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01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 1
Inhaler techniques.
Additional information/guidelines can be found at:
http://www.asthma.org.uk/using_your_inhaler.html
http://www.asthma.org.uk
http://www.lunguk.org
http://www.ginasthma.com
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 2
Inhalation therapy
The inhaled route is the preferred route of
administration for most anti-asthma therapy
By this route
 the active ingredient can be delivered to the
smallest airways
 the dose required is much smaller than needed
for an equivalent effect via oral route
 minimises risk of systemic side effects
 onset of action faster
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 3
Inhalation therapy 2
Devices available to deliver inhaled
medication include pressurised metered-
dose inhalers, breath-actuated metered dose
inhalers, dry powder inhalers and nebulisers.
Spacer (or holding chamber) devices make
inhalers easier to use.
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 4
Drugs Administered Via Inhalers.
Corticosteroids. (Anti inflammatory)
Beclometasone
Beta agonists ( Bronchodilators) Salbutamol
& Terbutaline.
Anti muscarinic bronchodilators. Ipratropium
bromide
Combination therapy. The above drugs may
be administered separately or combined into
one inhaler device.
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 5
Metered dose aerosol inhaler
Metered dose aerosol (MDI)
Convenient, low dose form of therapy
Advantages
Low dose Portable
Cheap Fixed dose
Can feel & hear dose being delivered
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 6
Metered dose aerosol inhaler
 Disadvantages
Requires good hand/breath co-ordination
Not good for those with decreased dexterity
Jet aerosol can cause deposition of the drug in the
oropharynx – reduces dose available to the airways
and predisposes to local side effects (i.e. oral
candidiasis)
25-30% of patients unable to use properly
Don’t know how much is left in device
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 7
Using a metered dose inhaler
 Remove cap and check
mouthpiece is clear
 Shake inhaler
 Breathe out gently
 Place mouthpiece in mouth
and seal with lips
 At the start of breathing in,
press canister
 Continue to breath in as deep
as possible
 Hold breath for up to 10
seconds
 Wait half a minute before
repeating a dose
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 8
Using a spacehaler device
 Remove cap
 Shake inhaler
 Breathe out gently
 Put mouthpiece in mouth
and at the start of
inspiration, which should
be slow and deep, press
canister down and
continue to inhale deeply
 Remove from mouth, and
hold breath for 10
seconds
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 9
Using an Easi-breathe inhaler
 Shake inhaler
 Hold inhaler upright. Open the cap
 Breathe out gently. Keep inhaler
upright, put mouthpiece in mouth and
close lips and teeth around it (the
airholes on the top must not be
blocked by your hand)
 Breathe in steadily through the
mouthpiece. Don’t stop breathing
when the inhaler puffs continue
taking a deep breath.
 Remove from mouth and continue to
hold breath for 10 seconds.
 After use, hold inhaler upright and
immediately close cap.
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 10
Dry Powder Inhaler devices
Dry powder devices
 require no special co-ordination
 work well even with low inspiratory flow rates
 suitable for younger children
 should avoid exhaling through the device as this
will dampen the dry powder
 any air holes in the device must not be covered
during inspiration
 Includes accuhaler, disk inhaler and turbohaler
devices
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 11
Dry Powder Inhaler devices
 Advantages
 Easy to use
 No co-ordination needed
 Patient breath actuated
 Know how many doses left
 Disadvantages
 Air can escape if you don’t form a good seal around the
mouthpiece
 Expensive in comparison to MDI’s
 May need a higher respiratory effort
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 12
Using Accuhaler Device
 Hold the outer casing of the
accuhaler in one hand whilst
pushing the thumb grip away
until a click is heard
 Hold accuhaler with mouthpiece
towards you, slide lever away
until it clicks. This primes the
dose.
 Holding the accuhaler horizontal,
breathe out gently away from the
device, put mouthpiece in mouth
and suck in steadily and deeply.
 Remove from mouth and hold
breath for about 10 seconds.
 To close, slide thumb grip back
towards you as far as it will go till
it clicks.
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 13
Using a Turbohaler
1. Unscrew and lift off cover.
Hold turbohaler upright and
twist grip forwards and
backwards as far as it will go.
You should hear a click.
2. Breathe out gently, put
mouthpiece between lips and
breathe in as deeply as
possible. Even when a full
dose is taken there may be no
taste
3. Remove from mouth and hold
breath for 10 seconds
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 14
Spacer devices
 Spacer devices and expansion chambers
 reduce jet effect
 overcome hand-breath co-ordination problems
 disperses aerosol discharge within a chamber
 may breathe in and out of chamber without breath
holding - this may suit small children.
 Less effort.
 Decreases local side effects
 Increases drug concentration delivered to the small airways
so maximises treatment without having to increase dose
 Work at least as well as nebulisers at treating most asthma
attacks in children and adults
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 15
Volumatic device
 Remove cap, shake inhaler and
insert into device
 Place mouthpiece in mouth or
mask over mouth and nose
 Depress canister and leave device
in same position.
 Take a deep breath (this will make
a clicking sound as the valve
opens and closes) and hold your
breath for ten seconds (or for as
long as is comfortable) then
breathe out slowly.
 If you find it difficult to take deep
breaths, breathing in and out of
the mouthpiece several times is
just as good
 Remove device from mouth
 Wait 30 seconds before repeating
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 16
Aerochamber
 Remove cap
 Shake inhaler and insert in back of
aerochamber
 Place mouthpiece in mouth
 Press the canister once to release a
dose of the drug
 Take a slow deep breath in. If you hear
a whistling sound you are breathing
too quickly
 Hold breath for about 10 seconds,
then breathe out through the
mouthpiece
 If you find it difficult to take deep
breaths, breathing in and out of the
mouthpiece several times is just as
good
 Remove mouthpiece from mouth and
breathe out
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 17
Maintenance & Hygiene
 Spacer devices should be cleaned once a month in
warm soapy water and left to “drip dry” on a clean
draining board.
 After using corticosteroids via an inhaler patients
should be encouraged to clean their teeth. The
steroid particulate can damage teeth enamel as
well as cause oral thrush.
 Therefore all patients are encouraged to brush
teeth after use of an inhaler or rinse mouth with
water
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 18
Nebuliser Therapy
http://www.brit-thoracic.org.uk/page261.html
 A nebuliser is a device which converts drug solution into an
aerosol for direct inhalation via a mask or mouthpiece
 The solution is contained within a reservoir through which
oxygen or compressed air is passed.
 It may be powered by electricity (mains or battery) or by a
compressed oxygen or air supply.
 A flow rate of 6-8 litres/minute is required to drive the
nebuliser.
 normal breathing over 5-10 minutes is usually sufficient for
drug delivery
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 19
Advantages of nebulisers:
 patients whose condition makes MDI use difficult
 shortness of breath
 weakness
 Simple to apply
 Effective in use
 Large doses can be administered
 Can be used for delivering drug direct to lungs even
if not available in inhaler form
 e.g. antibiotics
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 20
Disadvantages of nebulisers
Not very portable
 Requires compressed gas, so only suitable for
clinical environment unless bulky compressor
used
inefficient
 only about 10% of the prescribed dose reaches
the lung.
