Inhaled therapy in asthma | Medicina Clínica (English Edition)

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Cámara inh: cámara de inhalación; DPI: dry powder inhaler («inhalador de polvo»); pMDI: pressurized metered-dose inhaler («cartucho presurizado de dosis medida»). * El profesional sanitario implicará al paciente, según sus preferencias, en la elección final del dispositivo, entre los recomendados en dicho grupo. 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IV:6, IV:3 and IV:2: FXS; III 1, III: 2; III: 3: FXPOI; II:1: FXTAS; IV:4: asymptomatic premutation/full mutation mosaic." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Jesús González-Pérez, Silvia Izquierdo-Álvarez, Cristina Fuertes-Rodrigo, Lorena Monge-Galindo, José Luis Peña-Segura, Francisco Javier López-Pisón" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Jesús" "apellidos" => "González-Pérez" ] 1 => array:2 [ "nombre" => "Silvia" "apellidos" => "Izquierdo-Álvarez" ] 2 => array:2 [ "nombre" => "Cristina" "apellidos" => "Fuertes-Rodrigo" ] 3 => array:2 [ "nombre" => "Lorena" "apellidos" => "Monge-Galindo" ] 4 => array:2 [ "nombre" => "José Luis" "apellidos" => "Peña-Segura" ] 5 => array:2 [ "nombre" => "Francisco Javier" "apellidos" => "López-Pisón" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S002577531500648X" "doi" => "10.1016/j.medcli.2015.11.022" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S002577531500648X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616302625?idApp=UINPBA00004N" "url" => "/23870206/0000014600000007/v1_201607151011/S2387020616302625/v1_201607151011/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Inhaled therapy in asthma" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "316" "paginaFinal" => "323" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Vicente Plaza Moral, Jordi Giner Donaire" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Vicente" "apellidos" => "Plaza Moral" "email" => array:1 [ 0 => "vplaza@santpau.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Jordi" "apellidos" => "Giner Donaire" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomédica Sant Pau (IIB Sant Pau), Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Terapia inhalada en el asma" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2410 "Ancho" => 3145 "Tamanyo" => 699157 ] ] "descripcion" => array:1 [ "en" => "Diagnostic evaluation and treatment of adult asthma exacerbations. Source: Taken from the Spanish Guide for Asthma Management (GEMA) 4.0<a class="elsevierStyleCrossRef" href="#bib0350">11</a> and Rodrigo et al.<a class="elsevierStyleCrossRef" href="#bib0500">41</a>" ] ] ] "textoCompleto" => "IntroductionThe main drawback of inhalation as a form of administering medication is patients’ difficulty of using the devices correctly.<a class="elsevierStyleCrossRefs" href="#bib0300">1–3</a> Their inappropriate use contributes to poor control of both asthma<a class="elsevierStyleCrossRef" href="#bib0315">4</a> and COPD.<a class="elsevierStyleCrossRef" href="#bib0320">5</a> Therefore, patients should be trained in their proper use. However, many recent studies have shown that health professionals’ knowledge on the theoretical and practical aspects of inhalation therapy is insufficient.<a class="elsevierStyleCrossRefs" href="#bib0325">6,7</a> In an effort to alleviate these shortcomings, two documents were recently published which the reader of this review should consult for further information.<a class="elsevierStyleCrossRefs" href="#bib0335">8,9</a> However, and considering the application of that inhaled therapy in the treatment of asthma, which this document summarises, recently two significant clinical practice guidelines for asthma, one international (GINA, 2015)<a class="elsevierStyleCrossRef" href="#bib0345">10</a> and other national (GEMA 4.0, also published in 2015),<a class="elsevierStyleCrossRef" href="#bib0350">11</a> have updated their statements with relevant news.Concepts and theoretical foundations of aerosolsAn “aerosol” is the suspension of microscopic particles of solid or liquid material in air or other gas.<a class="elsevierStyleCrossRef" href="#bib0340">9</a> The size of the aerosol particles is measured by the mass median aerodynamic diameter (MMAD), which is the diameter at which half the particulate mass of an aerosol is larger, and the other half lower. The respirable mass of an aerosol is the amount of particles with a diameter of less than 5μm.<a class="elsevierStyleCrossRef" href="#bib0340">9</a> The smaller particles (0.5–2μm) can reach terminal bronchioles and the alveolar region, 2–5μm sized particles are deposited into small airways, those that are 5–10μm, in the large airways, and sizes greater than 10μ m, in the oropharynx.<a class="elsevierStyleCrossRef" href="#bib0340">9</a> Deposits of a medication depend on several factors,<a class="elsevierStyleCrossRefs" href="#bib0355">12–14</a> including the size of the particle. According to this, the aerosol is deposited by different mechanisms: impact or shock, sedimentation and diffusion.<a class="elsevierStyleCrossRefs" href="#bib0355">12,13</a>DevicesPressurised metered dose cartridgesThey are known by the acronym pMDI, from pressurised metered-dose inhaler. Inside these devices, the medication is dissolved or suspended in the propellant (gas vehicle) which transforms into gas when it comes into contact with atmospheric pressure (aerosol). The main advantages of these devices are their portability, the dose accuracy and low cost; and the disadvantages are that a correct inhalation is difficult to perform (especially the coordination between inspiration and pressing) and the oropharynx impact of the medication.<a class="elsevierStyleCrossRefs" href="#bib0335">8,9,15</a> Types (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the deposits and MMAD):<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Conventional pressurised metered dose cartridges. They consist of a small canister or cartridge pressurised at 5atm, of approximately 10ml, containing the medication particles in suspension by the propellant; a metering valve which releases the dose deposited in it, and a outer plastic housing, into which the cartridge is inserted and on which rests the outlet valve of the aerosol. The former chlorofluorocarbon propellants have been replaced today by hydrofluoroalkane.<a class="elsevierStyleCrossRef" href="#bib0375">16</a>Pressurised metered dose cartridges of ultrafine particles (Modulite®). This is a pMDI that contains the medication in a solution (so that it does not need to be shaken).<a class="elsevierStyleCrossRef" href="#bib0360">13</a> The valve outlet is smaller than the conventional pMDI size, which provides the aerosol with fine particles (“ultrafine”), which are deposited in the small distal airways, providing a large intrapulmonary deposit.<a class="elsevierStyleCrossRefs" href="#bib0380">17,18</a>Auto-trigger pressurised metered dose cartridges (Autohaler® and Easybreath®). Of a similar, conventional pMDI design, but which triggers automatically with the patient's inspiration. Coordinating pressing and inspiration is not necessary.<a class="elsevierStyleCrossRef" href="#bib0390">19</a>Fine mist inhaler (Respimat®). Halfway between an pMDI and portable nebuliser. The solution flows through a filter with 1000 holes (Uniblock®), which divides and redirects the aerosol to the exterior in two opposing columns, that generate a fine mist when they collide.<a class="elsevierStyleCrossRef" href="#bib0395">20</a>Inhalation chambers or spacersA device that adjusts to pMDIs; upon separating the pMDI aerosol outlet, the impact on the oropharynx by large particles is less.<a class="elsevierStyleCrossRefs" href="#bib0400">21,22</a> The main advantages are that coordination between inhalation-pressing is not necessary and that there is a reduction in local secondary effects; and among the disadvantages is its limited portability. There are a variety of chambers available, among others, with one-way, collapsible or inflatable valve.<a class="elsevierStyleCrossRef" href="#bib0340">9</a>Dry powder inhaler devicesThey are known as DPI, for dry powder inhaler. They are small, portable, and do not contain propellant gases, they are released with inspiration. The powdered medication is in the device, either agglomerate or, more often, in combination with carrier particles (usually lactose). The inspiratory pressure and flow turbulence generates the release of particles (agglomerated or combined with a carrier). Its main advantages include that coordination between inhalation and pressing is not necessary, the new multidose systems’ simple technique of inhaling (usually only 3 or 4 steps) and its portability; and among its drawbacks, that a volunteer inspiration is necessary with higher flows than pressurised metered dose cartridges.<a class="elsevierStyleCrossRefs" href="#bib0335">8,9,15</a> They can be grouped into 2 types or systems (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises their deposits and MMAD):Unidosis systems (in alphabetical order: Aerolizer®, Breezhaler®, Handihaler®, Inhalator Ingelheim®, Spinhaler®). Single dose devices. The medication is in the inside of a hard gelatin capsule that is manually entered into the reservoir device.<a class="elsevierStyleCrossRefs" href="#bib0335">8,9</a> Its main drawback is that many steps for inhalation are required, which can be a source of error when handling.Multidose systems (in alphabetical order: Accuhaler®, Aerolizer®, Easyhaler®, Ellipta®, Genuair®, Handihaler®, Nexthaler®, Spiromax®, Turbuhaler® and Twisthaler®). The medication, in powder, is located inside a reservoir which is removed by a metering system, or is preloaded in alveoli. The latest offer some technological improvements, including that: they detect whether the patient inhaled the dose (Nexthaler®), they are locked after the last administered dose (Genuair®), it is loaded by simply opening the device (Spiromax®, Nexthaler ®, Ellipta®, Twisthaler®) or by pressing a button (Easyhaler®, Genuair®), they have visual and auditory feedback after inhalation (Nexthaler® and Genuair®).<a class="elsevierStyleCrossRef" href="#bib0370">15</a> They may be preferred by some patients<a class="elsevierStyleCrossRef" href="#bib0410">23</a> (see the section “Education and training of inhalation techniques” of this review).NebulisersNebulisers generate a stream of aerosol particles from a solution in liquid phase. The aerosol is formed by atomisation of a liquid after applying certain energy (gas, electric, etc.).<a class="elsevierStyleCrossRefs" href="#bib0370">15,24</a> Its main advantage is that no collaboration by the patient is required and different medications and combinations can be administered, hence the reason they are often used in emergency medicine. Among their drawbacks is that they require prolonged treatment times and are a potential source of contamination.<a class="elsevierStyleCrossRefs" href="#bib0340">9,13</a> Types: Pneumatic or jet, the aerosol is generated when a high pressure gas is project on the solution; ultrasonics, through a piezoelectric crystal that converts electrical energy into high-frequency ultrasonic waves (above 1MHz; and fixed or vibrating mesh, where the aerosol exit is made through a mesh with holes of a predetermined thickness.<a class="elsevierStyleCrossRef" href="#bib0420">25</a>Inhaled treatment of adult asthmaMost medications use the inhalation method; both the oral (glucocorticoid administration in exacerbation situations) and subcutaneous (omalizumab in severe, uncontrolled allergic asthma, salbutamol in exacerbating and life-threatening situations) methods are currently circumscribed to very specific indications, and the intravenous method is practically relegated.Maintenance treatmentThe medications used in the treatment of asthma maintenance coalesce into 2 groups: control medication and relief (or “rescue”) medication. Control medications, which need to be administered daily for prolonged periods, include inhaled glucocorticoids (IGC) (or inhaled corticosteroids ICS) or systemic, leukotriene receptor antagonists (LTRA), long-acting β2 agonists (LABA, β “long-acting β2 adrenergic receptor agonists”), tiotropium and anti-IgE monoclonal antibodies (omalizumab). Sustained release hormones and theophylline have fallen into disuse because of their lower efficiency. Relief medications are used on demand to treat or prevent bronchoconstriction quickly, and these include the short-acting β2 agonists (SABA, β “short-acting β2-adrenergic receptor agonists”) inhaled (salbutamol or terbutaline) and short-acting inhaled anticholinergics (ipratropium bromide).