  avaliar as caractersticas dos usurios de dispositivos inalatrios e a prevalncia de uso desses em adolescentes e adultos com diagnstico mdico autorreferido de asma , bronquite ou enfisema .
  estudo de base populacional realizado em pelotas , rs , incluindo 3.670 indivduos com idade  10 anos , avaliados com um questionrio .
entre esses , 59% apresentaram sintomas respiratrios no ltimo ano , e , desses , apenas metade usou inaladores . o uso de inaladores diferiu significativamente de acordo com o nvel socioeconmico ( 39% e 61% entre mais pobres e mais ricos , respectivamente ; p = 0,01 ) .
entre indivduos com enfisema , o uso da combinao broncodilatador + corticoide inalatrio foi mais frequente que o uso isolado de broncodilatador .
somente entre os indivduos que referiram diagnstico mdico de asma e sintomas atuais , a proporo de uso de inaladores foi maior que 50% .
  em nossa amostra , os inaladores foram subutilizados , e o tipo de medicamento usado por aqueles que referiram enfisema parece no estar de acordo com o preconizado em consensos sobre essa doena .
inadequate management of asthma and copd is detrimental to the quality of life of patients and generates avoidable costs to the health care system . 




  among the available drugs , those administered via inhaler devices constitute the treatment of choice for the control of asthma and copd and are indicated for all such patients , except for those who have cognitive deficits or who do not adapt to inhaler devices and opt for a nebulizer . 




  in brazil ,
the number of hospitalizations for asthma in adults dropped in the last decade ; however , asthma is still among the leading causes of hospitalization and , in 2011 , was the fourth leading cause of hospitalization among patients of all ages . 


  another leading cause of hospitalization is copd , and the burden of the disease on the health care system
, copd is expected to have become the fifth leading cause of disability - adjusted life years . 


 
although the worsening of symptoms and the frequency of exacerbations do not always indicate disease progression , they can indicate poor treatment adherence or inability to use inhalers , 


  which is aggravated by the fact that many health professionals do not have enough knowledge to instruct patients on how to use inhaler devices correctly . 


  according to data from the projeto latino - americano de
investigao em obstruo pulmonar ( platino , latin - american project for the investigation of pulmonary obstruction ) , the proportion of patients receiving inhaled medication is smaller than expected , and the form of administration and frequency of use are not in accordance with the recommendations . 


 
regarding asthma , despite advances in asthma control , the proportion of patients seeking emergency room treatment because of poor adherence to inhaled corticosteroid ( ic ) therapy is high . 




 
studies investigating inhaler use among asthma and copd patients are needed in order to identify shortcomings and , indirectly , assess the quality of the health care provided to such patients . however , a recent review of the literature revealed no population - based studies conducted in brazil and primarily focusing on inhaler use .   in this scenario ,
the objective of the present study was to describe inhaler use among individuals with self - reported physician - diagnosed asthma , bronchitis , emphysema , or any combination of the three in the city of pelotas , brazil .
this was a descriptive , cross - sectional , population - based study conducted in the city of pelotas between february and june of 2012 as part of a large population health survey .
the strategy used is designated " research consortium " , 


