handling of inhaler devices - · pdf fileshahirah binti zainudi nicholas leow chun wei...
Post on 01-Feb-2018
220 Views
Preview:
TRANSCRIPT
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
PHARMACEUTICAL SERVICES DIVISION MINISTRY OF HEALTH MALAYSIA
DISCLAIMER
Unless otherwise specifically stated, the information contained in this book is made available to pharmacists by the Ministry of Health (MOH) and Clinical Pharmacy Committee (Respiratory Specialty),[CPC(RS)], Pharmaceutical Services Division (PSD), MOH for use as a guide and may not reflect the realities of an actual setting in each institution. The purpose of this book is to standardise counseling on inhaler devices by pharmacists. Neither the Ministry of Health, CPC (RS), PSD, MOH nor any other agency or entities thereof, assumes any legal liability or responsibility for the accuracy, completeness, nor usefulness of any information, product or process disclosed in this book. Reference herein to any specific commercial product, process, service by trade name, trademark, manufacturer, or otherwise, does not constitute or imply its endorsement, recommendation, or favoring by the CPC (RS), PSD, MOH or any entities thereof.
The views and opinions of the CPC (RS), PSD, MOH expressed therein do not necessarily state or reflect those of the other institutions in Ministry of Health or any agency or entities thereof.
ACKNOWLEDGEMENT
The Clinical Pharmacy Committee (Respiratory Specialty) of the Pharmaceutical Services Division, MOH is grateful to all those involved either directly or indirectly in the preparation of this guide. This committee would also like to express its appreciation to relevant drug companies who have provided information on the various inhaler products and their permission for allowing us to include the relevant diagrams of their products in this book.
ADVISORS
Eisah binti A. Rahman Senior Director of Pharmaceutical Services Division,MOH
Hasnah binti Ismail
Director of Pharmacy Practice and Development, Pharmaceutical Services Division, MOH
EDITORIAL COMMITTEE Abida Haq Syed M. Haq Abdol Malek bin Abd. Aziz Pharmaceutical Services Division, MOH Melaka Hospital Sameerah binti Shaikh Abdul Rahman Shahirah binti Zainudi Pharmaceutical Services Division, MOH Selayang Hospital Nurul Adha binti Othman Suhadah binti Ahad Pharmaceutical Services Division, MOH Melaka Hospital Sarah a/p Nagalingam Pharmaceutical Services Division, MOH Tengku Malini binti Tengku Mohmed Noor Izam Pharmaceutical Services Division, MOH
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS (MAIN COMMITTEE)
Abdol Malek bin Abd. Aziz Marzirah binti Ibrahim Melaka Hospital Tuanku Ampuan Najihah Hospital,
Kuala Pilah Shahirah binti Zainudi Nicholas Leow Chun Wei Selayang Hospital Sibu Hospital Suhadah binti Ahad Nurulhayati binti Abdul Jamal Melaka Hospital Sultanah Nur Zahirah Hospital Kuala Terengganu Chong Meng Fei Rohaya binti Sulaiman Pulau Pinang Hospital Tengku Ampuan Afzan Hospital,
Kuantan Chow Foong Yan Suzana binti Mustafa Raja Permaisuri Bainun Hospital, Ipoh Queen Elizabeth Hospital
Kota Kinabalu
Jaya Muneswarao a/l Ramadoo @Devudu Syaziyah binti Ahmad Kulim Hospital Sultanah Bahiyah Hospital
Alor Setar
Lim Yan Chun Wong Hui Shean Sultanah Aminah Hospital, Johor Bahru Tuanku Ampuan Najihah Hospital
Kuala Pilah
HANDLING OF INHALER DEVICES : A PRACTICAL GUIDE FOR PHARMACISTS
(CONTRIBUTORS)
