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therapeutic Asthma Inhaler techniques
Dr. Ashraf El Adawy 
Consultant Chest Physician 
TB TEAM EXPERT – WHO 
Mansoura – Egypt
History of Inhaled Therapy
5
6
7
8
Asthma therapy 
Controllers 
Inhaled corticosteroids 
Inhaled long-acting b2- agonists 
Oral anti-leukotrienes 
Oral ...
Beclomethasone 
Budesonide 
Fluticasone 
Inhaled corticosteroids
ICS 
11
LABA’s 
12
Combination-LABA/Steroids 
13
14 
Combination-LABA/Steroids
Not all asthma inhalers are the same
16
17
What are the advantages of inhaled therapy? 
Direct delivery of drug to site of action 
Rapid onset of action 
Lower do...
Pharmacokinetics of Inhaled Drugs 
19
20
Factors affecting lung deposition 
1.Particle size 
2.Speed of inspiration (inspiratory flow) 
3.Integrity of airway 
4.Pr...
Airway anatomy (tree) Wiebel 
Upper & lower respiratory tract 
Conducting & gas exchange
Particle dynamics in respiratory tract 
The physical mechanisms governing the movement and deposition of aerosol particle...
Inertial impaction occurs in either the oropharynx or at bifurcations of main branches of the bronchial tree, particularl...
Gravitational sedimentation occurs for smaller particles that are able to follow the airstream and penetrate the more per...
Particle deposition 
26
27 
Deposition of particles 
> 5 μ impaction 
1-5 μ sedimentation 
< 1 μ like gas
28
Particle size is important: those that are too small may be exhaled; those that are too large experience inertial impacti...
●The observed clinical effect is dependent on the amount of drug reaching the lungs at inhalation, lung deposition 
●The a...
Fine-particle fraction (FPF) 
Fine-particle fraction (FPF) is percentage of the aerosol between 1–5 μm that deposit in th...
Mean aerodynamic diameter (MMAD) 
Deposit of particles by size 
Particles > 8 μm are deposited in the oropharynx (90% abso...
MMAD 
Mass Median Aerodynamic Diameter (MMAD) is defined as the diameter at which 50% of the particles by mass are larger...
MMAD =5 μm means ? 
The calculated aerodynamic diameter that divides the particles of an aerosol in half, based on the we...
35
36
How MDI Technology Works
38 
Lung deposition and MMAD
Aim : 
To make an aerosol from the drugs solution or solid particles 
i.Metered dose inhaler (MDI) 
ii.Dry powder inhaler...
Inhalers 
Breath Activated Inhaler 
Nebulizer 
Pressurized Metered Dose Inhaler (pMDI) 
Pressurized Aerosol Inhaler with S...
1.Pressurized metered dose inhaler (pMDI) 
2.MDI with spacers or holding chambers 
3.Breath actuated MDI(BAIs) 
4.Dry powd...
42
43 
Definition of an aerosol 
Aero → air 
Sol → solution 
Liquid or solid suspensions into gas medium 
Particles which...
44
Barriers for using inhalers 
Sub optimal communication between HCP & patient 
Lack of opportunity to discuss fear of sid...
Inhaler technique is it important?
Compton et al (2006) 
Review of evidence from 6 European countries ( Spain, Italy, France, Germany, Netherlands, UK) found...
BTS/SIGN 2011 
Proportion of patients making no mistake with their inhaler 
MDI 23-43% 
DPI 53-59% 
MDI and spacer 55-57%
BTS/SIGN 2011 
Teaching inhaler technique however improved the score 
MDI from 23-43% to 63% 
 DPI from 55-57% to 75%
BTS/SIGN 2011 
Recommend 
Prescribe inhalers only after patients have received training in the use of the device And have...
51
52
Reasons for poor asthma control 
1.Wrong diagnosis or confounding illness 
2.Incorrect choice of inhaler or poor technique...
The most expensive inhaler is an inhaler not taken correctly 
The right inhaler and the right technique is very important
By now: 
–What do you know about MDI? 
–What do you know about DPI? 
–What do you know regarding Nebulizer?
56 
Pressurized metered dose inhaler (pMDI)
57
58
Pressurized MDI
Propellants 
Provides the force to generate the aerosol cloud and is also the medium in which the active component must be...
62
63
HFA and CFC propellant pMDI 
HFA pMDI 
CFC pMDI
HFA improve lung deposition
67
The Global Solution 
Montreal Protocol on Substances that Deplete the Ozone Layer, 1987 
–International treaty, signed by...
In the early days of MDIs the most commonly used propellants were the chlorofluorocarbons CFC 
In 2008 the Food FDA anno...
pMDI-Propellants -HFA 
1.Hydrofluoroalkane- propellant replaced CFC 
2.Safer for ozone layer - environmental friendly 
3.N...
71 
Lung deposition of ICS
The inhaler is called an "Evohaler" - these are just parts of the brand name, and reflect the fact that the inhalers conta...
73
Determine when an inhaler is empty 
 It is not always possible to determine when your inhaler is empty by shaking it; eve...
Build in dose counter
76
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...
LATEST IN MDI
79 
Not include dosimeter
If your inhaler does not have a counter but you use it on a regular basis (eg, two puffs twice per day), you will need a ...
If you use your rescue inhaler infrequently, write the date you start using it on the canister in permanent marker and co...
Priming and wasting doses in pMDIs 
Priming- discharging one or more doses of medication prior to use 
Recommended befor...
Care and Maintenance of the Pressurized Metered-Dose Inhaler 
As with any pressurized container, it is best to avoid temp...
84 
Care and Maintenance of the Pressurized Metered-Dose Inhaler
85
Advantages: 
1.Consistent dose emission 
2.Wide range of available drugs 
3.Multi-dose 
4.Quick to use 
5.Small, portable...
87 
limitations of pMDIs
limitations of pMDIs 
Drug delivery is highly dependent on the patient’s inhaler technique. 
Failure to coordinate or sy...
Another problem with CFC pMDIs is that even with good inhaler technique they deposit only 10–20% of the dose in the lungs...
Among patients taking ICS, failure to maintain meticulous oral hygiene (rinse, gargle and spit) after each dose increases...
The cold freon effect refers to the phenomenon where the arrival of the cold propellant spray on the back of the throat h...
CFC - can turn to liquid in cold temperatures 
Chlorofluorocarbon-driven devices Less effective in cold climate ( delive...
The inhaler should be replaced when the medication has expired (see date printed on canister) or when the inhaler is near...
Hand function in elderly and device
Metered Dose Inhalers 
3 basic techniques: 
1)Directly in mouth 
2)Finger breadth method 
3) Usewith a spacer 
95
96
Using MDI without Spacer
Failing to wait following each puff of medication may result in little or no medication being delivered during the next a...
99
100
Disadvantages of MDIs 
Complicated technique to master 
Failure to shake can alter drug dose. 
Needs correct actuation ...
High Oropharyngeal drug deposition deposition (lower with some CFC-free–devices due to lower emission velocity with small...
Overcoming challenges- pMDI Spacers /holding chambers 
Eliminates need for coordination 
Allow aerosol to expand 
Allow...
Metered-Dose Inhaler 
104
105
106
Advantages of MDI with spacer 
Compensate for poor technique/coordination with MDI 
Spacers slow down the speed of the a...
Using a spacer device with a pMDI increases the proportion of dose delivered to the lungs to 20- 35%, by allowing the par...
109
110 
MDI spacer 
Decrease of oropharyngeal deposition Proposing inhaled CS
©1998, Respironics Inc. Without Spacer With Spacer
Not all Spacers are created equal
114 
Aerochamber spacer
115 
Aerochamber spacer with mask
116 
Aerochamber spacer 
Aerochamber spacer with mask
117
118
119
120
Ventahaler type spacer device
122
Aerochamber (VHC) vs Ventahaler 
Aerochamber plus 
Ventahaler 
1) a 145-mL rigid cylinder made 
of polyester 
2) Adapter t...
124
Using MDI with Spacer
There are many spacers on the market, although little is known about the benefit of one type versus another. In general, ...
127
Cleaning Your Spacer 
Take the spacer apart. 
Gently move the parts back and forth in warm water using a mild soap. 
Ne...
Spacers should be cleaned before first use and then monthly by soaking in a solution of warm water with kitchen detergent...
Anti-Static Holding Chamber 
Introducing the new PARI Vortex™ Non- Electrostatic Valved Holding Chamber. It's a revolution...
Important Reminders About Spacers 
Only use your spacer with a pressurized inhaler, not with a dry-powder inhaler. 
Spra...
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
After using ICS , the throat and mouth should be rinsed thoroughly (gargle deeply, rinse, and spit out) or in young child...
Indications of spacing devices 
1.To overcome difficulties of patients who are unable to use pMDIs correctly (ie, because ...
136 
Notes
137 
MDI and spacer use
MDI with spacing device 
138
•Easier to use than pMDI: no coordination needed 
•Reduced oropharyngeal deposition 
•Smaller particles penetrate further ...
Use and care of spacers 
Inhaler devices. Thorax 2003; 58 (Suppl I): 
•Ensure spacer compatible with pMDI used 
•Administe...
Overview: Inhaler devices 
Inhaler devices. Thorax 2003; 58 (Suppl I): i1-i92 
•pMDI + spacer is preferred delivery method...
142
143
144 
Breathe actuated MDI 
Autohaler
The concept of a breath-actuated pMDI is a good one,because it solves the problem of patient coordination of actuation wi...
146
147
148 
Dry powder inhaler (DPI) single dose
150
151
152
Turbuhaler use
Using Turbuhaler
Turbohalers 
Dry powder 
No propellant 
Requires patient effort 
Not compatible with spacer 
Requires breath hold 
W...
157
158
159
160
162
Using aerolizer 
163
164
Do not swallow FORADIL capsules. 
Never place a capsule directly into the mouthpiece 
Hold the mouthpiece of the AEROLI...
Breathe in quickly and deeply . This will cause the FORADIL capsule to spin around in the chamber and deliver your dose o...
Remove the AEROLIZER Inhaler from your mouth. Continue to hold your breath as long as you can and then exhale. 
Open the...
Improving inhaler technique: basic principles 
There is no clinical difference between inhaler devices when they are used...
Dry powder inhalers 
Advantages: 
Small and portable. 
Built-in dose counter. 
Propellant-free. 
Breath-actuated. 
Sh...
170
Conclusion 
A number of inhalation devices are available for the treatment of pulmonary diseases, each with its own advan...
PITFALLS IN INHALER TECHNIQUE 
Most physicians, pharmacists and asthma patients do not use inhalers properly. 
Many stud...
Improving inhaler technique 
Physical demonstration is essential 
1.Face-to-face or video (van der Palen 1997; Basheti 20...
174
175
Each type of inhalers requires a different pattern of inhalation for optimal drug delivery to the lungs 
Problems with i...
Key recommendations: 
Invest the time to train each patient in proper inhaler technique: 
Observe technique & let patien...
Asthma control can be improved by brief verbal instruction and physical demonstration of correct inhaler technique, takin...
179
Work hard in silence 
Let success make the noise 
180
181
Asthma Inhaler techniques
Asthma Inhaler techniques
Asthma Inhaler techniques
Asthma Inhaler techniques
Asthma Inhaler techniques
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Asthma Inhaler techniques

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Inhaler techniques

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Asthma Inhaler techniques

  1. 1. 1
  2. 2. therapeutic Asthma Inhaler techniques
  3. 3. Dr. Ashraf El Adawy Consultant Chest Physician TB TEAM EXPERT – WHO Mansoura – Egypt
  4. 4. History of Inhaled Therapy
  5. 5. 5
  6. 6. 6
  7. 7. 7
  8. 8. 8
  9. 9. Asthma therapy Controllers Inhaled corticosteroids Inhaled long-acting b2- agonists Oral anti-leukotrienes Oral theophyllines Relievers Inhaled fast-acting b2- agonists
  10. 10. Beclomethasone Budesonide Fluticasone Inhaled corticosteroids
  11. 11. ICS 11
  12. 12. LABA’s 12
  13. 13. Combination-LABA/Steroids 13
  14. 14. 14 Combination-LABA/Steroids
  15. 15. Not all asthma inhalers are the same
  16. 16. 16
  17. 17. 17
  18. 18. What are the advantages of inhaled therapy? Direct delivery of drug to site of action Rapid onset of action Lower dose (than systemic administration) to produce desired effects Minimizes systemic adverse effects
  19. 19. Pharmacokinetics of Inhaled Drugs 19
  20. 20. 20
  21. 21. Factors affecting lung deposition 1.Particle size 2.Speed of inspiration (inspiratory flow) 3.Integrity of airway 4.Proper inhaled device technique
