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Transcript

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  • Errors while using inhalers can be so common. 
  • So today […] we are going to de-mist-ify the three types of inhaler delivery systems and how they are used. 

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  • But first, […] let’s take a deep breath, and start with two key points
  • First, there is no single delivery method that provides superior control of asthma or COPD. 
  • Second, At the end of the day, the best inhaler type is the one that your patient can afford.

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  • Let’s get into the different types of inhalers. We are also going to introduce common brand names for each type of delivery system… because honestly that is how you may see it in EMR and how patients may  refer to their inhalers.

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  1. pMDI
  • First, we’ll dive into pressurized metered dose inhalers or pMDIs. They are also commonly referred to as “HFA” inhalers as many of them contain the aerosolizing agent Hydrofluoroalkane. Other common brand names for these delivery systems include “Digihaler,” “Respiclick,” “Aerosphere,” and “Redihaler.” 
  • The common naming convention for any kind of inhaler is the brand name medication followed by the type of delivery system. For example, you may have seen  “ProAir HFA” or “ProAir Respiclick” prescribed for your patients, where “ProAir” is the brand name for albuterol and HFA represents the delivery system. 

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  • pMDIs have medication stored in a pressurized canister
  • First, the pMDI  needs to be shaken, […] and if it’s a new inhaler or it hasn’t been used for several days, then it needs to be primed by pumping the canister 2-3 times. 
  • Next, patients should exhale fully to get ready for the big deep breath in that they need to take the medication.
  • Now it’s time to actually use the inhaler. You have to coach patients to inhale and press down on the canister at the same time. Doing this at the same time can be technically challenging so it’s a good idea to watch them and give them feedback on how they are using their inhaler.
  • And last but not least, (and maybe most important) tell patients to hold their breath for 10 seconds after the medication is released in order to get the full dose. 

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  • Thankfully, there are devices that ensure optimal dose delivery for patients, such as spacers and valved holding chambers. 
  • Spacers are reservoirs that can be attached to the inhaler. Valved holding chambers are like spacers with a one way valve. 
  • They both work by slowing down and reducing the size of the drug particles, so that the medication reaches farther down into the lungs. The spacer reduces deposition in the mouth that can cause throat irritation. 

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  • What’s another advantage to using spacers or valved holding chambers with pMDIs? They make it so that patients don’t have to coordinate inhalation and pushing down on the canister simultaneously, breaking step 2 into two steps. 

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  • Patients should only administer one puff at a time into the reservoir. Doing more than one puff at a time decreases the dose of medication that is delivered and defeats the purpose of using one of these handy devices!

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  1. DPI 
  • Next, let’s talk about the dry powder inhaler or DPI.
  • Common brand names for DPI delivery systems include Ellipta, Diskus, Flexhaler, Handihaler, and Inhub. For example, you may have prescribed the “Breo Ellipta” for a patient. To break that down, Breo is the medication and Ellipta is the system used to give Breo. 

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  • Using DPIs is a little less tricky than the other two delivery systems. First, have patients load the medication by pushing the lever back until it clicks. Have them prepare for a deep inhalation by breathing out all the way. 
  • Then, with the inhaler held like a hamburger, have patients put their mouth on the opening and breathe in as quickly and forcefully as they can, like they’re taking a big gulp of a milkshake. Have them hold their breath for 10 seconds after they breathe in, just like we do for the other inhalers.

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  • This type of inhaler requires patients to generate a strong enough inspiratory effort, or FEV1,  in order to aerosolize the medication.  So it’s important to coach your patients to take a very deep breath when using DPIs.
  • So, these inhalers may not be the ideal choice for patients with severe COPD or a recent exacerbation. As a rule of thumb, these inhalers work best for patients who can generate an FEV1 of 60 or higher.

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  1. SMI
  • This brings us to our last type of inhaler, the soft mist inhaler or SMI, which does not depend on inspiratory effort. 
  • These inhalers may be referred to by their brand name, Respimat. Perhaps you have prescribed a Spiriva Respimat or a Stiolto Respimat for your patients.

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  • Like metered dose inhalers, these require coordinated actions in order to optimize dose delivery, […] meaning patients have to inhale and press down on the canister at the same time. However, they do not require shaking before use. 
  • To use an SMI, first patients have to twist the base of the inhaler, then inhale as they press down on the button that releases the aerosolized medication. 
  • And again with all these delivery systems, patients should hold their breath for 10 seconds.

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  • And what’s the advantage of using an SMI over a pMDI? Well with SMI, the mist moves more slowly and the aerosol lasts in the air longer than pMDIs, resulting in better dose delivery and less deposition of medication in the mouth. 

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  • There are a few downsides to these inhalers. They tend to be more expensive because they are newer, and because they are newer, not all medications are available in this format yet.
  • Another potential downside is that they can be difficult to use for patients with limited dexterity, such as patients with arthritis.

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  • So which inhaler should you prescribe for your patients? 
    • Remember, […] if you are prescribing more than one inhaler, do your best to prescribe the same type of inhaler delivery system for all medications to improve ease of use for your patients.
    • Of course, this is not always possible, because not all medications are available in the same delivery system.

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  • That being said, the most important thing to remember is that the inhaler that is best for your patient is the one that they can afford and use confidently and correctly.

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