Ang Yu Joe Nor Aziah binti Idris
Adibah Yuhana Ismail Nor Hafizah binti Salehudin
Chan Yeen Yee Norehan binti Abdul Rashid
Chen Siaw Ming Norhafidah binti Othman
Chong Mei Fei Norhayati binti Mustapha
Chong Mei Yoong Nurah Zainal Abidin
Chow Foong Yan Nur Eillena binti Mat Deris
Karen Wong Yoke Sim Ong Ser Via
Kho Zhi Min Phan Hui Seng
Kon Ee Wen Rohaya Sulaiman
Kuah Lean Fung Roksanah binti Shaukat Ali
Lai Siok Wah Rosminah binti Mohd Din
Lee Chui Peng Soh Kwang Chin
Lee Sock Hui Suzana binti Mustafa
Mastura binti Safie Tan Jou Ann
Ng Min Mei Wah Mei Chin
Noorulhida binti Ishak Wong Yee Cheat
Noorliana binti Ismail
HANDLING INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACIST
vi
CONTENT
PAGE NUMBER
Abbreviations……………………………………………………………………………. ix
Introduction ……………………………………………………………………..………. x
1 METERED DOSE INHALER (MDI)
1.1 Introduction ……………………………………………………………………… 1
1.2 Directions For Use ………………………………………………………………...
2
1.3 Maintenance ……………………………………………………………………. 7
1.4 Determining Contents Of An MDI Canister ………………………………… 9
1.5 Summary Of Metered Dose Inhalers …………………………………………. 10
1.6 References ……………………………………………………………………… 15
2 TURBUHALER®
2.1 Introduction ……………………………………………………………………… 16
2.2 Directions For Use
A. Preparing A New Turbuhaler® (Priming) ……………………………....... 17
B. Used Turbuhaler® ………………………………………………………….. 18
2.3 Maintenance ……………………………………………………………………. 23
2.4 How To Know When The Turbuhaler® Is Empty? …………………………... 23
2.5 Determining The Functionality Of The Device When In Doubt ……………. 24
2.6 Summary Of Turbuhaler® ……………………………………………………… 25
2.7 References ……………………………………………………………………… 27
HANDLING INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACIST
vii
3
EASYHALER®
PAGE NUMBER
3.1 Introduction ……………………………………………………………………… 28
3.2 Directions For Use
A. Preparing The Powder Inhaler For First Use ……………………………. 30
B. Delivering The Medication …………………………………………………. 31
3.3 Maintenance ……………………………………………………………………. 35
3.4 How Do You Know When Your Easyhaler® Is Empty? …………………….. 35
3.5 Summary Of Easyhaler® ………………………………………………………. 36
3.6 References ……………………………………………………………………… 38
4 ACCUHALER®
4.1 Introduction ……………………………………………………………………… 39
4.2 Directions For Use ……………………………………………………………... 40
4.3 Maintenance ………………………………………………………………….. 42
4.4 Summary Of Accuhaler® ……………………………………………………….. 43
4.5 References ……………………………………………………………………… 44
5 HANDIHALER®
5.1 Introduction……………………………………………………………………… 45
5.2 Directions For Use …………………………………………………………….. 46
5.3 Maintenance …………………………………………………………………….. 53
5.4 Summary Of HandiHaler® …………………………………………………… 55
5.5 References ……………………………………………………………………. 56
HANDLING INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACIST
viii
6
SPACER DEVICES
PAGE NUMBER
6.1 Introduction ……………………………………………………………………… 57
a) BI Tube ………………………………………………………………………. 58
b) Chamber With Mouthpiece ………………………………………………... 58
c) Chamber With Mask ………………………………………………………... 59
6.2 Directions For Use
6.2.1 BI Tube ……………………………………………………………….. 60
6.2.2 Chamber With Mask ………………………………………………… 63
6.2.3 Chamber With Mouthpiece ………………………………..…..……. 66
6.3 Maintenance
6.3.1 BI Tube ……………………………………………………………..… 69
6.3.2 Chamber With Mask Or Mouthpiece ………………………………. 69
6.4 References …………………………………………………………………….. 71
7 PEAK FLOW METER
7.1 Introduction ………………………………………………………………….… 72
a) A "Normal" Peak Flow Rate …………………………………………...…… 72
b) Measuring Reversibility Of Airflow Obstruction ………………………...... 73
c) Determine A "Normal" Peak Flow Rate …………………………………… 73
7.2 Directions For Use ……………………………………………………………... 74
7.3 Maintenance …………………………………………………………………… 77
7.4 References …………………………………………………………………….. 78
HANDLING INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACIST
ix
ABBREVIATIONS
BI Tube Boehringer Ingelheim Tube
BP British Pharmacopoeia
CFC Chlorofluorocarbon
COPD Chronic Pulmonary Airway Disease
LABA Long-acting beta-2 agonist
mcg Microgram
MDI Metered Dose Inhaler
PEFR Peak Expiratory Flow Rate
SABA Short-acting beta-2 agonist
HANDLING INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACIST
x
INTRODUCTION Asthma and Chronic Obstructive Pulmonary Disease (COPD) can lead to chronic morbidity and mortality throughout the world and their prevalence has increased considerably over the past 20 years. Asthma is a chronic inflammatory disorder of the airways. Chronically inflamed airways are hyperresponsive; they become obstructed and airflow is limited (by bronchoconstriction, mucus plugs and increased inflammation) when airways are exposed to various risk factors.
COPD consists of chronic bronchitis and emphysema, two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath. In contrast to asthma, the limitation of airflow is poorly reversible and usually gets progressively worse over time.
An inhaler or puffer is a medical device used for delivering medication into the body via the lungs. It is mainly used in the treatment of asthma and COPD. Recent studies have shown that incorrect inhaler technique prevent patients from receiving maximal benefits from medications. Poor medication delivery leads to reduced quality of life, more frequent and longer hospital stay and poor control of the symptoms of asthma such as wheeze, cough and breathlessness.
“Handling of Inhaler Devices: A Practical Guide for Pharmacists” is a collaborative effort involving pharmacists within the Ministry of Health from all states. This guidebook aims to provide pharmacists, prescribers and other health care professionals with standard inhaler techniques to assist patients.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
1
METERED DOSE INHALER (MDI) 1.1 INTRODUCTION
An inhaler is a medical device that administers medication to the lungs in an aerosolised form for the measurement of asthma, chronic obstructive pulmonary disease (COPD) and other respiratory conditions. The most commonly used type of inhaler is the metered dose inhaler (MDI). This type of inhaler consists of a small canister that holds the medicine. The medicine is administered in a metered dose, which saves the users from having to measure their dosage. MDIs are used to administer bronchodilators, anticholinergics and steroids. A MDI consists of 2 major components: the canister and an actuator (or mouthpiece). The canister itself consists of a metering dose valve with an actuating stem. The formulation resides within the canister and is made up of the drug, a liquefied gas propellant and, in many cases, stabilising excipient. The actuator contains the mating discharge nozzle and generally includes a dust cap to prevent contamination.
Picture 1: Cross Section of a Metered Dose Inhaler.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
2
Note: May use both hands for patients with difficulty in handling the device.
1.2 DIRECTIONS FOR USE
STEP 1:
Remove the mouthpiece cover. Remain standing or seated upright to obtain the full dose of each actuation.
STEP 2:
Hold the inhaler in an upright position as shown in diagram.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
3
Note: Each shake constitute from top to bottom, back to top again.
STEP 3:
Shake the MDI 3 - 5 times in an up-down motion before each puff to mix the contents of the canister. If the device is being used for the first time, prime it by actuating the canister mid-air until an even spray is obtained.
STEP 4:
Exhale slowly and completely through your mouth before holding your breath.
DO NOT exhale into the mouthpiece.
3-5X
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
4
STEP 5:
Device should be held at an upright position. Insert into mouth with no obstruction to the mouthpiece with the head slightly tilted. DO NOT bite the mouthpiece.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
5
Note: Ability to hold breath for less than 4 seconds, consider use of a spacer. No extra benefit for holding breath more than 10 seconds.
STEP 6:
Begin inhaling slowly through the mouth (NOT nose) (1) and simultaneously actuate the MDI ONCE (2). Continue inhalation for about 3-5 seconds until the lungs are full (3).
STEP 7:
Hold breath for 4-10 seconds.
It is recommended to leave the inhaler in the mouth while holding breath.
2
1
3
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
6
STEP 8:
Remove inhaler (1) from mouth and exhale slowly (2).
STEP 9:
Wait 30 seconds to 1 minute before repeating step 3-8 if subsequent doses are required.
STEP 10:
Close cap and keep the inhaler in a dry place.
1
2
Note: 1. Patients should be advised to gargle with water after using certain types of MDIs
e.g. Anticholinergics and Inhaled Corticosteroids (ICS). 2. If on two types of inhalers (steroid & bronchodilator), it is recommended to use
the bronchodilator first and wait for 5 minutes before using the steroid.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
7
1.3 MAINTENANCE
} It is important to keep the device clean to: ◦ Prevent medication accumulation. ◦ Prevent blockage over the nozzle.
} Clean the plastic mouthpiece only, NOT the metal canister.
} Clean at least ONCE A WEEK.
} For inhalers that are not used for more than 2 weeks, it should be primed before use.
STEP 1:
Remove the mouthpiece cover and canister from the actuation body.
DO NOT use detergent or soap.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
8
STEP 2:
Wash the actuator from the top with running tap water for 30 seconds.
Repeat by running tap water through the mouthpiece of the actuator for 30 seconds.
STEP 3:
Let the actuator dry overnight after shaking off as much water as possible.
Note: If the patient needs to use the MDI during exacerbation, shake the actuator dry and then actuate twice away from face to ensure no blockage. The inhaler is ready for use.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
9
Blocked nozzle
Clean nozzle
STEP 4:
When the actuator has dried, assemble the canister to the actuator body. Ensure a tight fit.
Shake the device well and actuate twice away from face to ensure no blockage.
Replace the cap and store the device safely before the next use.
1.4 DETERMINING CONTENTS OF AN MDI CANISTER
} It is hard to determine the remaining contents of the MDI.
