The Aerosol Drug Management Improvement Team ADMIT Slide Deck 2018

Part 8 Choice of drug-device combinations to use in the emergency room and in hospital Borja Cosío

Aerosol Delivery of Short-Acting ß2-Agonists in the Hospital E.D. “The delivery of ß2-agonists in the ED setting by nebulisers or MDIs with holding chambers (eg, AeroChamber, Volumatic, or InspirEase) is equally effective for improving pulmonary function and reducing symptoms of acute asthma in both adult and pediatric patients (quality of evidence: good).” Dolovich et al. Device selection guidelines-Chest 2005

Treatment should be started with repeated administration of SABA (in most patients by pMDI and Spacer)……. For mild exacerbations, repeated administration of inhaled SABA (up to 4-10 puffs every 20 min for the first hour) is usually the most effective and efficient way to achieve rapid reversal of airflow limitation (1) Evidence A (less robust in severe and near fatal asthma) Delivery of SABA via pMDI and spacer leads to a similar improvement in lung function as delivery via nebuliser (1) and is the most cost effective (2) Global Initiative for Asthma 2017 - 1. Cates CJ et al. Cochrane Database Syst Rev 2013; 2. Newman KB et al. Chest 2002; 121:1036-41

Spacers Spacer devices have three basic designs—the open tube, the reservoir or holding chamber, and the reverse flow design. Adding a one-way valve creates a holding chamber, enabling retention of aerosol within the chamber for a finite time after pMDI actuation. Holding chambers produce a fine aerosol because of the high level of impaction of larger drug particles and partial evaporation of propellant within the chamber. Larger-volume spacers and holding chambers capture and retain more of the aerosol cloud, whereas smaller-volume spacers and holding chambers reduce the amount of available aerosol generated from the impaction of the formulation on their walls. Dolovich, Lancet 2011; 377: 1032

Holding Chambers-Spacers Advantages Disadvantages Reduce need for patient coordination Inhalation can be more complex for some patients Reduce pharyngeal deposition Can reduce dose available if not used properly More expensive than MDI alone Integral actuator devices may alter aerosol properties Single inhaler (NS) Little perceived benefit (1.4) Gender (NS) Dolovich et al. Device selection guidelines-Chest 2005

Use and care of valved holding chambers The spacer should be compatible with the pMDI being used  The drug should be administered by repeated single actuations of the metered dose inhaler into the spacer, each followed by inhalation (1) There should be minimal delay between pMDI actuation and inhalation Tidal breathing is as effective as single breaths Spacers should be pre-washed with detergent and air-dried to be ready for immediate use(2). A new spacer should be primed with at least 20 puffs of salbutamol before use Drug delivery may vary significantly due to static charge. Metal and other antistatic spacers are not affected in this way Attention! Multiple actuations into the spacer before inhalation, or delay of inhalation after actuation, may reduce drug delivery BTS Guide 2011 - 1.Barry PW, O’Callaghan C. Eur Resp J 1994;7:1707 2. Pierart F et al. Eur Resp J 1999;13:673

The use of a spacer/holding chamber reduces oral-pharyngeal aerosol deposition, thus reducing the proportion of gastro-intestinal absorption, a relevant effect with inhaled corticosteroids. Newman SP et al. Thorax 1994;39:935 Both nebulisers and pMDIs with spacers/holding chambers are appropriate for use in the inpatient setting. Dolovich et al. Device selection Guidelines. Chest 2005

Aerosol delivery of Short-Acting ß2-Agonists in the hospital E.D. Hydrofluoroalkane formulation delivers more salbutamol than the CFC formulation when used either with the Aerochamber® or Nebuhaler® spacer This may be because less drug is deposited in the spacer from the hydrofluoroalkane formulation, which is emitted from the metered-dose inhaler at a slower speed and occupies a smaller volume than the conventional formulation The difference may be important in severe asthma, where high doses of salbutamol may be administered through a spacer Barry PW. Eur Resp J- 1997;10:1345

Little perceived benefit (1.4) Holding Chambers Trade Name Volume (ml) Use in small Children Valved Compatibility Flow signal Nebuhaler* 750 no yes oval Volumatic* GSK-specific Fisonair 800 universal Inspirease 650 direct Aerochamber 145 With mask Optichamber 218 A2A 210 Single inhaler (NS) Little perceived benefit (1.4) Gender (NS) (*) presently not available in some countries

Spacers and Holding Chambers (name and volume)

Selection of aerosol device at admission to hospital for acute illness Patients’ knowledge about their medication and inhaler technique should be assessed Patients may often need help with their medication, especially the first few days Hospital stay is a good opportunity for assessing and instructing patients on the use of inhalers