1. The Aerosol Drug Management Improvement Team
ADMIT
Slide Deck 2018

2. Part 7
Choice of drug-device combinations to use at home
Roland Buhl

3. Choice of drug-device combinations to use at home
Device options for treating patients at home
Choice of device the patient can and will use
How to use the device correctly
Control
Necessary drugs and dosage
Check inhalation technique regularly

4. Inhalation therapy to use at home
Main Indications
Asthma and COPD
Other Indications
Pulmonary Arterial Hypertension (PAH)
HIV – Infected Patients
Cystic Fibrosis (CF) / Bronchiectasis

5. Conditions for successful inhalation
Keep it strictly simple. Easy to handle = better adherence
Choose the device the patient is able and willing to handle
If more than one drug has to be inhaled try to use fixed dose combinations if available and / or only one type of inhaler if possible
Instruct the patient how to inhale correctly
Control
Drugs, their number and dosage and
Inhalation technique regularly

6. Especially if step up of therapy seems to be necessary!
“It is more important to choose the right inhaler than the right drug”
Choose an inhaler in which the drug is available and which the patient is able and willing to use
(for DPIs: measure inspiratory flow if possible)
Teach the correct inhalation technique
Demonstrate the inhalation technique
Explain the typical do´s and don´ts (ADMIT Webpage)
Let patients practice the inhalation (if placebo available)
Provide additional information
printout of the ADMIT Website
product flyer of pharmaceutical company
And
Control inhalation technique regularly
Correct mistakes or change inhaler if necessary
Especially if step up of therapy seems to be necessary!

7. Available inhalers
pMDIs
Without or with Spacer
BA – pMDIs
DPIs
Soft Mist Inhalers
Nebulisers
Nozzle Nebuliser
Ultrasonic Nebulisers

8. Handling pMDIs and DPIs correctly: similarities and differences
without spacer
with spacer
Open the device or take off the cap
Shake the inhaler
Don't shake the inhaler
Breathe out slowly and almost fully away from the inhaler
Seal your lips around mouthpiece or the spacer mouthpiece
Take a slow deep breath in and near the breath actuate the inhaler
After actuating the
inhaler breath in
Breath in briskly, quickly and deeply until the lungs are full
Hold breath as long as comfortably you can
Replace the cap or close the device
Always keep a spare device or spare capsules

9. Handling pMDIs and DPIs correctly: similarities and differences
without spacer
with spacer
Open the device or take off the cap
Yes
Shake the inhaler No
Breathe out slowly and almost fully
Yes, away form inhaler
Seal your lips around mouth-piece or the spacer mouthpiece
Take a slow deep breath in and activate the inhaler after starting
Breathe in after activating the inhaler
Breathe in briskly, quickly and deeply until the lungs are full
Hold the breath as long as comfortable
Replace the cap or close the device
Always keep a spare device or spare capsules

10. Choice of Inhaler Drugs Which drugs are necessary
In which inhalers are these drugs available
Inhaler
Which inhalers are available to deliver the chosen drugs
Which inhalers can the patient use correctly
Patient
Which inhalers is the patient able and willing to use

11. 10 rules for inhalation
Information about disease and requirement for treatment
Information about drugs and their effects
Information about important unwanted effects
Doctor - patient contract
Choice of drug(s)
Choice of inhaler (if possible only one type)
Demonstration of inhalation technique
Practice if placebo inhalers are available
Provide additional information (e.g. handout, mention
Check again after a short interval, then regularly thereafter

12. To match patient and device
In general
A typical patient may be able to use all available devices
Potential problem(s)
A typical prescriber may recommend a device which he/she prefers for a variety of reasons (design, experience, handling, relationship/contact with a pharmaceutical firm) without thinking of the patient- centered consequences

13. Possible inhaler device(s)
Questions to consider when recommending an inhaler
Question
Possible inhaler device(s)
Limited dexterity?
pMDI +/- spacer, Respimat, nebuliser
Cannot load/handle the device at all?
Helper?
Often forgets to shake the device?
DPI
Poor coordination of inhalation and actuation?
BA-pMDI, DPI
Limited inspiratory flow?
pMDI + spacer, DPI with low resistance, Respimat
Very limited inspiratory flow?
pMDI + spacer, nebuliser
Drug available in preferred device?
Patient agrees with prescriber‘s choice?
Cost implications?
Single inhaler (NS)
Little perceived benefit (1.4)
Gender (NS)

14. Questions to consider when recommending an inhaler
1. Spontaneous respiration ?
Yes: Medical needs and patient preference
No, e.g. intubated patient
Recommendation:
pMDI without or with spacer, Respimat, nebuliser

15. Questions to consider when recommending an inhaler
2. Conscious breathing possible ?
Yes: Medical needs and patient preference
No, e.g. unconscious patients with spontaneous breathing (e.g. accident, stroke patient), dementia, Alzheimer´s disease, mental retardation
Recommendation:
Assisted inhalation with pMDI, Respimat, nebuliser, pMDI with spacer (only if patient is able to comply with request to seal lips around mouthpiece and inhale)
Role of the helper (see next slide)

16. Little perceived benefit (1.4)
Role of the helper
pMDI
Respimat®
Nebuliser
Removes cap
Opens inhaler
Fills chamber
Shakes inhaler
Loads inhaler
Switches on nebulizer
Holds device in front of patients mouth
Holds mouthpiece in front of patient’s mouth
– asks patient to open his mouth or (if not able to do this on request)
– closes the nose by pressing the soft parts together
Observes breathing pattern then activates inhaler when patient starts to breathe in
Repeats procedure if first inhalation does not seem to be successful
Continues until medicine chamber is empty
Replaces cap
Closes device
Cleans medicine chamber
Checks dose counter or stock of medicine
Single inhaler (NS)
Little perceived benefit (1.4)
Gender (NS)

17. Questions to consider when recommending an inhaler
3. Ability to seal lips around an inhaler mouthpiece ?
Yes: Medical needs and patient preference
No, e.g. congenital oral abnormality, oral dysfunction after apoplexy, facial nerve paresis etc.
Recommendation:
pMDI, Respimat, nebuliser