} The floating/immersion technique is no longer endorsed by a panel of experts.
Keep a spare one. The shaking method can be done to estimate the remaining contents of the MDI canister but it does not reflect the actual content of the canister.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
10
1.5 SUMMARY OF METERED DOSE INHALERS
INHALER/PROPELLANT/ PACKAGING
STRENGTH PER PUFF
(MCG) GROUP
DAILY DOSE ADVERSE EFFECT REMARKS
MINIMUM MAXIMUM
SALBUTAMOL BP
(ASTHALIN®) 400 doses
100
Adult and children
100 - 200 mcg
2400 mcg
1. Slight tremor (particularly in the
hands) 2. Headache 3. Peripheral dilatation 4. Palpitations 5. Tachycardia 6. Arrhythmias 7. Disturbances of sleep and
behavior in children 8. Muscle cramps 9. Hypersensitivity reactions
including paradoxical bronchospasm, urticaria, angioedema, hypotension, pulmonary oedema, erythema multiforme
Short-acting beta-agonist (SABA)
Exercise induced bronchospasm
200 mcg 15 minutes before
exercise
Acute exacerbation
400 mcg every
10 minutes
2400 mcg
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
11
INHALER/PROPELLANT/ PACKAGING
STRENGTH PER PUFF
(MCG) GROUP
DAILY DOSE ADVERSE EFFECT REMARK
MINIMUM MAXIMUM
IPRATROPIUM BROMIDE (ATROVENT®)/200 doses
20
Adult and children ≥ 6 years
60 mcg
240 mcg
1. Gastrointestinal motility disorders (e.g.
constipation, diarrhea, vomiting) 2. Dryness of the mouth 3. Increased heart rate, palpitations,
supraventricular tachycardia, atrial fibrillation
4. Urinary retention 5. Cough 6. Local irritation 7. Mydriasis 8. Increased intraocular pressure,
narrow-angle glaucoma, eye-pain 9. Skin rashes or urticaria 10. Pruritus 11. Angio-edema of the tongue, lips and
face 12. Laryngospasm
Anticholinergic
Children < 6 years
60 mcg
IPRATROPIUM BROMIDE
MONOHYDRATE & SALBUTAMOL SULPHATE (COMBIVENT®)/200 doses
21/120
Adult
42/240 mcg
252/1440
mcg
1. Headache or dizziness 2. Nervousness, tachycardia, fine tremor
or palpitations 3. Dryness of mouth 4. Dysphonia 5. Ocular complications 6. Allergic type reactions
Anticholinergic and short acting beta-agonist (SABA)
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
12
INHALER/PROPELLANT/ PACKAGING
STRENGTH PER PUFF
(MCG) GROUP
DAILY DOSE ADVERSE EFFECT REMARK
MINIMUM MAXIMUM
BUDESONIDE/300 doses
200
Adult
200 mcg
1600 mcg
1. Mild irritation of the throat and thirst 2. Candidiasis of the mouth and throat 3. Cough 4. Generally reversible hoarseness of
the voice 5. Bad taste and dryness of the throat 6. Paradoxical bronchoconstriction 7. Headache 8. Nausea 9. Tiredness 10. Diarrhea 11. Skin reaction 12. Osteoporosis For Beclomethasone dipropionate only: 1. Secondary hypocortisolism 2. Cataract 3. Glaucoma
Glucocorticoid
C/hildren 2 – 7years > 7 years
200 mcg 200 mcg
400 mcg 800 mcg
BECLOMETHASONE
DIPROPIONATE (BECLAZONE®)/200 doses
100
Adult
300 mcg
800 mcg
Children > 6 years
100 mcg
400 mcg
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
13
INHALER/PROPELLANT/ PACKAGING
STRENGTH PER PUFF
(MCG) GROUP
DAILY DOSE ADVERSE EFFECT REMARK
MINIMUM MAXIMUM
CICLESONIDE (ALVESCO®)/
60 doses
160
Adult
160 mcg
320 mcg
Side effects are similar with Budesonide PLUS: 1. Epistaxis 2. Nasopharyngitis 3. Bruising 4. Cataracts 5. Glaucoma
Glucocorticoid
FLUTICASONE PROPIONATE
(FLIXOTIDE®)/120 doses
125
Adult
100 mcg
2000 mcg
1. Mouth and throat candidiasis 2. Hoarseness (patients are advised to
gargle after using the medication) 3. Paradoxical bronchospasm 4. Cutaneous hypersensitivity reactions 5. Headache 6. Giddiness or dizziness 7. Sleep disorders 8. Migraine 9. Paralysis of cranial nerves 10. Mood disorders
Children 4 -11years
100 mcg
200 mcg
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
14
INHALER/PROPELLANT/ PACKAGING
STRENGTH PER PUFF
(MCG) GROUP
DAILY DOSE ADVERSE EFFECT REMARK
MINIMUM MAXIMUM
FLUTICASONE PROPIONATE
& SALMETEROL XINAFOATE (SERETIDE® EVOHALER®)/
120 doses
25/50 25/125 25/250
Adult and children ≥ 4 years
25 mcg (1 puff
Salmeterol alone)
50 mcg (2 puffs
Salmeterol alone)
1. Transient tremor 2. Subjective palpitations and
headache 3. Cardiac arrhythmias (atrial
fibrillation, supraventricular tachycardia and extrasystoles)
4. Athralgia 5. Hypersensitivity reactions such as
rash, edema and angioedema 6. Side effects for fluticasone are
similar with Flixotide®
Glucocorticoid and long acting beta-agonist (LABA)
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
15
1.6 REFERENCES
1. Clark AR. MDIs: physics of aerosol formation. J Aerosol Med 1996; 9 Suppl: S19–S26.
2. Fink JB. Metered-dose inhalers, dry powder inhalers and transitions. Respir Care 2000; 45(6):623–635.
3. Dolovich MB, Fink JB. Aerosols and devices. Respir Care Clin N Am 2001; 7(2):131–173.
4. Tomlinson HS, Corlett SA, Allen MB, Chrystyn H. Assessment of different methods of inhalation from salbutamol metered dose inhalers by urinary drug excretion and methacholine challenge. Br J Clin Pharmaco 2005, 60:6 605–610.
5. Fink JB, Rubin BK. Problems with Inhaler Use: A Call for Improved Clinician and Patient Education. Respir Care 2005; 50(10):1360 –1374.
6. Hesselink AE et al. Determinants of an Incorrect Inhalation Technique in Patients with Asthma or COPD. Scand J Prim Health Care 2001; 19:255–260.
7. Basheer YK et al. Handling of inhaler Devices in Actual Pulmonary Practice: Metered-Dose Inhaler Versus Dry Powder Inhalers. Respir Care 2008; 53(3):324 –328.
8. Wanda HTH et al. Assessment of Inhalation Technique in Children in General Practice: Increased Risk of Incorrect Performance with New Device. Journal of Asthma 2008, 45:67–71.
