Bronchodilator administration by pressurized inhaler during invasive mechanical ventilation in adults: A scoping review. / [Artículo traducido] Administración de broncodilatadores mediante inhalador de dosis medida durante la ventilación mecánica invasiva: una revisión sistemática exploratoria.

OBJECTIVE: To identify the administration characteristics and connection methods of bronchodilators by pressurized inhalers to the ventilatory circuit of patients under invasive mechanical ventilation. METHODS: A scope review was conducted following the PRISMA for Scoping Review, using the PubMed, Embase Elsevier, Cochrane Library, and Lilacs databases without language restrictions, up to July 2023. Eligible sources included reviews and consensuses (based on clinical studies), experimental and observational studies involving adult patients admitted to the Intensive Care Unit and undergoing invasive mechanical ventilation, regardless of the underlying condition, who used bronchodilator drugs contained in pressurized inhalers. Information regarding inhalation technique, pressurized inhalers connection mode to the circuit, and patient care were collected by two researchers independently, with discrepancies resolved by a third reviewer. Studies involving bronchodilators combined with other pharmacological classes in the same device, as well as reviews containing preclinical studies, were excluded. RESULTS: In total, 23 publications were included, comprising 19 clinical trials and 4 non-randomized experimental studies. Salbutamol (albuterol) was the bronchodilator of study in the majority of the articles (n=18), and the spacer device was the most commonly used to connect the pressurized inhaler to the circuit (n=15), followed by an in-line adapter (n=3) and a direct-acting device without chamber (n=3). Concerning the pressurized inhaler placement in the circuit, 18 studies positioned it in the inspiratory limb, and 19 studies synchronized the jet actuation with the start of the inspiratory phase. Agitation of the pressurized inhaler before each actuation, waiting time between actuations, airway suction before administration, and semi-recumbent patient positioning were the most commonly described measures across the studies. CONCLUSIONS: This review provided insights into the aspects related to inhalation technique in mechanically ventilated patients, as well as the most prevalent findings and the existing gaps in knowledge regarding bronchodilator administration in this context. The evidence indicates the need for further research on this subject.

The environmental burden of inhalation.

Inhalation systems, mostly metered dose inhalers (MDIs) and dry powder inhalers (DPIs), are currently submitted to a critical assessment for their carbon footprint (CF) and environmental impact. They are related to greenhouse gas (GHG) emissions and they produce waste of used devices with withheld drug residues and unused doses. However, with estimated contributions to anthropogenic GHG-emissions of 0.03% for MDIs and 0.0012% for DPIs globally, it may not be expected that mitigating the GHG emissions from inhalers will have a meaningful effect on the current climate change and global warming, notwithstanding that nationally these percentages may be somewhat higher, depending on the ratio of MDIs to DPIs and the total national CF. MDIs are particularly the preferred type of inhalers over DPIs in the USA and UK with ratios of 9: 1 and 7: 3 respectively. In such countries, a partial switch from MDIs to DPIs is to be recommended, providing that such a switch does not jeopardize the therapy. Using renewable energy only for the production and waste management of DPIs will make this type of inhaler almost climate neutral. A greater concern exists about inhaler waste, more particularly about the residual drug and unused doses in discarded devices. Inhalers contribute less than 0.02% to global plastic waste annually and most plastic inhalers end in the domestic waste bin and not as litter polluting the environment with plastic. However, they do contain retained drug and unused doses, whereas even full inhalers are disposed. Because globally most municipal waste (70%) ends up in dumps and landfills, leakage of the drugs into the soil and surface waters is a serious problem. It pollutes drinking water and endangers species and biodiversity. Therefore, a good collection system and an adequate waste management program for used inhalers seems to be the most meaningful measure to take for the environment, as this will stop inhalers and drugs from putting ecosystems at risk.

[Recommendations for Reducing the Environmental Impact of Inhalers in Portugal: Consensus Document]. / Recomendações para a Redução do Impacto Ambiental dos Inaladores em Portugal: Documento de Consenso.

This consensus document addresses the reduction of the environmental impact of inhalers in Portugal. It was prepared by the Portuguese Council for Health and the Environment and the societies representing the specialties that account for these drugs' largest volume of prescriptions, namely the Portuguese Society of Pulmonology, the Portuguese Society of Allergology and Clinical Immunology, the Portuguese Society of Pediatrics, the Portuguese Society of Internal Medicine, the Portuguese Association of General and Family Medicine and also a patient association, the Respira Association. The document acknowledges the significant impact of pressurized metered-dose inhalers on greenhouse gas emissions and highlights the need to transition to more sustainable alternatives. The carbon footprint of pressurized metered-dose inhalers and dry powder inhalers in Portugal was calculated, and the level of awareness among prescribing physicians on this topic was also estimated. Finally, recommendations were developed to accelerate the reduction of the ecological footprint of inhalers.

Este documento de consenso aborda a redução do impacto ambiental dos inaladores em Portugal. Foi elaborado pelo Conselho Português para a Saúde e Ambiente e pelas sociedades que representam as especialidades com maior volume de prescrição destes medicamentos, nomeadamente a Sociedade Portuguesa de Pneumologia, a Sociedade Portuguesa de Alergologia e Imunologia Clínica, a Sociedade Portuguesa de Pediatria, a Sociedade Portuguesa de Medicina Interna e a Associação Portuguesa de Medicina Geral e Familiar em conjunto com uma associação de doentes, a Associação Respira. Reconhece-se o impacto significativo dos inaladores pressurizados doseáveis nas emissões de gases com efeito de estufa e a necessidade de transição para alternativas mais sustentáveis. Calculou-se a pegada de carbono dos inaladores pressurizados doseáveis e dos inaladores de pó seco em Portugal e estimou-se o nível de literacia dos médicos prescritores relativamente a este tema. Finalmente, foram elaboradas recomendações com o objetivo de acelerar a redução da pegada ecológica dos inaladores.

Bronchodilator administration by pressurized inhaler during invasive mechanical ventilation in adults: A scoping review.

OBJECTIVE: To identify the administration characteristics and connection methods of bronchodilators by pressurized inhalers to the ventilatory circuit of patients under invasive mechanical ventilation. METHODS: A scope review was conducted following the PRISMA for Scoping Review, using the PubMed, Embase Elsevier, Cochrane Library, and Lilacs databases without language restrictions, up to July 2023. Eligible sources included reviews and consensuses (based on clinical studies), experimental and observational studies involving adult patients admitted to the intensive care unit and undergoing invasive mechanical ventilation, regardless of the underlying condition, who used bronchodilator drugs contained in pressurized inhalers. Information regarding inhalation technique, pressurized inhalers connection mode to the circuit, and patient care were collected by 2 researchers independently, with discrepancies resolved by a third reviewer. Studies involving bronchodilators combined with other pharmacological classes in the same device, as well as reviews containing preclinical studies, were excluded. RESULTS: In total, 23 publications were included, comprising 19 clinical trials and 4 non-randomized experimental studies. Salbutamol (albuterol) was the bronchodilator of study in the majority of the articles (n=18), and the spacer device was the most commonly used to connect the pressurized inhaler to the circuit (n=15), followed by an in-line adapter (n=3), and a direct-acting device without chamber (n=3). Concerning the pressurized inhaler placement in the circuit, 18 studies positioned it in the inspiratory limb, and 19 studies synchronized the jet actuation with the start of the inspiratory phase. Agitation of the pressurized inhaler before each actuation, waiting time between actuations, airway suction before administration, and semi-recumbent patient positioning were the most commonly described measures across the studies. CONCLUSIONS: This review provided insights into the aspects related to inhalation technique in mechanically ventilated patients, as well as the most prevalent findings and the existing gaps in knowledge regarding bronchodilator administration in this context. The evidence indicates the need for further research on this subject.

Development of a self-microemulsifying drug delivery system to deliver delamanid via a pressurized metered dose inhaler for treatment of multi-drug resistant pulmonary tuberculosis.

Tuberculosis (TB) is a serious health issue that contributes to millions of deaths throughout the world and increases the threat of serious pulmonary infections in patients with respiratory illness. Delamanid is a novel drug approved in 2014 to deal with multi-drug resistant TB (MDR-TB). Despite its high efficiency in TB treatment, delamanid poses delivery challenges due to poor water solubility leading to inadequate absorption upon oral administration. This study involves the development of novel formulation-based pressurized metered dose inhalers (pMDIs) containing self-microemulsifying mixtures of delamanid for efficient delivery to the lungs. To identify the appropriate self-microemulsifying formulations, ternary diagrams were plotted using different combinations of surfactant to co-surfactant ratios (1:1, 2:1, and 3:1). The combinations used Cremophor RH40, Poly Ethylene Glycol 400 (PEG 400), and peppermint oil, and those that showed the maximum microemulsion region and rapid and stable emulsification were selected for further characterization. The diluted self-microemulsifying mixtures underwent evaluation of dose uniformity, droplet size, zeta potential, and transmission electron microscopy. The selected formulations exhibited uniform delivery of the dose throughout the canister life, along with droplet sizes and zeta potentials that ranged from 24.74 to 88.99 nm and - 19.27 to - 10.00 mV, respectively. The aerosol performance of each self-microemulsifying drug delivery system (SMEDDS)-pMDI was assessed using the Next Generation Impactor, which indicated their capability to deliver the drug to the deeper areas of the lungs. In vitro cytotoxicity testing on A549 and NCI-H358 cells revealed no significant signs of toxicity up to a concentration of 1.56 µg/mL. The antimycobacterial activity of the formulations was evaluated against Mycobacterium bovis using flow cytometry analysis, which showed complete inhibition by day 5 with a minimum bactericidal concentration of 0.313 µg/mL. Moreover, the cellular uptake studies showed efficient delivery of the formulations inside macrophage cells, which indicated the potential for intracellular antimycobacterial activity. These findings demonstrated the potential of the Delamanid-SMEDDS-pMDI for efficient pulmonary delivery of delamanid to improve its effectiveness in the treatment of multi-drug resistant pulmonary TB.

Overcoming the Low-Stability Bottleneck in the Clinical Translation of Liposomal Pressurized Metered-Dose Inhalers: A Shell Stabilization Strategy Inspired by Biomineralization.

Currently, several types of inhalable liposomes have been developed. Among them, liposomal pressurized metered-dose inhalers (pMDIs) have gained much attention due to their cost-effectiveness, patient compliance, and accurate dosages. However, the clinical application of liposomal pMDIs has been hindered by the low stability, i.e., the tendency of the aggregation of the liposome lipid bilayer in hydrophobic propellant medium and brittleness under high mechanical forces. Biomineralization is an evolutionary mechanism that organisms use to resist harsh external environments in nature, providing mechanical support and protection effects. Inspired by such a concept, this paper proposes a shell stabilization strategy (SSS) to solve the problem of the low stability of liposomal pMDIs. Depending on the shell material used, the SSS can be classified into biomineralization (biomineralized using calcium, silicon, manganese, titanium, gadolinium, etc.) biomineralization-like (composite with protein), and layer-by-layer (LbL) assembly (multiple shells structured with diverse materials). This work evaluated the potential of this strategy by reviewing studies on the formation of shells deposited on liposomes or similar structures. It also covered useful synthesis strategies and active molecules/functional groups for modification. We aimed to put forward new insights to promote the stability of liposomal pMDIs and shed some light on the clinical translation of relevant products.

Cuidando do ambiente ­ Logística reversa e dispositivos inalatórios / Caring for the environment: reverse logistics and inhalation devices

A asma é uma das doenças crônicas mais prevalentes e representa um problema de saúde pública global que afeta mais de 300 milhões de pessoas em todo o mundo, com um aumento adicional estimado de 100 milhões até 2025. A asma é uma doença típica de origem ambiental com exposição a infeções, alérgenos, poluentes e outros fatores estressores implicados na sua patogênese. O impacto ambiental causado pelos dispositivos inalatórios é cada vez mais importante, e pouco abordado ou valorizado. Até 88% dos profissionais de saúde não têm conhecimento que os dispositivos de aerossol dosimetrado contêm gás propelente que afeta a camada de ozônio e causa aquecimento global. São necessárias estratégias alternativas de tratamento se quisermos evitar a piora das alterações climáticas. Portanto, diante desse cenário existem oportunidades de ouro para tornar o tratamento da asma mais eficaz, moderno, seguro e ecológico.

Asthma is one of the most prevalent chronic diseases and represents a global public health problem, affecting more than 300 million people worldwide, with an estimated additional increase of 100 million cases by 2025. Asthma is a textbook disease of environmental origin, with exposure to infections, allergens, pollutants, and other environmental stressors implicated in its pathogenesis. The environmental impact of inhalation devices is increasingly important and has been rarely addressed and undervalued. Up to 88% of healthcare professionals are unaware that metered-dose aerosol devices contain a propellant gas that affects the ozone layer and causes global warming. Alternative treatment strategies are needed if we are to avoid worsening climate change. Given this scenario, there are excellent opportunities to make asthma treatment more effective, modern, safe, and eco-friendly.

Promoting knowledge of metered dose inhaler (MDI) usage among pharmacy professional students through a mobile app.

INTRODUCTION: Efficient asthma management necessitates optimal usage of metered-dose inhalers (MDIs). As future health professionals, pharmacy students are pivotal in disseminating accurate methodologies for MDI usage. Despite having hands-on experience, there is room to enhance their comprehension, highlighting the need for prompt patient educational interventions. OBJECTIVE: This study aims to evaluate the effectiveness of a mobile app-assisted educational method in improving pharmacy students' understanding of MDI usage. METHODS: A pre-experimental study was conducted from March to August 2021 with 45 participants enrolled in the Pharmacist Professional Study Program at the Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta. Using a one-group pretest-post-test design, the study measured the app's impact on students' knowledge and MDI usage skills. RESULTS: The intervention significantly improved students' scores on a 9-step MDI usage checklist, with increases ranging from 0.10 to 0.50 across verbal and motor components. A Mann-Whitney U test validated these findings, showing a statistically significant p-value of 0.001. CONCLUSION: The mobile app-assisted educational approach substantially enhanced pharmacy students' proficiency in MDI use. The significant rise in mean scores for the 9-step checklist, along with the notable p-value, supports the effectiveness of this intervention in healthcare education.

Application of different counseling strategies for better adult asthma control.

OBJECTIVE: We aimed to compare the effectiveness of three distinct counseling methods to determine the most effective approach. METHODS: In this prospective cohort study with a two-month follow-up, A group of non-smoking adults, aged 19-60 years, were randomly collected at outpatients clinic with prior asthma diagnosis, based on the forced expiratory volume in one seconds to forced vital capacity ratio (FEV1/FVC) and the guidelines outlined by the Global Initiative for Asthma (GINA), At the baseline assessment, all patients, underwent FEV1/FVC measurements, asthma symptom evaluations using Asthma Control Test (ACT), Asthma Control Questionnaire (ACQ), and GINA symptoms control assessment questionnaire, and assessment of pressurized metered-dose inhaler (pMDI) usage. The patients were divided into three groups, each assigned a distinct counseling strategy: traditional verbal counseling, advanced counseling utilizing the Asthma smartphone-application, and a combination of advanced-verbal counseling. We conducted a two-month monitoring period for all three groups. RESULTS: Significant differences (p < .001) were observed among the three counseling groups in ACT, FEV1/FVC ratio, and GINA symptoms control assessment scores from the first month to the second month visit. Regarding ACQ, the study unveiled a noteworthy disparity in ACQ scores during the second week, with a significant difference (p = .025) observed between the verbal and advanced-verbal counseling groups. Similarly, a significant difference (p = .016) was noted between the advanced counseling group and the advanced-verbal counseling groups. CONCLUSION: The study findings indicate that the combining advanced-verbal counseling by incorporating the Asthma smartphone-application alongside traditional verbal counseling is a more effective approach for improving asthma control in adults.

