How to Administer Asthma Medications to Children of Varying Ages

Web-Training

Developed by:

Mona G. Tsoukleris, PharmDAssociate Professor

Charles Ng, PharmD StudentClass of 2017

Learning ObjectivesAt the conclusion of this live webinar, child care providers will be able to:

• Explain the difference between everyday controller and quick-relief inhaled medications

• Describe proper use of currently available inhaled asthma medications (metered dose inhalers, dry powder inhalers, nebulizers)

• Explain what masks are and when they are most commonly used • Explain what spacers are and how they improve medication use• Describe how to administer medications to children of different ages• Describe common errors in medication administration and ways to correct

them

Overview of the Program• Overview of asthma• Different types of asthma medications • Basics of medication delivery • Specifics of using each type of inhaler • How to administer inhalers to children • Common errors and how to correct them

Overview of Asthma

Inflammation

Bronchoconstriction

Picture source: http://www.ehow.com/how_2322644_reduce-risk-asthma.html

Different Types of Asthma Medications

1. Quick-relief Medicines 2. Everyday Controller Medicines3. Other Medicines

What Medicines Do You Encounter?Inhaled Steroids• Beclomethasone

(Qvar®)• Budesonide

(Pulmicort®)• Ciclesonide

(Alvesco®)• Flunisolide

(Aerospan®)• Fluticasone

(Flonase®)• Mometasone

(Nasonex®)

Bronchodilators• Albuterol (Proventil®,

Ventolin®, ProAir®)

• levalbuterol (Xopenex® HFA)

• Ipratropium (Atrovent® HFA)

• Formoterol (Foradil®, Perforomist®)

• Aformoterol (Brovana®)

• Salmeterol (Serevent®)

• Tiotropium (Spiriva®) • Theophylline

Combinations• Advair Diskus®

(Fluticasone/Salmeterol) • Breo Ellipta®

(Fluticasone/Vilanterol)• Symbicort HFA®

(Budesonide/Formoterol)• Dulera®

(Mometasone/Formoterol)• Combivent®

(Ipratropium/Albuterol)

Others• Roflumilast

(Daliresp®)• Prednisone • Montelukast

(Singular®)

Different Types of Asthma Medications

1. Quick-relief Medicines – Used to treat asthma symptoms– Work fast – Relax muscles around breathing tubes– Only a “quick-fix”– Unable to treat lung swelling (inflammation)

Different Types of Asthma Medications

2. Everyday Controller Medicines – Treats asthma’s main problem (inflammation)– Used every day – Keeps asthma controlled – Controllers PREVENT symptoms from happening

When Is Asthma Controlled? • Does asthma keep child from doing some things? • Is quick-relief inhaler needed for relief more than twice a week? • Does asthma wake the child up with cough or trouble breathing

more twice a month? • Are more than 2 canisters of Quick-Relief medicine used in a

year?

Did you answer YES to any question?

If so, asthma is NOT controlled. The patient should talk to the doctor. The child might need to be on an everyday controller

medicine.

Quick-Relief Medicines • “Quick Fix” - Do not reduce swelling (inflammation)

albuterol (Proventil®, Ventolin®, ProAir®)

levalbuterol (Xopenex® HFA)

How do they work? • FAST! They work in minutes.• They relax muscles around the breathing tubes. That

makes it easier to breathe.• Can also be used to prevent exercise symptoms

albuterol (Proventil®, Ventolin®, ProAir®)

levalbuterol (Xopenex® HFA)

Other Types of Quick-Relief Medicines – By Mouth Steroids

• When taken by mouth, these medicines are very strong.

• The doctor may give this for a bad asthma attack.

• Also used to get quick control of asthma in some people.

• This medicine does not replace your controller medicine.

Examples of Steroids

prednisone (Deltasone®, LiquidPred®, Orasone®)

methylprednisolone (Medrol®)

prednisolone (Orapred®, Pediapred®,

Prelone®)

Everyday Controller Medicines • Most common and important treatment for

asthma • Work slowly• Treat inflammation (swelling), which is the

cause of asthma• If we can treat inflammation, we can prevent

permanent damage to the lungs.

Types of Everyday Controller Medicines

1. Anti-inflammatory medicines – control the inflammation and swelling in your lung

2. Medicines that relax lung muscles – also used with the anti-inflammatory medicines

beclomethasone (QVar®)

Fluticasone (Advair®, Flovent®)

formoterol (Foradil®, Symbicort®)

Basics of Medication Delivery • Different types of inhalers – Metered dose inhalers– Dry powder inhalers– Nebulizers

• Spacers • Masks • Slow versus fast inhalation

What are Metered Dose Inhalers?• MDIs deliver either quick-relief medication or

everyday controller medications to treat asthma. • They deliver a measured amount of drug

through the generation of an aerosol spray • Once the canister is activated by depressing the

canister into the plastic mouthpiece, drug aerosol is propelled from the canister. Then, the drug is inhaled by the patient and deposited in the patient’s lungs.

