Logo: to the web site of Uppsala University

uu.sePublications from Uppsala University
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Inhaled pharmacological treatment and critical inhaler technique errors in patients with chronic obstructive pulmonary disease
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmacy. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Centre for Research and Development, Gävleborg.ORCID iD: 0000-0002-1444-752x
2021 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Chronic obstructive pulmonary disease (COPD) is an inflammatory lung disease characterised by persistent respiratory symptoms and a high risk of exacerbations. Preventive and maintenance pharmacological treatment is primarily administered through handheld inhalers, which are available in several different device-drug combinations. This thesis is about increasing the quality of drug treatment in COPD, where problems related to inhaled drugs are common. The overall aim was to assess and evaluate inhaled pharmacological treatment and critical inhaler technique errors in patients with COPD. 

The four studies included in this thesis derived from the Tools for Identifying Exacerbations study, which is an observational multicentre study in primary and secondary care in Sweden including 571 patients with COPD.

The consequences of a change in the Global Initiative for Obstructive Lung Disease guidelines were investigated (Paper I). The refined COPD assessment of symptoms/risk of exacerbations lead to a high proportion of patients being reclassified to a lower risk group, which in turn had consequences for patients’ pharmacological treatment.

The patients’ inhaled pharmacological treatments were assessed (Paper II). A high prevalence of inhaled corticosteroids (ICS) was identified, especially as a triple treatment, i.e., in combination with dual long-acting bronchodilators. Based on a previously developed tool, discontinuation of ICS could be tried in more than half of the patients.

Proper inhaler technique is a prerequisite for adequate COPD treatment. Video-recorded demonstrations of inhaler technique were analysed (Paper III). Two-thirds of the patients made at least one critical inhaler technique error. The majority of the patients used a combination of different inhaler device models, which was the only factor associated with critical inhaler technique errors.

The changes in inhaled pharmacological COPD treatment and inhaler technique were investigated one year after an initial evaluation and training (Paper IV). A reduction in the proportion of patients making critical inhaler technique errors was found but not in the subgroup of patients who had switched device models during the year. However, no association with COPD symptoms or exacerbations could be detected.

The overall results contribute to increased knowledge and understanding of drug treatment in COPD. In order to optimise pharmacological treatment, it is essential to assess disease severity and inhaler technique, particularly in patients who switch device models. Further research is warranted to determine the most optimal educational intervention regarding inhaler technique, which has not yet been settled.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2021. , p. 61
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Pharmacy, ISSN 1651-6192 ; 296
Keywords [en]
chronic obstructive pulmonary disease, COPD, critical inhaler technique error, pharmacological treatment, ICS, inhaled corticosteroid
National Category
Respiratory Medicine and Allergy
Research subject
Pharmaceutical Science
Identifiers
URN: urn:nbn:se:uu:diva-439958ISBN: 978-91-513-1211-8 (print)OAI: oai:DiVA.org:uu-439958DiVA, id: diva2:1545579
Public defence
2021-06-11, A1:107a, Biomedicinskt centrum, Husargatan 3, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2021-05-19 Created: 2021-04-19 Last updated: 2021-06-21
List of papers
1. 2017 Global Initiative for Chronic Obstructive Lung Disease reclassifies half of COPD subjects to lower risk group
Open this publication in new window or tab >>2017 Global Initiative for Chronic Obstructive Lung Disease reclassifies half of COPD subjects to lower risk group
Show others...
2018 (English)In: The International Journal of Chronic Obstructive Pulmonary Disease, ISSN 1176-9106, E-ISSN 1178-2005, Vol. 13, no `, p. 165-173Article in journal (Refereed) Published
Abstract [en]

Background: Unlike the 2014 guidelines, the 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have removed lung function from the risk assessment algorithm of patients with COPD. The aim of this investigation was to analyze the proportion of subjects who would change to a lower risk group when applying GOLD(2017) and determine if they exhibit different characteristics in terms of inflammation, symptoms and comorbidity compared to the subjects who would remain in a high-risk group.

Subjects and methods: A total of 571 subjects with physician-diagnosed and spirometry-verified COPD were included in the present study. The data consisted of measurements of lung function, inflammatory markers, together with questionnaires that covered comorbidities, COPD symptoms and medication.

Results: From group C, 53% of the subjects would be reclassified to the lower risk group A, and from group D, 47% of the subjects would be reclassified to the lower risk group B when using GOLD(2017) instead of GOLD(2014). Compared to the subjects who would remain in group D, those who would change to group B were more often men (56% vs 72%); of an older age, mean (SD), 71 (8) years vs 68 (7) years; had more primary care contact (54% vs 33%); had lower levels of blood neutrophils, geometrical mean (95% CI), 5.3 (5.0, 5.7) vs 4.6 (4.3, 4.9); reported less anxiety/depression (20% vs 34%); experienced less asthma (29% vs 46%) and had fewer symptoms according to the COPD assessment test, 16 (5) vs 21 (7). All p-values were <0.05.

