Inhaler Delivery Devices Handouts: Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2008 update – highlights for primary care CTS COPD Slimjim COPD Action Plan from COPD Guidelines.ca Puffer pictures Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: A Canadian Thoracic Society clinical practice guideline by Sharon Porter RRT CRE Registered Respiratory Therapist Certified Respiratory Educator Coordinator COPD/Pulmonary Rehab Program St. Joseph’s Health Centre, Guelph

About the Presenter Registered Respiratory Therapist (>30 years) Certified Respiratory Educator Employed by Guelph General Hospital and marketed to St. Joseph’s Health Centre, Guelph Coordinator COPD/Pulmonary Rehab Program at SJH Council Member of the Waterloo/Wellington LHIN Rehab Council – Cardiopulmonary stream

Disclosures Employment: Financial Interests: Other Interests: Guelph General Hospital / St. Joseph’s Health Centre, Guelph Financial Interests: This presentation sponsored by Novartis Other Interests: None

Can Respir J 2008;15(Suppl A):1A-8A. COPD is… Treatable Preventable Under-diagnosed Can Respir J 2008;15(Suppl A):1A-8A.

Statistics COPD is the fourth leading cause of death world-wide, and a leading cause of morbidity in Canada. One in four people will likely suffer from COPD in their lifetime. COPD kills more people than diabetes or cancer (World Health Organization. Epidemiology and burden of disease 2003). Many who have COPD don’t know it, yet it is simply diagnosed with a spirometry test. COPD is a leading cause of health care utilization, including hospitalizations and emergency room visits and poses a large economic burden.

Treatment of COPD Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2008 update – highlights for primary care

Issues impacting effective drug delivery in COPD patients Many respiratory clients have poor control of their condition due to improper use of their inhalers. Improper technique can result from: Poor patient instruction Cognitive issues Physical limitations – Hand issues like arthritis or injury Reduced inspiratory flow rates or volumes secondary to disease state

Factors affecting drug distribution and deposition Fine particle fraction (FPF) is defined as a fraction of particles less than 5 m in diameter. This is considered the optimum particle size for drug deposition in the bronchi and alveoli. The ability of the inhaler to generate these fine particles is critical for the effectiveness of the drug. Some inhalers require a high internal resistance in order to generate these fine particles. And some clients are not able to generate enough sustained inspiratory flow to overcome this resistance and receive the medication optimally.

Treatment of COPD Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2008 update – highlights for primary care

Pressurized Metered Dose Inhaler (pMDI) with Aerochamber™ RRT’s recommend to always use a valved holding chamber, i.e. Aerochamber™, with pMDI’s, as it: eliminates the need for coordination of actuation with inhalation, reduces oropharyngeal deposition while increasing pulmonary deposition, without increasing systemic exposure 30 lpm inspiratory flow rate required. Can use multiple breath technique for clients who are unable to breath hold, (i.e. some stroke clients or advanced COPD) Br J Clin Pharmacol. 2011 Dec;72(6): 932-939 doi: 10.111/j.1365-2125-2011.04024.x "Effect of AeroChamber Plus on the lung and systemic bioavailability of beclometasone dipropionate/formoterol pMDI"

How to use pMDI with Aerochamber™ Instructions for use: Shake pMDI and place in Aerochamber™ Exhale fully, place mouthpiece in mouth, and inhale fully and deeply, not so quickly that Aerochamber™ whistles (typically at 60 lpm inspiratory flow rate) Breath hold for 5-10 sec Wait 30 seconds before next dose Repeat above if second dose is required.

pMDI with Aerochamber™ using multiple breath method By blowing into chamber (with pMDI attached) positive expiratory pressure (PEP) therapy is created. This “back pressure” helps prevent airway collapse, thus reducing air trapping, and improving drug deposition. Can also be used without activating the drug to help relieve SOB, similar to pursed lips breathing. Instructions: similar to single breath method, except client blows into chamber before activating pMDI, and continues to inhale and exhale into device for 5 breaths without breath hold.

Diskus ™ - Glaxo Smith Kline Ventolin™ (SABS salbutamol Sulfate), Flovent™ (ICS fluticasone proprionate) , Serevent™ (LABA salmaterol) and Advair™ (ICS fluticasone proprionate and LABA salmeterol) Dry Powder Inhaler (DPI). Closed system with Integrated dose counter Effective drug delivery as low as 30 lpm for Ventolin and Salmeterol, however greater drug deliver achieved at 60 lpm for Flovent (and thus Advair) Instructions for use – Slice cover to open position, push down lever, exhale fully, inhale fully from device, breath hold for min 4 sec, exhale and close cover. Reduced Peak Inspiratory Effort through the Diskus and the Turbuhaler due to Mishandling is Common in Clinical Practice

Handihaler™ - Boehringer-Ingelheim™ Spiriva™ (LAMA tiatropium bromide) Dry Powder Inhaler (DPI) in a capsule Low resistance device (0.07 cm H(2)O(½)/L/min), allowing users to generate high inspirtory flow rates (>60 lpm) through device, increasing optimal drug deposition. Approx 39lpm inspiratory flow rate required

How to use a Handihaler™ Instructions for use – Open Handihaler™ device. Remove 1 capsule from blister package by peeling back the foil wrap. Place the capsule in the device. Close the device. Depress the button on the side of the device to pierce the capsule. Release button Exhale fully, place device in mouth, and inhale fully and deeply. Hold breath for 5-10 seconds. Open device and dispose of capsule, preferably without touching capsule. Close device, replace cover Advise users to wash any medication off of hands after use to prevent rubbing medication into eyes.

