Welcome to Pulmonary Rehab

Inhalation Therapy For COPD & Asthma

Babette Parthum, RRTClinical CoordinatorRespiratory Therapy

Types

●Pressurized Metered Dose Inhaler (MDI)

●Dry Powder Inhaler (DPI)●Nebulizers

Pressurized MDI

Propellants● Provides the force to generate the aerosol

cloud● The medium for which the active

component is dissolved● Typically make up more than 99% of the

delivered dose

● Chlorofluorocarbons (CFCs)○ Used to be the most commonly used

propellants○ Banned due to adverse effect on ozone layer

● Hydrofluoroalkanes (HFA)○ More effective○ Produces an aerosol with a smaller particle

size which improves deposition in the small airways and provides greater efficacy

● When the valve is actuated the propellant and medication leave the inhaler at a high velocity

● Majority of medication impacts in the oropharynx

● Less than 25% reaches the lung

How To Efficiently Use Your MDI

1. Shake the canister2. Place the MDI mouthpiece between your lips3. Breathe out steadily4. Press the metered dose inhaler down once to

release the medication into your mouth 5. Breathe in slowly and as deep as possible6. Hold the breath in while counting to 10

Advantages of MDIs

● Compact, portable, convenient● Multi-dose delivery capable● Lower risk of bacterial

contamination● Suitable for an emergency situation

Disadvantages of MDIs● Needs correct actuation and inhalation

coordination - can be difficult in children and elderly patients

● Cold freon effect● High pharyngeal drug deposition● Flammability possibility of new HFA propellants● Remaining dose is difficult to determine

MDI with Spacer

Using a Spacer With an MDI

● Insert the inhaler into spacer and shake● Breathe out● Put the spacer mouthpiece into your mouth● Press down on the inhaler once● Breathe in slowly and deeply (3-5 seconds)● Hold breath for 10 seconds

Advantages of MDI with Spacer● Compensates for poor

technique/coordination with MDI● Allows more medication to reach your lungs● Prevents medication from escaping into the

air● Fewer side effects from corticosteroid

residue in the mouth

Disadvantages of MDI with Spacer

● Large size and volume of device● Bacterial contamination is

possible - clean the device periodically

Cleaning Your Spacer● Wash the mouthpiece and the spacer in warm,

soapy water at least once a week. More frequently when sick.

● Dry carefully with a clean, lint-free cloth.● Wipe off mouthpiece daily.● Keep the cap on the mouthpiece when not in use.● DO NOT share your inhaler or spacer with others.● Have an extra spacer on hand if possible.

Dry Powder Inhaler (DPI)● Single Dose Devices

o Have to be reloaded with a capsule containing micronized medication in a large particle carrier powder

o Contains just the medication, no propellant

Left: Spiriva®

Right: Foradil®

Dry Powder Inhaler (DPI)● Multi-Dose Devices

o Medication is in the device, no capsuleo No propellant

Advair®

How to Use Your DPI1. Remove the cap2. Load a dose of the medication (depends on the type of

inhaler you have)3. Turn your head and breathe out as much air as you can (try

to empty your lungs)4. Put the dry powder inhaler in your mouth with your lips

firmly around the opening5. Using just your mouth, breathe in once, very deep and

fast. Fill your lungs as deeply as you can. NEVER breathe into the inhaler.

6. Take your mouth off the inhaler, hold your breath, and count to 10. Then slowly breathe out.

7. If your doctor prescribed more than one dose of the medication, wait about 1 minute before taking the next dose.

8. Replace the cap on the dry powder inhaler. If using a steroid-type inhaler, gargle and rinse your mouth with water.

http://youtube.com/v/VYMDHaQMj_w

Advantages of DPI● Breath actuated● Less patient coordination required● Spacer not necessary● Compact, portable● No propellant● Usually higher lung deposition than a

pressurized MDI

Disadvantages of DPI● Work poorly if inhalation is not forceful

enough● Most are moisture sensitive - humidity can

cause the powder to clump therefore reducing the dispersal of fine particle mass

● In single dose devices, need to reload the capsule each time

Nebulizer● Changes liquid medication into a fine

mist to let you breathe it into your airways

● Given to help you breathe easier● The nebulizer equipment and medication

must be prescribed by a doctor

How to Efficiently Use Your Nebulizer

1. Wash your hands with an antibacterial soap2. Connect the hose to an air compressor3. Fill the medicine cup with your prescription.

Close the medicine cup tightly to avoid spills.4. Attach the hose and mouthpiece/mask to the

nebulizer.5. Sit up straight and keep the nebulizer vertical.

6. Place the mouthpiece in your mouth keeping your lips firm around the mouthpiece. OR Place the mask over your nose and your mouth. If using a mouthpiece, breathe through your mouth until all of the medication is used. If using a mask, breathe in through your nose and out through your mouth until all of the medication is used. Usually takes 10-20 minutes to use all of the medication.

7. Tap the medication cup several times to ensure all the medication is nebulized.

8. Turn off the machine when done.9. Clean the nebulizer, mouthpiece, and mask.

**Remember to cough and bring up the loose mucus at the end of your treatment.

Advantages of Using a Nebulizer

● Provides therapy for patients who cannot use other inhalation devices (MDIs and DPIs)

● Allows administration of large doses of medications

● Patient coordination not required● Can be used with supplemental oxygen

Disadvantages of Using a Nebulizer

● Decreased portability● Longer set-up and administration time● Higher cost● Electrical power source required● Higher risk of contamination

How To Clean Your Nebulizer● After each treatment: Rinse the nebulizer cup

with warm water, shake off excess water, and air dry.

● At the end of each day: Wash the nebulizer cup and mask or mouthpiece in warm soapy water using a mild detergent. Rinse thoroughly and allow to air dry. Do not clean the tubing.

● On Monday, Wednesday, and Friday: disinfect the equipment using a vinegar/water solution. Mix together 1 part vinegar to 3 parts water. Soak the equipment in the vinegar solution for 20 minutes. Rinse well under a steady stream of water. Shake off the excess water and allow to air dry on a paper towel.

● Change the nebulizer filter as recommended

in your owner’s manual, or when it appears

grey or dirty. Failure to change the filter

will make your compressor unit work

harder than it should and will eventually

cause the unit to fail.

● Proper care of your equipment prevents infection

● Cleaning should be done in a dust-free, smoke-free environment away from open windows

● Always allow equipment to completely dry before storing in a plastic, zippered bag

● It is a good idea to have an extra nebulizer, mouthpiece, mask, and tubing

Storing Your Equipment & Medication● Cover the compressor with a clean cloth when not in use.

Keep it clean by wiping with a clean, damp cloth as needed.● Do not put the compressor on the floor either for treatments

or for storage.● Medications should be stored in a cool, dry place. Some

medications require refrigeration and some require protection from light. Check your medications often for discoloration or crystal formation. If either of these happens, throw the medication away.

Conclusion● There are 3 main types of inhalation

devices to treat pulmonary disease.● Each has its own advantages,

disadvantages, and side effects.● The key to successful treatment is

proper inhalation technique.● Proper cleaning techniques will

decrease the risk of infection.

Important ReminderCold and flu season worsens between October and April and now we have the new risk of the Ebola Virus.● Get your flu shot● Get you pneumonia shot if you haven’t had one

in the last 5 years● The main key to staying well is proper hand

washing.

References● American Thoracic Society● Asthma Society of Canada● Dr. Aslam Calicut, Junior Resident MD

Respiratory Medicine at Pariyaram Medical College

● Mayo Clinic● Ohio State University Wexner Medical Center● West Virginia Asthma Education & Prevention