Uso de inhaladores para la enfermedad pulmonar obstructiva crónica en un grupo de pacientes colombianos

Introducción: En Colombia son escasos los datos sobre el uso de los inhaladores en pacientes con EPOC. Objetivo: Describir la técnica de uso de inhaladores de dosis medida y polvo seco en pacientes de un hospital colombiano. Materiales y métodos: Estudio descriptivo en pacientes mayores de 40 años con EPOC atendidos en un hospital en La Virginia, Risaralda, Colombia, entre el 1 de septiembre de 2019 al 31 de enero de 2020. La unidad de análisis fueron los pacientes. Se incluyeron variables sociodemográficas, clínicas y lista de chequeo para uso de inhaladores. Se aplicaron frecuencias y proporciones para variables discretas, estadísticas de tendencia central y dispersión para variables continuas. Resultados: Se incluyeron 104 pacientes con edad media de 73,6 ± 10,1 años; 57 eran mujeres (54,8 %). Además, 48 pacientes estaban clasificados como GOLD-D (46,2 %). Igualmente, 89 pacientes manifestaron haber recibido educación sobre el uso de broncodilatadores (85,6 %). Los más frecuentes fueron los inhaladores de dosis medida (DM) en 95 casos (91,3 %), seguido de los de polvo seco unidosis (7,7 %). Así mismo, 37 pacientes que usaron DM sin inhalocámara (35,6 %) no cumplieron los pasos de la lista de chequeo. En el sistema multidosis, el más realizado fue cerrar de manera adecuada el inhalador y el menos ejecutado, expulsar el aire lentamente evitando hacerlo cerca del inhalador (n = 6; 5,7 %). Discusión: Se lograron describir las características de la técnica de uso de los inhaladores en pacientes con EPOC. A pesar de que ningún paciente logró utilizar el inhalador de forma "perfecta", la mayoría han recibido educación por parte de los profesionales de la salud. Conclusión: Un alto porcentaje de pacientes usa inadecuadamente los dispositivos para suministrar los broncodilatadores. Esto puede impactar negativamente en el control de la enfermedad.

Introduction: In Colombia, there is limited data on the use of inhalers in patients with COPD. Objective: The objective was to describe the technique of using metered-dose inhalers and dry powder in patients in a Colombian hospital. Methods: Observational, descriptive study of patients over 40 years of age with COPD, treated in a hospital in La Virginia, Risaralda, Colombia, between September 1st, 2019 and January 31st, 2020. The unit of analysis were patients in consultation. Sociodemographic and clinical variables, and a checklist for use of inhalers were included. Frequencies and proportions were applied for discrete variables, statistics of central tendency and dispersion for continuous variables. Results: A total of 104 patients with an average age of 73.6 ± 10.1 years were included; 57 were women (54.8%). In addition, 48 patients were classified as GOLD-D (46.2%). Similarly, 89 patients reported having received education on the use of bronchodilators (85.6%). The most common were metered-dose (MD) inhalers in 95 cases (91.3%), followed by single-dose dry powder inhalers in eight patients (7.7%). Likewise, 37 patients who used DM without inhalochamber (35.6%) did not comply with the steps of the checklist. In the multidose system, the most performed was to properly close the inhaler and the least performed was to expel the air slowly, avoiding doing so near the inhaler (n=6; 5.7%). Discussion: The characteristics of the technique of using inhalers in patients with COPD were described. Although no patient was able to use the inhaler "perfectly", most have received education from health professionals. Conclusion: A high percentage of patients misuse the devices to deliver bronchodilators. This can negatively impact the control of the disease.

Hiding in Plain Sight: Quantifying Salbutamol and Ipratropium Inhaler Wastage in Hospitals.

Background: Previous studies have found significant inhaler wastage in the inpatient setting, which contributes to unnecessary health care expenditures. Wastage may involve inhalers available in automated dispensing cabinets (ADCs). Objectives: To evaluate whether salbutamol and ipratropium inhalers were unnecessarily withdrawn from ADCs for hospital inpatients. Methods: This cross-sectional study included patients from 16 health care facilities in British Columbia. ADC reports were run for the period August 2021 to January 2022 to identify salbutamol and ipratropium inhalers removed from ADCs. Results: Over the study period, 8.3% (2180/26 324) of salbutamol and ipratropium inhalers were withdrawn from ADCs unnecessarily for the same patient encounter within a 2-day timeframe, and another 1118 (4.2%) represented instances when multiple inhalers were withdrawn for the same patient at the same time. Overall, 12.5% (3298/26 324) of all salbutamol and ipratropium inhalers were withdrawn unnecessarily. The total cost of these inhalers was about $31 600 over the 6-month period. Conclusions: This evaluation revealed considerable wastage of inhalers, leading to wasted expenditures. Other health authorities should conduct similar analyses to determine whether similar problems exist in their settings.