  22. 22. Airway anatomy (tree) Wiebel Upper & lower respiratory tract Conducting & gas exchange
  23. 23. Particle dynamics in respiratory tract The physical mechanisms governing the movement and deposition of aerosol particles in the air are: 1.Impaction 2.Sedimentation 3.Diffusion
  24. 24. Inertial impaction occurs in either the oropharynx or at bifurcations of main branches of the bronchial tree, particularly in the large central airways.  It occurs mainly with large particles or high velocity particles (i.e., those with high inertia), where they are unable to follow the airstream when it changes direction, thus impacting on the airway wall. 24
  25. 25. Gravitational sedimentation occurs for smaller particles that are able to follow the airstream and penetrate the more peripheral bronchioles Particles to settle on to the airway surfaces either during the course of slow steady breathing or during breath-holding Breath-holding is important for smaller particle sizes owing to the increased chance of exhalation of the drug, because they can remain airborne for a considerable time 25
  26. 26. Particle deposition 26
  27. 27. 27 Deposition of particles > 5 μ impaction 1-5 μ sedimentation < 1 μ like gas
  28. 28. 28
  29. 29. Particle size is important: those that are too small may be exhaled; those that are too large experience inertial impaction in the oropharynx and large conducting airways. Increased aerosol particle speed increases the probability of deposition by impaction in the oropharynx and large conducting airways . Slow aerosol particle speed allows more particles to penetrate the peripheral bronchial tree. Breath-holding increases gravitational sedimentation 29
  30. 30. ●The observed clinical effect is dependent on the amount of drug reaching the lungs at inhalation, lung deposition ●The amount of drug reaching the lungs at inhalation, lung deposition, is dependent on the fine particle dose = Fine particle fraction (FPF)
  31. 31. Fine-particle fraction (FPF) Fine-particle fraction (FPF) is percentage of the aerosol between 1–5 μm that deposit in the lung
  32. 32. Mean aerodynamic diameter (MMAD) Deposit of particles by size Particles > 8 μm are deposited in the oropharynx (90% absorbed) Particles with size 5-8 μm are deposited in the large airways Particles with size 2-5 μm are deposited in tracheobronchial region Particles with size 1-2 μm are deposited in the alveolar region Particles with size < 1 μm are passed expiration Rau JL Jr. Respiratory care pharmacology. 2002
  33. 33. MMAD Mass Median Aerodynamic Diameter (MMAD) is defined as the diameter at which 50% of the particles by mass are larger and 50% are smaller
  34. 34. MMAD =5 μm means ? The calculated aerodynamic diameter that divides the particles of an aerosol in half, based on the weight of the particles. By weight, 50% of the particles will be larger than the MMAD and 50% of the particles will be smaller than the MMAD. MMAD of 5 μm =? 50 % of the total sample mass will be present in particles having diameters less than 5 μm, and that 50 % of the total sample mass will be present in particles having an diameter larger than 5 μm.
  35. 35. 35
  36. 36. 36
  37. 37. How MDI Technology Works
  38. 38. 38 Lung deposition and MMAD
  39. 39. Aim : To make an aerosol from the drugs solution or solid particles i.Metered dose inhaler (MDI) ii.Dry powder inhaler iii.Nebulizer Inhalation Devices
  40. 40. Inhalers Breath Activated Inhaler Nebulizer Pressurized Metered Dose Inhaler (pMDI) Pressurized Aerosol Inhaler with Spacer Dry Powder Inhaler (DPI)
  41. 41. 1.Pressurized metered dose inhaler (pMDI) 2.MDI with spacers or holding chambers 3.Breath actuated MDI(BAIs) 4.Dry powder inhaler (DPI) 5.Nebulizers Inhaler devices
  42. 42. 42
  43. 43. 43 Definition of an aerosol Aero → air Sol → solution Liquid or solid suspensions into gas medium Particles which are sufficiently small so as to remain airborne for a considerable period of time
  44. 44. 44
  45. 45. Barriers for using inhalers Sub optimal communication between HCP & patient Lack of opportunity to discuss fear of side effects Patients under-estimate the severity Over-estimate their level of control Technique
  46. 46. Inhaler technique is it important?
  47. 47. Compton et al (2006) Review of evidence from 6 European countries ( Spain, Italy, France, Germany, Netherlands, UK) found : Up to 50% of patients are unable to take their inhaler correctly Up to 40% of children make errors even with a spacer
  48. 48. BTS/SIGN 2011 Proportion of patients making no mistake with their inhaler MDI 23-43% DPI 53-59% MDI and spacer 55-57%
  49. 49. BTS/SIGN 2011 Teaching inhaler technique however improved the score MDI from 23-43% to 63%  DPI from 55-57% to 75%
  50. 50. BTS/SIGN 2011 Recommend Prescribe inhalers only after patients have received training in the use of the device And have demonstrated a satisfactory technique
  51. 51. 51
  52. 52. 52
  53. 53. Reasons for poor asthma control 1.Wrong diagnosis or confounding illness 2.Incorrect choice of inhaler or poor technique 3.Concurrent smoking 4.Concomitant rhinitis 5.Unintentional or intentional nonadherence 6.Individual variation in treatment response 7.Undertreatment Haughney J et al. Respir Med. 2008;102:1681–93.
  54. 54. The most expensive inhaler is an inhaler not taken correctly The right inhaler and the right technique is very important
  55. 55. By now: –What do you know about MDI? –What do you know about DPI? –What do you know regarding Nebulizer?
  56. 56. 56 Pressurized metered dose inhaler (pMDI)
  57. 57. 57
  58. 58. 58
  59. 59. Pressurized MDI
  60. 60. Propellants Provides the force to generate the aerosol cloud and is also the medium in which the active component must be suspended or dissolved. Propellants in MDIs typically make up more than 99% of the delivered dose
  61. 61. 62
  62. 62. 63
  63. 63. HFA and CFC propellant pMDI HFA pMDI CFC pMDI
  64. 64. HFA improve lung deposition
  65. 65. 67
  66. 66. The Global Solution Montreal Protocol on Substances that Deplete the Ozone Layer, 1987 –International treaty, signed by 195 countries Aims to control ozone depleting substances –CFCs, halons, carbon tetrachloride Set phase-out schedule for CFC production and consumption worldwide Final phase-out date set: January 1, 2010
  67. 67. In the early days of MDIs the most commonly used propellants were the chlorofluorocarbons CFC In 2008 the Food FDA announced that inhalers using chlorofluorocarbons as a propellant, could no longer be manufactured or sold as of 2013 69
  68. 68. pMDI-Propellants -HFA 1.Hydrofluoroalkane- propellant replaced CFC 2.Safer for ozone layer - environmental friendly 3.No cold freon effect 4.Remains a gas at very low temperatures 5.Improved delivery to peripheral airways 8
  69. 69. 71 Lung deposition of ICS
  70. 70. 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. 72
  71. 71. 73
  72. 72. Determine when an inhaler is empty  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 medication used, including Ventolin- HFA 74
  73. 73. Build in dose counter
  74. 74. 76
  75. 75. 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 77 Determine when an inhaler is empty
  76. 76. LATEST IN MDI
  77. 77. 79 Not include dosimeter
  78. 78. If your inhaler does not have a counter but you use it on a regular basis (eg, two puffs twice per day), you will need a refill in 30 days. Write the date you will need the refill on the canister in permanent marker, and mark this date on your calendar or planner. 80 Determine when an inhaler is empty
  79. 79. 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) 81 Determine when an inhaler is empty
  80. 80. Priming and wasting doses in pMDIs Priming- discharging one or more doses of medication prior to use Recommended before their initial use - ensure accurate mixing of propellant and medication pMDIs have extra doses - initial priming Additional priming – –if a period of time has elapsed between uses –If pMDI is dropped. 12
  81. 81. Care and Maintenance of the Pressurized Metered-Dose Inhaler As with any pressurized container, it is best to avoid temperature extremes such as heat and cold. 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. 83
  82. 82. 84 Care and Maintenance of the Pressurized Metered-Dose Inhaler
  83. 83. 85