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 21
Jet nebuliser
 Jet of gas forced
through narrow
opening (venturi)
 negative pressure in
reservoir
 mist of droplets of
drug solution
 5- 10 microns size
 Larger droplets fall
back into reservoir
Compressed gas
Reservoir of
drug
droplets Venturi
baffle
Aerosol of drug
for inhalation
01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 22
Used for
 Emergency treatment
 acute asthma
 COPD
 Long term bronchodilator treatment
 Preventive drugs for asthma
 Antibiotics
 cystic fibrosis
 Bronchiectasis
 HIV/AIDS
 Symptom relief in palliative care

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Inhaler Devices

  • 1. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 1 Inhaler techniques. Additional information/guidelines can be found at: http://www.asthma.org.uk/using_your_inhaler.html http://www.asthma.org.uk http://www.lunguk.org http://www.ginasthma.com
  • 2. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 2 Inhalation therapy The inhaled route is the preferred route of administration for most anti-asthma therapy By this route  the active ingredient can be delivered to the smallest airways  the dose required is much smaller than needed for an equivalent effect via oral route  minimises risk of systemic side effects  onset of action faster
  • 3. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 3 Inhalation therapy 2 Devices available to deliver inhaled medication include pressurised metered- dose inhalers, breath-actuated metered dose inhalers, dry powder inhalers and nebulisers. Spacer (or holding chamber) devices make inhalers easier to use.
  • 4. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 4 Drugs Administered Via Inhalers. Corticosteroids. (Anti inflammatory) Beclometasone Beta agonists ( Bronchodilators) Salbutamol & Terbutaline. Anti muscarinic bronchodilators. Ipratropium bromide Combination therapy. The above drugs may be administered separately or combined into one inhaler device.
  • 5. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 5 Metered dose aerosol inhaler Metered dose aerosol (MDI) Convenient, low dose form of therapy Advantages Low dose Portable Cheap Fixed dose Can feel & hear dose being delivered
  • 6. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 6 Metered dose aerosol inhaler  Disadvantages Requires good hand/breath co-ordination Not good for those with decreased dexterity Jet aerosol can cause deposition of the drug in the oropharynx – reduces dose available to the airways and predisposes to local side effects (i.e. oral candidiasis) 25-30% of patients unable to use properly Don’t know how much is left in device
  • 7. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 7 Using a metered dose inhaler  Remove cap and check mouthpiece is clear  Shake inhaler  Breathe out gently  Place mouthpiece in mouth and seal with lips  At the start of breathing in, press canister  Continue to breath in as deep as possible  Hold breath for up to 10 seconds  Wait half a minute before repeating a dose
  • 8. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 8 Using a spacehaler device  Remove cap  Shake inhaler  Breathe out gently  Put mouthpiece in mouth and at the start of inspiration, which should be slow and deep, press canister down and continue to inhale deeply  Remove from mouth, and hold breath for 10 seconds
  • 9. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 9 Using an Easi-breathe inhaler  Shake inhaler  Hold inhaler upright. Open the cap  Breathe out gently. Keep inhaler upright, put mouthpiece in mouth and close lips and teeth around it (the airholes on the top must not be blocked by your hand)  Breathe in steadily through the mouthpiece. Don’t stop breathing when the inhaler puffs continue taking a deep breath.  Remove from mouth and continue to hold breath for 10 seconds.  After use, hold inhaler upright and immediately close cap.
  • 10. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 10 Dry Powder Inhaler devices Dry powder devices  require no special co-ordination  work well even with low inspiratory flow rates  suitable for younger children  should avoid exhaling through the device as this will dampen the dry powder  any air holes in the device must not be covered during inspiration  Includes accuhaler, disk inhaler and turbohaler devices
  • 11. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 11 Dry Powder Inhaler devices  Advantages  Easy to use  No co-ordination needed  Patient breath actuated  Know how many doses left  Disadvantages  Air can escape if you don’t form a good seal around the mouthpiece  Expensive in comparison to MDI’s  May need a higher respiratory effort
  • 12. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 12 Using Accuhaler Device  Hold the outer casing of the accuhaler in one hand whilst pushing the thumb grip away until a click is heard  Hold accuhaler with mouthpiece towards you, slide lever away until it clicks. This primes the dose.  Holding the accuhaler horizontal, breathe out gently away from the device, put mouthpiece in mouth and suck in steadily and deeply.  Remove from mouth and hold breath for about 10 seconds.  To close, slide thumb grip back towards you as far as it will go till it clicks.
