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Commentary: Interventional Studies of Inhalation Technique in Patients With Chronic Obstructive Pulmonary Disease Have Methodological Drawbacks, But Are Nonetheless Necessary
Comentario: Los estudios de intervención sobre técnicas de inhalación en EPOC tienen dificultades metodológicas, pero son necesarios
E. Calvo Corbellaa
a Centro de Salud Universitario Pozuelo I, Pozuelo de Alarcón, Unidad Docente de Medicina de Familia y Comunitaria, Area VI, Madrid, Spain, Member of the Grupo de Respiratorio semFYC.
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    "textoCompleto" => "<p class="elsevierStylePara">The article by Leal Hern&#225;ndez et al is of interest for several reasons&#46; Firstly&#44; few studies are available on inhalation technique in patients with chronic obstructive pulmonary disease &#40;COPD&#41; seen in primary care centers&#46; Noteworthy among these studies is that by Benito et al in 1997&#46; These authors found that at three health centers in Burgos&#44; 52&#37; of the patients in a group of participants who had asthma or COPD used inhalers incorrectly&#46;<span class="elsevierStyleSup">1</span> Secondly&#44; and more importantly&#44; this was the first interventional study in the primary care setting in Spain to examine inhalation technique in patients with COPD&#46;</p><p class="elsevierStylePara">The question the researchers posed to study the issue is attractive&#58; should written or verbal information be chosen for interventions intended to teach inhalation technique&#63; However&#44; the authors faced a number of obstacles that kept them from reaching conclusions with practical applications&#46;</p><p class="elsevierStylePara">Studies of inhalation technique are not easy to carry out&#46; Most such studies are limited to describing compliance with previously agreed criteria&#46; In Spain&#44; the recommendations of the Spanish Society of Respiratory Diseases &#40;SEPAR&#41;<span class="elsevierStyleSup">2</span> are usually followed&#46; The problem here is that these criteria have not been validated&#46; The SEPAR guidelines claim that each step in the instructions for inhalation technique is supported by published studies&#44; but no references are given in the guidelines themselves&#46; In fact&#44; it is fundamental to know whether the particles of the drug are appropriately dispersed in the gas vehicle&#44; impact as little as possible on the pharynx&#44; are delivered to the lungs at a suitable rate&#44; and are diffused correctly&#46; The fraction of the dose exhaled should be likewise contact the pharynx as little as possible&#46; The gold standard for studies of pulmonary diffusion continues to be scintigraphy with isotope-labeled drugs&#46;</p><p class="elsevierStylePara">Because such studies are impractical&#44; systems that make it possible to monitor the steps in the inhalation process more easily have become common&#46; Two studies are worth mentioning in this connection&#46; De Blaquiere et al&#44; in 1989&#44; reported the use of a monitored system that determined inspiration&#44; inhaler activation and duration of breath-holding&#46;<span class="elsevierStyleSup">3</span> Cimas et al validated a checklist for inhalation technique for pressurized canister inhalers and dry powder inhalers &#40;&#34;turbohalers&#34;&#41;&#44; using 2 electronic monitoring systems as their gold standard&#46; This latter study is of greater interest&#44; as it describes the only instrument validated for use in Spanish&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">This was not the case in the study by Leal Hern&#225;ndez et al&#44; who used a nonvalidated test for which no information is given in the Material and Methods section regarding validity &#40;sensitivity and specificity&#41; or intraobserver reliability&#46; &#40;It would have been advisable to include a second observer to determine interobserver reliability&#46;&#41; These shortcomings raise questions about the applicability of the method these authors used&#46;</p><p class="elsevierStylePara">Unfortunately&#44; this was not the only problem with the study&#46; Although of less concern &#40;because it does not affect the results&#41;&#44; it should be pointed out that the study population might not have consisted exclusively of patients with COPD&#46; Why&#63; Because no reversibility test was done to distinguish between patients with asthma and those with COPD among patients with spirometric findings indicative of obstruction&#46; In the authors&#39; defense&#44; it should be said that it can be difficult to distinguish between these two entities&#46; This is why many studies make no distinction between the two kinds of patient&#44; and include both under the heading of chronic obstructive lung disease&#46; In any case&#44; I believe that selecting men between 60 and 75 years of age may have helped keep the number of patients with asthma low&#44; although patients who had never been smokers but who had findings of obstruction should