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Aerosol Delivery Devices and Peak Flowmeters. Fritz Merkel , BS, RCP Community Healthworker Training February 2008. Hang in there!. Getting near the end. Hopefully we’ll have a little fun, and Learn something. NAEPP says….blah, blah, blah

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Aerosol delivery devices and peak flowmeters
Aerosol Delivery Devices and Peak Flowmeters

  • Fritz Merkel, BS, RCP

  • Community Healthworker Training

  • February 2008


Hang in there
Hang in there!

  • Getting near the end.

  • Hopefully we’ll have a little fun, and

  • Learn something.

  • NAEPP says….blah, blah, blah

  • But you HAVE TO KNOW HOW TO USE THESE AEROSOL DEVICES.


Delivery devices choices
Delivery Devices- Choices-

  • Choice of aerosol delivery system depends on: - Effective dose - Drug deposition - Patient ability - Patient acceptance - Cost (immediate vs. cost effective) 1

  • Incorrect use of aerosol devices is a major factor in sub-optimal therapy.


Poor technique poor medication delivery
Poor Technique =Poor Medication Delivery

  • Majority of health professionals teaching MDI use do not perform procedure perfectly. 2-3

  • Allow 10-30 minutes for instruction. (Few patients ever get this)

  • Explain > Demonstrate > Practice > Return demonstration.

  • Repeated demonstration improves performance.(Up to 3 sessions required).


Output range is 30-100 ml. 4

Velocity 15 m/s > falls rapidly (0.2 second) 4

80% deposition in oropharynx.

10-15% deposited in in lungs.

Optimal deposition size is < 6 mm (1-5 mm) 5

Propellant chlorofluorocarbon – banned 1987 (exempted under “essential use” ruling) -lose permanent exemption end 2008.

MDI


Distribution of aerosol mdi
Distribution of Aerosol-MDI

  • Radiolabeled aerosol delivered with no add-on spacer device. 16


Mdi problems common
MDI Problems - Common

  • Hard to do right for anyone: esp. very young, very old, handicapped, mentally compromised.

  • Cough (medication lost ).

  • Rapid inhalation. Short breath hold.

  • Cold MDI (poor aerosolization).

  • Plugged orifice-Keep capped when not in use.

  • Multiple actuations/breath.

  • Poor timing - too soon, too late, blow out…

  • Oral deposition


Oral vocal cord deposition
Oral & Vocal Cord Deposition

**Candida (thrush)/hoarseness, mouth sore**

(for inhaled steroids only)

  • Use a VHC or Spacer

  • Tilt head back and “open” the throat shaping it as though making a deep “O”.

  • Inhale slowly…slower…..even slower.

  • Immediately rinse, gargle and spit.

  • Use mouthwash instead of water.


Lose track of doses
Lose Track of Doses

  • Check package insert for number of doses.

  • Mark off on calendar.

  • Put tape on MDI and checkoff doses.

  • Dose counter-(30 day calendar)

  • Water floatation not recommended (inaccurate + may plug nozzle)17


Spacers
Spacers

  • Add-on tube; no valve.

  • Needs sufficient volume (100-700cc) for propellant to evaporate.

  • Reduces oral/vocal cord deposition but does NOT help with hand-breath coordination problems.

  • Reduces (bad) “taste”. (users may need to be re-educated that this is OK.)


Valved holding chamber
Valved Holding Chamber

  • One-way inspiratory valve protecting the patient from poor hand-breath coordination

  • Traps large particles:> reduce pharyngeal deposition > 10-15x less than MDI alone. 4-5

  • Slows down & “matures” droplets.

  • Better lung distribution.


Vhc infants
VHC & Infants

  • Infants/children (0~5/6) – May use multiple breaths to empty the aerosol from the VHC.

  • Minimal mask dead space > Good mask fit.


Vhc infants1
VHC & Infants

  • No benefit to VHC volume > 150cc. Need to be able to evacuate chamber.

  • Do not give to crying babies! - Poor deposition (same with nebs) - - Crying is an exhalation maneuver.


Young elderly handicapped
Young/Elderly/Handicapped

  • Young > add mask+VHC (<5-6 years)

    - “Parent” must know how to use.

  • Elderly > VHC

  • Explain > Demonstrate > Practice > Return demonstration

  • Analyze failure > Nebulizer if appropriate.

  • Add Leukotreine Modifiers ?

