improving medication adherence in copd with an effective device orapan poachanukoon, md
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Improving Medication Adherence in COPD with an Effective Device
Orapan Poachanukoon, MD.
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Particle deposition in the respiratory tract
Relationship between aerodynamic chamber and lung deposition
Laube et al Eur Respir J 2011; 37: 1308–1331.
Total
Oropharynx
Bronchial/Conductingairways
Alveolar
Factor affecting deposition of aerosols in lung
Physical Ventilatory Anatomic
Particle sizeParticle shapeParticle densityHumidityTemperature
Tidal volumeInspiratory flowBreath-hold timeBreathing frequencyNose vs mouth breathing
Airway diameterAgeDisease
Rubin BK, Fink JB. Respir Care Clin N Am 2001;7:175-213.
Patient-related variables impacting correct device use
Pulmonary function and disease stageSmoking status, age, sex, being overweightComorbiditiesManual dexterityAbility to understand and follow instructionsEyesightPsychosocial issues
Fink JB et al. COPD 2013;10: 1-13.
Patient’s inhaler device preference in COPD
Increased patient satisfaction and preference with a device can help optimize patient adherence to treatment1,2.
Factors affecting patient preferences: Perceived efficacy of device by patients Ability to use a given inhaler easily Psychological or physical issues
o Such as comorbidities (neuromuscular disorders and arthritis) can impact inhaler technique.
Inhaler features considered “very
important” by COPD patients
Inhaler features considered “very
important” by COPD patients
(Data from Moore and Stone 2004)
Restrepo et al. Int J COPD 2008:3(3) 371-3841. Anderson et al. ERR 20052. Jones et al. PCRJ 2004
MDI vs MDI with Spacer
Spacer devices
E
Valved holding chamber
Nebuchamber Aerochamber
Babyhaler ACE spacer
Volumatric
DIY Spacer
Petty patent of Thailand No. 5479
DIY
• 2013. Gold Prize in International Exhibition of Inventions of Geneva.Swiss Confederation. 10-14 April 2013
• 2013. Special Award from Taiwan Invention Association.
• 2012. Silver Prize in SII: Korea
• 2012. Excellence Award “Thai-ASEAN”Thaksin University National Conference.
AWARDSAWARDS
DIY SPACER on
THAMMASAT DIY SPACER https://www.youtube.com/watch?v=XeTBTJLnWyg
อ�ปกรณ์ ช่�วยพ่�นื้ยา TU Asthma Clubhttps://www.youtube.com/watch?v=kMbXeOo6S3I
www.tuasthmaclub.com
Clinical efficacy of spacer therapy with/without electrostatic charge
Arch. Dis. Child. 2001;84;178-182.
This study showed no negative influence of ESC on plastic spacers in children with asthma.
Dry Powder Inhaler (DPI)
MDI and DPI:advantages and disadvantages
Advantages Disadvantages
Portable and compact Coordination of actuation and inhalation needed
Short treatment time Most patients inhale too fast
No contamination risk Important to prime before first use
High reproducibility between doses Often difficult to determine remaining doses
Spacers available for some devices Spacers more expensive and less portable
Chrystyn & Price. Prim Care Resp J 2009; Laube et al. Eur Respir J 2011
No coordination required Forceful inhalation needed to aerosolize particles
Not to be used with spacer More expensive than MDIs
Portable and compact; multi-dose devices available
Only used with drug that is dispensed with the device
Single-dose devices with doses kept separately in sealed packs
Must be kept upright or horizontal during inhalation
Breath actuated Patients not to exhale into device once prepared
Short treatment time Single devices require repeat loading
DP
IM
DI
MDI and DPI:advantages and disadvantages
Advantages Disadvantages
Portable and compact Coordination of actuation and inhalation needed
Short treatment time Most patients inhale too fast
No contamination risk Important to prime before first use
High reproducibility between doses Often difficult to determine remaining doses
Spacers available for some devices Spacers more expensive and less portable
Chrystyn & Price. Prim Care Resp J 2009; Laube et al. Eur Respir J 2011
No coordination required Forceful inhalation needed to aerosolize particles
Not to be used with spacer More expensive than MDIs
Portable and compact; multi-dose devices available
Only used with drug that is dispensed with the device
Single-dose devices with doses kept separately in sealed packs
Must be kept upright or horizontal during inhalation
Breath actuated Patients not to exhale into device once prepared
Short treatment time Single devices require repeat loading
DP
IM
DI
Why dry powder inhalers?