perhaps be analyzed separately&#46;</p><p class="elsevierStylePara">Finally&#44; the greatest drawback of the study needs to be considered&#46; The authors state in the Discussion section that there were no differences between using written information &#40;which is cheaper&#41; and verbal information &#40;which takes more time&#41;&#46; However&#44; it is hard to avoid the suspicion of a type II &#40;beta&#41; error&#59; consequently&#44; the only thing that can be said is that no differences between the two interventions could be established&#46; This&#44; however&#44; does not rule out that such differences may in fact exist&#46; Because the authors did not indicate the power of the study design in the Materials and Methods section&#44; we cannot share their conclusions&#46; What is clearly worth taking into account&#44; however&#44; is the authors&#39; conclusion that verbal and written information are both superior to the control condition &#40;no intervention&#41;&#46; Nevertheless&#44; it is difficult to answer the question raised in the Introduction&#58; is information supplied verbally as effective as information supplied in writing&#63;</p><p class="elsevierStylePara">To conclude&#44; it is important to understand the role of teaching inhalation technique to patients with COPD in the context of educational measures for patients with a chronic disease&#46; Although education for patients with asthma has been shown effective &#40;improved quality of life and pulmonary function&#44; and lower costs&#41;&#44;<span class="elsevierStyleSup">5</span> this has not been the case for COPD&#46; Respiratory rehabilitation seems to improve quality of life and exercise tolerance&#44; and written instructions about managing exacerbations may decrease the use of rescue medication &#40;beta 2 agonists&#41;&#44; facilitating early treatment of exacerbations with antibiotics and oral corticosteroids&#46;<span class="elsevierStyleSup">6</span> In this regard&#44; teaching inhalation technique should be seen as one more element in educational programs&#44; along with counseling to quit smoking&#44; incentives to exercise&#44; and advice about nutrition and eating habits&#46; However&#44; teaching inhalation technique does not always improve compliance&#44; and in patients with COPD&#44; the lack of variation in symptoms &#40;compared to asthma&#41; along with the lack of perceived improvement&#44; appear to lead to low levels of compliance&#46; However&#44; avoiding the overuse or underuse of inhalation treatment is useful&#44; a factor not considered in the aims of the study by Leal Hern&#225;ndez et al&#46; In contrast to asthma&#44; the aim for patients with COPD is for the patient to enjoy an acceptable degree of health while avoiding the appearance of iatrogenic illnesses&#44; given that the course of the disease cannot be changed &#40;unless the patient stops smoking or uses oxygen therapy&#44; if indicated&#41;&#46; Naturally&#44; the skillful performance of inhalation technique is of relevance for these patients&#46;</p><p class="elsevierStylePara">Ultimately&#44; the questions we must ask are these&#58; what is the minimum amount of education that will be effective&#44; and how can compliance be improved&#63; Another important issue is of course how to obtain the greatest benefit from the time invested in teaching our patients how to use inhalers&#46;</p><p class="elsevierStylePara">The efforts of Leal Hern&#225;ndez et al should be appreciated in an area where further research is needed along the lines of the study these authors have published&#46; It is hoped that their efforts will lead to further interventional studies in primary care in the field of respiratory disease&#46;</p><p class="elsevierStylePara">Key Points</p><p class="elsevierStylePara">&#42; Interventional studies on the use of inhalation techniques should use validated evaluation systems&#46; Scintigraphy remains the gold standard&#46;</p><p class="elsevierStylePara">&#42; A method based on electronic monitoring has been validated in Spanish and is available to test performance of inhalation techniques&#46;</p><p class="elsevierStylePara">&#42; The study this editorial comments on does not prove that there are differences between written and verbal instructions&#44; nor does it prove that no difference exists&#46;</p><p class="elsevierStylePara">&#42; Teaching inhalation technique is part of patient education for persons with chronic obstructive pulmonary disease&#46;</p><p class="elsevierStylePara">&#42; Correct inhalation technique does not ensure compliance with therapy&#46; Other factors are the perceived response to bronchodilation treatment and the patient&#39;s attitudes regarding the need for bronchodilators&#46;</p><p class="elsevierStylePara"> &#42; Studies designed to evaluate educational interventions for patients with COPD are needed&#46;</p>"
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Article information
ISSN: 02126567
Original language: English
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos