The use of inhaler devices in adults
- Dean Hess, RRT, PhD
Dean Hess, RRT, PhD
- Associate Professor of Anesthesia
- Harvard Medical School
- Rajiv Dhand, MD, FCCP, FACP, FAARC
Rajiv Dhand, MD, FCCP, FACP, FAARC
- Professor and Chairman, Department of Medicine
- University of Tennessee Graduate School of Medicine
Inhaler devices are the major method for delivery of asthma medication, but their effectiveness can be compromised if the patient uses the inhaler device incorrectly . The magnitude of this problem has been well documented; in several studies less than half of the patients used their inhaler correctly [2-9].
The use of inhaler devices by adults will be presented here. More general discussions of the delivery of inhaled medication via nebulizers and what patients need to know about their asthma are presented separately (table 1). (See "Delivery of inhaled medication in adults" and "What do patients need to know about their asthma?".)
TYPES OF INHALER DEVICES
Inhaler devices are used to deliver a variety of inhaled medications, including beta-agonists, anticholinergics, glucocorticoids, tobramycin, and insulin. Three main types of inhaler devices are available, the pressurized metered dose inhaler (MDI), the dry powder inhaler (DPI), and the soft mist inhaler (SMI) [10,11].
Metered dose inhalers with CFC and HFA — MDI devices consist of a pressurized canister, a metering valve and stem, and a mouthpiece actuator (picture 1). The pressurized canister contains the drug suspended in a mixture of propellants, surfactants, preservatives, flavoring agents, and dispersal agents. Following adoption of the Montreal protocol, an international agreement to ban chlorofluorocarbons (CFCs), the CFC-free propellant hydrofluoroalkane (HFA)-134a has replaced CFC-containing devices [12-24]. Delivery of most aerosol medications to the lungs is comparable between HFA and traditional CFC devices, although a few of the HFAs deliver a greater portion of the dose than the comparable CFC MDI [21,25-30].
Dry powder inhalers — DPIs are breath-actuated devices that deliver micronized drug particles with a mass median aerodynamic diameter (MMAD) of less than 5 µm, which usually are aggregated with carrier particles (such as lactose or glucose) of greater diameter [31,32]. Drug is delivered to the airways by the inhalation of air over a punctured capsule, blister, or reservoir [31,32]. Inspiratory flow rates of 30 to 60 L/min are required to disaggregate and aerosolize the drug when using a DPI device [33-35].
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- TYPES OF INHALER DEVICES
- Metered dose inhalers with CFC and HFA
- Dry powder inhalers
- Soft mist inhalers
- SPACERS AND HOLDING CHAMBERS
- COMMON PROBLEMS WITH INHALER DEVICES
- Upper airway deposition
- Actuation-inhalation coordination
- Insufficient breath-hold
- TEACHING INHALER USE SKILLS
- MDI technique
- MDI technique with spacer/chamber
- DPI technique
- Soft mist inhaler technique
- Determining when an inhaler device is empty
- MECHANICALLY VENTILATED PATIENTS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS