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Jon BellJon BellDirector,Director, CandayCanday Medical Ltd.Medical Ltd.
©© Canday Medical Ltd.Canday Medical Ltd. 20112011
Inhaler TechniqueInhaler Technique
Belgian Chocolate, French Champagne andBelgian Chocolate, French Champagne andInhaled Medication:Inhaled Medication:
Too Good To Waste ?Too Good To Waste ?
Jon BellJon BellDirector,Director, CandayCanday Medical Ltd.Medical Ltd.
DisclosureDisclosure
Jon Bell:
Director of a commercialorganisation that investigatesinhaler devices and their use.
(Canday Medical Ltd.)
Jon Bell / Canday Medical Ltd. do notreceive any remuneration or commission
based on the use of productsmanufactured by other companies.
Jon Bell and Canday MedicalLtd. have received sponsorshipto research and/or lecture oninhaler devices from:
GlaxoSmithKlineTEVAPfizerBoehringer IngelheimChiesiAltanaMerck GenericsNeolabKnowledgeworks Ltd.AstraZenecaClement Clarke InternationalNovartis
Pearce L. Do Health Professionals Have Sufficient Knowledge And Skill To Teach OptimumInspiratory Flow (OIF)? A Study Using The In-Check Dial ™ (ICD) To Evaluate InspiratoryTechnique Poster: C1 ATS Meeting, Atlanta, May 2002
……… in 2002……… in 2002
Baverstock M, Woodhall N & Maarman V. Do Health Care Professionals have sufficientknowledge of inhaler techniques in order to educate their patients effectively in their use?Poster presented at Winter Scientific Meeting British Thoracic Society 2010
……… in 2010……… in 2010
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.http://www.youtube.com/watch?v=dMAS2S51bM8
“Poor Technique”“Poor Technique”
Target site
Unnecessary Waste
1. Lower than expected deliveryto target site
2. Reduced benefits3. Increased deposition in regions
outside target site4. Increased risk of side-effects
“Poor Technique”“Poor Technique”
…. But very happy to practice technique
UK: MDI and DPI Inhalation technique:UK: MDI and DPI Inhalation technique:inhalationinhalation too fast fortoo fast for pMDIpMDI, or too slow for DPI, or too slow for DPI
Al-Showair R, Tarsin W, Assi K, Pearson S, Chrystyn H Can patients with COPD use thecorrect inhalation with all inhalers and does training help ? Res Med 2007: 101, 2395-2401
163 COPD patientsaverage age 72.5 years
FEV1 47.8% predicted
MDI
Accuhaler
Turbohaler
59.5 %
HandiHaler
4.9 %
57.0 %
14.2 %
Too Fast
Too Slow
Too Slow
TooSlow
Initial presentation – before training
Results later …….
“How you would instruct the patient to inhale” using that type of inhaler
Single measurement
“How would“How would youyou inhale” challengeinhale” challenge
Quick test of how you wouldinhale through commonly-useddevices
•pMDI measurement first•DPI measurement second
Need to:1. Simulate resistance of device2. Measure speed of inhalation
What type of Inhaler is this ?What type of Inhaler is this ?
How does the aerosol get made ?How does the aerosol get made ?
How does the aerosol get made ?How does the aerosol get made ?
What type of Inhaler are these ?What type of Inhaler are these ?
What type of Inhaler is this ?What type of Inhaler is this ?
How does the aerosol get made ?How does the aerosol get made ?
What type of device are these ?What type of device are these ?
How does the aerosol get made ?How does the aerosol get made ?
What type of Inhaler are these ?What type of Inhaler are these ?
How does the aerosol get made ?How does the aerosol get made ?
