Inhaler technique performance in elderly patients with asthma and COPD

Chronic Obstructive Pulmonary Disease (COPD) and Asthma affect up to 400 million people worldwide, and almost half of these patients have poor disease control. The elderly are more vulnerable to exacerbations, and that is due to the presence of comorbidities and frequent inhaler misuse. Educational programmes may reduce exacerbation risk, but its real impact on clinical outcomes is still unknown, as well as the main factors associated with individual risk. This thesis aims to evaluate the impact of inhaler technique performance on major outcomes in elderly patients and to identify their principal potential predictors. Several methods were performed: A systematic review with meta-analysis focusing on interventional studies with inhaler education and clinical outcomes was carried out; through its results, a cost-effectiveness analysis was performed, estimating potential cost-savings and available budget for educational interventions; In addition, a cross-sectional study was performed, aiming to identify major predictors of inhaler performance and clinical risk. Several variables were collected as predictors, as well as the main clinical outcomes; finally, we designed a protocol for a randomised, single-blinded clinical trial, aiming to test the impact of a teach-to-goal placebo device education programme on clinical outcomes, in a one-year follow-up, versus "usual care". The systematic review with meta-analysis collected data from eight interventional studies and a significant reduction in exacerbation risk of 29% (95% CI=14-41) was observed in the clinical trials. From the cost-effectiveness perspective, the affordable budget for educational interventions was estimated to be up to 1800 euros per patient per year, and the estimated average savings is 311.88 euros per patient per year, which may represent up to 131 million euros for the whole National Health Service. The cross-sectional study was performed with 130 elderly patients, with a mean age of 74.4 (± 6.4) years. The prevalence of errors in the inhaler technique was 71.6% (95% CI: 64-78.5) and that of critical errors was 31.1% (95% CI: 24-38.8). Major predictors of inhaler performance were: cognitive performance, adherence index, male gender, having previous education with placebo device performed by a physician, the existence of allergies or comorbidities with respiratory impact, active smoking and depression. The main predictors of symptoms control were: having previous teaching of inhaler technique delivered by a physician, smoking load, anti-influenza vaccination, depression, respiratory comorbidities, and educational level. Lung function was associated with smoking load, as well as presence of errors in drug activation and absence of end pause. Our results suggest that interventions with inhaler technique education can significantly reduce the risk of exacerbations in elderly patients with Asthma or COPD, and are cost-effective. Moreover, it is possible to identify patients who are at greater risk of misusing their devices, and also have an increased risk of poor outcomes. However, causal studies with longitudinal designs and well-designed clinical trials should be carried out to clarify the major predictors for individual risk, as well as the real impact of inhaler performance education programmes.A Doença Pulmonar Obstrutiva Crônica (DPOC) e a Asma afetam até 400 milhões de pessoas em todo o mundo, e cerca de metade dos doentes têm a doença mal controlada. Os idosos são mais vulneráveis a exacerbações, e isso deve-se à presença de comorbilidades e frequentes erros no uso dos inaladores. Os programas educacionais podem reduzir o risco de exacerbação, mas o seu real impacto nos resultados clínicos ainda é desconhecido, assim como os principais fatores associados ao risco individual dos doentes. Esta tese tem como objetivo avaliar o impacto da performance da técnica inalatória nos principais parâmetros clínicos em doentes idosos e identificar seus principais preditores. Vários métodos foram usados: Realizou-se uma revisão sistemática com meta-análise sobre estudos intervencionais com ensino da técnica inalatória nos parâmetros clínicos. Através dos seus resultados, foi realizada uma análise de custo-efetividade, estimando potenciais poupanças de custos e de orçamentação disponível para intervenções educativas. Além disso, foi realizado um estudo transversal, com o objetivo de identificar os principais preditores da performance da técnica inalatória e do risco clínico. Diversas variáveis foram recolhidas como preditores, assim como os principais parâmetros clínicos. Finalmente, desenhou-se um protocolo para um ensaio clínico aleatorizado, de ocultação simples, com o objetivo de testar o impacto de um programa de ensino por treino com dispositivos placebo nos parâmetros clínicos, ao longo de um ano, comparando com “ambiente real” (usual care). Na revisão sistemática com metanálise recolheram-se dados de oito estudos intervencionais, e nos ensaios clínicos observou-se uma redução significativa no risco de exacerbações de 29% (IC95% = 14-41). Na perspetiva da relação custo-efectividade, o orçamento disponível para intervenções educacionais foi estimado em 1800 euros por doente por ano, e a poupança média estimada é de 311,88 euros por doente por ano, o que pode representar 131 milhões de euros para todo o Serviço Nacional de Saúde. O estudo transversal foi realizado com 130 idosos, com média de 74,4 (± 6.4) anos. A prevalência de erros na técnica inalatória foi de 71,6% (IC95%: 64-78,5) e de erros críticos foi de 31,1% (IC95%: 24-38,8). Os principais preditores de desempenho do inalador foram: desempenho cognitivo, índice de adesão, sexo masculino, ensino prévio com dispositivo placebo realizada por um médico, a existência de alergias ou comorbilidades com impacto respiratório, tabagismo ativo e depressão. Os principais preditores do controle dos sintomas foram: receber ensino prévio de técnica inalatória de um médico, carga tabágica, vacinação antigripal, depressão, comorbilidades respiratórias e escolaridade. A função pulmonar foi associada à carga tabágica, assim como à presença de erros na ativação do fármaco e à ausência de apneia final. Estes resultados sugerem que as intervenções com ensino da técnica inalatória podem reduzir significativamente o risco de exacerbações em doentes idosos com Asma ou DPOC e são custo-efetivas. Além disso, é possível identificar pacientes com maior risco para o uso indevido dos dispositivos, bem como para um maior risco de desfechos clínicos adversos. No entanto, devem ser realizados mais estudos longitudinais de causalidade e ensaios clínicos bem desenhados, de modo a esclarecer os principais preditores do risco individual, bem como o real impacto de programas de ensino sobre técnica inalatória