9. Fink JB, Rubin BK. Problems with Inhaler Use: A Call for Improved Clinician and Patient Education. Respir Care 2005; 50(10):1360 –1374.
10. David A. Warrell, Timothy M. Cox, John D. Firth, Edward J. Benz. Oxford Textbook of Medicine 4th Edition. Oxford University Press, 2005; p1305.
11. http://en.wikipedia.org/wiki/Inhaler. 2009
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
16
2. TURBUHALER® 2.1 INTRODUCTION Turbuhaler® is an easy-to-use, multiple-dose, inspiratory flow-driven dry powder inhaler. Currently there are 4 types of Turbuhaler® which are Budesonide (Pulmicort®), combination of Budesonide/Formoterol (Symbicort®), Formoterol (Oxis®) and Terbutaline (Bricanyl®).
Picture 1: Turbuhaler® (Adapted from
http://www.astrazeneca.ca/documents/ProductPortfolio/SYMBICORT_CIL_en.pdf)
Picture 2: Different types of Turbuhaler® (Adapted from
http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-the-basics)
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
17
2.2 DIRECTIONS FOR USE
A. Preparing a new Turbuhaler® (Priming):
STEP 1:
Unscrew and lift off the cover.
STEP 2:
Hold the Turbuhaler® upright with the grip facing downwards.
Turn the grip as far as it will go and then turn it back as far as it will go in the opposite direction until a “CLICK” sound is heard.
Perform this procedure TWICE.
“CLICK”
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
18
B. Used Turbuhaler®
STEP 1:
Unscrew and lift off the cover.
STEP 2:
Hold the Turbuhaler® upright with the grip facing downwards.
DO NOT hold the mouthpiece when turning the grip.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
19
STEP 3: To load the Turbuhaler® with a dose, turn the grip as far as it will go in one direction as shown in the diagram.
STEP 4:
Then turn it back again as far as it will go in the opposite direction until a “CLICK” sound is heard.
The Turbuhaler® is now loaded with the desired dose and is ready for use.
“CLICK”
Note: If the turbuhaler is accidentally dropped, a new dose should be loaded and inhaled.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
20
STEP 5: Breathe out away from the mouthpiece.
STEP 6:
Place the mouthpiece gently between the lips.
Ensure a tight seal around it as in diagram.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
21
STEP 7:
Breathe in forcefully and deeply through the mouth only.
STEP 8:
Remove the Turbuhaler® from the mouth before breathing out again.
DO NOT breathe into the mouthpiece.
Note: Holding breath after inhalation is optional.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
22
STEP 9:
Repeat step 2 - 8 if more than one dose is required.
STEP 10:
Replace the cover and store Turbuhaler® in a dry place.
Note: 1. Patients should be advised to gargle with water after using steroid containing
Turbuhalers®. 2. If on two types of Turbuhalers® (steroid & bronchodilator), it is recommended to
use the bronchodilator first and wait for 5 minutes before using the steroid.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
23
2.3 MAINTENANCE
2.4 HOW TO KNOW WHEN THE TURBUHALER® IS EMPTY?
Picture 3: Shows how many doses are left (Adapted from: http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-the-basics/)
Turbuhaler® has a dose indicator that shows how many doses are left in the inhaler. It moves slowly when each time a dose is loaded.
For example, Budesonide/Formoterol (Symbicort®) Turbuhaler® dose indicator marks every 10th dose, and every 20th dose is displayed numerically. When the red colour first appears in dose indicator, it shows that there are only 20 doses left.
1. Clean the outside of the mouthpiece once a week with a dry cloth or tissue.
2. Never use water or any other fluid when cleaning the mouthpiece.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
24
Terbutaline (Bricanyl®), Budesonide (Pulmicort®) and Formoterol (Oxis®)Turbuhaler® dose indicators are not displayed numerically. When the red colour first appears in dose indicator, it shows that there are only 20 doses left.
The Turbuhaler® can be safely disposed off when the dose indicator window has turned red completely. The sound heard when the device is shaken is produced by a drying agent, and not the medication. Turbuhaler® cannot be re-filled with drug and should be discarded. 2.5 DETERMINING THE FUNCTIONALITY OF THE DEVICE WHEN IN DOUBT
Picture 4: Determining the functionality of the device when in doubt (Adapted from: http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-function-and-use/)
Turbuhaler® makes no sound when the drug is released. Moreover, since the amount of drug delivered by Turbuhaler® is small, there is either no or only a faint taste in the mouth when the drug is delivered. This can, in some cases, lead to patients being uncertain as to whether they have received the required dose. The correct functionality of the Turbuhaler® can easily be checked by inhaling through a piece of dark cloth.
Drug Dark cloth
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
25
2.6 SUMMARY OF TURBUHALER®
INHALER/PACKAGING
STRENGTH PER
INHALATION (MCG)
GROUP DAILY DOSE
ADVERSE EFFECT REMARK MINIMUM MAXIMUM
TERBUTALINE (BRICANYL®)/
200 doses
500
Adult
500 mcg
6000 mcg
1. Mouth & throat irritation 2. Cardiac arrhythmias 3. Headache 4. Fine skeletal muscle tremor 5. Paradoxical bronchospasm 6. Potentially severe
hypokalemia
*Use with caution in patient with hyperthyroidism *Monitor potassium level in acute severe asthma
Short-acting beta-agonist (SABA)
Children 3 -12 years
500 mcg
4000 mcg
FORMOTEROL (OXIS®)/
4.5 mcg/60 doses 9 mcg/60 doses
4.5
Adult
4. 5 - 9 mcg
54 mcg
Long-acting beta-agonist (LABA)
Children > 6 years
18 mcg
9
Adult
9 mcg
54 mcg
Children > 6 years
18 mcg
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
26
INHALER/PACKAGING
STRENGTH PER
INHALATION (MCG)
GROUP DAILY DOSE
ADVERSE EFFECT REMARK MINIMUM MAXIMUM
BUDESONIDE & FORMOTEROL
(SYMBICORT®)/ 160/4.5 mcg/60 doses 160/4.5mcg/120 doses
160/4.5
Adult
160 / 4.5
mcg
1920 / 54
mcg
1. Palpitation 2. Candida infection in the
oropharynx 3. Mild irritation of the throat 4. Headache 5. Tremor 6. Coughing 7. Reversible hoarseness of
the voice 8. Side effects for Formoterol
are similar with Oxis®
Combination of glucocorticoid and long-acting beta-agonist (LABA)
Aldolescents Reliever therapy: 1 inhalation as needed in response to symptoms Max daily dose including reliever therapy: 12 inhalations
BUDESONIDE (PULMICORT®)
100mcg/200 doses & 200 mcg/100 doses
100
Or
200
Adult
200 - 1600
mcg
1600 mcg
Glucocorticoid
Children > 7 years
200 - 800
mcg
800 mcg
Children 2 - 7 years
200 - 400
mcg
400 mcg
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
27
2.7 REFERENCES
1. AZ-AIR. Part III: Consumer information on Symbicort® Turbuhaler®
[monograph on the internet]. Mississauga, Ontario: AstraZeneca Canada Inc; 2009 [cited 2009 May 26]. Available from: http://www.astrazeneca.ca/documents/Product Portfolio/SYMBICORT_CIL_en.pdf
2. AZ-AIR. Turbuhaler – the basics [homepage on the internet]. AstraZeneca Inc; 2008 [cited 2009 August 23]. Available from: http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-the-basics/
3. AZ-AIR. Turbuhaler function and use [homepage on the internet]. AstraZeneca Inc; 2008 [cited 2009 May 26]. Available from: http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-function-and-use/
4. Editorial development by CMPMedica. MIMS:Disease Management Guide to Asthma. Petaling Jaya: United Medica Sdn. Bhd; 2008.
