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Consensus guideline on the use of inhaler devices in asthma

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  Supplement produced in association with Consensus guidelineon the use o inhalerdevices in asthma Supported by aneducational grantrom Teva UK Ltd  2the use of inhaler devices in asthma Mike Thomas 1 , Henry Chrystyn 2 , Jane Leyshon 3 , David Price 4 , June Roberts 5 , Richard Russell 6   1 GP, Hospital Practitioner and General Practice Airways Group (GPIAG) Research Fellow, University o Aberdeen; 2 Head o Pharmacy,University o Huddersfeld; 3 Respiratory Team Leader, Education or Health; 4 Proessor o Primary Care, University o Aberdeen; 5 Respiratory Nurse Consultant to Salord Royal Foundation NHS Trust and Salord PCT; 6 Honorary Clinical Senior Lecturer, National Heart and Lung Institute Consensus guideline on the use o inhaler devices in asthma Introduction Asthma is a chronic respiratory disease characterised by variableairow limitation and airway hyper-responsiveness. It is highly prevalent, aecting 5.2 million people in the UK. 1 Eective inhaledmedications are available, which improve symptoms, pulmonaryunction and quality o lie and reduce exacerbations. However, ormany patients, symptoms remain poorly controlled. 2,3 Incorrect useo inhaler devices and/or non-compliance with inhaled medicationsare among several actors that compromise asthma management   . 4,5  Furthermore, the result o inadequate asthma control has a signicantimpact on the overall costs o asthma. In the UK, the nancialburden o this disease was estimated at almost £900 million, 1 withlack o control responsible or up to 75% o costs. 6 Several types o inhaler device are available, including pressurised metered-dose inhalers (pMDIs), pMDIs plus spacers, breath-actuated pMDIs (BAIs), and dry powder inhalers (DPIs). Inhaler devices varygreatly; or example in relative ease o use, the ormulations available, degree o lung deposition, and cost. Tis guideline is intended toguide primary care healthcare proessionals (HCPs) in how to selectan appropriate inhaler device or their asthma patient. Inhaled therapy: the concepts Targeted delivery  Inhalation delivers medication to the airways; thereore the drug is ã delivered to the areas aected by the disease and systemic exposureis limitedBronchodilator drugs (anti-cholinergics and– β 2 agonists) targetthe large to intermediate bronchi, which contain smooth muscleand β 2 receptors 7,8 Inammation occurs throughout the airways, including the–distal airways, particularly in severe asthma 8–10 Inhaled corticosteroids (ICS) reduce–airway inammation 11 However, only a proportion o the inhaled drug will be deposited ã  precisely where it is neededSome o the drug will be lef in the oropharynx. Tis undesired–deposition can cause side-eects, or example dysphonia orthrush with ICS 12 Systemic absorption o ICS can also occur through either the–gastrointestinal tract or the lungs, depending on the molecule,inhaler device, and inhalation technique 13 Te degree o lung deposition is determined by the ormulation, ã the inhaler device, and the patient’s ability to use the inhalercorrectly 8 Lung deposition–can be improved with both DPIs and BAIs versus pMDIs 14,15 Particle size Te size o the inhaled drug particles ã aects their lung deposition 8 Smaller particles–have a greater potential to penetrate narrowairways than larger particles. Tis may have importantimplications or controlling inammation in the distal airwayso the lungs. Smaller particles may also show less oropharyngealdeposition than larger particles 8 Dierent inhaler devices contain several dierent particle sizes–o a particular drug, which may aect the amount o inhaleddrug that deposits in the lung  16 For example, the var– ® beclometasone chlorouorocarbon(CFC)-ree inhaler is twice as potent as CFC-containing beclometasone inhalers at the same dose, whereas the Clenil ®  beclometasone CFC-ree inhaler is equipotent toCFC-containing beclometasone inhalers at the same dose 17 Inhaler technique and compliance Good inhaler technique is undamental to optimal delivery o  ã the asthma drug and, thereore, maximum therapeutic eect 4,5 Ease o use varies between inhaler devices– Poor inhaler technique is ofen apparent in asthma patients,– particularly with pMDIs as these require good coordinationbetween actuation and inhalation. 2 It is estimated that 58–89%o asthma patients in the UK use these devices incorrectly 18 Te joint British Toracic Society (BS) and Scottish–Intercollegiate Guidelines Network (SIGN) asthmamanagement guideline recommends that, beore initiating therapy, the patients should be taught how to use the inhalerand then must be able to demonstrate satisactory technique.Furthermore, patient inhaler technique should be reassessedat regular asthma reviews (e.g. annually). 17 Tis applies toswitching as well as initial prescriptions, as poor inhalertechnique in either circumstance can be associated with loss o asthma controlHealthcare proessionals (HCPs) need to be trained to teach– patients competently, and should keep up-to-date with newdevices  3the use of inhaler devices in asthma Placebo inhaler devices should be used during teaching,–although inection control issues need to be borne in mind (seeBS website or advice on cleaning: www.brit-thoracic.org.uk) 19 raining aids are available to teach patients to use the correct–speed o inhalation 20 Booklets and a CD-ROM detailing how to use inhaler devices–are available rom Education or Health(www.educationorhealth.org.uk)Compliance to the prescribed regimen is critical to achieving  ã optimal clinical results with the drug and reducing asthma-related mortality 21,22 Non-compliance may be intentional (or example as a result–o regimen inconvenience or ears associated with treatment),or non-intentional (due to poor inhaler technique or amisunderstanding o the nature o asthma) 18,21 Compliance should be monitored because it is requently low,– particularly with ICS therapy where patients may take less than50% o the prescribed medication 22 ools are available to monitor compliance (e.g. rells and– patient sel-report orms - see www.asthmatrak.org)Involving the patient in the choice o inhaler device may help–improve compliance ratesInhaler technique and compliance should be evaluated beore ã stepping-up asthma therapy Diferent types o device Pressurised metered-dose inhalers Tese were the rst type o inhaler device to be introduced, ã and remain the most commonly prescribed delivery system orbronchodilators and ICS in the UKTe devices rely on a propellant to expel the drug  ã raditionally, the propellants were CFCs but these are now–being phased outDierences exist between CFC and CFC-ree inhaler devices–(see separate guideline on the phasing out o CFC-containing inhalers 23 )Te larger particle size typical o  ã  pMDIs results in a low level o lung deposition 16 Introduction o CFC-ree propellants and molecules o smaller– particle size has led to the development o some pMDI devices with improved lung deposition; e.g. extrane beclometasone(var ® ) and ciclesonide (Alvesco ® )Patients oen have poor technique with pMDIs ã 2,18 Advantages: ã Consistent dose emission– Wide range o available drugs–Multi-dose–Quick to use–Small, portable, and discreet–Familiar to HCPs and patients–ypically less expensive than other inhaler devices–Disadvantages: ã Complicated technique to master (see below)–High oropharyngeal deposition (lower with some CFC-ree–devices due to lower emission velocity with smaller particlesize) 16  Variable lung deposition– 16 Associated with the cold reon eect (reduced with–hydrouoroalkane [HFA] devices) (see Box 1)Oen difcult to know when empty or close to empty: only–one device available has a dose counterNot easy or HCPs to teach to patients– 18 est ring commonly wastes drug supply–echnique issues ã Reliant on high level o coordination between actuation and–inhalation 4, A degree–o manual dexterity needed 24 Requires slow inhalation– 20 Some devices are more orgiving o poor technique (e.g. BAIs)– Pressurised metered-dose inhalers plus spacers Adding a spacer to a pMDI increases the level o lung deposition ã and lowers oropharyngeal deposition 25 Spacers may be useul or younger