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HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS

PHARMACEUTICAL SERVICES DIVISION MINISTRY OF HEALTH MALAYSIA

DISCLAIMER

Unless otherwise specifically stated, the information contained in this book is made available to pharmacists by the Ministry of Health (MOH) and Clinical Pharmacy Committee (Respiratory Specialty),[CPC(RS)], Pharmaceutical Services Division (PSD), MOH for use as a guide and may not reflect the realities of an actual setting in each institution. The purpose of this book is to standardise counseling on inhaler devices by pharmacists. Neither the Ministry of Health, CPC (RS), PSD, MOH nor any other agency or entities thereof, assumes any legal liability or responsibility for the accuracy, completeness, nor usefulness of any information, product or process disclosed in this book. Reference herein to any specific commercial product, process, service by trade name, trademark, manufacturer, or otherwise, does not constitute or imply its endorsement, recommendation, or favoring by the CPC (RS), PSD, MOH or any entities thereof.

The views and opinions of the CPC (RS), PSD, MOH expressed therein do not necessarily state or reflect those of the other institutions in Ministry of Health or any agency or entities thereof.

ACKNOWLEDGEMENT

The Clinical Pharmacy Committee (Respiratory Specialty) of the Pharmaceutical Services Division, MOH is grateful to all those involved either directly or indirectly in the preparation of this guide. This committee would also like to express its appreciation to relevant drug companies who have provided information on the various inhaler products and their permission for allowing us to include the relevant diagrams of their products in this book.

ADVISORS

Eisah binti A. Rahman Senior Director of Pharmaceutical Services Division,MOH

Hasnah binti Ismail

Director of Pharmacy Practice and Development, Pharmaceutical Services Division, MOH

EDITORIAL COMMITTEE Abida Haq Syed M. Haq Abdol Malek bin Abd. Aziz Pharmaceutical Services Division, MOH Melaka Hospital Sameerah binti Shaikh Abdul Rahman Shahirah binti Zainudi Pharmaceutical Services Division, MOH Selayang Hospital Nurul Adha binti Othman Suhadah binti Ahad Pharmaceutical Services Division, MOH Melaka Hospital Sarah a/p Nagalingam Pharmaceutical Services Division, MOH Tengku Malini binti Tengku Mohmed Noor Izam Pharmaceutical Services Division, MOH

HANDLING OF INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACISTS (MAIN COMMITTEE)

Abdol Malek bin Abd. Aziz Marzirah binti Ibrahim Melaka Hospital Tuanku Ampuan Najihah Hospital,

Kuala Pilah Shahirah binti Zainudi Nicholas Leow Chun Wei Selayang Hospital Sibu Hospital Suhadah binti Ahad Nurulhayati binti Abdul Jamal Melaka Hospital Sultanah Nur Zahirah Hospital Kuala Terengganu Chong Meng Fei Rohaya binti Sulaiman Pulau Pinang Hospital Tengku Ampuan Afzan Hospital,

Kuantan Chow Foong Yan Suzana binti Mustafa Raja Permaisuri Bainun Hospital, Ipoh Queen Elizabeth Hospital

Kota Kinabalu

Jaya Muneswarao a/l Ramadoo @Devudu Syaziyah binti Ahmad Kulim Hospital Sultanah Bahiyah Hospital

Alor Setar

Lim Yan Chun Wong Hui Shean Sultanah Aminah Hospital, Johor Bahru Tuanku Ampuan Najihah Hospital

Kuala Pilah

HANDLING OF INHALER DEVICES : A PRACTICAL GUIDE FOR PHARMACISTS

(CONTRIBUTORS)

Ang Yu Joe Nor Aziah binti Idris

Adibah Yuhana Ismail Nor Hafizah binti Salehudin

Chan Yeen Yee Norehan binti Abdul Rashid

Chen Siaw Ming Norhafidah binti Othman

Chong Mei Fei Norhayati binti Mustapha

Chong Mei Yoong Nurah Zainal Abidin

Chow Foong Yan Nur Eillena binti Mat Deris

Karen Wong Yoke Sim Ong Ser Via

Kho Zhi Min Phan Hui Seng

Kon Ee Wen Rohaya Sulaiman

Kuah Lean Fung Roksanah binti Shaukat Ali

Lai Siok Wah Rosminah binti Mohd Din

Lee Chui Peng Soh Kwang Chin

Lee Sock Hui Suzana binti Mustafa

Mastura binti Safie Tan Jou Ann

Ng Min Mei Wah Mei Chin

Noorulhida binti Ishak Wong Yee Cheat

Noorliana binti Ismail

HANDLING INHALER DEVICES: A PRACTICAL GUIDE FOR PHARMACIST

vi

CONTENT

PAGE NUMBER

Abbreviations……………………………………………………………………………. ix

Introduction ……………………………………………………………………..………. x

1 METERED DOSE INHALER (MDI)

1.1 Introduction ……………………………………………………………………… 1

1.2 Directions For Use ………………………………………………………………...

2

1.3 Maintenance ……………………………………………………………………. 7

1.4 Determining Contents Of An MDI Canister ………………………………… 9

1.5 Summary Of Metered Dose Inhalers …………………………………………. 10

1.6 References ……………………………………………………………………… 15

2 TURBUHALER®

2.1 Introduction ……………………………………………………………………… 16

2.2 Directions For Use

A. Preparing A New Turbuhaler® (Priming) ……………………………....... 17

B. Used Turbuhaler® ………………………………………………………….. 18

2.3 Maintenance ……………………………………………………………………. 23

2.4 How To Know When The Turbuhaler® Is Empty? …………………………... 23

2.5 Determining The Functionality Of The Device When In Doubt ……………. 24

2.6 Summary Of Turbuhaler® ……………………………………………………… 25

2.7 References ……………………………………………………………………… 27


vii

3

EASYHALER®

PAGE NUMBER

3.1 Introduction ……………………………………………………………………… 28


A. Preparing The Powder Inhaler For First Use ……………………………. 30

B. Delivering The Medication …………………………………………………. 31

3.3 Maintenance ……………………………………………………………………. 35

3.4 How Do You Know When Your Easyhaler® Is Empty? …………………….. 35

3.5 Summary Of Easyhaler® ………………………………………………………. 36

3.6 References ……………………………………………………………………… 38

4 ACCUHALER®

4.1 Introduction ……………………………………………………………………… 39

4.2 Directions For Use ……………………………………………………………... 40

4.3 Maintenance ………………………………………………………………….. 42

4.4 Summary Of Accuhaler® ……………………………………………………….. 43

4.5 References ……………………………………………………………………… 44

5 HANDIHALER®

5.1 Introduction……………………………………………………………………… 45

5.2 Directions For Use …………………………………………………………….. 46

5.3 Maintenance …………………………………………………………………….. 53

5.4 Summary Of HandiHaler® …………………………………………………… 55

5.5 References ……………………………………………………………………. 56


viii

6

SPACER DEVICES

PAGE NUMBER

6.1 Introduction ……………………………………………………………………… 57

a) BI Tube ………………………………………………………………………. 58

b) Chamber With Mouthpiece ………………………………………………... 58

c) Chamber With Mask ………………………………………………………... 59


6.2.1 BI Tube ……………………………………………………………….. 60

6.2.2 Chamber With Mask ………………………………………………… 63

6.2.3 Chamber With Mouthpiece ………………………………..…..……. 66

6.3 Maintenance

6.3.1 BI Tube ……………………………………………………………..… 69

6.3.2 Chamber With Mask Or Mouthpiece ………………………………. 69

6.4 References …………………………………………………………………….. 71

7 PEAK FLOW METER

7.1 Introduction ………………………………………………………………….… 72

a) A "Normal" Peak Flow Rate …………………………………………...…… 72

b) Measuring Reversibility Of Airflow Obstruction ………………………...... 73

c) Determine A "Normal" Peak Flow Rate …………………………………… 73

7.2 Directions For Use ……………………………………………………………... 74

7.3 Maintenance …………………………………………………………………… 77

7.4 References …………………………………………………………………….. 78


ix

ABBREVIATIONS

BI Tube Boehringer Ingelheim Tube

BP British Pharmacopoeia

CFC Chlorofluorocarbon

COPD Chronic Pulmonary Airway Disease

LABA Long-acting beta-2 agonist

mcg Microgram

MDI Metered Dose Inhaler

PEFR Peak Expiratory Flow Rate

SABA Short-acting beta-2 agonist


x

INTRODUCTION Asthma and Chronic Obstructive Pulmonary Disease (COPD) can lead to chronic morbidity and mortality throughout the world and their prevalence has increased considerably over the past 20 years. Asthma is a chronic inflammatory disorder of the airways. Chronically inflamed airways are hyperresponsive; they become obstructed and airflow is limited (by bronchoconstriction, mucus plugs and increased inflammation) when airways are exposed to various risk factors.

COPD consists of chronic bronchitis and emphysema, two commonly co-existing diseases of the lungs in which the airways become narrowed. This leads to a limitation of the flow of air to and from the lungs causing shortness of breath. In contrast to asthma, the limitation of airflow is poorly reversible and usually gets progressively worse over time.

An inhaler or puffer is a medical device used for delivering medication into the body via the lungs. It is mainly used in the treatment of asthma and COPD. Recent studies have shown that incorrect inhaler technique prevent patients from receiving maximal benefits from medications. Poor medication delivery leads to reduced quality of life, more frequent and longer hospital stay and poor control of the symptoms of asthma such as wheeze, cough and breathlessness.

“Handling of Inhaler Devices: A Practical Guide for Pharmacists” is a collaborative effort involving pharmacists within the Ministry of Health from all states. This guidebook aims to provide pharmacists, prescribers and other health care professionals with standard inhaler techniques to assist patients.

http://en.wikipedia.org/wiki/Chronic_bronchitis

http://en.wikipedia.org/wiki/Emphysema

http://en.wikipedia.org/wiki/Airways

http://en.wikipedia.org/wiki/Shortness_of_breath

http://en.wikipedia.org/wiki/Asthma


1

METERED DOSE INHALER (MDI) 1.1 INTRODUCTION

An inhaler is a medical device that administers medication to the lungs in an aerosolised form for the measurement of asthma, chronic obstructive pulmonary disease (COPD) and other respiratory conditions. The most commonly used type of inhaler is the metered dose inhaler (MDI). This type of inhaler consists of a small canister that holds the medicine. The medicine is administered in a metered dose, which saves the users from having to measure their dosage. MDIs are used to administer bronchodilators, anticholinergics and steroids. A MDI consists of 2 major components: the canister and an actuator (or mouthpiece). The canister itself consists of a metering dose valve with an actuating stem. The formulation resides within the canister and is made up of the drug, a liquefied gas propellant and, in many cases, stabilising excipient. The actuator contains the mating discharge nozzle and generally includes a dust cap to prevent contamination.

Picture 1: Cross Section of a Metered Dose Inhaler.


2

Note: May use both hands for patients with difficulty in handling the device.

1.2 DIRECTIONS FOR USE

STEP 1:

Remove the mouthpiece cover. Remain standing or seated upright to obtain the full dose of each actuation.

STEP 2:

Hold the inhaler in an upright position as shown in diagram.


3

Note: Each shake constitute from top to bottom, back to top again.

STEP 3:

Shake the MDI 3 - 5 times in an up-down motion before each puff to mix the contents of the canister. If the device is being used for the first time, prime it by actuating the canister mid-air until an even spray is obtained.

STEP 4:

Exhale slowly and completely through your mouth before holding your breath.

DO NOT exhale into the mouthpiece.

3-5X


4

STEP 5:

Device should be held at an upright position. Insert into mouth with no obstruction to the mouthpiece with the head slightly tilted. DO NOT bite the mouthpiece.


5

Note: Ability to hold breath for less than 4 seconds, consider use of a spacer. No extra benefit for holding breath more than 10 seconds.

STEP 6:

Begin inhaling slowly through the mouth (NOT nose) (1) and simultaneously actuate the MDI ONCE (2). Continue inhalation for about 3-5 seconds until the lungs are full (3).

STEP 7:

Hold breath for 4-10 seconds.

It is recommended to leave the inhaler in the mouth while holding breath.

2

1

3


6

STEP 8:

Remove inhaler (1) from mouth and exhale slowly (2).

STEP 9:

Wait 30 seconds to 1 minute before repeating step 3-8 if subsequent doses are required.

STEP 10:

Close cap and keep the inhaler in a dry place.

1

2

Note: 1. Patients should be advised to gargle with water after using certain types of MDIs

e.g. Anticholinergics and Inhaled Corticosteroids (ICS). 2. If on two types of inhalers (steroid & bronchodilator), it is recommended to use

the bronchodilator first and wait for 5 minutes before using the steroid.


7

1.3 MAINTENANCE

} It is important to keep the device clean to: ◦ Prevent medication accumulation. ◦ Prevent blockage over the nozzle.

} Clean the plastic mouthpiece only, NOT the metal canister.

} Clean at least ONCE A WEEK.

} For inhalers that are not used for more than 2 weeks, it should be primed before use.

STEP 1:

Remove the mouthpiece cover and canister from the actuation body.

DO NOT use detergent or soap.


8

STEP 2:

Wash the actuator from the top with running tap water for 30 seconds.

Repeat by running tap water through the mouthpiece of the actuator for 30 seconds.

STEP 3:

Let the actuator dry overnight after shaking off as much water as possible.

Note: If the patient needs to use the MDI during exacerbation, shake the actuator dry and then actuate twice away from face to ensure no blockage. The inhaler is ready for use.


