inhaler therapy copd asthma mdi dpi nebulisation drugs method advantage disadvantage guidelines

1. INHALATION THERAPY
IN ASTHMA AND COPD
Dr Muhammed Aslam
Junior Resident
MD Respiratory Medicine
Academy Of Medical Science
Pariyaram , Kanuur

2. Inhalation delivery systems
• Bronchodilator aerosol for asthma -1935
• Conventional pressurized MDI - 1956

3. Types
• Pressurized metered dose inhaler
(pMDI)
• MDI with spacers or holding
chambers
• Breath actuated MDI
• Dry powder inhaler (DPI)
• Nebulizers

4. Pressurized MDI

6. 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

7. • Chlorofluorocarbons (CFCs)
most commonly used propellants were the
chlorofluorocarbons CFC-11, CFC-12 and CFC-114.
Banned due to adverse effect on ozone layer
• hydrofluoroalkanes (HFA)
HFA 134a (1,1,1,2,-tetrafluoroethane)
These new devices are more effective. The HFA
propellant produces an aerosol with smaller particle size,
resulting in improved deposition in the small airways and
greater efficacy at equivalent doses compared with CFC
MDIs.

8. • When the valve is actuated propellant
and drug leave the inhaler at high
velocity
• Majority of drug impacts in
oropharynx
• Less than 25% reaches the lung

9. Most efficient way of using MDI- steps
• Shake the canister
• Place the mouthpiece of actuator between
the lips
• Breathe out steadily
• Release the dose while taking a slow
deep breath in
• Hold the breath in while counting to 10

10. Advantages of MDIs
• Compact, portable ,convenient
• Multidose delivery capability
• Lower risk of bacterial contamination
• Suitable for emergency situation

11. Disadvantages of MDIs
• Needs correct actuation and inhalation
coordination- difficult for children and
elderly patients
• Cold freon effect
• High pharyngeal drug deposition
• Flammability possibility of new HFA
propellants
• Remaining dose –difficult to determine

12. MDI with Spacer

13. Steps for Using a Spacer with an MDI
• Insert the inhaler/canister into spacer and
shake.
• Breathe out.
• Put the spacer mouthpiece into your
mouth.
• Press down on the inhaler once.
• Breathe in slowly (for 3-5 seconds).
• Hold breath for 10 seconds.

14. 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.

15. Disadvantages
• Large size and volume of device
• Bacterial contamination is
possible; device needs to be
cleaned periodically
• Electrostatic charges may reduce
drug delivery to the lungs

16. Breath actuated MDI

17. LATEST IN MDI

18. Dry powder inhaler (DPI)

19. Single dose Devices
Had to be reloaded with capsule containing
micronized drug in a large particle carrier
powder ,usually lactose

20. Multiple DoseDevices

21. Advantages
• Breath-actuated
• Less patient coordination required
• Spacer not necessary
• Compact Portable
• No propellant
• Usually higher lung deposition
than a pMDI

22. Disadvantages of DPI
• Work poorly if inhalation is not forceful enough
• Many patients cannot use them correctly (e.g.
capsule handling problems for elderly
• Most types are moisture sensitive
Humidity potentially causes powder clumping
and reduced dispersal of fine particle mass
• Need to reload capsule each time

23. Nebulizers
Jet nebulizer Ultrasonic nebulizer

24. Pneumatic Jet Nebulizer
• Delivers compressed gas through a jet, causing an area
of negative pressure and drawing the liquid up the tube
by the Bernoulli effect. The solution is entrained into the
gas stream and then sheared into a liquid film that is
unstable and is broken into droplets by surface tension
forces. The fundamental concept of nebulizer
performance is the conversion of the medication solution
into droplets in the respirable range of 1-5 micrometers

26. Ultrasonic Nebulizer
• Generates high-frequency ultrasonic waves
(1.63 MHz) from electrical energy via a
piezoelectric element in the transducer. These
ultrasonic waves are transmitted to the surface
of the solution to create an aerosol. Aerosol
delivery is by a fan or the patient’s inspiratory
flow; particle sizes may be larger with this
device. A limitation of ultrasonic nebulizers is
that they do not nebulize suspensions efficiently

27. Advantages Of Nebulizers
• Provide therapy for patients who cannot
use other inhalation modalities (eg, MDI,
DPI)
• Allow administration of large doses of
medicine
• Patient coordination not required
• Effective with tidal breathing
• Dose modification possible
• Can be used with supplemental oxygen

28. Disadvantages Of Nebulizers
• Decreased portability
• Longer set-up and
administration time
• Higher cost
• Electrical power source
required
• Contamination possible

