Asthma treatment - inhalers

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Patients with asthma are usually prescribed two types of inhalers- a ‘reliever’ or a ‘preventer’. Relievers are used for immediate relief of asthma symptoms (e.g. wheezing and shortness of breath). Preventers are used regularly to provide long-term control and prevent symptoms. At times, a combination inhaler (both a reliever and preventer) may be prescribed.

Inhalers are well-designed to deliver medication in the form of aerosol, mist or dry powder. These go directly into the lung for faster action and lesser side effects as compared with oral medication.

Correct inhaler technique plays an ESSENTIAL part in ensuring that you receive the optimum amount of medication, and thus the desired outcome i.e. good control of asthma.

Every time before using your inhaler, inspect the inhaler's mouthpiece to ensure it is clean and free from foreign objects.

Please consult your doctor or pharmacist if you are unsure regarding the technique.

Features
  • Dry powder inhaler (DPI)
  • No coordination required
  • Device dispenses a small amount of very fine powder-like medication directly into the lungs
  • Comes with a dose indicator (Indicates the amount of doses remaining)

Symbicort Turbuhaler

  • When you first see a red mark at the edge of the indicator window, there are approximately 20 doses left (it's time to get a new Turbuhaler ready)
  • When the '0' on the red background has reached the middle of the window. you must start using your new Turbuhaler.

Pulmicort Turbuhaler

Bricanyl Turbuhaler

When you first see a red mark at the edge of the indicator window, there are approximately 20 doses left (it's time to get a new Turbuhaler ready)

When the red mark has reached the bottom of the indicator. you must start using your new Turbuhaler.

 

 

 

 

 

 

 

 

 

 

 

Source of the picture:
Preparing (Priming) your new Turbuhaler (for first time only)

Before using your new Turbuhaler for the first time, you need to prepare it for use as follows;

  1. Unscrew the cover and lift it off.
  2. Hold your Turbuhaler upright with the coloured grip at the bottom.
  3. Turn the coloured grip as far as it will go in one direction. Then turn it as far as it will go in the other direction (it does not matter which way you turn it first). You should hear a click sound.
  4. Repeat step 3 and second click would be heard.
  5. Your Turbuhaler is now ready for use.
How to use?

Step 1: Unscrew the cap and lift it off

Step 2: Load the Turbuhaler
  • Hold the device upright
  • Turn the coloured grip as far as it will go in one direction. Then turn it as far as it will go in the other direction (it does not matter which way you turn it first).
  • You will hear a ‘CLICK’ (Now ready for use). Be careful not to drop or shake the Turbuhaler.
  • Sit or stand up straight and slightly tilt your chin up
  • Breathe out slowly and completely, away from the Turbuhaler.

Step 3: ‘INHALE’ the medication
  • Place mouthpiece gently between your teeth, without biting. Ensure a tight seal of your lips around the mouthpiece.
  • Breathe in forcefully and deeply (not through your nose). Do not cover the air vent
  • Remove the device from your mouth
  • Hold your breath for about 10 seconds or as long as you comfortably can. Then breathe out slowly (away from the Turbuhaler)
  • Repeat step 2 to 3 if more than one dose is required

Step 4: Replace the cap
  • Screw the cap back on
  • Do not turn the coloured grip again

Step 5: Rinse your mouth with water and spit it out.
How to care and clean?
  • Wipe the inhaler with clean, dry tissue. Do not wash any part of the Turbuhaler
Special note
  • May not feel or taste anything during or after inhalation
  • If the device is twisted more than once during the loading procedure, you will still only receive a single dose of medicine. However, the dose indicator will register all the loaded doses every ‘Click’
  • Never breathe into your device
  • The powder you hear when you shake the device is NOT medication, it is a drying agent.
Available Brand in Malaysia (Full list may not be displayed here)
  • Symbicort® Turbuhaler (Budesonide/Formoterol)
  • Pulmicort® Turbuhaler (Budesonide)
  • Bricanyl® Turbuhaler (Terbutaline)
References

a) Asthma UK, How to use your inhaler. (available at https://www.asthma.org.uk/advice/inhaler-videos)

b) The Aerosol Drug Management Improvement Team (ADMIT) (available at http://www.admit-inhalers.org)

c) Laube BL, Janssens HM, de Jongh FH, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J. 2011;37(6):1308-31

d) Product Information Leaflet 

e) Handling of inhaler devices, A Practical Guide for Pharmacists (1st ed), Pharmaceutical Services Division, MOH, 2010 