9

Blocked nozzle

Clean nozzle

STEP 4:

When the actuator has dried, assemble the canister to the actuator body. Ensure a tight fit.

Shake the device well and actuate twice away from face to ensure no blockage.

Replace the cap and store the device safely before the next use.

1.4 DETERMINING CONTENTS OF AN MDI CANISTER

} It is hard to determine the remaining contents of the MDI.

} The floating/immersion technique is no longer endorsed by a panel of experts.

Keep a spare one. The shaking method can be done to estimate the remaining contents of the MDI canister but it does not reflect the actual content of the canister.


10

1.5 SUMMARY OF METERED DOSE INHALERS

INHALER/PROPELLANT/ PACKAGING

STRENGTH PER PUFF

(MCG) GROUP

DAILY DOSE ADVERSE EFFECT REMARKS

MINIMUM MAXIMUM

SALBUTAMOL BP

(ASTHALIN®) 400 doses

100

Adult and children

100 - 200 mcg

2400 mcg

1. Slight tremor (particularly in the

hands) 2. Headache 3. Peripheral dilatation 4. Palpitations 5. Tachycardia 6. Arrhythmias 7. Disturbances of sleep and

behavior in children 8. Muscle cramps 9. Hypersensitivity reactions

including paradoxical bronchospasm, urticaria, angioedema, hypotension, pulmonary oedema, erythema multiforme

Short-acting beta-agonist (SABA)

Exercise induced bronchospasm

200 mcg 15 minutes before

exercise

Acute exacerbation

400 mcg every

10 minutes

2400 mcg


11


STRENGTH PER PUFF

(MCG) GROUP

DAILY DOSE ADVERSE EFFECT REMARK

MINIMUM MAXIMUM

IPRATROPIUM BROMIDE (ATROVENT®)/200 doses

20

Adult and children ≥ 6 years

60 mcg

240 mcg

1. Gastrointestinal motility disorders (e.g.

constipation, diarrhea, vomiting) 2. Dryness of the mouth 3. Increased heart rate, palpitations,

supraventricular tachycardia, atrial fibrillation

4. Urinary retention 5. Cough 6. Local irritation 7. Mydriasis 8. Increased intraocular pressure,

narrow-angle glaucoma, eye-pain 9. Skin rashes or urticaria 10. Pruritus 11. Angio-edema of the tongue, lips and

face 12. Laryngospasm

Anticholinergic

Children < 6 years

60 mcg

IPRATROPIUM BROMIDE

MONOHYDRATE & SALBUTAMOL SULPHATE (COMBIVENT®)/200 doses

21/120

Adult

42/240 mcg

252/1440

mcg

1. Headache or dizziness 2. Nervousness, tachycardia, fine tremor

or palpitations 3. Dryness of mouth 4. Dysphonia 5. Ocular complications 6. Allergic type reactions

Anticholinergic and short acting beta-agonist (SABA)


12


STRENGTH PER PUFF

(MCG) GROUP


MINIMUM MAXIMUM

BUDESONIDE/300 doses

200

Adult

200 mcg

1600 mcg

1. Mild irritation of the throat and thirst 2. Candidiasis of the mouth and throat 3. Cough 4. Generally reversible hoarseness of

the voice 5. Bad taste and dryness of the throat 6. Paradoxical bronchoconstriction 7. Headache 8. Nausea 9. Tiredness 10. Diarrhea 11. Skin reaction 12. Osteoporosis For Beclomethasone dipropionate only: 1. Secondary hypocortisolism 2. Cataract 3. Glaucoma

Glucocorticoid

C/hildren 2 – 7years > 7 years

200 mcg 200 mcg

400 mcg 800 mcg

BECLOMETHASONE

DIPROPIONATE (BECLAZONE®)/200 doses

100

Adult

300 mcg

800 mcg

Children > 6 years

100 mcg

400 mcg


13


STRENGTH PER PUFF

(MCG) GROUP


MINIMUM MAXIMUM

CICLESONIDE (ALVESCO®)/

60 doses

160

Adult

160 mcg

320 mcg

Side effects are similar with Budesonide PLUS: 1. Epistaxis 2. Nasopharyngitis 3. Bruising 4. Cataracts 5. Glaucoma

Glucocorticoid

FLUTICASONE PROPIONATE

(FLIXOTIDE®)/120 doses

125

Adult

100 mcg

2000 mcg

1. Mouth and throat candidiasis 2. Hoarseness (patients are advised to

gargle after using the medication) 3. Paradoxical bronchospasm 4. Cutaneous hypersensitivity reactions 5. Headache 6. Giddiness or dizziness 7. Sleep disorders 8. Migraine 9. Paralysis of cranial nerves 10. Mood disorders

Children 4 -11years

100 mcg

200 mcg


14


STRENGTH PER PUFF

(MCG) GROUP


MINIMUM MAXIMUM

FLUTICASONE PROPIONATE

& SALMETEROL XINAFOATE (SERETIDE® EVOHALER®)/

120 doses

25/50 25/125 25/250

Adult and children ≥ 4 years

25 mcg (1 puff

Salmeterol alone)

50 mcg (2 puffs

Salmeterol alone)

1. Transient tremor 2. Subjective palpitations and

headache 3. Cardiac arrhythmias (atrial

fibrillation, supraventricular tachycardia and extrasystoles)

4. Athralgia 5. Hypersensitivity reactions such as

rash, edema and angioedema 6. Side effects for fluticasone are

similar with Flixotide®

Glucocorticoid and long acting beta-agonist (LABA)


15

1.6 REFERENCES

1. Clark AR. MDIs: physics of aerosol formation. J Aerosol Med 1996; 9 Suppl: S19–S26.

2. Fink JB. Metered-dose inhalers, dry powder inhalers and transitions. Respir Care 2000; 45(6):623–635.

3. Dolovich MB, Fink JB. Aerosols and devices. Respir Care Clin N Am 2001; 7(2):131–173.

4. Tomlinson HS, Corlett SA, Allen MB, Chrystyn H. Assessment of different methods of inhalation from salbutamol metered dose inhalers by urinary drug excretion and methacholine challenge. Br J Clin Pharmaco 2005, 60:6 605–610.

5. Fink JB, Rubin BK. Problems with Inhaler Use: A Call for Improved Clinician and Patient Education. Respir Care 2005; 50(10):1360 –1374.

6. Hesselink AE et al. Determinants of an Incorrect Inhalation Technique in Patients with Asthma or COPD. Scand J Prim Health Care 2001; 19:255–260.

7. Basheer YK et al. Handling of inhaler Devices in Actual Pulmonary Practice: Metered-Dose Inhaler Versus Dry Powder Inhalers. Respir Care 2008; 53(3):324 –328.

8. Wanda HTH et al. Assessment of Inhalation Technique in Children in General Practice: Increased Risk of Incorrect Performance with New Device. Journal of Asthma 2008, 45:67–71.