  84. 84. Advantages: 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 86 pMDI
  85. 85. 87 limitations of pMDIs
  86. 86. limitations of pMDIs Drug delivery is highly dependent on the patient’s inhaler technique. 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 ICS pMDIs is associated with decreased asthma stability 88
  87. 87. 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. 89 limitations of pMDIs
  88. 88. Among patients taking ICS, failure to maintain meticulous oral hygiene (rinse, gargle and spit) after each dose increases the risk of ‘thrush’ (oropharyngeal candidiasis) and hoarseness, caused by medication 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. 90 limitations of pMDIs
  89. 89. 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) 91 limitations of pMDIs
  90. 90. CFC - can turn to liquid in cold temperatures Chlorofluorocarbon-driven devices Less effective in cold climate ( deliver reduced doses when exposed to cold ). Hydrofluoroalkane driven canisters deliver consistent doses even when exposed to temperatures as low as –20°C 92 limitations of pMDIs
  91. 91. 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 canister . 93 limitations of pMDIs
  92. 92. Hand function in elderly and device
  93. 93. Metered Dose Inhalers 3 basic techniques: 1)Directly in mouth 2)Finger breadth method 3) Usewith a spacer 95
  94. 94. 96
  95. 95. Using MDI without Spacer
  96. 96. 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 98
  97. 97. 99
  98. 98. 100
  99. 99. Disadvantages of MDIs Complicated technique to master Failure to shake can alter drug dose. Needs correct actuation and inhalation coordination- difficult for children and elderly patients Proper inhalation pattern (slow inspiration to total lung capacity) and breath-hold can be difficult.
  100. 100. High Oropharyngeal drug deposition deposition (lower with some CFC-free–devices due to lower emission velocity with smaller particlesize) Cold freon effect effect (reduced with–HFA hydrofuoroalkane devices) Flammability possibility of new HFA propellants Remaining dose –difficult to determine (no dose counter). Disadvantages of MDIs
  101. 101. Overcoming challenges- pMDI Spacers /holding chambers Eliminates need for coordination Allow aerosol to expand Allow more complete evaporation of propellants & deposition of these in device before inhalation Ensure aerosol particles have –A slower velocity –A smaller particle size when they reach patient –↓ Oropharyngeal deposition (from 80% to 30%)
  102. 102. Metered-Dose Inhaler 104
  103. 103. 105
  104. 104. 106
  105. 105. Advantages of MDI with spacer Compensate for poor technique/coordination with MDI Spacers slow down the speed of the aerosol coming from the inhaler, meaning that less of drug impacts on the back of the mouth and somewhat more may get into the lungs. Because of this, less medication is needed for an effective dose to reach the lungs, and there are fewer side effects from corticosteroid residue in the mouth.
  106. 106. Using a spacer device with a pMDI increases the proportion of dose delivered to the lungs to 20- 35%, by allowing the particles to partly evaporate, by removing the need to coordinate releasing the drug and inhaling, and by reducing the amount of drug deposited at the back of the throat 108
  107. 107. 109
  108. 108. 110 MDI spacer Decrease of oropharyngeal deposition Proposing inhaled CS
  109. 109. ©1998, Respironics Inc. Without Spacer With Spacer
  110. 110. Not all Spacers are created equal
  111. 111. 114 Aerochamber spacer
  112. 112. 115 Aerochamber spacer with mask
  113. 113. 116 Aerochamber spacer Aerochamber spacer with mask
  114. 114. 117
  115. 115. 118
  116. 116. 119
  117. 117. 120
  118. 118. Ventahaler type spacer device
  119. 119. 122
  120. 120. Aerochamber (VHC) vs Ventahaler Aerochamber plus Ventahaler 1) a 145-mL rigid cylinder made of polyester 2) Adapter that makes it compatible with most pMDIs 3) Is available with a mouthpiece or a mask 1) An elliptical-shaped device made of rigid, transparent plastic 2) Capacity of 750 Ml 3) Designed to fit GlaxoSmithKline Products Not fit all pMDIs.