Inhaler technique education in elderly patients with asthma or COPD: impact on disease exacerbations-a protocol for a single-blinded randomised controlled trial

Chronic Obstructive Pulmonary Disease (COPD)and asthma affect more than 10% of the population. Most patients use their inhaler incorrectly, mainly the elderly, thereby becoming more susceptible to poor clinical control and exacerbations. Placebo device training is regarded as one of the best teaching methods, but there is scarce evidence to support it as the most effective one to improve major clinical outcomes. Our objective is to perform a single-blinded RCT to assess the impact of this education tool in these patients. Introduction Chronic Obstructive Pulmonary Disease (COPD)and asthma affect more than 10% of the population. Most patients use their inhaler incorrectly, mainly the elderly, thereby becoming more susceptible to poor clinical control and exacerbations. Placebo device training is regarded as one of the best teaching methods, but there is scarce evidence to support it as the most effective one to improve major clinical outcomes. Our objective is to perform a single-blinded RCT to assess the impact of this education tool in these patients. Methods and analysis A multicentre single-blinded Randomised Controlled Trial (RCT) will be set up, comparing an inhaler education programme with a teach-to-goal placebo-device training versus usual care, with a 1-year follow-up, in patients above 65 years of age with asthma or COPD. Intervention will be provided at baseline, and after 3 and 6 months, with interim analysis at an intermediate time point. Exacerbation rates were set as primary outcomes, and quality of life, adherence rates, clinical control and respiratory function were chosen as secondary outcomes. A sample size of 146 participants (73 in each arm) was estimated as adequate to detect a 50% reduction in event rates. Two-sample proportions χ² test will be used to study primary outcome and subgroup analysis will be carried out according to major baseline characteristicsFaculty of Health Sciences at the University of Beira Interior and Life and Health Sciences Research Institute (ICVS)/3B’s at University of Minho in Portugal. This work was prepared with scientific support from Harvard Medical School, in accordance with the Portuguese Clinical Scholarship Research Training Program

COVID-19 or threat of a nuclear war in Europe? A cross-sectional study of anxiety levels in adults living in Portugal