9. Fink JB, Rubin BK. Problems with Inhaler Use: A Call for Improved Clinician and Patient Education. Respir Care 2005; 50(10):1360 –1374.

10. David A. Warrell, Timothy M. Cox, John D. Firth, Edward J. Benz. Oxford Textbook of Medicine 4th Edition. Oxford University Press, 2005; p1305.

11. http://en.wikipedia.org/wiki/Inhaler. 2009

http://en.wikipedia.org/wiki/Inhaler. 2009


16

2. TURBUHALER® 2.1 INTRODUCTION Turbuhaler® is an easy-to-use, multiple-dose, inspiratory flow-driven dry powder inhaler. Currently there are 4 types of Turbuhaler® which are Budesonide (Pulmicort®), combination of Budesonide/Formoterol (Symbicort®), Formoterol (Oxis®) and Terbutaline (Bricanyl®).

Picture 1: Turbuhaler® (Adapted from

http://www.astrazeneca.ca/documents/ProductPortfolio/SYMBICORT_CIL_en.pdf)

Picture 2: Different types of Turbuhaler® (Adapted from

http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-the-basics)

http://www.astrazeneca.ca/documents/ProductPortfolio/SYMBICORT_CIL_en.pdf

http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-the-basics


17


A. Preparing a new Turbuhaler® (Priming):

STEP 1:

Unscrew and lift off the cover.

STEP 2:

Hold the Turbuhaler® upright with the grip facing downwards.

Turn the grip as far as it will go and then turn it back as far as it will go in the opposite direction until a “CLICK” sound is heard.

Perform this procedure TWICE.

“CLICK”


18

B. Used Turbuhaler®

STEP 1:

Unscrew and lift off the cover.

STEP 2:

Hold the Turbuhaler® upright with the grip facing downwards.

DO NOT hold the mouthpiece when turning the grip.


19

STEP 3: To load the Turbuhaler® with a dose, turn the grip as far as it will go in one direction as shown in the diagram.

STEP 4:

Then turn it back again as far as it will go in the opposite direction until a “CLICK” sound is heard.

The Turbuhaler® is now loaded with the desired dose and is ready for use.

“CLICK”

Note: If the turbuhaler is accidentally dropped, a new dose should be loaded and inhaled.


20

STEP 5: Breathe out away from the mouthpiece.

STEP 6:

Place the mouthpiece gently between the lips.

Ensure a tight seal around it as in diagram.


21

STEP 7:

Breathe in forcefully and deeply through the mouth only.

STEP 8:

Remove the Turbuhaler® from the mouth before breathing out again.

DO NOT breathe into the mouthpiece.

Note: Holding breath after inhalation is optional.


22

STEP 9:

Repeat step 2 - 8 if more than one dose is required.

STEP 10:

Replace the cover and store Turbuhaler® in a dry place.

Note: 1. Patients should be advised to gargle with water after using steroid containing

Turbuhalers®. 2. If on two types of Turbuhalers® (steroid & bronchodilator), it is recommended to

use the bronchodilator first and wait for 5 minutes before using the steroid.


23

2.3 MAINTENANCE

2.4 HOW TO KNOW WHEN THE TURBUHALER® IS EMPTY?

Picture 3: Shows how many doses are left (Adapted from: http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-the-basics/)

Turbuhaler® has a dose indicator that shows how many doses are left in the inhaler. It moves slowly when each time a dose is loaded.

For example, Budesonide/Formoterol (Symbicort®) Turbuhaler® dose indicator marks every 10th dose, and every 20th dose is displayed numerically. When the red colour first appears in dose indicator, it shows that there are only 20 doses left.

1. Clean the outside of the mouthpiece once a week with a dry cloth or tissue.

2. Never use water or any other fluid when cleaning the mouthpiece.

http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-the-basics/


24

Terbutaline (Bricanyl®), Budesonide (Pulmicort®) and Formoterol (Oxis®)Turbuhaler® dose indicators are not displayed numerically. When the red colour first appears in dose indicator, it shows that there are only 20 doses left.

The Turbuhaler® can be safely disposed off when the dose indicator window has turned red completely. The sound heard when the device is shaken is produced by a drying agent, and not the medication. Turbuhaler® cannot be re-filled with drug and should be discarded. 2.5 DETERMINING THE FUNCTIONALITY OF THE DEVICE WHEN IN DOUBT

Picture 4: Determining the functionality of the device when in doubt (Adapted from: http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-function-and-use/)

Turbuhaler® makes no sound when the drug is released. Moreover, since the amount of drug delivered by Turbuhaler® is small, there is either no or only a faint taste in the mouth when the drug is delivered. This can, in some cases, lead to patients being uncertain as to whether they have received the required dose. The correct functionality of the Turbuhaler® can easily be checked by inhaling through a piece of dark cloth.

Drug Dark cloth

http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-function-and-use/


25

2.6 SUMMARY OF TURBUHALER®

INHALER/PACKAGING

STRENGTH PER

INHALATION (MCG)

GROUP DAILY DOSE

ADVERSE EFFECT REMARK MINIMUM MAXIMUM

TERBUTALINE (BRICANYL®)/

200 doses

500

Adult

500 mcg

6000 mcg

1. Mouth & throat irritation 2. Cardiac arrhythmias 3. Headache 4. Fine skeletal muscle tremor 5. Paradoxical bronchospasm 6. Potentially severe

hypokalemia

*Use with caution in patient with hyperthyroidism *Monitor potassium level in acute severe asthma

Short-acting beta-agonist (SABA)

Children 3 -12 years

500 mcg

4000 mcg

FORMOTEROL (OXIS®)/

4.5 mcg/60 doses 9 mcg/60 doses

4.5

Adult

4. 5 - 9 mcg

54 mcg

Long-acting beta-agonist (LABA)

Children > 6 years

18 mcg

9

Adult

9 mcg

54 mcg

Children > 6 years

18 mcg


26

INHALER/PACKAGING

STRENGTH PER

INHALATION (MCG)

GROUP DAILY DOSE


BUDESONIDE & FORMOTEROL

(SYMBICORT®)/ 160/4.5 mcg/60 doses 160/4.5mcg/120 doses

160/4.5

Adult

160 / 4.5

mcg

1920 / 54

mcg

1. Palpitation 2. Candida infection in the

oropharynx 3. Mild irritation of the throat 4. Headache 5. Tremor 6. Coughing 7. Reversible hoarseness of

the voice 8. Side effects for Formoterol

are similar with Oxis®

Combination of glucocorticoid and long-acting beta-agonist (LABA)

Aldolescents Reliever therapy: 1 inhalation as needed in response to symptoms Max daily dose including reliever therapy: 12 inhalations

BUDESONIDE (PULMICORT®)

100mcg/200 doses & 200 mcg/100 doses

100

Or

200

Adult

200 - 1600

mcg

1600 mcg

Glucocorticoid

Children > 7 years

200 - 800

mcg

800 mcg

Children 2 - 7 years

200 - 400

mcg

400 mcg


27

2.7 REFERENCES

1. AZ-AIR. Part III: Consumer information on Symbicort® Turbuhaler®

[monograph on the internet]. Mississauga, Ontario: AstraZeneca Canada Inc; 2009 [cited 2009 May 26]. Available from: http://www.astrazeneca.ca/documents/Product Portfolio/SYMBICORT_CIL_en.pdf

2. AZ-AIR. Turbuhaler – the basics [homepage on the internet]. AstraZeneca Inc; 2008 [cited 2009 August 23]. Available from: http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-the-basics/

3. AZ-AIR. Turbuhaler function and use [homepage on the internet]. AstraZeneca Inc; 2008 [cited 2009 May 26]. Available from: http://www.az-air.com/respiratory-products/turbuhaler/turbuhaler-function-and-use/

4. Editorial development by CMPMedica. MIMS:Disease Management Guide to Asthma. Petaling Jaya: United Medica Sdn. Bhd; 2008.

