This document provides an overview of inhaled therapy for asthma. It discusses the history of inhaled treatments and different types of inhalers. The key aspects covered include: - Inhaled therapy is the cornerstone of asthma treatment and works by directly delivering medication to the airways. - Different types of inhalers include pressurized metered dose inhalers, dry powder inhalers, and soft mist inhalers. - Inhaled medications are divided into controllers taken daily to control inflammation and relievers used as needed to provide quick symptom relief. - Proper inhaler technique is important for effective delivery of medication to the lungs.

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4. History of Inhaled Therapy

8. Not all asthma inhalers are the same

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11. pMDIs DPIs Respimat®
SMI
pMDI, pressurized metered-dose inhaler; DPI, dry powder inhaler; SMI, Soft Mist™ inhaler
Seretide® Evohaler® and Accuhaler®, Allen & Hanburys (GlaxoSmithKline); Symbicort® Turbuhaler®, AstraZeneca;
Pulmicort® Flexhaler®, AstraZeneca; Onbrez® Breezhaler®, Novartis; SPIRIVA® HandiHaler®, Boehringer Ingelheim;
Pressair ® /Genuair ®, Almirall; SPIRIVA® Respimat® SMI , Boehringer Ingelheim; Breo®/Relvar® ELLIPTA, GSK

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15. Airway
inflammation
Airflow
obstruction
Bronchial
hyperresponsiveness
Symptoms
Asthma Pathophysiology
The tip of the iceberg

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Controllers =
Medications taken
daily on a long-term
basis to keep
asthma under
control  due to
antiinflammatory
effects
Relievers =
Medications used on
an as-needed basis
reverse
bronchoconstriction
and relieve its
symptoms that act
quickly
Controllers Vs Relievers

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Controllers
 Inhaled corticosteroids
 Inhaled long-acting b2-
agonists
 leukotrienes modifiers
 Sustained release
theophylline
 Systemic
glucocorticosteroids
 Anti-IgE (Omalizumab)
Relievers
 Inhaled short acting b2-agonists
 Short acting anticholinergics
 Methylxanthines
Medications for Asthma
Management

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Inhaled therapy constitutes the cornerstone
of asthma treatment .

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Relievers - SABA

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Beclomethasone
Dipropionate 100
ug/dose
Beclomethasone
Dipropionate 50 ug/dose
ICS

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LABA

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55. ICS +LABA

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69. LAMA

70. Pharmacokinetics of Inhaled Drugs
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71. 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

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

74. 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

75.  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,
where they are unable to follow the airstream when it changes
direction, thus impacting on the airway wall.
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76.  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, Breath-holding increases gravitational
sedimentation.

77.  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 settle on to the
airway surfaces i.e Gravitational sedimentation .
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78. Particle deposition
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Deposition of particles
> 5 µ impaction
1-5 µ sedimentation
< 1 µ like gas

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82.  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) is percentage of the aerosol between 1–5
μm that deposit in the lung.

83. MMAD
 The calculated aerodynamic diameter that divides the particles of an
aerosol in half, based on the weight of the particles.
 Mass Median Aerodynamic Diameter (MMAD) is defined as the
diameter at which 50% of the particles by mass are larger and 50%
are smaller .
 By weight, 50% of the particles will be larger than the MMAD and 50%
of the particles will be smaller than the MMAD.

84. 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.

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Lung deposition and MMAD

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89. 1) Sub optimal communication between HCP & patient
2) Lack of opportunity to discuss fear of side effects
3) Patients under-estimate the severity
4) Over-estimate their level of control
5) Technique
Barriers for using inhalers

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Fate of inhaled drugs – Good Technique
Swallowed
GI tract
Deposited in lung
Lungs
Metabolism or absorption
from the lung
Liver
Oral
bioavailability
Absorption
from gut
First-pass
metabolism
Systemic
Circulation
Mouth
pharynx
mucociliary
clearance
80%
20%
Schematic representation of potential dose distribution
A Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for
Respiratory Care. 1st Edition. Page 1.
Webpage: http://www.aarc.org/education/aerosol_devices/
Adapted from Barnes et al. AJRCCM 1998;157:S1-S53

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Fate of inhaled drugs – Good Technique
Swallowed
GI tract
Deposited in lung
Lungs
Metabolism or absorption
from the lung
Liver
Oral
bioavailability
Absorption
from gut
First-pass
metabolism
Systemic
Circulation
Mouth
pharynx
mucociliary
clearance
80%
20%
Schematic representation of potential dose distribution
A Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for
Respiratory Care. 1st Edition. Page 1.
Webpage: http://www.aarc.org/education/aerosol_devices/
Adapted from Barnes et al. AJRCCM 1998;157:S1-S53
Swallowed
GI tract
Deposited in lung
Lungs
Metabolism or absorption
from the lung
Liver
Oral
bioavailability
Absorption
from gut
First-pass
metabolism
Systemic
Circulation
Mouth
pharynx
mucociliary
clearance
95%
5%
Schematic representation of potential dose distributionAdapted from Barnes et al. AJRCCM 1998;157:S1-S53
A Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for
Respiratory Care. 1st Edition. Page 1.
Webpage: http://www.aarc.org/education/aerosol_devices/
Fate of inhaled drugs – Poor Technique

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 Inhaled medications is a waste of money if not used properly
 Poor technique is a barrier to good asthma control
 Check at each visit
 Don’t rely on patient’s knowledge – ask them to demonstrate

97. BTS/SIGN 2011 Recommend
 Prescribe inhalers only after patients have received training
in the use of the device And have demonstrated a
satisfactory technique.

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103. Q1 .Which of the following is/are not a correct combination?
a) Salbutamol-blue MDI inhaler
b) Salmeterol-turbuhaler
c) Tiotropium Bromid-white MDI inhaler
d) Budesonide- MDI inhaler
e) Formoterol-Handihaler

104. Q2 .The Accuhaler can contain the following :
a) Fluticasone Proprionate
b) Salbutamol
c) Budesonide
d) Salmeterol
e) Tiotropium Bromide

105. Q3 . Which of these is/are not a correct combination?
a) Blue MDI-short acting beta agonist
b) Purple MDI-anticholinergic
c) Red MDI-inhaled Corticosteroid
d) Handihaler-anticholinergic
e) Aerolizer-Long acting beta agonist

106. Q4 . Which of the following comes as a dry powdered inhaler?
a) Fluticasone/Salmeterol (Seretide Diskus)
b) Albuterol HFA (Ventolin HFA )
c) Tiotropium (Spiriva Respimat )
d) Tiotropium (Spiriva Handihaler )
e) A & D

107. Q5 . The optimal delivery method of albuterol for a typical 16-
year-old asthma patient is:
a) A. Nebulization
b) B. Oral solution
c) C. MDI with a valved-holding chamber and mask
d) D. MDI
e) E. Oral tablet

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