5. Spier S, Robert LT. Inhalation therapy for the asthmatic child. The Canadian Journal of Pediatrics.1991 December.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
28
3. EASYHALER® 3.1 INTRODUCTION The Easyhaler® is a new generation, multidose dry powder inhaler preloaded with 200 doses of asthma medications. Easyhaler® has been designed to resemble a MDI in terms of the small size of the device, but importantly avoids the need to coordinate drug release and inhalation. The Easyhaler® product range currently includes four products; anti-inflammatory inhaled corticosteroids Budesonide (Giona®) Easyhaler® and Beclomethasone (Beclomet®) Easyhaler® as well as bronchodilators Formeterol Easyhaler® and Salbutamol (Buventol®) Easyhaler®. Salbutamol via Easyhaler® is at least as effective as salbutamol via Turbuhaler® in the treatment of histamine-induced bronchoconstriction (Zetterstrom et al. 2000). The efficacy via Easyhaler® is unaffected by low inspiratory flow.
Picture 1: Easyhaler® (Adapted from http://www.medscape.com/viewarticle/531818_3)
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
29
Picture 2: Different types of Easyhaler® (Adapted from http://www.orion.fi/en/Products-and-services/Human-prescription-medicines/Proprietary-
products-portfolio/Easyhaler/)
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
30
3.2 DIRECTIONS FOR USE
A. Preparing the powder inhaler for first use
STEP 1: Remove the powder inhaler from the laminated pouch.
STEP 2:
Insert the powder inhaler into the protective cover.
The dust cap on the mouthpiece prevents accidental actuation of the inhaler when inserting it into the protective cover.
Protective cover
Dust cap
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
31
B. Delivering the medication
STEP 1: Remove the dust cap.
STEP 2:
Shake the device prior to each dose
After shaking, hold the device in the upright position.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
32
STEP 3: Press the device only ONCE between the thumb and forefinger until a “CLICK” sound is heard.
Keep holding the device in the upright position.
STEP 4:
Breathe out normally, away from the mouthpiece.
“CLICK”
Note: If more than one dose is accidentally released, remove the dose from the mouthpiece by tapping it against the palm of the hand.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
33
STEP 5: Place the mouthpiece between lips and close tightly around the mouthpiece.
Breathe in forcefully and deeply through the mouth only.
STEP 6:
Remove the inhaler from mouth and hold breath for 5-10 seconds.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
34
STEP 7: Repeat step 2-6 if more than one dose is required.
STEP 8: Put the dust cap back on the mouthpiece.
Store Easyhaler® in a dry place.
Note: 1. Patients should be advised to gargle with water after using steroid containing
Easyhalers®. 2. If on two types of Easyhalers® (steroid & bronchodilator), it is recommended to
use the bronchodilator first and wait for 5 minutes before using the steroid.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
35
3.3 MAINTENANCE
3.4 HOW DO YOU KNOW WHEN YOUR EASYHALER® IS EMPTY?
Picture 3: Identification Easyhaler® is empty (Adapted from http://www.medasverige.se/vardpersonal/astma_allergi_och_kol/bilder/easyhaler)
Easyhaler® has a dose counter which indicates the number of remaining doses. The counter turns after every five actuations. When the counter turns red there are 20 doses left. A clear window on the back of the inhaler allows viewing of the powder. The device must be replaced when the dose counter indicates zero.
1. The mouthpiece can be cleaned with a dry cloth or tissue.
2. Never use water or any other fluid
when cleaning the mouthpiece. 3. Inhalation powder should not be
exposed to humidity. If the powder becomes damp, it is not suitable for use and should be disposed of.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
36
3.5 SUMMARY OF EASYHALER®
INHALER/PACKAGING
STRENGTH PER
INHALATION (MCG)
GROUP DAILY DOSE
ADVERSE EFFECT REMARK MINIMUM MAXIMUM
SALBUTAMOL (BUVENTOL®)/
200 doses
200
Adult
200 - 400
mcg
2400 mcg
Common
1. Tremor 2. Palpitation 3. Headache
Infrequent
1. Hyperglycaemia (high dose) 2. Tachycardia 3. Muscle cramps 4. Agitation 5. Hyperactivity in children 6. Insomnia
Rare
1. Paradoxical bronchospasm 2. Allergic reactions including
urticaria and angioedema
Short-acting beta-agonist (SABA) Use with caution in patient with hyperthyroidism Monitor potassium level in acute severe asthma
Children 6 - 12 years
200 mcg
1200 mcg
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
37
INHALER/PACKAGING
STRENGTH PER
INHALATION (MCG)
GROUP
DAILY DOSE
ADVERSE EFFECT REMARK MINIMUM MAXIMUM
BUDESONIDE (GIONA®)/
200 doses
200
Adult
200 mcg
1600 mcg
Common
1. Dysphonia 2. Oropharyngeal candidiasis 3. Bruishing
Rare
1. Allergic reactions Others (if used in high doses)
1. Adrenal impairment 2. Bone density loss 3. Glaucoma 4. Cataract 5. Skin thinning 6. Bruising 7. Impaired growth
Glucocorticoid
Children 6 - 12 years
200 mcg
800 mcg
BECLOMETHASONE
(BECLOMET®)/ 200 doses
200
Adult
200 mcg
1600 mcg
Children 6 - 12 years
200 mcg
800 mcg
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
38
3.6 REFERENCES
1. Asthma, Allergy and KOL [homepage on the internet] [cited 2009 Sept 2]. Available from: http://www. medasverige. se/ vardpersonal/ astma_allergi_ och_ kol/bilder/easyhaler.
2. Buventol Easyhaler® [Package Insert]. Findland: Orion Corporation. 3. Medscape [homepage on the internet]. Closer to an 'Ideal Inhaler' With the
Easyhaler: Patient Use Inspiration Rate. 2005 [cited 2009 Sept 2];[about 6 screens]. Available from: http://www.medscape.com/viewarticle/531818_3.
4. Orion’s Portfolio of Medicines/Easyhaler. Orion Corporation [homepage on the internet]. 2009 [cited 2009 Sept 2]. Available from: http: //www.orion.fi/en/Products-and-services/Human-prescription-medicines/ Proprietary-products-portfolio/Easyhaler/.
