In severe asthma, poor control could reflect issues of medication adherence or inhaler technique, or that the condition is refractory. This study aimed to determine if an intervention with (bio)feedback on the features of inhaler use would identify refractory asthma and enhance inhaler technique and adherence.Patients with severe uncontrolled asthma were subjected to a stratified-by-site random block design. The intensive education group received repeated training in inhaler use, adherence and disease management. The intervention group received the same intervention, enhanced by (bio)feedback-guided training. The primary outcome was rate of actual inhaler adherence. Secondary outcomes included a pre-defined assessment of clinical outcome. Outcome assessors were blinded to group allocation. Data were analysed on an intention-to-treat and per-protocol basis.The mean rate of adherence during the third month in the (bio)feedback group (n=111) was higher than that in the enhanced education group (intention-to-treat, n=107; 73% 63%; 95% CI 2.8%-17.6%; p=0.02). By the end of the study, asthma was either stable or improved in 54 patients (38%); uncontrolled, but poorly adherent in 52 (35%); and uncontrolled, but adherent in 40 (27%).Repeated feedback significantly improved inhaler adherence. After a programme of adherence and inhaler technique assessment, only 40 patients (27%) were refractory and adherent, and might therefore need add-on therapy.

Vol. 63 electric medium and the well known rule of electrostatic forces would apply.Equation 4 yields at «mo = 0 (pure glycol) the value In « = 0.207 and AH* = 5.4 kcal./mole. This predicts the dielectric constant of ethylene glycol at 25°to be 43 using the above assumption while the measured value is 37.7. Such agreement as this is satisfactory in view of the crudeness of the assumptions. Further investigation to determine the actual polymer phase composition (in terms of water content) and measurements of at varying temperatures to separate out entropy effects are needed to determine whether AH* actually inversely proportional to dielectric constant.If the linearity of log with amo observed is general to other solvating solutions, e.g., water plus alcohols, this simple rule will permit data on the diffusion of ions in ion-exchange polymers in partially non-aqueous media to be extended with a minimum of experimental effort.The present approach to the conductivity of a partially hydrated ion-exchange polymer may differ only formally from that of ion pair formation employed by Gregor19 and that of hydration shells employed by Glueckauf.20

RationalePoor adherence to inhaler use can be due to poor temporal and/or technique adherence. Up until now there has been no way of reliably tracking both these factors in everyday inhaler use.ObjectivesThis paper introduces a device developed to create time stamped acoustic recordings of an individual's inhaler use, in which empirical evidence of temporal and technique adherence in inhaler use can be monitored over time. The correlation between clinical outcomes and adherence, as determined by this device, was compared for temporal adherence alone and combined temporal and technique adherence.FindingsThe technology was validated by showing that the doses taken matched the number of audio recordings (r2 = 0.94, p<0.01). To demonstrate that audio analysis of inhaler use gives objective information, in vitro studies were performed. These showed that acoustic profiles of inhalations correlated with the peak inspiratory flow rate (r2 = 0.97, p<0.01), and that the acoustic energy of exhalations into the inhaler was related to the amount of drug removed. Despite training, 16% of participants exhaled into the mouthpiece after priming, in >20% of their inhaler events. Repeated training reduced this to 7% of participants (p = 0.03). When time of use was considered, there was no evidence of a relationship between adherence and changes in AQLQ (r2 = 0.2) or PEFR (r2 = 0.2). Combining time and technique the rate of adherence was related to changes in AQLQ (r2 = 0.53, p = 0.01) and PEFR (r2 = 0.29, p = 0.01).ConclusionsThis study presents a novel method to objectively assess how errors in both time and technique of inhaler use impact on clinical outcomes.Trial Registration EudraCT 2011-004149-42

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