Instruction on inhalation technique: What are we doing with our COPD patients?

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This could cause vacuolization of muscle fibers, degeneration of organelles, and an increase in susceptibility to mechanical stress.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> B) The use of statins decreases the serum concentration of the coenzyme Q10, a molecule that forms part of important physiological processes such as the production of energy in muscle fibers or the decrease of oxidative stress.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> C) The decrease in squalene synthesis in turn reduces cholesterol synthesis and its concentration in the cellular membranes of myocytes, making them susceptible to lysis.<a class="elsevierStyleCrossRef" href="#bib0170">34</a> D) Statins favor the increase of atrogin-1 synthesis, a molecule which has been linked to an increase in protein catabolism in muscle fibers in situations of muscle mass loss. Its possible role as an effector in statin-associated muscle toxicity is still not fully described.<a class="elsevierStyleCrossRef" href="#bib0175">35</a> E) Statins alter the physiological homeostasis of calcium, increasing its intracellular concentration in muscle fibers by means of the activation of ryanodine receptors.<a class="elsevierStyleCrossRef" href="#bib0160">32</a>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "A. Muñoz-Blanco, R. Gómez-Huelgas, J.F. Gómez-Cerezo" "autores" => array:3 [ 0 => array:2 [ "nombre" => "A." "apellidos" => "Muñoz-Blanco" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Gómez-Huelgas" ] 2 => array:2 [ "nombre" => "J.F." 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All types of inhalers have a similar efficacy when tested under strict clinical conditions. However, in real life, each inhaler has characteristics with advantages and disadvantages, affecting clinical outcomes, patient satisfaction, and treatment adherence<a class="elsevierStyleCrossRef" href="#bib0015">3</a>.Various studies have shown that between 50% and 92% of patients do not correctly perform the inhalation technique<a class="elsevierStyleCrossRefs" href="#bib0010">2,4–7</a>. This is a significant problem because it entails a decrease in the therapeutic effect, worse symptoms control, and thus, ineffective disease control<a class="elsevierStyleCrossRefs" href="#bib0025">5,7</a>. In addition, it is related to an increase in the number of hospitalizations, emergency department visits, and use of antibiotics and glucocorticoids which cause an increase in the cost associated with the disease, adverse effects, and a decrease in treatment alternatives<a class="elsevierStyleCrossRefs" href="#bib0030">6–8</a>.When analyzing the published literature on inhalation technique errors among COPD patients, the majority of authors related said errors to the characteristics of the prescribed device: complexity in its use, number of steps for its proper use, and use of multiple devices<a class="elsevierStyleCrossRefs" href="#bib0010">2,5</a>. Therefore, in habitual clinical practice, when a patient’s disease does not improve with the prescribed treatment, the option his or her physician tends to propose is changing the device used. However, there are studies that demonstrate that these errors are not due to the device prescribed, but rather are due to the patient’s characteristics: not having received instructions on the technique for using it or having received them a long time ago<a class="elsevierStyleCrossRefs" href="#bib0010">2,5,6</a>, presenting with cognitive impairment<a class="elsevierStyleCrossRef" href="#bib0020">4</a>, having a low level of education<a class="elsevierStyleCrossRef" href="#bib0010">2</a>, or not obtaining benefits with the treatment<a class="elsevierStyleCrossRef" href="#bib0030">6</a>.If we continue to propose changing the device as a solution in consultations and not verifying what errors the patient is making and why he or she is making them, we are never going to achieve optimal disease control. Correctly training patients is fundamental<a class="elsevierStyleCrossRefs" href="#bib0030">6,9</a> and in order to become skilled in the use of this medication, you must properly teach and train patients as well as healthcare professionals, as this has been demonstrated to be the most effective measure<a class="elsevierStyleCrossRef" href="#bib0030">6</a>.It has been verified that only a small proportion of patients receive education on the use of their inhalers<a class="elsevierStyleCrossRef" href="#bib0020">4</a>. In this sense, not only is good training not enough<a class="elsevierStyleCrossRefs" href="#bib0005">1,6,10,11</a>, it is also necessary for this training to be periodically reviewed for it to be effective<a class="elsevierStyleCrossRefs" href="#bib0005">1,11</a> given that a relationship has been observed between periodic training and adherence<a class="elsevierStyleCrossRef" href="#bib0055">11</a> with an improvement in quality of life<a class="elsevierStyleCrossRef" href="#bib0055">11</a> and a reduction in the need