An Interesting Case of a Tattoo Artist's Subdermal Chest Implants.

Inhaled bronchodilators and corticosteroids delivered pressurised metered-dose inhalers (pMDIs) or dry powder inhalers (DPIs) are the cornerstone of pharmacological treatment for COPD. When used correctly, inhalers across categories can be equally effective [], yet handling errors are frequent and associated with worse outcomes and greater healthcare use [–]. In a large observation study [], critical inhaler errors occurred in 28% of pMDI users and in 11–32% of DPI users []. In older adults, these errors can precipitate exacerbations, avoidable hospital use, and functional decline []. Older adults face additional barriers. >10% of those aged >75 years have COPD [], and age-related changes, comorbidities, polypharmacy and physical or cognitive decline contribute to incorrect technique [, , ]. Inhaler error rates with DPIs rise steeply with age, reaching 80% in those aged ≥80 years []. Cognitive impairment is particularly relevant, as deficits in attention, memory and executive functioning hinder learning, and retention of correct inhaler use [–]. Reduced grip strength, poor dexterity, and musculoskeletal disease further contribute [, , ]. In long-term care and during care transitions, inhaler use is often supervised, so device complexity increases the burden of medication-administration and the risk of errors. Brief training may help, but inhaler misuse often persists in older patients with cognitive or physical impairment []. Inhaler design influences the likelihood of handling errors []. Capsule-based DPIs (cDPI, the Breezhaler; Novartis, Switzerland), require capsule insertion/perforation, which challenge patients with visual or motor deficits [], whereas multidose DPIs (mDPI, the Ellipta; GlaxoSmithKline, UK), are pre-loaded and involve a three-step operation []. Although fewer handling errors have been reported with Ellipta in healthy adults [], its performance in frail cognitively impaired older populations remains uncertain. Structured training can improve inhaler technique acquisition and retention [, ]. Building on this evidence, we applied a previously validated [, ], intensive, three-step programme, combining expert tuition, video instruction and repeated assessment, to older COPD patients with physical and cognitive impairment. We compared correct technique acquisition and 1-month retention across three devices (Ellipta mDPI, Breezhaler cDPI and pMDI) and assessed whether device design confers additional benefit beyond structured training.