Features
  • The Propellant-free technology works just with the power of tensioned spring
  • Dispenses fine and easy to inhale droplets directly deep into the lungs with less disposition on the throat
  • Requires very less effort during inhalation
  • Comes with a dose indicator (Pointer at Red zone means enough medication left for approximately 14 puffs and this is when you need to a get a new prescription)

 

 

 

 

 

 

 

Source of the picture: https://www.medicines.org.uk/emc/files/pil.407.pdf

Prepare for First Time Use and Priming (for the first time only)

Correct priming method will not affect the number of doses available in the inhaler. After preparation and initial priming, your inhaler will be able to deliver the labelled number of doses. Proper priming of the inhaler is important to make sure the correct amount of medicine is delivered.

1. With the cap closed, press the safety catch while pulling off the clear base.
2. Push the narrow end of the cartridge into the inhaler. The cartridge can be pushed against a firm surface to ensure that it is correctly inserted. Do not remove the cartridge once it has been inserted into the inhaler.
3. Put the clear base back into place until it clicks.
4. Keep the cap closed. Turn the clear based in the direction of the arrows on the label until it clicks (half a turn).
5. Fill the cap until it snaps fully open.

6. Point your inhaler toward the ground. Press the dose-release button. Close the cap.

Repeat steps 4, 5 and 6 until a spray is visible. Once the spray is visible, repeat steps 4, 5 and 6 three more times. Your inhaler is now ready to use.

 

How to use?

Daily Use (T O P: TURN, OPEN, PRESS)

TURN

  • Keep the cap closed.
  • TURN the clear base in the direction of the arrows on the label until it clicks (half a turn)

OPEN

  • OPEN the cap until it snaps fully open.

PRESS

  • Sit or stand up straight and slightly tilt your chin up.
  • Breathe out slowly and completely away from the Respimat.
  • Close your lips around the mouthpiece without covering the air vents, Ensure a tight seal of your lips around the mouthpiece.
  • Point your inhaler to the back of your throat.
  • While taking a slow, deep breath through your mouth, PRESS the dose-release button and continue to breathe in breathe in slowly for as long as comfortable.
  • Remove the Respimat from your mouth. Hold your breath for 10 seconds or for as long as comfortable.
  • Breathe out slowly away from the inhaler.
  • Repeat Turn, Open, Press (TOP) for a total of 2 puffs.
  • Close the cap until you use your inhaler again.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source of the picture: https://link.springer.com/content/pdf/10.1007%2Fs41030-017-0040-8.pdf

Keynote

TOP - TURN, OPEN, PRESS

How to care and clean?

Clean the mouthpiece including metal part inside mouth pience with a damp cloth or dry tissue only, at least once a week.

Discard inhaler 3 months after inserting the cartridge even if you havent used all the medication

Special note
  • If the inhaler has not been used for more than 7 days, release one puff to the ground to prepare the inhaler for use.
  • If the inhaler has not been used for more than 21 days, repeat the steps TURN, OPEN & PRESS (TOP) until a spray is visible. Then repeat T.O.P for another three more times to prepare the inhaler for use
Available Brand in Malaysia

Spriva Respimat® (Tiotropium)

References

a) Asthma UK, How to use your inhaler. (available at https://www.asthma.org.uk/advice/inhaler-videos)

b) The Aerosol Drug Management Improvement Team (ADMIT) (available at http://www.admit-inhalers.org)

c) Laube BL, Janssens HM, de Jongh FH, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J. 2011;37(6):1308-31

d) Product Information Leaflet 

e) Handling of inhaler devices, A Practical Guide for Pharmacists (1st ed), Pharmaceutical Services Division, MOH, 2010 

Description
  • Dry powder inhaler (DPI)
  • No coordination required
  • Device dispenses a small amount of very fine powder-like medication directly into the lungs
  • Comes with a dose indicator (Number 5 to 0 appear RED to warn you that there are only a few doses left and it's time to get a new inhaler ready). Once the counter shows 0, your inhaler is empty
How to use?