  whereby several researchers combine their questionnaires into a single instrument , thus streamlining data collection and reducing costs .
sampling was conducted in two stages : in the first stage , 130 of the 495 census sectors in the urban area were systematically selected , the probability being proportional to the number of households ; because the number of households in each census sector had last been determined in 2010 by the brazilian institute of geography and statistics , we mapped the households in each sector before starting the fieldwork ; in the second stage , the number of selected households was defined by the growth of the sector in relation to the 2010 count , and an average of 13 households were selected in each sector , a total of 1,722 households having been selected .  
all of the residents that were in the target age group were invited to participate , institutionalized or mentally disabled individuals being excluded .
standardized questionnaires addressing demographic , socioeconomic , behavioral , and health aspects were administered by trained interviewers .  
the use of inhalers was evaluated only in those who reported having any of the following physician - diagnosed respiratory diseases : asthma / wheezy bronchitis , bronchitis , emphysema , or any combination of the three .
the adolescents ( i.e. , those in the 10 - 19 year age bracket ) were asked only about asthma / wheezy bronchitis .  
whenever an individual gave at least one affirmative answer , the individual was asked about symptoms and inhaler use .
we determined the presence of symptoms in the previous year by asking the following question : " since ( month ) of last year , have you had attacks or symptoms of this / these disease(s ) , such as wheezing , cough , or breathlessness ?
the interviewers were instructed to replace the word " month " with the corresponding month in the 12-month recollection period . for the same period
, we asked about nebulizer use ( yes / no ) and inhaler use ( yes / no ) , using the terms " pump , dry powder inhaler , or any other medication for inhalation / aspiration " .  
those who had used an inhaler were asked to provide the package for collection of the name(s ) of the drug(s ) .
those who did not have the package were shown a catalog of drugs so that they could indicate the drug or drugs that they had used .
the drugs were categorized by type of inhaler , i.e. , metered dose inhaler ( mdi ) or dry powder inhaler ( dpi ) , and type of medication , i.e. , bronchodilator ( bd ) , ic , or a combination of both ( bd + ic ) .   those who reported not having used an inhaler were asked why they had not , the reasons being grouped into the following categories : belief that there was no need to use an inhaler ; lack of financial resources to purchase an inhaler ; lack of physician recommendation ; difficulty using inhalers ; and fear of side effects .   of the demographic , socioeconomic , and behavioral variables collected ,
the following were used in the present study : gender ; age ; years of completed schooling ; the indicador econmico nacional ( ien , national economic indicator ) , 


  categorized into quintiles ( in ascending order by socioeconomic status , from the lowest to the highest ) ; and smoking status , i.e. , never smoker , smoker ( having smoked at least one cigarette per day for more than one month ) , and former smoker ( having smoked no cigarettes for more than one month ) .  
data were collected through netbooks running the pendragon forms 6.1 software ( pendragon software corporation , libertyville , il , usa ) with the questionnaire , and the interviews were synchronized weekly to the database . for quality control ,
10% of the participants answered 14 of the questions again in a visit that took place within up to 15 days after the interview .
the question regarding the diagnosis of asthma / wheezy bronchitis showed a kappa statistic of 0.65 .  
the findings were expressed as absolute and relative frequencies , with the respective 95% cis .
we used the chi - square test for heterogeneity for nominal categorical variables and the chi - square test for linear trend for ordinal categorical variables .
data analysis was performed with the stata statistical software package , version 12.0 ( stata corp . , college station , tx , usa ) .  
the participants or their legal guardians gave written informed consent , and the study project was approved by the research ethics committee of the federal university of pelotas school of medicine , located in the city of pelotas , brazil , on december 1 , 2011 ( protocol no .
of the 4,168 eligible individuals , 3,670 were included in the study sample ( 12.1% having been lost to follow - up or having declined to participate ) . of those ,
402 ( 11% ) reported having been diagnosed with at least one of the respiratory diseases under study .
the overall prevalence of asthma was 7.5% ( 95% ci , 6.6 - 8.3 ) , the overall prevalence of bronchitis was 6.1% ( 95% ci , 5.2 - 6.9 ) , and the overall prevalence of emphysema was 1.6% ( 95% ci , 1.2 - 2.1 ; table 1 ) .
the characteristics of the study sample and the prevalence of each disease ( according to the demographic characteristics , socioeconomic characteristics , and smoking status ) are shown in table 1 .  

table 1description of the sample and prevalence of self - reported physician - diagnosed respiratory disease , pelotas , brazil , 2012.variablesamplerespiratory diseaseasthmabronchitisemphyseman ( % ) ( n = 274)(n = 178)(n = 47)gender 
 p = 0.063p = 0.110p = 0.838 
 male1,562 ( 42.6)6.5 ( 5.3 - 7.8)5.2 ( 4.0 - 6.5)1.7 ( 0.9 - 2.4 ) 
 female2,108 ( 57.4)8.2 ( 7.0 - 9.3)6.7 ( 5.5 - 7.8)1.6 ( 1.0 - 2.2)age 
 p
< 0.001 * * 
 p = 0.957 * * 
 p < 0.001 * * 

