Asthma Medications and
Devices
Krista D. Capehart, PharmD, MSPharm, AE-C
Assistant Professor of Pharmacy Practice
University of Charleston School of Pharmacy
Objectives
• Identify quick relief and controller
medications for asthma.
• Discuss the different delivery devices for
inhaled asthma medications.
• Demonstrate how to assist in
administering asthma medications.
Quick Relief Medications
• Medications that are used to help relieve symptoms of
an asthma attack
• Albuterol is one of the most commonly used quick-relief
medications that works to relax the airways and make it
easier to breath
• Can start to work in 5-15 minutes after use for symptoms
Bronchodilators – Beta 2 Agonists –
Nebulized: every 4-6 hours as needed*
Albuterol (pre-mixed)
Ventolin, Proventil,
Accuneb
Albuterol (concentrate)
Levalbuterol
Levalbuterol (concentrate)
Xopenex
0.63mg/3mL unit dose vial
1.25mg/3mL unit dose vial
2.5mg/3mL unit dose vial
2.5mg/0.5mL – must be mixed
with saline or another solution
0.31mg/3mL unit dose vial
0.63mg/3mL unit dose vial
1.25mg/3mL unit dose vial
1.25/0.5mL – must be mixed with
saline or another solution
* Per NHLBI:EPR3 Guidelines for “Home” management of asthma
exacerbations – Up to two nebulized treatments 20 minutes apart may be
administered, assessing condition throughout both treatments to
determine if emergency transport/emergency department treatment is
necessary.
Bronchodilators – Beta 2 Agonists –
Metered Dose Inhalers (MDIs) every 4-6
hours as needed*
Albuterol
Levalbuterol
Ventolin HFA, Proventil
HFA, ProAir HFA
Xopenex HFA
Pirbutrol
Maxair
2-6 puffs per dose (always
use a spacer)
2-6 puffs per dose (always
use a spacer)
2-6 inhalations per dose
(breath activated – do not
use spacer)
* Per NHLBI:EPR3 Guidelines for “Home” management of asthma
exacerbations – Up to two treatments 20 minutes apart may be
administered, assessing condition throughout both treatments to
determine if emergency transport/emergency department treatment
is necessary.
Bronchodilators – Anti-cholinergics – Metered Dose
Inhalers (MDIs) every 4-6 hours as needed – Not for use
alone in asthma
Ipratropium bromide
Atrovent HFA
4-8 puffs every 20 minutes as
needed up to 3 hours for
exacerbation
* Per NHLBI:EPR3 Guidelines for “Home” management of asthma
exacerbations – Up to two nebulized treatments 20 minutes apart may be
administered, assessing condition throughout both treatments to determine
if emergency transport/emergency department treatment is necessary.
Errors in inhaler use
• Requires coordination & skill for MDI
• In a study that examined inhaler (MDI &
DPI) use over 1 month, half made at least
one error & 76% using MDI made an error
• Critical errors resulted in almost no drug
being administered and those occurred in
11% of those using DPI & 28% in those
using MDI
Spacer Devices
• Advantages
– Reduces need for
patient coordination
– Reduces pharyngeal
deposition
• Disadvantages
– Inhalation can be more
complex for some patients
– Can reduce dose available
if not used properly
– More expensive than MDI
alone
– Less portable than MDI
alone
– Integral actuation devices
may alter aerosol
properties
Ensure that each student has a Personal Written Asthma Action Plan
Ensure that each student has a Personal Written Asthma Action Plan
Management of Asthma Exacerbations: School Treatment
(Per National Asthma Education Prevention Program)
• The following slides are the suggested Emergency
Nursing Protocol for Students with Asthma Symptoms
who don’t have a personal asthma action plan.
• A student with asthma symptoms should be placed in an
area where he/she can be closely observed. Never send
a student to the health room alone or leave a student
alone. Limit moving a student who is in severe distress.
Go to the student instead.
