AT ATS 2016

SAN FRANCISCO (FRONTLINE MEDICAL NEWS) – Pulmonologists generally have a high level of knowledge about inhalational devices used in the treatment of chronic obstructive pulmonary disease (COPD), but there are areas where more education would be welcomed, according to a survey conducted by the American Thoracic Society and sponsored by Sunovion Pharmaceuticals.

More than half of respondents believed that they were at least very knowledgeable about medications used to treat COPD and the devices as a whole, Dr. Sidney S. Braman reported in a press conference and poster session at an international conference of the American Thoracic Society. But only a third knew what hand-held small-volume nebulizers were intended for or how to use them, and respondents varied in their views regarding which patients are candidates for use.

The survey assessed knowledge, attitudes, and practices regarding the management of COPD, including the use of metered-dose inhalers, dry powder inhalers, and handheld small-volume nebulizers. In all, 205 U.S. pulmonologists and pulmonology fellows participated.

Overall, 79% and 54% of respondents indicated that they were extremely or very knowledgeable about medications used to manage COPD and about the inhalational devices, respectively, lead author Dr. Braman, a professor of medicine; pulmonary, critical care, and sleep medicine at the Icahn School of Medicine at Mount Sinai in New York, reported. Additionally, 68% had this level of knowledge when it came to preventing exacerbations, and 43% and 22% did when it came to teaching patients how to use the devices and how to clean and store them, respectively. Large proportions – 72%-89%, depending on the topic – were somewhat or very interested in receiving additional education.

Only a minority of respondents reported being extremely or very knowledgeable specifically about handheld small-volume nebulizers. Just 34% knew well their intended use, 33% when to use them, 32% how to use them, 31% who should use them, and 20% how to clean and maintain them.

As expected, respondents were increasing likely to say that they typically recommended a nebulized medication as the severity of the disease increased. Some 52% recommended it early in treatment for patients with the most severe dyspnea (modified Medical Research Council scale grade 4), and 69% did so early in treatment after acute exacerbations.

Similarly, respondents were increasing likely to say that they found handheld small-volume nebulizers more effective than the inhalers as the severity of disease rose. Overall, 63% endorsed this viewpoint for patients with grade 4 disease, and 70% did so for patients who had experienced acute exacerbations.

“The results I think were somewhat expected and somewhat not expected,” commented Dr. Braman. “I think this all tells us that we really need better education. And for us at the ATS, this is so important, because what it’s saying is we need to get out there, we need to have better studies in terms of what are the appropriate uses, and then turn around and give our members and others around the world education about the small-volume nebulizer use.”

While the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guideline “gives clinicians a wonderful road map on how to approach COPD,” by explaining what medications to deliver as the disease progresses, the guideline is lacking information about the devices, particularly the small-volume nebulizer.

During an interview, press conference moderator Dr. David Mannino, professor and chair of preventive medicine & environmental health at the University of Kentucky College of Public Health in Lexington, said he was not surprised by the survey’s results.

“Years ago and certainly when I was going through training as a resident, there was this body of literature being developed showing that respiratory therapists working with patients in hospitals with the use of metered-dose inhalers and spacers got results that equaled that of the nebulizer, which I frankly never bought because although the data may have supported that, people don’t take respiratory therapists home with them. … I know my sick patients cling to their nebulized therapies very stringently.

“Ultimately, we have patients who very much would benefit by having a truly very small nebulizer that they could take with them because the problem with inhaled therapies in COPD – your metered-dose inhalers, your dry powder inhalers, and all these other devices – is that you basically get one opportunity in somewhere between about half a second and 2 seconds to get your dose of medication in,” Dr. Mannino said. “Even when you throw a spacer on, it does not pass what I would call the ‘my mom test,’” meaning that use would be difficult for an older adult with suboptimal hand-eye-breathing coordination and possibly comorbidities such as arthritis and cognitive impairment.

In contrast, nebulizers deliver medication during a full 2-3 minutes of tidal breathing. “That’s why nebulizers work better for patients, because they have more of an opportunity to get the medication,” Dr. Mannino maintained. “Once we get to the point where we actually can figure out how to get nebulized therapy in a truly easily transportable form – and I think there is some technology that is being developed – ultimately, what I’d love to see is a nebulizer that is truly the size of a little metered-dose inhaler. That will then be the game changer, I think.”

The online survey was designed by a steering committee of ATS clinicians and scientists and was conducted by Harris Poll during January 2016. Pulmonologists and fellows with an interest in COPD from the ATS membership roster who had attended recent conferences were invited to participate.

Dr. Braman disclosed that he had no relevant conflicts of interest. The study was sponsored by Sunovion Pharmaceuticals, and the survey data were provided by Harris Poll.


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