5. Zetterstrom et al. Respiratory Medicine 2000. Nov;94(11):1097-1102. 6. Easyhaler Multidose Dry Powder Inhaler Monograph. 2008 Orion
Corporation
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
39
4. ACCUHALER® 4.1 INTRODUCTION
The combination of Salmeterol and Fluticasone Propionate (Seretide®) Accuhaler® is a moulded plastic inhaler device containing a foil strip with 60 blisters. Each blister contains lactose as a carrier. The blisters protect the inhalation powder from the effects of the atmosphere.
Picture 1: Cross Section of Accuhaler®.
Mouthpiece
Lever
Thumb grip
Dose counter
Outer case
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
40
4.2 DIRECTIONS FOR USE
Check that the dose counter read 60, indicating the full number of doses.
STEP 1: Hold the outer case in one hand and put the thumb of the other hand on the thumb grip to open the Seretide® Accuhaler®.
Push the thumb grip as far as it will go until a “CLICK” sound is heard.
STEP 2:
Hold the device horizontally with the mouthpiece towards the patient.
Slide the lever as far as it will go as in diagram until another “CLICK” sound is heard to load a dose in the device.
Note: Never hold the inhaler with the mouthpiece pointing downwards during or after loading a dose, as the medication can be dislodged. Always keep it horizontal.
“CLICK”
“CLICK”
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
41
STEP 3: Hold the Accuhaler® away from mouth and breathe out completely.
DO NOT breathe into the device.
STEP 4:
Put the mouthpiece into the mouth and ensure a good seal.
Breathe in forcefully and deeply through the mouth only.
STEP 5: Remove the Accuhaler® from the mouth and hold breath for 10 seconds or as long as possible.
DO NOT breathe into the mouthpiece.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
42
4.3 MAINTENANCE
1. Wipe the mouthpiece of the Seretide® Accuhaler® with a dry cloth or tissue to
clean it. 2. The Accuhaler® is recommended to be cleaned at least ONCE A WEEK.
3. The content of the device is susceptible to moisture. For this reason keep it in a
dry place away from humidity.
STEP 6:
Close the device by sliding the thumb grip back to its original position until a “CLICK” sound is heard.
The lever will return to its original position and will be reset.
STEP 7: Repeat step 1-6 if more than one dose is required.
Note: 1. Patients should be advised to gargle with water after using the Seretide®
Accuhaler®
2. Number 5 to 1 appear RED to warn that there are only a few doses left.
“CLICK”
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
43
4.4 SUMMARY OF ACCUHALER®
INHALER/PACKAGING
STRENGTH PER
INHALATION (MCG)
GROUP DAILY DOSE
ADVERSE EFFECT REMARK MINIMUM MAXIMUM
SALMETEROL & FLUTICASONE
PROPIONATE (SERETIDE®)/ 60 doses
50/100* 50/250 50/500
Adult and adolescents (> 12 years)
1 inhalation (50/100) *
OR
1 inhalation
(50/250)
OR
1 inhalation (50/500)
2 inhalations (50/100) *
OR
2 inhalations
(50/250)
OR
2 inhalations (50/500)
1. ß2-agonist treatment side effects
like tremor, palpitations, cardiac arrhythmias etc.
2. Arthralgia 3. Hypersensitive reactions like
rash, oedema and angioedema 4. Hoarseness and candidiasis of
the mouth 5. Possible systemic steroid effects
like Cushing’s syndrome and adrenal suppression
Combination of glucocorticoid and long-acting beta-agonist (LABA)
*Not available in MOH Drug Formulary (updated November 2009)
Children > 4 years
1 inhalation (50/100) *
2 inhalations (50/100) *
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
44
4.5 REFERENCES
1. Chrystyn H. The Diskus™: a review of its position among dry powder inhaler devices. Int J Clin Pract. 2007 Jun; 61(6): 1022–36.
2. Lavorini F, Magnan A, Dubus JC, Voshaar T, Corbetta L, Broeders M, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med. 2008; 102(4): 593–604.
3. Rau JL. Practical problems with aerosol therapy in COPD. Respir Care. 2006 Feb; 51 (2): 158–72.
4. Seretide™ Accuhaler™ [package insert]. Ware (UK): Glaxo Wellcome Operations; 2005.
5. Kesten S, Zive K, Chapman KR. Pharmacist knowledge and ability to use inhaled medication delivery systems. Chest 1993; 104(6): 1737-42.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
45
5. HANDIHALER®
5.1 INTRODUCTION HandiHaler® is a device to deliver Tiotropium bromide (Spiriva®) into the lung. Tiotropium bromide (Spiriva®) comes in light green, hard gelatine capsule-containing powder form and contains 18 mcg tiotropium blended with lactose monohydrate as a carrier. Spiriva® capsules should not be swallowed and must be used with HandiHaler® device only.
Spiriva® is not a rescue medicine and should not be used for acute exacerbation.
Picture 1: Spiriva® capsules.
Picture 2: HandiHaler®.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
46
5.2 DIRECTIONS FOR USE
STEP 1: Open the dust cap by pressing the green piercing button.
STEP 2: Pull the dust cap upwards to expose the mouthpiece.
Note: Some HandiHaler® devices may require the dust cap to be manually opened upwards.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
47
STEP 3: Open the mouthpiece by pulling it upwards.
STEP 4: The blister cards are perforated in the middle. Tear the card along the perforation.
Note: 1. Store Spiriva® capsules in a dry place. 2. Keep away from extreme heat or moisture.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
48
STEP 5: Carefully open the blister cavity by peeling back the aluminum foil until ONE capsule is fully visible. DO NOT exceed the STOP line.
STEP 6: Remove the capsule from the blister pack.
Note: In case a second capsule is exposed to air accidently, it has to be discarded. The capsule should be removed from the blister pack just before using it.
Note: DO NOT swallow the capsule.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
49
STEP 7: Place the capsule in the centre of the chamber.
STEP 8: Close the mouthpiece firmly until a “CLICK” sound is heard.
“CLICK”
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
50
STEP 9: Hold the HandiHaler® device with the mouthpiece pointed upright. Press the green piercing button completely as shown in diagram before releasing it. This will make holes in the capsules to allow the medication to be delivered when inhaled.
STEP 10: Breathe out completely. DO NOT breathe into the mouthpiece.
1
2
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
51
STEP 11: Place the HandiHaler® horizontally to the mouth and close the lips tightly around the mouthpiece. Breathe in slowly and deeply at a rate sufficient to hear the CAPSULE VIBRATE.
STEP 12: Remove device from the mouth and hold breath for 5-10 seconds or as long as possible. Then resume normal breathing.
STEP 13: To ensure that all the medicine is inhaled, repeat step 10-12.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
52
STEP 14: Open the mouthpiece and dispose the empty capsule into rubbish bin as in diagram.