Conclusion: The removal of spirometry from risk assessment in GOLD(2017) would lead to the reclassification of approximately half of the subjects in the risk groups C and D to the lower risk groups A and B. There are differences in age, gender, health care contacts, inflammation, comorbidity and symptom burden among those changing from group D to group B. The effects of reclassification and changes in eventual treatment for disease control and symptom burden need further investigation.

Place, publisher, year, edition, pages
DOVE MEDICAL PRESS LTD, 2018
Keywords
COPD, lung function test, eosinophils, neutrophils, comorbidity, GOLD
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-341327 (URN)10.2147/COPD.S151016 (DOI)000419105400001 ()29379281 (PubMedID)
Funder
Swedish Heart Lung Foundation
Available from: 2018-02-07 Created: 2018-02-07 Last updated: 2021-04-19Bibliographically approved
2. A Cross-Sectional Study Assessing Appropriateness Of Inhaled Corticosteroid Treatment In Primary And Secondary Care Patients With COPD In Sweden
Open this publication in new window or tab >>A Cross-Sectional Study Assessing Appropriateness Of Inhaled Corticosteroid Treatment In Primary And Secondary Care Patients With COPD In Sweden
Show others...
2019 (English)In: The International Journal of Chronic Obstructive Pulmonary Disease, ISSN 1176-9106, E-ISSN 1178-2005, Vol. 14, p. 2451-2460Article in journal (Refereed) Published
Abstract [en]

Purpose: Inhaled corticosteroids (ICS) are often more widely prescribed in the treatment of chronic obstructive pulmonary disease (COPD) than what is recommended in the guidelines. The aim of this study was to evaluate the appropriateness of ICS treatment in COPD patients using the algorithm proposed by the International Primary Care Respiratory Group (IPCRG) and to identify factors associated with ICS treatment.

Patients and methods: Appropriateness of ICS therapy was studied with respect to concomitant asthma, history of exacerbations and blood eosinophils (B-Eos) in a Swedish cohort of primary and secondary care patients with COPD. Factors associated with ICS were investigated using multivariable logistic regression.

Results: Triple treatment was found to be the most common treatment combination, used by 46% of the 561 included patients, and in total 63% were using ICS. When applying the IPCRG algorithm, there was a possible indication for discontinuation of ICS in 55% of the patients with ICS treatment. Of the patients not using ICS, 18% had an indication for starting such treatment. The strongest factors associated with ICS therapy were frequent exacerbations (aOR 8.61, 95% CI 4.06, 20.67), secondary care contacts (aOR 6.99, 95% CI 2.48, 25.28) and very severe airflow limitation (aOR 5.91, 95% CI 1.53, 26.58).

Conclusion: More than half of the COPD patients on ICS met the criteria where withdrawal of the treatment could be tried. There was, however, also a subgroup of patients not using ICS for whom there was an indication for starting ICS treatment. Patients using ICS were characterized by more frequent exacerbations and lower lung function.

Place, publisher, year, edition, pages
DOVE MEDICAL PRESS LTD, 2019
Keywords
ICS, pharmacological management, inappropriate therapy, chronic obstructive pulmonary disease, IPCRG
National Category
Respiratory Medicine and Allergy
Identifiers
urn:nbn:se:uu:diva-397585 (URN)10.2147/COPD.S218747 (DOI)000494042200001 ()
Funder
Swedish Heart Lung Foundation
Available from: 2019-11-25 Created: 2019-11-25 Last updated: 2021-04-19Bibliographically approved
3. Critical inhaler technique errors in Swedish patients with COPD: a cross-sectional study analysing video-recorded demonstrations
Open this publication in new window or tab >>Critical inhaler technique errors in Swedish patients with COPD: a cross-sectional study analysing video-recorded demonstrations
Show others...
2021 (English)In: npj Primary Care Respiratory Medicine, E-ISSN 2055-1010, Vol. 31, no 1, article id 5Article in journal (Refereed) Published
Abstract [en]

A correct use of inhaler devices is essential in chronic obstructive pulmonary disease (COPD) treatment. Critical errors were studied by analysing 659 video-recorded demonstrations of inhaler technique from 364 COPD patients using six different inhaler device models. The majority of the included patients used two (55%) or more (20%) device models. Overall, 66% of the patients made ≥1 critical error with at least one device model. The corresponding numbers for patients using 1, 2 and ≥3 device models were 43%, 70% and 86%, respectively. The only factor associated with making ≥1 critical error was simultaneous use of two (adjusted odds ratios (aOR) 3.17, 95% confidence interval (95% CI) 1.81, 5.64) or three or more (aOR 8.97, 95% CI 3.93, 22.1) device models. In conclusion, the proportion of patients making critical errors in inhaler technique was substantial, particularly in those using several different device models. To obtain optimal COPD treatment, it is important to assess a patient's inhaler technique and to minimise the number of inhaler device models.

