Respiratory inhalers

Description
Inhaler and nebulizer devices are used to deliver medication directly to the lungs in people who have respiratory conditions such as asthma, bronchitis and emphysema.
Various devices are available. The choice of inhaler or nebulizer will depend on the person's age, individual needs and ability to use the device. Instructions on how to properly use an inhaler and nebulizer, as well as information on medication used with these devices, are included below.


Purpose
Inhaled medications are used to control symptoms and manage certain respiratory conditions, such as asthma, bronchitis and emphysema. Since the medication goes directly to the lungs, it works more quickly than medications taken in pill form.

Indications
Respiratory inhalers and nebulizers are used to deliver medications either on a scheduled or "as-needed" basis, as prescribed by your doctor. Certain asthma medications help prevent and treat asthma attacks by reducing inflammation and spasms of the airways.

Inhalers
Metered-dose inhalers
A metered-dose inhaler (MDI) contains medication mixed with a propellant gas in a canister to create a pressurized aerosol. Each canister contains a certain number of doses, which are delivered as a spray when the inhaler device is activated.

Benefits of MDIs:

MDIs are small, portable and inexpensive.
When used properly, MDIs deliver medication quickly and effectively.
Some MDIs are breath-activated to release the medication when you inhale.
Risks of MDIs:

People commonly experience problems when first using MDIs. If your technique isn't correct, you won't receive a complete dose of medication and the relief won't be complete.

The propellant in MDIs is cold, which may irritate your throat and cause coughing. Also, some propellants don't work as well in cold climates. Talk with your doctor about any problems you're experiencing.
Spacers
Spacers are chambers connected to MDIs. The spacer holds the medication to allow more medication to be directed into the lungs. Spacers help coordinate the action of activating a metered-dose inhaler and breathing in the medication, often especially helpful for children and older adults. Spacers with face masks are available for babies.

Benefits of spacers:

Spacers allow people of all ages to use MDIs.
Spacers are effective at delivering medication to people who have severe asthma.
Risks of spacers:

Spacer valves can stick or become incompetent.
Spacers may be designed for use with specific products. Follow the instructions provided by the manufacturer or your doctor regarding the use of a spacer with your medication.
Dry-powder devices
Dry-powder devices create an aerosol when air flows through the device and then flows over powdered medication contained in a foil disk or capsule. Examples are turbuhaler, diskhalers, rotahalers and spinhalers.

Benefits of dry-powder devices:

These devices are breath-activated and easy to use.
Risks of dry-powder devices:

With a dry-powder device, you may need to inhale rapidly instead of the slow inhale technique required with a metered-dose inhaler.
Dry-powder inhalers do not contain propellants, which may make it difficult to detect the actual medication delivery.
The device needs to be positioned correctly during use to prevent spilling the medication.
Using your metered-dose inhaler
How you use your MDI can affect how well you receive and respond to the medication. If you use more than one inhaler, you need to understand what each medication does and when and how to use it in order for the medication to be effective. First, remember to read all instructions included with your medicine. All MDIs are not the same. Here are some general guidelines. (Instructions for using a spacer with your inhaler follow this section.)

Remove the cap from the mouthpiece, and shake the canister well. Hold the canister upright.

Stand or sit up straight, tilt your head slightly back, and exhale.

"Closed-mouth" method: Close your mouth around the inhaler mouthpiece. (Note that dry-powder inhalers are used differently. You must close your mouth tightly around the mouthpiece and breathe in very fast to activate the inhaler.)

"Open-mouth" method: Hold the inhaler 1 to 2 inches from your open mouth.

With both methods, press down on the canister once to start the medication spray at the beginning of the inhalation. This is a "puff." Inhale slowly, taking three to five seconds to fill your lungs as deeply as possible. (Correctly timing the puff with your inhalation is usually the most challenging technique to master.)

After you have taken as much air into your lungs as you can, hold your breath for another 10 seconds.

Exhale slowly through your nose.

If you normally take two puffs, wait a minute after the first spray before administering the second. By giving the first dose a chance to work, the second dose will penetrate more deeply into your airways and will be absorbed more completely into your lungs, especially for quick-relief medicines such as the beta-2 agonists.

If you've been prescribed a corticosteroid inhaler as well as a bronchodilator, use the bronchodilator first to open your lungs for the corticosteroid.

If you use a corticosteroid inhaler, rinse your mouth after inhaling to prevent fungal infections in your mouth. You may also want to use a spacer.

Only use your inhaler in the prescribed dose. If the prescribed dose is not working well for you, call your doctor.

Demonstrate your inhaler technique to your doctor periodically to be sure you are using it correctly.
If you use a spacer or spacer mask, keep these instructions in mind before using the inhaler:

Remove caps from both the spacer and the inhaler.
Shake the canister.
Attach the spacer and hold the device according to package instructions.
Exhale. Then, place the mouthpiece of the spacer in your mouth OR place the spacer mask over your nose and mouth.
Press the button on the canister once and inhale the medication.
Hold your breath for 10 seconds, then exhale. (Note: If your doctor recommends that you take more than one inhalation with each puff of the canister, be sure to hold your breath for 10 seconds with each inhalation.)
If you normally take two puffs, wait a minute to repeat the process before taking the next puff.
Inhaler mouthpieces should be washed in mild soapy water, rinsed and air-dried often (daily if used frequently). Spacers and spacer masks should be washed weekly in mild soapy water, rinsed and air-dried. Spacers are usually replaced every six months.