 10 - 19 

 743 ( 20.3)13.3 ( 10.8 - 15.8)-- 
 20 - 29612 ( 16.7)6.7 ( 4.7 - 8.7)6.2 ( 4.3 - 8.1)- 
 30 - 39540 ( 14.7)7.0 ( 4.9 - 9.2)5.7 ( 3.8 - 7.7)0.4 ( 0.0 - 0.9 ) 
 40 - 49595 ( 16.2)5.4 ( 3.6 - 7.2)5.9 ( 4.0 - 7.8)0.8 ( 0.1 - 1.6 ) 
 50 - 59514 ( 14.0)5.8 ( 3.8 - 7.9)6.8 ( 4.6 - 9.0)2.3 ( 1.0 - 3.6 ) 
 60 or older666 ( 18.2)5.1 ( 3.4 - 6.8)5.9 ( 4.1 - 7.6)4.2 ( 2.7 - 5.7)schooling 
 , yearsp = 0.031 * * 
 p = 0.061 * * 
 p < 0.001 * * 

 up to 4 651 ( 17.8)9.2 ( 7.0 - 11.4)8.6 ( 6.2 - 11.0)4.2 ( 2.5 - 5.9 ) 
 5 - 91,313 ( 35.8)7.3 ( 5.9 - 8.7)5.2 ( 3.7 - 6.7 ) 1.5 ( 0.7 - 2.3 ) 
 10 - 141,217 ( 33.2)7.6 ( 6.2 - 9.1)6.1 ( 4.7 - 7.6)1.1 ( 0.4 - 1.7 ) 
 15 or more486 ( 13.3)5.1 ( 3.2 - 7.1)5.0 ( 3.0 - 6.9)0.2 ( 0.0 - 0.6)ien 
 , quintiles 
 p = 0.094 * * 
 p = 0.477 * * 
 p = 0.010 * * 

 1st ( the poorest)735 ( 20.2)8.0 ( 6.1 - 10.0)7.0 ( 4.9 - 9.0)2.4 ( 1.1 - 3.6 ) 
 2nd723 ( 19.9)7.9 ( 6.0 - 9.9)6.5 ( 4.5 - 8.6)2.2 ( 1.0 - 3.4 ) 
 3rd732 ( 20.1)7.7 ( 5.7 - 9.6)4.6 ( 2.9 - 6.3)1.4 ( 0.4 - 2.3 ) 
 4th720 ( 19.8)8.6 ( 6.6 - 10.7)6.2
( 4.3 - 8.2)1.4 ( 0.4 - 2.3 ) 
 5th ( the richest)727 ( 20.0)5.1 ( 3.5 - 6.7)6.0 ( 4.1 - 8.0)0.7
( 0.0 - 1.4)smoking status 
 p = 0.726p = 0.001p = 0.001 
 never smoker2,397 ( 65.3)7.7 ( 6.7 - 8.8)5.1 ( 4.1 - 6.2)0.9 ( 0.4 - 1.3 ) 
 former smoker634 ( 17.3)6.9 ( 5.0 - 8.9)5.5 ( 3.7 - 7.2)2.2 ( 1.1 - 3.4 ) 
 smoker639 ( 17.4)7.0 ( 5.1 - 9.0)9.4 ( 7.1 - 11.7)3.0 ( 1.6 - 4.3)total3,670 ( 100)7.5 ( 6.6 - 8.3)6.1 ( 5.2 - 6.9)1.6 ( 1.2 - 2.1)ien : indicador econmico
nacional ( national economic indicator).apatients in this age bracket were asked only about asthma or wheezy bronchitisb3 observations ignoredc33 observations ignored*chi - square test for heterogeneity , except where otherwise indicated**chi - square test for linear trend 
  : indicador econmico nacional ( national economic indicator ) .
patients in this age bracket were asked only about asthma or wheezy bronchitis 3 observations ignored 33 observations ignored chi - square test for heterogeneity , except where otherwise indicated chi - square test for linear trend of the 402 individuals who reported having a respiratory disease , 146 ( 36.2% ; 95% ci , 31.4 - 40.9 ) had used an inhaler device in the previous year , and 237 ( 59% ) reported having had symptoms in the same period . of the 237 symptomatic individuals , 120 ( 50.6% ; 95% ci , 44.2 - 57.0 ) reported having used an inhaler . of those who remained asymptomatic , 25
( 15.2% ; 95% ci , 9.7 - 20.8 ) reported having used an inhaler .  