patients, together with ã tight-tting and age-appropriate masksAdult masks are available i required–Spacers should be replaced as per manuacturer’s ã recommendations (typically 6–12 months or plastic spacers), ori visibly damagedAdvantages: ã Associated with a reduced cold reon eect–Can be used to deliver high-dose bronchodilators in severe–asthma 17 Reduce the need or patient coordination with actuation and–inhalationDisadvantages: ã Potential compatibility issues—although some spacers can–accommodate all pMDI mouthpieces, others will only tspecic pMDIsPlastic spacers are susceptible to static-charge–Tey can be bulky and not easily portable–Spacers are oen unpopular with patients– 26,27 Box 1: Cold reon efect Te cold reon eect reers to the phenomenon whereby acold spray hitting the epiglottis stimulates cough and preventseective inhalation. Tis occurs particularly withCFC-containing inhaler devices.  the use of inhaler devices in asthma4 echnique issues: ã Each actuation should be inhaled separately–idal breathing is eective in patients unable to take a large single–breathMinimal delay between actuation and inhalation is required–Spacer ã cleaning issues—patients should be advised o the ollowing care instructions: 17 Clean monthly– Wash in warm soapy water–Do not rinse–Air dry–Afer washing, wipe mouthpiece clean o detergent beore use– Breath-actuated pressurised metered-dose inhalers Tese ã more modern devices overcome some o the coordination problems associated with ‘press-and-breathe’ pMDIs because theyautomatically actuate on inspirationDevices are available or both bronchodilators and ICS ã Advantages: ã Overcome coordination problems between inhalation and–actuationFew steps, easy to use–Easy or HCPs to teach–Popular with patients– 26 Small and portable–Relatively inexpensive– Disadvantages: ã Require slow inhalation–Limited range o drugs available–Cold reon eect present, particularly with CFC ormulations;–reduced with HFA devicesCannot be used with a spacer–Unsuitable or younger children (<5 years)–echnique issues: ã Autohaler– ® device requires a moderate degree o manual dexterity Generation o inspiratory ow is required to actuate the device– Dry powder inhalers Tese breath-actuated devices were developed to overcome usage ã  problems associated with pMDIsInspiratory ow o the patient deaggregates the drug and allows ã small particles to reach the bronchi, carried on the inspired air Advantages: ã No propellant–No cold reon eect–High level o lung deposition than traditional pMDIs– 14,15  Wide range o available drugs–Most have a dose counter or indicator–Few steps, easy to use–Easy or HCPs to teach to patients–Small, portable, and discreet–Disadvantages: ã Powder inhalation can trigger cough–Dependent on ow rate and acceleration o inspiration–May have storage restrictions: some are susceptible to humidity–so must be kept dryGenerally more expensive than pMDIs– Table 2: Selected eatures o each type o inhaler device or asthma Device typeSizePropellantCold reon efectRequiredcoordination betweenactuation and breathEase o technique/teaching  pMDI Small, portable,discreetYesYes (reduced withHFA devices)HighDifcult  pMDI + spacer Bulky, not easily portableYesReducedMediumModerate BAI Small, portable,discreetYesYes (reduced withHFA devices)LowEasy DPI Small, portable,discreetNoNoLow Easy  pMDI=  pressurised metered-dose inhalers; HFA=hydrouoroalkane; BAI= breath-actuated pMDIs; DPI= dry powder inhalers. *Guide cost can vary between ormulations, strengths, and molecule selected. Table 1: Inhaler devices for asthma available in the UK  12,28 Device typeAvailable devices  pMDISpacer Able Spacer ® , AeroChamber ® Plus, Babyhaler ® , E-Z Spacer ® , Fisonair ® , Haleraid ® , Nebuchamber ® , Nebuhaler ® , PARI Vortex Spacer ® ,Pocket Chamber ® , Volumatic ® BAI Autohaler ® , Easi-Breathe ® DPI Accuhaler ® , Clickhaler ® , Cyclohaler ® , Diskhaler ® , Easyhaler ® , Novolizer ® , Pulvinal ® , Spinhaler ® , urbohaler ® , wisthaler ®    pMDI=  pressurised metered-dose inhalers; BAI= breath-actuated pMDIs; DPI= dry powder inhalers.
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