5. Spier S, Robert LT. Inhalation therapy for the asthmatic child. The Canadian Journal of Pediatrics.1991 December.








28

3. EASYHALER® 3.1 INTRODUCTION The Easyhaler® is a new generation, multidose dry powder inhaler preloaded with 200 doses of asthma medications. Easyhaler® has been designed to resemble a MDI in terms of the small size of the device, but importantly avoids the need to coordinate drug release and inhalation. The Easyhaler® product range currently includes four products; anti-inflammatory inhaled corticosteroids Budesonide (Giona®) Easyhaler® and Beclomethasone (Beclomet®) Easyhaler® as well as bronchodilators Formeterol Easyhaler® and Salbutamol (Buventol®) Easyhaler®. Salbutamol via Easyhaler® is at least as effective as salbutamol via Turbuhaler® in the treatment of histamine-induced bronchoconstriction (Zetterstrom et al. 2000). The efficacy via Easyhaler® is unaffected by low inspiratory flow.

Picture 1: Easyhaler® (Adapted from http://www.medscape.com/viewarticle/531818_3)

http://www.medscape.com/viewarticle/531818_3


29

Picture 2: Different types of Easyhaler® (Adapted from http://www.orion.fi/en/Products-and-services/Human-prescription-medicines/Proprietary-

products-portfolio/Easyhaler/)

http://www.orion.fi/en/Products-and-services/Human-prescription-medicines/Proprietary-products-portfolio/Easyhaler/



30


A. Preparing the powder inhaler for first use

STEP 1: Remove the powder inhaler from the laminated pouch.

STEP 2:

Insert the powder inhaler into the protective cover.

The dust cap on the mouthpiece prevents accidental actuation of the inhaler when inserting it into the protective cover.

Protective cover

Dust cap


31

B. Delivering the medication

STEP 1: Remove the dust cap.

STEP 2:

Shake the device prior to each dose

After shaking, hold the device in the upright position.


32

STEP 3: Press the device only ONCE between the thumb and forefinger until a “CLICK” sound is heard.

Keep holding the device in the upright position.

STEP 4:

Breathe out normally, away from the mouthpiece.

“CLICK”

Note: If more than one dose is accidentally released, remove the dose from the mouthpiece by tapping it against the palm of the hand.


33

STEP 5: Place the mouthpiece between lips and close tightly around the mouthpiece.


STEP 6:

Remove the inhaler from mouth and hold breath for 5-10 seconds.


34

STEP 7: Repeat step 2-6 if more than one dose is required.

STEP 8: Put the dust cap back on the mouthpiece.

Store Easyhaler® in a dry place.

Note: 1. Patients should be advised to gargle with water after using steroid containing

Easyhalers®. 2. If on two types of Easyhalers® (steroid & bronchodilator), it is recommended to

use the bronchodilator first and wait for 5 minutes before using the steroid.


35

3.3 MAINTENANCE

3.4 HOW DO YOU KNOW WHEN YOUR EASYHALER® IS EMPTY?

Picture 3: Identification Easyhaler® is empty (Adapted from http://www.medasverige.se/vardpersonal/astma_allergi_och_kol/bilder/easyhaler)

Easyhaler® has a dose counter which indicates the number of remaining doses. The counter turns after every five actuations. When the counter turns red there are 20 doses left. A clear window on the back of the inhaler allows viewing of the powder. The device must be replaced when the dose counter indicates zero.

1. The mouthpiece can be cleaned with a dry cloth or tissue.

2. Never use water or any other fluid

when cleaning the mouthpiece. 3. Inhalation powder should not be

exposed to humidity. If the powder becomes damp, it is not suitable for use and should be disposed of.

http://www.medasverige.se/vardpersonal/astma_allergi_och_kol/bilder/easyhaler


36

3.5 SUMMARY OF EASYHALER®

INHALER/PACKAGING

STRENGTH PER

INHALATION (MCG)

GROUP DAILY DOSE


SALBUTAMOL (BUVENTOL®)/

200 doses

200

Adult

200 - 400

mcg

2400 mcg

Common

1. Tremor 2. Palpitation 3. Headache

Infrequent

1. Hyperglycaemia (high dose) 2. Tachycardia 3. Muscle cramps 4. Agitation 5. Hyperactivity in children 6. Insomnia

Rare

1. Paradoxical bronchospasm 2. Allergic reactions including

urticaria and angioedema

Short-acting beta-agonist (SABA) Use with caution in patient with hyperthyroidism Monitor potassium level in acute severe asthma


200 mcg

1200 mcg


37

INHALER/PACKAGING

STRENGTH PER

INHALATION (MCG)

GROUP

DAILY DOSE


BUDESONIDE (GIONA®)/

200 doses

200

Adult

200 mcg

1600 mcg

Common

1. Dysphonia 2. Oropharyngeal candidiasis 3. Bruishing

Rare

1. Allergic reactions Others (if used in high doses)

1. Adrenal impairment 2. Bone density loss 3. Glaucoma 4. Cataract 5. Skin thinning 6. Bruising 7. Impaired growth

Glucocorticoid


200 mcg

800 mcg

BECLOMETHASONE

(BECLOMET®)/ 200 doses

200

Adult

200 mcg

1600 mcg


200 mcg

800 mcg


38

3.6 REFERENCES

1. Asthma, Allergy and KOL [homepage on the internet] [cited 2009 Sept 2]. Available from: http://www. medasverige. se/ vardpersonal/ astma_allergi_ och_ kol/bilder/easyhaler.

2. Buventol Easyhaler® [Package Insert]. Findland: Orion Corporation. 3. Medscape [homepage on the internet]. Closer to an 'Ideal Inhaler' With the

Easyhaler: Patient Use Inspiration Rate. 2005 [cited 2009 Sept 2];[about 6 screens]. Available from: http://www.medscape.com/viewarticle/531818_3.

