Asthma Inhaler techniques

therapeutic Asthma Inhaler techniques

Dr. Ashraf El Adawy
Consultant Chest Physician
TB TEAM EXPERT – WHO
Mansoura – Egypt

Asthma therapy
Controllers
Inhaled corticosteroids
Inhaled long-acting b2- agonists
Oral anti-leukotrienes
Oral theophyllines
Relievers
Inhaled fast-acting b2- agonists

Beclomethasone
Budesonide
Fluticasone
Inhaled corticosteroids

Not all asthma inhalers are the same

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

Pharmacokinetics of Inhaled Drugs
19

Factors affecting lung deposition
1.Particle size
2.Speed of inspiration (inspiratory flow)
3.Integrity of airway
4.Proper inhaled device technique

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 particles in the air are:
1.Impaction
2.Sedimentation
3.Diffusion

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

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

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Deposition of particles
> 5 μ impaction
1-5 μ sedimentation
< 1 μ like gas

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

●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)

Fine-particle fraction (FPF)
Fine-particle fraction (FPF) is percentage of the aerosol between 1–5 μm that deposit in the lung

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

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

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.

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

Inhalers
Breath Activated Inhaler
Nebulizer
Pressurized Metered Dose Inhaler (pMDI)
Pressurized Aerosol Inhaler with Spacer
Dry Powder Inhaler (DPI)

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

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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

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

Inhaler technique is it important?

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

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 demonstrated a satisfactory technique

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.

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?

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Pressurized metered dose inhaler (pMDI)

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

HFA and CFC propellant pMDI
HFA pMDI
CFC pMDI

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

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

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

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

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

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

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

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

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

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

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Care and Maintenance of the Pressurized Metered-Dose Inhaler

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
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pMDI

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

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

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

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

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

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

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

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

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.

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

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%)

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.

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

110
MDI spacer
Decrease of oropharyngeal deposition Proposing inhaled CS

Not all Spacers are created equal

115
Aerochamber spacer with mask

116
Aerochamber spacer
Aerochamber spacer with mask

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.

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

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

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

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.
131

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 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.
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Important Reminders About Spacers

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

•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

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

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

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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 with inhalation.
Breath-actuated inhalers sense the patient’s inhalation through the actuator and fire the inhaler automatically in synchrony.
145

148
Dry powder inhaler (DPI) single dose

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

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

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

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

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

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.

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

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

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

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

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.

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:

Work hard in silence
Let success make the noise
180

Asthma Inhaler techniques

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