Inhaled Medications & Delivery Devices

• Medication can be delivered via the inhaled route.
• There are various inhaled medication delivery and auxiliary devices.
• It is important to be able to recognize the advantages and disadvantages of different devices.
• Patient factors must be identified to adequately use inhaled delivery devices.
• In healthcare, it is important to identify the most appropriate delivery system for a patient.

Why Inhaled Medications?

• Inhaled medications are delivered topically to the airways.
• Systemic effects, are avoided, and lower doses of medications are typically needed.
• Rapid onset of action can be achieved with inhaled medications.
• There are no food interactions with inhaled medications.
• Inhaled medications avoid degradation by the stomach and first-pass metabolism.

Inhaled Medication Deposition

• Aerosol particle size determines the site of deposition of inhaled medication.
• Particles > 5 μm deposit by impaction in the oropharyngeal and tracheo-bronchial region, potentially being swallowed.
• The optimal particle size for deposition is 1-5 μm for sedimentation in terminal bronchioles and the alveolar region.
• Particles with a size of < 1 μm are exhaled out.

Inhaled Delivery systems

• Types of delivery devices include:
• pMDIs (pressurized meter dose inhalers)
• DPIs (dry powder inhaler)
• Nebulizers and compressors
• Soft mist inhalers (SMIs)
• Breath-actuated inhalers
• Auxiliary devices:
• Valved holding chambers (VHC)

pMDIs

• pMDIs use a metering device that accurately delivers a known volume of propellant.
• The medication in a pMDI is in suspension or solution.
• Original pMDI propellants contained chlorofluorocarbons (CFCs).
• CFCs were phased out according to the 1987 Montreal Protocol on Substances that Deplete the Ozone Layer.
• Current pMDIs use Hydrofluoroalkanes (HFAs) as the propellant.
• pMDIs are portable and compact.
• pMDIs are available for many inhaled medications.
• Multiple doses can be delivered through pMDIs.
• pMDIs provide consistent dosing.
• pMDIs can be difficult to use.
• Coordination of inhalation and actuation is required.
• High oropharynx drug deposition, even with good technique.

Steps for Using a pMDI

• Remove the cap from the MDI and look for any objects in the inhaler.
• Shake the inhaler if necessary.
• Breathe out completely.
• Place the mouthpiece between teeth and seal lips tightly.
• Start breathing in slowly through the mouth, pressing down on the canister one time.
• Continue breathing in slowly to completely fill your lungs for ~5 seconds.
• Hold breath for 10 seconds.
• Exhale.

Using a Valved Holding Chamber (VHC)

• Attaches to a pMDI and holds the aerosol.
• VHCS require less coordination of inhalation with actuation.
• VHCS may improve lung drug deposition.
• VHCS may cause less oropharynx drug deposition, resulting in fewer adverse effects.
• VHCS can be used by any age group.
• VHCS are bulky and less portable.
• VHCS increase costs and may not be covered by insurance.

How to Use a VHC with a Mouthpiece

• Remove the cap from the MDI and VHC and look for objects in the inhaler.
• Shake inhaler if necessary.
• Insert the MDI into the back of the chamber.
• Breathe out all the way.
• Put mouthpiece into the mouth and close lips around it.
• Press down on the canister one time and breathe in slowly.
• Keep breathing in slowly to completely fill the lungs (~5 seconds).
• Some chambers may make a whistle noise if the patient is inhaling too quickly.
• Hold breath for 10 seconds.
• The patient can remove chamber from the mouth at this time.
• Exhale.

How to Use a VHC with a Mask

• Remove cap from the MDI and look for objects in the inhaler.
• Shake inhaler if necessary.
• Insert the MDI into the back of the chamber.
• Apply mask to the face, completely covering the mouth and nose.
• Ensure that the mask has a good seal on the face.
• Press down on the canister one time at the beginning of an inhalation.
• Maintain the seal for 5-6 breaths after the canister is pressed down.
• Remove mask from the face.

DPIs (Dry Powder Inhalers)

• DPIs deliver medication as a powder.
• DPIs are available as multi-dose or single-dose units.
• Medication may come in capsule form for single-dose.
• Drug delivery with DPIs depends on the patient's inspiratory flow rate.
• Forceful and deep inhalation is necessary to de-aggregate the powder formulation into respirable particles.
• DPIs should not be used with a VHC.
• DPIs utilize lactose carriers.
• DPIs are portable and compact.
• No coordination of inhalation and actuation is required.
• Forceful inhalation is necessary with DPIs.
• DPIs are sensitive to moisture.