BackgroundSince 2019, Europe has experienced ongoing stressors with the emergence of the COVID-19 pandemic and the Russian–Ukrainian War, which have had social, financial, physical, and psychological impacts. Studies suggest that anxiety, fear, post-traumatic stress disorder, depression, and other psychological disorders are common in such situations, and there is a need for more research on the impact of the war on mental health in Portugal. The main goal of the present study was to assess the impact of the fear of COVID-19 and anxiety related to nuclear war on the general anxiety levels of adult individuals living in Portugal.MethodsA cross-sectional study was conducted from May to July 2022 using an online questionnaire built on the Google Forms platform. Portuguese-speaking male and female individuals aged 18 years or older, who provided informed consent and agreed to participate, were included. The outcome variable was defined using the Portuguese version of the GAD-7 scale, while the main predictors were the FCV-19S and the NWA Scale in Portuguese. Linear and logistic regression models were used to test associations between predictors and outcome variable.ResultsThe study included 1,182 participants, with a mean age of 46.5 (±11.7) years, mostly women (80.6%). The global mean GAD-7 score was 5.8 (±4.5) points, and 17.9% of the participants scored above the 10-point cutoff. Higher scores were found in both the FCV-19S and the NWA scale among participants with anxiety, as measured by both a 10-point cutoff (p < 0.001), and GAD-7 scale mean scores (p < 0.001). The study showed that fear of COVID-19 [OR of 1.133 (95%CI: 1.097–1.170)] and, at a lesser extent, nuclear war anxiety [OR of 1.020 (95%CI, 1.009–1.031)] contribute to anxiety in the general population. This is also true for those with a personal history of anxiety, revealed by multiple regression.DiscussionThis study contributes to the research on COVID-19’s impact on anxiety and provides the first comprehensive assessment of nuclear war anxiety in Portugal. Results highlight the need for long-term care for anxiety, as prevalence is expected to increase due to the pandemic and war, even in non-conflict areas like Portugal

A meta-analysis on the structure of pulmonary rehabilitation maintenance programmes on COPD patients' functional capacity.

Pulmonary rehabilitation (PR) improves functional capacity, health-related quality of life (HRQoL) in COPD patients, and maintenance programmes are relevant in preserving those improvements. However, little is known about the structure of maintenance programmes after PR. We performed a systematic review and meta-analysis of experimental and quasi-experimental studies evaluating individuals with COPD admitted to a maintenance PR programme, delivered after an initial PR programme. We reported functional capacity evaluation (6-minute-walking-test), HRQoL, dyspnoea and symptom control. Searches were performed on the 11th April 2021 using MEDLINE, Embase, EBSCO, CINAHL, Web of Science and Cochrane Library. We extracted summary-level data from trial publications and used a random-effects model, predicting that severe heterogeneity was detected. The protocol was registered in PROSPERO (CRD42021247724). Fifteen studies were included in the meta-analysis, with 1151 participants. Maintenance programmes were associated with a pooled mean increase of 27.08 meters in 6mWT (CI: 10.39 to 43.77; I2 = 93%; p 12 month) home-based programmes; and having a potential MD of -4.20 pts in SGRQ (CI: -4.49 to -3.91; I2 = 0%; p = 0.74). Regarding dyspnoea and exacerbations, we found a nonsignificant trend for improvement after maintenance PR programmes. Severe COPD patients showed smaller improvements in programmes up to a year. Overall, the strength of the underlying evidence was moderate. Despite limitations of risk of bias and heterogeneity, our results support that home-based, supervised, long-term maintenance PR programmes may significantly improve functional capacity in COPD patients and HRQoL

Determining factors associated with inhaled therapy adherence on asthma and COPD: A systematic review and meta-analysis of the global literature