 

 

 

 

 

 

 

Step 1: Open

  • Keep the inhaler horizontally. Hold the outer case with one hand and put the thumb of your other hand on the thumb grip.
  • Push your thumb away from your as far as it will go. You will hear a click.

 

 

 

 

 

 

 

Step 2: Slide

  • While holding the inhaler horizontally. SLIDE’ the lever on the side away from you, as far as it will go- until it clicks (Now ready for use). Do not tilt or shake the device.
  • Sit or stand up straight and slightly tilt your chin up.
  • Breathe out slowly and comfortably, away from the Accuhaler.

 

 

 

 

 

 

Step 3: Inhale

  • Put mouthpiece gently between your lips. Ensure a tight seal of your lips around the mouthpiece. Breathe in forcefully and deeply (not through your nose).
  • Remove the device from your mouth.
  • Hold your breath for about 10 seconds or as long as you comfortably can. Then breathe out slowly (away from the Accuhaler).

Step 4: Close

  • You can now close the device by putting your thumb in the thumb grip again and sliding it back towards you, as far as it will go
  • When you close the device, it clicks shut. The lever will automatically return to its original position and is reset

Step 5: Rinse your mouth with water and spit it out

Keynote

OPEN, SLIDE, INHALE, CLOSE

How to care and clean?

Wipe the inhaler with clean, dry tissue. Do not wash any part of the Accuhaler

Special note
  • May not feel or taste anything during or after inhalation
  • Only slide the lever when you are ready to take a dose
  • Never breathe into your device
Available Brand in Malaysia (Full list may not be displayed here)

Seretide® Accuhaler (Salmeterol/Fluticasone)

Reference

a) Asthma UK, How to use your inhaler. (available at https://www.asthma.org.uk/advice/inhaler-videos)

b) The Aerosol Drug Management Improvement Team (ADMIT) (available at http://www.admit-inhalers.org)

c) Laube BL, Janssens HM, de Jongh FH, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J. 2011;37(6):1308-31

d) Product Information Leaflet 

e) Handling of inhaler devices, A Practical Guide for Pharmacists (1st ed), Pharmaceutical Services Division, MOH, 2010 

Description
  • Dry powder inhaler (DPI).
  • No coordination required.
  • Comes with a dose indicator (It counts down with 1 each time you open the cover when fewer than 10 doses are left, half of the dose counter shows red and after you have used last dose, half of the dose counter shows red and the number ‘0’ is displayed). Your inhaler is empty.
  • Device dispenses a small amount of very fine powder-like medication directly into the lungs.
How to use?

 

 

 

 

 

 

 

 

Step 1: Open

  • Open the cover when ready to take a dose
  • Do not shake the inhaler
  • Slide the cover until you hear a ‘click’ (Now ready for use)

Source of the picture: https://www.medicines.org.uk/emc/files/pil.5225.pdf

Step 2: Inhale

  • Sit or stand up straight and slightly tilt your chin up
  • Hold the inhaler away from your mouth and breathe out slowly and completely
  • Do not block the air-vents with your fingers
  • While holding the Ellipta horizontally, put the mouthpiece gently between your lips. Ensure a tight seal of your lips around the mouthpiece. Breathe in forcefully and deeply (not through your nose).
  • Remove the inhaler from your mouth.
  • Hold your breath for about 10 seconds or as long as you comfortably can and then breathe out slowly (away from the Ellipta)

Step 3: Close

  • Slide the cover upwards as far as it will go to cover the mouthpiece

Step 4: Rinse your mouth with water and spit it out

Keynote

Open, Inhale, Close

How to care and clean?

Wipe the inhaler with clean, dry tissue before closing the cover. Do not wash any part of the Ellipta.

Available Brand in Malaysia (Full list may not be displayed here)

Revlar Ellipta® (Fluticasone furoate/Vilanterol)

Reference

a) Asthma UK, How to use your inhaler. (available at https://www.asthma.org.uk/advice/inhaler-videos)

b) The Aerosol Drug Management Improvement Team (ADMIT) (available at http://www.admit-inhalers.org)

c) Laube BL, Janssens HM, de Jongh FH, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J. 2011;37(6):1308-31

d) Product Information Leaflet 

e) Handling of inhaler devices, A Practical Guide for Pharmacists (1st ed), Pharmaceutical Services Division, MOH, 2010 

Special Note
  • Do not open the mouthpiece until you are ready to inhale the dose; if the mouthpiece is closed without an inhalation, the dose is lost.
  • Never breathe into your device.
  • The inhaler is packaged in a tray. Don't open the tray until you are ready to start using your new inhaler. Do not use your Ellipta more than 6 weeks after tray is opened.

