OBAT-OBAT INHALASI

Dra. Endang Martiniani M.Pharm, Apt

Type of aerosol inhalers : • Metered-dose inhaler • Dry powder inhaler • Nebulizer : jet nebulizer ultrasonic nebulizer

Advantages : 1

Very smaller dose

2

Faster onset of action

3

Delivered directly to the target organ

4 5

Minimal systemic exposure

Less painful and comfortable

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Deposition of particles

> 5 µ impaction

1-5 µ sedimentation

< 1 µ like gas

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How MDI Technology Works

Hypothesis from available data Particle size (microns)

Regional deposition

>5

Mouth / oesophageal region

No clinical effect

Absorption from GI tract if swallowed

1–5

Upper / central airways

Clinical effect

Subsequent absorption from lung

<1

Peripheral airways / alveoli

Efficacy

Some local clinical effect

Safety

High systemic absorption

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Disadvantages • Low fraction of lung deposition (10-20%) • Inproper use can affect lung deposition & dose reproducibility • Difficulty coordinating hand action & inhalation with MDI • The variability of device may confuse patients • Lack of standarized technical instruction on inhalers • different types do not have the same dose

INHALER MEDICATIONS

INHALER MEDICATIONS

METERED DOSE INHALER

DRY POWDER INHALER

Metered Dose Inhaler

MDI :

Freon (CFC) • Cold freon effect • Oropharyngeal irritation, cough and bronchospasm • Harmfull for ozone layer • Cardiac arrhytmia • Less effective in cold climate

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Directions to use MDI 1. Remove the cap 2. Hold the inhaler with the mouthpiece towards you 3. Place your thumb on the bottom of the plastic mouthpiece and your index finger on the top of the metal canister 4. Shake inhaler 5. Breath out away from inhaler 6. Put the mouthpiece in your mouth and close your lips around it

6. As beginning to inhale, press the metal canister down (actuation), breath in slowly (5 seconds) and deeply 7. Hold your breath for 5-10 seconds to allow the medication deposit in the airways of the lungs 8. Breath out normally 9. Rinse your mouth with water or mouthwash after each use For the next dose, wait for one minute, to allow the medication working, then repeat the steps

Mark the date of firstly used on the canister Calculate the number of dose used : MDI = 200 puffs, 8 puffs/day  25 days

Advantages of MDI 1

Portable and compact

2

Short treatment time

3

Accurate and reproducible dose

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Disadvantages of MDI : • Difficult in hand-breathing coordination (esp for elderly and children • No dose counter • Need holding chamber / spacer to minimize oropharyngeal impaction • Failure to shake can alter drug dose • Propellants of excipients may affect some patients • Foreign body aspiration from mouthpiece • Lung deposition is only 10-20%

Ingredients : • Propellants / co-solvent (80%) : liquified compressed gasses in which the drug is dissolved or suspended • Surfactants • Active medication (1%)

MDI plus spacer

Spacer ADVANTAGES : • Reduced oropharyngeal impaction & drug loss • Simplify patient coordination between actuation and inhalation • Can be used for patients with airflow obstruction with dyspnea • Fewer side effects especially with steroid (cough, dysphonia, thrush)

Spacer DISADVANTAGES : Larger than MDI More expensive It’s difficult to find spacer May induce error : multiple puffs into chamber before inhaling Delay between actuation and inhalation

Dry Powder Inhaler

Types of DPIs

Dry Powder Inhaler (DPI) SERETIDE DISKUS

ADVANTAGES : Does not contain propellant No actuation and inhalation coordination required more stable (because of solid particle) DISADVANTAGES : More expensive Lung depostion is dependent on patient’s inspiratory airflow

SEREVENT DISKUS

TURBUHALER (DPI)

Direction to use 1. Remove the cap & hold upright 2. Turn the base in one direction and back again till listen for ‘click’ 3. Breath out 4. Place the device between your lips 5. Breath in quickly and deeply 6. Hold your breath for 5-10 seconds

Nebulizer • In hospital setting or ambulatory care • Larger and less conveniet • Deliver continously over an extended period of time

Jet Nebulizer

Schematic of Large Volume Jet Nebulizer

MJC Respiratory Care Theory 2

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Schematic of Ultrasonic Nebulizer (USN)

MJC Respiratory Care Theory 2

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Solutions Used for Nebulizer • Water - most irritating • Normal Saline (0.9% NaCl) - least irritating; salt crystals can condense on water intake causing no aerosol to be produced • Hypertonic Saline - 5 or 10% - used only for sputum inductions

MJC Respiratory Care Theory 2

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Advatages of nebulizer • Abililty to aerosolize some drug solution • Ability to aerosolilze drug mixtures (> 1 drug solution) if they are compatible • It does not need coordination between breathing in and pressing the device (for MDI) • It can be used for any age and clinical condition of patients including debilitating patients • It does not need to breath hold • Dosage can be modified

Disadvantages of Nebulizer • The equipment is bigger and not handy • It needs power suply • Variability of performance characteristic with different brands • Possible contamination with inadequate cleaning • Potentially drug spray

Particle Velocity and Patient Breathing Requirements by Device Particle velocity

Nebulizer Slow

Breathing Slow tidal, with occasional deep breaths

DPI Depends on inspiratory flow

MDI Fast (slower with spacer)

Rapid (60 L/min or 1-2 sec) deep inhalation

Slow (30 L/min or 3-5 sec) deep inhalation

NAEPP. Publication no. 97-4051; Kamin et al. J Aerosol Med. 2002;15:65-73; Agertoft et al. J Aerosol Med. 1999;12:161-169. Tandon et al. Chest. 1997;111:1361-1365. Bisgaard et al. Chapter 12. Drug 40 Delivery to the Lung. Marcel Dekker 2001;162:389-420.

COUNSELLING • • • • • • •

Why is the patient indicated for using aerosol meds ? What is the inhaler medication for ? How to use the device ? Why do they need to shake the MDI ? Why do they need to breath out ? Why are they not allowed to bite the mouthpiece ? The importance of coordination between inhalation and actuation (pressing the canister) • The importance of holding the breath for 10secs

• Why and how to clean the device ? • How to know if the active ingredient is almost empty ? / How to check the remaining active ingredient ? • Why need to waif for one minute before next use ? • How to check the expiration date ? • Always bring everywhere to go for RELIEVER • Why does he have to always use controller although no asma attack happening in the last weeks ?