<a class="elsevierStyleCrossRef" href="#bib0350">11</a>Treatment is adjusted at each visit in order to ensure continuous control of the patient. After verifying that the patient understands and avoids specific (allergens) and non-specific (smoking) trigger behaviours, and has proper adherence to treatment and the proper breathing technique for the inhalers they use, the maintenance of medication treatment is increased if their asthma is not well controlled, or, on the contrary, is decreased if it has been well controlled for at least 3 months prior to the visit.<a class="elsevierStyleCrossRef" href="#bib0425">26</a>The chosen inhaling treatments recommended in the latest edition of the Spanish Guidelines for Asthma Management (GEMA 4.0)<a class="elsevierStyleCrossRef" href="#bib0350">11</a> are distributed in the 6 steps shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, and the medications and inhalers sold in Spain (in July 2015) are summarised in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Briefly:<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Step 1. Inhaled SABA (salbutamol or terbutaline) on demand upon isolated symptoms of asthma. Inhaled SABA – administered 10–15min before exercise – are the mediations of choice to prevent exercise-induced bronchoconstriction.<a class="elsevierStyleCrossRef" href="#bib0430">27</a>Step 2. IGC (beclomethasone, budesonide, ciclesonide, fluticasone or mometasone) at low doses and administered daily. The usual dosage ranges between 200 and 400μg/day of budesonide or equivalent.<a class="elsevierStyleCrossRef" href="#bib0435">28</a><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> recommended equipotent doses of IGC are shown.<a class="elsevierStyleCrossRefs" href="#bib0345">10,11</a> The IGC are the most effective maintenance treatment for persistent asthma in controlling daily symptoms and preventing exacerbations.<a class="elsevierStyleCrossRefs" href="#bib0440">29,30</a> Adding a LABA to a IGC at this level of mild asthma does not provide a relevant benefit.<a class="elsevierStyleCrossRef" href="#bib0450">31</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Step 3. IGC at low doses (see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) together with a LABA (salmeterol or formoterol or vilanterol) inhaled,<a class="elsevierStyleCrossRefs" href="#bib0455">32,33</a> which are preferably administered in a single device. Combinations marketed in Spain (in 2015) are: fluticasone propionate with salmeterol, formoterol budesonide, beclomethasone with formoterol, fluticasone propionate with formoterol, and fluticasone furoate with vilanterol. LABAs should never be used alone. Formoterol is a rapid onset LABA which, combined with low doses of a IGC (budesonide or beclomethasone) in a single inhaler, can be used for both maintenance and relief therapy (a strategy known as MART: maintenance and rescue therapy) in patients with persistent and moderate or severe asthma (steps 3–6).<a class="elsevierStyleCrossRefs" href="#bib0465">34,35</a>Step 4. IGC at half dose (see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) together with a LABA,<a class="elsevierStyleCrossRefs" href="#bib0455">32,36</a> administered in a single inhaler. Alternatively, the combination of a half dose IGC, together with an LTRA could be considered; however, the addition of a LABA to an IGC provides better results.<a class="elsevierStyleCrossRef" href="#bib0480">37</a>Step 5. IGC at high doses (see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) together with a LABA,<a class="elsevierStyleCrossRefs" href="#bib0455">32,36</a> administered in a single inhaler. This above combination in insufficiently controlled patients who have a chronic airflow obstruction could also be combined with tiotropium.<a class="elsevierStyleCrossRefs" href="#bib0485">38,39</a>Step 6. Other specific inhaled treatments for patients that are not controlled with the medication recommended in the previous step are not recommended. In this case, different therapies would be used, such as subcutaneous omalizumab, oral theophylline, endobronchial thermoplasty and parenteral glucocorticoids.<a class="elsevierStyleCrossRefs" href="#bib0345">10,11,40</a>Treatment of exacerbationDepending on the severity of asthma exacerbations diagnosed objectively by pulmonary function tests that determine the degree of obstruction (spirometry or peak expiratory flow), exacerbations are classified as mild, moderate–severe or very severe–life-threatening and cardiorespiratory arrest imminent<a class="elsevierStyleCrossRefs" href="#bib0350">11,41</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Inhalers are the best way to administer treatment in the first 2 cases.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Mild. SABA (salbutamol or terbutaline) (see dosis in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) are the medications of first choice, preferably administered with an inhalation chamber.<a class="elsevierStyleCrossRef" href="#bib0505">42</a> Systemic glucocorticoids are added (orally, preferably) if: a reversal of bronchial obstruction is not obtained with inhaled SABA; the patient was already taking oral glucocorticoids; other treatment options have been tried without favourable clinical response; or there is a history of severe exacerbations.<a class="elsevierStyleCrossRefs" href="#bib0350">11,43</a>Moderate to severe. Salbutamol and ipratropium bromide (dose in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), which can be combined in the nebulisation itself, is associated with an increase in pulmonary function and a decrease in hospitalisations.<a class="elsevierStyleCrossRef" href="#bib0515">44</a> Systemic glucocorticoids, administered early (in the first hour) and preferably orally (doses in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), accelerate the resolution of the crisis and prevent recurrences.<a class="elsevierStyleCrossRef" href="#bib0520">45</a> Early use of high doses of IGC and only during the first 2h (dose in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) reduces hospitalisations.<a class="elsevierStyleCrossRef" href="#bib0520">45</a> Magnesium sulphate, inhaled or oral, reduces the need for hospitalisation in very serious cases that have not responded to previous treatment.<a class="elsevierStyleCrossRef" href="#bib0525">46</a> Heliox (a mixture of oxygen and helium) can be used to administer nebulised medication.<a class="elsevierStyleCrossRef" href="#bib0530">47</a>Practical aspectsPrescription of inhaler and patient preferencesVarious elements can be decisive in choosing an inhaler at the time of prescription. <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> proposes a rational approach by combining some of them, to help in the decision-making process.<a class="elsevierStyleCrossRef" href="#bib0535">48</a> However, adherence to treatment and control of asthma is highest when the choice of inhaler is made collaboratively between both the patient and the doctor.<a class="elsevierStyleCrossRef" href="#bib0540">49</a> Several studies have shown that devices with easy breathing techniques and few steps are preferred by patients.<a class="elsevierStyleCrossRefs" href="#bib0545">50–52</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Education and training of inhalation techniquesThe main drawback of inhalers is that patients must be taught how to use them,<a class="elsevierStyleCrossRefs" href="#bib0310">3,53</a> which is one of the essential elements of asthma education programmes,<a class="elsevierStyleCrossRefs" href="#bib0345">10,11</a> which must also be monitored regularly.<a class="elsevierStyleCrossRef" href="#bib0565">54</a><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> exposes a proposal<a class="elsevierStyleCrossRef" href="#bib0570">55</a> with the steps to follow at an initial visit and the monitoring sessions.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Adherence to inhalersLow adherence to inhalers is associated with worse asthma control,<a class="elsevierStyleCrossRef" href="#bib0575">56</a> so increasing treatment compliance is a key issue. This includes, firstly, establishing the level of adherence, and secondly, initiating a specific therapeutic action. Simple medical history overestimates it, so using the information provided after acquiring the medications at the pharmacy (usually in electronic databases) is recommended and/or standardised questionnaires filled out by the patient themself.<a class="elsevierStyleCrossRefs" href="#bib0345">10,11</a> A new questionnaire has recently been developed designed specifically to assess patients’ with asthma or COPD adherence to inhaler techniques; the Test of Adherence to Inhalers (TAI).<a class="elsevierStyleCrossRef" href="#bib0580">57</a> This identifies patients who have low adherence, establishes their intensity (good, intermediate or poor) and guides them in their error pattern (erratic, deliberate or unconscious). Therapeutic adhesion improves when easy guidelines are outlined: incorporate the patient's opinion on the prescribed inhaler, administer an education programme and use specific actions for non-compliance patterns, for example, motivational interviewing for “deliberate” patients<a class="elsevierStyleCrossRef" href="#bib0585">58</a> and electronic reminders or telemedicine techniques for “erratic” patients.<a class="elsevierStyleCrossRef" href="#bib0590">59</a>Conclusions<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Inhalers are the best choice for the treatment of asthma.</li><li class="elsevierStyleListItem" id="lsti0010">2.Maintenance treatment for mild persistent asthma (step 2) is IGC at low-doses; for moderate persistent asthma (steps 3 and 4) it is the combination of an IGC at low or medium doses inhaled with an LABA; and for severe persistent asthma (steps 5 and 6), it is an IGC at high doses in combination with a LABA.</li><li class="elsevierStyleListItem" id="lsti0015">3.For asthma attacks, treatment with inhaled SABA is recommended. In the more serious cases, inhaled ipratropium bromide, IGC and parenteral corticosteroids (orally, preferably) should be added.</li><li class="elsevierStyleListItem" id="lsti0020">4.Patients should be trained in inhalation techniques. Their preferences should be considered when choosing the inhaler. Adherence to inhalers must be established (by, among other actions, using the TAI questionnaire) and a specific therapeutic action should be initiated.</li></ul>Conflict of interestThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres690132" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec696174" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres690133" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec696175" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Concepts and theoretical foundations of aerosols" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Devices" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Pressurised metered dose cartridges" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Inhalation chambers or spacers" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Dry powder inhaler devices" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Nebulisers" ] ] ] 7 => array:3 [ "identificador" => "sec0040" "titulo" => "Inhaled treatment of adult asthma" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Maintenance treatment" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Treatment of exacerbation" ] ] ] 8 => array:3 [ "identificador" => "sec0055" "titulo" => "Practical aspects" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Prescription of inhaler and patient preferences" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Education and training of inhalation techniques" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Adherence to inhalers" ] ] ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Conflict of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-09-03" "fechaAceptado" => "2015-09-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec696174" "palabras" => array:2 [ 0 => "Asthma" 1 => "Aerosolised drugs" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec696175" "palabras" => array:2 [ 0 => "Asma" 1 => "Fármacos aerosolizados" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Because of its advantages, inhaled administration of aerosolised drugs is the administration route of choice for the treatment of asthma and COPD. Numerous technological advances in the devices used in inhaled therapy in recent decades have boosted the appearance of multiple inhalers and aerosolised drugs. However, this variety also requires that the prescribing physician is aware of their characteristics. The main objective of the present review is to summarise the current state of knowledge on inhalers and inhaled drugs commonly used in the treatment of asthma. The review ranges from theoretical aspects (fundamentals and available devices and drugs) to practical and relevant aspects for asthma care in the clinical setting (therapeutic strategies, education, and adherence to inhalers)." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La administración de fármacos aerosolizados mediante la vía inhalada, dadas sus ventajas, constituye la vía de administración de elección para el tratamiento del asma y de la EPOC. El desarrollo tecnológico experimentado en las últimas décadas ha propiciado la aparición de múltiples inhaladores y fármacos aerosolizables. Tal variedad obliga al facultativo que los debe prescribir a conocerlos en profundidad. La presente revisión tiene como principal objetivo resumir el estado actual del conocimiento sobre inhaladores y fármacos inhalados habitualmente empleados en el tratamiento de mantenimiento y de la exacerbación del asma. El texto aborda desde aspectos teóricos (fundamentos, dispositivos y fármacos disponibles), a otros más prácticos y de relevancia en la asistencia clínica diaria del asma (pautas terapéuticas, educación y adhesión a los inhaladores)." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Plaza Moral V, Giner Donaire J. Terapia inhalada en el asma. Med Clin (Barc). 2016;146:316–323." ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2023 "Ancho" => 3171 "Tamanyo" => 455152 ] ] "descripcion" => array:1 [ "en" => "Therapeutic steps in the maintenance treatment of adult asthma. LTRA: leukotriene receptor antagonists; IGC: inhaled glucocorticoid; LABA: long-acting β2 agonists (“long-acting β β2 adrenergic receptor agonists”). Source: Taken from Spanish Guidelines for Asthma Management (GEMA) 4.0.<a class="elsevierStyleCrossRef" href="#bib0350">11</a>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2410 "Ancho" => 3145 "Tamanyo" => 699157 ] ] "descripcion" => array:1 [ "en" => "Diagnostic evaluation and treatment of adult asthma exacerbations. Source: Taken from the Spanish Guide for Asthma Management (GEMA) 4.0<a class="elsevierStyleCrossRef" href="#bib0350">11</a> and Rodrigo et al.<a class="elsevierStyleCrossRef" href="#bib0500">41</a>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1480 "Ancho" => 2711 "Tamanyo" => 223716 ] ] "descripcion" => array:1 [ "en" => "Support for the choice of inhaler outline. Inh chamber: inhalation chamber; DPI: dry powder inhaler; pMDI: pressurised metered dose inhaler. * The health professional will involve the patient according to their preferences; the final choice of the device will be one of those recommended in this group. Source: Based in part on Broeders et al.<a class="elsevierStyleCrossRef" href="#bib0535">48</a>" ] ] 3 => array:9 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Update from the SEPAR-ALAT Consensus on Inhaled therapy.<a class="elsevierStyleCrossRef" href="#bib0340">9</a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "MMAD: mass median aerodynamic diameter; DPI: dry powder inhaler; pMDI: pressurised metered-dose inhaler.The comparison of the values shown between different devices must be taken with caution – given the different methods and medications used in its determination, and studies in humans – as they have been conducted under various clinical conditions (healthy subjects and patients with different processes and severity levels), with different inspiratory flow and ages." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Lung deposit (%)</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Oropharynx deposit (%)</th><th class="td" title="table-head " align="left" valign="top" scope="col">MMAD (μm) \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">In vivo \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">In vitro \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">In vivo \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">In vitro \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">pMDI</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Conventional pMDI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.8–34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53.9–82.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4–8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Conventional pMDI+inhalation chamber \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.2–68.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2–3.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">pMDI auto-trigger \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50–60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Modulite® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31–34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33–58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alvesco® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50–52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Respimat® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40–53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19.3–39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="6" align="left" valign="top">DPI (in alphabetical order)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Accuhaler® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12–37.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15–30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aerolizer® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13–28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.7–28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.9–7.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breezhaler® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Easyhaler® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.5–31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Genuair® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.1–34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54.7–61.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Handihaler® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18–22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.3–22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inhalator Ingelheim® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nexthaler® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.4–1.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spinhaler® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spiromax® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.92–2.53 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Turbuhaler® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.2–38 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53–71.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">57.3 69.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.7–5.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Twisthaler® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36–37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2–2.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1122974.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Deposits and mass median aerodynamic diameter of aerosols provided by inhalers." ] ] 4 => array:9 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Taken from the Spanish Guide for Asthma Management (GEMA) 4.0.<a class="elsevierStyleCrossRef" href="#bib0350">11</a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low dose (μg/day) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Average dose (μg/day) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High doses (μg/day) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beclomethasone dipropionate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">200–500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">501–1000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1001–2000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Extrafine beclomethasone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100–200 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">201–400 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">>400 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Budesonide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">200–400 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">401–800 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">801–1600 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ciclesonide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80–160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">161–320 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">321–1280 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluticasone propionate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100–250 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">251–500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">501–1000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluticasone furoate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">184 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mometasone furoate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100–200 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">201–400 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">401–800 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1122973.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Equipotent doses of inhaled glucocorticoids in alphabetical order." ] ] 5 => array:9 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Update from the SEPAR-ALAT Consensus on Inhaled therapy.<a class="elsevierStyleCrossRef" href="#bib0340">9</a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "DPI: dry powder inhaler; IGC: inhaled glucocorticoid; FMI: fine mist inhaler; LABA: long-acting β2agonists; LAMA: long-acting muscarinic antagonists; pMDI: pressurised metered-dose inhaler; SABA: short-acting β2 agonists." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">μg/no. dosis \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">SABA</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Salbutamol</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ventolin® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Salbutamol Aldo-Unión® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Salbutamol Sandoz® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ventilastin (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ventoaldo® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Terbutaline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Terbasmin® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">500/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">LABA</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Formoterol</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Foradil® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oxis® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.5/60; 9/60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Broncoral® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12/50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Broncoral® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neblik® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Formoterol Stada® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Formoterol Aldo-Unión® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Salmeterol</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serevent® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Betamican® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inaspir® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beglan® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Indacaterol</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ombrez® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">150 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oslif® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">150 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hirobriz® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">150 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Olodaterol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Striverdi® (FMI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.5/60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Inhaled glucocorticoid</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Budesonide</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pulmicort® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">400/120; 200/100; 100/100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pulmictan® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200/120; 100/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Olfex Bucal® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200/200; 50/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Budesonida Aldo-Unión® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200/100; 200/200; 50/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ribujet® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Budesonida Easyhaler® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100/200; 200/200; 400/100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Miflonide® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200; 400 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Novopulm® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">200/200; 400/100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Fluticasone</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Flixotide® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250/120; 50/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inalacor® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250/120; 50/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Trialona® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250/120; 50/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Flusonal® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250/120; 50/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Beclomethasone</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beclo-asma® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250/200; 50/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Becotide® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Becloforte® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">250/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Mometasone</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asmanex® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">400/600 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Ciclesonide</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alvesco® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80/120; 160/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Glucocorticoid+LABA</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Formoterol+budesonide</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Symbicort® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80+4.5/120; 160+4.5/120; 320+9/60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rilast® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">80+4.5/120; 160+4.5/120; 320+9/60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bufomix® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">160+4.57120; 320+9/60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duoresp® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">160+4.57120; 320+9/60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Salmeterol+fluticasone</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Seretide® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25+50/120; 25+125/120; 25+250/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Brisair® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25+50/120; 25+125/120; 25+250/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Plusvent® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25+50/120; 25+125/120; 25+250/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anasma® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25+50/120; 25+125/120; 25+250/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inaladuo® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25+50/120; 25+125/120; 25+250/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Formoterol+beclometasone</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Foster® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100+6/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Formodual® (pMDI, DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100+6/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Formoterol+fluticasone</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Flutiform® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50+5/120; 125+5/120; 250+10/1205 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Vilanterol+fluticasone furoate</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Relvar® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">92+22/30; 184+22/30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Inhaled glucocorticoid+SABA</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Salbutamol+beclomethasone</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Butosol® \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100+50/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Anticholinergics</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Ipratropio</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atrovent® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atroaldo® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20/200 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Tiotropium</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spiriva® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spiriva® (INF) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.5/60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Aclidinium bromide</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Eklira® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">322/60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bretaris® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">322/60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Glycopyrronium bromide</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Seebri® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Enurev® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tovanor® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Umeclidinium</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Incruse® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55/30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Chromones</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Nedocromil sodium</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tilad® (pMDI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2mg/112 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Inhaled glucocorticoid+SAMA</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Formoterol+ipratropium</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Berodual® HFA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50+20/120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">LABA+LAMA</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Indacaterol+glycopyrronium</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ultibro® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85/43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ulunar® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85/43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Xoterna® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85/43 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vilanterol+umeclidinium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anoro® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55/22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Formoterol+aclidinium \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duaklir Genuair® (DPI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12+340/60 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1122971.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Inhaled medications for the treatment of asthma or chronic obstructive pulmonary disease commercialised in Spain in 2015." ] ] 6 => array:9 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Horne.<a class="elsevierStyleCrossRef" href="#bib0575">56</a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Initial visit \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hold the session in person or delegate it to another health professional with specific training \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Verbally explain the inhalation technique and the reasons for each of the steps \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Practical demonstration of the technique, describing each step \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Repeat the demonstration without explanation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Repeat the demonstration again with comments \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ask the patient to demonstrate the technique \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Explain the errors made by the patient, if any \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Repeat the demonstration and ask the patient to repeat the technique \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Make an appointment with the patient for future testing of the technique \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Follow-up visit \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hold the session in person or delegate it to a health professional with specific training \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ask the patient to demonstrate the technique (without explanation) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Explain the errors made by the patient, if any \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Practical demonstration of the technique, describing each step, placing special emphasis on the errors observed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Repeat the demonstration without explanation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Repeat the demonstration again with comments \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Make an appointment with the patient for future testing of the technique \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1122972.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommended steps for patient education-instruction in the correct inhalation technique for the device, at the initial visit and the follow-up steps." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:59 [ 0 => array:3 [ "identificador" => "bib0300" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use and misuse of metered-dose inhalers by patients with chronic lung disease. 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Inhaled therapy in asthma

Terapia inhalada en el asma

Vicente Plaza Moral

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vplaza@santpau.cat

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, Jordi Giner Donaire

Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomédica Sant Pau (IIB Sant Pau), Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain

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from pressurised metered-dose inhaler&#46; Inside these devices&#44; the medication is dissolved or suspended in the propellant &#40;gas vehicle&#41; which transforms into gas when it comes into contact with atmospheric pressure &#40;aerosol&#41;&#46; The main advantages of these devices are their portability&#44; the dose accuracy and low cost&#59; and the disadvantages are that a correct inhalation is difficult to perform &#40;especially the coordination between inspiration and pressing&#41; and the oropharynx impact of the medication&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">8&#44;9&#44;15</span></a> Types &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises the deposits and MMAD&#41;&#58;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conventional pressurised metered dose cartridges&#46;</span> They consist of a small canister or cartridge pressurised at 5<span class="elsevierStyleHsp" style=""></span>atm&#44; of approximately 10<span class="elsevierStyleHsp" style=""></span>ml&#44; containing the medication particles in suspension by the propellant&#59; a metering valve which releases the dose deposited in it&#44; and a outer plastic housing&#44; into which the cartridge is inserted and on which rests the outlet valve of the aerosol&#46; The former chlorofluorocarbon propellants have been replaced today by hydrofluoroalkane&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">16</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pressurised metered dose cartridges of ultrafine particles</span> &#40;Modulite<span class="elsevierStyleSup">&#174;</span>&#41;&#46; This is a pMDI that contains the medication in a solution &#40;so that it does not need to be shaken&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">13</span></a> The valve outlet is smaller than the conventional pMDI size&#44; which provides the aerosol with fine particles &#40;&#8220;ultrafine&#8221;&#41;&#44; which are deposited in the small distal airways&#44; providing a large intrapulmonary deposit&#46;<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">17&#44;18</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Auto-trigger pressurised metered dose cartridges</span> &#40;Autohaler<span class="elsevierStyleSup">&#174;</span> and Easybreath<span class="elsevierStyleSup">&#174;</span>&#41;&#46; Of a similar&#44; conventional pMDI design&#44; but which triggers automatically with the patient&#39;s inspiration&#46; Coordinating pressing and inspiration is not necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">19</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Fine mist inhaler</span> &#40;Respimat<span class="elsevierStyleSup">&#174;</span>&#41;&#46; Halfway between an pMDI and portable nebuliser&#46; The solution flows through a filter with 1000 holes &#40;Uniblock<span class="elsevierStyleSup">&#174;</span>&#41;&#44; which divides and redirects the aerosol to the exterior in two opposing columns&#44; that generate a fine mist when they collide&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Inhalation chambers or spacers</span><p id="par0040" class="elsevierStylePara elsevierViewall">A device that adjusts to pMDIs&#59; upon separating the pMDI aerosol outlet&#44; the impact on the oropharynx by large particles is less&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">21&#44;22</span></a> The main advantages are that coordination between inhalation-pressing is not necessary and that there is a reduction in local secondary effects&#59; and among the disadvantages is its limited portability&#46; There are a variety of chambers available&#44; among others&#44; with one-way&#44; collapsible or inflatable valve&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Dry powder inhaler devices</span><p id="par0045" class="elsevierStylePara elsevierViewall">They are known as DPI&#44; for <span class="elsevierStyleItalic">dry powder inhaler&#46;</span> They are small&#44; portable&#44; and do not contain propellant gases&#44; they are released with inspiration&#46; The powdered medication is in the device&#44; either agglomerate or&#44; more often&#44; in combination with carrier particles &#40;usually lactose&#41;&#46; The inspiratory pressure and flow turbulence generates the release of particles &#40;agglomerated or combined with a carrier&#41;&#46; Its main advantages include that coordination between inhalation and pressing is not necessary&#44; the new multidose systems&#8217; simple technique of inhaling &#40;usually only 3 or 4 steps&#41; and its portability&#59; and among its drawbacks&#44; that a volunteer inspiration is necessary with higher flows than pressurised metered dose cartridges&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">8&#44;9&#44;15</span></a> They can be grouped into 2 types or systems &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarises their deposits and MMAD&#41;&#58;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Unidosis systems</span> &#40;in alphabetical order&#58; Aerolizer<span class="elsevierStyleSup">&#174;</span>&#44; Breezhaler<span class="elsevierStyleSup">&#174;</span>&#44; Handihaler<span class="elsevierStyleSup">&#174;</span>&#44; Inhalator Ingelheim<span class="elsevierStyleSup">&#174;</span>&#44; Spinhaler<span class="elsevierStyleSup">&#174;</span>&#41;&#46; Single dose devices&#46; The medication is in the inside of a hard gelatin capsule that is manually entered into the reservoir device&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">8&#44;9</span></a> Its main drawback is that many steps for inhalation are required&#44; which can be a source of error when handling&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Multidose systems</span> &#40;in alphabetical order&#58; Accuhaler<span class="elsevierStyleSup">&#174;</span>&#44; Aerolizer<span class="elsevierStyleSup">&#174;</span>&#44; Easyhaler<span class="elsevierStyleSup">&#174;</span>&#44; Ellipta<span class="elsevierStyleSup">&#174;</span>&#44; Genuair<span class="elsevierStyleSup">&#174;</span>&#44; Handihaler<span class="elsevierStyleSup">&#174;</span>&#44; Nexthaler<span class="elsevierStyleSup">&#174;</span>&#44; Spiromax<span class="elsevierStyleSup">&#174;</span>&#44; Turbuhaler<span class="elsevierStyleSup">&#174;</span> and Twisthaler<span class="elsevierStyleSup">&#174;</span>&#41;&#46; The medication&#44; in powder&#44; is located inside a reservoir which is removed by a metering system&#44; or is preloaded in alveoli&#46; The latest offer some technological improvements&#44; including that&#58; they detect whether the patient inhaled the dose &#40;Nexthaler<span class="elsevierStyleSup">&#174;</span>&#41;&#44; they are locked after the last administered dose &#40;Genuair<span class="elsevierStyleSup">&#174;</span>&#41;&#44; it is loaded by simply opening the device &#40;Spiromax<span class="elsevierStyleSup">&#174;</span>&#44; Nexthaler <span class="elsevierStyleSup">&#174;</span>&#44; Ellipta<span class="elsevierStyleSup">&#174;</span>&#44; Twisthaler<span class="elsevierStyleSup">&#174;</span>&#41; or by pressing a button &#40;Easyhaler<span class="elsevierStyleSup">&#174;</span>&#44; Genuair<span class="elsevierStyleSup">&#174;</span>&#41;&#44; they have visual and auditory feedback after inhalation &#40;Nexthaler<span class="elsevierStyleSup">&#174;</span> and Genuair<span class="elsevierStyleSup">&#174;</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">15</span></a> They may be preferred by some patients<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">23</span></a> &#40;see the section &#8220;Education and training of inhalation techniques&#8221; of this review&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Nebulisers</span><p id="par0060" class="elsevierStylePara elsevierViewall">Nebulisers generate a stream of aerosol particles from a solution in liquid phase&#46; The aerosol is formed by atomisation of a liquid after applying certain energy &#40;gas&#44; electric&#44; <span class="elsevierStyleItalic">etc&#46;</span>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">15&#44;24</span></a> Its main advantage is that no collaboration by the patient is required and different medications and combinations can be administered&#44; hence the reason they are often used in emergency medicine&#46; Among their drawbacks is that they require prolonged treatment times and are a potential source of contamination&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">9&#44;13</span></a> Types&#58; <span class="elsevierStyleItalic">Pneumatic</span> or <span class="elsevierStyleItalic">jet</span>&#44; the aerosol is generated when a high pressure gas is project on the solution&#59; <span class="elsevierStyleItalic">ultrasonics</span>&#44; through a piezoelectric crystal that converts electrical energy into high-frequency ultrasonic waves &#40;above 1<span class="elsevierStyleHsp" style=""></span>MHz&#59; and <span class="elsevierStyleItalic">fixed or vibrating mesh</span>&#44; where the aerosol exit is made through a mesh with holes of a predetermined thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">25</span></a></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Inhaled treatment of adult asthma</span><p id="par0065" class="elsevierStylePara elsevierViewall">Most medications use the inhalation method&#59; both the oral &#40;glucocorticoid administration in exacerbation situations&#41; and subcutaneous &#40;omalizumab in severe&#44; uncontrolled allergic asthma&#44; salbutamol in exacerbating and life-threatening situations&#41; methods are currently circumscribed to very specific indications&#44; and the intravenous method is practically relegated&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Maintenance treatment</span><p id="par0070" class="elsevierStylePara elsevierViewall">The medications used in the treatment of asthma maintenance coalesce into 2 groups&#58; control medication and relief &#40;or &#8220;rescue&#8221;&#41; medication&#46; Control medications&#44; which need to be administered daily for prolonged periods&#44; include inhaled glucocorticoids &#40;IGC&#41; &#40;or inhaled corticosteroids ICS&#41; or systemic&#44; leukotriene receptor antagonists &#40;LTRA&#41;&#44; long-acting <span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleInf">2</span> agonists &#40;LABA&#44; &#946; &#8220;long-acting &#946;2 adrenergic receptor agonists&#8221;&#41;&#44; tiotropium and anti-IgE monoclonal antibodies &#40;omalizumab&#41;&#46; Sustained release hormones and theophylline have fallen into disuse because of their lower efficiency&#46; Relief medications are used on demand to treat or prevent bronchoconstriction quickly&#44; and these include the short-acting <span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span> agonists &#40;SABA&#44; &#946; &#8220;short-acting &#946;2-adrenergic receptor agonists&#8221;&#41; inhaled &#40;salbutamol or terbutaline&#41; and short-acting inhaled anticholinergics &#40;ipratropium bromide&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Treatment is adjusted at each visit in order to ensure continuous control of the patient&#46; After verifying that the patient understands and avoids specific &#40;allergens&#41; and non-specific &#40;smoking&#41; trigger behaviours&#44; and has proper adherence to treatment and the proper breathing technique for the inhalers they use&#44; the maintenance of medication treatment is increased if their asthma is not well controlled&#44; or&#44; on the contrary&#44; is decreased if it has been well controlled for at least 3 months prior to the visit&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The chosen inhaling treatments recommended in the latest edition of the Spanish Guidelines for Asthma Management &#40;GEMA 4&#46;0&#41;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">11</span></a> are distributed in the 6 steps shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; and the medications and inhalers sold in Spain &#40;in July 2015&#41; are summarised in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; Briefly&#58;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Step 1&#46;</span> Inhaled SABA &#40;salbutamol or terbutaline&#41; on demand upon isolated symptoms of asthma&#46; Inhaled SABA &#8211; administered 10&#8211;15<span class="elsevierStyleHsp" style=""></span>min before exercise &#8211; are the mediations of choice to prevent exercise-induced bronchoconstriction&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">27</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Step 2&#46;</span> IGC &#40;beclomethasone&#44; budesonide&#44; ciclesonide&#44; fluticasone or mometasone&#41; at low doses and administered daily&#46; The usual dosage ranges between 200 and 400<span class="elsevierStyleHsp" style=""></span>&#956;g&#47;day of budesonide or equivalent&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">28</span></a><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> recommended equipotent doses of IGC are shown&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">10&#44;11</span></a> The IGC are the most effective maintenance treatment for persistent asthma in