Advanced Inhaler Technique. Learning Outcomes. Disclosure 1.1. Belgian Chocolate, French Champagne and Inhaled Medication: Too Good To Waste?

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1 Advanced Inhaler Technique Learning Outcomes Describe the mechanism of different inhalers Explain how inspiratory flow can effect drug delivery for different inhalers Counsel a patient on the correct use of all inhalers Check a patient s metered dose inhaler technique using the Aerosol Inhalation Monitor (AIM) Select the appropriate inhaler for a patient using the In-check device Wales Centre for Professional Pharmacy Education in 22 Belgian Chocolate, French Champagne and Inhaled Medication: Too Good To Waste? Pearce L. Do Health Professionals Have Sufficient Knowledge And Skill To Teach Optimum Inspiratory Flow (OIF)? A Study Using The In-Check Dial (ICD) To Evaluate Inspiratory Technique Poster: C1 ATS Meeting, Atlanta, May 22 Disclosure in 21 Jon Bell: Director of a commercial organisation that investigates inhaler devices and their use. (Canday Medical Ltd.) Jon Bell / Canday Medical Ltd. do not receive any remuneration or commission based on the use of products manufactured by other companies. Baverstock M, Woodhall N & Maarman V. Do Health Care Professionals have sufficient knowledge of inhaler techniques in order to educate their patients effectively in their use? Poster presented at Winter Scientific Meeting British Thoracic Society

2 How would you inhale challenge Quick test of how you would inhale through commonly-used devices pmdi measurement first DPI measurement second Need to: 1. Simulate resistance of device 2. Measure speed of inhalation From the hit TV Series House MD on Fox NBC. Video clip from Season 5 Episode 11 - when Dr. House asked a patient how she uses her inhaler. How you would instruct the patient to inhale using that type of inhaler Single measurement Results later. Poor Technique What type of Inhaler is this? 1. Lower than expected delivery to target site 2. Reduced benefits 3. Increased deposition in regions outside target site 4. Increased risk of side-effects Target site Unnecessary Waste UK: MDI and DPI Inhalation technique: inhalation too fast for pmdi, or too slow for DPI What type of Inhaler are these? Too Fast 59.5 % Too Slow 4.9 % Too Slow 14.2 % Too Slow 57. % Al-Showair R, Tarsin W, Assi K, Pearson S, Chrystyn H Can patients with COPD use the correct inhalation with all inhalers and does training help? Res Med 27: 11,

3 What type of Inhaler is this? Fate of inhaled drugs Good Technique Mouth pharynx 2% Deposited in lung Metabolism or absorption from the lung 8% Swallowed mucociliary clearance Absorption from gut Liver Systemic Circulation Oral bioavailability GI tract First-pass metabolism Adapted from Barnes et al. AJRCCM 1998;157:S1 S53 Schematic representation of potential dose distribution A Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for Respiratory Care. 1 st Edition. Page 1. Webpage: What type of Inhaler are these? Fate of inhaled drugs Poor Technique Mouth pharynx 5% Deposited in lung Metabolism or absorption from the lung 95% Swallowed mucociliary clearance Absorption from gut Liver Systemic Circulation Oral bioavailability GI tract First-pass metabolism Adapted from Barnes et al. AJRCCM 1998;157:S1 S53 Schematic representation of potential dose distribution A Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for Respiratory Care. 1 st Edition. Page 1. Webpage: Mean resistance of various DPIs Resistance in (cmh 2 O) ½ Lmin -1 Aerosol made for you (e.g. MDI) How changes in inspiratory flow affect output Low Inspiratory flow High MDI / Spacer Aeroliser Accuhaler Turbohaler Clickhaler Twisthaler Easyhaler Assi KH, Chrystyn H. The different resistance of dry powder inhalers (DPIs). Am. J Respir. Crit. Care Med. 21;163(5): A443 (Adapted from) 1.3

