INHALERS AND
INHALER
TECHNIQUE
SITI SABARIAH BT ZAINUDDIN
PEGAWAI FARMASI UF48
HOSPITAL BALIK PULAU
OPENING STATEMENT
• Inhaled therapy remains the cornerstone of treatment for pulmonary
disorders such as asthma and chronic obstructive pulmonary disease (COPD)
• Inhaled therapy is very useful for administering drugs for asthma and COPD.
Its efficacy is associated with the amount of drug directly deposited in the
airway, which in turn depends on the type of administration device and
dosing technique used
• The defective use of inhalers is a serious clinical problem, since it hampers
disease control in asthma and increases the frequency and severity of
exacerbations in COPD
Molimard M, Raherison C, Lignot S, Balestra A, Lamarque S, Chartier A, et al. Chronic obstructive pulmonary disease exacerbation and inhaler device handling: real-life assessment
of 2935 patients. Eur Respir J. 2017;49, [Link] pii:1601794
J.L. Viejo-Ba˜nuelos, J. Sanchis / Arch Bronconeumol. Inhaler Devices: Better Management or New Devices? The Blind Leading the Blind 2018;54(5):245–246
Price D, Keininger DL, Viswanad B, Gasser M, Walda S, Gutzwiller FS. Factors associated with appropriate inhaler use in patients with COPD – lessons from the REAL survey Volume
2018;13:695-702
Dekhuijzen, Pieter & Lavorini, Federico & Usmani, Omar. (2016). Patients’ perspectives and preferences in the choice of inhalers: The case for Respimat® or HandiHaler®. Patient
Preference and Adherence. Volume 10. 1561-1572. 10.2147/PPA.S82857.
ADVANTAGES OF INHALATION THERAPY
TYPES OF INHALERS
Pressurized metered Dry powder inhalers Soft mist inhalers (SMI)
dose inhalers (pMDI) (DPI)
Conventional (pMDI) DPIs use ‘breath-actuated’ Like nebulizers, transform
inhalation devices use a method & powder aqueous liquid solution to
“press-and breathe” formulation is released liquid aerosol droplets
upon breathing through the suitable for inhalation
BA pMDI (eg: Autohaler, inhaler
Easibreathe) e.g. Respimat® (multi-unit
e.g. Breezhaler® and dose system)
Multi unit dose system HandiHaler® (Capsule-
based single-unit dose
system) and Diskus® (Non-
capsule based multi-unit
dose system*)
Newman SP. Eur Respir Rev Inhaler Treatment Option in COPD 2005;14:102–108
Pressurised Metered Dose
Inhalers (pMDIs)
Pressurised Metered Dose
Inhalers (pMDIs)
• Consists of a pressurized canister, a
chamber fitted with a mouthpiece and
protective cover
• The canister contains a medication, a
surfactant and/or a solvent, and a
liquid propellant
o Chorolofluorocarbons (CFCs)
o Hydrofluroalkens (HFAs)
• The inhaler is designed to deliver exact
dose of medication
Propellants (CFCs and HFAs): Provide the force to
generate the aerosol cloud and is the medium in
which the active component is suspended or
dissolved.
Pressurised Metered Dose Inhalers (pMDIs)
PROS CONS
Portable and compact Not breath actuated
Multidose device Many patients cannot use it
correctly
Relatively inexpensive
High oropharyngeal deposition
Cannot contaminate contents
Available for most inhaled
medications
Pressurised Metered Dose
Inhalers (pMDIs)
• Availability in Hospital Balik Pulau:
SOFT MIST INHALERS (SMIs)
SOFT MIST INHALERS (SMIs)
PROS CONS
Small / Portable Not breath actuated
No chemical propellant
Soft mist – less deposition in throat
High peak inspiratory flow rates attained
Locking mechanism when empty
SOFT MIST INHALERS (SMIs)
• Availability in Hospital Balik Pulau:
DRY POWDER INHALERS (DPIs)
DRY POWDER INHALERS (DPIs)
• Breath actuated – No hand mouth co-ordination required
• Main factors which determine drug delivery to lung
o Internal resistance of the device
o Inspiratory flow generated by the patient
• Some devices contain additives such as lactose or glucose to improve the
perception of inhalation
DRY POWDER INHALERS (DPIs)
PROS CONS
Breath-actuated Dependence on patients’
Inspiratory force
Hand mouth co-ordination not
required Moisture sensitive
Spacer not necessary Need to reload capsule each time
Compact
Portable
No propellant
Higher lung deposition than a pMDI
DRY POWDER INHALERS (DPIs)
• Availability in Hospital Balik Pulau:
DRY POWDER INHALERS (DPIs)
• Availability in Hospital Balik Pulau:
HOLDING CHAMBER/SPACER
• AEROCHAMBER
• PHILIPS RESPIRONICS
OPTICHAMBER.
CHOOSING THE RIGHT DEVICE
FOR THE RIGHT PATIENT
THREE ASPECTS OF INHALATION
THERAPY
ERRORS IN INHALER
TECHNIQUE
• Inadequate inhaler technique lowers drug deposition to the lungs, wastes medication and may lead to
poor disease control, reduced quality of life, increased emergency hospital admissions and higher
treatment costs
• Incorrect use of inhaler devices is common – real-world studies estimate that up to 94% of patients do
not use their inhalers properly
Lavorini F, Magnan A, Dubus JC et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med 2008;102:593–604. doi:
10.1016/[Link].2007.11.003
Dekhuijzen, Pieter & Lavorini, Federico & Usmani, Omar. (2016). Patients’ perspectives and preferences in the choice of inhalers: The case for Respimat® or HandiHaler®.
Patient Preference and Adherence. Volume 10. 1561-1572. 10.2147/PPA.S82857.
ERRORS IN
INHALER
TECHNIQUE
Common errors
encountered in pMDI,
DPI and SMIs (eg: MDI
Salbutamol, Spiolto
Respimat, Spiriva
Respimat)
Dekhuijzen, Pieter & Lavorini, Federico
& Usmani, Omar. (2016). Patients’
perspectives and preferences in the
choice of inhalers: The case for
Respimat® or HandiHaler®. Patient
Preference and Adherence. Volume 10.
1561-1572. 10.2147/PPA.S82857.
ERRORS IN
INHALER
TECHNIQUE
DPIs (eg: Symbicort
Turbuhaler, Seretide
Accuhaler)
[Link], Bosnic-Anticevich, [Link],
[Link] [Link]. Inhaler competence
in asthma: Common errors, barriers to
use and recommended solutions.
Respir Med 2013;107(1):37-46
ERRORS IN INHALER
TECHNIQUE
• BREEZHALER
Not standing or sitting up to use the Breezhaler.
Not holding the Breezhaler upright when using it.
Piercing the capsule several times or not at all.
Not inhaling strongly and deeply enough to draw the medication out of the
Breezhaler and in to the lungs.
Not taking a second inhalation to ensure you receive the full dose out of the
capsule.
Not holding your breath long enough after breathing in the contents.
Not replacing the protective cap on the mouthpiece.
PHARMACISTS’ ROLE
• To maximise the benefits of medication therapy in Asthma/COPD patients.
• To increase patient’s adherence towards Asthma/COPD medications.
• To educate and encourage patients/caregivers on the appropriate use of asthma/COPD
medications and self-care inhalers/devices.
• To minimise adverse effects or complications resulting from the asthma/COPD
medications and/or multiple drug regimens.
• To reduce the frequency of emergency room visits and thus, reduce the total health
care costs in treating Asthma/COPD.
• To collaborate with consultative services physicians and other health care professionals
on Asthma/COPD medication related issues.
Reference: RMTAC Protocol Asthma/COPD, 2 nd Edition 2015
IN HOSPITAL BALIK PULAU
• The pharmacist in charge will assess all patients’ inhaler technique as well as
compliance.
• Patients needing follow-up assessments will be identified, and seen in the pharmacy
as part as our counselling session monthly when the patient comes to refill their
prescription.
• Monthly assessment is done until good technique and compliance achieved.
COUNSELLING
CHECKLIST
• SINCE 2 WRONGS DOESN’T MAKE A
RIGHT
COUNSELLING CHECKLIST -
pMDI
COUNSELLING CHECKLIST -
pMDI
COUNSELLING CHECKLIST-
TURBUHALER
COUNSELLING CHECKLIST-
RESPIMAT
COUNSELLING CHECKLIST-
BREEZHALER
IN CONCLUSION
• Health care professionals play a critical role in educating their patients on
appropriate inhaler use and in ensuring medication adherence
• Health professionals need to be familiar with the available devices, their
characteristics and procedures, critical issues associated with their use, and the
instructions they must give their patients
• One device is not for all.
• Choosing the right device for the right patient ensures an effective outcome in
disease control.
THE END
THANK YOU FOR YOUR TIME.
