{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T16:45:05Z","timestamp":1790181905458,"version":"4.1.0"},"reference-count":30,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2021,6,29]],"date-time":"2021-06-29T00:00:00Z","timestamp":1624924800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004663","name":"Ministry of Science and Technology, Taiwan","doi-asserted-by":"publisher","id":[{"id":"10.13039\/501100004663","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Pharmacol."],"abstract":"<jats:p>Optimal peak inspiratory flow rate (PIFR) is crucial for inhalation therapy in patients with chronic obstructive pulmonary disease (COPD). However, little is known about the impact of PIFR-guided inhalation therapy on the clinical outcomes among patients with varying severities of COPD. A PIFR-guided inhalation therapy, including PIFR assessment and PIFR-guided inhaler education, was introduced in a pay-for-performance COPD management program in National Taiwan University Hospital. Among 383 COPD patients, there was significant reduction in incidence of severe acute exacerbation in the PIFR-guided inhalation therapy (PIFR group) than conventional inhaler education (control group) (11.9 vs. 21.1%, <jats:italic>p<\/jats:italic> = 0.019) during one-year follow-up. A multivariable Cox\u2019s proportional-hazards analysis revealed that the PIFR-guided inhalation therapy was a significant, independent factor associated with the reduced risk of severe exacerbation (adjusted hazard ratio = 0.49, 95% confidence interval, 0.28\u20130.84, <jats:italic>p<\/jats:italic> = 0.011). Subgroup analysis found PIFR-guided inhalation therapy was more beneficial to patients with older age, short body stature, COPD stage 1&amp;amp;2, group C&amp;amp;D (frequent exacerbation phenotype), and using multiple inhalers. This study showed the PIFR-guided inhalation therapy significantly reduced the incidence of severe acute exacerbation than conventional inhaler education in patients with COPD. Careful PIFR-assessment and education would be crucial in the management of COPD.<\/jats:p>","DOI":"10.3389\/fphar.2021.704316","type":"journal-article","created":{"date-parts":[[2021,6,29]],"date-time":"2021-06-29T05:54:38Z","timestamp":1624946078000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":11,"title":["Peak-Inspiratory-Flow-Rate Guided Inhalation Therapy Reduce Severe Exacerbation of COPD"],"prefix":"10.3389","volume":"12","author":[{"given":"Shih-Yu","family":"Chen","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chun-Kai","family":"Huang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hui-Chuan","family":"Peng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hsing-Chen","family":"Tsai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Szu-Ying","family":"Huang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chong-Jen","family":"Yu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jung-Yien","family":"Chien","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2021,6,29]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"763","DOI":"10.2147\/COPD.S3930","article-title":"Higher Lung Deposition with Respimat Soft Mist Inhaler Than HFA-MDI in COPD Patients with Poor Technique","volume":"3","author":"Brand","year":"2008","journal-title":"Int. J. Chron. Obstruct Pulmon Dis."},{"key":"B2","doi-asserted-by":"publisher","first-page":"1257","DOI":"10.1056\/nejmra1900500","article-title":"Update on Clinical Aspects of Chronic Obstructive Pulmonary Disease","volume":"381","author":"Celli","year":"2019","journal-title":"N. Engl. J. Med."},{"key":"B3","doi-asserted-by":"publisher","first-page":"7271","DOI":"10.1038\/s41598-020-64235-6","article-title":"Inappropriate Peak Inspiratory Flow Rate with Dry Powder Inhaler in Chronic Obstructive Pulmonary Disease","volume":"10","author":"Chen","year":"2020","journal-title":"Sci. Rep."