controlling daily symptoms and preventing exacerbations&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">29&#44;30</span></a> Adding a LABA to a IGC at this level of mild asthma does not provide a relevant benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">31</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Step 3&#46;</span> IGC at low doses &#40;see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; together with a LABA &#40;salmeterol or formoterol or vilanterol&#41; inhaled&#44;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">32&#44;33</span></a> which are preferably administered in a single device&#46; Combinations marketed in Spain &#40;in 2015&#41; are&#58; fluticasone propionate with salmeterol&#44; formoterol budesonide&#44; beclomethasone with formoterol&#44; fluticasone propionate with formoterol&#44; and fluticasone furoate with vilanterol&#46; LABAs should never be used alone&#46; Formoterol is a rapid onset LABA which&#44; combined with low doses of a IGC &#40;budesonide or beclomethasone&#41; in a single inhaler&#44; can be used for both maintenance and relief therapy &#40;a strategy known as MART&#58; maintenance and rescue therapy&#41; in patients with persistent and moderate or severe asthma &#40;steps 3&#8211;6&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0465"><span class="elsevierStyleSup">34&#44;35</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Step 4&#46;</span> IGC at half dose &#40;see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; together with a LABA&#44;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">32&#44;36</span></a> administered in a single inhaler&#46; Alternatively&#44; the combination of a half dose IGC&#44; together with an LTRA could be considered&#59; however&#44; the addition of a LABA to an IGC provides better results&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">37</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Step 5&#46;</span> IGC at high doses &#40;see <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; together with a LABA&#44;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">32&#44;36</span></a> administered in a single inhaler&#46; This above combination in insufficiently controlled patients who have a chronic airflow obstruction could also be combined with tiotropium&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">38&#44;39</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Step 6&#46;</span> Other specific inhaled treatments for patients that are not controlled with the medication recommended in the previous step are not recommended&#46; In this case&#44; different therapies would be used&#44; such as subcutaneous omalizumab&#44; oral theophylline&#44; endobronchial thermoplasty and parenteral glucocorticoids&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">10&#44;11&#44;40</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment of exacerbation</span><p id="par0115" class="elsevierStylePara elsevierViewall">Depending on the severity of asthma exacerbations diagnosed objectively by pulmonary function tests that determine the degree of obstruction &#40;spirometry or peak expiratory flow&#41;&#44; exacerbations are classified as mild&#44; moderate&#8211;severe or very severe&#8211;life-threatening and cardiorespiratory arrest imminent<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">11&#44;41</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Inhalers are the best way to administer treatment in the first 2 cases&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mild&#46;</span> SABA &#40;salbutamol or terbutaline&#41; &#40;see dosis in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; are the medications of first choice&#44; preferably administered with an inhalation chamber&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a> Systemic glucocorticoids are added &#40;orally&#44; preferably&#41; if&#58; a reversal of bronchial obstruction is not obtained with inhaled SABA&#59; the patient was already taking oral glucocorticoids&#59; other treatment options have been tried without favourable clinical response&#59; or there is a history of severe exacerbations&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">11&#44;43</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Moderate to severe&#46;</span> Salbutamol and ipratropium bromide &#40;dose in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; which can be combined in the nebulisation itself&#44; is associated with an increase in pulmonary function and a decrease in hospitalisations&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">44</span></a> Systemic glucocorticoids&#44; administered early &#40;in the first hour&#41; and preferably orally &#40;doses in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; accelerate the resolution of the crisis and prevent recurrences&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">45</span></a> Early use of high doses of IGC and only during the first 2<span class="elsevierStyleHsp" style=""></span>h &#40;dose in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; reduces hospitalisations&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">45</span></a> Magnesium sulphate&#44; inhaled or oral&#44; reduces the need for hospitalisation in very serious cases that have not responded to previous treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">46</span></a> Heliox &#40;a mixture of oxygen and helium&#41; can be used to administer nebulised medication&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Practical aspects</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Prescription of inhaler and patient preferences</span><p id="par0130" class="elsevierStylePara elsevierViewall">Various elements can be decisive in choosing an inhaler at the time of prescription&#46; <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> proposes a rational approach by combining some of them&#44; to help in the decision-making process&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">48</span></a> However&#44; adherence to treatment and control of asthma is highest when the choice of inhaler is made collaboratively between both the patient and the doctor&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">49</span></a> Several studies have shown that devices with easy breathing techniques and few steps are preferred by patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">50&#8211;52</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Education and training of inhalation techniques</span><p id="par0135" class="elsevierStylePara elsevierViewall">The main drawback of inhalers is that patients must be taught how to use them&#44;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">3&#44;53</span></a> which is one of the essential elements of asthma education programmes&#44;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">10&#44;11</span></a> which must also be monitored regularly&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">54</span></a><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> exposes a proposal<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">55</span></a> with the steps to follow at an initial visit and the monitoring sessions&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Adherence to inhalers</span><p id="par0140" class="elsevierStylePara elsevierViewall">Low adherence to inhalers is associated with worse asthma control&#44;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">56</span></a> so increasing treatment compliance is a key issue&#46; This includes&#44; firstly&#44; establishing the level of adherence&#44; and secondly&#44; initiating a specific therapeutic action&#46; Simple medical history overestimates it&#44; so using the information provided after acquiring the medications at the pharmacy &#40;usually in electronic databases&#41; is recommended and&#47;or standardised questionnaires filled out by the patient themself&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">10&#44;11</span></a> A new questionnaire has recently been developed designed specifically to assess patients&#8217; with asthma or COPD adherence to inhaler techniques&#59; the Test of Adherence to Inhalers &#40;TAI&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">57</span></a> This identifies patients who have low adherence&#44; establishes their intensity &#40;good&#44; intermediate or poor&#41; and guides them in their error pattern &#40;erratic&#44; deliberate or unconscious&#41;&#46; Therapeutic adhesion improves when easy guidelines are outlined&#58; incorporate the patient&#39;s opinion on the prescribed inhaler&#44; administer an education programme and use specific actions for non-compliance patterns&#44; for example&#44; motivational interviewing for &#8220;deliberate&#8221; patients<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">58</span></a> and electronic reminders or telemedicine techniques for &#8220;erratic&#8221; patients&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">59</span></a></p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Inhalers are the best choice for the treatment of asthma&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Maintenance treatment for mild persistent asthma &#40;step 2&#41; is IGC at low-doses&#59; for moderate persistent asthma &#40;steps 3 and 4&#41; it is the combination of an IGC at low or medium doses inhaled with an LABA&#59; and for severe persistent asthma &#40;steps 5 and 6&#41;&#44; it is an IGC at high doses in combination with a LABA&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0160" class="elsevierStylePara elsevierViewall">For asthma attacks&#44; treatment with inhaled SABA is recommended&#46; In the more serious cases&#44; inhaled ipratropium bromide&#44; IGC and parenteral corticosteroids &#40;orally&#44; preferably&#41; should be added&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Patients should be trained in inhalation techniques&#46; Their preferences should be considered when choosing the inhaler&#46; Adherence to inhalers must be established &#40;by&#44; among other actions&#44; using the TAI questionnaire&#41; and a specific therapeutic action should be initiated&#46;</p></li></ul></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Concepts and theoretical foundations of aerosols"
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Devices"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Pressurised metered dose cartridges"
            ]
            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Inhalation chambers or spacers"
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Dry powder inhaler devices"
            ]
            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Nebulisers"
            ]
          ]
        ]
        7 => array:3 [
          "identificador" => "sec0040"
          "titulo" => "Inhaled treatment of adult asthma"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Maintenance treatment"
            ]
            1 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Treatment of exacerbation"
            ]
          ]
        ]
        8 => array:3 [
          "identificador" => "sec0055"
          "titulo" => "Practical aspects"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Prescription of inhaler and patient preferences"
            ]
            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Education and training of inhalation techniques"
            ]
            2 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Adherence to inhalers"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Conclusions"
        ]
        10 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Conflict of interest"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-09-03"
    "fechaAceptado" => "2015-09-30"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec696174"
          "palabras" => array:2 [
            0 => "Asthma"
            1 => "Aerosolised drugs"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec696175"
          "palabras" => array:2 [
            0 => "Asma"
