1. INHALATION THERAPY FOR ASTHMA AND COPD
DR TINKU JOSEPH
Resident
Dept of pulmonary medicine
Dy patil medical college

2. AEROSOL THERAPY DURING THE ANCIENT TIMES
3000 BC until 400 BC (Egyptian period)
Asthma caused by
Demons, spirits, foreign gods
Treatment
Prayers, Sacrifices
Offerings to Gods, spells
Burning incense to please Gods

3. INHALATION OF FUMES FROM DATURA PLANT (Asthma Bidis / Cigarettes)
2000 BC INDIA
Datura Stramonium

4. ROMAN HOT WATER SPRINGS
Healing effects of water and steam inhalation for various respiratory illness
A Roman Hot Water Spring Temple, UK

5. ARABS - Water-Seal SMOKING PIPES

6. DISCOVERY OF THE PRESSURIZED METERED DOSE INHALER
March 1955
SUSIE MASON, 13 year old asthmatic
‘Why can’t they put my asthma medication in a spray can like they do for my mothers hair sprays?’
Dr Maison who worked with Riker Labs (now 3M) ran to Irving, a Chemist with this idea.
- Coca Cola bottle
- Meshberg Valve
- Freon Propellant - ice cream freezer
- Ascorbic Acid
First clinical trial – 1956 by Carr at Veterans Hospital in California. Launched in March 1956 (Medihaler-Epi, Medihaler-Iso).
Today – more than 800 million pMDIs are sold every year.

7. AEROSOLS
DEFINITION: Aerosol is the suspension of fine solid or liquid particles in air.
The size of the particles should be sufficiently large not to diffuse like gas molecules and sufficiently small to remain air borne for sometime.

8. ADVANTAGE OF AEROSOL THERAPY IN ASTHMA
Deposition of the drug directly at the local site
Faster onset of action
Lower dose of medication required
Lower side effects

9. Aerosol Therapy for asthma and COPD
The success of therapy using aerosolized medicine depends on the ability to deliver adequate amounts of drug to the lungs with few side effects

10. Deposition pattern of drugs
DEVICE
AEROSOL
FORMULATION
PATIENT FACTORS
AND TECHNIQUE

11. Particle size and airway deposition
> 5 m
2-5 m
<2 m

12. DEPOSITION OF AEROSOLS
SIZE (MMAD)
SITE
<0.5 U
Stable (no
deposition)
0.5-2 U
Alveoli
2-5 U
Bronchi &
bronchioles
5-100 u
Mouth, nose &
upper airway
>100 u
Filtered by
URT

13. AEROSOL GENERATION SYSTEMS
Jet and Ultrasonic nebulizers
Pressurized metered dose inhalers (pMDIs), with or without spacers (static and non static)
Dry powder inhalers (DPIs): Unit dose and Multidose

14. Pressurized METERED DOSE INHALER

15. PARTS Cannister Drug Propellant Surfactant Metering valve Nozzle
Mouth piece
Protective cover

18. TECHNIQUE

19. Pressurized METERED DOSE INHALER
ADVANTAGES
DISADVANTAGES
Portable &compact
Rx time is short
No drug preparation
required
Dose-dose reproducibility
high
No contamination of
contents
Coordination of breathing
and actuation needed
High pharyngeal
deposition
Cold Freon effect
Remaining doses difficult
to determine
Potential for abuse
Many use CFC

20. pMDI can cause thermal / chemical burns
11 year old boy with chronic asthma
Repeatedly firing his Salbutamol MDI with the noozle placed directly against the skin – firing up to 10 times at one time
(Patel R et al, Arch Dis Childhood 2004; 89: 1129)
                                                                                                                                                                                                                                                   
                                                                                                                                                                                                                                                   
                                                                                                                                                                                                                                                   

21. Autohaler
Reduces need for hand mouth coordination by firing in response to patients inspiratory efforts.
Usage:
In patients with poor MDI technique use of autohaler increased lung deposition.
Used in : older patients with severe airflow obstruction
Arthritis

22. Use of a spacer device
Chamber reservoir where the actuated aerosol can be held prior to inhalation.
Attached to an MDI.
Amount of drug delivered is increased by using a spacer.
First developed by Newman et al as a device that reduced oropharyngeal deposition in 1981 (Newman et al, Am Rev Respir Dis 1981; 124: )

24. ACE Spacer
Inspirease Spacer
Aerochamber
EZ Spacers

25. Indications In patients who are unable to use pMDI.
To reduce risk of adverse effects with inhaled medications.
To decrease or eliminate coughing or arrested respiration experienced by some patients.
To administer inhaled medication during severe exacerbations as recommended by ATS

26. Technique

27. spacer device DISADVANTAGES ADVANTAGES Reduces need for
patient co-ordination
Reduces pharyngeal
deposition.
Reduces cold Freon effect
More expensive
Less portable
Can reduce dose
available if not used
properly
Inhalation can be
more complex for
some patients
Some patients find them embarassing to use in public

28. Zerostat V spacer

29. Zerostat VT spacer

30. Face mask

31. DRY POWDER INHALERS Single dose Multi-dose - Reservoir - Singlet
Handihaler
Rotahaler
Single dose
Multi-dose
- Reservoir
- Singlet
Turbohaler
Diskhaler
Accuhaler

32. DRY POWDER INHALERS COMPONENTS: DEVICE: (Rotahaler /Spinhaler /
Turbuhaler/ Diskhaler)
DRUG RESERVIOR:- discrete gelatin capsules(Rotacaps,transcaps,multidose strips)

34. DRY POWDER INHALERS ADVANTAGES:
Breath actuated – no co-ordination skills required
Easy and convenient to use
No propellant – environmentally friendly
DISADVANTAGES:
Requires a good inspiratory effort
Carries a single dose at a time
Capsule and drug life reduced by moisture and humidity
can result in high pharyngeal deposition
DRY POWDER INHALERS

35. Creates a fine mist of the drug which can be inhaled
ADVANTAGES:
Creates a fine mist of the drug which can be inhaled
Does not require co-ordination or a minimum inspiratory pressure
DISADVANTAGES:
Unpredictable lung dose
Inefficient lung deposition
Bulky
Expensive
NEBULIZERS
Ultrasonic
Jet

36. NEBULIZER

37. Respule

39. (Fink JB, Respir Care 2000; 45(6): 623-635)
(2,500 mcg)
(200 mcg)
(200 mcg)
(200 mcg)
(Fink JB, Respir Care 2000; 45(6): )

40. WHICH IS THE BEST INHALER DEVICE?

41. ASK THE PATIENT
Assess the inhaler technique
Prime importance to correct inhaler technique

42. AGE AS A DETERMINING FACTOR
Children < 2 years - nebuliser
Children 2-5 years - MDI with spacer with face mask
Children > 5 years - DPI, MDI with spacer
Children > 12 years - MDI alone (if suitable), DPI
Very old people - DPI or breath actuated MDI

43. WHAT IS IN THE FUTURE?

44. PREVIEW – LOOKING INTO THE FUTURE
Antibiotics
Inhaled Insulin for management of Diabetes
Morphine
Growth factors
Vasopressin

45. AEROSOL THERAPY FOR ASTHMA IN INDIA
Asthma – grossly under-diagnosed in India
Amongst diagnosed asthmatics - < 10% use inhaler therapy
Misconceptions about inhaler therapy
- Addictive
- Very strong medicine
Both physicians and patients to be made more aware

46. Peak flow meters