Asthma and inhaler usage tips - part 2

Active ingredients, such as salbutamol or beclometasone, are mixed with a propellant in a canister. When
a person presses upwards on the actuator, a standardised dose of the active ingredients is pushed by the
metering valve into the mouthpiece The person then inhales the active ingredients into his/her airways

 The first pressurized metered-dose inhaler (pMDI) was developed way
back in 1955 by Dr. George Maison.
 A pMDI is designed to deliver a precise (metered) amount (dose) of
medication in a fine mist (an aerosol) that can be inhaled directly into
the lungs .
 Drug delivery with the pMDIs is approximately 10–20% of the nominal
dose per actuation.

 The pMDI is now considered one of the most popular ways to deliver
aerosol medication.
 Regardless of manufacturer or the medication included, the basic
components of the pMDI include the canister, propellants, drug (also
called formulary), metering valve, actuator (or boot), and sometimes a
dose counter.

 The medication is released from the pMDI by pressing the canister into the
boot. This is called actuation.
 The canister is in the boot is upside down so that the valve sits inside the
nozzle.
 When the canister valve is pressed into the nozzle, the pressurized
propellant forces a dose of the medication through the nozzle.The liquid
medication is immediately turned into an aerosol, which you inhale. The
same amount of medication is released with each actuation.

Propellants
 Provides the force to generate the aerosol cloud and is also the medium
in which the active component must be suspended or dissolved.
 The two types of propellants used with pMDIs are CFCs and HFAs.
 Because of CFCs’ detrimental effect on the earth’s ozone layer and
contributions to global warming, CFCs were banned worldwide.

CFC pMDIHFA pMDI
HFA and CFC propellant pMDI
CFC inhalers emit a strong and sharp mist when used. In contrast, HFA inhalers emit a soft and gentle
mist

pMDI-Propellants -HFA
1. Hydrofluoroalkane- propellant replaced CFC
2. Safer for ozone layer - environmentally friendly
3. No cold freon effect
4. Remains a gas at very low temperatures
5. Improved delivery to peripheral airways
8

25
The inhaler is called an "Evohaler" - these are just parts of the brand
name, and reflect the fact that the inhalers contains no CFC propellants.

Occasionally you may experience a problem when using your pMDI. The most common problem is low
output or no mist following actuation.

 When pMDIs were first released onto the market, there was no way to know
how many puffs of medication were left in the canister.
 Many people thought that as long as they heard or felt something inside the
canister when it was shaken, then there was medication left.
 However, there is not an exact 1-to-1 ratio of medication to propellant. There
is always slightly more propellant than medication. So even if you still
feel/hear something inside the canister when shaken, it may only be
propellant.

 It is not always possible to determine when your inhaler is empty by
shaking it; even when the medication is gone, some propellant
remains in the canister.
 A few inhalers now have dose counters to track the amount of the
medication used, including Ventolin-HFA.
Determine when an inhaler is empty

 In the past, you may have been told to drop the canister into a bowl of
water and see how it floats. However, this method is not reliable and
it is no longer recommended.
 Spraying the inhaler is also not recommended because even an empty
inhaler will continue to spray.

 If you use your rescue inhaler infrequently, write the date you start using it
on the canister in permanent marker and consider refilling it after three
to four months, or sooner if you think it is no longer effective.
 Another option is to check the package insert to determine the number of
puffs or sprays available in the inhaler. You can then divide that number
by the average number of puffs you use each month.
 For example: If you use about eight puffs each week, divide 200 by 8 =
25 weeks (about 5 months)33

 The only reliable method to determine the number of doses remaining
in a pMDI is to manually count and record in a log every individual puff
(actuation) given, including both priming and therapy doses.
 This tally is then subtracted from the total number of puffs (actuations)
listed on the label until all have been used.

 For example, if a new pMDI has 200 actuations when full, the canister
would need to be replaced when the total number of actuations
(including priming) started to reach 200. At that time the pMDI should
be properly disposed of.
 Unfortunately, the manual counting of doses may not be practical and/or
dependable, especially if you are using your medication as a quick
reliever and are always on the go.

 Fortunately, the U.S. Food and Drug Administration (FDA) now requires
all new pMDIs to have dose counters built into the boot.
 The dose counter is set to the total number of actuations. With each
actuation, the number is decreased until no more doses are left.

Shaking the Canister:
 If your pMDI is left sitting for an extended period of time between uses,
the medication and the propellant can separate. So you will need to
shake the canister before you use the pMDI.
 Not shaking the pMDI canister before use can reduce the delivered
dose of medication by as much as 25%.

 The patient should also be instructed that on first use, and after several
days or weeks of disuse, the pMDI should be primed.
 Priming the pMDI involves discharging two to four doses into the
surrounding air (away from the patient) prior to use.
 Patients should be encouraged to follow the priming instructions described
in the PIL , pMDIs have extra doses - initial priming.
Priming

 Priming is Recommended before their initial use - ensure accurate mixing of
propellant and medication
 Additional priming –
1) if a period of time has elapsed between uses
2) If pMDI is dropped.
 pMDIs that are brand new or have not been used for a period of time should
be primed. Simply shake the pMDI, depress the canister, and release 1 or
more sprays into the room.

 Initial and frequent priming of pMDIs is required in order to provide an
adequate dose.
 The drug may be separated from the propellant and other ingredients in
the canister and metering valve when the pMDI is new or has not been
used for awhile.
 Because shaking the pMDI will mix the suspension in the canister but not
the metering chamber, priming of the pMDI is required.

 Whenever you use a pMDI, you should begin by shaking the canister. This
is done to mix the propellant and the medication. But what about the
dose that is already in the metering chamber and is about to be inhaled
into the airway with the next actuation?
 This dose may not be mixed and the drug may have separated from the
propellant. This uncertain dose should be released into the air. This is
called priming.

Storage Temperature:
 For best results, pMDIs should be stored at or near room temperature.
 If a pMDI is left in a cold car overnight, it might not work until it returns to
room temperature.
 Outdoor use of pMDIs in very cold weather may signiﬁcantly decrease
aerosol drug delivery. For example, although dose delivery from CFC
pMDIs decreased by 70% at 10ºC, it was constant with HFA pMDIs over
the range of -20º to 20ºC.

 Cold temperatures will reduce the efficacy of a CFC-driven pMDI;
therefore, the canister should be kept warm (ie, stored close to the body
when outside in winter).
 In case of exposure to cold, one should roll the canister between the
palms of the hands to warm it up.
46

Timing of Actuation Intervals:
 When you take your treatment, you should allow for a pause between
each puff from the inhaler.
 It is recommended that you wait approximately 1 minute between
each puff as this may improve the action of the drug.
 The rapid actuation of more than two puffs with the pMDI may reduce
drug delivery because of turbulence and the coalescence of particles.

 Failing to wait following each puff of medication may result in little
or no medication being delivered during the next actuation
 This because the metering chamber may not have refilled
completely and redistribution of the drug and gas propellant will be
inadequate.
48

Advantages of pMDI:
1. Consistent dose emission
2. Wide range of available drugs
3. Multi-dose
4. Quick to use
5. Small, portable, and discreet
6. Familiar to HCPs and patients
7. Typically less expensive than other inhaler devices
8. Lower risk of bacterial contamination
50

 Drug delivery is highly dependent on the patient’s inhaler technique.
1) Failure to coordinate or synchronize actuation with inhalation is the
most important problem patients have with pMDIs.
 The misuse of pMDIs can result in a suboptimal, or even zero, lung
deposition, Misuse of pMDIs is associated with poor asthma control.
52
limitations of pMDIs

2) High oropharyngeal deposition :
 Another problem with CFC pMDIs is that even with good inhaler technique
they deposit only 10–20% of the dose in the lungs, with most of the dose
being deposited in the oropharynx.
 High oropharyngeal deposition of ICS can cause localized adverse effects
(dysphonia and candidiasis) and systemic adverse effects.

 Among patients taking ICS by using a pMDI, failure to maintain
meticulous oral hygiene (rinse, gargle and spit) after each dose will
increase the risk of ‘thrush’ (oropharyngeal candidiasis) and hoarseness,
caused by ICS deposited in the mouth and pharynx.
 For those using a pMDI, the risk of these local side-effects can also be
reduced by using a valved spacer.

3)The cold freon effect :
 Refers to the phenomenon where the arrival of the cold propellant
spray on the back of the throat hitting the posterior pharynx-
stimulates cough and causes patient to momentarily stop breathing
and prevents effective inhalation.
 This occurs particularly with CFC-containing inhaler devices., (Freon is
the registered trademark of CFCs from DuPont)

 CFC (Chlorofluorocarbon-driven devices), Less effective in cold climate
( deliver reduced doses when exposed to cold ).
 HFA (Hydrofluoroalkane driven canisters) deliver consistent doses even
when exposed to temperatures as low as –20°C

 The inhaler should be replaced when the medication has expired (see date
printed on canister) or when the inhaler is nearing empty.
 It should be noted that CFC pMDIs need to be replaced ( shortly at least one
or two weeks ) before they are completely empty because the dose
delivered becomes inaccurate as it nears empty…...This is commonly
known as the tailoff effect (reduction of drug output as the device nears
empty).
 HFA pMDIs deliver a more consistent dose throughout the life of the
4)The Tailoff effect :

Metered Dose Inhalers -3 basic techniques

Overcoming challenges- pMDI
Spacers /holding chambers
 Eliminates need for coordination
 Allow aerosol to expand
 Allow more complete evaporation of propellants &
deposition of these particles in the device before inhalation
 Ensure aerosol particles have
 A slower velocity
 A smaller particle size when they reach patient
 ↓ Oropharyngeal deposition (from 80% to 30%)

82
Aerochamber spacer With mouth piece
Aerochamber spacer with mask

Not all Spacers are created equal

 There are many spacers on the market, although little is known about
the benefit of one type versus another. In general, larger-sized spacers
appear to be more effective than smaller ones.
 Proper technique and frequent cleaning are important to ensure
optimal drug delivery.

 Easier to use than pMDI, no
coordination needed
 Reduced oropharyngeal
deposition
 Smaller particles penetrate further
into lungs depositing a greater
proportion of drug
 Available with mask
 More bulky than pMDI
 Propellants required
 Plastic spacers particularly
susceptible to effects of static
charge
 Multiple actuations into spacer
reduce output per dose
 Bacterial contamination is possible
Advantages Disadvantages
pMDI plus spacer

Cleaning Your Spacers /holding chambers
 Take the spacer apart.
 Gently move the parts back and forth in warm water using a mild soap.
 Never use high-pressure or boiling hot water, rubbing alcohol or
disinfectant.
 Do not dry inside of the spacer with a towel as it will cause
electrostatic charge that attracts aerosolized particles to the walls of
the chamber, thereby decreasing drug output..
 let the parts air dry (for example, leave them out overnight).
 Put the spacer back together.

Cleaning Your Spacers /holding chambers
 Spacers should be cleaned before first use and then monthly by
soaking in a solution of warm water with kitchen detergent for 15
minutes
 Shake out the excess water and allow to air dry.
 Drying with a cloth or paper towel can result in electrostatic charge on
the inside of the spacer, which can reduce availability of dose.
 Spacers should be reviewed every 6–12 months to check the structure
is intact (e.g. no cracks) and the valve is functioning.

Anti-Static Holding Chamber
Introducing the new PARI Vortex™ Non-
Electrostatic Valved Holding Chamber. It's a
revolutionary breakthrough in holding
chamber technology.
The non-electrostatic charge of the PARI
Vortex ensures that patients receive a more
consistent medication dose treatment after
treatment, day after day.

Important reminders about Spacers
 Only use your spacer with a pressurized inhaler, not with a dry-powder
inhaler.
 Spray only one puff into a spacer at a time.
 Use your spacer as soon as you've sprayed a puff into it.
 Never let anyone else use your spacer.
 Spacers should be replaced as per manufacturer’s recommendations
(typically 6–12 months for plastic spacers), or if visibly damaged.

True or false?
crying is good……
more medication
gets into the
lungs!

No… It is a myth!
When the child cries they have
prolonged expiration with very short and fast inhalation

 Only After using ICS , the throat and mouth should be rinsed
thoroughly (gargle deeply, rinse, and spit out) or in young children
using a spacer with face mask, the face should be washed off with
plain water.
 Multiple doses should be given as separate doses..Never double puff
(i.e. depress canister once, then immediately depress again) because
the second puff contains only propellant; wait at least 30 seconds
between puffs to allow proper medication-propellant mixing.

1. To overcome difficulties of patients who are unable to use pMDIs correctly
(ie, because of coordination problems, physical or mental handicaps, etc)
2. To reduce the risk of adverse effects with inhaled respiratory medications
(especially when using high doses of inhaled corticosteroids)
3. To decrease or eliminate coughing or arrested inspiration experienced by
some patients when using CFC-driven devices
4. To administer inhaled medication during severe asthma exacerbations as
recommended by ATS

Use and care of spacers
Inhaler devices. Thorax 2003; 58 (Suppl I):
 Ensure spacer compatible with pMDI used
 Administer drug by repeated single actuations of pMDI into
spacer, each followed by inhalation
 Minimise delay between pMDI actuation and inhalation
 Tidal breathing is as effective as single breaths
 Spacers should be cleaned monthly by washing in detergent
and air drying ,with mouthpiece wiped clean of detergent
before use
 Drug delivery may vary significantly due to static charge
 Replace after 6-12 months

Use and care of spacers
Inhaler devices. Thorax 2003; 58 (Suppl I):
 Ensure spacer compatible with pMDI used
 Administer drug by repeated single actuations of pMDI
into spacer, each followed by inhalation
 Minimise delay between pMDI actuation and inhalation
 Tidal breathing is as effective as single breaths
 Spacers should be cleaned monthly by washing in
detergent and air drying, with mouthpiece wiped clean of
 pMDI + spacer is preferred delivery method in children
aged 0-5 years
 pMDI + spacer is as effective as other delivery methods
for other age groups
 Choice of inhaler should be based on patient preference
and ability to use

120
Breathe actuated MDI
Autohaler

Breath-actuated pressurised metered-dose inhalers
 BA-pMDIs that are currently available are the Autohaler1 and Easi-
Breathe1.
 They were developed to overcome the commonly encountered problem of
poor actuation–inhalation coordination with standard pMDIs
 Salbutamol and beclomethasone are available as BA-pMDIs in Europe, in
the USA, only pirbuterol is available

Breath-actuated pressurised metered-dose inhalers
 Instruct patients to be sure that they have triggered the dose during the
inhalation. This is noticed by taste, sensation, or a noise that confirms
dose emission. The noise from the Easi- Breathe is quiet and resembles
a ‘‘whoosh’’ sound.
 With extra-fine QVAR1 BA-pMDI and instruct patients to rinse their
mouths out after inhaling.

Dry-Powder Inhalers (DPIs)
 DPIs deliver the medication to the lungs as a very fine powdered
form.
 Since DPIs have no propellant, the medication is drawn into your
lungs as you take in a breath. This means you need to inhale quickly
and deeply to get the medication from the device way into your
lungs.