Metered Dose Inhalers (MDI)

albuterol (ProAir® HFA, Proventil® HFA, Ventolin® HFA) AeroChamber® Plus

Types of Metered Dose Inhalers (MDI)• Freon propellant (CFC) MDIs

• Hydrofluoralkane (HFA) propellant MDIs

• Breath-Actuated MDIs

ipratropium/albuterol

(Combivent®)

albuterol (ProAir® HFA, Proventil® HFA,

Ventolin® HFA)

MaxAir® AutoHalerTM®

(pirbuterol)

Properties of MDI propellants • Freon – Chlorofluorocarbons (CFCs) serve as propellants

for these inhalers. The spray is forceful and cold, coming form the mouth piece at almost 60 mph.

• HFA – Hydrofluoroalkane (HFA) is a replacement for CFC

propellant. HFA propellant is less forceful (30 mph) and doesn’t feel as cold when compared to the CFC propellant.

How to use MDIs without a spacer? 1. Assemble the inhaler by placing canister firmly, but gently into plastic

mouthpiece. 2. Remove the cap. Check that nothing is inside the plastic case. 3. Shake the inhaler vigorously.4. Exhale normally.5. Close lips tightly around mouthpiece or Position mouthpiece of inhaler 2-3 finger

widths from wide open mouth. 6. Press canister once and at the same time, inhale slowly (over 3-5 seconds) to a

full, deep breath, keeping lips around mouthpiece (or mouth open) for entire inhalation.

7. Remove inhaler from mouth.8. Hold breath at least 5 seconds, preferably 10 seconds. 9. Exhale slowly10. If taking additional puffs, wait 1 - 3 minutes before repeating steps above.11. Rinse mouth with water, gargle, and expectorate after taking dose.

MDIs Without a Spacer Video• Infants• Toddlers• Young children• Older children• Teenagers

What to expect when using a Freon-based MDI?

• A cold, forceful puff (60 mph)• If it is a quick-relief medication, it should start opening the

patient’s airways within 5 minutes, but maximal effect may not occur up to 30 minutes.

• If it is an everyday controller medication, the medication may not produce any identifiable change for at least a few days, if not a few weeks.

What to expect when using a HFA-based MDI?

• A warmer, less forceful puff than a Freon-based MDI (30 mph)• If it is a quick-relief medication, it should start opening the

patient’s airways within 5 minutes, but maximal effect may not occur up to 30 minutes.

• If it is an everyday controller medication, the medication may not produce any identifiable change for at least a few days, if not a few weeks.

When should an Inhaler be replaced?

• To tell if the inhaler is empty, the only good way is to count the number of puffs used or to calculate them based on the prescribed dose.

• An old technique called for “floating” the inhaler in a bowl of water is no longer recommended since it can make an inhaler unusable.

Breath-Actuated Metered Dose Inhalers

• The only currently-available breath-actuated metered dose inhaler at this time is the AutoHaler

• This device delivers the aerosol when the device is triggered by the force of the patient’s inhalation

• This is useful for patients who have difficulty triggering the canister at the beginning of inhalation

How to use a Breath-Actuated Metered Dose Inhaler?

1. Remove the Autohaler mouthpiece cover. 2. Hold the Autohaler upright while raising the lever until it snaps. 3. Shake the Autohaler gently several times. 4. Exhale normally.5. Close lips tightly around mouthpiece.6. Inhale deeply with steady, moderate force to a full, deep breath for at least 3

seconds.7. Remove Autohaler from mouth. 8. Hold breath for at least 5 seconds, preferably 10 seconds.9. Exhale slowly.10. Lower lever.11. If taking additional puffs, wait at least 1 minute before repeating steps 2-10,

above.12. Rinse, gargle and expectorate after use.

Breath-Actuated Metered Dose Inhaler Video

• Infants• Toddlers• Young children• Older children• Teenagers

What to expect when using a Breath-Actuated MDI?

• A loud click noise will sound as the cool burst of medication aerosol is released.

• Cold, less forceful puff than a Freon-based MDI

• If it is a quick-relief medication, it should start opening the patient’s airways within 5 minutes, but maximal effect may not occur up to 30 minutes.

Spacers• They are used with typical CFC or HFA inhalers, but

can not be used with Breath Actuated MDIs or with Dry Powder Inhalers.

• A spacer is a tube that lengthens the space between the inhaler mouthpiece and the user’s mouth

• Spacers are used to improve drug delivery and reduce side effects.

• Spacers minimize drug particle deposition on the upper airway (oropharynx). This also decrease the amount of medication that is swallowed.

