A Full List of All Our Published INCA Articles & Links

Remotely Monitored Therapy and Nitric Oxide Suppression Identifies Non-Adherence in Severe Asthma

Digital technologies and adherence in respiratory diseases: the road ahead

Evaluation of criteria for clinical control in a prospective, international, multicenter study of patients with COPD

Eosinophils increase airway sensory nerve density in mice and in human asthma

Personalising adherence-enhancing interventions using a smart inhaler in patients with COPD: an exploratory cost-effectiveness analysis


A novel statistical method for assessing effective adherence to medication and calculating optimal drug dosages.


Objective Assessment of Patient Inhaler User Technique Using an Audio-Based Classification Approach


Reduction in exhaled nitric oxide tracks improved patient inhaler compliance in difficult asthma–a case study


A randomised clinical trial of feedback on inhaler adherence and technique in patients with severe uncontrolled asthma


Colonisation of Irish patients with chronic obstructive pulmonary disease by Streptococcus pneumoniae and analysis of the pneumococcal vaccine coverage: a non-interventional, observational, prospective cohort study


In patients with severe uncontrolled asthma, does knowledge of adherence and inhaler technique using electronic monitoring improve clinical decision making? A protocol for a randomised controlled trial


Irregular and Ineffective: A Quantitative Observational Study of the Time and Technique of Inhaler Use


The Impact of Common Inhaler Errors on Drug Delivery: Investigating Critical Errors with a Dry Powder Inhaler


Changing a hospital inhaler policy to improve in-hospital inhaler use


The INCA (Inhaler Compliance Assessment): A Comparison with established measures of adherence


P220 Determinants of inhaler adherence in a copd population


P152 Inhaled corticosteroid (ICS) and long acting beta-adrenoceptor agonist (LABA) therapy adherence reporting and monitoring in clinical trials of severe adult asthma drug treatments: a systematic review


P208 Behavioural feed-back education intervention to enhance adherence in patients with severe uncontrolled asthma, a randomised clinical trial


Characterization of patient inhaler inhalation sounds using non-contact and tracheal microphones


Changes in inhaler inhalation acoustic features during induced bronchoconstriction: A pilot study


Abstract: A new clinically relevant method of calculating adherence


Objective assessment of adherence to inhalers by COPD patients.


A protocol for a randomised clinical trial of the effect of providing feedback on inhaler technique and adherence from an electronic device in patients with poorly controlled severe asthma


The effect of providing feedback on inhaler technique and adherence from an electronic audio recording device, INCA®, in a community pharmacy setting: study protocol for a randomised controlled trial.


A method to assess adherence in inhaler use through analysis of acoustic recordings of inhaler events


The Acoustic Features of Inhalation can be Used to Quantify Aerosol Delivery from a Diskus™ Dry Powder Inhaler. 


Acoustic Analysis of Inhaler Sounds From Community-Dwelling Asthmatic Patients for Automatic Assessment of Adherence.


Using acoustics to estimate inspiratory flow rate and drug removed from a dry powder inhaler.


An acoustic method of automatically evaluating patient inhaler technique.


A Method to Calculate Adherence to Inhaled Therapy That Reflects the Changes in Clinical Features of Asthma


An acoustic method to automatically detect pressurized metered dose inhaler actuations.


An Acoustic-Based Method to Detect and Quantify the Effect of Exhalation into a Dry Powder Inhaler.


A method of estimating inspiratory flow rate and volume from an inhaler using acoustic measurements.


Predicting asthma exacerbations employing remotely monitored adherence.×tamp=20170314192957&signature=c63366c7de26937c31f20b1f49a90bf3&tinyUrl=


Automatic identification and accurate temporal detection of inhalations in asthma inhaler recordings.


Investigating the relationship between peak inspiratory flow rate and volume of inhalation from a Diskus™ Inhaler and baseline spirometric parameters: a cross-sectional study.


In vitro correlation of inhalational acoustics from a Dry Powder Inhaler with drug delivery.


Monitoring Inhaler Inhalations Using an Acoustic Sensor Proximal to Inhaler Devices.


Influences of gender and anthropometric features on inspiratory inhaler acoustics and peak inspiratory flow rate.


A nurse-led intervention study: Promoting compliance with Diskus Inhaler use in asthma patients.




BACKGROUND:  Cross-sectional observational studies suggest that between 50% and 60% of patients misuse a dry powder inhaler, whereas studies with electronic monitors indicate that patients sometimes overuse/underuse their inhalers. It is not known what impact errors and erratic use have on inhaler adherence.