},{"key":"B4","doi-asserted-by":"publisher","first-page":"267","DOI":"10.15326\/jcopdf.6.3.2018.0168","article-title":"Inhalation Technique Errors with Metered-Dose Inhalers Among Patients with Obstructive Lung Diseases: A Systematic Review and Meta-Analysis of U.S. Studies","volume":"6","author":"Cho-Reyes","year":"2019","journal-title":"J. Copd F"},{"key":"B5","doi-asserted-by":"publisher","first-page":"585","DOI":"10.2147\/copd.s195438","article-title":"Prevalence and Factors Associated with Suboptimal Peak Inspiratory Flow Rates in COPD","author":"Ghosh","year":"2019","journal-title":"Copd"},{"key":"B6","unstructured":"Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report)2020"},{"key":"B7","doi-asserted-by":"publisher","first-page":"237","DOI":"10.1186\/s12931-018-0936-3","article-title":"Use and Inhalation Technique of Inhaled Medication in Patients with Asthma and COPD: Data from a Randomized Controlled Trial","volume":"19","author":"Gregoriano","year":"2018","journal-title":"Respir. Res."},{"key":"B8","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1016\/j.rmed.2016.07.013","article-title":"Inhalation Device Requirements for Patients' Inhalation Maneuvers","volume":"118","author":"Haidl","year":"2016","journal-title":"Respir. Med."},{"key":"B9","doi-asserted-by":"publisher","first-page":"105298","DOI":"10.1016\/j.ejps.2020.105298","article-title":"Prevalence and Predictors of Suboptimal Peak Inspiratory Flow Rate in COPD Patients","volume":"147","author":"Harb","year":"2020","journal-title":"Eur. J. Pharm. Sci."},{"key":"B10","doi-asserted-by":"publisher","first-page":"e0193082","DOI":"10.1371\/journal.pone.0193082","article-title":"Assessment of Inhalation Flow Patterns of Soft Mist Inhaler Co-prescribed with Dry Powder Inhaler Using Inspiratory Flow Meter for Multi Inhalation Devices","volume":"13","author":"Hira","year":"2018","journal-title":"PLoS One"},{"key":"B11","doi-asserted-by":"publisher","first-page":"131","DOI":"10.2147\/MDER.S48888","article-title":"Inhalation Drug Delivery Devices: Technology Update","volume":"8","author":"Ibrahim","year":"2015","journal-title":"Med. Devices (Auckl)"},{"key":"B12","doi-asserted-by":"publisher","first-page":"78","DOI":"10.1183\/09031936.00024807","article-title":"Inspiratory Flow Rates at Different Levels of Resistance in Elderly COPD Patients","volume":"31","author":"Janssens","year":"2008","journal-title":"Eur. Respir. J."},{"key":"B13","doi-asserted-by":"publisher","first-page":"17","DOI":"10.2147\/jaa.s127580","article-title":"Peak Inspiratory Flow Rate Measurement by Using In-Check DIAL for the Different Inhaler Devices in Elderly with Obstructive Airway Diseases","author":"Kawamatawong","year":"2017","journal-title":"J. Asthma Allergy"},{"key":"B14","doi-asserted-by":"publisher","first-page":"1308","DOI":"10.1183\/09031936.00166410","article-title":"What the Pulmonary Specialist Should Know about the New Inhalation Therapies","volume":"37","author":"Laube","year":"2011","journal-title":"Eur. Respir. J."},{"key":"B15","doi-asserted-by":"publisher","first-page":"1305","DOI":"10.1513\/annalsats.201611-903oc","article-title":"Suboptimal Inspiratory Flow Rates Are Associated with Chronic Obstructive Pulmonary Disease and All-Cause Readmissions","volume":"14","author":"Loh","year":"2017","journal-title":"Ann. ATS"},{"key":"B16","doi-asserted-by":"publisher","first-page":"1103","DOI":"10.1513\/AnnalsATS.201702-156PS","article-title":"Peak Inspiratory Flow Rate as a Criterion for Dry Powder Inhaler Use in Chronic Obstructive Pulmonary Disease","volume":"14","author":"Mahler","year":"2017","journal-title":"Ann. Am. Thorac. Soc."},{"key":"B17","doi-asserted-by":"publisher","first-page":"321","DOI":"10.15326\/jcopdf.6.4.2019.0137","article-title":"Nebulized versus Dry Powder Long-Acting Muscarinic Antagonist Bronchodilators in Patients with COPD and Suboptimal Peak Inspiratory Flow Rate","volume":"6","author":"Mahler","year":"2019","journal-title":"Chronic Obstr Pulm. Dis."},{"key":"B18","doi-asserted-by":"publisher","first-page":"1577","DOI":"10.1164\/rccm.201901-0005le","article-title":"Peak Inspiratory Flow Rate: An Emerging Biomarker in Chronic Obstructive Pulmonary Disease","volume":"199","author":"Mahler","year":"2019","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"B19","doi-asserted-by":"publisher","first-page":"174","DOI":"10.1089\/jamp.2012.0987","article-title":"Prevalence and COPD Phenotype for a Suboptimal Peak Inspiratory Flow Rate against the Simulated Resistance of the Diskus Dry Powder Inhaler","volume":"26","author":"Mahler","year":"2013","journal-title":"J. Aerosol Med. Pulm. Drug Deliv."