            1 => "F&#225;rmacos aerosolizados"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Because of its advantages&#44; inhaled administration of aerosolised drugs is the administration route of choice for the treatment of asthma and COPD&#46; Numerous technological advances in the devices used in inhaled therapy in recent decades have boosted the appearance of multiple inhalers and aerosolised drugs&#46; However&#44; this variety also requires that the prescribing physician is aware of their characteristics&#46; The main objective of the present review is to summarise the current state of knowledge on inhalers and inhaled drugs commonly used in the treatment of asthma&#46; The review ranges from theoretical aspects &#40;fundamentals and available devices and drugs&#41; to practical and relevant aspects for asthma care in the clinical setting &#40;therapeutic strategies&#44; education&#44; and adherence to inhalers&#41;&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La administraci&#243;n de f&#225;rmacos aerosolizados mediante la v&#237;a inhalada&#44; dadas sus ventajas&#44; constituye la v&#237;a de administraci&#243;n de elecci&#243;n para el tratamiento del asma y de la EPOC&#46; El desarrollo tecnol&#243;gico experimentado en las &#250;ltimas d&#233;cadas ha propiciado la aparici&#243;n de m&#250;ltiples inhaladores y f&#225;rmacos aerosolizables&#46; Tal variedad obliga al facultativo que los debe prescribir a conocerlos en profundidad&#46; La presente revisi&#243;n tiene como principal objetivo resumir el estado actual del conocimiento sobre inhaladores y f&#225;rmacos inhalados habitualmente empleados en el tratamiento de mantenimiento y de la exacerbaci&#243;n del asma&#46; El texto aborda desde aspectos te&#243;ricos &#40;fundamentos&#44; dispositivos y f&#225;rmacos disponibles&#41;&#44; a otros m&#225;s pr&#225;cticos y de relevancia en la asistencia cl&#237;nica diaria del asma &#40;pautas terap&#233;uticas&#44; educaci&#243;n y adhesi&#243;n a los inhaladores&#41;&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Plaza Moral V&#44; Giner Donaire J&#46; Terapia inhalada en el asma&#46; Med Clin &#40;Barc&#41;&#46; 2016&#59;146&#58;316&#8211;323&#46;</p>"
      ]
    ]
    "multimedia" => array:7 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2023
            "Ancho" => 3171
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Therapeutic steps in the maintenance treatment of adult asthma&#46; LTRA&#58; leukotriene receptor antagonists&#59; IGC&#58; inhaled glucocorticoid&#59; LABA&#58; long-acting <span class="elsevierStyleItalic">&#946;<span class="elsevierStyleInf">2</span></span> agonists &#40;&#8220;long-acting &#946; &#946;2 adrenergic receptor agonists&#8221;&#41;&#46; <span class="elsevierStyleItalic">Source</span>&#58; Taken from Spanish Guidelines for Asthma Management &#40;GEMA&#41; 4&#46;0&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">11</span></a></p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 2410
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diagnostic evaluation and treatment of adult asthma exacerbations&#46; <span class="elsevierStyleItalic">Source</span>&#58; Taken from the Spanish Guide for Asthma Management &#40;GEMA&#41; 4&#46;0<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">11</span></a> and Rodrigo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">41</span></a></p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1480
            "Ancho" => 2711
            "Tamanyo" => 223716
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Support for the choice of inhaler outline&#46; Inh chamber&#58; inhalation chamber&#59; DPI&#58; dry powder inhaler&#59; pMDI&#58; pressurised metered dose inhaler&#46; &#42; The health professional will involve the patient according to their preferences&#59; the final choice of the device will be one of those recommended in this group&#46; <span class="elsevierStyleItalic">Source</span>&#58; Based in part on Broeders et al&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">48</span></a></p>"
        ]
      ]
      3 => array:9 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Update from the SEPAR-ALAT Consensus on Inhaled therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">9</span></a>"
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">MMAD&#58; mass median aerodynamic diameter&#59; DPI&#58; dry powder inhaler&#59; pMDI&#58; pressurised metered-dose inhaler&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The comparison of the values shown between different devices must be taken with caution &#8211; given the different methods and medications used in its determination&#44; and studies in humans &#8211; as they have been conducted under various clinical conditions &#40;healthy subjects and patients with different processes and severity levels&#41;&#44; with different inspiratory flow and ages&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Lung deposit &#40;&#37;&#41;</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Oropharynx deposit &#40;&#37;&#41;</th><th class="td" title="table-head  " align="left" valign="top" scope="col">MMAD &#40;&#956;m&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">In vivo</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">In vitro</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">In vivo</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">In vitro</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">pMDI</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Conventional pMDI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;8&#8211;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#46;9&#8211;82&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;4&#8211;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Conventional pMDI<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>inhalation chamber&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;2&#8211;68&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#8211;3&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>pMDI auto-trigger&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#8211;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Modulite<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&#8211;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#8211;58&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#8211;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Alvesco<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&#8211;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Respimat<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&#8211;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19&#46;3&#8211;39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="6" align="left" valign="top"><span class="elsevierStyleItalic">DPI &#40;in alphabetical order&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Accuhaler<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#8211;37&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#8211;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aerolizer<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#8211;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;7&#8211;28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;9&#8211;7&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Breezhaler<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Easyhaler<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#46;5&#8211;31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Genuair<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;1&#8211;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&#46;7&#8211;61&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Handihaler<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&#8211;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&#46;3&#8211;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inhalator Ingelheim<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nexthaler<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;4&#8211;1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Spinhaler<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">30&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Spiromax<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;92&#8211;2&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Turbuhaler<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;2&#8211;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&#8211;71&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57&#46;3 69&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;7&#8211;5&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Twisthaler<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36&#8211;37&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#8211;2&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Deposits and mass median aerodynamic diameter of aerosols provided by inhalers&#46;</p>"
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Taken from the Spanish Guide for Asthma Management &#40;GEMA&#41; 4&#46;0&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">11</span></a>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Low dose &#40;&#956;g&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Average dose &#40;&#956;g&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">High doses &#40;&#956;g&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beclomethasone dipropionate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">200&#8211;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">501&#8211;1000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1001&#8211;2000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Extrafine beclomethasone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#8211;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">201&#8211;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#62;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Budesonide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">200&#8211;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">401&#8211;800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">801&#8211;1600&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ciclesonide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#8211;160&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">161&#8211;320&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">321&#8211;1280&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluticasone propionate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#8211;250&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">251&#8211;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">501&#8211;1000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fluticasone furoate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">184&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mometasone furoate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&#8211;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">201&#8211;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">401&#8211;800&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Equipotent doses of inhaled glucocorticoids in alphabetical order&#46;</p>"
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      5 => array:9 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "fuente" => "<span class="elsevierStyleItalic">Source</span>&#58; Update from the SEPAR-ALAT Consensus on Inhaled therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">9</span></a>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">DPI&#58; dry powder inhaler&#59; IGC&#58; inhaled glucocorticoid&#59; FMI&#58; fine mist inhaler&#59; LABA&#58; <span class="elsevierStyleItalic">long-acting &#946;</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">agonists</span>&#59; LAMA&#58; long-acting muscarinic antagonists&#59; pMDI&#58; pressurised metered-dose inhaler&#59; SABA&#58; short-acting <span class="elsevierStyleItalic">&#946;</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">2</span></span> agonists&#46;</p>"