    (~ 50% effective)


Hydrofluroalkane hfa
Hydrofluroalkane (HFA)

  • Replaces chlorofluorocarbon (CFC).

  • Lower Jet velocity (slower med plume)

  • Quieter, softer sound.

  • Less affected by ambient temperature.

  • Less cold freon effect.

  • As effective as CFC MDI >>possibly more effective<<

  • QVAR (ICS), Proventil & XopenexHFA


Gamma scan: Beclomethasone (BDP)-healthy subject Right: BDP with HFA propellant = greater lung deposition & less oropharygeal deposition than CFC propellant. 9 (no spacer)


Beclomethasone with hfa vs cfc hfa dose 200 g vs half cfc 400 g single dose 14 days
Beclomethasone with HFA (¨ ) vs CFC (*).HFA dose (200 µg) vs. half CFC (400 µg)Single dose14 Days


Don t use with hfa built in canister actuator
Don’t Use with HFABuilt in canister actuator

Medispacer

E Z Spacer


Spacer vhc variations
Spacer/VHC Variations

  • One device can increase lung drug delivery and decrease delivery with another drug.

  • 2-6 fold variation in respirable dose emitted with various devices.

  • Due to variations it may be best to use same combinations that were studied.

  • But-no specific combinations have been specifically approved by FDA.14


Spacer vhc cleaning prep
Spacer/VHC Cleaning & Prep

  • Rinse plastic Spacer/VHC when new and once a month with dilute liquid household detergent.

  • 1-2 drops/cup of water.

  • Let drip dry, do not rinse.

  • Defeats static cling (so does normal use)


Dpi requirements
DPI-Requirements

  • Rapid, deep inhalation critical: 30-120 lpm required. 5

  • Inadequate flow = inadequate delivery.

  • Unsuited to the very young, very ill, weak patients, elderly, or altered mental status.

    (But so are MDI’s)

  • Conflicts with breathing pattern for MDI. (Slow vs. Fast)


Fast vs slow inhalation
Fast vs. Slow Inhalation

  • Higher flow picks up more medication.


Dpi problems
DPI-Problems

  • Particulate irritation may cause cough (rare).

  • High humidity may cause clumping of powder, esp. when leaving the cap off or moving from very cold to warm environment (non-blister pack).

  • Blowing into DPI may blow drug out and will introduce internal humidity.

  • Different inhalation pattern from MDI.



Dpi internal resistance
DPI – Internal Resistance

  • Turbuhaler greater resistance than Discus (easier for kids). Aerosolizer = low


Lung deposition of the emitted dose different dpis 2 different inspiratory flow rates dolovich 9
Lung deposition; % of the emitted dose, Different DPIs 2 different inspiratory flow rates.Dolovich.9


Dpi instruction
DPI-Instruction

  • Health care provider MUST know technique appropriate to the device to teach effectively.

  • New devices and techniques being developed requiring providers to stay abreast of developments.

  • Different devices = different techniques.


Dpi models and instruction
DPI - Models and Instruction

  • DISKUS - 60 doses (blister pack tape)

  • Pulmicort Turbuhaler – 200 dose (single container)

  • Floradil Aerosolizer – single doses (blister pack - pill)

  • Asmanex Twisthaler - 30, 60, 120 dose (single cont.)



Nebulizer
Nebulizer

  • Newer designs provide enhanced performance.

  • Breath Actuated Nebs > BAN - one-way valves; Pari AeroEclipse.

  • Various reservoir types.

  • Thumb valves.


Nebulizer cups
Nebulizer Cups

  • Many different kinds. Little attention often paid to matching compressor to cups.

  • Some models are proprietary and MUST be matched.

  • Inexpensive models are usually disposable but may be used (regularly) for > 1 month if cleaned regularly.

  • Non-disposable (Pari) may have superior output and may be used for 6-12 months.


Neb medication problem
Neb - Medication Problem

  • Unit-dose bronchodilator usual Rx.

  • Mixing medication problems > Children:Unit-dose bronchodilator + Unit-dose Intal = excessive dilution > (longer treatment).

  • Get “concentrate” bronchodilator solution.

  • Less of a problem than it used to be.

  • “Blow by” has not been found to be effective in children-use a mask. 14


Neb cleaning
Neb Cleaning

  • After each treatment, rinse the nebulizer cup with warm water, shake off excess water and let it air dry.

  • At the end of each day, the nebulizer cup, mask or mouthpiece should be washed in warm, soapy water using a mild detergent, rinsed thoroughly and allowed to air dry. The Pari reusable nebulizer is dishwasher safe, run through cycle on top rack only in a small parts basket.