4. Orion’s Portfolio of Medicines/Easyhaler. Orion Corporation [homepage on the internet]. 2009 [cited 2009 Sept 2]. Available from: http: //www.orion.fi/en/Products-and-services/Human-prescription-medicines/ Proprietary-products-portfolio/Easyhaler/.

5. Zetterstrom et al. Respiratory Medicine 2000. Nov;94(11):1097-1102. 6. Easyhaler Multidose Dry Powder Inhaler Monograph. 2008 Orion

Corporation

http://www.medscape.com/viewarticle/531818_3





39

4. ACCUHALER® 4.1 INTRODUCTION

The combination of Salmeterol and Fluticasone Propionate (Seretide®) Accuhaler® is a moulded plastic inhaler device containing a foil strip with 60 blisters. Each blister contains lactose as a carrier. The blisters protect the inhalation powder from the effects of the atmosphere.

Picture 1: Cross Section of Accuhaler®.

Mouthpiece

Lever

Thumb grip

Dose counter

Outer case


40


Check that the dose counter read 60, indicating the full number of doses.

STEP 1: Hold the outer case in one hand and put the thumb of the other hand on the thumb grip to open the Seretide® Accuhaler®.

Push the thumb grip as far as it will go until a “CLICK” sound is heard.

STEP 2:

Hold the device horizontally with the mouthpiece towards the patient.

Slide the lever as far as it will go as in diagram until another “CLICK” sound is heard to load a dose in the device.

Note: Never hold the inhaler with the mouthpiece pointing downwards during or after loading a dose, as the medication can be dislodged. Always keep it horizontal.

“CLICK”

“CLICK”


41

STEP 3: Hold the Accuhaler® away from mouth and breathe out completely.

DO NOT breathe into the device.

STEP 4:

Put the mouthpiece into the mouth and ensure a good seal.


STEP 5: Remove the Accuhaler® from the mouth and hold breath for 10 seconds or as long as possible.

DO NOT breathe into the mouthpiece.


42

4.3 MAINTENANCE

1. Wipe the mouthpiece of the Seretide® Accuhaler® with a dry cloth or tissue to

clean it. 2. The Accuhaler® is recommended to be cleaned at least ONCE A WEEK.

3. The content of the device is susceptible to moisture. For this reason keep it in a

dry place away from humidity.

STEP 6:

Close the device by sliding the thumb grip back to its original position until a “CLICK” sound is heard.

The lever will return to its original position and will be reset.

STEP 7: Repeat step 1-6 if more than one dose is required.

Note: 1. Patients should be advised to gargle with water after using the Seretide®

Accuhaler®

2. Number 5 to 1 appear RED to warn that there are only a few doses left.

“CLICK”


43

4.4 SUMMARY OF ACCUHALER®

INHALER/PACKAGING

STRENGTH PER

INHALATION (MCG)

GROUP DAILY DOSE


SALMETEROL & FLUTICASONE

PROPIONATE (SERETIDE®)/ 60 doses

50/100* 50/250 50/500

Adult and adolescents (> 12 years)

1 inhalation (50/100) *

OR

1 inhalation

(50/250)

OR

1 inhalation (50/500)

2 inhalations (50/100) *

OR

2 inhalations

(50/250)

OR

2 inhalations (50/500)

1. ß2-agonist treatment side effects

like tremor, palpitations, cardiac arrhythmias etc.

2. Arthralgia 3. Hypersensitive reactions like

rash, oedema and angioedema 4. Hoarseness and candidiasis of

the mouth 5. Possible systemic steroid effects

like Cushing’s syndrome and adrenal suppression

Combination of glucocorticoid and long-acting beta-agonist (LABA)

*Not available in MOH Drug Formulary (updated November 2009)

Children > 4 years

1 inhalation (50/100) *

2 inhalations (50/100) *


44

4.5 REFERENCES

1. Chrystyn H. The Diskus™: a review of its position among dry powder inhaler devices. Int J Clin Pract. 2007 Jun; 61(6): 1022–36.

2. Lavorini F, Magnan A, Dubus JC, Voshaar T, Corbetta L, Broeders M, et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respir Med. 2008; 102(4): 593–604.

3. Rau JL. Practical problems with aerosol therapy in COPD. Respir Care. 2006 Feb; 51 (2): 158–72.

4. Seretide™ Accuhaler™ [package insert]. Ware (UK): Glaxo Wellcome Operations; 2005.

5. Kesten S, Zive K, Chapman KR. Pharmacist knowledge and ability to use inhaled medication delivery systems. Chest 1993; 104(6): 1737-42.


45

5. HANDIHALER®

5.1 INTRODUCTION HandiHaler® is a device to deliver Tiotropium bromide (Spiriva®) into the lung. Tiotropium bromide (Spiriva®) comes in light green, hard gelatine capsule-containing powder form and contains 18 mcg tiotropium blended with lactose monohydrate as a carrier. Spiriva® capsules should not be swallowed and must be used with HandiHaler® device only.

Spiriva® is not a rescue medicine and should not be used for acute exacerbation.

Picture 1: Spiriva® capsules.

Picture 2: HandiHaler®.


46


STEP 1: Open the dust cap by pressing the green piercing button.

STEP 2: Pull the dust cap upwards to expose the mouthpiece.

Note: Some HandiHaler® devices may require the dust cap to be manually opened upwards.


47

STEP 3: Open the mouthpiece by pulling it upwards.

STEP 4: The blister cards are perforated in the middle. Tear the card along the perforation.

Note: 1. Store Spiriva® capsules in a dry place. 2. Keep away from extreme heat or moisture.


48

STEP 5: Carefully open the blister cavity by peeling back the aluminum foil until ONE capsule is fully visible. DO NOT exceed the STOP line.

STEP 6: Remove the capsule from the blister pack.

Note: In case a second capsule is exposed to air accidently, it has to be discarded. The capsule should be removed from the blister pack just before using it.

Note: DO NOT swallow the capsule.


49

STEP 7: Place the capsule in the centre of the chamber.

STEP 8: Close the mouthpiece firmly until a “CLICK” sound is heard.

“CLICK”


50

STEP 9: Hold the HandiHaler® device with the mouthpiece pointed upright. Press the green piercing button completely as shown in diagram before releasing it. This will make holes in the capsules to allow the medication to be delivered when inhaled.

STEP 10: Breathe out completely. DO NOT breathe into the mouthpiece.

1

2


51

STEP 11: Place the HandiHaler® horizontally to the mouth and close the lips tightly around the mouthpiece. Breathe in slowly and deeply at a rate sufficient to hear the CAPSULE VIBRATE.

STEP 12: Remove device from the mouth and hold breath for 5-10 seconds or as long as possible. Then resume normal breathing.

STEP 13: To ensure that all the medicine is inhaled, repeat step 10-12.


52

STEP 14: Open the mouthpiece and dispose the empty capsule into rubbish bin as in diagram.

