https://flore.unifi.it/bitstream/2158/1140466/1/JACI%20in%20Practice_March2017_Critikal%20study.pdf

Inhaler Errors in the CRITIKAL Study: Type, Frequency, and Association with Asthma Outcomes

Inhaled drug delivery is the cornerstone treatment for asthma and chronic obstructive pulmonary disease (COPD). However, use of inhaler devices can be challenging, potentially leading to critical errors in handling that can significantly reduce drug delivery to the lungs and effectiveness of treatment. A systematic review was conducted to define ‘critical’ errors and their impact on health outcomes and resource use between 2004 and 2016, using key search terms for inhaler errors in asthma and COPD (Search-1) and associated health-economic and patient burden (Search-2). Search-1 identified 62 manuscripts, 47 abstracts, and 5 conference proceedings (n = 114 total). Search-2 identified 9 studies. We observed 299 descriptions of critical error. Age, education status, previous inhaler instruction, comorbidities and socioeconomic status were associated with worse handling error frequency. A significant association was found between inhaler errors and poor disease outcomes (exacerbations), and greater health-economic burden. We have shown wide variations in how critical errors are defined, and the evidence shows an important association between inhaler errors and worsened health outcomes. Given the negative impact diminished disease outcomes impose on resource use, our findings highlight the importance of achieving optimal inhaler technique, and a need for a consensus on defining critical and non-critical errors.

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Critical inhaler errors in asthma and COPD: a systematic review of impact on health outcomes

The aim of this systematic review is to compare the effect on the upper airways of orthopedic treatment for skeletal Class III malocclusion with untreated controls. Nine databases were searched up to August 2020 for randomized or nonrandomized clinical trials comparing orthopedic Class III treatment (facemask or chin-cup) to untreated Class III patients. After duplicate study selection, data extraction, and risk of bias assessment (Risk Of Bias In Non-randomized Studies - of Interventions [ROBINS-I]), random-effects meta-analyses of Mean Differences (MDs)/Standardized Mean Differences (SMD) and 95% Confidence Intervals (CIs) were performed, followed by the Grading of Recommendations Assessment, Development and Evaluation assessment evidence-quality. A total of 10 papers (9 unique nonrandomized studies) with 466 patients (42.7% male; average age 9.1 years) were finally included. Limited evidence indicated that compared to normal growth, maxillary protraction with facemask was associated with increases in total airway area (n = 1; MD = 222.9 mm$^{2}$; 95% CI = 14.0-431.7 mm$^{2}$), total nasopharyngeal area (n = 4; SMD = 1.6; 95% CI = 1.2-2.0), and individual airway dimensions (upper-airway MD = 2.5 mm; lower-airway MD = 2.1 mm; upper-pharynx MD = 1.6 mm; lower-pharynx MD = 1.0 mm; all n = 6). Subgroup/meta-regression analyses did not find any significant effect-modifiers, while the results were retained 2-5 years postretention. Our confidence in these estimates was, however, very low, due to the inclusion of nonrandomized studies with methodological issues. Limited data from 2 chin-cup studies indicated smaller benefits on airway dimensions. Existing evidence from controlled clinical studies on humans indicates that maxillary protraction for skeletal Class III treatment might be associated with increased airway dimensions, which are, however, mostly minor in magnitude.

https://www.zora.uzh.ch/id/eprint/194618/1/p22_ok.pdf

Effect of Orthopedic Treatment for Class III Malocclusion on Upper Airways: A Systematic Review and Meta-Analysis

Inhaled medications are the cornerstone of treatment and management of asthma and COPD. However, inhaler device errors are common among patients and have been linked with reduced symptom control, an increased risk of exacerbations, and increased healthcare utilisation. These observations have prompted GINA (Global INitiative for Asthma) and GOLD (Global initiative for chronic Obstructive Lung Disease) to recommend regular assessment of inhaler technique in a bid to improve therapeutic outcomes. To better define the relationship between device errors and health outcomes (clinical outcomes, quality of life, and healthcare utilisation) in asthma and COPD, we conducted a systematic review of the literature, with a particular focus on the methods used to assess the relationship between device errors and outcomes. Sixteen studies were identified (12 in patients with asthma, one in patients with COPD, and three in both asthma and COPD) with varying study designs, endpoints, and patient populations. Most of the studies reported that inhalation errors were associated with worse disease outcomes in patients with asthma or COPD. Patients who had a reduction in errors over time had improved outcomes. These findings suggest that time invested by healthcare professionals is vital to improving inhalation technique in asthma and COPD patients to improve health outcomes.

https://pure.rug.nl/ws/files/67859896/s41533_018_0110_x.pdf

Systematic review of association between critical errors in inhalation and health outcomes in asthma and COPD

The final training of the master's degree on Right to Food and Rural Development, between June 18 th , 2012 and January 11 st , 2013, was held at the Foundation for Education and Development (FED), in Bissau. From it, resulted this document which describes the activities performed: (i) research and translation of teaching materials; (ii) support the development of curricula for technical courses in the agricultural domain, (iii) support training at the Training and Production Centre of Nhacra-Teda; (iv) organizing meetings on Food Security and on Associations and Cooperatives; (v) short study on the food situation in 15 communities benefiting from projects managed by FED and (vi) webpage. FED aims to support community development and has focused its activities on education, food security and health areas and operates in the sectors of Nhacra and Safim. Once Guinea-Bissau is largely affected by food insecurity, with 22% of the population undernourished, all the work done to counter these facts is of major importance. Despite the work developed by FED in the communities, we concluded that they still don’t meet the parameters which allow achieving food security.

