Kaplan Alan, van Boven Job F M
Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
Primary Care Respiratory Research, Observational and Pragmatic Research Institute, Singapore, Singapore.
Pulm Ther. 2020 Dec;6(2):381-392. doi: 10.1007/s41030-020-00133-6. Epub 2020 Oct 13.
The choice of an inhaler device is often as important as the medication put in it to achieve optimal outcomes for our patients with asthma and/or COPD. With a multitude of drug-device combinations available, optimization of respiratory treatment could well be established by switching devices rather than changing or even augmenting pharmacological or non-pharmacological therapies. Importantly, while notable between-device differences in release mechanism, particle size, drug deposition and required inspiratory flow exist, a patient uncomfortable with their device is unlikely to use it regularly and certainly will not use it properly. Switching requires a careful process and should not be done without patient consent. Switching devices entails several steps that need to be considered, which can be guided using the UR-RADAR mnemonic. It starts with (i) UncontRolled asthma/COPD (or UnaffoRdable device), followed by RADAR: (ii) review the patient's condition (e.g. diagnosis, phenotype, co-morbidities) and address reasons for suboptimal control (e.g. triggers, smoking, non-adherence, poor inhaler technique) to be ruled out before switching; (iii) assess patient's skills related to inhalation (e.g. inspiratory force); (iv) discuss inhaler switch options, patient preferences (e.g. size, daily regimen) and treatment goals; (v) allow patients input and use shared decision-making to decide final treatment choice, acknowledging individual patient skills, preferences and goals; and (vi) re-educate to the new device (at minimum, physical demonstration, verbal explanation and patient repetition, both verbally and physically) and prime the patient for the follow-up (i.e. explain the future patient journey, including multidisciplinary work flows with physicians, nurses and pharmacists).
对于哮喘和/或慢性阻塞性肺疾病(COPD)患者而言,吸入装置的选择往往与其中所使用的药物同等重要,这对于实现最佳治疗效果至关重要。鉴于有多种药物与装置的组合可供选择,优化呼吸治疗很可能通过更换装置来实现,而非改变甚至增加药物或非药物治疗方法。重要的是,虽然不同装置在释放机制、颗粒大小、药物沉积和所需吸气流量方面存在显著差异,但患者若对其使用的装置感到不适,就不太可能定期使用,而且肯定无法正确使用。更换装置需要一个谨慎的过程,未经患者同意不应进行。更换装置需要考虑几个步骤,可使用UR-RADAR助记法来指导。首先是(i)未得到控制的哮喘/COPD(或负担不起的装置),接着是RADAR:(ii)在更换装置之前,复查患者的病情(如诊断、表型、合并症),并排除控制不佳的原因(如触发因素、吸烟、不依从、吸入技术不佳);(iii)评估患者与吸入相关的技能(如吸气力量);(iv)讨论吸入器更换选项、患者偏好(如尺寸、每日用药方案)和治疗目标;(v)允许患者参与并采用共同决策来决定最终的治疗选择,同时考虑患者的个人技能、偏好和目标;以及(vi)对新装置进行再教育(至少进行实物演示、口头解释以及患者的口头和实际重复操作),并让患者为后续治疗做好准备(即解释未来的患者就医流程,包括与医生、护士和药剂师的多学科工作流程)。