Summary of inhalational drug delivery devices

manually actuated pressurised metered dose inhalers (pMDIs)

breath-actuated pMDIs

mist inhalers

multiple-dose DPIs

single-dose dry powder inhalers (DPIs) (capsule system)

nebuliser

spacers

Types and instructions

“puffer”, CFC-free inhaler, metered aerosol—see video and handout

Rapihaler—see video

Available drugs (and brand examples) for device

ICS

• ciclesonide (Alvesco)
• fluticasone propionate (Cipla, Flixotide, Fluair)
• beclometasone (Qvar)

SABA

• salbutamol (Airomir, Asmol, Ventolin)

SAMA

• ipratropium (Atrovent)

ICS+LABA

• beclometasone+formoterol (Fostair)
• budesonide+formoterol (Symbicort Rapihaler)
• fluticasone propionate+salmeterol (Cipla, SalplusF, Seretide)
• fluticasone propionate+formoterol (Flutiform)

Considerations

preferred device for infants and children

use with a spacer (and facemask if required); see below

new inhalers should be primed by spraying a number of actuations in the air (away from the patient)

some formulations have a dose counter

a Haleraid device can be used for patients with poor manual dexterity

Types and instructions

Autohaler—see video and handout

Available drugs (and brand examples) for device

ICS:

• beclometasone (Qvar Autohaler)

SABA:

• salbutamol (Airomir Autohaler)

Considerations

consider for patients with poor manual dexterity

can’t be used with a spacer

does not have a dose counter

Types and instructions for use

Respimat—see video and handout

Available drugs (and brand examples) for device

LAMA:

• tiotropium (Spiriva)

LABA+LAMA:

• olodaterol+tiotropium (Spiolto)

Considerations

cartridge must be loaded into device before first use (see video)

can be used with a spacer

Types and instructions

Accuhaler—see video and handout

Ellipta—see video and handout

Genuair—see video and handout

Spiromax—see video and handout

Turbuhaler—see video and handout

Available drugs (and brand examples) for device

ICS:

• fluticasone propionate (Flixotide Accuhaler)
• fluticasone furoate (Arnuity Ellipta)
• budesonide (Pulmicort Turbuhaler)

LABA:

• formoterol (Oxis Turbuhaler)
• salmeterol (Serevent Accuhaler)

LAMA:

• aclidinium (Bretaris Genuair)
• umeclidinium (Incruse Ellipta)

SABA:

• terbutaline (Bricanyl Turbuhaler)

ICS+LABA:

• budesonide+formoterol (Symbicort Turbuhaler, DuoResp Spiromax)
• fluticasone propionate+salmeterol (Seretide Accuhaler)
• fluticasone furoate+vilanterol (Breo Ellipta)

LABA+LAMA:

• vilanterol+umeclidinium (Anora Ellipta)
• formoterol+aclidinium (Brimica Genuair)

ICS+LAMA+LABA:

• fluticasone furoate+umeclidinium+vilanterol (Trelegy Ellipta)

Considerations

strong inspiratory flow required to transform powder into particles—inadequate inspiratory flow can result in inadequate drug delivery to lungs

moisture prevents medicine dispersing properly—device must be stored in dry area, and patients must not breath into device

can’t be used with spacer

Types and instructions

Breezhaler—see video and handout

Handihaler—see video and handout

Aerolizer—see inhaler checklist

Zonda—see video

Available drugs (and brand examples) for device

LABA:

• indacaterol (Onbrez Breezhaler)
• formoterol (Foradile Aerolizer)

LAMA:

• glycopyrronium (Seebri Breezhaler)
• tiotropium (Spiriva Handihaler, Braltus)

LABA+LAMA:

• indacaterol+glycopyrronium (Ultibro Breezhaler)

Considerations

strong inspiratory flow required to transform powder into particles—inadequate inspiratory flow can result in inadequate drug delivery to lungs

can’t be used with spacer

tablet must be loaded into device before each use

Available drugs (and brand examples) for device

SABA:

• salbutamol (Ventolin)
• terbutaline (Bricanyl)

SAMA

• ipratropium (Atrovent)

ICS

• budesonide (Pulmicort)
• fluticasone propionate (Flixotide)

Considerations

requires use of higher doses because of low drug deposition in lungs—increases the risk of adverse effects

pMDI with a spacer is more effective than nebuliser for delivering SABA in an acute wheezing episode; however, a nebuliser may be useful in severe exacerbations requiring large SABA doses over long periods

longer time required to deliver equivalent dose compared to other devices

regular servicing needed to maintain function and reduce risk of microbial contamination

not suitable for patients with acute infection, as device can spread infective organisms

risk of local adverse effects (eg acute angle glaucoma with SAMA) if used with a mask rather than a mouthpiece

Types and instructions

small-volume spacer—see video and handout

large-volume spacer—see video and handout

Considerations

for use with manually actuated pMDI or mist inhaler

benefits:

• avoids need to coordinate actuation and inhalation (eg in infants, children and older adults)
• minimises oropharyngeal drug deposition and local adverse effects (eg with ICS)
• improves drug delivery to the lungs; during an acute attack, pMDI with spacer provides better drug delivery to the lungs than a nebuliser

can be used with a face mask if required—face mask should be tightly fitted (a poorly fitted face mask increases the risk of eyes and skin being exposed to drug); if using an ICS, the patient’s face must be washed after each dose

small-volume spacer is usually preferred because it requires fewer tidal breaths—eg to inhale salbutamol adequately, two tidal breaths from a small-volume spacer are required for adults; three tidal breaths are required for a large-volume spacer

for children, four to six tidal breaths are required for adequate dose delivery, depending on the type of spacer and the child’s age

slow inhalation with a single breath is the best technique

priming and cleaning requirements vary between spacers—see handout