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Relatório de Estágio Profissionalizante

Introduction: Chronic obstructive pulmonary disease and asthma affect almost 300 million individuals. Inhaled therapy is often associated with technical errors reducing efficacy and compliance. Objective: To evaluate the inhalation technique and its relation with clinical and functional control in asthma and chronic obstructive pulmonary disease. Material and Methods: Analytical cross-sectional study including patients with asthma and chronic obstructive pulmonary disease treated with any type of inhaler device. Demographic data and inquiry about previous teaching of inhalation technique were collected in all participants. Inhalation technique was evaluated in: Step 1 - device activation; Step 2 - previous expiration; Step 3 - inspiration; Step 4 - end inspiratory pause. Clinical control was assessed from the questionnaires Asthma Control Test, Control of Allergic Rhinitis and Asthma Test, modified Medical Research Council and Chronic Obstructive Pulmonary Disease Assessment Test. Spirometric evaluation was performed in all participants. Results: From a total of 62 subjects, 74.19% made at least one error, mainly during step 2 (53.2%). Previous education on inhalation technique was associated with lower number of errors (p = 0.014). There was no association between number of errors and age (p = 0.321), years of diagnosis (p = 0.119) or spirometric evaluation (p > 0.05). In asthma an association was found between number of errors and Asthma Control Test (p = 0.032) and Control of Allergic Rhinitis and Asthma Test (p = 0.008). Discussion and Conclusion: Teaching inhalation technique has a positive impact on its future performance. Most patients make mistakes, affecting clinical control in asthma, although in chronic obstructive pulmonary isease no relation was found. This is an ongoing work that aims to reevaluate inhalation technique after patients’ education and its further impact.

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Assessment of Inhalation Technique in Clinical and Functional Control of Asthma and Chronic Obstructive Pulmonary Disease.

To assess the impact that educational interventions to improve inhaler techniques have on the clinical and functional control of asthma and COPD, we evaluated 44 participants before and after such an intervention. There was a significant decrease in the number of errors, and 20 patients (46%) significantly improved their technique regarding prior exhalation and breath hold. In the asthma group, there were significant improvements in the mean FEV1, FVC, and PEF (of 6.4%, 8.6%, and 8.3% respectively). Those improvements were accompanied by improvements in Control of Allergic Rhinitis and Asthma Test scores but not in Asthma Control Test scores. In the COPD group, there were no significant variations. In asthma patients, educational interventions appear to improve inhaler technique, clinical control, and functional control. RESUMO Para avaliar o impacto do ensino da tecnica inalatoria no controle clinico e funcional de pacientes com asma ou DPOC, incluiram-se 44 participantes antes e apos essa intervencao. Houve uma diminuicao significativa no numero de erros cometidos, sendo que 20 pacientes (46%) melhoraram significativamente sua tecnica na expiracao previa e apneia final. No grupo asma, houve significativa melhora nas medias de FEV1 (6,4%), CVF (8,6%) e PFE (8,3%), e essa melhora correlacionou-se com os resultados no Control of Allergic Rhinitis and Asthma Test, mas nao com os do Asthma Control Test. No grupo DPOC, nao houve variacoes significativas. O ensino da tecnica inalatoria parece melhorar seu desempenho e os controles clinico e funcional em pacientes com asma.

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Educational interventions to improve inhaler techniques and their impact on asthma and COPD control: a pilot effectiveness-implementation trial.

Introduction: COPD and asthma affect almost 300 million individuals worldwide. Inhaled therapy is often associated with technical errors reducing efficacy and compliance. Objective: To assess the impact of teaching the inhalation technique in clinical and functional control of Asthma and COPD. Methods: Inhalation was evaluated in 4 steps: previous expiration, device activation, forced inspiration and end inspiratory pause. Clinical control was measured through Asthma Control Test (ACT), Control of Allergic Rhinitis and Asthma Test (CARAT), modified Medical Research Council and COPD Assessment Test. Pulmonary function tests were performed in all patients. After the first visit patients were educated on correct use of their devices using repeated placebo devices manipulation and visual support material. They were reevaluated 6 to 8 months later. Results: 44 participants were included. Overall there was a significant decrease in the number of performed errors (average 0.7) (p Conclusions: Inhalation technique education improves its performance, leading to an improvement in clinical and functional control in Asthma. These findings were not reproduced in the COPD group, which may reflect its physiopathological hallmark of irreversible obstruction.

