Inhaler Therapy

Jacob Lee

Current Inhaler Device Delivery Options

Device

Mechanism

Pros

Cons

Examples
Metered dose inhaler (MDI) Pressurized canister releases a measured dose of aerosolized medication
  • Delivers precise & consistent doses when used correctly
  • Can be used with spacer
  • Requires handbreath coordination (timing 3-5 seconds slow inhalation with 5-10 seconds breath hold with release of medicine
 Albuterol, Flucticasone (Flovent), Ipratropium (Atrovent), Budesonide/Formoterol (Symbicort)
Soft mist inhaler (SMI)
  • Uses a mechanical spring to generate slowmoving mist that is inhaled without a propellant
  • Releases a mist that lasts longer and is slower than MDIs
  • Better lung deposition than MDI
  • Easier to use for patients with poor coordination
  • Typically more expensive and less options
  • Must be primed if not used frequently.
 Tiotropium (Spiriva Respimat), Ipratropium/Albuterol (Combivent)
Dry powder inhaler (DPI) Delivers a fine powder of medication when inhaling without a propellant
  • Environmentally friendly (no HFA – propellants)
  • Breath actuated (no need for coordination)
  • Relies on patients inspiratory effort which needs to be strong to get adequate lung deposition
  • Inconsistent dose delivery
 Fluticasone (Arnuity Ellipta, Flovent Diskus), Salmeterol/Fluticasone (Advair Diskus), Umeclidium/Vilanterol (Anoro Ellipta), Budesonide (Pulmicort), Trelegy
Nebulizer Converts a liquid medication into a fine mist, allowing it to be inhaled using a mask or mouthpiece
  • Does not require deep inhalation effort or coordination
  • Ideal for emergencies - continuous medication delivery
  • Short-acting
  • expensive
  • Not always portable
  • Longer administration time
 Albuterol (Ventolin), Ipratropium (Atrovent), Albuterol/Ipratropiu m (DuoNeb), Budesonide (Pulmicort), Hypertonic Saline, Dornase Alfa, Tobramycin

Videos Demonstrating Appropriate Techniques

https://www.nationaljewish.org/conditions/medications/inhaled-medication-asthma-inhalercopd- inhaler/instructional-videos

Classes of Inhaled Medications 

  • Bronchodilators
    • Beta Agonists: beta-2 agonism of bronchial smooth muscle for bronchodilation; also decreases mast cell mediator release
      • Short-acting beta agonists (SABA): albuterol, levalbuterol (theoretically has less side effects but data does not support this); available as both MDI and nebs
      • Long-acting beta agonist (LABA): same as SABA but longer acting. Ex: formoterol (shortest acting LABA), salmeterol, olodaterol o LABA monotherapy for asthma should be avoided due to increased risk for mortality
    • Anticholinergics: block M3 receptors in airway smooth muscle leading to both bronchodilation and decreased bronchial secretions
      • Short-acting muscarinic antagonists (SAMA): ipratropium (Atrovent)
      • Long-acting muscarinic antagonists (LAMA): tiotropoium (Spiriva), revefenacin (Yupelri)
      • Indicated for COPD, not generally indicated for asthma unless part of a combination inhaler for exacerbation or triple therapy for maintenance for refractory disease
    • COPD and asthma exacerbation: bronchodilation and secretion inhibition in acute setting
      • Ipratropium (Atrivent) intermittent nebulizer or Ipratropium-albuterol (Duo-Neb) intermittent or continuous nebulizer
  • Corticosteroids: suppress airway inflammation
    • NOT bronchodilators; Budesonide inhaler (Pulmicort) or neb, fluticasone furoate (Arnuity Ellipta)
  • Combination Therapies: Combine beta-2 agonists, antimuscarinics, and/or corticosteroids. Generally better to combine multiple medications in a single inhaler rather than each individually (improved outcomes likely related to compliance)
    • SABA/SAMA: albuterol/ipratropium available as nebulizer (DuoNeb) or MDI (Combivent) o SABA/ICS: albuterol/budesonide (AirSupra)
    • LABA/ICS: only way to get LABA due to aforementioned increased mortality in LABA monotherapy; vilanterol-fluticasone (Breo Ellipta), salmeterol-fluticasone (Advair Diskus/HFA)
    • LAMA/LABA: umeclidinium/vilanterol (Anoro)
    • LABA/LAMA/ICS: triple therapy for refractory COPD/asthma. Formoterol/glycopyrrolate/budesonide (Breztri – now available inpatient as an MDI), vilanterol/umeclidinium/fluticasone (Trelegy – only outpatient as a DPI)
  • Airway Clearance Agents:
    • Expectorants: Hypertonic saline, NS, 3% and 7%
      • Can be used to thin secretions and produce deep cough in pts who need to expectorate as part of treatment. For CF, chronic tracheostomy, NM weakness. No evidence for benefit in COPD
    • Mucolytics
      • Enzymatic Agents (Dornase alpha/Pulmozyme/DNAse): enzyme that breaks down polymerized DNA in high concentrations in CF airways; indicated specifically for CF pts
      • Disulfide disruptors (NAC/Mucomyst): Sever disulfide bonds of glycoproteins in mucus, lowering its viscosity and making it more amenable to suction, expectoration

Antibiotics 

  • Generally used in pts with CF, non-CF bronchiectasis for suppressive therapy, may be indicated for VAP as salvage therapy
  • Tobramycin: only nebulized antibiotic available at VUMC
  • Pentamidine: nebulized antibiotic for PJP prophylaxis, given monthly

VUMC Inpt Options 

  • SABA : Albuterol (Proventil/Ventolin/Proair) - MDI, neb, continuous aerosol available
  • SABA/SAMA: Ipratropium-albuterol (Duo-Neb) - neb and continuous neb available
  • LABA – only available in combination w/ ICS. LABA/ICS: vilanterol-fluticasone (Breo Ellipta), salmeterol-fluticasone (Advair Diskus/HFA)
  • LAMA: Tiotropium (Spiriva Respimat)
  • ICS: Budesonide inhaler (Pulmicort) or neb, fluticasone furoate (Arnuity Ellipta)
  • Triple therapies Breztri; if insurance won't cover, Combine ICS/LABA with LAMA as replacement.

Stroke Prevention (for AF and flutter)

  • CHA2DS2-VASc risk score >2 in M or >3 in F should prompt long term AC in AF persisting >48 hours
  • DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) are preferred to warfarin except in moderate to severe MS or mechanical valve
  • If cardioversion planned for new onset AF, start AC as soon as possible
  • Post-cardioversion, anticoagulate for at least 4 weeks due to atrial stunning and stroke risk
  • If no contraindications or procedures, continue anticoagulation while inpatient
  • Typically do not need to bridge AC for AF in the setting of procedures unless mechanical valve is present. Decide on a case by-case basis
  • Left atrial appendage closure can be considered in those with increased risk of bleeding (WATCHMAN, Amulet devices)
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