Contexte: De précédentes études ont mis au jour un gaspillage important d'inhalateurs en milieu hospitalier, ce qui contribue à des dépenses de soins de santé inutiles. Ce gaspillage peut comprendre des inhalateurs disponibles dans des cabinet de distribution automatisé (CDA). Objectif: Évaluer si les inhalateurs de salbutamol et d'ipratropium ont été inutilement retirés des CDA pour les patients hospitalisés. Méthodes: Cette étude transversale comprenait des patients provenant de 16 établissements de soins de santé en Colombie-Britannique. Des rapports portant sur les CDA ont été générés pour la période d'août 2021 à janvier 2022 afin de recenser les inhalateurs de salbutamol et d'ipratropium qui ont été retirés des CDA. Résultats: Pendant la période de l'étude, 8,3 % (2180/26 324) des inhalateurs de salbutamol et d'ipratropium ont été inutilement retirés des CDA pour la même rencontre avec le patient dans une fenêtre de 2 jours, et dans le cas de 1118 (4,2 %) inhalateurs, plusieurs inhalateurs ont été retirées en même temps pour un même patient. Dans l'ensemble, 12,5 % (3298/26 324) de tous les inhalateurs de salbutamol et d'ipratropium ont été inutilement retirés. Le coût total de ces inhalateurs s'élevait à environ 31 600 $ sur une période de 6 mois. Conclusions: Cette évaluation a révélé un gaspillage considérable d'inhalateurs, ce qui entraîne des dépenses inutiles. D'autres autorités sanitaires devraient mener des analyses similaires pour savoir si des problèmes similaires se produisent dans leurs établissements.

Metered dose inhalers in the transition to low GWP propellants: what we know and what is missing to make it happen.

INTRODUCTION: The urgency to replace the propellants currently in use with the new sustainable ones has given rise to the need for investigation and reformulation of pMDIs. AREAS COVERED: The reformulation requires in-depth knowledge of the physico-chemical characteristics of the new propellants, which impact the atomization capacity and the plume geometry. Among the investigated propellants, HFA 152a, due to its lower vapor pressure and higher surface tension compared to HFA 134a, deliver larger particles and has a higher solvent capacity toward lipophilic drugs. On the other hand, HFO 1234ze has properties more similar to HFA 134a, but showed lower reproducibility of the generated spray, indicating a possible high susceptibility to variation in the consistency of the dose delivered. In addition, the device components currently in use are compatible with the new propellants. This allowed promising preliminary results in the re-formulation of pMDIs by academia and pharma companies. However, there is little information about the clinical studies required to allow the marketing of these new products. EXPERT OPINION: Overall, studies conducted so far show that the transition is technically possible, and the main obstacle will be represented by the investment required to put the product on the market.

[Assessment of inhalation technique in patients with bronchial asthma and chronic obstructive pulmonary disease].

AIM: Investigate inhalation techniques using different inhalers types and their effect on the course of disease. MATERIALS AND METHODS: This cross-sectional study included 110 patients with asthma, chronic obstructive pulmonary disease using the inhaler at least one month. Inhaler errors performed during demonstration were evaluated for each patient and entered in the check-lists. We also collected information about co-morbidities, education, mMRC dyspnea score, rate of exacerbations, and performed spirometry. RESULTS: 80.9% of patients used metered-dose inhaler, 20.9% - single-dose and 21.8% - multiple-dose dry powder inhaler, 22.7% - soft-mist inhaler. Inhaler errors were made by 80.9% patients. The mean number of mistakes in metered-dose inhaler use was 2±1.6, single-dose powder inhaler -1.5±1.3, multiple-dose dry powder inhaler - 1.25±1.4, soft-mist inhaler - 0.68±0.7 (р=0.003). Age, diagnosis, duration of disease, education level, inhalers usage by relatives have no influence on the inhalation technique. A number of errors was related to female gender (р=0.007) and usage of more than 2 inhalers (r=0.3, p=0.002), previous instruction about inhalation technique (r=0.3, p=0.001). On the other hand, there were correlations between the number of errors and degree of bronchial obstruction, asthma control, severity of dyspnea by mMRC score, exacerbation rate. CONCLUSION: Patients with bronchoobstructive diseases perform many inhaler errors, that substantially influences the severity and course of asthma and chronic obstructive pulmonary disease.