Inhalation technique education and its impact in asthma and COPD

Erasmus Syndrome refers to the association between Systemic Sclerosis and exposure to silica, with or without silicosis. There are no specific clinic, radiologic or histologic findings, except the overlapping symptoms of the two diseases. Pneumoconiosis due to exposure to silica can evolve to Systemic Sclerosis. The mechanism seems to involve the inflammatory response triggered by silica exposure. Since it is potentially lethal and has no effective treatment, the primary prevention and early recognition are very important. We present the case of a patient exposed to silica who developed Systemic Sclerosis.

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Erasmus Syndrome (exposure to silica and systemic sclerosis): a case report.

Mixed connective tissue disease (MCTD) is a rare systemic rheumatic disease characterized by the expression of autoantibodies targeting the U1-ribonucleoprotein and overlapping clinical features of systemic sclerosis, systemic lupus erythematosus, and inflammatory myopathies. Interstitial lung disease (ILD) is present in 47% to 78% of patients and has been associated with higher mortality rates. Associations of ILD with Raynaud’s phenomenon, dysphagia, anti-Ro52 antibodies, and a scleroderma pattern on nailfold capillaroscopy have been reported in MCTD patients.This study aims to identify clinical and serological associations and independent predictors of ILD for patients with MCTD.Multicenter retrospective study using data collected from clinical records. Adult patients who underwent lung computed tomography (CT) and met at least one of four MCTD diagnostic criteria (Sharp, Alarcón-Segovia, Kasukawa, or Kahn criteria) were included. Univariate analysis was performed using Chi-Square, Fischer’s Exact, and Mann-Whitney tests, as appropriate. Multivariate analysis was performed using binary logistic regression modelling. The linearity of the continuous variables concerning the logit of the dependent variable was assessed via the Box-Tidwell procedure. Cases with missing information and outliers were excluded from the multivariate analysis to fulfil all assumptions necessary to assure the validity of the regression.Fifty-seven patients, of whom 37 were Caucasian (64.9%) and 48 were females (84.2%), with a mean age of 39.4±14.0 years, were included. Twenty-seven patients had ILD (47.4%), of whom 22 had nonspecific interstitial pneumonia (81.5%), 4 had usual interstitial pneumonia (14.8%), and 1 had lymphoid interstitial pneumonia (3.7%) pattern on CT. Among patients with ILD, 13 were asymptomatic (48.1%), while 14 had respiratory symptoms (51.9%), including dyspnea (N=13, 48.1%), cough (N=7, 25.9%), and pleuritic chest pain (N=1, 3.7%). Pulmonary function tests were performed in 22 patients (81.5%), 20 of whom had a restrictive pattern (90.9%).In the univariate analysis, lymphadenopathy at disease onset (22.2% vs 3.3%, p=0.045) and esophageal involvement at any time point (40.7% vs 16.7%, p=0.043), were associated with ILD.The binary logistic regression model predicting ILD included 56 patients, and the model explained 36.5% (Nagelkerke R2) of the variance in ILD and correctly classified 75% of all cases. Older age at diagnosis (OR 1.10/year, 95%CI: 1.00-1.12, p=0.046) and lymphadenopathy at disease onset (OR 19.65, 95%CI: 1.91-201.75, p=0.012) were identified as predictors of ILD in MCTD patients, irrespective of sex and esophageal involvement.Older age at diagnosis and lymphadenopathy at disease onset were independent predictors of ILD in MCTD. Therefore, these factors should be considered when evaluating MCTD patients, especially at the time of diagnosis. To the best of our knowledge, this is the largest study ever describing predictors of ILD for MCTD patients.[1]Fagundes MN, Caleiro MT, Navarro-Rodriguez T, Baldi BG, Kavakama J, Salge JM, Kairalla R, Carvalho CR. Esophageal involvement and interstitial lung disease in mixed connective tissue disease. Respir Med. 2009 Jun;103(6):854-60. doi: 10.1016/j.rmed.2008.12.018. Epub 2009 Feb 6. PMID: 19201182.[2]Gunnarsson R, Aaløkken TM, Molberg Ø, Lund MB, Mynarek GK, Lexberg AS, Time K, Dhainaut AS, Bertelsen LT, Palm O, Irgens K, Becker-Merok A, Nordeide JL, Johnsen V, Pedersen S, Prøven A, Garabet LS, Gran JT. Prevalence and severity of interstitial lung disease in mixed connective tissue disease: a nationwide, cross-sectional study. Ann Rheum Dis. 2012 Dec;71(12):1966-72. doi: 10.1136/annrheumdis-2011-201253. Epub 2012 May 1. PMID: 22550317None declared

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Alcina Saraiva

Papers

Assessment of Inhalation Technique in Clinical and Functional Control of Asthma and Chronic Obstructive Pulmonary Disease.

Educational interventions to improve inhaler techniques and their impact on asthma and COPD control: a pilot effectiveness-implementation trial.

Inhalation technique education and its impact in asthma and COPD

Erasmus Syndrome (exposure to silica and systemic sclerosis): a case report.

Pos0901 interstitial lung disease in mixed connective tissue disease: clinical and serological associations