figure 1 shows the distribution of inhaler users by ien quintile among the individuals who reported having had respiratory symptoms in the previous year .
although the 95% cis overlapped , a higher ien translated to a higher frequency of inhaler use , a linear trend being observed ( p = 0.010 ) .
similar results were obtained with the use of other socioeconomic indicators , such as the brazilian association of survey firms classification 


  ( data not shown ) .
the frequency of inhaler use did not differ by gender or age in the sample as a whole or in the symptomatic individuals .  

figure 1prevalence of inhaler use in those who reported symptoms in the previous year ( n = 234 ) , by indicador econmico nacional ( ien , national economic indicator ) quintile , pelotas , brazil , 2012 .
p = 0.01 , as assessed by the chi - square test for linear trend . 
 
the proportion of individuals who had not used any type of inhaler was higher than 50% among those who reported having bronchitis or emphysema . among those who had used an inhaler in the previous year , mdis were
the most widely used by patients with asthma or bronchitis , whereas there was no difference between mdi use and dpi use among those with emphysema ( figure 2 ) .  

figure 2type of inhaler used in the previous year by those who reported symptoms in the previous year ( n = 235 ) , by self - reported diagnosis , pelotas , brazil , 2012 . none : no inhaler use in the previous year ; mdi : metered dose inhaler ; and dpi : dry powder inhaler . 
  regarding the drug regimen used by the symptomatic individuals , figure 3 shows the distribution of bd use and bd + ic use . only among those reporting
emphysema was the proportion of bd + ic users higher than was that of bd - only users .
two of the respondents did not know the type of inhaler that they had used .  

figure 3drug regimen used by those who reported symptoms in the previous year ( n = 118 ) , by self - reported diagnosis , pelotas , brazil , 2012 .
bd : bronchodilator ; and ic : inhaled corticosteroid . 
  of the 117 individuals who reported that they had had symptoms and had not used any type of inhaler , 38% reported nebulizer use . the most common reasons for not using an inhaler were " belief that there was no need to use an inhaler " ( 60.7% ) and " lack of physician recommendation " ( 23.9% ) , followed by " fear of side effects " , " lack of financial resources to purchase an inhaler " , and " difficulty using inhalers " .
inhaler devices are of great importance in the treatment of respiratory diseases , having advantages such as direct deposition of the drug in the target organ and rapid effect in reducing symptoms . 


 
the objective of the present study was to describe inhaler use among individuals who gave affirmative answers to questions regarding asthma , bronchitis , and emphysema .
it is of note that this can not be considered the real prevalence of inhaler use in the population , because inhalers can be indicated for other conditions or used as self - medication .
another limitation of the present study is the use of self - reported diagnosis , which can lead to information bias .
however , unlike other studies conducted in brazil and investigating inhaler use - most of which evaluated samples of individuals selected from among those being treated at primary health care clinics or hospitals - our study evaluated a sample that was representative of the general population .  
the prevalence of self - reported physician - diagnosed asthma was investigated in adults ( 20 years of age or older ) in studies conducted in the city of pelotas in 2000 


  and 2010 . 


 
however , the criteria used in those studies in order to define the outcome differ from those used in the present study , and it is therefore difficult to compare the studies in terms of the reported prevalence . the prevalence of self - reported asthma in the previous year has been reported to be 4.7% 


  and 5.2% . 