Automatic co-ordination of inhalation and drug release1,2:– reduces patient errors associated with need to
co-ordinate inhalation and drug release
Dose counting or low warning (multi-dose DPIs) – also a feature of newer pMDIs
Lack of propellant is environmentally friendly3
– although plastics content, electronics (with some devices) and fewer doses per device may contribute to a less environmentally friendly profile
1. Ashurst, et al. Pharm Sci Technol Today 2000; 2. Newman, Busse. Respir Med 2002 3. Byron. PATS 2004
Lung deposition of devices
Respir Care Clin N Am 2001
How to choose right aerosol delivery device
Inspiratory flow> 30 L/min
Inspiratory flow< 30 L/min
Inspiratory flow> 30 L/min
Inspiratory flow< 30 L/min
pMDI
DPI
Nebulizer
pMDI
Nebulizer
pMDI+spacer
DPI
Nebulizer
pMDI+spacer
Nebulizer
Good coordination Poor coordination
Laube et al Eur Respir J 2011; 37: 1308–1331.
Evaluating Drug Delivery of DPI
Fine Particle Mass
Inspiratory Flow
Device Resistance
Airflow resistance in DPIs
sis
0
20
40
60
80
100
120
0 2 4 6 8 10
Inspiratory effort (kPa)
Flo
w r
ate
(L/m
in)
Breezhaler 2.2 10-2 kPa1/2 L-1 minDiskus 2.7 10-2 kPa1/2 L-1 minTurbuhaler 3.4 10-2 kPa1/2 L-1 minHandihaler 5.1 10-2 kPa1/2 L-1 min
Increasingtan
rece
Singh D et al. ATS 2010 (poster)
• Patients with mild to very severe COPD achieved a flow rate of ≥60 L/min (>18.9 cmH2O pressure drop) using Breezhaler®
140
120
100
80
60
40
20
0Mild Moderate Moderate/ Severe Very
severe severe
PIF
R (
L/m
in)
COPD severity
Peak inspiratory flow rate (PIFR) Breezhaler was not affected by COPD severity
Peak inspiratory flow rates via the device were determined in patients with COPD using an Inhalation Profile Recorder. Each bar represents one patient Pavkov et al. CMRO 2010; 26 (11): 2527-2533
N=26 COPD patients
Particle size & Dose Regional Deposition in Lung
• Delivered dose are usually in range of 75%-90% of metered dose.• FPD/FPM are very much dependent from formulation and delivery system but never 100% of delivered dose.
Consistent results for fine particle mass
Indacaterol 150 Indacaterol 150 µgµg Indacaterol 300 Indacaterol 300 µgµg
** Fine particle mass = drug particles <4.7 μm in diameter Pavkov et al. CMRO 2010; 26 (11): 2527-2533
Estimated drug deposition in Breezhaler® and HandiHaler® In
trat
hora
cic
depo
siti
on
(% o
f del
iver
ed d
ose)
Breezhaler Handihaler
Patient 1 2 3 4 5 6 7 Mean 1 2 3 4 5 6 7 Mean±SD ±SD
35
30
25
20
15
10
5
0
1. Laube et al. Eur Respir J 2011; 2. Chapman et al. Int J COPD 2011
Particles <5 μm have greatest potential for lung deposition1
FPF (proportion of particles <5 μm) was higher with Breezhaler (27%) vs HandiHaler (10%)2
Mean estimated intrathoracic drug deposition: 31% Breezhaler; 22% HandiHaler2
Mean estimated extrathoracic drug deposition: 57% Breezhaler; 71% HandiHaler2
Breezhaler-new capsule based DPI
Reasons for Non-adherenceReasons for Non-adherence
Impact on adherenceImpact on adherence
Pt/HCW partnership
patients featurescost/reimbursement
difficult to access
patient education
complexity of treatment, S/E
Pos
sibl
e av
oida
nce
chronicity
Technique to improve adherence to aerosol medications
Written explanation and demonstrationHave patient bring medication to every appointment and check technique at each visitAsk the patient specifically about adherence Follow up on unfilled and refilledMinimized medications, keep it simpleParents need to take responsibility (> 13 years take medicine independently)
Respiratory care 2011.
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