STEP 15: Close the mouthpiece and dust cap for storage.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
53
5.3 MAINTENANCE
STEP 1: Open the dust cap, mouthpiece and chamber as in diagram.
STEP 2: Rinse all parts with warm water to remove any powder. DO NOT use cleaning agents or detergents.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
54
STEP 3: Dry the HandiHaler® thoroughly by shaking off the excess water and air-drying it.
STEP 4: It takes 24 hours to air dry, so clean it immediately after use.
Note: It is recommended to clean the device EVERY MONTH.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
55
5.4 SUMMARY OF HANDIHALER®
INHALER/PACKAGING
STRENGTH PER
INHALATION (MCG)
GROUP DAILY DOSE ADVERSE EFFECT REMARK
TIOTROPIUM BROMIDE (SPIRIVA®)/
30 capsules
18
Adult *Use in children and adolescent under 18 years old is not recommended
18 mcg
1. Dryness of mouth or xerostomia 2. Upper respiratory infections 3. Sinusitis 4. Rash 5. Cataracts 6. Angioedema 7. Bitter or metallic taste 8. Tachycardia 9. Urinary retention 10. Angina pectoris 11. Hypercholesterolemia 12. Hyperglycemia
Long acting anticholinergic
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
56
5.5 REFERENCES
1. Hvizdos KM, Goa KL. Tiotropium bromide. Drugs 2002;62(8):1195-1203.
2. Van Noord JA, Bantje TA, Eland ME et al. A randomized controlled comparison of tiotropium and ipratropium in the treatment. Thorax 2000;55(4):289-94.
3. Vincken W, van Noord JA, Greefhorst APM et al. Improved health outcomes in patients with COPD during 1 years treatment with tiotropium. Eur Resp J 2002;19(2):209-16.
4. CCOHTA. Tiotropium: A potential replacement for ipratropium in patients with COPD. Issues in Emerging Health Technologies 2002;35:1-4
5. Donohue JF, van Noord JA, Bateman ED et al. A 6-month, placebo-controlled study comparing lung function and health status changes in COPD patients treated with tiotropium or salmeterol. Chest 2002;122(1):47-55.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
57
6. SPACER DEVICES 6.1 INTRODUCTION A spacer is a device attached to a metered-dose inhaler that aids delivery of inhaled medications and to increase the effectiveness of a metered dose inhaler (MDI). A spacer is usually used for children and elderly patients who have poor coordination to MDI technique. The advantages of spacers are:
1. Eliminate the problem of hand-breath coordination. 2. Improve the delivery of medication and allows more medicine into the lungs. 3. Reduce throat irritation and/or fungal growth in the upper airways
(e.g. candidiasis, hoarseness and bad taste).
Picture 1: The advantages using MDI with Spacer devices (Adapted from http://trudellmed.com/_Content/PDFs/AC+Fv_StudySummary.pd)
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
58
There are 2 types of spacer device, namely the extension tube (i.e. BI tube) and holding chamber (i.e. Chamber with mouthpiece & Chamber with mask).
a) BI Tube
b) Chamber with Mouthpiece
c) Chamber with Mask
Inhalation/ exhalation valve
Whistle
Cap
Mouthpiece
Body
Mouthpiece
MDI Adaptor Picture 2: BI Tube
Picture 3: Chamber with Mouthpiece (Adapted from http://trudellmed.com/Consumers/cn_aerochamber_wfv.asp)
Aerodynamic Chamber MDI Adaptor
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
59
Picture 5: Different types of chamber (Adapted from http://trudellmed.com/Consumers/cn_aerochamber_wfv.asp)
6.2 DIRECTIONS FOR USE
6.2.1 BI TUBE
MDI Adaptor
Aerodynamic Chamber Exhalation Valve
Mask
Inhalation Valve
Aerochamber Whistle
Picture 4: Chamber with Mask (Adapted from http://trudellmed.com/Consumers/cn_aerochamber_wfv.asp)
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
60
STEP 1:
Remove the mouthpiece cover from the
metered dose inhaler (MDI).
STEP 2:
Attach the large end of the BI tube to
the mouthpiece of the MDI.
STEP 3:
Shake the MDI 5 times in an up-down
motion (as shown in diagram) before
use.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
61
STEP 3:
Shake the MDI 5 times in an up-down
motion (as shown in diagram) before
use.
STEP 5:
Press the base of the canister (1) and
inhale the nebulised aerosol (2).
STEP 6:
Hold breath for 5-10 seconds.
STEP 4:
Exhale slowly and completely
through your mouth before holding
your breath.
DO NOT exhale into the BI tube.
1
2
Note: To prevent the spray from depositing on the tube, inhale immediately after pressing the canister.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
62
STEP 8:
After use, remove the BI Tube and
replace the mouthpiece cover on the
MDI.
Note: The BI Tube may be left attached to the MDI.
STEP 7:
Wait 30 seconds to 1 minute before
repeating step 3-6 if subsequent doses
are required.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
63
6.2.2 CHAMBER WITH MASK
STEP 1:
Visually check for foreign objects
before each use.
STEP 2:
Remove the mouthpiece cover from
the MDI.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
64
STEP 3:
Insert the MDI into the adaptor of the
chamber.
STEP 5:
Apply mask to face and ensure that
there is a good seal.
STEP 4:
While holding the chamber with MDI
firmly, shake the MDI for 5 times in an
up-down motion (as in diagram).
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
65
STEP 6:
Press MDI ONCE at beginning of
normal breath.
Breathe normally between 5-10
breaths while holding the mask
firmly to your face.
STEP 7:
Slow down inhalation if the
WHISTLE sound is heard.
STEP 8:
Wait 30 seconds to 1 minute before repeating step 4-6 if subsequent doses are required.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
66
6.2.3 CHAMBER WITH MOUTHPIECE
STEP 1:
Visually check for foreign objects
before each use.
STEP 2:
Remove the cap from the MDI and the
mouthpiece cover of the chamber.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
67
STEP 3:
Insert the MDI into the adaptor of the
mouthpiece (1).
While holding the mouthpiece with
MDI firmly, shake the unit for 5 times
in an up-down motion as shown in
diagram (2).
STEP 4:
Put the mouthpiece in the mouth.
2
1
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
68
STEP 5:
Simultaneously press the MDI ONCE
(1) at the beginning of a slow and deep
inhalation (2).
Hold breath as long as possible,
between to 4-10 seconds before
breathing out through the nose.
STEP 6:
Slow down inhalation if a WHISTLE sound is heard.
STEP 7:
Wait 30 seconds to 1 minute before repeating step 3-6 if subsequent doses are required.
Note: 1. Alternatively, the mouthpiece may be kept tightly in the mouth. 2. Inhale slowly through the mouth and exhale through the nose for 5 times
after pressing the MDI.
1
2
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
69
6.3 MAINTENANCE
6.3.1 BI TUBE
• Wash the BI tube at least ONCE A MONTH with tap water and air dry.
• It is not recommended to wipe the BI tube dry after washing.
