Multidisciplinary consensus on inhaled therapy in asthma

Figures & data

Table 1. Statements about general aspects of inhaled therapy in asthma and selection of inhaled drugs

	Median (IQR)	Percentage of panelists in the median region*	Results
Block I. General aspects of inhaled therapy
(1) In terms of clinical effectiveness, the inhaled device is more important than the active drug (s) included within the different therapeutic groups (e.g., LABA, ICS, etc.).	6 (3–7)	31.6%	No consensus
(2)In a patient with a good inhaler technique, the particle size determines the lung deposition.	8 (7–9)	88.5%	Agreement in 1^st round
(3)In the asthmatic patient, there are no clinically significant efficacy differences when using inhalers that generate fine or extra-fine particles.	4 (3–7)	22.0%	No consensus
(4)A high lung deposition rate is the one that reaches at least 40% of the metered dose.	7 (7–8)	77.5%	Agreement in 1^st round
(5)More than half of primary care physicians have inadequate knowledge in the inhaler technique of the inhalers they prescribe.	7 (6–9)	69.9%	Agreement in 1^st round
(6)More than half of specialized physicians have inadequate knowledge in the inhaler technique of the inhalers they prescribe.	7 (3–8)	54.1%	No consensus
(7)Critical errors in the handling of inhaled devices associated with poor control and/or the presence of exacerbations are common amongst patients.	8 (7–9)	90.0%	Agreement in 1^st round
The most common cause of poor asthma control is:
(8)Inadequate inhaler technique.	7 (5.5–8)	65.6%	No consensus
(9)Poor therapeutic adherence.	8 (7–9)	90.0%	Agreement in 1^st round
When deciding on which type of inhaler to prescribe, it is necessary to consider:
(10)The level of severity of asthma.	8 (6–9)	72.2%	Agreement in 1^st round
(11)The patient’s degree of cognitive impairment.	9 (8–9)	92.8%	Agreement in 1^st round
(12)The patient’s social support.	8 (7–9)	78.5%	Agreement in 1^st round
Block II. Selection of inhaled drugs
The most recommended treatment for intermittent asthma in adults and adolescents is:
(13)PRN low-dose ICS/formoterol.	7 (4–8)	62.7%	No consensus
(14)PRN low-dose ICS/salbutamol.	3 (2–7)	52.2%	No consensus
(15)PRN SABA monotherapy.	4 (2–7)	18.2%	No consensus
The most recommended maintenance treatment for mild persistent asthma in adults and adolescents is:
(16)Daily low-dose ICS	7 (5–8)	68.4%	Agreement in 1^st round
(17)PRN low-dose ICS/formoterol.	7 (3–8)	53.1%	No consensus
(18)The most recommended salvage treatment for moderate persistent asthma in adults and adolescents is MART	8 (7–9)	85.6%	Agreement in 1^st round
(19)In a controlled patient, it is necessary to wait for 3 to 6 months before stepping down therapy.	8 (7–9)	82.3%	Agreement in 1^st round
(20)In an uncontrolled patient, the patient’s inhaler technique is usually checked before stepping up therapy.	9 (8–9)	85.6%	Agreement in 1^st round

*It indicates the percentage of panelists who voted in the region where the median is (1–3; 4–6; 7–9).

ICS: Inhaled Corticosteroid; IQR: Interquartile Range; LABA: Long-Acting β2 Agonists; MART: Maintenance and Reliever Therapy; PRN: as needed; SABA: Short-Acting β2 Agonists.

Table 2. Statements about pressurized metered-dose inhalers and spacers, and about dry-powder inhalers