29. Drugs used in inhaler therapy

30. For Asthma
Taken from
The Global Initiative for Asthma (GINA) 2011 guidelines

31. Inhaler Therapy
• CONTROLLERS
Inhaled glucocorticoids ,Long acting
inhaled beta 2 agonists,Cromones,
• RELIEVERS
Short acting beta 2 agonists,
Anticholinergics

32. Inhaled Glucocorticosteroids
• Most effective anti inflammatory
medication for the treatment of persistent
asthma
• Reduces asthma symptoms
• Improves quality of life
• Decrease Airway hyper responsiveness
• Improve lung function
• Control airway inflammation
• Decrease frequency and severity of
exacerbations
• Decrease mortality

33. Inhaled Glucocorticosteroids
• Beclomethasone dipropionate
• Budesonide
• Ciclesonide
• Flunisolide
• Fluticasone propionate
• Mometasone furoate
• Triamsinalone acetonide

35. • Most of the benefit – dose equivalent of
400 microgram budesonide per day
• Increasing dose – Little benefit & more
side effect
• Add-on therapy with another class
controller is preferred over increasing dose
of steroids
• Tobacco smoking decreases
responsiveness to inhaled glucocorticoids

36. Local Side effects
• Oropharyngeal candidiasis
• Dysphonia
• Cough (upper airway irritation)
• s/e reduced by –spacer,mouth
washing, prodrug(ciclesonide,beclom
ethasone)

37. Systemic side effect
• Depends on dose , potency, delivery
system, systemic bio availability ,half
life, first pass metabolism, treatment
duration
• Easy bruising, adrenal suppression,
decreased bone mineral density
,cataract, glaucoma

38. Long acting inhaled beta2 agonists
• Salmeterol and formoterol
• Not as monotherapy
• Most effective when combined
with inhaled glucocorticoids

39. Advantages of combination therapy
• Improve symptoms scores
• Decreases nocturnal asthma symptoms
• Improve lung functions
• Decreases use of rapid acting inhaled b2
agonists
• Reduces no: of exacerbation
• Rapid control
• Reduces dose of inhaled glucocorticoids

41. • Salmeterol and Formoterol has
similar duration of action , but
formoterol has more rapid onset
• Formoterol Budesonide
combination can be given for both
rescue and maintenance

42. Side effects
• Less than oral treatment
• Cvs stimulation , skeletal muscle
tremor
• Hypokalemia
• Refractoriness to beta 2 agonists

43. Cromones
• Sodium cromo Glycate , Nedocromil
sodium
• Limited role
• Mild persistent asthma and exercise
induced bronchospasm
• Less effective than low dose inhaled
glucocorticoids
• s/e – cough, sore throat , unpleasant taste

46. Reliever medications
• Short acting beta 2 agonists
• Anti cholinergic

47. Rapid acting inhaled beta 2 agonist
• Salbutamol , terbutaline, fenoterol,
levalbuterol,reproterol,pirbuterol
• Medication of choice for relief of bronchospasm during
acute exacerbation of asthma and pre treatment of
exercise induced broncho constriction
• Should be used only on an as needed basis at lowest
dose and frequency
• s/e – tremor, tachycardia

48. Anti cholinergic broncho dilators
• Ipratropium bromide, oxitropium
bromide
• Less effective than beta 2 agonists
• Combination with b2 agonist-
significant improvement
• S/e dryness, bitter taste

50. In children

51. In children

52. Inhaler Therapy For COPD
Taken from Global Initiative for Chronic Obstructive Lung Disease
(GOLD) Guidelines 2011

56. Beta2 Agonists
• Effect of short acting b2 agonist- 4to 6 hrs
• Improves FEV1 and symptoms
• Long acting beta2 agonist -12 hr or more
• Formoterol and salmeterol improves FEV1 ,lung
volumes,dyspnoea,health related quality of
life,exacerbation rates
• Indacaterol – duration of action 24hrs

57. Anti cholinergic
• Ipratopium bromide , oxitropium bromide,
tiotropium bromide
• Broncho dilator action last longer than
SABA- upto 8 hrs
• Tiotropium – >24 hrs

58. Inhaled corticosteroids
• Long term treatment with inhaled CS
improves symptom , lung function
,quality of life, and reduces frequency
of exacerbations in COPD patients
with FEV1 < 60%
• Does not decline the long term
decline of FEV1 nor mortality

59. Combination Therapy
• Inhaled Coticosteroid with Long
Acting B2 Agonist is more
effective
• A triple therapy by adding
tiotropium may furthur improves

60. Oxygen therapy

61. 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

62. Thank you !!