6.3.2 CHAMBER WITH MASK OR MOUTHPIECE
• It is recommended to clean ONCE A WEEK.
• Remove the backpiece only.
• DO NOT remove the mask or valve assembly.
• Soak both parts for 15 minutes in a mild solution of liquid dish detergent and warm clean water.
• Agitate gently.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
70
• DO NOT rinse the chamber as shown, as this may lead to static build up.
• If concern about potential for contact dermatitis, rinse only the mouthpiece/mask portion in water.
• Shake out excess water and allow to air dry in a vertical position.
• DO NOT rub dry.
• To reassemble, centre the alignment feature on the back piece as shown.
Note: Cleaning of the product varies between the different variants of the AeroChamber®. Please refer to each individual product information leaflet.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
71
6.4 REFERENCES
1. Boehringer Ingelheim. Product Leaflet: Instructions of Use for Metered Aerosol Inhaling Device.
2. Corner WT, Dolovich P and Newhouse MT. Reliable salbutamol adminitration in 6- to 36-month-old children by means of a metered dose inhaler and aerochamber with mask; Pediatric Pulmonary 1989; 6:263-267.
3. Dolovich P, Ruffin R and Newhouse MT. Clinical evaluation of a simple demand inhalation MDI aerosol delivery device. Chest 1983; 84:1.
4. Pedersen S. Spacer Devices. [updated 2003 May 21; cited 2009 May 15] Available from: http://www.ginasthma.com/download.asp?intld=107.
5. Spier S and Robert LT. Inhalation therapy for the asthmatic child. The Canadian
6. Journal of Pediatrics 1991. 7. Trudell Medical International. c1997-2009 [cited 2009 May]. AeroChamber
Plus* VHC with Flow-Vu* Inspiratory Flow Indicator. Available from:http://trudemed.com/Consumers/cn_aerochamber_wfv.asp.
8. Trudell Medical International; c 1997-2009 [cited 2009 May]. Study summary: Use of the AeroChamber Plus* Valved Holding Chamber with Flow-Vu* Inspiratory Flow Indicator. Available from: http://trudemed.com/_Content/PDFs?AC+Fv_StudySummary.pd
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
72
7. PEAK FLOW METER 7.1 INTRODUCTION
A peak flow meter is a small portable device with a measuring gauge. It measures the force and speed that air is blown out of the lungs. This measurement is referred to as the peak expiratory flow rate (PEFR). a) “NORMAL” PEAK FLOW RATE Normal peak flow rate is based on a person's age, height, sex and race. A personal best normal may be obtained from measuring the patient's own peak flow rate. Therefore, it is important that patients discuss with their health care provider on what is considered as “normal”. Once patients have learned their usual and expected peak flow rate, changes or trends of their disease condition can easily be recognised.
Marker
Holder Scales
Mouthpiece
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
73
b) MEASURING REVERSIBILITY OF AIRFLOW OBSTRUCTION To measure the degree of reversibility (usually increased in asthma) of airflow obstruction, perform peak flow meter measurement before and approximately 15 minutes after administering a bronchodilator by metered dose inhaler or nebuliser. Short acting Beta-2 agonists (e.g. salbutamol, terbutaline) are generally considered the benchmark bronchodilator. c) DETERMINE A “NORMAL” PEAK FLOW RATE Three zones of measurement are commonly used to interpret peak flow rates. In general, a normal peak flow rate can vary as much as 20 percent.
Green Zone (80-100% of patients’ usual or "normal" peak flow rate): This zone signals that patients’ asthma is under reasonably good control. It is advisable to continue the prescribed program or management. Yellow Zone (50-80% of patients’ usual or "normal" peak flow rate): This zone signals that more attention should be given to patients’ asthma program or management. Patients are advised to consult their healthcare provider to review their regimen.
Red Zone (<50% of patients’ usual or "normal" peak flow rate): This zone signals a medical alert. Immediate decisions and actions must be taken. Patients are advised to use their rescue medications right away and consult their healthcare provider immediately.
e.g:
Your Personal Best
peak flow meter
reading is:
You are in the
Green Zone if your peak flow meter reading is:
You are in the
Yellow Zone if your peak flow meter reading is
between:
You are in the
Red Zone if your peak flow meter reading is:
100 above 80 80 and 50 below 50
125 above 100 100 and 63 below 63
150 above 120 120 and 75 below 75
175 above 140 140 and 88 below 88
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
74
7.2 DIRECTIONS FOR USE
STEP 1: Place the mouthpiece on the peak flow meter.
STEP 2:
Reset the marker to the bottom of the scale (zero or the lowest number on the scale).
Note: Alternatively, the originally supplied plastic mouthpiece may be detached and replaced with a disposable mouthpiece.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
75
STEP 3:
Hold the peak flow meter in the way that the scale and marker is not obstructed by the fingers of the patient (As shown in diagram).
STEP 4: Stand in an upright position and breathe in as deep as possible.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
76
STEP 5: Place the peak flow meter in the mouth and maintain it horizontally, closing the lips around the mouthpiece. Make sure the opening of the mouthpiece is not blocked by the tongue.
STEP 6:
Blow as hard and fast as possible.
DO NOT tilt the head forward while blowing.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
77
7.3 MAINTENANCE
Most peak flow meters need to be cleaned. Follow the cleaning instructions which are available when the unit is purchased.
Record this reading e.g.: 500L/min
STEP 7:
Record the measurement and reset the marker to its original position at the bottom of the scale.
STEP 8: Breathe normally and repeat step 2-7 two more times. Note down the date, time, and highest of the 3 peak flow measurements. DO NOT average the numbers.
Note: The highest of the 3 readings will be used to assess a patient’s PEFR.
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
78
7.4 REFERENCES
1. Radeos MS, Camargo CA. Predicted peak expiratory flow: differences across formulae in the literature. Am J Emerg Med. 2004 Nov; 22(7):516-21.
2. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med. 1999 Jan;159(1):179-87
3. Bheekie A, Syce JA, Weinberg EG. Peak expiratory flow rate and symptom self-monitoring of asthma initiated from community pharmacies. J Clin Pharm Ther. 2001 Aug; 26(4):287-96.
4. Reddel HK, Marks GB, Jenkins CR. When can personal best peak flow be determined for asthma action plans?. Thorax. 2004 Nov; 59(11):922-4
5. Murata GH, Kapsner CO, Lium DJ, Busby HK. Patient compliance with peak flow monitoring in chronic obstructive pulmonary disease. Am J Med Sci. 1998 May; 315(5):296-301.
6. http://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_disease. 2009
HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS
79
PHARMACEUTICAL COMPANIES
AstraZeneca Sdn Bhd
Boehringer Ingelheim (M) Sdn Bhd
Cipla Ltd
GlaxoSmithKline Pharmaceutical Sdn Bhd
Nycomed Division Diethelm (M) Sdn Bhd
Orion Pharma
Pharmaniaga Logistics Sdn Bhd
top related