	Median (IQR)	Percentage of panelists in the median region*	Results
Block III. Pressurized metered dose inhalers and spacers
(21)The most frequent critical error of patients on pMDI treatment is the lack of coordination between actuation and inhalation.	9 (8–9)	99.0%	Agreement in 1^st round
(22)In pMDI, slower plume speed implies less oropharyngeal deposition.	7 (6–8)	68.4%	Agreement in 1^st round
(23)In acute asthma exacerbations attended in Primary Care, the use of pMDI with spacers is preferred to the use of nebulizers for the administration of short-acting bronchodilators.	8 (5–9)	68.4%	Agreement in 1^st round
(24)In acute asthma exacerbations attended in a hospital setting, the use of pMDI with spacers is preferred to the use of nebulizers for the administration of short-acting bronchodilators.	7 (3–8)	55.5%	No consensus
(25)In your specialty consultations, the spacer is prescribed for more than 30% of patients on maintenance treatment with pMDI.	7 (3–8)	56.0%	No consensus
(26)It is recommended to use spacers when pMDI are prescribed as maintenance treatment for elderly patients	9 (8–9)	89.0%	Agreement in 1^st round
When a patient performs the inhaler technique with a pMDI poorly, the most common approach is:
(27)To switch to a non-pMDI device.	7 (4–8)	59.3%	No consensus
(28)To add a spacer to the pMDI.	8 (7–9)	81.3%	Agreement in 1^st round
Block IV. Dry-powder inhalers
(29)The most frequent critical error of the patients on treatment with DPI is not to perform a forceful inhalation.	8 (7–9)	83.7%	Agreement in 1^st round
(30)Before prescribing a DPI, the ability of the patient to inhale forcefully is not checked.	7 (3,5–8)	62.2%	No consensus
(31)DPI requires a higher inspiratory flow than pMDI and BAI.	9 (8–9)	94.3%	Agreement in 1^st round
(32)DPI produces more oropharyngeal side effects than pMDI and BAI.	7 (6–8)	67.5%	Agreement in 1^st round
When a patient performs the inhaler technique with a DPI poorly, the most common approach is:
(33)To switch to another DPI.	4 (2–7)	15.3%	No consensus
(34)To switch to a of non-DPI device	7 (6–8)	71.3%	Agreement in 1^st round

* It indicates the percentage of panelists who voted in the region where the median is (1–3; 4–6; 7–9). BAI: Breath-Actuated Inhaler; DPI: Dry-Powder Inhaler; IQR: Interquartile Range; pMDI: pressurized Metered-Dose Inhaler.

Table 3. Statements about breath-actuated inhalers

	Median (IQR)	Percentage of panelists in the median region*	Results
Block V. Breath-actuated inhalers
(35)The fact that the BAI require neither coordination, nor a forceful inhalation, makes them a suitable option for all those patients with the ability to inhale voluntarily.	9 (8–9)	98.6%	Agreement in 1^st round
(36)It is easier to train patients to use BAI than pMDI.	9 (8–9)	92.3%	Agreement in 1^st round
(37)It is easier to train patients to use BAI than DPI.	8 (6–9)	74.6%	Agreement in 1^st round
(38)It is easier for patients to use a BAI than a pMDI.	9 (8–9)	95.7%	Agreement in 1^st round
(39)It is easier for patients to use a BAI than a DPI.	8 (7–9)	80.4%	Agreement in 1^st round
(40)To activate the BAI, only minimal inspiratory effort is required.	8 (8–9)	94.3%	Agreement in 1^st round
(41)The low error rate observed with BAI devices helps to improve asthma control.	8 (8–9)	94.3%	Agreement in 1^st round
(42)The low error rate observed with BAI helps to reduce the overall cost of treatment (healthcare and non-healthcare related costs).	8 (7–9)	81.3%	Agreement in 1^st round

* It indicates the percentage of panelists who voted in the region where the median is (1–3; 4–6; 7–9). BAI: Breath-Actuated Inhaler; DPI: Dry-Powder Inhaler; IQR: Interquartile range; pMDI: Pressurized Metered Dose Inhalers.

Table 4. Statements about therapeutic adherence and educational aspects

	Median (IQR)	Percentage of panelists in the median region*	Results
Block VI. Therapeutic adherence and educational aspects
(43)Patients need to get involved in the choice of inhaler device.	9 (8–9)	92.3%	Agreement in 1^st round
(44)The ease of use of inhaler devices is the most important factor in promoting therapeutic adherence.	8 (7–9)	85.2%	Agreement in 1^st round
(45)The instructions on how to use the inhaler in the package leaflets are difficult for patients to read and understand.	7 (6–8)	71.3%	Agreement in 1^st round
(46)In check-up visits it is common that the inhaler technique is NOT checked periodically.	7 (6–8)	69.4%	Agreement in 1^st round
(47)In check-up visits, a reevaluation of the inhaler technique should be carried out.	9 (8–9)	98.1%	Agreement in 1^st round
(48)In check-up visits, adherence must be verified with a validated method.	9 (8–9)	92.3%	Agreement in 1^st round
(49)In check-up visits, therapeutic adherence is verified with a validated method before stepping-up therapies.	6 (3–8)	17.7%	No consensus
(50)In check-up visits, the patient is given a written Action Plan.	7 (3–8)	53.6%	No consensus
(51)Nursing professionals are capable to assess therapeutic adherence and correct errors of the inhaler technique.	8 (7–9)	76.6%	Agreement in 2^nd round
(52)The use of software applications helps to improve adherence to treatment and control of the disease.	7 (6–8)	70,8%	Agreement in 2^nd round

* It indicates the percentage of panelists who voted in the region where the median is (1–3; 4–6; 7–9). IQR: Interquartile range.