STEP 15: Close the mouthpiece and dust cap for storage.


53

5.3 MAINTENANCE

STEP 1: Open the dust cap, mouthpiece and chamber as in diagram.

STEP 2: Rinse all parts with warm water to remove any powder. DO NOT use cleaning agents or detergents.


54

STEP 3: Dry the HandiHaler® thoroughly by shaking off the excess water and air-drying it.

STEP 4: It takes 24 hours to air dry, so clean it immediately after use.

Note: It is recommended to clean the device EVERY MONTH.


55

5.4 SUMMARY OF HANDIHALER®

INHALER/PACKAGING

STRENGTH PER

INHALATION (MCG)

GROUP DAILY DOSE ADVERSE EFFECT REMARK

TIOTROPIUM BROMIDE (SPIRIVA®)/

30 capsules

18

Adult *Use in children and adolescent under 18 years old is not recommended

18 mcg

1. Dryness of mouth or xerostomia 2. Upper respiratory infections 3. Sinusitis 4. Rash 5. Cataracts 6. Angioedema 7. Bitter or metallic taste 8. Tachycardia 9. Urinary retention 10. Angina pectoris 11. Hypercholesterolemia 12. Hyperglycemia

Long acting anticholinergic


56

5.5 REFERENCES

1. Hvizdos KM, Goa KL. Tiotropium bromide. Drugs 2002;62(8):1195-1203.

2. Van Noord JA, Bantje TA, Eland ME et al. A randomized controlled comparison of tiotropium and ipratropium in the treatment. Thorax 2000;55(4):289-94.

3. Vincken W, van Noord JA, Greefhorst APM et al. Improved health outcomes in patients with COPD during 1 years treatment with tiotropium. Eur Resp J 2002;19(2):209-16.

4. CCOHTA. Tiotropium: A potential replacement for ipratropium in patients with COPD. Issues in Emerging Health Technologies 2002;35:1-4

5. Donohue JF, van Noord JA, Bateman ED et al. A 6-month, placebo-controlled study comparing lung function and health status changes in COPD patients treated with tiotropium or salmeterol. Chest 2002;122(1):47-55.


57

6. SPACER DEVICES 6.1 INTRODUCTION A spacer is a device attached to a metered-dose inhaler that aids delivery of inhaled medications and to increase the effectiveness of a metered dose inhaler (MDI). A spacer is usually used for children and elderly patients who have poor coordination to MDI technique. The advantages of spacers are:

1. Eliminate the problem of hand-breath coordination. 2. Improve the delivery of medication and allows more medicine into the lungs. 3. Reduce throat irritation and/or fungal growth in the upper airways

(e.g. candidiasis, hoarseness and bad taste).

Picture 1: The advantages using MDI with Spacer devices (Adapted from http://trudellmed.com/_Content/PDFs/AC+Fv_StudySummary.pd)

http://trudellmed.com/_Content/PDFs/AC+Fv_StudySummary.pd


58

There are 2 types of spacer device, namely the extension tube (i.e. BI tube) and holding chamber (i.e. Chamber with mouthpiece & Chamber with mask).

a) BI Tube

b) Chamber with Mouthpiece

c) Chamber with Mask

Inhalation/ exhalation valve

Whistle

Cap

Mouthpiece

Body

Mouthpiece

MDI Adaptor Picture 2: BI Tube

Picture 3: Chamber with Mouthpiece (Adapted from http://trudellmed.com/Consumers/cn_aerochamber_wfv.asp)

Aerodynamic Chamber MDI Adaptor


59

Picture 5: Different types of chamber (Adapted from http://trudellmed.com/Consumers/cn_aerochamber_wfv.asp)


6.2.1 BI TUBE

MDI Adaptor

Aerodynamic Chamber Exhalation Valve

Mask

Inhalation Valve

Aerochamber Whistle

Picture 4: Chamber with Mask (Adapted from http://trudellmed.com/Consumers/cn_aerochamber_wfv.asp)

http://trudellmed.com/Consumers/cn_aerochamber_wfv.asp


60

STEP 1:

Remove the mouthpiece cover from the

metered dose inhaler (MDI).

STEP 2:

Attach the large end of the BI tube to

the mouthpiece of the MDI.

STEP 3:

Shake the MDI 5 times in an up-down

motion (as shown in diagram) before

use.


61

STEP 3:

Shake the MDI 5 times in an up-down

motion (as shown in diagram) before

use.

STEP 5:

Press the base of the canister (1) and

inhale the nebulised aerosol (2).

STEP 6:

Hold breath for 5-10 seconds.

STEP 4:

Exhale slowly and completely

through your mouth before holding

your breath.

DO NOT exhale into the BI tube.

1

2

Note: To prevent the spray from depositing on the tube, inhale immediately after pressing the canister.


62

STEP 8:

After use, remove the BI Tube and

replace the mouthpiece cover on the

MDI.

Note: The BI Tube may be left attached to the MDI.

STEP 7:

Wait 30 seconds to 1 minute before

repeating step 3-6 if subsequent doses

are required.


63

6.2.2 CHAMBER WITH MASK

STEP 1:

Visually check for foreign objects

before each use.

STEP 2:

Remove the mouthpiece cover from

the MDI.


64

STEP 3:

Insert the MDI into the adaptor of the

chamber.

STEP 5:

Apply mask to face and ensure that

there is a good seal.

STEP 4:

While holding the chamber with MDI

firmly, shake the MDI for 5 times in an

up-down motion (as in diagram).


65

STEP 6:

Press MDI ONCE at beginning of

normal breath.

Breathe normally between 5-10

breaths while holding the mask

firmly to your face.

STEP 7:

Slow down inhalation if the

WHISTLE sound is heard.

STEP 8:



66

6.2.3 CHAMBER WITH MOUTHPIECE

STEP 1:

Visually check for foreign objects

before each use.

STEP 2:

Remove the cap from the MDI and the

mouthpiece cover of the chamber.


67

STEP 3:

Insert the MDI into the adaptor of the

mouthpiece (1).

While holding the mouthpiece with

MDI firmly, shake the unit for 5 times

in an up-down motion as shown in

diagram (2).

STEP 4:

Put the mouthpiece in the mouth.

2

1


68

STEP 5:

Simultaneously press the MDI ONCE

(1) at the beginning of a slow and deep

inhalation (2).

Hold breath as long as possible,

between to 4-10 seconds before

breathing out through the nose.

STEP 6:

Slow down inhalation if a WHISTLE sound is heard.

STEP 7:


Note: 1. Alternatively, the mouthpiece may be kept tightly in the mouth. 2. Inhale slowly through the mouth and exhale through the nose for 5 times

after pressing the MDI.

1

2


69

6.3 MAINTENANCE

6.3.1 BI TUBE

• Wash the BI tube at least ONCE A MONTH with tap water and air dry.

• It is not recommended to wipe the BI tube dry after washing.

