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Inhaler Therapy

Patrick Barney

Inhaler therapy

  • Current inhaler device delivery options

    • MDI – typical handheld inhaler

      • Pro is same dose of medicine each time you use them – if used correctly.

      • Con is that it requires coordination. Patient must be able to time 3-5s slow inhalation and 5-10s breath hold w/ release of medicine, can be helped w/ spacer.

    • SMI – “soft mist inhaler,” handheld. Creates cloud of medicine that is inhaled without propellant.

      • Pros are more medicine gets into lungs than w/ MDI so lower dose can be used, does not require coordination.
    • DPI - handheld inhaler, delivers medicine whenever patient breathes in through the device, requiring less coordination.

      • Pro is lack of need to coordinate breath; Con is inconsistent dose delivery.
  • Nebulizers

    • Saline

      • Hypertonic saline, NS, 3% and 7%. Can be used to thin secretions and produce deep cough in patients who need to expectorate as part of treatment. For CF, chronic tracheostomy, NM weakness. No evidence for benefit in COPD.
    • Enzymatic Agents

      • Dornase alpha – Pulmozyme – “DNAse’ - enzyme that breaks down polymerized DNA in high concentrations in CF airways, indicated specifically for patients with CF
    • Anticholinergics

      • COPD exacerbation, asthma exacerbation – bronchodilation and secretion inhibition in acute setting

      • Ipratropium (Atrovent) intermittent nebulizer or Ipratropium-albuterol (Duo-Neb) intermittent or continuous nebulizer

    • Disulfide Disrupters

      • Sever disulfide bonds of glycoproteins in mucus, lowering its viscosity and making it more amenable to suction, expectoration

      • N-acetylcysteine (Mucomyst) - nebulized form available in “adult burn inhalation injury protocol” when search “mucomyst”

  • Antibiotics

    • May be indicated in patients w/ CF, non-CF bronchiectasis, VAP as salvage therapy

    • Tobramycin – only nebulized antibiotic available at VUMC

Categories of inhaled medications

  • Short-acting beta agonist (SABA): beta-2 agonism of bronchial smooth muscle to achieve bronchodilation; also decrease mast cell mediator release. Ex: albuterol, levalbuterol

  • Long-acting beta agonist (LABA): - beta-2 agonists, same as SABAs but have lipophilic side chains that allow longer binding but also slow the onset of action. Ex: formoterol, salmeterol, olodaterol

  • Long-acting muscarinic antagonist (LAMA): - non-specific muscarinic receptor antagonists, leads to bronchodilation and reduced secretions. Ex: tiotropium, umeclidinium, glycopyrrolate

  • Inahled corticosteroid (ICS): - suppress airway inflammation. Ex: budesonide, fluticasone, mometasone

VUMC Inpatient Options

  • SABA : Albuterol (Proventil/Ventolin/Proair) - MDI, neb, continuous aerosol available

  • SABA/SAMA: Ipratropium-albuterol (Duo-Neb) - neb and continuous neb available

  • LABA – only available in combination w/ ICS. LABA/ICS: vilanterol-fluticasone (Breo Ellipta), salmeterol-fluticasone (Advair Diskus/HFA)

  • LAMA: Tiotropium (Spiriva Respimat)

  • ICS: Budesonide inhaler (Pulmicort) or neb, fluticasone furoate (Arnuity Ellipta)

Last update: 2022-06-26 16:28:13