Dry-Powder Inhalers (DPIs)
 DPIs are breath actuated. This means that DPIs do not contain propellant
(the stuff in the pMDI that produces the force to change liquid medication
into an aerosol).
 Instead, the fine powder is drawn from the DPI when you take a fast, deep
breath through the DPI. So, it is the patient using the DPI who provides the
force to get the medication out of the device.

 Do not swallow FORADIL capsules.
 Never place a capsule directly into the mouthpiece
 Hold the mouthpiece of the AEROLIZER Inhaler upright and press both
buttons at the same time. Only press the buttons ONCE.
 You should hear a click as the FORADIL capsule is being pierced.
 Do not exhale into the AEROLIZER mouthpiece
 Tilt your head back slightly. Keep the AEROLIZER Inhaler level, with the
blue buttons to the left and right (not up and down)
149
Using aerolizer

 Breathe in quickly and deeply . This will cause the FORADIL capsule to
spin around in the chamber and deliver your dose of medicine.
 You should hear a whirring noise and experience a sweet taste in your
mouth.
 If you do not hear the whirring noise, the capsule may be stuck. If this
occurs, open the AEROLIZER Inhaler and loosen the capsule allowing it to
spin freely.
 Do not try to loosen the capsule by pressing the buttons again.
150
Using aerolizer

Turbuhalers
o Dry powder
o No propellant
o Requires patient effort
o Not compatible with spacer
o Requires breath hold
o Window with dose information
o Twist the base in both directions
to load

Step 1. Pull off cap
Step 2. Open inhaler
Step 3. Prepare capsule
Step 4. Remove a UTIBRON capsule (Capsules should always be stored in the
blister and only removed immediately before use).
Step 5. Insert capsule
Step 6. Close the inhaler
Step 7. Pierce the capsule (Do not press the piercing buttons more than 1 time).
Step 8. Release the piercing buttons fully
Step 9. Breathe out
Step 10. Inhale the medicine (Breathe in rapidly but steadily, as deeply as you can)
Simple Steps to Use Neohaler

Step 11. Note If you do not hear a whirring noise, (the capsule may be stuck in the
capsule chamber. If this occurs, open the inhaler and carefully loosen the capsule
tapping the base of the inhaler)
Step 12. Hold breath
Open the inhaler to see if any powder is left in the capsule. If there is powder left
the capsule, close the inhaler and repeat steps 9 to 12.
Most people are able to empty the capsule in 1 or 2 inhalations.
Some people may cough soon after inhaling the medicine. If you do, don’t worry,
long as the capsule is empty, you have received 1 full dose.
Step 13. Remove capsule
Simple Steps to Use Neohaler

FOR INTERNAL USE ONLY. STRICTLY CONFIDENTIAL.
DO NOT COPY, DETAIL OR DISTRIBUTE EXTERNALLY
Respimat® unique mist
• The Respimat® unique mist has all the properties needed for deep lung deposition
Aerosol velocity: the unique mist is slow-moving, allowing it to
follow the natural curve of the throat, resulting in lower deposition
in mouth and throat1
Aerosol duration: the unique mist cloud is long-lasting (1.5 s).
Patients have enough time to breathe in the medication1
Highly respirable, fine droplets: up to 77% of the droplets are in
the fine particle fraction, helping patients get the medication deep
into the lungs2
Respimat® generates a unique mist leading to deep lung deposition
Features and benefits
1. Hochrainer 2005.
2. Ziegler 2005.