Aeroliser Accuhaler Turbohaler Clickhaler Twisthaler Easyhaler
Resistance in (cmH2O)½Lmin-1
Mean resistance of variousMean resistance of various DPIsDPIs
Assi KH, Chrystyn H. The different resistance of dry powder inhalers (DPIs).Am. J Respir. Crit. Care Med. 2001;163(5): A443 (Adapted from)
MDI /Spacer
Fate of inhaled drugsFate of inhaled drugs –– Good TechniqueGood Technique
Swallowed
GI tractGI tract
Deposited in lung
Lungs
Metabolism or absorptionfrom the lung
Liver
Oralbioavailability
Absorptionfrom gut
First-passmetabolism
SystemicCirculation
Mouthpharynx
mucociliaryclearance
80%
20%
Schematic representation of potential dose distributionA Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for Respiratory Care.1st Edition. Page 1. Webpage: http://www.aarc.org/education/aerosol_devices/
Adapted from Barnes et al. AJRCCM 1998;157:S1-S53
Swallowed
GI tractGI tract
Deposited in lung
Lungs
Metabolism or absorptionfrom the lung
Liver
Oralbioavailability
Absorptionfrom gut
First-passmetabolism
SystemicCirculation
Mouthpharynx
mucociliaryclearance
95%
5%
Fate of inhaled drugsFate of inhaled drugs –– PoorPoor TechniqueTechnique
Schematic representation of potential dose distributionA Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for Respiratory Care.1st Edition. Page 1. Webpage: http://www.aarc.org/education/aerosol_devices/
Adapted from Barnes et al. AJRCCM 1998;157:S1-S53
• Design of inhalers vary• Formulation of drug• Mechanical activation
(passive MDI vs active DPI)• Internal resistance to airflow
• Patients vary• Pulmonary function
(reversible Vs irreversible disease )• Ability to learn / be taught the correct
technique• Physical size of lungs (child vs adult)• Effort varies from dose to dose
Why are there problems ?Why are there problems ?
inappropriateselection
and/orincorrectinhaler
technique
How changes in inspiratory flow affectHow changes in inspiratory flow affect outputoutput
HighInspiratory flow
Low
Inhalation createsaerosol (e.g. DPI)
Aerosol made for you(e.g. MDI)
Lactose (in some DPIs)
Drug
Aerosol Deposition at varying Particle SizeAerosol Deposition at varying Particle Size
0
Micron size
0.5
2
5
10DepositionDeposition
Pharynx, larynx &Pharynx, larynx &Upper respiratoryUpper respiratorytracttract
OptimalOptimaltracheobronchialtracheobronchialdepositiondeposition
Optimal alveolarOptimal alveolardepositiondepositionParticles exhaled if <0.5 micronParticles exhaled if <0.5 micron
FacioFacio--MaxillaryMaxillaryView (lateral)View (lateral)
n.b. note the angles in the airways
RightRight BronchogramBronchogram
Trachea
Bronchi
Bronchioles
IMPACT
IMPACT
Direction of flow
IMPACT
Particle Deposition In Respiratory TractParticle Deposition In Respiratory TractThree mechanisms of aerosol kinetics govern the majority of
particle deposition within the respiratory tract.
1. Inertial impaction 2. Sedimentation 3. DiffusionMost important Least Important
Particle Deposition In Respiratory TractParticle Deposition In Respiratory Tract
Speed
Gravity
Brownian motion*
* Whitley Bay SmokeChamber
Mass
Three mechanisms of aerosol kinetics govern the majority ofparticle deposition within the respiratory tract.
1. Inertial impaction 2. Sedimentation 3. DiffusionMost important Least Important
ImplicationsImplications
Metered Dose InhalersMetered Dose Inhalers
Lung deposition fromLung deposition from pMDIspMDIs isisinfluenced by inspiratory flowinfluenced by inspiratory flow
Newman S et al, Eur J Respir Dis 1982;63: Suppl 119 57-65
30L/min
Total lungdeposition
(% of inhaleddose)
0
5
10
15
90L/min10 second breath hold
20%
VC
50%
VC
80%
VC
Metered DoseInhaler (MDI)
20%
VC
50%
VC
80%
VC
ImplicationsImplications
Spacer DevicesSpacer Devices
Metered DoseInhaler (MDI)
Spacer DevicesSpacer Devices –– How they helpHow they help
Drug
1. Capture aerosol avoiding coordination problems2. Reduces particles deposited in oropharynx
Leach, C. L., P. J. Davidson and R. Boudreau: HFA-Beclomethasone Provides Equivalent LungDeposition with or without Add-on Spacers. Eur. Res. J. 10(25): P1522, p. 236S, 1997.