  in the present study , by combining the questions regarding the diagnosis of asthma ( no specific recollection period ) and symptoms in the previous year , we found that 4.5% of those who were 20 years of age or older reported this condition .
in addition , when analyzing that age group , we found significant differences between the genders in terms of the prevalence of asthma ; this finding is consistent with those of previous studies , 




  the prevalence of asthma being higher among females ( 7.1% vs. 4.3% ; p = 0.002 ) .   in individuals in the 10 - 19 year age bracket ,
the prevalence of asthma found in the present study was similar to that found in a study conducted in the city of santa maria , brazil , i.e. , 14.9% for self - reported physician - diagnosed asthma ever ; however , that study investigated individuals in the 13 - 14 year age bracket . 


 
both proportions are superior to the 7.4% prevalence of self - reported asthma found in individuals in the 10 - 19 year age bracket in southern brazil in 2008 . 


 
the questions regarding bronchitis and emphysema were asked only to adults ( 20 years of age or older ) because copd affects individuals over 40 years of age . 


  because the term " bronchitis " is used by asthma and copd patients alike
, we believe that the prevalence found in the present study refers to both conditions . it is likely that the smokers or former smokers over 40 years of age reporting bronchitis have copd .
the proportion of individuals with self - reported bronchitis was highest among current smokers .  
regarding emphysema , data from the platino 


  showed that the prevalence of self - reported physician - diagnosed emphysema in the city of so paulo , brazil , in 2003 was 1.2% .
we found a higher prevalence in individuals 20 years of age or older ( i.e. , 1.6% ) and in those 40 years of age or older ( i.e. , 2.5% ) , the latter age group being the target of the platino .  
we chose the terms " bronchitis " and " emphysema " because the population is more familiar with those terms than it is with the term " copd " . in the platino , 


 
the prevalence of self - reported physician - diagnosed copd was 0.8% , whereas , in a study conducted in the city of so paulo in the 2008 - 2009 period , 


  the prevalence of copd was 4.2% , suggesting greater familiarity with the term .  
half of those who were expected to have used an inhaler ( i.e. , those with a self - reported diagnosis of respiratory disease and symptoms in the previous year ) had . however , 38% of those who reported no inhaler use reported nebulizer use ; that is , 12% of the symptomatic individuals had not used any type of inhalation treatment .
it is of note that nebulizer use has disadvantages in comparison with inhaler use , including the lack of standardization of the devices regarding the emission of aerosol particles , causing uncertainty regarding the inhaled dose 


 ; nebulizer use is indicated only for those who do not adapt to the inhalation of a controlled dose , such as debilitated patients or those with cognitive deficits , who fail to use the medication , even with a spacer . 


 
each type of inhaler device has its own particularities , and the choice of inhaler to be prescribed depends on factors such as personal preferences , cost - benefit ratio , and patient cognition . 






  of the two types of inhalers , mdis are the most readily available in the public health care system , being the most widely used in the present study .  
the main reason for not having used an inhaler was the belief that there was no need to use it .
this finding might reflect treatment nonadherence in those patients . in a study 


  evaluating the treatment of eight chronic diseases ,
only 16% of all asthma patients were considered to have adhered to treatment , that proportion being the lowest proportion of treatment adherence among the diseases investigated ; copd ranked third , 38% of all copd patients having adhered to treatment .  
the lack of adherence to inhaler use has been attributed to factors such as difficulty using inhalers , little satisfaction with the benefits of inhaler use , fear of adverse effects , prolonged duration of use , periods of symptom remission , and drug costs . 




 
a significant number of individuals reported lack of physician recommendation as the reason for not using inhalers ; this reflects a situation that is common in brazil and other countries ; that is , the medication is not prescribed as recommended in consensus guidelines . 




  in a study conducted in the city of porto alegre , brazil , 


  the medical records of patients treated in a pulmonology department were analyzed .
approximately 68% of the patients had received treatment that was not in accordance with the recommendations in current guidelines , and 71% of those patients had uncontrolled asthma that was not being treated with corticosteroids . in the usa , the medical records of asthma patients were investigated , and it was found that less than 40% of the patients had been prescribed short - acting 2 agonists and that less than 10% of the patients who used bds daily had been prescribed ics 


 ; regarding copd , 72% of the patients with the disease had been prescribed at least one bd , and 64% of the patients with frequent exacerbations had been prescribed ics . 