After long-term use of inhaled steroids, some people develop thrush (a fungal infection of the mouth). If you notice thrush, call your doctor for treatment. To reduce the risk of thrush, your doctor may instruct you to rinse your mouth after using the inhaler.

Considerations
Generally, MDIs are not appropriate for children under age 5 or elderly adults with impaired dexterity or coordination problems. If the MDI is used with a spacer mask, however, children ages 2 to 4 may be able to use it.

If you use an MDI or a spacer and aren't achieving enough bronchodilation from a beta-agonist medication, a nebulizer may be an option.

It's important to count the number of doses used and compare this with the total number of doses listed on the canister label. This way you can avoid running out of medication or receiving a puff with no medication. If you use your inhaler(s) on a scheduled basis, it's a good idea to calculate when you'll run out. Mark this on your calendar to remind you to get a refill.

Notify your doctor if you develop throat irritation, thrush, increased coughing, wheezing or shortness of breath.


Nebulizers
A nebulizer is a device that changes liquid medicine into a fine mist by using a jet of air created by a special type of electric or battery-operated air compressor. The compressor forces a jet of air across a chamber that contains medicine, which is breathed in through mouthpiece or face mask. Nebulizers are often used by children under age 5, by people of all ages who can't use MDIs, or when people have a moderate to severe worsening of their symptoms.
Benefits of nebulizers:

Nebulizers are a good option for young children or those who have difficulty using MDIs to receive inhaled medication.
Nebulizers allow for more medication to enter the lungs than an inhaler.
Risks of nebulizers:
The air compressor is bulky and needs a power source.
A nebulizer that hasn't been cleaned properly could lead to infection or machine malfunction.
Using your nebulizer
Some medications come premixed and ready for use in the nebulizer. Others require adding saline solution to the medication. First, remember to read all instructions included with your medication and the nebulizer. Here are some general guidelines.

Place the compressor on a hard surface and plug it in.

Place the prescribed amount of medication into the nebulizer using a dropper or syringe, or you may have a premixed vial of medication. Be sure to keep the medication upright at all times. Attach the nebulizer to the compressor tubing, then attach the mouthpiece or mask to the nebulizer.

If using a mouthpiece, put it in your mouth and place your lips tightly around it.
If using a mask, place it on your face and make sure it's snug against the nose, cheeks and chin.

Turn the power on. Breath in slowly and deeply through the mouth. Hold each breath for one to two seconds before breathing out. Be certain to keep the medication cup upright at all times. Continue until all the medication is gone and the nebulizer makes a constant sputtering noise (approximately 10 minutes).

Remove the mouthpiece or mask. Turn the power off.

Clean the equipment according to manufacturer's recommendations. Thorough cleaning is essential to prevent infection and ensure the device is in proper working order.

Types of inhaled medication
It's important to understand the difference between short-acting (quick-relief or rescue) medications and long-acting (preventive or controller) medications.
Short-acting (quick-relief/rescue) bronchodilators
Short-acting (quick-relief) bronchodilators, also known as short-acting beta-2 agonists, relieve sudden asthma attacks. These medications relax the muscles around the airway to prevent or reverse airway narrowing. They are used at the first sign of an asthma attack.

Examples of short-acting bronchodilators include albuterol (brand names Proventil or Ventolin), bitolterol (Tornalate), metaproterenol (Alupent), pirbuterol (Maxair) and terbutaline (Brethaire).

Preventive or controller medications
Long-acting bronchodilators, also known as long-acting beta-2 agonists, control symptoms by decreasing inflammation and narrowing of the airways. These medications are not used to treat acute attacks. Salmeterol (Serevent) is an example.

Anti-inflammatories help reduce airway inflammation and prevent asthma attacks. Anti-inflammatories must be taken on a regular basis to be effective in preventing or decreasing the number of asthma attacks, even if you don't have symptoms. They are not used to treat an acute asthma attack.

Anti-inflammatory inhalers may be either corticosteroids or the anti-inflammatory medicines cromolyn (Intal) and nedocromil (Tilade). Examples of inhaled steroids include beclomethasone (Vanceril or Beclovent), flunisolide (AeroBid), triamcinolone (Azmacort), fluticasone (Flovent) or budesonide (Pulmicort).

Some people have concerns about taking steroids of any type, but remember that an inhaled steroid gets the medicine to the lungs, right where it's needed. Only a small amount of the steroid reaches the rest of your body. (Oral steroids may be used in more severe cases when an inhaled steroid is not powerful enough.)

Anticholinergic bronchodilators help dilate the airways in the lungs. When used to treat an airway disease, the anticholinergic bronchodilator, such as ipratropium bromide (Atrovent), is taken immediately after a dose of a long-acting beta-2 agonist. Currently, Atrovent is approved for the treatment of bronchitis and emphysema. Atrovent can also be used for severe asthma attacks in combination with a short-acting bronchodilator. Combination MDI devices may have both an anticholinergic and a beta-2 agonist medication.