A Novel Trans-Tracheostomal Retrograde Inhalation Technique Increases Subglottic Drug Deposition Compared to Traditional Trans-Oral Inhalation.

Subglottic stenosis represents a challenging clinical condition in otolaryngology. Although patients often experience improvement following endoscopic surgery, recurrence rates remain high. Pursuing measures to maintain surgical results and prevent recurrence is thus necessary. Steroids therapy is considered effective in preventing restenosis. Currently, however, the ability of trans-oral steroid inhalation to reach and affect the stenotic subglottic area in a tracheotomized patient is largely negligible. In the present study, we describe a novel trans-tracheostomal retrograde inhalation technique to increase corticosteroid deposition in the subglottic area. We detail our preliminary clinical outcomes in four patients treated with trans-tracheostomal corticosteroid inhalation via a metered dose inhaler (MDI) following surgery. Concurrently, we leverage computational fluid-particle dynamics (CFPD) simulations in an extra-thoracic 3D airway model to gain insight on possible advantages of such a technique over traditional trans-oral inhalation in augmenting aerosol deposition in the stenotic subglottic region. Our numerical simulations show that for an arbitrary inhaled dose (aerosols spanning 1-12 µm), the deposition (mass) fraction in the subglottis is over 30 times higher in the retrograde trans-tracheostomal technique compared to the trans-oral inhalation technique (3.63% vs. 0.11%). Importantly, while a major portion of inhaled aerosols (66.43%) in the trans-oral inhalation maneuver are transported distally past the trachea, the vast majority of aerosols (85.10%) exit through the mouth during trans-tracheostomal inhalation, thereby avoiding undesired deposition in the broader lungs. Overall, the proposed trans-tracheostomal retrograde inhalation technique increases aerosol deposition rates in the subglottis with minor lower-airway deposition compared to the trans-oral inhalation technique. This novel technique could play an important role in preventing restenosis of the subglottis.

Thinking "Green" When Treating "Pink Puffers" and "Blue Bloaters"-Reducing Carbon Footprint When Prescribing Inhalers.

The impact of man-made climate change is already affecting millions of people worldwide. The health care sector in the US is a relevant contributor, accounting for about 8 to 10% of national greenhouse gas emissions. This special communication describes the harmful impact of propellant gases in metered dose inhalers (MDI) on the climate and summarizes and discusses current knowledge and recommendations from European countries. Dry powder inhalers (DPI) are a good alternative to MDIs and are available for all inhaler drug classes recommended in current asthma and COPD guidelines. Changing an MDI to PDI can significantly reduce carbon footprints. The majority of the US population is willing to do more to protect the climate. Primary care providers can engage in this by addressing the impacts of drug therapy on climate change in medical decision making.

Impact of Asthma Inhalers on Global Climate: A Systematic Review of Their Carbon Footprint and Clinical Outcomes in Spain.

BACKGROUND: Pressurized metered-dose inhalers (pMDIs) exert an environmental impact resulting from CO2 emissions. Therapeutic alternatives with less environmental impact are widely used. Nevertheless, the choice of device and appropriate therapy should meet the clinical needs and the characteristics of the patient. OBJECTIVE: The primary objective was to estimate the impact of pMDIs prescribed for any indication on annual CO2 emissions in Spain.The secondary objective was to evaluate the potential impact of switching pMDIs to dry-powder inhalers (DPIs) in patients with asthma. METHODS: A systematic review of the evidence published during 2010-2021 was carried out. Average annual CO2 emissions of DPIs and pMDIs were calculated in 2 scenarios: the current situation and a hypothetical situation involving a switch from all pMDIs to DPIs. The impact of the switch on clinical outcomes was also evaluated. RESULTS: The total value of CO2-eq/year due to DPIs and pMDIs accounted for 0.0056% and 0.0909%, respectively, of total emissions in Spain. In the event of switching pMDIs to DPIs, except those used for rescue medication, the percentages were 0.0076% and 0.0579%. The evaluation of efficacy, handling, satisfaction, safety, and use of health care resources was not conclusive. CONCLUSIONS: Current CO2 emissions by pMDIs account for a small percentage of the total CO2 footprint in Spain. Nevertheless, there is a need for research into new and more sustainable devices. Suitability and patient clinical criteria such as age and inspiratory flow should be prioritized when prescribing an inhaler.