Source of the picture: https://gskpro.com/en-ie/products/ellipta-inhaler/#

Description
  • Medication is stored under pressure in the metal canister
  • A fine mist of medication is released upon pressing the canister that can be inhaled into the lungs
  • Works well with a valved holding chamber (VHC) or spacer.
Priming (Using your pMDI for the first time and when your inhaler has not been used for a period of time).
  • Removed the mouthpiece cover and shake the inhaler well. Press the canister in mid-air to release the medication spray (away from you).
  • The number of sprays and the non-use period is depending on the type of pMDI you are using. Please consult your doctor or pharmacist for more information.
How to use?

Step 1:

  • Remove the mouthpiece cover and hold the inhaler in an upright position.
  • Shake your inhaler well in an up-down motion before each puff to mix the content in the canister.
  • Sit or stand up straight and slight tilt your chin up.

Step 2:

  • Hold your inhaler upright with your index finger on the top of the canister and your thumb supporting the bottom of the inhaler.
  • Breathe out slowly and completely through your mouth, away from the mouthpiece.

Step 3:

  • Place the mouthpiece gently between teeth, without biting. Ensure a tight seal of the lips around the mouthpiece. Do not block the opening of the mouthpiece with your tongue.

Step 4:

  • Begin breathing in slowly and deeply through your mouth and at the same time press down firmly on the canister once
  • Continue to breathe in slowly and deeply for 4 to 5 seconds until your lungs are full of air.

Step 5:

  • Remove the inhaler from the mouth and hold your breath for about 10 seconds or as long as comfortable.

Step 6:

  • Breathe out slowly, away from the pMDI.
  • Wait about 30 seconds and repeat step 2 to 6 for the subsequent puff

Step 7:

  • Replace the mouthpiece cover after use.
  • Rinse your mouth with water and spit it out (for a steroid-containing inhaler)
How to care and clean?
  • Clean inhaler at least once weekly. Cleaning methods are depending on which pMDI you are using. Please consult your doctor or pharmacist for more information. As an example, the different cleaning method between Ventolin (salbutamol) and Flutiform (Fluticasone/Formoterol) pMDI are listed in the table below:
Products Cleaning Methods
pMDI Ventolin (Salbutamol)
  • Remove the metal canister from the plastic casing of the inhaler and remove the mouthpiece cover.
  • Rinse the plastic casing thoroughly under running water(through the top and bottom of the plastic casing)
  • Dry the plastic casing thoroughly inside and out.
  • Replace the metal canister into the plastic casing and put on the mouthpiece cover.
  • Do not put the metal canister in water.
pMDI Flutiform (Fluticasone/Formoterol)
  • Remove the mouthpiece cover.
  • Do not remove the aerosol can from the actuator.
  • Wipe the inside and outside of the mouthpiece and the actuator with a clean, dry cloth or tissue.
  • Replace the mouthpiece cover.
  • Do not put the metal canister in water.

 

Available Brand in Malaysia (Full list may not be displayed here)

Ventolin® MDI (Salbutamol)

Flixotide MDI (Fluticasone)

Flutiform® MDI (Fluticasone/Formoterol)

Foster®  MDI (Beclometasone/Formoterol)

Alvesco® MDI (Ciclesonide)

Reference

a) Asthma UK, How to use your inhaler. (available at https://www.asthma.org.uk/advice/inhaler-videos)

b) The Aerosol Drug Management Improvement Team (ADMIT) (available at http://www.admit-inhalers.org)

c) Laube BL, Janssens HM, de Jongh FH, et al. What the pulmonary specialist should know about the new inhalation therapies. Eur Respir J. 2011;37(6):1308-31

d) Product Information Leaflet 

e) Handling of inhaler devices, A Practical Guide for Pharmacists (1st ed), Pharmaceutical Services Division, MOH, 2010 

Special Note
  • Do not breathe in too fast with pMDI.
  • Do not stop breathing when you feel the medicine in your mouth.
  • Do not press the pMDI before you start breathing in