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"textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The basis of treatment for chronic obstructive pulmonary disease (COPD) is medication inhaled using pressurized metered dose inhalers (pMDI) that can be connected to a chamber, metered dose inhalers (MDI), dry powder inhalers (DPI), and soft mist inhalers (SMI)<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>. 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"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Various studies have shown that between 50% and 92% of patients do not correctly perform the inhalation technique<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4–7</span></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"><span class="elsevierStyleSup">5,7</span></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"><span class="elsevierStyleSup">6–8</span></a>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">2,5</span></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"><span class="elsevierStyleSup">2,5,6</span></a>, presenting with cognitive impairment<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>, having a low level of education<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>, or not obtaining benefits with the treatment<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">6,9</span></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"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">It has been verified that only a small proportion of patients receive education on the use of their inhalers<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. In this sense, not only is good training not enough<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6,10,11</span></a>, it is also necessary for this training to be periodically reviewed for it to be effective<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,11</span></a> given that a relationship has been observed between periodic training and adherence<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> with an improvement in quality of life<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and a reduction in the need for hospitalization by up to 80%<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>.</p><p id="par0030" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">4,9</span></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"><span class="elsevierStyleSup">5</span></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"><span class="elsevierStyleSup">3</span></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"><span class="elsevierStyleSup">13</span></a>.</p><p id="par0035" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">3</span></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"><span class="elsevierStyleSup">14</span></a>, together with the fact that they do not often have placebo mechanisms available<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0040" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">4,5</span></a>.</p><p id="par0045" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0050" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">1,10</span></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"><span class="elsevierStyleSup">9</span></a>, hospitalizations<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>, and thus mortality.</p><p id="par0055" class="elsevierStylePara elsevierViewall">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"><span class="elsevierStyleSup">13</span></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"><span class="elsevierStyleSup">15</span></a>.</p><p id="par0060" class="elsevierStylePara elsevierViewall">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.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">No funding was received for this work.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest.</p></span></span>"
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