Management of Asthma Exacerbations: School Treatment
(Per National Asthma Education Prevention Program)
Management of Asthma Exacerbations: School Treatment
(Per National Asthma Education Prevention Program)
Management of Asthma Exacerbations: School Treatment
(Per National Asthma Education Prevention Program)
Long-acting Controller
Medications
• These are medications that are taken daily to help prevent
symptoms of asthma by decreasing inflammation and will NOT
treat an asthma attack
• Inhaled corticosteroids like fluticasone (Flovent®) and
budesonide (Pulmicort®) and oral medications like
montelukast (Singulair®) and zafirlukast (Accolate®) are the
drugs that used most often to prevent symptoms of asthma
• Must be taken as prescribed even if you are not having
symptoms every day
Routine Maintenance Inhaled Medications “Controller
medications” Dosages listed are from NHLBI EPR3
Guidelines for ages 5- 11 year old unless otherwise noted
Beclomethasone HFA 40 or
80mcg/puff
QVAR
Budesonide DPI 90mcg,
180mcg, or
Pulmicort Flexhaler
Low dose: 80-160mcg total
per day to be divided and
given every 12 hours
Medium dose: >160mcg320mcg total per day to be
divided and given every 12
hours
High dose: >320mcg total per
day to be divided and given
every 12 hours
Low dose: 180-400mcg total
per day to be divided and
given every 12 hours
Medium dose: > 400-800mcg
total per day to be divided
and given every 12 hours
High dose: >800mcg total per
day to be divided and given
every 12 hours
Routine Maintenance Inhaled Medications “Controller
medications” Dosages listed are from NHLBI EPR3 Guidelines for
ages 5- 11 year old unless otherwise noted
Budesonide inhalation suspension
for nebulization
0.25mg/2ml,0.5mg/2ml, and
1mg/2mL
Pulmicort Respules
Low dose: 0.5mg total per day to
be given in one or two treatments
Medium dose: 1mg total per day
to be given in one or two
treatments
High dose: 2mg total per day to be
given in two treatments
Mometasone DPI
110mcg/puff, 220mcg/puff
Asmanex Twisthaler
1 puff in the evening
Routine Maintenance Inhaled Medications “Controller medications”
Dosages listed are from NHLBI EPR3 Guidelines for ages 5-11 year old
unless otherwise noted
Fluticasone HFA 44mcg, 110mcg,
220mcg/puff
Flovent HFA
Fluticasone DPI 50mcg, 100mcg, or
250mcg per inhalation
Flovent Diskus
Low dose:88-176mcg total per day
to be divided and given every 12
hours
Medium dose: > 176-352mcg total
per day to be divided and given
every 12 hours
High dose: >352mcg total per day
to be divided and given every 12
hours
Low dose: 100-200mcg total per
day to be divided and given every
12 hours
Medium dose: > 200-400mcg total
per day to be divided and given
every 12 hours
High dose: >400mcg total per day
to be divided and given every 12
hours
Combination Medications Inhaled – Beta2
Agonist and Corticosteroid
Fluticasone/Salmeterol Advair Diskus
DPI
100mcg-50mcg
Fluticasone/Salmeterol Advair HFA
HFA
45mcg-21mcg
115mcg-21mcg
230mcg-21mcg
Budesonide/formoterol Symbicort HFA
HFA
80mcg-4.5mcg
1 inhalation twice daily
(12 hours apart)
Not approved for
children <12 years
2 puffs twice daily (12
hours apart)
Long Acting Beta 2 Bronchodilators – not
recommended for use alone in asthma without an
inhaled corticosteroid
Salmeterol DPI
50mcg/inhalation
Formoterol DPI
12mcg/single use
capsule for inhalation
Serevent Diskus
Foradil
1 inhalation every 12
hours
Inhale the contents of
one capsule every 12
hours
Oral Medications
• Oral Corticosteroids
Methylprednisolone 2, 4,
8, 16, 32mg tablets
Prednisolone 5mg tablets
5mg/5mL liquid
15mg/5ml
10mg ODT (Oral
disintegrating tablet)
15mg ODT
30mg ODT
Prednisone
1, 2.5, 5, 10, 20, 50mg
tablets
5mg/mL
5mg/5mL
Medrol
Prelone, Pediapred
Prelone, Orapred
Orapred ODT
0.25-2mg/kg daily in single
morning or every other day
as needed for control
0.25-2mg/kg daily in single
morning or every other day
as needed for control
0.25-2mg/kg daily in single
morning or every other day
as needed for control
Leukotriene Receptor
Antagonist (LTRAs)
Montelukast 4mg or Singulair
5mg chewable
tablet, 10mg tablet
Zafirlukast 10mg,
Accolate
20mg
5mg at bedtime (614 years of age)
10mg twice daily (711 years of age)
Food and Drug Administration
(FDA) Decision
• March 31, 2005 – FDA rules that
manufacturers needed to phase out
production and sale of CFC MDI by
December 31, 2008
• Manufacturers began to develop HFA MDI
for both “quick relief” medications
(albuterol and levalbuterol) and for “longterm controller” medications (inhaled
corticosteroids)
Differences between CFC and
HFA MDIs
Component
CFC
HFA
Dose delivery from near
empty container
Variable
Consistent
Variable ambient
temperature
Variable
Consistent (-20C)
Force of spray
More forceful
Softer
Mist Temperature
Colder
Warmer
Mist Volume
Higher
Lower
Taste
Different
Different
Breath-holding
< important with CFC
> Important with HFA
Priming
General guidelines for all Very specific to product
Cleaning
Periodic cleaning
necessary
Stressed as REGULAR
cleaning necessary
Hess DR, Myers TR, Rau JL. A Guide to Aerosol Delivery Devices. Access at http://www/AARC.org/aerosol_delivery on July 25, 2008.