},{"key":"B20","doi-asserted-by":"publisher","first-page":"103","DOI":"10.1089\/jamp.2013.1038","article-title":"Comparison of Dry Powder versus Nebulized Beta-Agonist in Patients with COPD Who Have Suboptimal Peak Inspiratory Flow Rate","volume":"27","author":"Mahler","year":"2014","journal-title":"J. Aerosol Med. Pulm. Drug Deliv."},{"key":"B21","doi-asserted-by":"publisher","first-page":"257","DOI":"10.2147\/copd.s11474","article-title":"Inspiratory Flows through Dry Powder Inhaler in Chronic Obstructive Pulmonary Disease: Age and Gender rather Than Severity Matters","volume":"5","author":"Malmberg","year":"2010","journal-title":"Int. J. Chron. Obstruct Pulmon Dis."},{"key":"B22","doi-asserted-by":"publisher","first-page":"1601794","DOI":"10.1183\/13993003.01794-2016","article-title":"Chronic Obstructive Pulmonary Disease Exacerbation and Inhaler Device Handling: Real-Life Assessment of 2935 Patients","volume":"49","author":"Molimard","year":"2017","journal-title":"Eur. Respir. J."},{"key":"B23","doi-asserted-by":"publisher","first-page":"e0227737","DOI":"10.1371\/journal.pone.0227737","article-title":"Association between Peak Inspiratory Flow Rate and Hand Grip Muscle Strength in Hospitalized Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease","volume":"15","author":"Samarghandi","year":"2020","journal-title":"PLoS One"},{"key":"B24","doi-asserted-by":"publisher","first-page":"1495867","DOI":"10.1155\/2017\/1495867","article-title":"Guiding Inspiratory Flow: Development of the In-Check DIAL G16, a Tool for Improving Inhaler Technique","volume":"2017","author":"Sanders","year":"2017","journal-title":"Pulm. Med."},{"key":"B25","doi-asserted-by":"publisher","first-page":"217","DOI":"10.15326\/jcopdf.4.3.2017.0183","article-title":"Prevalence of Low Peak Inspiratory Flow Rate at Discharge in Patients Hospitalized for COPD Exacerbation","volume":"4","author":"Sharma","year":"2017","journal-title":"Chronic Obstr Pulm. Dis."},{"key":"B26","doi-asserted-by":"publisher","first-page":"236","DOI":"10.3390\/diagnostics11020236","article-title":"Using Blood Eosinophil Count as a Biomarker to Guide Corticosteroid Treatment for Chronic Obstructive Pulmonary Disease","volume":"11","author":"Sivapalan","year":"2021","journal-title":"Diagnostics (Basel)"},{"key":"B27","doi-asserted-by":"publisher","first-page":"1497","DOI":"10.1164\/rccm.200410-1414oc","article-title":"Regional Lung Deposition and Bronchodilator Response as a Function of \u03b22-Agonist Particle Size","volume":"172","author":"Usmani","year":"2005","journal-title":"Am. J. Respir. Crit. Care Med."},{"key":"B28","doi-asserted-by":"publisher","first-page":"461","DOI":"10.2147\/tcrm.s160365","article-title":"Choosing the Right Inhaler for Your Asthma or COPD Patient","author":"Usmani","year":"2019","journal-title":"Ther. Clin. Risk Manag."},{"key":"B29","doi-asserted-by":"publisher","first-page":"10","DOI":"10.1186\/s12931-017-0710-y","article-title":"Critical Inhaler Errors in Asthma and COPD: a Systematic Review of Impact on Health Outcomes","volume":"19","author":"Usmani","year":"2018","journal-title":"Respir. Res."},{"key":"B30","doi-asserted-by":"publisher","first-page":"151","DOI":"10.1159\/000088095","article-title":"Inspiratory Muscle Training May Increase Peak Inspiratory Flow in Chronic Obstructive Pulmonary Disease","volume":"73","author":"Weiner","year":"2006","journal-title":"Respiration"}],"container-title":["Frontiers in Pharmacology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fphar.2021.704316\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,6,29]],"date-time":"2021-06-29T05:54:44Z","timestamp":1624946084000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fphar.2021.704316\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,6,29]]},"references-count":30,"alternative-id":["10.3389\/fphar.2021.704316"],"URL":"https:\/\/doi.org\/10.3389\/fphar.2021.704316","relation":{},"ISSN":["1663-9812"],"issn-type":[{"value":"1663-9812","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,6,29]]},"article-number":"704316"}}