Turbuhaler™ - AstraZeneca Pulmicort™ (ICS Budesonide), Oxeze™ (LABA formoterol fumarate) and Symbicort™ (ICS Budesonide and LABA formoterol fumarate) Dry Powder Inhaler (DPI). Closed system with Integrated dose counter 60 lpm inspiratory flow rate required Reduced Peak Inspiratory Effort through the Diskus and the Turbuhaler due to Mishandling is Common in Clinical Practice

How to use a Turbuhaler™ Remove cover. Holding device upright, twist the bottom clockwise then counter-clockwise. Once it clicks the dose is loaded. Exhale fully. Inhale deeply, fully, and very quickly through device. Hold breath for 5-10 sec. Repeat if required. When complete, replace lid.

Twisthaler™ - Merck Asthmanex™ (ICS Mometasone furoate Dry Powder Inhaler (DPI). Closed system with Integrated dose counter 60 lpm inspiratory flow rate required Instructions for use – Hold the inhaler upright and twist the cap off. At this point the dose is already loaded. Fully exhale, inhale through device fully, deeply, and quickly. Breath hold for 5-10 sec. Twist the cap on to close and reset the device.

Breezhaler™ - Novartis Seebre™ (LAMA glycopyrronium bromide), Onbrez™ (LABA indacaterol maleate), Ultibro™ (LAMA glycopyrronium bromide and LABA indacaterol maleate) Dry Powder Inhaler (DPI) in a capsule Capsule is see through, allowing client to visually confirm inhaling full dose. Low resistance device (0.07 cm H(2)O(½)/L/min), allowing users to generate high inspirtory flow rates (>60 lpm) through device, increasing optimal drug deposition. Approx 30 lpm inspiratory flow rate required characteristics of a capsule based dry powder inhaler for the delivery of indacaterol •PubMed Source: http://www.ncbi.nlm.nih.gov/pubmed/20843166

How to use a Breezhaler™ Instructions for use – Remove lid and Open Breezhaler™ device. Remove 1 capsule from blister package by peeling back the foil wrap. Place the capsule in the device. Close the device. Depress the buttons on both sides of the device to pierce the capsule. Release buttons Exhale fully, place device mouthpiece in mouth, and inhale fully and deeply. Hold breath for 5-10 seconds. Open device and dispose of capsule, preferably without touching capsule. Close device, replace cover Advise users to wash any medication off of hands after use to prevent rubbing medication into eyes.

Tudorza™ Genuair™ (Almirall) Tudorza™ (Aclidinium bromide) LAMA Dry powder inhaler (DPI). Closed system with integrated dose counter. Optimal inspiratory flow rate 45 lpm. Integrated flow indicator that turns green when optimal inspiratory flow has been reached. Has a “trigger threshold” feature that prevents another dose from being loaded until after the first dose has been successfully inhaled. Dose is one inhalation BID. Respiratory Medicine (2009) 103, 1832-1837: Peak Inspiratory flow through the Genuair inhaler in patients with moderate or severe COPD

How to use Genuair™ device Instructions for use: Remove cap Depress and release button. The control indicator will turn green. Exhale fully, place in mouth, inhale fully and deeply, quickly enough to activate dose indicator and turn the control indicator to green. There will be an audible click as well. Hold breath for 5-10 seconds. Replace cap

Ellipta™ - Glaxo Smith Kline Breo™ (ICS fluticasone furoate and LABA vilanterol) and Anoro™ (LAMA umeclidinium and LABA vilanterol) Dry Powder Inhaler (DPI). Fewer steps to use than diskus. Closed system with Integrated dose counter 43 lpm inspiratory flow rate required Instructions for use – Open cover, exhale fully, inhale fully from device, breath hold for min 4 sec, exhale and close cover. Information obtained from GSK representative.

Respimat™ - Boehringer-Ingelheim Spiriva™, Combivent (Ventolin and Atrovent), Striverdi™ (LABA olodaterol) Soft mist inhaler (SMI) Prior to first use, the device requires loading and priming. A canister must be inserted into the device and primed. Unable to find data on flow rate requirements Daily use instructions – Open lid, turn the base until it clicks. Place in mouth, depress button while inhaling slowly.

Effective puffer use Many patients are not able to use the puffer they are given, either due to inability to understand device operation, or due to poor insp flow and volume. Turbuhaler , Twistheler, and Diskus require an insp flow of 60 lpm, with a sustained, deep inhalation, for maximum drug delivery. Slightly lower flow rates required for Ventolin diskus and Serevent Diskus. Genuair – 40-50 lpm insp flow Ellipta – 43 lpm insp flow Spiriva Handihaler– 39 lpm insp flow Breezhaler – 30-40 lpm insp flow pMDI with aerochamber – Recommend 30 lpm. 30 lpm 40 lpm 50 lpm 60 lpm

Further Recommendations The Canadian Thoracic Society (CTS) established the Canadian Respiratory Guidelines Committee (CRGC to produce and update clinical practice guidelines for respiratory disease management in Canada. Guidelines and resources are available at: www.respiratoryguidelines.ca www.regionalhealthprogramsww.com