  121. 121. 124
  122. 122. Using MDI with Spacer
  123. 123. 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 126
  124. 124. 127
  125. 125. Cleaning Your Spacer 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. 128
  126. 126. 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. 129 Cleaning Your Spacer
  127. 127. 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.
  128. 128. 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. 131
  129. 129. True or false? crying is good…… more medication gets into the lungs!
  130. 130. No… It is a myth! When the child cries they have prolonged expiration with very short and fast inhalation
  131. 131. 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. 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 Multiple doses should be given as separate doses. 134 Important Reminders About Spacers
  132. 132. Indications of spacing devices 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 exacerbations as recommended by ATS 135
  133. 133. 136 Notes
  134. 134. 137 MDI and spacer use
  135. 135. MDI with spacing device 138
  136. 136. •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
  137. 137. 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
  138. 138. Overview: Inhaler devices Inhaler devices. Thorax 2003; 58 (Suppl I): i1-i92 •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
  139. 139. 142
  140. 140. 143
  141. 141. 144 Breathe actuated MDI Autohaler
  142. 142. The concept of a breath-actuated pMDI is a good one,because it solves the problem of patient coordination of actuation with inhalation. Breath-actuated inhalers sense the patient’s inhalation through the actuator and fire the inhaler automatically in synchrony. 145
  143. 143. 146
  144. 144. 147
  145. 145. 148 Dry powder inhaler (DPI) single dose
  146. 146. 150
  147. 147. 151
  148. 148. 152
  149. 149. Turbuhaler use
  150. 150. Using Turbuhaler
  151. 151. Turbohalers Dry powder No propellant Requires patient effort Not compatible with spacer Requires breath hold Window with dose information Twist the base in both directions to load
  152. 152. 157
  153. 153. 158
  154. 154. 159
  155. 155. 160
  156. 156. 162
  157. 157. Using aerolizer 163
  158. 158. 164
  159. 159. 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) 165 Using aerolizer
  160. 160. 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. 166 Using aerolizer
  161. 161. Remove the AEROLIZER Inhaler from your mouth. Continue to hold your breath as long as you can and then exhale. Open the AEROLIZER Inhaler to see if any powder is still in the capsule. If any powder remains in the capsule repeat steps 10 to 13. Most people are able to empty the capsule in one or two inhalations.  After use, open the AEROLIZER Inhaler, remove and discard the empty capsule. Do not leave a used capsule in the chamber. Close the mouthpiece and replace the cover. 167 Using aerolizer
  162. 162. 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. 168
  163. 163. Dry powder inhalers Advantages: Small and portable. Built-in dose counter. Propellant-free. Breath-actuated. Short preparation and administration time. DISADVANTAGES Dependence on patient’s inspiratory flow. Patients less aware of delivered dose. Relatively high oropharyngeal impaction can occur. Vulnerable to ambient humidity or exhaled humidity into mouthpiece.
  164. 164. 170
  165. 165. Conclusion A number of inhalation devices are available for the treatment of pulmonary diseases, each with its own advantages and disadvantages. None has proven to be superior to the others in any of the clinical situations tested. Whichever device is chosen, the key to successful treatment lies at a proper inhaler technique
  166. 166. PITFALLS IN INHALER TECHNIQUE Most physicians, pharmacists and asthma patients do not use inhalers properly. Many studies have shown that the majority of asthmatics do not use ideal technique, and that even after having their inhaler technique corrected, within six months their technique is once again inadequate 172
  167. 167. 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) 173
  168. 168. 174
  169. 169. 175
  170. 170. 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 All patients should be trained in technique, and trainers should be competent with the inhalation technique
  171. 171. Key recommendations: Invest the time to train each patient in proper inhaler technique: Observe technique & let patient observe self (using video demonstrations) Devices to check technique & maintain trained technique are available Recheck inhaler technique on each revisit Haughney J et al. Respir Med. 2008;102:1681–93.
  172. 172. Asthma control can be improved by brief verbal instruction and physical demonstration of correct inhaler technique, taking only a few minutes and repeated regularly 178 Key recommendations:
  173. 173. 179
  174. 174. Work hard in silence Let success make the noise 180
  175. 175. 181

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