To treat any disease, you must get the medicine to its appropriate site of action. There are a variety of delivery devices to accomplish this task. The choice of device can, in some cases, be almost as important as the medication that is being delivered. An inappropriate device, or the right device used improperly, can be the only reason a person’s asthma is not controlled.

 

The following sections will describe the different device types, advantages and disadvantages.

 

Metered dose inhalers (MDIs) are the most widely used delivery devices.

The advantages of MDIs are:

They deliver a reliable, consistent dose of medication directly to the lungs.

Most medicines are available in this form.

 

The main disadvantages of the MDI are:

Need for good coordination to combine taking a deep breath in with pressing the MDI

No built-in dose counter

Not very efficient as a delivery device unless used with a spacer device (see Holding chambers and spacers)

 

Medications available: Most bronchodilators are available in MDI form. Triamcinolone acetate (Azmacort) is available with a built-in spacer.

Detailed instructions for use here.

 

The Autohaler is the only device in this category at this time; the only medication delivered via the Autohaler in the US is pirbuterol (Maxair).

 

Advantages include:

It is easy to use because there is no need to combine taking a deep breath with activating the MDI.

It contains 400 doses.

 

Disadvantages include:

Requires a more rapid inspiration (breath in) than the standard MDI.

Activating lever may be hard to use for people with dexterity or strength issues.

Pirbuterol is not indicated for children under 12 years.

No built-in dose counter

Only pirbuterol is available in this device.

 

Detailed instructions for use are here.

 

MDIs should be ‘primed’ (pressed a few times) before first use and if not used for some time.

The Autohaler needs two priming sprays before first use and if not used for 48 hours. MDIs need to be shaken before use

The plain plastic holder for the MDI should be washed weekly.

The Autohaler has specific cleaning instructions-read package insert.

Avoid leaving the MDI in extreme temperatures.

 

There are several different dry powder devices. Dry-powder devices are all breath-actuated. The dry powder is held in a capsule or in a reservoir within the device. When the person takes a brisk deep breath in, the medicine is delivered to the airways. These devices are generally easier to use than MDIs, and all have some sort of dose counter. In some the powder may be lost if the device is tipped when the powder is ready for inhalation. There are several different dry powder devices.

 

Medicine is held in a gel capsule on a foil blister card. Immediately prior to use, one gel capsule is removed from its blister and placed in the base of the Aerolizer. The Aerolizer is not meant to be washed. A new device is dispensed monthly.

 

Advantages:

Doses are external to the device so are easy to count.

Easy to use for most people

May take repeated puffs in order to inhale all medication in the capsule.

Long, small mouthpiece may be easier to use for some persons.

 

Disadvantages:

The capsules are moisture sensitive.

The device is difficult to use if person has problems with hand movement/coordination

The medicine and device are separate.

 

Medicines available: formoterol (Floradil) is the only medication available in the US in the Aerolizer.

Detailed instructions for use are here.

 

Medicine is held in “caps” or “blisters” on a tape inside the device. Each Diskus has 60 doses.

 

Advantages:

Has dose counter

Easy to teach and to use

 

Disadvantages:

Can lose doses by playing with activation lever

 

Medicines available in this device: A combination medication, fluticasone/salmeterol (Advair) is available in three different strengths: 100/50, 250/50, 500/50.

Detailed instructions for use are here.

 

Medicine is held in a reservoir in the bottom of the device. Each Turbuhaler contains 200 doses. To clean, just wipe the mouthpiece with a clean cloth. Keep dust cover on when not in use.

 

Advantages:

Breath actuated

Indicator tells when 20 doses left

Easy to teach and to use

No taste, which many persons prefer

Indicated for once-daily dosing in stable asthma

Is safe for use in pregnancy

 

Disadvantages:

Only one medicine currently available in this device

Can lose doses by “playing” with device

Moisture sensitive

No taste, so persons think they’re not getting anything

 

Medicines available: budesonide (Pulmicort) is the only medication available in the US in the Turbuhaler.

Detailed instructions for use are here.

 

 

Medicine is held inside the device. When the cap is removed, the medication is ready to inhale. When the cap is properly replaced, the next dose is loaded.

 

Advantages:

Breath actuated

Easy to use and to teach

Has a dose counter

Cap locks when no medication remain

 

 Disadvantages:

Moisture sensitive

No taste, so patients may think they are not getting any medication

Cap must be correctly replaced in order to load the next

 

Medicines available in this device: mometasone (Asmanex). It comes in a single dosage strength of 220 mcg/inhalation. The device is available with 3 different numbers of doses: 30, 60 or 120 inhalations.

Detailed instructions for use are here.

 

To treat any disease, you must get the medicine to its appropriate site of action; for asthma, that means the small airways. Pharmaceutical companies have developed a variety of delivery devices to accomplish this task. Use of a spacer or a valved holding chamber has been shown to increase delivery of the medication to the lungs. The choice of device can, in some cases, be almost as important as the medication that is being delivered. An inappropriate device, or the right device used improperly, can be the only reason a person’s asthma is not controlled.

 

Many devices are available in the US. Some have one-way valves, such as the Aerochamber, OptiChamber, Pocket Chamber and Vortex; some do not, such as the Inspirease, Optihaler, and Pocket Spacer. We will use the term “spacer” to refer to both types. The MDI is inserted into a port on the spacer; the medicine is actuated into the chamber one puff at a time prior to inhalation. This gives several advantages over using the standard MDI without a spacer.

 

Children younger than four or five will probably need to use the spacer with a mask

 

Not every MDI fits into every spacer, so it’s important to make sure that the inhaler and the spacer are compatible.

 

Sometimes medication can stick to the inside of the spacer chamber. To prevent this, the spacer should be washed once in dishwashing liquid, and left (un-rinsed) to drain dry. An exception to this is the Vortex spacer.

 

A nebulizer may be used to deliver medicine to the lungs., To do so an electric or battery-operated compressor is connected to a small cup, which holds the medication. This cup is the nebulizer. In a nebulizer, the medication solution is broken up into a fine aerosol which is then inhaled through a mouthpiece or a facemask. Directions for use are here.

 

Advantages

The person does not have to inhale deeply; the dose is delivered via normal quiet breathing over 5-15 minutes.

The doses used can be much higher than with inhalers (MDI)

The high dose is often effective where lower dose bronchodilators have failed.

The medication is delivered more effectively during an acute exacerbation.

 

Disadvantages

Nebulizers may be bulky and expensive.

They require ongoing maintenance (change tubing, filter, nebulizer chamber).

Filling and cleaning the nebulizer chamber requires a degree of manual dexterity and is time consuming.

Nebulizing medications takes longer than a few inhalations with inhaler device.

Most compressors require a power source which may restrict the person’s ability to get out and about.

 

Cleaning the nebulizer is important! The nebulizing chamber should be washed and air dried carefully after each use to prevent the medication from crystallizing and blocking the jet holes. Mouthpieces and masks should be washed regularly. Two methods for cleaning involve either warm soap and water or a solution of 1/3 white vinegar and 2/3 water.

 

The chamber should be dried after each use and after washing the equipment. Nebulizing equipment that is left damp is a potential source of infection so careful drying is necessary. The jet holes of the nebulizer chamber can be dried by attaching the clean chamber to the compressor and “blowing” air through for a few minutes. Tubing should not be washed inside since it is impossible to dry it thoroughly.