  • 13. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 13 Using a Turbohaler 1. Unscrew and lift off cover. Hold turbohaler upright and twist grip forwards and backwards as far as it will go. You should hear a click. 2. Breathe out gently, put mouthpiece between lips and breathe in as deeply as possible. Even when a full dose is taken there may be no taste 3. Remove from mouth and hold breath for 10 seconds
  • 14. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 14 Spacer devices  Spacer devices and expansion chambers  reduce jet effect  overcome hand-breath co-ordination problems  disperses aerosol discharge within a chamber  may breathe in and out of chamber without breath holding - this may suit small children.  Less effort.  Decreases local side effects  Increases drug concentration delivered to the small airways so maximises treatment without having to increase dose  Work at least as well as nebulisers at treating most asthma attacks in children and adults
  • 15. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 15 Volumatic device  Remove cap, shake inhaler and insert into device  Place mouthpiece in mouth or mask over mouth and nose  Depress canister and leave device in same position.  Take a deep breath (this will make a clicking sound as the valve opens and closes) and hold your breath for ten seconds (or for as long as is comfortable) then breathe out slowly.  If you find it difficult to take deep breaths, breathing in and out of the mouthpiece several times is just as good  Remove device from mouth  Wait 30 seconds before repeating
  • 16. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 16 Aerochamber  Remove cap  Shake inhaler and insert in back of aerochamber  Place mouthpiece in mouth  Press the canister once to release a dose of the drug  Take a slow deep breath in. If you hear a whistling sound you are breathing too quickly  Hold breath for about 10 seconds, then breathe out through the mouthpiece  If you find it difficult to take deep breaths, breathing in and out of the mouthpiece several times is just as good  Remove mouthpiece from mouth and breathe out
  • 17. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 17 Maintenance & Hygiene  Spacer devices should be cleaned once a month in warm soapy water and left to “drip dry” on a clean draining board.  After using corticosteroids via an inhaler patients should be encouraged to clean their teeth. The steroid particulate can damage teeth enamel as well as cause oral thrush.  Therefore all patients are encouraged to brush teeth after use of an inhaler or rinse mouth with water
  • 18. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 18 Nebuliser Therapy http://www.brit-thoracic.org.uk/page261.html  A nebuliser is a device which converts drug solution into an aerosol for direct inhalation via a mask or mouthpiece  The solution is contained within a reservoir through which oxygen or compressed air is passed.  It may be powered by electricity (mains or battery) or by a compressed oxygen or air supply.  A flow rate of 6-8 litres/minute is required to drive the nebuliser.  normal breathing over 5-10 minutes is usually sufficient for drug delivery
  • 19. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 19 Advantages of nebulisers:  patients whose condition makes MDI use difficult  shortness of breath  weakness  Simple to apply  Effective in use  Large doses can be administered  Can be used for delivering drug direct to lungs even if not available in inhaler form  e.g. antibiotics
  • 20. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 20 Disadvantages of nebulisers Not very portable  Requires compressed gas, so only suitable for clinical environment unless bulky compressor used inefficient  only about 10% of the prescribed dose reaches the lung.
  • 21. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 21 Jet nebuliser  Jet of gas forced through narrow opening (venturi)  negative pressure in reservoir  mist of droplets of drug solution  5- 10 microns size  Larger droplets fall back into reservoir Compressed gas Reservoir of drug droplets Venturi baffle Aerosol of drug for inhalation
  • 22. 01/22/16 © Clinical Skills Resource Centre, University of Liverpool, UK 22 Used for  Emergency treatment  acute asthma  COPD  Long term bronchodilator treatment  Preventive drugs for asthma  Antibiotics  cystic fibrosis  Bronchiectasis  HIV/AIDS  Symptom relief in palliative care