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#956;g&#47;no&#46; dosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">SABA</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Salbutamol</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ventolin<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Salbutamol Aldo-Uni&#243;n<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Salbutamol Sandoz<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Ventilastin &#40;DPI&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ventoaldo<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Terbutaline</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Terbasmin<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">500&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">LABA</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Formoterol</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Foradil<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Oxis<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;5&#47;60&#59; 9&#47;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Broncoral<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#47;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Broncoral<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Neblik<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Formoterol Stada<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Formoterol Aldo-Uni&#243;n<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Salmeterol</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Serevent<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Betamican<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Inaspir<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Beglan<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Indacaterol</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ombrez<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Oslif<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Hirobriz<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Olodaterol</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Striverdi<span class="elsevierStyleSup">&#174;</span> &#40;FMI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;5&#47;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Inhaled glucocorticoid</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Budesonide</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Pulmicort<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">400&#47;120&#59; 200&#47;100&#59; 100&#47;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Pulmictan<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200&#47;120&#59; 100&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Olfex Bucal<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200&#47;200&#59; 50&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Budesonida Aldo-Uni&#243;n<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200&#47;100&#59; 200&#47;200&#59; 50&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ribujet<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Budesonida Easyhaler<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100&#47;200&#59; 200&#47;200&#59; 400&#47;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Miflonide<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200&#59; 400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Novopulm<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">200&#47;200&#59; 400&#47;100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Fluticasone</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Flixotide<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250&#47;120&#59; 50&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Inalacor<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250&#47;120&#59; 50&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Trialona<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250&#47;120&#59; 50&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Flusonal<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250&#47;120&#59; 50&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Beclomethasone</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Beclo-asma<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250&#47;200&#59; 50&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Becotide<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Becloforte<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">250&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Mometasone</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Asmanex<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">400&#47;600&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Ciclesonide</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Alvesco<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80&#47;120&#59; 160&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Glucocorticoid</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">LABA</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Formoterol</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">budesonide</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Symbicort<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#46;5&#47;120&#59; 160<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#46;5&#47;120&#59; 320<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>9&#47;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Rilast<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">80<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#46;5&#47;120&#59; 160<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#46;5&#47;120&#59; 320<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>9&#47;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Bufomix<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">160<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#46;57120&#59; 320<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>9&#47;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Duoresp<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">160<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#46;57120&#59; 320<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>9&#47;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Salmeterol</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">fluticasone</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Seretide<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>50&#47;120&#59; 25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>125&#47;120&#59; 25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>250&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Brisair<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>50&#47;120&#59; 25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>125&#47;120&#59; 25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>250&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Plusvent<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>50&#47;120&#59; 25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>125&#47;120&#59; 25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>250&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Anasma<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>50&#47;120&#59; 25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>125&#47;120&#59; 25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>250&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Inaladuo<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>50&#47;120&#59; 25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>125&#47;120&#59; 25<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>250&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Formoterol</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">beclometasone</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Foster<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>6&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Formodual<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#44; DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>6&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Formoterol</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">fluticasone</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Flutiform<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>5&#47;120&#59; 125<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>5&#47;120&#59; 250<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>10&#47;1205&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Vilanterol</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">fluticasone furoate</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Relvar<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">92<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>22&#47;30&#59; 184<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>22&#47;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Inhaled glucocorticoid</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">SABA</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Salbutamol</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">beclomethasone</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Butosol<span class="elsevierStyleSup">&#174;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">100<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>50&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Anticholinergics</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Ipratropio</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Atrovent<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Atroaldo<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#47;200&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Tiotropium</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Spiriva<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Spiriva<span class="elsevierStyleSup">&#174;</span> &#40;INF&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;5&#47;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Aclidinium bromide</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Eklira<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">322&#47;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Bretaris<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">322&#47;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Glycopyrronium bromide</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Seebri<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Enurev<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Tovanor<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">44&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Umeclidinium</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Incruse<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#47;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Chromones</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Nedocromil sodium</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Tilad<span class="elsevierStyleSup">&#174;</span> &#40;pMDI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2<span class="elsevierStyleHsp" style=""></span>mg&#47;112&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Inhaled glucocorticoid</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">SAMA</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Formoterol</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ipratropium</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Berodual<span class="elsevierStyleSup">&#174;</span> HFA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#43;20&#47;120&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">LABA</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">LAMA</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Indacaterol</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">glycopyrronium</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ultibro<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&#47;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Ulunar<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&#47;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Xoterna<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&#47;43&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Vilanterol</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">umeclidinium</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Anoro<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">55&#47;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Formoterol</span><span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">aclidinium</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Duaklir Genuair<span class="elsevierStyleSup">&#174;</span> &#40;DPI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>340&#47;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Inhaled medications for the treatment of asthma or chronic obstructive pulmonary disease commercialised in Spain in 2015&#46;</p>"
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