how can we improve the technique of inhaler devices? what is the impact of conducting a workshop and educating health care professionals

1. Respiratory devices
Dr Ahmed Sayeed, MD,MRCP(UK)

2. Case scenario
 30 year School teacher was diagnosed to have asthma since
the age of 15 years.
 She is currently on
Seretide 2 puffs twice a day
Salbutamol MDI 2 puffs PRN
 Her symptoms are still not controlled
 https://youtu.be/zG2DVoRP86g

3. INHALER TECHNIQUE

4. Objectives of the workshop
 To know different types of inhalers
 To know the uses of inhalers
 To learn techniques of inhaler use
 To know briefly about other devices

5. The quality of inhaler
teaching provided to
patients as self-
assessed by physicians
before (grey bars) and
after (black bars) the
inhaler education.

6. Evaluation of Inhaler Techniques Among Asthma
Patients Seen in Nigeria

7. Study to assess inhaler technique in Saudi
hospitalized patients with asthma & COPD
Saudi Medical Journal, smj.2016.

8. INTRODUCTION
INHALER DEVICES ARE THE MAJOR METHOD FOR
DELIVERY OF ASTHMA MEDICATION
 EFFECTIVENESS CAN BE COMPROMISED IF THE
PATIENT USES THE INHALER DEVICE INCORRECTLY

9. Drugs used in inhaler devices
Inhaled beta agonist and anticholinergic bronchodilators for chronic obstructive
lung diseases.
 Asthma,
 COPD,
 Bronchiectasis,
 Bronchiolitis.

10. Drugs used in inhaler devices
Inhaled glucocorticoids for
 Asthma,
 Eosinophilic bronchitis,
 COPD

11. Drugs used in inhaler devices
 Airway secretion modifying agents for cystic fibrosis- acetylcysteine, DNase
 Inhaled pulmonary vasodilators for pulmonary hypertension- ileoprost
 Aerosol delivery of drugs (eg, opiates) may be used to treat some
nonrespiratory diseases.

12. TYPES OF INHALER DEVICES
 The pressurized metered dose
inhaler (MDI),
 The dry powder inhaler (DPI),
 The soft mist inhaler (SMI)

13. Metered dose inhalers

14. Dry powder inhalers
 Breath-actuated devices that deliver
micronized drug particles
 Drug is delivered to the airways by
the inhalation of air over a punctured
capsule, blister, or reservoir
 https://youtu.be/bXHHFmZ_DRI

15. Soft mist inhalers
 Release the medication in a soft mist,
 Respimat SMI have a mean aerodynamic
diameter ≤5.8 µm
 The lower velocity of the aerosol decreases
oropharyngeal deposition.

16. SPACERS AND HOLDING CHAMBERS
 Allows the velocity of particles to
decrease before reaching the mouth.
 Use of a valved holding chamber also
allows sequential actuation and
inhalation.

17. COMMON PROBLEMS WITH INHALER
DEVICES
 Upper airway deposition
 Actuation-inhalation
coordination
 Insufficient breath-hold

18. TEACHING INHALER USE SKILLS
 The clinician should first demonstrate the steps on
the checklist.
 The patient then practices in front of the clinician
so that errors may be corrected.
 The patient's technique should be evaluated
periodically & corrections made as necessary.
 Patients should be positively reinforced for correct
inhaler technique.

19. MDI TECHNIQUE

20. MDI inhalers must be cleaned
 Do not wash the canister or immerse it in water.
 Clean the top and bottom of the plastic mouthpiece
by running warm tap water through them for 30 to 60
seconds.
 Shake off excess water and allow the mouthpiece to
dry completely.
 Replace the canister in the mouthpiece when dry.
 Release one puff from the inhaler into the air away
from the patient’s face.

21. MDI WITH SPACER

22. DPI technique
DPIs come in two main types
 https://youtu.be/bXHHFmZ_DRI
 https://youtu.be/Kr02is6jVUk

23. SINGLE DOSE DPI

24. MULTI DOSE DPI

25. Turbohaler
 https://www.youtube.com/watch?v=r-
wUuf1mODg&index=2&list=FLheMeQDqGiXQW-SshP3Fyhg&t=0s

26. Soft mist inhaler technique
 SMIs release the medication in a soft mist, which lasts in the air
about six times longer than the aerosol from an MDI.
 Respimat SMI have a mean aerodynamic diameter ≤5.8 µm.
 Particles less than 1 µm tend to be exhaled, rather than impacting on
the airway.
 https://youtu.be/NfI1ogOyWLE

27. SOFT MIST INHALER

28. Use of Respimat® Soft Mist™ Inhaler in COPD
patients
Int J Chron Obstruct Pulmon Dis. 2006

29. Common errors while using inhaler devices

30. Determining when an inhaler device is
empty
 Some MDIs are have integrated dose counters.
 Electronic dose counters such as the 3M
Integrated Dose by Dose Counter.
 Maintain a log of the number of actuations.
 DPI devices have counters that display the
number of puffs remaining.

31. Patients with tracheostomy
Two systems for delivery of nebulized medication.
 Either a mask can be placed over the tracheostomy
opening.
 The nebulizer chamber can be attached to the
tracheostomy tube using a T-piece made of ventilator
tubing and a connector.

32. Mechanically ventilated patients
 Humidification of inhaled gas decreases aerosol
deposition by approximately 40 %.
 Increased dosage of medication is often required.
 Inhaled medications can be delivered using
either an MDI or a nebulizer.
 MDI may deliver a more consistent dose than a
nebulizer.

33. INFORMATION FOR PATIENTS
Two types of patient education
"The Basics"
 "Beyond the Basics."

34. Other devices
Incentive spirometry involves
deep breathing facilitated by a
simple mechanical device to
provide visual feedback
 https://www.youtube.com/wat
ch?v=uqwCZdXdDrI&list=FL
heMeQDqGiXQW-
SshP3Fyhg&index=2

35. The peak flow meters
 The peak expiratory flow is the
maximal rate that a person can
exhale during a short maximal
expiratory effort after a full
inspiration.
 https://www.youtube.com/w
atch?v=055fSYXgNKU&ind
ex=4&list=FLheMeQDqGiX
QW-SshP3Fyhg

36. Cough assist device
Patients with an ineffective cough due to
 muscular dystrophy,
 myasthenia gravis,
 poliomyelitis,
 https://www.youtube.com/watch?v=oUMy
b9h2-2w

37. Take home messages
 Common problems with inhaler usage are
deposition of medication in the oropharynx, poor
coordination.
 Use of a spacer device reduces oropharyngeal
deposition and improves coordination.
 MDI can be used in mechanically ventilated
patients.

38. References
 Up-to-date 2018
 YouTube for inhaler technique videos