MDI Bonanza Dwayne Griffin, DO
Bonanza 3. A MDI costing $200 - $500 per month
SISYPHUS
MDI Griffin Mountain
Evolution of Deliver Systems for COPD in the US 2003 2009 2011 2013 2004 2012 2014
Prescribing an Inhaler Short vs. Long-acting B-agonist vs. Muscarinic antagonist Delivery System
Aerosol Particle Size and Lung Disposition
Errors in Inhaler Use* Pressurized Metered Dose Inhalers Poor coordination 45% Inadequate speed an/or depth of inhalation 44% No breath hold 46% * Systematic review of 144 articles on inhalation technique that included 54,354 subjects Sanchis, CHEST 2016; 150:394
Errors in Inhaler Use* Dry Powder Inhalers Incorrect preparation - 29% Not exhaling completely before inhaling - 46% No breath hold 37% * Systematic review of 144 articles on inhalation technique that included 54,354 subjects Sanchis, CHEST 2016; 150:394
Pressurized Metered-dose Inhaler (pmdi) An aerosol is released when the canister is depressed. With correct technique, ~ 20% of the aerosol reaches the lungs.
Priming the pmdi Shake the inhaler and press down on the canister to spray the aerosol into the air 3-4 times
Closed Mouth Technique Exhale completely. Then place the mouthpiece inside the mouth with lips closed.
Open Mouth Technique Exhale completely. Then place the inhaler two finger in front of your mouth.
When to Use A Space with pmdi If difficulty with coordination If the pmdi contains an inhaled corticosteroid
Soft Mist Inhaler Delivers a slow-moving mist 53% of the dose reaches the lungs* *Brand, Int J COPD 2008; 3:763
Press After breathing out completely, PRESS the button to release mist and inhale SLOW and STEADY. Hold breath for 10 seconds or as long as possible.
Dry Powder Inhaler Bronchodilators in US 2003 2004 Internal resistance Breath actuated 2011 2012 2013
Internal Resistances Bronchodilator Dry Powder Inhaler Neohaler Diskus Ellipta PressAor HandiHaler Resistance (kpa0.5[l/min]) 0.022 0.027 0.029 0.031 0.051 Mahler. Ann ATS 2017;14:1105
Use of a Dry Powder Inhaler Need to breathe in HARD and FAST to generate an adequate inspiratory flow to break up the powder into small particles (<5 micron in diameter) that can be inhaled into the lungs. Mahler. Ann ATS 2017;14:1105
Correct Inhaler Use Delivery System Pressurized MDI Soft Mist Inhaler Dry Powder Inhaler Nebulizer Inhalation Slow and steady Slow and steady Hard and fast Normal breathing in and out Mahler. Breathe Easy 2017; p.94
Indications for Nebulized Bronchodilator Therapy Cognitive or physical impairment Frail, difficulty with coordinating Persistent or unstable symptoms, history of frequent exacerbations/hospitalizations Low peak inspiratory flow rate unable to optimally inhale powder out of the DPI Wise. J COPD F 2017;4:1
Indications for Nebulized Bronchodilator Therapy Laryngectomy present Patient prefers nebulization Cannot afford handheld devices Wise. J COPD F 2017;4:1
Nebulized Bronchodilator Therapy Advantages Minimal coordination and effort required Normal breathing in and out Medications usually covered by insurance Disadvantages Require external power source Time for preparartion and inhaling medication Fewer medications available Dhand. COPD 2012;9:58
NEJM May 3, 2018
Triple Inhaler
Short-acting Beta2-agonist Bronchodilators ProAir HFA Proventil HFA ProAir RespiClick Ventolin HFA Xopenex HFA
Long-acting Beta2-agonist Bronchodilators Arcapta Neohaler Serevent Diskus Striverdi Respimat
Inhaled Corticosteroids Alvesco HFA Arnuity Ellipta Asmanex FHA Aerospan Asmanex Twisthaler Flovent Diskus Flovent HFA Pulmicort Flexhaler QVAR RediHaler
Combination Inhaled Corticosteroid and Long-acting Beta2-agonist Advair Diskus Advair HFA Breo Ellipta Dulera Symbicort (HFA)
Combination Inhaled Anticholinergic and Long-acting Beta2-agonist Anoro Ellipta Bevespi Aerosphere Stiolto Respimat Utibron Neohaler
Anticholinergics Atrovent HFA Seebri Neohaler Incruse Ellipta Spiriva HandiHaler Spiriva Respimat Tudorza Pressair
Combination Inhaled Anticholinergic and Short-acting Beta2-agonist Combivent Respimat
Questions