Jon BellJon BellDirector,Director, CandayCanday Medical Ltd.Medical Ltd.

©© Canday Medical Ltd.Canday Medical Ltd. 20112011

Inhaler TechniqueInhaler Technique

Belgian Chocolate, French Champagne andBelgian Chocolate, French Champagne andInhaled Medication:Inhaled Medication:

Too Good To Waste ?Too Good To Waste ?

Jon BellJon BellDirector,Director, CandayCanday Medical Ltd.Medical Ltd.

DisclosureDisclosure

Jon Bell:

Director of a commercialorganisation that investigatesinhaler devices and their use.

(Canday Medical Ltd.)

Jon Bell / Canday Medical Ltd. do notreceive any remuneration or commission

based on the use of productsmanufactured by other companies.

Jon Bell and Canday MedicalLtd. have received sponsorshipto research and/or lecture oninhaler devices from:

GlaxoSmithKlineTEVAPfizerBoehringer IngelheimChiesiAltanaMerck GenericsNeolabKnowledgeworks Ltd.AstraZenecaClement Clarke InternationalNovartis

Pearce L. Do Health Professionals Have Sufficient Knowledge And Skill To Teach OptimumInspiratory Flow (OIF)? A Study Using The In-Check Dial ™ (ICD) To Evaluate InspiratoryTechnique Poster: C1 ATS Meeting, Atlanta, May 2002

……… in 2002……… in 2002

Baverstock M, Woodhall N & Maarman V. Do Health Care Professionals have sufficientknowledge of inhaler techniques in order to educate their patients effectively in their use?Poster presented at Winter Scientific Meeting British Thoracic Society 2010

……… in 2010……… in 2010

From the hit TV Series House MD on Fox NBC.Video clip from Season 5 Episode 11 - when Dr. House asked a patient how she uses her inhaler.http://www.youtube.com/watch?v=dMAS2S51bM8

“Poor Technique”“Poor Technique”

Target site

Unnecessary Waste

1. Lower than expected deliveryto target site

2. Reduced benefits3. Increased deposition in regions

outside target site4. Increased risk of side-effects

“Poor Technique”“Poor Technique”

…. But very happy to practice technique

UK: MDI and DPI Inhalation technique:UK: MDI and DPI Inhalation technique:inhalationinhalation too fast fortoo fast for pMDIpMDI, or too slow for DPI, or too slow for DPI

Al-Showair R, Tarsin W, Assi K, Pearson S, Chrystyn H Can patients with COPD use thecorrect inhalation with all inhalers and does training help ? Res Med 2007: 101, 2395-2401

163 COPD patientsaverage age 72.5 years

FEV1 47.8% predicted

MDI

Accuhaler

Turbohaler

59.5 %

HandiHaler

4.9 %

57.0 %

14.2 %

Too Fast

Too Slow

Too Slow

TooSlow

Initial presentation – before training

Results later …….

“How you would instruct the patient to inhale” using that type of inhaler

Single measurement

“How would“How would youyou inhale” challengeinhale” challenge

Quick test of how you wouldinhale through commonly-useddevices

•pMDI measurement first•DPI measurement second

Need to:1. Simulate resistance of device2. Measure speed of inhalation

What type of Inhaler is this ?What type of Inhaler is this ?

How does the aerosol get made ?How does the aerosol get made ?

How does the aerosol get made ?How does the aerosol get made ?

What type of Inhaler are these ?What type of Inhaler are these ?

What type of Inhaler is this ?What type of Inhaler is this ?

How does the aerosol get made ?How does the aerosol get made ?

What type of device are these ?What type of device are these ?

How does the aerosol get made ?How does the aerosol get made ?

What type of Inhaler are these ?What type of Inhaler are these ?

How does the aerosol get made ?How does the aerosol get made ?