How to Use a DPI

• Get medication ready to inhale, don't shake or tip device
• Exhale while holding the mouthpiece away from mouth, do not blow into device
• Put the mouthpiece to your mouth, and do not block with tongue/teeth.
• Breathe in quickly and deeply through your mouth.
• Hold your breath.
• Breathe out.

Nebulizers and Compressors

• Nebulizers generate aerosol particles with a jet of high-velocity gas (oxygen).
• The medication is in liquid form.
• No special inhalation technique is necessary with nebulizers.
• Nebulizers and compressors are big and bulky.
• Using nebulizers is time consuming.
• They require an outside energy source.

How to Use a Nebulizer and Compressor

• Place the compressor where it can safely reach the power source.
• Put the nebulizer together if necessary.
• Put the medicine into the medicine cup.
• Attach the lid and mouthpiece to the medicine cup.
• Connect the air tubing from the compressor to the nebulizer.
• Turn the compressor on to ensure that it is misting.
• Put the mouthpiece in your mouth between your teeth and close your lips around it, or attach a mask.
• Breathe in and out throughout the treatment (while the medication mists) while holding the nebulizer in an upright position.
• Occasionally tap the side of the nebulizer to help the solution drop to where it can be misted.
• Continue breathing until the onset of inconsistent nebulization (i.e., sputtering).
• Treatment is complete when sputtering occurs.

Soft Mist Inhalers (SMIs)

• SMIs transform aqueous liquid solutions into aerosol droplets.
• SMIs do not contain propellant.
• Respimat® is the only soft mist inhaler in the US.
• SMIs are portable and multi-dose.
• SMIs are expensive.

How to Use an SMI

• Hold the Respimat® upright with the cap closed.
• Turn the clear base in the direction of the arrows on the label until it clicks.
• Flip the cap until it snaps fully open.
• Breathe out slowly and fully.
• Bring the Respimat® up to your mouth with the mouthpiece facing toward you.
• Place the mouthpiece in your mouth, holding it in a horizontal position and close your lips around it.
• Don't block mouthpiece with teeth/tongue or cover vent holes
• Point the Respimat® inhaler to the back of your throat.
• While taking in a slow, deep breath through your mouth, press the dose-release button and continue to breathe in slowly for as long as you can.
• Hold breath for 10 seconds or for as long as comfortable.
• Remove Respimat® from your mouth.
• Breathe normally again.

Breath-Actuated Inhalers

• Patient's inspiratory flow releases medication.
• RediHaler™ is the only breath-actuated inhaler available in the U.S.
• Breath-actuated inhalers are portable and compact.
• They do not require coordination of inhalation and actuation.
• Breath-actuated inhalers do not utilize a VHC.
• The generation of adequate inspiratory flow is necessary.

How to Use the RediHaler™™

• Open the cap when ready to take a dose.
• Breathe out fully away from the mouthpiece.
• Place the mouthpiece in your mouth and close your lips around it with a good seal.
• Inhale deeply to release the medicine.
• Remove the inhaler and hold breath for 5-10 seconds.
• Breathe out slowly away.
• Close the cap after inhaling to prepare for the next inhalation.

What Do Healthcare Professionals Know About Inhaler Devices?

• Only 15-69% of healthcare professionals can demonstrate proper inhaler device use.

How Do Patients Perform with Inhaler Devices?

• 50-90% of asthma patients demonstrate incorrect inhaler technique.
• 40% of COPD patients demonstrate at least one error.
• Inadequate inhaler device use can increase the risk of hospitalizations, ED visits, antibiotic and oral corticosteroid prescribing.

What Are the Common Mistakes Patients Make?

• MDIs:
  • Coordination of inhalation with actuation is a common mistake.
  • Speed and/or depth of inspiration is often incorrect.
  • Patients commonly forget to hold their breath post-inhalation.
• DPIs:
  • Incorrect preparation of device prior to inhalation
  • Patients often do not fully exhale before inhalation.
  • Forgetting to hold their breath post-inhalation.

Does Teaching Device Technique Matter?

• Yes, a 2.5-minute device technique intervention by community pharmacists can lead to significant improvement in inhaler technique.
• Correct teaching can also lead to significant improvement in clinical and quality of life outcomes.

What Can You Do?

• Ensure that the patient can use the device prior to medicine recommendation.
• Inhaler Device technique should be taught (demonstration) and checked at every opportunity.