Chronic obstructive pulmonary disease (COPD) is associated with a high symptom burden, and repeated hospitalizations are the result. A common problem is the misuse of inhalers ( MI) and the associated poor disease control. The role MIs play in hospital discharge was investigated by a group of researchers from Bern.
MI may be due to poor inhalation technique or inadequate peak inspiratory flow ( PIF). In their prospective monocentric observational study, Dr. Philipp Suter, Department of Pneumology at Inselspital Bern and Department of Internal Medicine at HFR Cantonal Hospital Fribourg, and colleagues documented the proportion of MI at discharge from Internal Medicine at HFR Fribourg [1].
From a COPD patient group (n=80) hospitalized between April and June 2022, we examined all applied inhalers at hospital discharge. This assessment included
- the control of the inhalation technique by direct observation using a checklist,
- a measurement of the PIF using the In-Check Dial® and
- instruction to correct the inhalation technique.
Critical errors (CE) were defined as a handling or omission that potentially impairs delivery or transport of the agent to the distal airway. MI was present when an inhaler was associated with a CE or inadequate PIF.
Of the 80 patients studied, 46 were included. Patients used an average of 2.13 inhalers at discharge. Of the 98 inhalers evaluated, 60 were used incorrectly, 56 with at least one CE, and 16 with an inadequate PIF (Fig. 1). Training to correct inhaler technique reduced the number of inhalers used with a CE by 48% (95% CI 0.37-0.59, p<0.001). Nevertheless, 9 inhalers continued to be used with a critical defect after instruction. Combining persistent CE and inadequate PIF, 22 inhalers remained misused, the authors explain.
Misused inhalers are common at hospital discharge, and a significant number of MIs persist despite instruction, she concluded. A multimodal intervention combining inhaler technique assessment with PIF measurement, selection of an appropriate inhaler device, and therapeutic education was likely necessary to reduce the number of MIs at discharge, he said.
Physical activity in COPD
Physical activity (PA) slows disease progression and is strongly recommended for the management of COPD. On the other hand, however, exertion-induced dyspnea is a major symptom of COPD, leading affected patients to often avoid physical exertion. In their monocentric observational study, researchers led by PD Dr. Maximilian Bösch from the Cantonal Hospital St. Gallen [2] investigated the quantification of PA levels in COPD patients in a real-world setting and the association with self-reported disease activity.
For this, they included 42 patients with COPD GOLD B or higher. Over a one-year period, subjects were monitored using a commercially available activity tracker (Garmin Vivofit® 3) and an associated web client to which the study investigators had access. Patients provided weekly electronic COPD assessment test (CAT) results and came for semiannual study visits, during which supplemental measurements such as pulmonary function tests and blood analysis were performed.
After evaluation of the activity tracking, large differences with regard to the individual PA developmental trajectories became apparent. Analysis of the association between PA and CAT score revealed a significant inverse correlation (Fig. 2A), suggesting that PA may positively influence COPD progression. PA-based stratification of the study cohort supported this finding by showing a significant difference in CAT score development in patients with high PA compared with patients with low PA (Fig. 2B) .
Thus, the association of PA with an important self-reported marker of disease activity and quality of life was demonstrated under real-world conditions, the authors conclude. Their data formed the basis for future intervention studies to quantify effect sizes and establish training recommendations.
Allergy with negative influence on AECOPD
A group led by Dr. Meropi Karakioulaki from the Department of Pneumology at the University Hospital Basel investigated the differences in total IgE (tIgE) and specific IgE (sIgE) between COPD, asthma and control patients and further associated atopy and allergy with acute exacerbations of COPD (AECOPD) [3].
tIgE and sIgE have already been associated with asthma, but their role in COPD has only been considered in a few studies. The researchers included 73 COPD patients, 19 asthma patients, and 27 controls in their study. The confirmatory cohort consisted of 342 well-characterized COPD patients. Serum samples were collected and the concentration of tIgE and 300 individual sIgEs were determined using the ALEX2 Allergy Explorer. Patients were classified as atopic if tIgE was ≥100 kUA/l; they were considered allergic if their skin prick test was positive.
In the derivation cohort, there was a statistically significant difference between the three diagnostic groups with respect to aero- and non-aeroallergens, with asthma patients having the highest sIgE levels (p=0.005). The asthmatics differed significantly from COPD patients with respect to sIgE concentrations of seafood, yeast, grains, and pollen. In the confirmatory cohort, allergic COPD patients had a higher number of AECOPD per year (p=0.043). COPD patients positive for at least one aeroallergen on skin prick test had a higher risk of AECOPD than negative patients (43.40% vs. 28.77%, p=0.035). However, sIgE levels were higher in patients without AECOPD than in those who had experienced AECOPD in the previous year There was a positive association between time to onset of AECOPD during the study and tIgE level (p=0.020).
Asthma patients were more likely to be atopic than COPD patients. In COPD, allergy appears to have a negative impact on the occurrence of AECOPD, whereas tIgE does not appear to be associated with an increased risk of AECOPD, the authors concluded.
Congress: SGP Annual Meeting 2023
Sources:
- Suter P, Grobety T, Grandmaison G: Misused Inhalers by COPD Patients at Hospital Discharge – A Monocentric Observational Swiss Cohort Study. SSC/SSCS – SSP/SSTS Joint Annual Meeting 2023; P032.
- Boesch M, Rassouli F, Baty F, Brutsche M: Tracking Physical Activity in COPD: Results from a Prospective, Observational, Cohort Study. SSC/SSCS – SSP/SSTS Joint Annual Meeting 2023; P027.
- Karakioulaki M, Berkemeier CM, Grize L, et al: Allergy, Atopy to 300 Allergens, and the Exacerbation Risk in COPD. SSC/SSCS – SSP/SSTS Joint Annual Meeting 2023; P028.
InFo PNEUMOLOGY & ALLERGOLOGY 2023; 5(3): 36-37 (published 8/15/2013, ahead of print).
