropium bromide. Thirty-six patients were evaluable for efficacy analysis, and 38 patients were included in the safety analysis group. A significant improvement in pulmonary function was observed following inhalation of cumulative doses of ipratropium bromide (from 20 to 320 microg), but no statistically significant difference was found between the 2 formulations. The dose-response curves were similar. There was no statistical difference in area-under-the-curve during the 180 min period after the last dose for any of the pulmonary function variables. Overall, effects on pulse rate, blood pressure, and QT interval on electrocardiogram were no different between the devices. Six mild adverse events occurred in 4 patients: ventricular ectopic beats on electrocardiogram at 270 min with MDI, bad taste with both MDI and DPI, slight transient increase in blood pressure in the same patient during each study day with both MDI and DPI. Two moderate adverse events occurred in 2 patients: transient ventricular ectopic beats on electrocardiograms with DPI at 270 min, moderate bronchospasm with MDI at 200 min. Patients expressed a preference for DPI, which was found to have a better acceptability and appeared to be easier to use than MDI. The new lactose powder formulation of ipratropium bromide inhaled via the breath-activated DPI is a safe and effective alternative to the chlorofluorocarbon-propelled MDI.     

Dry powder inhalers for optimal drug delivery

Dry powder inhalers (DPIs) have been available for delivering drugs to the lungs for over 30 years. In the last decade there has been a big increase in DPI development, resulting partly from recognised limitations in other types of inhaler device. Many companies are developing DPIs for asthma and chronic obstructive pulmonary disease (COPD) therapy, and there is increasing recognition of the potential role of DPI systems for other therapies, such as inhaled antibiotics and peptides/proteins. Optimised drug delivery may be achieved not only by improvements to devices, but also via more sophisticated formulations that disperse easily in the inhaled air-stream and which may often be delivered by relatively simple inhaler devices. DPIs could become the device category of choice for a wide range of inhaled therapies, involving both local and systemic drug delivery.     

Can patients use all dry powder inhalers equally well?

If patients are unable to use their inhaler, drug delivery may be unsatisfactory and the patients may fail to benefit from the prescribed medication. It is important to consider whether patients can use all dry powder inhalers equally well. Changing a patient from a dry powder inhaler used well to one that the patient is unable to operate effectively could compromise asthma control. The many marketed dry powder inhalers reflect differences in design decisions that could affect lung deposition. Studies using different dry powder inhalers have confirmed that different lung deposition patterns are observed. Furthermore, there may be considerable individual variability in lung deposition. Differences in lung deposition patterns could have clinical effects. Studies may show similar clinical effectiveness with two inhalers, because most products are used at the plateau phase of the dose-response curve, although there may be differences in the adverse event profile. The ideal inhaler does not yet exist. Different dry powder inhalers show some but not all features of the ideal inhaler; hence, patients may prefer some aspects of one inhaler while favouring a different inhaler for other features. The individual balance of features will govern the overall preference for one inhaler over others. The method for operation of dry powder inhalers varies. Ease of use is seen as an important consideration when selecting an inhaler device, which should be evaluated in real-life studies using unselected patient populations. In conclusion, the evidence suggests that patients cannot use all dry powder inhalers equally well.     

Comparing clinical features of the nebulizer, metered-dose inhaler, and dry powder inhaler

Topically inhaled bronchodilators and corticosteroids are the mainstay of treatment for asthma and chronic obstructive pulmonary disease. These medications are delivered via jet or ultrasonic nebulizer, metered-dose inhaler (MDI), or dry powder inhaler (DPI). While the number of devices may be confusing to patients and clinicians, each device has distinct advantages and disadvantages. Most clinical evidence shows that any of these devices will work for most situations, including exacerbations and in the stable outpatient setting. There is a high rate of errors in device use with all these devices, especially the MDI. In choosing a drug/device combination for a patient, the clinician must take into account several factors, including the cognitive and physical ability of the patient, ease of use, convenience, costs, and patient preferences. Clinicians should also have a rudimentary understanding of aerosol principles in order to be able to teach appropriate use of aerosol devices to their patients.