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Inhalers and nebulizers 

Inhalers and nebulizers
Chapter:
Inhalers and nebulizers
Author(s):

Stephen Chapman

, Grace Robinson

, John Stradling

, Sophie West

, and John Wrightson

DOI:
10.1093/med/9780198703860.003.0055
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date: 29 November 2021

Background

Inhalers

  • There are many different inhaler devices that deliver drugs directly to the airways, but essentially two basic types MDIs and dry powder inhalers (DPIs). New devices are being introduced all the time, with one or two (or even three) drugs delivered simultaneously. Check what is available through your local formulary (see Table 55.1)

  • Ideally patients should try a range of devices to choose the most appropriate for them

  • Patients should receive advice and a demonstration on inhaler technique and use (see Table 55.2)

  • Technique should be checked regularly, and, if patients cannot manage a particular device, they should be switched to another

  • Many pharmacists have been trained to assess inhaler technique

  • The percentage of a drug delivered to the airway varies for each device (from 15% to 60%, according to the manufacturers) and depends on good technique

  • Spacer devices improve the delivery with MDIs and are particularly useful for the elderly, children, and those who find it difficult to coordinate inhaler administration with breathing. They reduce unwanted oropharyngeal deposition of steroids

  • Try to use the same type of inhaler device for all the drug classes used by a patient

  • Advise the patient how to recognize when a device is empty: some have dose counters; others are shaken to hear if they still have contents

  • Titrate inhaler doses with clinical response, using the minimum possible. Inhaled steroids do have side effects, and the dose should be kept to a minimum.

Table 55.1 Different medications available for inhalers (not exhaustive; new ones come on the market regularly; check with your local formulary)

Generic name of drug (with product names)

Mechanism of action

Usual inhaler colour

  • Salbutamol (Ventolin®, Asmasal®, Pulvinal®, Salbutamol, Salamol®, Salbutamol Cyclocaps®, Airomir®, Asmasal Clickhaler®, Salamol Easi-Breathe®)

  • Terbutaline (Bricanyl®)

  • Short-acting β‎2 agonist

  • Duration 3–5h

Blue

  • Salmeterol (Serevent®)

  • Formoterol (Foradil®, Oxis®, Atimos Modulite®)

  • Indacaterol maleate (Onbrez Breezhaler®)

  • LABA

  • Duration 12h

  • Duration 24h

  • Green

  • Green/turquoise

  • White/blue

Ipratropium bromide (Atrovent®) Ipratropium and salbutamol (Combivent®)

Short-acting anticholinergic

White/grey

  • Tiotropium (Spiriva®)

  • Aclidinium bromide (Eklira Genuair®)

  • Glycopyrronium bromide (Seebri Breezhaler®)

  • Long-acting anticholinergic

  • Duration 12h

  • Duration 24h

  • Grey Handihaler®, Respimat®

  • White/green

  • White/orange

  • Beclometasone dipropionate (Pulvinal®, Beclometasone, AeroBec®, AerobecForte®, Asmabec Clickhaler®, Qvar®, Pulvinal®)

  • Budesonide (Pulmicort®, Novolizer®) Fluticasone propionate (Flixotide®) Mometasone furoate (Asmanex®)

  • Ciclesonide (Alvesco®)

Corticosteroid

  • Brown

  • Brown

  • Red

  • Red

  • Red

  • Salmeterol and fluticasone (Seretide®)

  • Eformoterol and budesonide (Symbicort®)

  • Formoterol and beclometasone (Fostair®)

  • Fluticasone and formoterol (Flutiform®)

Combined steroid and bronchodilator

  • Purple

  • Red/white

  • White/orange

  • White/grey/orange

Sodium cromoglicate (Intal®) Neocromil sodium (Tilade®)

Unknown, stabilize mast cells

Yellow/white

Table 55.2 Instructions for use of different inhaler types

Type of device

Instructions for use

Pressurized aerosol MDI (e.g. aerosol Evohaler®)

  • Remove the mouthpiece, and shake the inhaler well. Hold the inhaler upright, with the thumb on the base below the mouthpiece and the first finger on the metal canister. Breathe out as far as is comfortable, then place the mouthpiece between the teeth, and close lips around it. Do not bite it. As you start to breathe in through the mouth, press on the top of the inhaler to release the medication whilst still breathing in steadily and deeply. Hold your breath; take the inhaler from your mouth, and continue holding your breath for up to 10s, if possible. Wait 30s prior to taking 2nd puff. Use with spacer device to improve drug delivery.

  • CFC-free inhalers need washing every 2–3 weeks, as they can block.