DO NOT COPY, DETAIL OR DISTRIBUTE EXTERNALLY.
What is the Respimat® Soft Mist™ Inhaler?
 The Respimat® Soft Mist™ Inhaler is a highly
efficient and effective inhaler developed by
Boehringer Ingelheim1,2
 It delivers a metered dosage of medication by
mechanical energy, without the use of propellants2,3
 The Respimat® Soft Mist™ Inhaler delivers
medication in a slow-moving fine mist and is
designed to overcome problems such as:2,3
o Limited drug deposition in the lung
o Reliance on adequate patient coordination
for effective inhalation
 Use once daily in two consecutive puffs
(2.5 mcg per puff)1
205

The Respimat® Soft Mist™ Inhaler delivers a higher
percentage dose than pMDIs
SLOW INHALATION
FINE
PARTICLES
1–5 µm
Whole lung deposition was higher with Respimat® Soft Mist™ Inhaler than
with pMDI in trained patients (53% of delivered vs. 21% of metered dose)
206
TOTAL LUNG DEPOSITION
Study undertaken in patients with COPD

Improving inhaler technique: basic principles
 There is no clinical difference between inhaler devices when they are used
correctly.
 Each inhaler type requires a different pattern of inhalation for optimal drug
delivery to the lungs
Key recommendations
 Invest the time to train each patient in proper inhaler technique.
 Recheck inhaler technique on each revisit.
 Take patient preference into account when choosing the inhaler device.
 Simplify the regimen and do not mix inhaler device types.

Improving inhaler technique
 Physical demonstration is essential
1. Face-to-face or video (van der Palen 1997; Basheti 2005)
2. Written instructions are ineffective (Bosnic-Anticevich 2010)
 Education must be repeated
1. Skills drop off within 4-6 weeks for both patients and health professionals
2. Useful to check periodically even for highly experienced patients
 Repeated inhaler skills training is highly effective
1. Brief education in community pharmacy leads to improved asthma
outcomes (Basheti JACI 2007)
2. Average 2.5 minutes (Basheti Patient Educ Couns 2008)218

Each type of inhalers requires a different pattern of inhalation for optimal
drug delivery to the lungs.
Problems with inhaler technique are common in clinical practice & can
lead to poor asthma control.
Asthma control worsens as the number of mistakes in inhaler technique
increases.
Key recommendations:

All patients should be trained in technique, and trainers should be
competent with the inhalation technique
Asthma control can be improved by brief verbal instruction and physical
demonstration of correct inhaler technique, taking only a few minutes
and repeated regularly
Key recommendations:

Q1. A spacer should only be used with what type of inhaler to
help enhance a patient’s use?
a) Metered dose inhalers
b) Dry powdered inhalers
c) Nebulizers
d) A & B
e) All of the above

Q2. Which of the following is/are not true of the volumatic
spacer device?
a) Reduces deposition of inhaled drug in the mouth
b) Allows drug to be inhaled in more than one breath
c) Allows an MDI to be used by people with poor coordination
d) Whistles when individual inhales with too great a force
e) Have a tendency to build up static charge which reduces the
amount of drug inhaled from the spacer

Q2. Which of the following is/are not true of the volumatic
spacer device?
a) Reduces deposition of inhaled drug in the mouth
b) Allows drug to be inhaled in more than one breath
c) Allows an MDI to be used by people with poor coordination
d) Whistles when individual inhales with too great a force
e) Have a tendency to build up static which reduces the amount of
drug inhaled from the spacer

Q3. Which of the following does not require a single intake of
breath?
a) Metered dose inhaler
b) Metered dose inhaler with volumatic spacer
c) Turbuhaler
d) Accuhaler
e) Handihaler

Q4. Which of the following are breath actuated?
a) Turbuhaler
b) Metered Dose Inhaler
c) Handihaler
d) Accuhaler
e) Noe of the above

Q5. The following is not common problems with all inhalers:
a) Candida Infection
b) Poor actuation–inhalation coordination
c) Insufficient inspiratory flow rate/strength to adequately inhale drug
d) Throat irritation and soreness
e) Difficulty using in patients with hand disorders

Q6 . Which of the following comes as a dry powdered inhaler?
a) Flixotide Diskus 
b) Ventolin HFA 
c) Combivent Respimat 
d) Seebri neohaler 
e) Symbicort turbuhaler 

Asthma and inhaler usage tips - part 2

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Asthma and inhaler usage tips - part 2