All About Inhalers

History, Pharmacokinetics and Drug Deposition, Types, Techniques, Differences between different inhalers, Pitfalls and Errors of use, and Drugs used by inhalation

1. How to Use Inhalers Workshop Dr Riham Hazem Raafat Lecturer of Chest Diseases

2. Module 1

3. Introduction Inhalation therapy refers to the delivery of a drug to the body via the airways by delivering it in an aerosol (spray) form. Advantages of inhalation therapy: Direct delivery to the site of action. Small quantity of drug. Rapid onset of action. Minimal systemic absorption → decreases systemic side effects . Disadvantages of inhalation therapy: Time and effort consuming

4. History of Inhalers

5. Pharmacokinetics of Inhaled Drugs

6. So for Successful Drug Delivery: Particle Size of the Aerosol Design of the Device Inspiratory Flow & Breath Hold Airway Caliber & Disease Distortion Correct Technique (1) Physical factors (2) Ventilatory factors (3) Anatomic factors (4) Patient-related factors

7. SO TO SUMMERIZE:

8. Lung Deposition of Different Inhalers

9. Module 2

10. Types of Inhalers 1- Metered Dose Inhalers (With or W/O Spacer) 2- Dry Powder Inhalers (Single/ Multiple Dose) 3- Nebulizers (Jet/Ultrasonic/Mesh)

11. Poor Technique

12. SO ,

13. More lung deposition (No cold Freon effect) (Gas at lower temp) Since 2010 More consistent even near empty Tail Off Effect (near empty)

14. Technique of MDIs:

15. Care and Maintenance: Priming and Wasting Doses: N.B.

16. Factors Affecting Performance: Advantages & Disadvantages: counter Disadvantages:

17. How to Know it’s Empty: (OLD METHOD) If No Counter

18. Autohaler - Breath Actuated MDI Inhaler (BA – MDI) Consists of a pressurized canister of medication in a plastic case with a mouthpiece. Is breath activated. This means when you inhale, the Autohaler automatically releases a mist of medication.

19. Aero-chamber

20. Adv / Disadv . of MDI with Spacer:

21. Technique of MDI with Spacer:

22. Care and Maintenance:

23. Advantages: Disadvantages:

24. HANDIHALER Tiotropium Bromide Spiriva (18ug) AEROLIZER & BREEZHALER Formoterol Budesonide Foradil (12ug) Miflonide (200-400mg) Indacetrol Glycopyronium Indac/ Glyco Onbrez (150-300 ug) Seebri (44ug) Ultibro (110/50 – 85/43)

25. Soft Mist Inhalers (SMI) RESPIMAT

26. S ome inhalers require forceful/strong and deep inhalation while others require calm/slow and deep inhalation depending on the internal inhaler resistance

27. Technique of Diskus:

28. Technique of Turbohaler:

29. Technique of Aerolizer:

30. Technique of Handihaler:

31. Technique of Respimat (SMI):

32. NEBULIZERS (mist inhalation form) using compressed gas Conventional Pneumatic (JET)

33. Advantages: Disadvantages: Useful in children , Handicapped persons , Seriously ill patients Ventilated patients Elderly individuals High doses can be given Combination drugs can be given Enhancement of secretion clearance Sputum induction (physiotherapy) Humidification of respired gases Prevent dehydration Prevent or relieve bronchospasm Plenty of drugs can be used • Bronchospasm • Over hydration • Delivery of contaminated aerosols • Tubing condensation • Swelling of retained secretions

34. Technique: 1 . Measure correct amount of saline solution using a clean dropper. Put the saline into the nebulizer cup . 2. Measure correct amount of medicine using a clean dropper and add it to nebulizer cup containing the saline. 3. If you are using a premixed medicine, add the correct amount . 4. Attach mouthpiece to T-shaped part . Fasten this unit or mask to the cup. 5. Turn on air compressor . - If connected to ventilator: to inspiratory limb with airflow 6-8 L/min 6. Put mouthpiece in mouth , between teeth and seal lips tightly around it. 7. Take slow, deep breaths in through the mouth 8. If you are unable to take slow, deep breaths, breathe normally into mask . 9. Hold each breath for 1 - 2 sec before breathing out or hold each breath for 1-5 sec every 3-5 inhalations . 10. Continue breathing this way until medicine is gone from the cup (about 5-15 minutes ).

35. Technique of Nebulizer :

36. Crucial Errors Nebulizers Incorrect size for child Not fitting tightly on face/mouth/nose Not holding nebulizer upright Stopping too early, before dose done

37. Module 3

38. Drugs Used for Inhalation

39. Distilled Water / NS

40. Available Devices in Egypt

41. Decision Tree

42. •Efficacy and safety • Availability ( and affordability) of prescribed drug in certain device • Patient’s ability to use the device correctly • Patient preferences • Preferably prescribe same type of device (with comparable instruction ) in individuals if using several inhaled drugs

43. Age Requirements for Use of Inhalers