Study: Choose Right Inhaler in COPD Patients

Allergies & Asthma

NEW ORLEANS — Nearly 60% of nursing facility residents with chronic obstructive pulmonary disease (COPD) had low peak inspiratory flow rate (PIFR, <60 L/min), and for most their treatment was substandard, a researcher reported here.

Although long-acting bronchodilators (LABD) are the best medications for patients with low PIFR, they were more likely to get short-acting bronchodilators (SABD) instead — and nearly all who did receive LABDs got them via handheld inhalers, which aren’t recommended when PIFR is low, according to Theresa Shireman, PhD, of the Center for Gerontology and Healthcare Research at Brown University in Providence, Rhode Island.

In a discussion of her group’s poster at CHEST 2019, sponsored by the American College of Chest Physicians, Shireman explained that in order to successfully use handheld inhalers, which deliver dry powder, a user needs to have a PIFR of at least 60 L/minute. Among the 135 nursing facility residents with COPD in the study, that optimal level could not be reached by most, she said.

Shireman told MedPage Today that a patient who cannot reach the 60 L/min PIFR threshold would be better off with nebulizer-based treatment.

The researchers recruited residents living in 26 nursing facilities for at least 6 months who were able to give consent to participate in the study. Hospice-eligible patients with <6 months life expectancy were excluded.

Eligible patients underwent spirometry (CareFusion Micro 1 portable spirometer) and the PIFR was calculated using an in-Check DIAL G16 device on the Diskus setting, the researchers explained.

The 80 residents with COPD and low PIFR were an average age of 81.4 versus 74.1 for the 55 nursing facility residents with COPD and an optimal PIFR (P<0.001). About 76% of the patients with a low PIFR were women. About 70% of the patients with low PIFR were white, as were about 86% of patients with an optimal PIFR. There were no differences between the groups for BMI and numbers of exacerbations in the past 6 months, but those with low PIFR had poorer lung function with a forced expiratory volume 1% predicted of 44.2 versus 55.5.

The researchers reported that residents with low PIFR were less likely to have a scheduled LABD (36.3% vs 78.2%, P<0.001), but more likely to have a scheduled SABD (52.5% vs 25.5%, P=0.001).

“SABDs were administered by nebulizer more often in residents with low PIFR compared to high PIFR (45.0% vs 21.8%, P=0.004),” they stated. “Of the 36.3% of residents with low PIFR and a scheduled LABD, the LABDs were administered by handheld inhalers to all but 1 study resident.”

“Despite evidence that long-acting bronchodilators significantly improve lung function, dyspnea, health status, and reduce exacerbation rates in individuals with COPD, over 60% of nursing facility resident with low PIFR were not receiving a schedule long-acting bronchodilator,” Shireman stressed. “The long-acting bronchodilators were mainly delivered by dry powder inhalers, which may not be the optimal delivery device for patients with low PIFR.”

“The high prevalence of low PIFR in nursing facility residents with COPD may have implications for device selection and clinical outcomes,” her group stated.

CHEST session moderator Antoine Abed, MD, of Mt. Sinai School of Medicine in New York City, commented that “physicians should be testing patients in nursing facilities for their PIFR. This is not being done regularly now.”

“I think that we should be changing how we prescribe these medications, taking these new data into consideration,” he told MedPage Today, adding that he was surprised that the researchers were able to perform the study on some nursing facility residents.

Shireman and Abed disclosed no relevant relationships with industry.


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