4 Aerosol made for you (e.g. MDI) How changes in inspiratory flow affect output Inhalation creates aerosol (e.g. DPI) Low Lactose (in some DPIs) Inspiratory flow Drug High Metered Dose Inhaler (MDI) Lung deposition from pmdis is influenced by inspiratory flow %VC 5%VC 8%VC 2%VC 5%VC 3L/min 9L/min 1 second breath hold 8%VC Newman S et al, Eur J Respir Dis 1982;63: Suppl Aerosol Deposition at varying Particle Size Spacers Micron size 1 Deposition Pharynx, larynx & Upper respiratory tract Optimal tracheobronchial deposition Optimal alveolar deposition Particles exhaled if <.5 micron Lung deposition from Turbohaler is influenced by inspiratory flow Spacer Devices How they help 4 3 6L/min Drug Metered Dose Inhaler (MDI) 2 3L/min 1 Dry Powder Inhaler (DPI) Lung deposition from a budesonide Turbohaler measured by gamma slcintigraphy. Borgstrom et al Eur Respir J 1994;7: Capture aerosol avoiding coordination problems 2. Reduces particles deposited in oropharynx Leach, C. L., P. J. Davidson and R. Boudreau: HFA-Beclomethasone Provides Equivalent Lung Deposition with or without Add-on Spacers. Eur. Res. J. 1(25): P1522, p. 236S,

5 Lung deposition from HFA-Beclometasone provides equivalent lung deposition with or without add-on spacers Please tell me the right inhalation technique for each of the inhalers below Press and Breathe MDI 75 5 Spacer 29% 5% Mouth Spacer 33% 2% Mouth Mouth 29% 25 53% 45% 51% P&B + Aerochamber P&B + Volumatic P&B Alone Deposition from T99-labelled HFA-Beclometasone measured by gamma scintigraphy. Leach, C. L., P. J. Davidson and R. Boudreau: HFA-Beclomethasone Provides Equivalent Lung Deposition with or without Add-on Spacers. Eur. Res. J. 1(25): P1522, p. 236S, You create aerosol inhale FORCEFULLY Please tell me the right inhalation technique for each of the inhalers below Assessment & Training Devices Monitoring inspiratory flow rate through the device Vitalograph s Aerosol Inhalation Monitor (AIM) Canday Medical s 2-Tone Trainer ( Allen & Hanburys Accuhaler Trainer Schering-Plough s Twisthaler Trainer 6 L/min 35 L/min AstraZeneca s Turbohaler Usage Trainer & Turbutesters Clement Clarke s In-Check and In-Check DIAL Fyne Dynamic s MagFlo Please tell me the right inhalation technique for each of the inhalers below Aerosol produced for you inhale GENTLY Isle of Wight Inhaler Technique Project Strategy 1. Patients to receive consistent inhaler technique training from GPs, Nurses, Pharmacists etc. 2. HCPs to MEASURE patients ability to use inhaler (In Check DIAL) 3. Targeted patients for maximum early benefit 4. Following training, MDI patient to be supplied with a free 2Tone 5. Strategy employed across primary and secondary care 6. Directed MURs for CPs 7. Enhanced service (MUR plus) for children offered by CPs 8. Train a trainer, including outside NHS 9. Extend to Schools, care homes, housebound etc. 1.5

6 +2% + 15% +1% + 5% National Average -5% Baseline Respiratory Medication status Annual spend: Inhaled corticosteroids > 1.7M Highest in Southern England Trend increasing > +11% Expenditure: Respiratory Medicines (overall) > +6% Short-acting beta agonists +2% Inhaled corticosteroids YTD 27 Points to take away 1. Internal resistance affects speed of inhalation 2. Speed of inhalation affects DPI device efficacy (little effect on MDI) 3. Speed of inhalation and particle size affect how much drug is deposited in the lungs and how much in the mouth and throat 4. Before initiating a new therapy, practitioners should check inhaler technique. Inhalation should be: GENTLE for a device that creates the aerosol for you (e.g. MDI), but FORCEFUL for those that rely on the energy of inhalation (e.g. DPI) 5. NMR / CDS / MURs and Asthma Reviews present unique opportunity to identify poor inhaler technique but HCPs need to know good technique first! 6. Evidenced by IOW project: NICE reference: IOW Medicines Management Data ; Data on file 2 th November 28 +2% Outcomes Respiratory Medication status 27 - Annual spend: Inhaled corticosteroids > 1.7M 27 - Highest in Southern England 27 - Trend increasing +2% YTD 27 Vs % + 15% +1% + 5% National Average -5% > +11% Expenditure: Respiratory Medicines (overall) > +6% < +2% National Average Short-acting beta agonists Inhaled corticosteroids Data collected over 9 month period No other interventions took place in Respiratory Medicine IOW Medicines Management Data ; Data on file 2 th November 28 Outcomes Effects on patients + 25% 9 months data 28 vs 27-25% -5% -75% Emergency admissions to hospital due to asthma ( n=2 Vs 41) Hospital length of stay due to asthma - 5% Asthma related deaths (n=2 Vs 8) Data collected over 9 month period No other interventions took place in Respiratory Medicine IOW Medicines Management Data ; Data on file 2 th November