Softer, warmer plume may cause patients to think the HFA inhalers do not work as well
as the CFCs. The HFA inhalers deliver 108 mcg of albuterol sulfate, which is equivalent
to 90mcg albuterol base. This is the same amount of active medication as is in the CFC
albuterol MDIs.
http://www.google.com/imgres?q=image+HFA+vs+CFC+plume&hl=en&client=firefox-a&hs=GND&sa=X&rls=org.mozilla:enUS:official&biw=1280&bih=579&tbm=isch&prmd=imvns&tbnid=ry2nJQGuKZghPM:&imgrefurl=http://www.expertreviews.com/doi/pdf/10.1586/17476348.2.2.149&docid=qSjR7QNpJcZOM&w=120&h=67&ei=F81wToruLMHcgQem4_EQ&zoom=1&iact=hc&dur=3717&page=1&tbnh=58&tbnw=104&start=0&ndsp=
21&ved=1t:429,r:2,s:0&tx=44&ty=31&vpx=486&vpy=217&hovh=58&hovw=104 Accessed September 2011
Priming…
• Each of the HFA metered-dose inhalers
must be “primed”
• What does “priming” mean?
• How many times for different inhalers?!?
Examples of HFA priming guidelines
Medication
When to prime
# of sprays
Proventil HFA
(albuterol)
Prior to 1st use
2 wks of non-use
4
4
Ventolin HFA
(albuterol)
Prior to 1st use
2 wks of non-use
4
4
ProAir HFA
(albuterol)
Prior to 1st use
2 wks of non-use
3
3
Flovent HFA
(fluticasone)
Prior to 1st use
With < 3 weeks of non-use
With > 3 weeks of non-use
4
1
4
QVAR
(beclomethasone)
Prior to 1st use
With 10 days of non-use
2
2
Advair HFA
(fluticasone and salmeterol)
Prior to 1st use
With 4 weeks of non-use
4
2
Atrovent HFA
(ipratropium)
Prior to 1st use
With 3 days of non-use
2
2
Inhalation technique for the HFA
MDIs
1.
2.
3.
4.
5.
Remove mouthpiece
cover and check for
foreign objects.
Shake the inhaler well
immediately before use.
Prime if necessary.
Breath out normally
through the mouth, getting
as much air out of the
lungs as possible.
Place the mouthpiece
between the lips and
teeth.
6. Breath in slowly and press
MDI canister down once at
the beginning of the
inhalation.
7. Hold breath as long as
possible, up to 10
seconds.
8. Remove inhaler from mouth
and breath out slowly
9. Wait 30-60 seconds
between doses.
10. Rinse mouth and spit with
ICSs.
Cleaning HFA MDIs
• All HFAs state actuator needs to be
cleaned at least once a week and as
needed
• Clean by removing the canister and
running warm water through the top and
air dry overnight if possible
Dry powder inhalation (DPI)
devices
•
•
•
•
•
No propellants
Built-in dose counters
Breath actuated
Formoterol – individual capsules
Diskus (salmeterol & fluticasone) – blister
strip
• Budesonide and mometasone– drug
reservoir
Technique for Diskus
•
•
1.
2.
Diskus expires 1 month from
the day the pouch is opened
Open, Click, Inhale
Open by placing the thumb
on the thumb grip and push
away from you until the
mouthpiece appears and
snaps into position.