Aeroliser Accuhaler Turbohaler Clickhaler Twisthaler Easyhaler

Resistance in (cmH2O)½Lmin-1

Mean resistance of variousMean resistance of various DPIsDPIs

Assi KH, Chrystyn H. The different resistance of dry powder inhalers (DPIs).Am. J Respir. Crit. Care Med. 2001;163(5): A443 (Adapted from)

MDI /Spacer

Fate of inhaled drugsFate of inhaled drugs –– Good TechniqueGood Technique

Swallowed

GI tractGI tract

Deposited in lung

Lungs

Metabolism or absorptionfrom the lung

Liver

Oralbioavailability

Absorptionfrom gut

First-passmetabolism

SystemicCirculation

Mouthpharynx

mucociliaryclearance

80%

20%

Schematic representation of potential dose distributionA Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for Respiratory Care.1st Edition. Page 1. Webpage: http://www.aarc.org/education/aerosol_devices/

Adapted from Barnes et al. AJRCCM 1998;157:S1-S53

Swallowed

GI tractGI tract

Deposited in lung

Lungs

Metabolism or absorptionfrom the lung

Liver

Oralbioavailability

Absorptionfrom gut

First-passmetabolism

SystemicCirculation

Mouthpharynx

mucociliaryclearance

95%

5%

Fate of inhaled drugsFate of inhaled drugs –– PoorPoor TechniqueTechnique

Schematic representation of potential dose distributionA Guide to Aerosol Delivery Devices for Respiratory Therapists. American Association for Respiratory Care.1st Edition. Page 1. Webpage: http://www.aarc.org/education/aerosol_devices/

Adapted from Barnes et al. AJRCCM 1998;157:S1-S53

• Design of inhalers vary• Formulation of drug• Mechanical activation

(passive MDI vs active DPI)• Internal resistance to airflow

• Patients vary• Pulmonary function

(reversible Vs irreversible disease )• Ability to learn / be taught the correct

technique• Physical size of lungs (child vs adult)• Effort varies from dose to dose

Why are there problems ?Why are there problems ?

inappropriateselection

and/orincorrectinhaler

technique

How changes in inspiratory flow affectHow changes in inspiratory flow affect outputoutput

HighInspiratory flow

Low

Inhalation createsaerosol (e.g. DPI)

Aerosol made for you(e.g. MDI)

Lactose (in some DPIs)

Drug

Aerosol Deposition at varying Particle SizeAerosol Deposition at varying Particle Size

0

Micron size

0.5

2

5

10DepositionDeposition

Pharynx, larynx &Pharynx, larynx &Upper respiratoryUpper respiratorytracttract

OptimalOptimaltracheobronchialtracheobronchialdepositiondeposition

Optimal alveolarOptimal alveolardepositiondepositionParticles exhaled if <0.5 micronParticles exhaled if <0.5 micron

FacioFacio--MaxillaryMaxillaryView (lateral)View (lateral)

n.b. note the angles in the airways

RightRight BronchogramBronchogram

Trachea

Bronchi

Bronchioles

IMPACT

IMPACT

Direction of flow

IMPACT

Particle Deposition In Respiratory TractParticle Deposition In Respiratory TractThree mechanisms of aerosol kinetics govern the majority of

particle deposition within the respiratory tract.

1. Inertial impaction 2. Sedimentation 3. DiffusionMost important Least Important

Particle Deposition In Respiratory TractParticle Deposition In Respiratory Tract

Speed

Gravity

Brownian motion*

* Whitley Bay SmokeChamber

Mass

Three mechanisms of aerosol kinetics govern the majority ofparticle deposition within the respiratory tract.

1. Inertial impaction 2. Sedimentation 3. DiffusionMost important Least Important

ImplicationsImplications

Metered Dose InhalersMetered Dose Inhalers

Lung deposition fromLung deposition from pMDIspMDIs isisinfluenced by inspiratory flowinfluenced by inspiratory flow

Newman S et al, Eur J Respir Dis 1982;63: Suppl 119 57-65

30L/min

Total lungdeposition

(% of inhaleddose)

0

5

10

15

90L/min10 second breath hold

20%

VC

50%

VC

80%

VC

Metered DoseInhaler (MDI)

20%

VC

50%

VC

80%

VC

ImplicationsImplications

Spacer DevicesSpacer Devices

Metered DoseInhaler (MDI)

Spacer DevicesSpacer Devices –– How they helpHow they help

Drug

1. Capture aerosol avoiding coordination problems2. Reduces particles deposited in oropharynx

Leach, C. L., P. J. Davidson and R. Boudreau: HFA-Beclomethasone Provides Equivalent LungDeposition with or without Add-on Spacers. Eur. Res. J. 10(25): P1522, p. 236S, 1997.