  the individuals who , despite having reported symptoms , believed that there was no need to use an inhaler , those who reported that they feared side effects , and those who reported having difficulty using inhalers are a reflection of the need for educational activities emphasizing the importance of inhaler use .  
our analysis of the drug regimens used by the individuals in our study sample showed that the proportion of combination therapy ( bd + ic ) users was highest among the individuals who reported having emphysema .
a recent systematic review highlighted that ics should be used only in those with frequent exacerbations . 


  according to the global initiative for chronic obstructive lung disease guidelines
, ics should be reserved for those belonging to high - risk groups . 


  in our study
, we did not evaluate the frequency or type of symptoms that can lead to an estimation of the severity of copd ; however , data from a previous population - based study showed that those for whom ics are indicated account for only approximately 1% of all copd patients . 


 
it is of note that inhalers are underused among socioeconomically disadvantaged populations , despite the fact that those populations have been reported as being the most affected by chronic respiratory diseases .  
when the present study was conducted , the public health care system was going through a transition phase regarding inhalers provided free of charge . at the beginning of data collection , inhalers were restricted to two types of medication delivered via mdis , and asthma patients with more severe disease had access to other inhalers . 


 
in addition , the brazilian popular pharmacy program 


  offered discounts of up to 90% on some of those drugs .
as of june of 2012 , certain types of inhalers had come to be provided free of charge under the program , 


  and , more recently , after the end of our data collection , new drugs began to be provided free of charge in the public health care system , with the objective of improving the treatment of patients diagnosed with copd . 


 
such changes can soon translate to changes in the inhaler use scenario , expanding the possibilities at the time of prescription and improving treatment adherence .  
in the evaluation of the association between low socioeconomic status and lower use of inhalers , mediators other than low income should be taken into account .
the underuse of inhalers can also be due to other factors , such as the type of facility used , access to specialist consultations , and the quality of the information provided .
although no such data were collected in the present study , the abovementioned factors can influence inhaler use and therefore should be examined in future studies .
therefore , multiple factors can be addressed in the development of measures to benefit this population and reduce the numbers of emergency room visits and hospitalizations due to preventable causes . 


 
we conclude that inhaler use among individuals with self - reported physician - diagnosed asthma , bronchitis , emphysema , or any combination of the three is far from ideal , especially among those of lower socioeconomic status .
a significant proportion of symptomatic individuals reported nebulizer use only ; however , this type of drug administration should not be the first choice for most individuals . 


 
the type of inhaled medication recommended for individuals with emphysema also deserves attention because it does not seem to be in accordance with the recommendations . 




  finally , the implementation of new policies for the free distribution of these drugs will meet the needs identified in the present study , because although few individuals reported lack of financial resources to purchase an inhaler as the reason for not using an inhaler , inhaler use is lowest among those of lowest socioeconomic status .
 objective : to evaluate the characteristics of users of inhalers and the prevalence of inhaler use among adolescents and adults with self - reported physician - diagnosed asthma , bronchitis , or emphysema . 
 methods : a population - based study conducted in the city of pelotas , brazil , involving 3,670 subjects  10 years of age , evaluated with a questionnaire . 
 results : approximately 10% of the sample reported at least one of the respiratory diseases studied . among those individuals , 59% reported respiratory symptoms in the last year , and , of those , only half reported using inhalers . 
 the use of inhalers differed significantly by socioeconomic status ( 39% and 61% for the lowest and the highest , respectively , p = 0.01 ) . 
 the frequency of inhaler use did not differ by gender or age . among the individuals reporting emphysema and inhaler use , the use of the bronchodilator - corticosteroid combination was more common than was that of a bronchodilator alone . only among the individuals reporting physician - diagnosed asthma and 
 current symptoms was the proportion of inhaler users higher than 50% . 
 conclusions : in our sample , inhalers were underutilized , and the type of medication used by the individuals who reported emphysema does not seem to be in accordance with the consensus recommendations . 
OBJETIVO:
MTODOS:
RESULTADOS:
CONCLUSES:
Introduction
Methods
Results
Discussion