Background Adherence to therapy has been reported worldwide as a major problem, and that is particularly relevant on inhaled therapy for Asthma and Chronic Obstructive Pulmonary Disease (COPD), considering its barriers and features. We reviewed the global literature reporting the main determinants for adherence on these patients. Methods Searches were made using the Cochrane Library, MEDLINE, EMBASE and ISI Web of Science databases. Analytical, observational and epidemiological studies (cohort, case-control and cross-sectional studies) were included, reporting association between any type of determinant and the adherence for inhaler therapy on Asthma or COPD. Random-effects meta-analysis were used to summarise the numerical effect estimates. Results 47 studies were included, including a total of 54.765 participants. In meta-analyses, the significant determinants of adherence to inhaled therapy were: older age [RR = 1.07 (1.03–1.10); I2 = 94; p < 0.0001] good disease knowledge/literacy [RR = 1.37 (1.28–1.47); I2 = 14; p = 0.33]; obesity [RR = 1.30 (1.12–1.50); I2 = 0; p = 0.37]; good cognitive performance [RR = 1.28 (1.17–1.40); I2 = 0; p = 0.62]; higher income [RR = 1.63 (1.05–2.56); I2 = 0; p = 0.52]; being employed [RR = 0.87 (0.83–0.90); I2 = 0; p = 0.76] and using multiple drugs/inhalers [RR = 0.81 (0.79–0.84); I2 = 0; p = 0.80]. Overall, the strength of the underlying evidence was only low to moderate. Conclusions Many determinants may be associated to patient's adherence, and personalised interventions should be taken in clinical practice to address it by gaining an understanding of their individual features.info:eu-repo/semantics/publishedVersio

COVID-19 or threat of a nuclear war in Europe? A cross-sectional study of anxiety levels in adults living in Portugal

Background: Since 2019, Europe has experienced ongoing stressors with the emergence of the COVID-19 pandemic and the Russian–Ukrainian War, which have had social, financial, physical, and psychological impacts. Studies suggest that anxiety, fear, post-traumatic stress disorder, depression, and other psychological disorders are common in such situations, and there is a need for more research on the impact of the war on mental health in Portugal. The main goal of the present study was to assess the impact of the fear of COVID-19 and anxiety related to nuclear war on the general anxiety levels of adult individuals living in Portugal. Methods: A cross-sectional study was conducted from May to July 2022 using an online questionnaire built on the Google Forms platform. Portuguese-speaking male and female individuals aged 18 years or older, who provided informed consent and agreed to participate, were included. The outcome variable was defined using the Portuguese version of the GAD-7 scale, while the main predictors were the FCV-19S and the NWA Scale in Portuguese. Linear and logistic regression models were used to test associations between predictors and outcome variable. Results: The study included 1,182 participants, with a mean age of 46.5 (±11.7) years, mostly women (80.6%). The global mean GAD-7 score was 5.8 (±4.5) points, and 17.9% of the participants scored above the 10-point cutoff. Higher scores were found in both the FCV-19S and the NWA scale among participants with anxiety, as measured by both a 10-point cutoff (p < 0.001), and GAD-7 scale mean scores (p < 0.001). The study showed that fear of COVID-19 [OR of 1.133 (95%CI: 1.097–1.170)] and, at a lesser extent, nuclear war anxiety [OR of 1.020 (95%CI, 1.009–1.031)] contribute to anxiety in the general population. This is also true for those with a personal history of anxiety, revealed by multiple regression. Discussion: This study contributes to the research on COVID-19’s impact on anxiety and provides the first comprehensive assessment of nuclear war anxiety in Portugal. Results highlight the need for long-term care for anxiety, as prevalence is expected to increase due to the pandemic and war, even in non-conflict areas like Portugal.info:eu-repo/semantics/publishedVersio

Factors associated with poor asthma symptom control in adult Angolan regularly seen at an outpatient respiratory clinic

Background: Asthma is one of the most common chronic respiratory diseases and one of the most frequent causes of hospital care. Objectives: To describe the clinical characteristics of asthma and factors associated with its control. Methods: A cross-sectional study was conducted at the Military Hospital in Luanda, from April 2018 to March 2019. Data collection was performed using questionnaires on asthma symptoms and treatment, socio-demographic and environmental questions, and a Global Initiative for Asthma (GINA) questionnaire to assess the level of asthma control. Ordinal logistic regression analyses were performed. We estimated odds ratios, for higher categories of asthma control. P<0.05 was considered significant. Results: The sample consisted of 305 asthmatics ≥18-years-old, 56% women, with a mean age of 41.3 years. About 28% of patients had controlled asthma, 36% partially controlled and 35% uncontrolled. Poor asthma control was associated with frequent use of short-acting beta-2 agonists [OR 5.70 (95%CI 2.37;13.7)], oral corticosteroids [OR 3.68 (95%CI 2.24;6.04)], and incorrect inhaler technique [OR 4.08 (95%CI 1.25;13.3)]. Conclusions: A significant number of adults living in Luanda have uncontrolled asthma due to the under-use of inhaled corticosteroid therapy. It is necessary to develop strategic management and prevention plans to improve Angolan asthmatics' medical care.info:eu-repo/semantics/publishedVersio