ImplicationsImplications

Dry Powder DevicesDry Powder Devices

Total emitted dose at different flow ratesTotal emitted dose at different flow rates

Malton et al, J Pharm Med 1996:6:35-48 (In-vitro data - laboratory analysis)This does not necessarily correlate with clinical effectiveness

30 60 900

20

40

60

80

100 Salbutamol Accuhaler

Terbutaline Turbohaler

% oflabel claim

Flow (L/min)

Aerosol produced for you –

inhale GENTLY

Please tell me the right inhalation techniquePlease tell me the right inhalation techniquefor each of the inhalers below……for each of the inhalers below……

You create aerosol –

inhale FORCEFULLY

Please tell me the right inhalation techniquePlease tell me the right inhalation techniquefor each of the inhalers below……for each of the inhalers below……

Assessment & Training DevicesAssessment & Training DevicesMonitoring inspiratory flow rate through the device

(www.2ToneTrainer.com)

Fyne Dynamic’sMagFloClement Clarke’s In-Check

and In-Check DIAL

Schering-Plough’sTwisthaler Trainer

Vitalograph’sAerosol Inhalation

Monitor (AIM)

60 L/min

CandayMedical’s

“2-Tone” Trainer

AstraZeneca’s TurbohalerUsage Trainer & Turbutesters

35 L/min

Allen & Hanburys’Accuhaler Trainer

Isle of Wight Inhaler Technique ProjectIsle of Wight Inhaler Technique Project ––

StrategyStrategy1. Patients to receive consistent inhaler technique training from GPs,

Nurses, Pharmacists etc.2. HCPs to MEASURE patients ability to use inhaler (In Check DIAL)3. Targeted patients for maximum early benefit4. Following training, MDI patient to be supplied with a free 2Tone5. Strategy employed across primary and secondary care6. Directed MURs for CPs7. Enhanced service (MUR plus) for children offered by CPs8. Train a trainer, including outside NHS9. Extend to Schools, care homes, housebound etc.

BaselineBaseline –– Respiratory Medication statusRespiratory Medication status

Expenditure:RespiratoryMedicines(overall)

YTD 2007

IOW Medicines Management Data ; Data on file 20th November 2008

Short-actingbeta agonists

+ 5%

+10%

-5%

> +11%

> +6%

+20%

Inhaledcorticosteroids

+ 15%

+20%

2007 2007 2007

•Annual spend: Inhaled corticosteroids > £1.7M•Highest in Southern England•Trend increasing

NationalAverage

OutcomesOutcomes –– Respiratory Medication statusRespiratory Medication status

Expenditure:RespiratoryMedicines(overall)

YTD 2007Vs 2008

IOW Medicines Management Data ; Data on file 20th November 2008

Short-actingbeta agonists

+ 5%

+10%

-5%

> +11%

> +6%

+20%

Inhaledcorticosteroids

+ 15%

+20%

NationalAverage

2007 2007 2007

< +2% NationalAverage

+15%

20082008 2008

•2007 - Annual spend: Inhaled corticosteroids > £1.7M

•2007 - Highest in Southern England•2007 - Trend increasing

•Data collected over 9 month period•No other interventions took place in Respiratory Medicine

OutcomesOutcomes –– Effects on patientsEffects on patients9 months data 2008 vs 2007

IOW Medicines Management Data ; Data on file 20th November 2008

Emergencyadmissions tohospital due to

asthma( n=20 Vs 41) Asthma related

deaths (n=2 Vs 8)

Hospitallength of

stay due toasthma

- 50%

0

+ 25%

-25%

-50%

-75%

•Data collected over 9 month period•No other interventions took place in Respiratory Medicine

1. Internal resistance affects speed of inhalation

2. Speed of inhalation affects DPI device efficacy (little effect on MDI)

3. Speed of inhalation and particle size affect how much drug is depositedin the lungs – and how much in the mouth and throat

4. Before initiating a new therapy, practitioners should check inhalertechnique. Inhalation should be:GENTLE for a device that creates the aerosol for you (e.g. MDI),butFORCEFUL for those that rely on the energy of inhalation (e.g. DPI)

5. NMR / CDS / MURs and Asthma Reviews present unique opportunity toidentify poor inhaler technique – but HCPs need to know good techniquefirst !

6. Evidenced by IOW project: NICE reference: http://tinyurl.com/6j9s5zv

Jon@canday.co.uk

Points to take awayPoints to take away