Neb disinfecting
Neb Disinfecting

  • Every third day, after washing your equipment, disinfect using a vinegar/water solution or the disinfectant solution your supplier suggests.

  • Vinegar solution-mix 1/2 cup white vinegar with 1-1/2 cups of water. Soak for 30 minutes and rinse well under a steady stream of water. Shake off the excess water and allow to air dry on a paper towel. Always allow the equipment to completely dry before storing in a plastic, zipper storage bag.


Nebulizer vs mdi vhc
Nebulizer vs. MDI+VHC

  • Several studies done with acutely ill infants and children in the ER.

  • With PROPER instruction and administration of MDI+VHC: > No difference shown in rate of improvement or clinical score over conventional nebulizer treatment. 6-7


Drug deposition
Drug Deposition

  • Deposition from major types of early (pre-1990) aerosol delivery devices: MDI, MDI-spacer, SVN, DPI 15


Approx of drug dose deposited dpi s vs pmdi dolovich 11 turbuhaler diskus spiros and clickhaler
Approx.% ofdrug dose depositedDPI’s vs. pMDI Dolovich.11 (Turbuhaler, Diskus, Spiros, and Clickhaler)


Traditional vs newer devices
Traditional vs. Newer Devices

Lung Deposition (various studies) between traditional and newer devices. hydrofluroalkane-beclomethasone, small volume neb, dry powder inhaler. 40-50% possible now vs. 10-15% 16


Dosage differences for various devices
Dosage Differencesfor Various Devices

  • Deposition of devices to the lungs (**has been**) similar.

  • Starting (nominal) dose is not the same.

  • Nebulizer starting dose is 11-12x larger than the MDI dose.

  • MDI’s can have similar clinical effect but may need increased # of puffs. 14


Ultrasonic nebulizer
Ultrasonic Nebulizer

  • More Expensive

  • Special batteries

  • Fragile

  • No insurance coverage

  • Silent

  • Fast > Dense output

  • Possibly less waste



Respimat soft mist inhaler
Respimat Soft Mist Inhaler

(propellant free, spring driven “MDI” - Boehringer Ingelheim)

Mouthpiece

Uniblock

Dosing Chamber

Dose-release button

Upper housing

Capillary tube

Transparent base

Spring

Cartridge


Spiros dpi
Spiros DPI

Breath-actuated, multi-dose cassette, battery-powered inhalation assist12


Aerx pulmonary device aradigm corporation
AERx Pulmonary Device Aradigm Corporation

  • Pre-packaged, single-use disposable blister packet and disposable nozzle.

  • Utilize a piston mechanism to expel formulation from the AERx Strip


Mystic inhaler ventaira pharmaceuticals pharmaceuticals pharmaceuticals
Mystic Inhaler Ventaira Pharmaceuticals Pharmaceuticals Pharmaceuticals

  • Electronic nebulization process. Electrical field is applied to a conductive liquid leading to the formation of a soft mist droplet aerosol.

  • Soft mist, breath-activated, robust, easy to use, programmable hand-held device.


Aria chrysalis technologies altria phillip morris that s right
Aria Chrysalis Technologies >Altria >Phillip Morris (that’s right!)

  • Looking for a cigarette that would appeal to health-conscious smokers ( speaker’s note - ????)

  • Device that allowed smokers to inhale a mist laced with nicotine rather than inhale smoke – Didn’t take off.

  • Aerosol device could be used to deliver drugs to the lungs.


Peak flow meters
Peak Flow Meters

  • Most useful for moderate-to severe persistent asthma.

  • Designed for monitoring.

  • Not a diagnostic tool.

  • Dependent on effort and technique.

  • Good instruction and frequent review is needed.


Pfm reliability
PFM-Reliability

  • Most units provide highly repeatable est. of PF.

  • Recommended > + 10% over full range: 100-400 L/min-children; 100-700 L/min-adults.

  • Reproducibility of + 10% or 5% of reading.

  • Different PFM’s will give different readings.

  • Astech met all criteria. 13


Pfm real world use
PFM - Real World Use

  • Most useful with an ACTION PLAN.

  • The patient must know WHAT to do with the PFM information.

  • Instruction is often inadequate due to time constraints. (So-what’s new?)

  • Action plans may take multiple visits and considerable time to set up.

  • Follow-ups necessary for maintenance.



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