Table 5. Discrepancies in the consensus among specialties in the post hoc analysis

Statements	Global*	Primary care physicians	Allergists	Pulmonologists
Block I. General aspects of inhaled therapy
5. More than half of primary care physicians have inadequate knowledge in the inhaler technique of the inhalers they prescribe.	AG 1^st R	NC 1^st R	NC 1^st R	AG 1^st R
8. The most common cause of poor asthma control is: Inadequate inhaler technique.	NC 1^st R	AG 1^st R	NC 1^st R	NC 1^st R
	NC 2^nd R	AG 2^nd R	NC 2^nd R	NC 2^nd R
10. When deciding on which type of inhaler to prescribe, it is necessary to consider: The level of severity of asthma.	AG 1^st R	AG 1^st R	AG 1^st R	NC 1^st R
Block II. Selection of inhaled drugs
13. The most recommended treatment for intermittent asthma in adults and adolescents is: PRN low-dose ICS/formoterol.	NC 1^st R	NC 1^st R	NC 1^st R	NC 1^st R
	NC 2^nd R	NC 2^nd R	NC 2^nd R	AG 2^nd R
16. The most recommended maintenance treatment for mild persistent asthma in adults and adolescents is: Daily low-dose ICS	AG 1^st R	AG 1^st R	NC 1^st R	AG 1^st R
Block III. Pressurized metered dose inhalers and spacers
22. In pMDI, slower plume speed implies less oropharyngeal deposition.	AG 1^st R	NC 1^st R	AG 1^st R	AG 1^st R
25. In your specialty consultations, the spacer is prescribed for more than 30% of patients on maintenance treatment with pMDI.	NC 1^st R	NC 1^st R	NC 1^st R	NC 1^st R
	NC 2^nd R	NC 2^nd R	NC 2^nd R	AG 2^nd R
27. When a patient performs the inhaler technique with a pMDI poorly, the most common approach is: To switch to a non-pMDI device.	NC 1^st R	NC 1^st R	NC 1^st R	NC 1^st R
	NC 2^nd R	NC 2^nd R	AG 2^nd R	NC 2^nd R
Block IV. Dry-powder inhalers
30. Before prescribing a DPI, the ability of the patient to inhale forcefully is not checked.	NC 1^st R	AG 1^st R	NC 1^st R	NC 1^st R
	NC 2^nd R	AG 2^nd R	NC 2^nd R	NC 2^nd R
32. DPI produces more oropharyngeal side effects than pMDI and BAI.	AG 1^st R	AG 1^st R	NC 1^st R	AG 1^st R
34. When a patient performs the inhaler technique with a DPI poorly, the most common approach is: To switch to a non-DPI device.	AG 1^st R	AG 1^st R	NC 1^st R	AG 1^st R
Block VI. Therapeutic adherence and educational aspects.
45. The instructions on how to use the inhaler in the package leaflets are difficult for patients to read and understand.	AG 1^st R	AG 1^st R	NC 1^st R	AG 1^st R
46. In check-up visits it is common that the inhaler technique is NOT checked periodically.	AG 1^st R	AG 1^st R	AG 1^st R	NC 1^st R
50. In check-up visits, the patient is given a written Action Plan.	NC 1^st R	NC 1^st R	AG 1^st R	NC 1^st R
	NC 2^nd R	NC 2^nd R	AG 2^nd R	NC 2^nd R

*Statements agreed on 1^st round were not submitted to a 2^nd round of voting.

AG: Agreement; NC: No Consensus; 1^st R: first round of voting; 2^nd R: second round of voting.

BAI: Breath-Actuated Inhaler; DPI: Dry-Powder Inhaler; ICS: Inhaled Corticosteroid; pMDI: Pressurized Metered Dose Inhaler; PRN: as needed.