for hospitalization by up to 80%<a class="elsevierStyleCrossRef" href="#bib0060">12</a>.The literature describes various forms of training: providing a brochure; a verbal explanation; a verbal explanation with a demonstration with the device; and, since several years ago, new strategies based on new technology: interactive computer programs, audiovisual media, etc<a class="elsevierStyleCrossRefs" href="#bib0020">4,9</a>. In this regard, it has been demonstrated that verbal or written information alone is less effective than training with a monitor who demonstrates the technique in addition to providing a verbal explanation<a class="elsevierStyleCrossRef" href="#bib0025">5</a>. Verbal instruction only temporarily improves the technique, given that patients quickly revert back to using a deficient inhalation technique. The assumption that the patient or caregiver will be able to correctly perform the technique by reading the device instructions does not appear to be justified<a class="elsevierStyleCrossRef" href="#bib0015">3</a>. Only regular training has been demonstrated to be an efficient strategy for reducing errors in inhalation technique when it is done both individually and in small groups<a class="elsevierStyleCrossRef" href="#bib0065">13</a>.The ideal setting for conducting this intervention is a consultation, given that it has the advantage of allowing for periodically evaluating the patient and easier access to the patient<a class="elsevierStyleCrossRef" href="#bib0015">3</a>. So, what are we doing with our patients? If we analyze this aspect, physicians report that providing training is complicated due to a highly overloaded healthcare system, little time available, and perhaps due to insufficient specific training<a class="elsevierStyleCrossRef" href="#bib0070">14</a>, together with the fact that they do not often have placebo mechanisms available<a class="elsevierStyleCrossRef" href="#bib0015">3</a>.Perhaps many physicians do not know that the educational intervention to improve inhalation technique in patients with COPD is quick, easy, and able to be done without much effort: one training session lasting less than 15 min is enough to teach it and training to improve it can be conducted in just 2.5 min<a class="elsevierStyleCrossRefs" href="#bib0020">4,5</a>.In addition, the instructors could be different healthcare professionals (physician, nurse, community pharmacist, etc.), given that there are no statistically significant differences when comparing the probability of performing the technique poorly after training with any one of them<a class="elsevierStyleCrossRef" href="#bib0030">6</a>.Currently, all COPD clinical practice guidelines pay special attention to adequately educating and instructing on the use of inhalers; it is an essential part of non-pharmacological treatment<a class="elsevierStyleCrossRefs" href="#bib0005">1,10</a> and another example of the importance of periodic instruction. In addition, some studies have observed the impact of improvement in inhalation technique on disease prognosis with a reduction in flare-ups<a class="elsevierStyleCrossRef" href="#bib0045">9</a>, hospitalizations<a class="elsevierStyleCrossRef" href="#bib0040">8</a>, and thus mortality.For all of the above, it is important to note that healthcare professionals are responsible for educating our patients, which makes it obligatory for us to be familiarized on the particularities of inhaled treatment and inhalation devices. However, various studies show that physicians and nurses who prescribe or supervise this type of treatment have poor knowledge and skills in handling the devices themselves<a class="elsevierStyleCrossRef" href="#bib0065">13</a>. Therefore, various authors insist on the need for training professionals on the handling of inhalation devices, highlighting the need to include this training within university studies as well as in specialization during residency<a class="elsevierStyleCrossRef" href="#bib0075">15</a>.For all of the above, we must make these findings known to all healthcare professionals so that they may reflect on their routine clinical practice and insist on the importance of periodic reviewing inhalation technique in their clinical practice.FundingNo funding was received for this work.Conflicts of interestThe authors declare that they do not have any conflicts of interest." 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Rev Clín Esp. 2022. https://doi.org/10.1016/j.rce.2022.03.012" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global strategy for the diagnosis, management and prevention of COPD, global initiative for chronic obstructive lung disease (GOLD)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Global Initiative for Chronic Obstructive Disease" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "WWW" => array:2 [ "link" => "http://www.goldcopd.org" "fecha" => "2020" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Device errors in asthma and COPD: systematic literature review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. 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