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Chronic Obstructive Pulmonary Disease (COPD) is a frequent and disabling disease, and it is responsible for important limitations in daily life and high economic impact on the health system. Patients with moderate to severe COPD are affected by chronic symptoms, poor quality of life and frequent exacerbations, and are at high risk of mortality for respiratory and non respiratory diseases. Pharmacologic treatment, based mainly on bronchodilators and inhaled corticosteroids, is able to modify several outcomes of the disease, although a clear demonstration of the possibility of improving survival is still lacking. Unfortunately, the adherence to the long-term use of inhaled drugs is very low, thereby reducing the impact of the pharmacologic treatment on the progression of the disease. While adherence in the randomised clinical trials is high, several observational data from real life have documented that a variable percentage of between 30 and 50% of patients with COPD use regularly inhaled drugs. Several factors have been associated with a poor adherence, some of them related to demographic characteristics such as age and gender, clinical aspects of the disease (severity, comorbidities), socio-economic factors (education, health literacy, social/familiar support, income), characteristics of the inhaled therapy (dose regimen, number and type of inhalers, satisfaction with inhalers), satisfaction with drug efficacy and clinician expertise. In real life, most severe patients have a better adherence to treatment than patients with mild to moderate disease, probably due to the greater limitation in daily life and to the perception of the efficacy of the treatment. In this issue of Pulmonology, Duarte-de-Araujo and coworkers extended a previous recent observation on a fairly large group of patients with COPD of different severity: they used a specific psychometric tool (Measure of Treatment Adherence), validated for the Portuguese population in 2001, consisting of seven questions leading to a total score ranging from 6 to 42. They demonstrated that 16.5% of the patients examined were classified as non-adherent, and that this percentage was significantly higher in less severe COPD patients. Furthermore, a significant relationship was found between non adherence and FEV1%, also when data were corrected in a logistic analysis by several confounding factors. This relationship may be expected, because the severity of symptoms may promote a more regular use of the inhaled drugs, confirming the positive effect of the pharmacologic treatment. This observation is not new, although the several observational studies in this topic area have not clearly underlined this specific point. In effect, in the usual current clinical practice, low adherence to treatment both in asthma and in COPD is more frequent in less severe patients who do not understand the need for a continuous regular treatment when they only have mild symptoms and limitations. In any case, low adherence to the pharmacologic treatment has been demonstrated to be associated with poor outcomes of the disease, such as increased frequency and severity of symptoms and exacerbations, progressive decline in pulmonary function and even mortality. A second point considered in the paper is the relationship between performance in using inhalers and adherence to treatment. The authors used a clearly defined checklist for the major critical errors according to the different drypowder inhalers (DPI), and they found that almost 40% of the patients misused the recommended inhalers; this was lower with DPIs than with metered dose inhalers (MDIs). In a multivariate analysis, misuse of inhalers was only significantly associated with age, gender, and socio-economic level, while no significant relationship was observed between inhaler technique and adherence to medications. This topic has been extensively reported in the literature: several observational studies showed the high prevalence of incorrect use of the inhalers in both asthma and COPD patients, and that this fact was associated with an inadequate control of the disease in many countries, including Italy and Portugal. In a recent large survey including almost 3000 patients with COPD selected by the general practitioners (GPs) or pulmonary specialists, more than 50% of the patients made one or more critical errors in the use of different devices, more frequently using MDIs and soft-mist inhalers; the rate of severe COPD exacerbations was twice

Is adherence to treatment influenced by the ability to use inhaled devices in patients with COPD correctly?