OBJECTIVES: The purpose of this study was to longitudinally quantify when and how patients adhered to a twice-daily preventer treatment by using a novel acoustic recording device attached to an inhaler (INhaler Compliance Assessment).

METHODS: Patients with a history of asthma or chronic obstructive pulmonary disease (n = 123) from primary care and community pharmacies were given an INhaler Compliance Assessment-adapted inhaler for 1 month. Analysis of the audio files provided quantitative information on time and technique of inhaler use.

RESULTS: Data were available for 103 patients. Twenty-one patients (20%) used their inhaler in the correct manner at the correct interval. There were 5045 audio files with attempted inhalations, of which 1204 had technique errors (24%). Errors included inadequate flow (27%), drug priming without inhalation (19%), exhalation into the inhaler (18%), and multiple inhalations (25%). On average, participants made errors 20% of the time. Of 60 doses expected to be taken in a month per person, on average 49 doses (82%) were attempted and when errors were accounted for, the average number of actual doses taken was 34 doses (57%; P < .01) comparing attempted to actual doses.

DISCUSSION: These data highlight that ineffective and irregular inhaler use is common and when combined in a single calculation indicate that only 20% of participants used their inhaler correctly and on time.




Objective Assessment of Adherence to Inhalers by COPD Patients

RATIONALE: Objective adherence to inhaled therapy by patients with COPD has not been reported.

OBJECTIVES: The aim of this study was to objectively quantify adherence to preventer DiskusTM inhaler therapy by patients with COPD with an electronic audio recording device (INCATM).

METHODS: This was a prospective observational study. On discharge from hospital patients were given a salmeterol/fluticasone inhaler with an INCATM device attached. Analysis of this audio quantified the frequency and proficiency of inhaler use.

MEASUREMENTS AND MAIN RESULTS: COPD patients (n=265) were recruited. The mean age 71 years, mean Forced Expiratory Volume in 1-second 1.3 Litres, and 80% had evidence of mild/moderate cognitive impairment. By combining time of use, interval between doses and critical technique errors, thus incorporating both intentional and unintentional non-adherence, a measure "Actual Adherence" was calculated. Mean Actual Adherence was 22.9% of that expected if the doses were taken correctly and on time. Seven percent had an Actual Adherence>80%. Hierarchical clustering found three equally sized well-separated clusters corresponding to distinct patterns: Cluster 1 (34%) had low inhaler use and high error rates, Cluster 2 (31%) had high inhaler use and high error rates, and Cluster 3 (30%) had overall good adherence. Lung function and co-morbidities were predictive of poor technique, while age and cognition with poor lung function distinguished those with poor adherence and frequent errors in technique.

CONCLUSION: These data may inform clinicians both in understanding why a prescribed inhaler is not effective and to devise strategies to promote adherence in COPD.




A Method to Assess Adherence in Inhaler Use

RATIONALE: Poor 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.

OBJECTIVES: This 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.

FINDINGS: The 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).

CONCLUSIONS: This 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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INCA Protocol

Introduction: In clinical practice, it is difficult to distinguish between patients with refractory asthma from those with poorly controlled asthma, where symptoms persist due to poor adherence, inadequate inhaler technique or comorbid diseases. We designed an audio recording device which, when attached to an inhaler, objectively identifies the time and technique of inhaler use, thereby assessing both aspects of adherence. This study will test the hypothesis that feedback on these two aspects of adherence when passed on to patients improves adherence and helps clinicians distinguish refractory from difficult-to-control asthma.

Methods: This is a single, blind, prospective, randomised, clinical trial performed at 5 research centres. Patients with partially controlled or uncontrolled severe asthma who have also had at least one severe asthma exacerbation in the prior year are eligible to participate. The effect of two types of nurse-delivered education interventions to promote adherence and inhaler technique will be assessed. The active group will receive feedback on their inhaler technique and adherence from the new device over a 3-month period. The control group will also receive training in inhaler technique and strategies to promote adherence, but no feedback from the device. The primary outcome is the difference in actual adherence, a measure that incorporates time and technique of inhaler use between groups at the end of the third month. Secondary outcomes include the number of patients who remain refractory despite good adherence, and differences in the components of adherence after the intervention. Data will be analysed on an intention-to-treat and a per-protocol basis. The sample size is 220 subjects (110 in each group), and loss to follow-up is estimated at 10% which will allow results to show a 10% difference (0.8 power) in adherence between group means with a type I error probability of 0.05.

Trial registration number NCT01529697; Pre-results.