inhalation therapy in asthma and copd

7/22/2019 Inhalation Therapy in Asthma and Copd

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INHALATION THERAPYIN ASTHMA AND COPD

Dr Muhammed Aslam

Junior Resident

MD Respiratory Medicine

Academy Of Medical Science

Pariyaram , Kannur


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Inhalation delivery systems

Bronchodilator aerosol for asthma -1935

Conventional pressurized MDI - 1956


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Types Pressurized metered dose inhaler

(pMDI)

MDI with spacers or holdingchambers

Breath actuated MDI

Dry powder inhaler (DPI)

Nebulizers


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PressurizedMDI


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PropellantsProvides the force to generate the aerosol cloud and is also the

medium in which the active component must be suspended or

dissolved. Propellants in MDIs typically make up more than 99% of

the delivered dose


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Chlorofluorocarbons (CFCs)

most commonly used propellants were thechlorofluorocarbons CFC-11, CFC-12 and CFC-114.

Banned due to adverse effect on ozone layer

hydrofluoroalkanes (HFA)HFA 134a (1,1,1,2,-tetrafluoroethane)

These new devices are more effective. The HFA

propellant produces an aerosol with smaller particle size,resulting in improved deposition in the small airways and

greater efficacy at equivalent doses compared with CFC

MDIs.


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When the valve is actuated propellant

and drug leave the inhaler at high

velocity Majority of drug impacts in

oropharynx

Less than 25% reaches the lung


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Shake the canister

Place the mouthpiece of actuator between

the lips

Breathe out steadily

Release the dose while taking a slow

deep breath in Hold the breath in while counting to 10

Most efficient way of using MDI- steps


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Advantages ofMDIs

Compact, portable ,convenient

Multidose delivery capability

Lower risk of bacterial contamination

Suitable for emergency situation


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Disadvantages of MDIs

Needs correct actuation and inhalation

coordination- difficult for children and

elderly patients

Cold freon effect

High pharyngeal drug deposition Flammability possibility of new HFA

propellants

Remaining dose difficult to determine


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MDI with Spacer


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Steps for Using a Spacer with an MDI

Insert the inhaler/canister into spacer and

shake.

Breathe out.

Put the spacer mouthpiece into your

mouth.

Press down on the inhaler once. Breathe in slowly (for 3-5 seconds).

Hold breath for 10 seconds.


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Advantages of MDI with spacer

Compensate for poor technique/coordination

with MDI

Spacers slow down the speed of the aerosol

coming from the inhaler, meaning that less ofdrug impacts on the back of the mouth and

somewhat more may get into the lungs. Because

of this, less medication is needed for an effective

dose to reach the lungs, and there are fewerside effects from corticosteroid residue in the

mouth.


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Disadvantages Large size and volume of device

Bacterial contamination is

possible; device needs to becleaned periodically

Electrostatic charges may reducedrug delivery to the lungs


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Breath actuated MDI


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LATEST IN MDI


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Dry powder inhaler (DPI)

Si l d D i


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Single dose DevicesHad to be reloaded with capsule containing

micronized drug in a large particle carrier

powder ,usually lactose


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Multiple DoseDevices


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Advantages Breath-actuated

Less patient coordination required

Spacer not necessary

Compact Portable

No propellant Usually higher lung deposition

than a pMDI


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Disadvantages of DPI Work poorly if inhalation is not forceful enough

Many patients cannot use them correctly (e.g.

capsule handling problems for elderly

Most types are moisture sensitive

Humidity potentially causes powder clumping

and reduced dispersal of fine particle mass

Need to reload capsule each time


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Nebulizers

Jet nebulizer Ultrasonic nebulizer


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Pneumatic Jet Nebulizer

Delivers compressed gas through a jet, causing an area

of negative pressure and drawing the liquid up the tube

by the Bernoulli effect. The solution is entrained into the

gas stream and then sheared into a liquid film that is

unstable and is broken into droplets by surface tensionforces. The fundamental concept of nebulizer

performance is the conversion of the medication solution

into droplets in the respirable range of 1-5 micrometers


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Ultrasonic Nebulizer Generates high-frequency ultrasonic waves

(1.63 MHz) from electrical energy via a

piezoelectric element in the transducer. These

ultrasonic waves are transmitted to the surfaceof the solution to create an aerosol. Aerosol

delivery is by a fan or the patients inspiratory

flow; particle sizes may be larger with this

device. A limitation of ultrasonic nebulizers isthat they do not nebulize suspensions efficiently


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Advantages Of Nebulizers Provide therapy for patients who cannot

use other inhalation modalities (eg, MDI,

DPI)