Impact of Asthma Inhalers on Global Climate: A Systematic Review of Their Carbon Footprint and Clinical Outcomes in Spain

Background: Pressurized metered-dose inhalers (pMDIs) exert an environmental impact resulting from CO2 emissions. Therapeutic alternatives with less environmental impact are widely used. Nevertheless, the choice of device and appropriate therapy should meet the clinical needs and the characteristics of the patient. Objective: The primary objective was to estimate the impact of pMDIs prescribed for any indication on annual CO2 emissions in Spain.The secondary objective was to evaluate the potential impact of switching pMDIs to dry-powder inhalers (DPIs) in patients with asthma. Methods: A systematic review of the evidence published during 2010-2021 was carried out. Average annual CO2 emissions of DPIs and pMDIs were calculated in 2 scenarios: the current situation and a hypothetical situation involving a switch from all pMDIs to DPIs. The impact of the switch on clinical outcomes was also evaluated. Results: The total value of CO2-eq/year due to DPIs and pMDIs accounted for 0.0056% and 0.0909%, respectively, of total emissions in Spain. In the event of switching pMDIs to DPIs, except those used for rescue medication, the percentages were 0.0076% and 0.0579%. The evaluation of efficacy, handling, satisfaction, safety, and use of health care resources was not conclusive. Conclusions: Current CO2 emissions by pMDIs account for a small percentage of the total CO2 footprint in Spain. Nevertheless, there is a need for research into new and more sustainable devices. Suitability and patient clinical criteria such as age and inspiratory flow should be prioritized when prescribing an inhaler (AU)

Estimated cost-savings from optimizing use of inhaled medications for inpatients with obstructive lung disease.

CONCLUSIONS: Models representing transitions from all-nebulized to nebulizer-plus-MDI respiratory medications resulted in cost savings, largely from the reduction of labor cost of nebulizer administration with nebs-only treatment. Therefore, transitioning from nebs to MDIs can lead to cost savings and could allow greater opportunities for inhaler education.

Inhaler technique in a pediatric emergency department: Impact of an education intervention among healthcare professionals.

BACKGROUND: Inhaler technique (IT) knowledge among healthcare providers is poor. The aim was to improve Pediatric Emergency Department (PED) healthcare providers' IT technique by carrying out an education intervention and sustain it for 6 months. METHODS: Open-label, quasi-experimental, prospective, and unicentric study. Healthcare professionals working at the PED were enrolled. The study was developed in three phases: baseline evaluation and education intervention (P1) and reevaluation 1 month (P2) and 6 months (P3) after the education intervention. Participants fulfilled an eight-question theoretical test. Practical skills were evaluated by demonstrating IT in all three phases. The education intervention consisted in a verbal explanation of IT followed by a demonstration of IT with metered-dose inhaler using a mannequin. RESULTS: A total of 84 healthcare providers (medical residents, nurses, and nursing assistants) were involved. In the theoretical questionnaire, the mean score at baseline was 4.4/8 (SD 1.7) improving to 6.3/8 (SD 1.2) in P2 and 6.47/8 (SD 1.1) in P3. In the IT evaluation for children <7 years old, the score improved from 5.7/7 (SD 1.3) to 6.5/7 in P2 and 6.7/7 in P3 (p < 0.001). For children >7 years old, the mean score of IT at baseline was 3.1/10 (SD 4), which improved to 7.4/10 (SD 3) and 8.2/10 in P2 and P3, respectively (p < 0.001). Only professional category influenced results at baseline. CONCLUSION: Healthcare providers' theoretical knowledge and practical skills on IT are low. The education intervention performed is a useful strategy to ameliorate IT among healthcare providers.