6.3.2 CHAMBER WITH MASK OR MOUTHPIECE

• It is recommended to clean ONCE A WEEK.

• Remove the backpiece only.

• DO NOT remove the mask or valve assembly.

• Soak both parts for 15 minutes in a mild solution of liquid dish detergent and warm clean water.

• Agitate gently.


70

• DO NOT rinse the chamber as shown, as this may lead to static build up.

• If concern about potential for contact dermatitis, rinse only the mouthpiece/mask portion in water.

• Shake out excess water and allow to air dry in a vertical position.

• DO NOT rub dry.

• To reassemble, centre the alignment feature on the back piece as shown.

Note: Cleaning of the product varies between the different variants of the AeroChamber®. Please refer to each individual product information leaflet.


71

6.4 REFERENCES

1. Boehringer Ingelheim. Product Leaflet: Instructions of Use for Metered Aerosol Inhaling Device.

2. Corner WT, Dolovich P and Newhouse MT. Reliable salbutamol adminitration in 6- to 36-month-old children by means of a metered dose inhaler and aerochamber with mask; Pediatric Pulmonary 1989; 6:263-267.

3. Dolovich P, Ruffin R and Newhouse MT. Clinical evaluation of a simple demand inhalation MDI aerosol delivery device. Chest 1983; 84:1.

4. Pedersen S. Spacer Devices. [updated 2003 May 21; cited 2009 May 15] Available from: http://www.ginasthma.com/download.asp?intld=107.

5. Spier S and Robert LT. Inhalation therapy for the asthmatic child. The Canadian

6. Journal of Pediatrics 1991. 7. Trudell Medical International. c1997-2009 [cited 2009 May]. AeroChamber

Plus* VHC with Flow-Vu* Inspiratory Flow Indicator. Available from:http://trudemed.com/Consumers/cn_aerochamber_wfv.asp.

8. Trudell Medical International; c 1997-2009 [cited 2009 May]. Study summary: Use of the AeroChamber Plus* Valved Holding Chamber with Flow-Vu* Inspiratory Flow Indicator. Available from: http://trudemed.com/_Content/PDFs?AC+Fv_StudySummary.pd


72

7. PEAK FLOW METER 7.1 INTRODUCTION

A peak flow meter is a small portable device with a measuring gauge. It measures the force and speed that air is blown out of the lungs. This measurement is referred to as the peak expiratory flow rate (PEFR). a) “NORMAL” PEAK FLOW RATE Normal peak flow rate is based on a person's age, height, sex and race. A personal best normal may be obtained from measuring the patient's own peak flow rate. Therefore, it is important that patients discuss with their health care provider on what is considered as “normal”. Once patients have learned their usual and expected peak flow rate, changes or trends of their disease condition can easily be recognised.

Marker

Holder Scales

Mouthpiece


73

b) MEASURING REVERSIBILITY OF AIRFLOW OBSTRUCTION To measure the degree of reversibility (usually increased in asthma) of airflow obstruction, perform peak flow meter measurement before and approximately 15 minutes after administering a bronchodilator by metered dose inhaler or nebuliser. Short acting Beta-2 agonists (e.g. salbutamol, terbutaline) are generally considered the benchmark bronchodilator. c) DETERMINE A “NORMAL” PEAK FLOW RATE Three zones of measurement are commonly used to interpret peak flow rates. In general, a normal peak flow rate can vary as much as 20 percent.

Green Zone (80-100% of patients’ usual or "normal" peak flow rate): This zone signals that patients’ asthma is under reasonably good control. It is advisable to continue the prescribed program or management. Yellow Zone (50-80% of patients’ usual or "normal" peak flow rate): This zone signals that more attention should be given to patients’ asthma program or management. Patients are advised to consult their healthcare provider to review their regimen.

Red Zone (<50% of patients’ usual or "normal" peak flow rate): This zone signals a medical alert. Immediate decisions and actions must be taken. Patients are advised to use their rescue medications right away and consult their healthcare provider immediately.

e.g:

Your Personal Best

peak flow meter

reading is:

You are in the

Green Zone if your peak flow meter reading is:

You are in the

Yellow Zone if your peak flow meter reading is

between:

You are in the

Red Zone if your peak flow meter reading is:

100 above 80 80 and 50 below 50

125 above 100 100 and 63 below 63

150 above 120 120 and 75 below 75

175 above 140 140 and 88 below 88


74


STEP 1: Place the mouthpiece on the peak flow meter.

STEP 2:

Reset the marker to the bottom of the scale (zero or the lowest number on the scale).

Note: Alternatively, the originally supplied plastic mouthpiece may be detached and replaced with a disposable mouthpiece.


75

STEP 3:

Hold the peak flow meter in the way that the scale and marker is not obstructed by the fingers of the patient (As shown in diagram).

STEP 4: Stand in an upright position and breathe in as deep as possible.


76

STEP 5: Place the peak flow meter in the mouth and maintain it horizontally, closing the lips around the mouthpiece. Make sure the opening of the mouthpiece is not blocked by the tongue.

STEP 6:

Blow as hard and fast as possible.

DO NOT tilt the head forward while blowing.


77

7.3 MAINTENANCE

Most peak flow meters need to be cleaned. Follow the cleaning instructions which are available when the unit is purchased.

Record this reading e.g.: 500L/min

STEP 7:

Record the measurement and reset the marker to its original position at the bottom of the scale.

STEP 8: Breathe normally and repeat step 2-7 two more times. Note down the date, time, and highest of the 3 peak flow measurements. DO NOT average the numbers.

Note: The highest of the 3 readings will be used to assess a patient’s PEFR.


78

7.4 REFERENCES

1. Radeos MS, Camargo CA. Predicted peak expiratory flow: differences across formulae in the literature. Am J Emerg Med. 2004 Nov; 22(7):516-21.

2. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. population. Am J Respir Crit Care Med. 1999 Jan;159(1):179-87

3. Bheekie A, Syce JA, Weinberg EG. Peak expiratory flow rate and symptom self-monitoring of asthma initiated from community pharmacies. J Clin Pharm Ther. 2001 Aug; 26(4):287-96.

4. Reddel HK, Marks GB, Jenkins CR. When can personal best peak flow be determined for asthma action plans?. Thorax. 2004 Nov; 59(11):922-4

5. Murata GH, Kapsner CO, Lium DJ, Busby HK. Patient compliance with peak flow monitoring in chronic obstructive pulmonary disease. Am J Med Sci. 1998 May; 315(5):296-301.

6. http://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_disease. 2009

http://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_disease


79

PHARMACEUTICAL COMPANIES

AstraZeneca Sdn Bhd

Boehringer Ingelheim (M) Sdn Bhd

Cipla Ltd

GlaxoSmithKline Pharmaceutical Sdn Bhd

Nycomed Division Diethelm (M) Sdn Bhd

Orion Pharma

Pharmaniaga Logistics Sdn Bhd

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