Allow administration of large doses of

medicine

Patient coordination not required

Effective with tidal breathing

Dose modification possible

Can be used with supplemental oxygen


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Disadvantages Of Nebulizers

Decreased portability

Longer set-up and

administration time

Higher cost

Electrical power source

required

Contamination ossible


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Drugs used in inhaler therapy


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For Asthma

Taken from

The Global Initiative for Asthma (GINA) 2011 guidelines


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Inhaler Therapy CONTROLLERS

Inhaled glucocorticoids ,Long acting

inhaled beta 2 agonists,Cromones,

RELIEVERSShort acting beta 2 agonists,

Anticholinergics


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Inhaled Glucocorticosteroids

Most effective anti inflammatory

medication for the treatment of persistent

asthma

Reduces asthma symptoms

Improves quality of life

Decrease Airway hyper responsiveness

Improve lung function

Control airway inflammation Decrease frequency and severity of

exacerbations

Decrease mortality


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Inhaled Glucocorticosteroids

Beclomethasone dipropionate

Budesonide

Ciclesonide

Flunisolide

Fluticasone propionate Mometasone furoate

Triamsinalone acetonide


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Most of the benefit dose equivalent of

400 microgram budesonide per day

Increasing dose Little benefit & more

side effect

Add-on therapy with another class

controller is preferred over increasing

dose of steroids

Tobacco smoking decreases

responsiveness to inhaled glucocorticoids


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Local Side effects

Oropharyngeal candidiasis

Dysphonia Cough (upper airway irritation)

s/e reduced by spacer,mouth

washing,

prodrug(ciclesonide,beclomethasone)


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Systemic side effect

Depends on dose , potency, delivery

system, systemic bio availability ,half

life, first pass metabolism, treatmentduration

Easy bruising, adrenal suppression,decreased bone mineral density

,cataract, glaucoma


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Long acting inhaled beta2 agonists

Salmeterol and formoterol

Not as monotherapy

Most effective when combinedwith inhaled glucocorticoids


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Advantages of combination therapy

Improve symptoms scores

Decreases nocturnal asthma symptoms

Improve lung functions Decreases use of rapid acting inhaled b2

agonists

Reduces no: of exacerbation Rapid control

Reduces dose of inhaled glucocorticoids


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Salmeterol and Formoterol has

similar duration of action , but

formoterol has more rapid onset

Formoterol Budesonidecombination can be given for both

rescue and maintenance


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Side effects Less than oral treatment

Cvs stimulation , skeletal muscle

tremor Hypokalemia

Refractoriness to beta 2 agonists


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Cromones Sodium cromo Glycate , Nedocromil

sodium

Limited role

Mild persistent asthma and exercise

induced bronchospasm

Less effective than low dose inhaled

glucocorticoids

s/e cough, sore throat , unpleasant taste


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Reliever medications Short acting beta 2 agonists

Anti cholinergic


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Rapid acting inhaled beta 2 agonist

Salbutamol , terbutaline, fenoterol,

levalbuterol,reproterol,pirbuterol

Medication of choice for relief of bronchospasm duringacute exacerbation of asthma and pre treatment of

exercise induced broncho constriction

Should be used only on an as needed basis at lowestdose and frequency

s/e tremor, tachycardia


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Anti cholinergic broncho dilators

Ipratropium bromide, oxitropium

bromide

Less effective than beta 2 agonists Combination with b2 agonist-

significant improvement

S/e dryness, bitter taste


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In children


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In children


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Inhaler Therapy For COPDTaken from Global Initiative for Chronic Obstructive Lung Disease

(GOLD) Guidelines 2011


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Beta2 Agonists Effect of short acting b2 agonist- 4to 6 hrs

Improves FEV1 and symptoms

Long acting beta2 agonist -12 hr or more

Formoterol and salmeterol improves FEV1 ,lung

volumes,dyspnoea,health related quality of

life,exacerbation rates

Indacaterol duration of action 24hrs


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Anti cholinergic

Ipratopium bromide , oxitropium bromide,

tiotropium bromide

Broncho dilator action last longer than

SABA- upto 8 hrs

Tiotropium >24 hrs


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Inhaled corticosteroids

Long term treatment with inhaled CS

improves symptom , lung function

,quality of life, and reduces frequency

of exacerbations in COPD patients

with FEV1 < 60%

Does not decline the long termdecline of FEV1 nor mortality


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Combination Therapy

Inhaled Coticosteroid with Long

Acting B2 Agonist is more

effectiveA triple therapy by adding

tiotropium may furthur improves


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Oxygen therapy


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Conclusion A number of inhalation devices are

available for the treatment of

pulmonary diseases, each with its

own advantages and disadvantages.

None has proven to be superior to the

others in any of the clinical situationstested. Whichever device is chosen,

the key to successful treatment lies at

a proper inhaler technique

Thank you !!


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Thank you !!

inhalation therapy in asthma and copd

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