Transcript The Least Imperfect Device

The Least Imperfect Device
Karen Meade
Clinical Nurse Specialist
The Hillingdon Hospital
The Development of Inhalers
1956 first pMDI
1968 first DPI (Sodium Cromoglycate)
1974 first breath actuated device
1977 first single dose DPI
1980 first large volume spacer
1988 first multi-dose DPI
1998 combination inhalers
On-going transition to CFC free pMDI’s
Snell (1995)
Why Use Inhalers?
Rapid action
 Smaller doses
 Fewer side
effects
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Pauwels 1993, Ariyananda
et al 1995
Why is the device important ?
Efficacy of treatment depends on;
Physical factors
 Mode of inhalation
 Patency of airways
 Patient compliance
 Patient ability
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Ariyananda et al 1995, Weller 1999, DTB 2000, Lenney et al 2000
Characteristics of the Ideal
Device - 1
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reliability & reproducibly delivers a
predetermined dose of drug
easy to use
cost effective
portable
easy to assess technique
low oropharangeal deposition
available in a range of therapies
Characteristics of the Ideal
Device - 2
suits all settings
 integral cap / cover
 dose counter / able to tell when empty
 environmentally friendly
 available in primary, secondary &
tertiary care
 easy to identify preventer/reliever
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Raine & Newberry 1991, Hanley 1995, Hobbs 1995, NARTC 1997,
DTB 2000
Main device types
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Aerosol
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– Pressurised metered dose inhaler (pMDI)
– Breath actuated
Dry powder (breath actuated) inhalers
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Turbohaler
Accuhaler
Diskus
Clickhaler
Diskhaler
Rotahaler
Pressurised Metered Dose
Inhalers (pMDI)
Metered dose inhaler devices
Beclomethasone 250
Beclomethasone
(QVAR)100
Beclomethasone 50
Beclomethasone
(QVAR) 50
Beclozone easi breathe 250
Metered dose inhalers - pMDI
7-20% drug delivery
+ range of therapies
+ cheap
+ portable
Leech(1998), DTB(2000),
NARTC(1997)
- need co-ordination
- no dose counter
except in combined
medications
- oro-pharangeal
deposition
- cold freon effect
Spacer devices – large and small
volume spacer devices
Spacers
15-30% drug delivery
+ reduce oral
deposition
+ tidal breathing
acceptable/suitable
for during an attack
+ suitable from birth
- wide variation in drug
delivery between
spacers
- bulky
DTB(2000), NARTC(1997),
Hobbs(1995)
Breath Actuated MDI’s –
“Easibreathe and Autohaler”
Breath Actuated MDI’s
15-20% drug delivery
+ portable
+ no co-ordination
required
+ lower inspiratory
flow required (2030L/min)
- no dose counter
- no LA ß2-agonist
- patient may block
vents
DTB(2000), NARTC (1997),
Hobbs(1995)
Dry Powder Inhalers - General
points
+ portable
+ CFC free
+ dose counter
+ breath actuated
+ suitable for 6+yrs
- need higher
inspiratory flows
- some susceptible to
damp
NARTC (1997), DTB (2000)
Clickhaler
Clickhaler
10-15% drug delivery
+ low inspiratory flow
(15 L/min)
+ locks when empty
- powder can fall out!
- no LA ß2 agonist
DTB(2000)
Rotahaler, Spinhaler, Diskhaler,
Aerohaler
Rotahaler, Spinhaler,
Diskhaler, Aerohaler
15% drug delivery
+ compact
+/- taste
+ able to monitor
doses
- require reloading
- loss of powder
- capsule can deteriorate
DTB(2000), NARTC(1997),
Hobbs(1995)
Handihaler
+ low inspiratory flow
+ once a day dosing
+ audible noise when
using it correctly
- only available in
Tiotropium
- needs reloading
- susceptible to damp
Accuhaler
Accuhaler
16-21% drug delivery
+ range of therapies
+ locks when empty
+ combination therapy
+ low inspiratory flow
30-90L/min
- requires monthly
replacement (60 doses)
DTB(2000), NARTC(1997)
Turbohaler
Turbohaler Inhaler devices
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Bricanyl, (Terbutaline)
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Pulmicort, (Budesonide)
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Oxis, (Eformoterol)
Symbicort,
100/6, 200/6, 400/12
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Turbohaler
20-30% drug delivery
+ range of therapies
+ visible warning when
20 doses left
+/- no taste
+ inspiratory flow 3060 L/min
- susceptible to damp
DTB(2000), NARTC(1997),
Hanley(1995)
Patient Preference Studies
Subjective measure
 Preference does not correlate with
technique
 Small studies
 Bias
 Not reproducible
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(Hanley 1995, Raine et al 1991, Lenney et al 200, Williams 1995)
Choosing the ‘least imperfect’
device
Drugs required i.e. ß2, ICS, LAß2
 devices available
 patient able to demonstrate a good
technique & health professional able to
check technique
 suits all settings
 device acceptable to the patient
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Checking Technique
Visual check with
placebo
 Independent
check
 Inspiratory flow
check
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Inhaler & Spacer Care
Rinse through MDI’s
 Wash spacer once a month & drip dry
 Remember to dry well before using
 Replace spacer every 6 months
 Do not leave DPI in damp environments
 Write start date on MDI & expected
finish date
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The Least Imperfect Device ?
The device which the patient
can, & will use
Thank you
Any questions ?