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Ovid: Oxford Handbook of Respiratory Medicine

Authors: Chapman, Stephen; Robinson, Grace; Stradling, John; West, Sophie Title: Oxford Handbook of Respiratory Medicine, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Part 3 – Supportive care > Chapter 54 – Inhalers and nebulizers Chapter 54 Inhalers and nebulizers P.620
Background Inhalers

  • There are many different inhaler devices that deliver drugs directly to the airways
  • Ideally patients should try a range of devices to choose the most appropriate for them
  • Patients should receive advice on techniques for inhaler use. Technique should be checked regularly and, if patients cannot manage a particular device, they should be switched to another
  • The percentage of a drug delivered to the airway varies for each device (from 15–60% according to the manufacturers), and depends on good technique
  • Spacer devices improve this delivery and are particularly useful for the elderly, children, and those who find it difficult to coordinate inhaler administration with breathing
  • Try to use the same inhaler device for all the drug classes used by a patient
  • Advise the patient how to recognize when a device is empty: some have dose counters; others are shaken to hear if they still have contents
  • Titrate inhaler doses with clinical response.

Nebulizers are used by patients who gain greater relief from nebulized therapy than from inhaled therapy. This may be during acute respiratory illnesses, because of disease severity, or because they are unable to use inhalers. Patients who are being considered for nebulizer therapy should be referred to a respiratory physician. If antibiotics are being nebulized, a more powerful nebulizer is required. How to use: Open the nebule containing the drug solution and squirt the solution into the nebulizer chamber. Salbutamol and ipratropium bromide can be taken together, but nebulized budesonide or antibiotics should be used separately. If ipratropium bromide only is being used, this should be delivered via a mouthpiece, as it can lead to glaucoma if used via a mask. Reattach the chamber to the nebulizer mask or mouthpiece. Put the mask over nose and mouth, or position mouthpiece between the lips in the mouth. Switch the nebulizer machine on. Breathe slowly in and out. Continue until all the solution is gone. If this takes more than 10 minutes, the machine should be serviced. Switch off the machine. Rinse the nebulizer chamber with water after each use. If the patient is using oxygen, this can still be used during nebulization, either via nasal prongs under the nebulizer mask or by using oxygen tubing attached directly to the nebulizer chamber to drive the nebulization. Nebulizer machines should be serviced annually. P.621
Different inhaler types and instructions for their use

Different inhaler types
Generic name of drug (with product names) Mechanism of action Inhaler colour
Salbutamol (Ventolin®, Asmasal®, Pulvinal® Salbutamol, Salamol®, Salbutamol Cyclocaps®, Airomir®, Asmasal Clickhaler®, Salamol Easi-Breathe®, Ventodisks®) Short-acting β2 agonist Duration 3–5 hours Blue
Terbutaline (Bricanyl®)
Salmeterol (Serevent®) Long-acting β2 agonist Green
Formoterol (Foradil®, Oxis®) Duration 12 hours Green/turquoise
Ipratropium bromide (Atrovent®) Short-acting anticholinergic White/grey
Ipratropium and salbutamol (Combivent®)
Tiotropium (Spiriva®) Long-acting anticholinergic Grey Handihaler®
Beclometasone dipropionate (Becotide®, Becloforte®, Pulvinal® Beclometasone, Beclomethasone Cyclocaps®, AeroBec®, AerobecForte®, Asmabec Clickhaler®, Beclazone Easi-Breathe®, Beco-disks®, Qvar®) Corticosteroid Brown Red
Budesonide (Pulmicort®, Budesonide Cyclocaps®) Brown
Fluticasone propionate (Flixotide®) Red
Mometasone furoate (Asmanex®) Red
Salmeterol and fluticasone (Seretide®) Combination steroid and bronchodilator Purple
Eformoterol and budesonide (Symbicort®) Red and white
Sodium cromoglicate (Intal®, Cromogen Easi-Breathe® Unknown, stabilize mast cells Yellow and white
Neocromil sodium (Tilade®)


Instructions for use of different inhaler types
Type of device Instructions for use
Pressurized aerosol metered dose inhaler (MDI) Aerosol Evohaler® Remove the mouthpiece and shake the inhaler well. Hold the inhaler upright with the thumb on the base below the mouthpiece and the first finger on the metal canister. Breathe out as far as is comfortable then place the mouth piece between the teeth and close lips around it. Do not bite it. As you start to breathe in through the mouth, press on the top of the inhaler to release the medication whilst still breathing in steadily and deeply. Hold your breath, take the inhaler from your mouth and continue holding your breath for up to 10 seconds if possible. Wait 30 seconds prior to taking second puff. Use with spacer device to improve drug delivery. CFC-free inhalers need device washing every 2–3 weeks, as they can block.
Spacer Nebuhaler® Volumatic® Aero Chamber® Able Spacer® Ensure spacer is compatible with patient’s inhaler. Remove cap of inhaler and shake it. Insert it into end of spacer device. Place the other end of the spacer in the mouth. Press the inhaler canister once to release one dose of the drug. Take one deep breath in and hold, or take 3–4 steady breaths in and out. Repeat as indicated. Valve should rattle. Clean the spacer once a month with mild detergent, rinse, and air-dry. Replace after 6–12 months.
Breath-actuated devices Autohaler® Easibreathe® Prime the device. If an autohaler, remove the cap and lift the red lever; if an easi-breathe, open the cap. Insert device into mouth. Inhale slowly and deeply. Continue inhaling when the device ‘clicks’. Hold breath for up to 10 seconds if possible. Slowly breathe out. To take a second inhaled dose, lower the red lever and lift again. If an autohaler, close the cap and reopen if an easi-breathe and repeat the above sequence.
Dry powder devices Accuhaler® Diskhaler® Turbohaler® Clickhaler® Twisthaler Cyclohaler® Aerocaps® Spincaps® Prime the device. Turbohaler: remove the cap, twist the base as far as possible until the click is heard and then twist back again. Clickhaler: shake the device, remove the cap, click the top down and release. Twisthaler: remove the cap by twisting and the dose is then ready. Accuhaler: Open inhaler cover, mouthpiece facing you and push lever down to pierce the blister containing dose. Diskhaler: insert disc into device by opening and pulling out mouthpiece section. To prepare dose, lift up back of lid to 90° until the blister is pierced, then lower the lid. To use all the devices, hold them level, exhale fully, place the mouthpiece into mouth between teeth and inhale steadily. Hold your breath and remove the inhaler. For a second dose, repeat the above actions.
Handihaler® Flip lid and white mouthpiece open and insert capsule. Close the mouthpiece back down until it clicks. Pierce the capsule by pressing the green button at the side. Exhale as far as is comfortable. Place mouthpiece into mouth and breathe in slowly and deeply. Remove inhaler from your mouth and hold your breath for 10 seconds if possible. Slowly breathe out. Repeat if necessary to ensure all the powder from capsule is gone.

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