Place, publisher, year, edition, pages
Springer Nature, 2021
National Category
Respiratory Medicine and Allergy
Research subject
Lung Medicine; Physiology
Identifiers
urn:nbn:se:uu:diva-435891 (URN)10.1038/s41533-021-00218-y (DOI)000616754300001 ()33563979 (PubMedID)
Available from: 2021-03-01 Created: 2021-03-01 Last updated: 2024-01-15Bibliographically approved
4. Changes in critical inhaler technique errors in inhaled COPD treatment: A one-year follow-up study in Sweden
Open this publication in new window or tab >>Changes in critical inhaler technique errors in inhaled COPD treatment: A one-year follow-up study in Sweden
Show others...
2022 (English)In: Respiratory Medicine, ISSN 0954-6111, E-ISSN 1532-3064, Vol. 197, article id 106849Article in journal (Refereed) Published
Abstract [en]

Background: Critical inhaler technique errors have been associated with lower treatment efficacy in chronic obstructive pulmonary disease (COPD). We aimed to assess and follow-up critical inhaler technique errors, and to investigate their association with COPD symptoms and exacerbations.

Methods: COPD-diagnosed primary and secondary care outpatients (n = 310) demonstrated inhaler technique with inhaler devices they were currently using. Critical errors in opening, positioning and loading the inhaler device, and exhalation through dry-powder inhalers were assessed and corrected, and the assessment was repeated one year later. COPD Assessment Test, the modified Medical Research Council dyspnoea scale and history of exacerbations were collected at both visits.

Results: The proportion of patients making >1 critical inhaler technique error was lower at follow-up in the total population (46% vs 37%, p = 0.01) and among patients with unchanged device models (46% vs 35%, p = 0.02), but not among patients with a new inhaler device model (46% vs 41%, p = 0.56). Not positioning the device correctly was the most common critical error at both visits (30% and 22%). Seventy-four percent of the patients had unchanged COPD treatment from baseline to follow-up. Treatment escalation, de-escalation, and switch was observed in 14%, 11%, and 1% of the patients, respectively. No association was found between critical errors and COPD symptoms or exacerbations.

Conclusions: Assessment and correction of inhaler technique was associated with a decrease in critical inhaler technique errors. This effect was most pronounced in patients using the same device models throughout the follow-up period.

Place, publisher, year, edition, pages
Elsevier, 2022
Keywords
COPD, Inhaler technique, Critical errors, COPD treatment
National Category
Respiratory Medicine and Allergy
Research subject
Lung Medicine; Lung Medicine
Identifiers
urn:nbn:se:uu:diva-439956 (URN)10.1016/j.rmed.2022.106849 (DOI)000830640600001 ()35483167 (PubMedID)
Funder
Swedish Heart Lung FoundationBror Hjerpstedts stiftelseRegion DalarnaUppsala UniversityRegion Gavleborg
Available from: 2021-04-12 Created: 2021-04-12 Last updated: 2023-01-03Bibliographically approved

Open Access in DiVA

UUthesis_Sulku,J_2021(912 kB)727 downloads
File information
File name FULLTEXT01.pdfFile size 912 kBChecksum SHA-512
d9fa6ee0f18d32ae75b6f335033c3073c88624fcb05b2825399cfcb298509b666ee4a8619281294712db93054ceba82c55ec1647fa5446f1b0de7ad5b3c6b588
Type fulltextMimetype application/pdf

Other links

Välkommen att delta digitalt via Zoom (meeting ID: 618 8459 1686)

Authority records

Sulku, Johanna

Search in DiVA

By author/editor
Sulku, Johanna
By organisation
Department of PharmacyCentre for Research and Development, Gävleborg
Respiratory Medicine and Allergy

Search outside of DiVA

GoogleGoogle Scholar
Total: 731 downloads
The number of downloads is the sum of all downloads of full texts. It may include eg previous versions that are now no longer available

isbn
urn-nbn

Altmetric score

isbn
urn-nbn
Total: 1012 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf