A multitude of devices Dr Andrew Scroop Respiratory Consultants 15 th September 2018 STEPWISE PHARMACOLOGICAL MANAGEMENT OF STABLE COPD COPD Inhalers MILD FEV 1 60 80% predicted few symptoms breathless on moderate exertion recurrent chest infections little or no effect on daily activities MODERATE FEV 1 40 59% predicted increasing dyspnoea breathless walking on level ground increasing limitation of daily activities cough and sputum production exacerbations requiring oral corticosteroids and/or antibiotics SEVERE FEV 1 <40% predicted dyspnoea on minimal exertion daily activities severely curtailed experiencing regular sputum production chronic cough exacerbations of increasing frequency and severity CHECK DEVICE USAGE TECHNIQUE AND ADHERENCE AT EACH VISIT Short-acting reliever medication: Short-acting ß 2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) Symptom relief (some agents have been shown to also prevent exacerbations) LAMA AND/OR LABA OR LAMA/LABA Exacerbation prevention When FEV 1 <50% predicted AND 2 exacerbations in 12 months LABA/ICS Add low dose theophylline REFERENCES: 1. Lung Foundation Australia. Stepwise management of stable COPD. February 2015. 2. Abramson M et al. COPD-X concise guide for primary care. Brisbane. Lung Foundation Australia. Version 3.02, August 2015. Adapted from: 1. Lung Foundation. COPD Medicines Chart May 2015. MDI = metered dose inhaler. The products included were those available on the PBS as at January 2016. Available via PBS for asthma only. Not on the PBS. Please visit www.ebs.tga.gov.au for full Product Information of the products listed. *Bretaris Genuair and Brimica Genuair are marketed in Australia by Menarini Australia Pty Ltd. MAINTAINING FUTURE TREATMENT OPTIONS Guide to addition of COPD maintenance treatments 1 LAMA LABA LAMA/LABA LABA/ICS LAMA LABA LAMA/LABA LABA/ICS Adapted from Lung Foundation Australia. Stepwise management of stable COPD. 1 Classes of treatments that should not be used together REFERENCE: 1. Lung Foundation Australia. Stepwise management of stable COPD. February 2015.
Inhaler Types Pressurized metered dose inhaler (pmdi) including spacer use and breath activated Dry powder inhaler Preloaded or requiring capsule insertion. Soft Mist inhaler Are there differences between inhaler classes? pmdis DPIs Active device 1 Delivers drug in Aerosol cloud of high powder form 2 velocity and short Breath-actuated duration 2 (passive) devices 2 Requires significant Delivered dose and coordination 2 particle size depends on inspiratory flow 2,3 Requires a forceful inhalation 2,3 Little coordination required 2 Soft Mist Inhaler Active device 4 Easy to Inhale 5-6 Does not contain propellants 4 Slow-moving aerosol cloud vs pmdis 7 Requires a slow inhalation 2 Improved coordination vs pmdis 4,7,8 References: 1. Laube B et al. Eur Respir J 2011;37:1308 31. 2. Newman S. Eur Respir Rev 2005;14:96 102 108. 3. Newman S and Busse W. Resp Med 2002; 96: 293 304. 4. Dalby R et al. Int J Pharm 2004; 283: 1 9. 5. Schurmann W et al. Treat Respir Med 2005; 4: 53-61. 6. Kardos P et al. Eur Respir J 2005; 26 (Suppl 49): 338s (abstract 2213). 7. Hochrainer D et al. J Aerosol Med 2005; 18: 273 282. 8. Hodder R et al. Int J Chron Obstruct Pulmon Dis 2009; 4: 225 232. On line inhaler instructions https://lungfoundation.com.au/patient-support/copd/inhaler-techniquefact-sheets/ https://www.nationalasthma.org.au/living-with-asthma/how-to-videos https://www.nationalasthma.org.au/living-withasthma/resources/health-professionals/information-paper/hp-inhalertechnique-for-people-with-asthma-or-copd https://www.nps.org.au/medical-info/medicine-finder Inhaler technique Most prescriptions are without personal instruction and demonstration / coaching Most use device incorrectly Duration of device use no indication of correct use Re-educate frequently Commonest mistakes no or incorrect device preparation, no breath out, incorrect inhalation speed and or timing, no breath hold pmdi Spacer
Autohaler Dry powder devices Inspiratory Flow Assessment Accuhaler Turbuhaler Ellipta
Genuair Spiromax Dry powder devices - capsule Aerolizer Handihaler Breezhaler
Respimat Device lifespan Confusing Check expiry date Do not forget re priming pmdis. Never prime a DPI Any air tight packaged device (including Respimat) must be discarded 6 weeks to 3 months after opening even if never used. On line inhaler instructions https://lungfoundation.com.au/patient-support/copd/inhaler-techniquefact-sheets/ https://www.nationalasthma.org.au/living-with-asthma/how-to-videos https://www.nationalasthma.org.au/living-withasthma/resources/health-professionals/information-paper/hp-inhalertechnique-for-people-with-asthma-or-copd https://www.nps.org.au/medical-info/medicine-finder Dr Andrew Scroop Respiratory Consultants