Background: The optimal inhalation effort using dry powder inhalers (DPI's) varies with the specific inhaler. Accordingly, the device used for instruction in the proper use of the specific DPI should have physical characteristics similar to the actual DPI. However, the precision with which these devices mimic the actual DPI's has not been established. Methods: We measured mouthpiece pressure (P_I) and flow through the In-Check with an added flow resistance (for Diskus^<TM>, Diskhaler^<TM>, Pulmicort^<TM>, Handihaler^<TM>, and Clickhaler^<TM>) and the training whistles (for Diskus, Pulmicort, Symbicort^<TM>, Twisthaler^<TM>) at different inhalation pressures. Results: Both the In-Check with an added flow resistance for individual DPI and the training whistles for each DPI had parabolic Pi-flow relationships similar to the actual DPI. When a curve was drawn from direct readings of the In-Check scale, it fell consistently below that based on the pneumotachometer values. P_I-flow curves of the actual DPI fell below both of the above curves. Among the same type of DPI, P_I-flow relationships resembled each other, but one of 13 in the Diskus group demonstrated curves above and one of 6 in Pulmicort demonstrated curves below the others. The flows at which sounds were generated from the whistle were between 25-50L/min. Conclusions: Both In-Check and training whistles had suitable P_I-flow relationships. Flow readings taken directly from In-Check tended to be lower than the measured value. A few training whistles might generate sounds with efforts below the optimal one.

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Background and Aims: Tulobuterol patch (Tulo) is often used for treatment of elder patient with asthma in Japan. However, there is no evidence either ICS plus Tulo or ICS/LABA combination is better for elder patient. Methods: Elder patients with asthma (aged &ge; 70, n=17) who had treated with budesonide (BUD) 400 μg/day plus Tulo 2mg/day, were randomly assigned either to change control medication to budesonide/formoterol combination (BUD/FM) 320/9μg/day or to keep BUD plus Tulo treatment for 12 weeks. Results: At week 4 and week 12, the BUD/FM group showed significant increase in lung function (FEV_1, %FEV_1) and mini AQLQ score compared with the BUD plus Tulo group. The BUD/FM group also showed decrease in Tumor Necrosis Factor-alpha level in exhaled breath condensate at week 12. No adverse event was observed in both groups. Conclusion: In elder patients with asthma, treatment with BUD/FM does not have any clinical disadvantage and may provide better efficacy in lung function, QOL, and possibly anti-inflammation compared with BUD plus Tulo treatment.

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