ImplicationsImplications
Dry Powder DevicesDry Powder Devices
Total emitted dose at different flow ratesTotal emitted dose at different flow rates
Malton et al, J Pharm Med 1996:6:35-48 (In-vitro data - laboratory analysis)This does not necessarily correlate with clinical effectiveness
30 60 900
20
40
60
80
100 Salbutamol Accuhaler
Terbutaline Turbohaler
% oflabel claim
Flow (L/min)
Aerosol produced for you –
inhale GENTLY
Please tell me the right inhalation techniquePlease tell me the right inhalation techniquefor each of the inhalers below……for each of the inhalers below……
You create aerosol –
inhale FORCEFULLY
Please tell me the right inhalation techniquePlease tell me the right inhalation techniquefor each of the inhalers below……for each of the inhalers below……
Assessment & Training DevicesAssessment & Training DevicesMonitoring inspiratory flow rate through the device
(www.2ToneTrainer.com)
Fyne Dynamic’sMagFloClement Clarke’s In-Check
and In-Check DIAL
Schering-Plough’sTwisthaler Trainer
Vitalograph’sAerosol Inhalation
Monitor (AIM)
60 L/min
CandayMedical’s
“2-Tone” Trainer
AstraZeneca’s TurbohalerUsage Trainer & Turbutesters
35 L/min
Allen & Hanburys’Accuhaler Trainer
Isle of Wight Inhaler Technique ProjectIsle of Wight Inhaler Technique Project ––
StrategyStrategy1. 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 benefit4. Following training, MDI patient to be supplied with a free 2Tone5. Strategy employed across primary and secondary care6. Directed MURs for CPs7. Enhanced service (MUR plus) for children offered by CPs8. Train a trainer, including outside NHS9. Extend to Schools, care homes, housebound etc.
BaselineBaseline –– Respiratory Medication statusRespiratory Medication status
Expenditure:RespiratoryMedicines(overall)
YTD 2007
IOW Medicines Management Data ; Data on file 20th November 2008
Short-actingbeta agonists
+ 5%
+10%
-5%
> +11%
> +6%
+20%
Inhaledcorticosteroids
+ 15%
+20%
2007 2007 2007
•Annual spend: Inhaled corticosteroids > £1.7M•Highest in Southern England•Trend increasing
NationalAverage
OutcomesOutcomes –– Respiratory Medication statusRespiratory Medication status
Expenditure:RespiratoryMedicines(overall)
YTD 2007Vs 2008
IOW Medicines Management Data ; Data on file 20th November 2008
Short-actingbeta agonists
+ 5%
+10%
-5%
> +11%
> +6%
+20%
Inhaledcorticosteroids
+ 15%
+20%
NationalAverage
2007 2007 2007
< +2% NationalAverage
+15%
20082008 2008
•2007 - Annual spend: Inhaled corticosteroids > £1.7M
•2007 - Highest in Southern England•2007 - Trend increasing
•Data collected over 9 month period•No other interventions took place in Respiratory Medicine
OutcomesOutcomes –– Effects on patientsEffects on patients9 months data 2008 vs 2007
IOW Medicines Management Data ; Data on file 20th November 2008
Emergencyadmissions tohospital due to
asthma( n=20 Vs 41) Asthma related
deaths (n=2 Vs 8)
Hospitallength of
stay due toasthma
- 50%
0
+ 25%
-25%
-50%
-75%
•Data collected over 9 month period•No other interventions took place in Respiratory Medicine
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 depositedin the lungs – and how much in the mouth and throat
4. Before initiating a new therapy, practitioners should check inhalertechnique. Inhalation should be:GENTLE for a device that creates the aerosol for you (e.g. MDI),butFORCEFUL for those that rely on the energy of inhalation (e.g. DPI)
5. NMR / CDS / MURs and Asthma Reviews present unique opportunity toidentify poor inhaler technique – but HCPs need to know good techniquefirst !
6. Evidenced by IOW project: NICE reference: http://tinyurl.com/6j9s5zv
Points to take awayPoints to take away