Hold the Diskus FLAT with
the mouthpiece toward you
and slide the level as far as it
will go until it clicks.
3. Inhale –
– Exhale fully while holding the
Diskus away from your mouth
and FLAT. Never breath into
the mouthpiece
– Put the mouthpiece to your
lips and inhale quickly and
deeply through your mouth
(not nose).
– Remove the Diskus from your
mouth and hold your breath
for about 10 seconds. Exhale
slowly.
– Rinse your mouth with water
and spit after breathing in the
medicine.
– Close the Diskus when you
are finished.
Technique for budesonide DPI
•
•
•
•
•
Prime before using for the 1st time
ONLY
Hold the inhaler so that the white
part is pointing up and remove the
cover by lifting up
Hold the inhaler by the brown grip
and grasp the inhaler in the
middle, still holding it upright
Twist the brown grip as far as
possible to one direction then fully
back again in the other direction
until it stops
The device is now primed and
does NOT need to be primed
again
•
Load the dose
– Twist the cover and lift off
– Hold inhaler in upright position
and grasp brown grip
– Place other hand in the middle of
the inhaler
– Twist all the way in one direction
and then fully back again in the
other direction until it clicks
•
Keep inhaler vertical until ready to
use
– Exhale completely (not into the
inhaler)
– Place mouthpiece in your mouth,
close lips around it, inhale deeply
and forcefully through the inhaler
– Remove the inhaler from your
mouth and exhale
– Replace the cover
– Rinse mouth with water and spit.
Technique for mometasone DPI
• Remove inhaler from pouch –
throw away 45 days after
opening or when dose counter
reads “00”
• Open the inhaler
– Hold inhaler straight up with
colored portion on the bottom.
– Holding the colored base twist
the cap counterclockwise to
remove it. Removing cap
loads the dose
• Inhale the dose
– Breathe out fully
– Place the inhaler in your
mouth holding it horizontally,
closing your mouth firmly
around the inhaler
– Take in a fast, deep breath.
Do not cover the ventilation
holes
– Do not breath into the inhaler.
Remove the inhaler from your
mouth and hold your breath
for 10 seconds.
– Rinse mouth with water and
spit.
Nebulizers
• Nebulizers uses ampules of medication
that is put in a special cup and usually air
is used to make the solution into a
breathing treatment
• It usually takes about 5-10 minutes to
complete a breathing treatment of 3 mL of
medication.
How do we see if the
medications are working?
• Peak flow meters
• Spirometry
Other asthma resources for you
at school
• The National Heart Lung and Blood
Institute – National Asthma Education and
Prevention Program has a large
assortment of resources available online
at
http://www.nhlbi.nih.gov/health/public/lung/
index.htm#schools
References
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Global Initiative For Asthma: Global Strategy for Asthma Management and Prevention. Revised 2006.
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http://www.google.com/imgres?q=image+HFA+vs+CFC+plume&hl=en&client=firefox-a&hs=GND&sa=X&rls=org.mozilla:enUS:official&biw=1280&bih=579&tbm=isch&prmd=imvns&tbnid=ry2nJQGuKZghPM:&imgrefurl=http://www.expertreviews.com/doi/pdf/10.1586/17476348.2.2.149&docid=qSjR7QNpJcZOM&w=120&h=67&ei=F81wToruLMHcgQem4_EQ&zoom=1&iact=hc&dur=3717&page=1&tbnh=58&tbnw=104&start
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Hess DR, Myers TR, Rau JL. A Guide to Aerosol Delivery Devices. Access at http://www/AARC.org/aerosol_delivery on July 25,
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Leach CL. The CFC to HFA transition and its impact on pulmonary drug development. Resp Care 2005;50:1201-1206.
Busse WW, Brazinsky S, Jacobson K, Schmitt K, Vanden Burgt J, et al. Efficacy response of inhaled beclomethasone
dipropionate in asthma is proportional to dose, and is improved by formulation with a new propellant. J Allergy Clin Immunol
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Prescribing information for Asmanex Twisthaler 2008, Advair Diskus 2008, Spiriva 2008, Pulmicort FlexHaler 2007, Proventil HFA
2007, Ventolin HFA 2008, ProAir HFA 2006, Foradil Aerolizer 2006, QVAR 2006
Use of Ozone Depleting Substances: Removal of Essential Use Designation; Final Rule. Federal Register April 4,
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