  • Spacer

  • Nebuhaler®

  • Nebuchamber®

  • Volumatic®

  • Aero Chamber®

  • Able Spacer®

  • PARI Vortex Spacer®

  • Pocket Chamber®

  • OptiChamber®

  • OptiHaler®

  • Ensure spacer is compatible with patient’s inhaler. Remove cap of inhaler, and shake it. Insert it into end of spacer device. Place the other end of the spacer in the mouth. Press the inhaler canister once to release one dose of the drug. Take one long, slow breath in and hold, or take 3–4 steady breaths in and out. Repeat as indicated. In some, the valve should click.

  • Clean the spacer once a month with mild detergent; rinse, and air-dry. Replace after 6–12 months. Some spacer devices will whistle or sound if you breathe in too fast.

  • Breath-actuated devices

  • Autohaler®

  • Easi-Breathe®

If an Autohaler®, remove the cap and lift the red lever. Insert device into mouth. Inhale slowly and deeply. Continue inhaling when the device ‘clicks’. Hold breath for up to 10s, if possible. Slowly breathe out. To take a 2nd inhaled dose, lower the red lever and lift again. If an Easi-Breathe®, open the hinged cap. Insert device into mouth. Inhale slowly and deeply. Continue inhaling when the device ‘clicks’. Hold breath for up to 10s, if possible. Slowly breathe out. Close the cap, and reopen for further doses. If Easi-Breathe® spacer used, it will need to be removed between each inhalation so that cap can be opened and closed.

  • Dry powder devices Accuhaler®

  • Breezhaler®

  • Turbohaler®

  • Dischaler®

  • Clickhaler®

  • Genuair®

  • Handihaler®

  • Inhaler

  • Pulvinal®

  • Twisthaler®

  • Easyhaler®

  • Cyclohaler®

  • Aerocaps®

  • Novolizer®

  • Prime the device. Turbohaler®: hold upright; remove the cap; twist the base as far as possible until the click is heard, and then twist back again. Clickhaler®: shake the device; remove the cap; click the top down and release, dose ready. Twisthaler®: remove the cap by twisting and the dose ready. Accuhaler®: open inhaler cover, mouthpiece facing you, and push lever down to pierce the blister containing dose. Diskhaler®: insert disc into device by opening and pulling out mouthpiece section. To prepare dose, lift up back of lid to 90° until the blister is pierced, then lower the lid. Handihaler® and Breezhaler®: open devices; insert capsule into chamber; close mouthpiece section; pierce capsule by firmly pressing side button(s).

  • To use all the devices, hold them level; exhale fully; place the mouthpiece into mouth between teeth, and inhale deeply and forcefully. Hold your breath, and remove the inhaler. For a 2nd dose, repeat the above actions.

Respimat® for Spiriva® and Combivent®

To load cartridge, remove clear base; insert cartridge until flush with device; replace clear base. Hold inhaler upright, with cap closed. Turn the transparent base until it clicks. Open the cap. Breathe out slowly, and insert the mouthpiece and seal with lips. Point towards the back of the throat. While taking a deep breath, press the button and continue to breathe in. Hold your breath for 10s, if possible, and breathe out slowly.

There are many YouTube videos showing how to use most of these inhalers.

Different inhaler types and instructions for their use

These lists (see Tables 55.1 and 55.2) are up to date at time of writing. Some inhalers are only licensed for asthma or COPD.

Nebulizers

are used when they bring greater relief than inhaled therapy, either during acute respiratory illnesses, because of disease severity, or because they are unable to use inhalers. Patients for possible nebulizer therapy should be referred to a respiratory physician. Nebulized antibiotics need a more powerful pump and special neb-set.

How to use

Open the ampoule containing the drug solution, and squirt the solution into the nebulizer chamber. Salbutamol and ipratropium bromide can be taken together, but nebulized budesonide or antibiotics should be used separately. If ipratropium bromide only is being used, this should be delivered via a mouthpiece, as it can lead to glaucoma if used via a mask (atropine-like constricting effects on the pupil). Re-attach the chamber to the nebulizer mask or mouthpiece. Put the mask over nose and mouth, or position mouthpiece between the lips fully in the mouth. Switch the compressor on. Breathe slowly in and out. Continue until all the solution is gone. Switch off the machine. Rinse the nebulizer chamber with hot water (and very dilute washing-up liquid) after each use. If nebulization takes >10min, change the neb-set (mask, chamber, tubing last 1–3 months). If no improvement, consider servicing the machine. If the patient is using O2, this can still be used during nebulization, either via nasal prongs under the nebulizer mask or by using O2 tubing attached directly to the nebulizer chamber to drive the nebulization; at home, most cylinders do not provide sufficient flow rates to allow this. Nebulizer machines should be serviced annually.