Managing asthma in primary healthcare

Asthma brings considerable challenges for family doctors because of its variety of shapes, different levels of severity, a wide age range, and the fact that in the last decades clinicians are able to offer much better treatment options with a better level of disease control and a higher quality of life. The objectives of the current review article are to provide an up-to-date review by primary care respiratory leaders from different countries of the most significant challenges regarding asthma diagnosis and management, the importance of team work and the problems in recognizing and dealing with difficult-to-manage and severe asthma in primary care. The article provides a short review of the main challenges faced by family physicians and other primary health care professionals in supporting their patients in the management of asthma, such as asthma diagnosis, promoting access to spirometry, the importance of a multiprofessional team for the management of asthma, how to organize an asthma review, the promotion of patient autonomy and shared decision-making, improving the use of inhalers, the importance of the personalized asthma action plan, dealing with difficult-to-manage and severe asthma in primary care and choosing when, where and how to refer patients with severe asthma. The article also discusses the development of an integrated approach to asthma care in the community and the promotion of Asthma Right Care

The Elderly’s Thoughts and Attitudes about Polypharmacy and Deprescribing: A Qualitative Pilot Study in Portugal

The high prevalence of polypharmacy and potentially inappropriate medications in the elderly makes them a vulnerable group to adverse drug events. Deprescribing is the medication review plus cessation of potentially inappropriate medications with a health professional’s help. Several barriers and enablers influence it, and its knowledge can help health professionals. The objective of the study is to understand the Portuguese elderly’s attitudes and ideas about polypharmacy and deprescription. We made a qualitative approach through a focus group with elderly patients from an adult daycare center with transcription and codification into themes and subthemes based on previous frameworks. Eleven elderly patients participated in the focus group. The identified elderly’s ideas and attitudes could be clustered into five main barriers: appropriateness, process, influences, fear, and habit, and five main enablers: appropriateness, process, influences, dislike, and cost. Although the elderly’s strong beliefs regarding medication benefits and necessity prevail, contrary opinions regarding lack of benefit/necessity, drug interaction/side effects, and medication complexity/number may influence their willingness to deprescribe positively. The health professional’s influence and the patient’s trust in their doctors were perceived essential for decision-making as either a barrier or an enabler. The medication benefit was a big barrier, and side effects/drug interaction experiences are an important enabler.info:eu-repo/semantics/publishedVersio

The link between happiness and health: a review of concepts, pathways and strategies for enhancing well-being

Background. Recent years have seen a signifcant body of research independently associatng the presence of happiness and well-being with a lower risk of mortality and with an improved physical and mental health status, which presents a relevant impact on public health. Nonetheless, there are stll gaps in literature, and the underlying mechanisms are stll unclear. Objectves. this paper reviews literature regarding the main concepts and measurements associated with well-being, discussing pathways that link happiness to health and compiling strategies to improve it. Material and methods. A narratve literature review was performed gathering the most relevant artcles concerning concepts, defnitons and measurements associated with well-being, as well as regarding pathways and mechanisms that link happiness to health. The concepts and defnitons associated with happiness and well-being are discussed, and common constructs related to the later are then considered. Additonally, the available methods to measure happiness and well-being, and their limitatons, are analysed. Results. The main pathways that link mental to physical well-being include: 1) neurobiological processes, 2) the indirect impact on health behaviours, 3) the promoton of protectve psychosocial resources and 4) stress buffering effects. Conclusions. Happiness and well-being play a major role on human’s health, and many features and dimensions may be involved in this relatonship. Public health measures should focus on upstream determinants of health and well-being, but more research is needed in order to fll in some gaps, such as the variety of available instruments to address, evaluate and promote efcient interventon.info:eu-repo/semantics/publishedVersio