Examples of Spacers

AeroChamber

OptiChamberOptiHaler

Ellipse

E-Z Spacer

InspirEase

How do spacers work? • Spacers minimize drug particle impaction on the

upper airway and improve drug delivery to the site of action

• Spacers accomplish these goals by slowing down the particle velocity before reaching the patient’s mouth. They minimize particle size as propellant evaporates and particles too large for lung delivery deposit in the spacer rather than in the patient’s upper airway (oropharynx).

Who should use a spacer?• Useful for patients who have difficulty mastering the numerous steps required for

effective MDI administration

• Children, patients who are cognitively impaired or unconscious, and any individual who has difficulty holding the breath or mastering the eye hand-lung coordination required for effective MDI delivery

• Patients who are using inhaled corticosteroids or anticholinergics because they are effective at minimizing ocular exposure to aerosolized drug.

• Because they minimize oropharyngeal deposition (and therefore the amount of swallows drug), they are particularly useful for administering corticosteroid MDIs to any patient

• They may be used in almost all patients regardless of age to improve drug delivery and reduce occurrence of side effects

What to expect when using a MDI with a Spacer?

• Less medication taste

• Less sensation of cold or forceful spray

• Symptom improvement within 5 minutes of using a quick-relief medication

• No change in symptoms when using daily controller medications

• Cloudiness of the space chamber after periods of use. This is due to the static discharge holding the drug particles against the spacer chamber and doesn’t mean that it is dirty on the inside.

Key Points in Using a MDI with Spacer• Keep the mouth wrapped tightly against the

mouthpiece for the full inhalation

• Time the activating of the inhaler at onset of inhalation

• Use 1 puff followed by 6 inhalations if unable to hold breath for at least 5 seconds

How to use an MDI with Spacer?1. Remove the cap. Check that nothing is inside the mouth piece. 2. Attach the inhaler to the spacer. 3. Shake the inhaler (with spacer attached) vigorously. 4. Exhale normally. 5. Press inhaler once AND at the same time, inhale slowly (over

3-5 seconds) to get full breath. Keep lips around mouthpiece for entire inhalation.

6. Hold breath at least 5 seconds, preferably 10 seconds 7. Exhale slowly8. Wait 1 - 3 minutes before taking another dose. 9. Rinse mouth with water, gargle, and spit when finished.

Use an MDI with Spacer Video• Infants• Toddlers• Young children• Older children• Teenagers

Other Types of Spacers: InspirEase, EZ-Spacer

• These are different from typical spacers in that they have collapsible reservoir bags. When the patient inhales, the bag close and open when patient exhales.

• These are useful for patients who need visual feedback to facilitate inhalation through the mouth rather than the nose.

InspirEase

EZ-Spacer

Other Types of Spacers: OptiHaler• These are different form typical spacers in that

it facilitates simultaneous canister activation with the onset of inhalation.

• It does this through use of an end cap, which must be pressed closed before use. When the end cap is in the closed position, the patient will have difficulty inhaling. Once the canister is depressed to release the medication, the end cap pops open and air can flow freely.

• Instruct the patient to exhale first, place the mouthpiece in the mouth, begin inhaling the canister is activated.

OptiHaler

Using the MDI and Spacer with a Mask• They are useful when a

patient isn't reliably inhaling through the mouth. This will help to maximize inhalation of drug and ensure optimal delivery of drug to the lungs.

• Mask come in a variety of sizes and can be used with patients of all ages, including children and adults with cognitive impairment.

Key Points in Using a MDI with Spacer & Mask

• Fit the mask so it covers both the mouth and nose and fits snug against the face

• Time the activating of the inhaler at onset of inhalation

• Use 1 puff followed by 6 inhalations if unable to hold breath for at let 5 seconds

What to expect using a MDI with Spacer & Mask?

• Less medication taste

• Less sensation of cold or forceful spray

• Symptom improvement within 5 minutes of using a quick-relief medication

• No change in symptoms when using daily controller medications

• Cloudiness of the space chamber after periods of use. This is due to the static discharge holding the drug particles against the spacer chamber and doesn’t mean that it is dirty on the inside.

Dry Powder Inhalers (DPI)

TurbuHaler TwistHalerDiskus

What are Dry Powder Inhalers? • Dry powder inhalers (DPIs) are devices that generate aerosols

through the force of a patient’s inhalation rather than through the use of a propellant.

• DPIs are designed in order to achieve the end result of delivering the dose to the lung

• Dry powder inhalers use blister packaging systems, gelatin capsules, or multidose reservoirs to make the powder available for inhalation

How do DPIs work?• Dry powder inhalers work by delivering the drug in powder form after the dose

is loaded and the patient steadily and forcefully for a full, deep inhalation.

• Lactose may be included with the drug as a carrier agent to help with powder dispersion.

• These are several steps in common between ALL dry powder inhalers:

1. Expose mouthpiece2. Load dose3. Exhale to residual volume 4. Inhale steadily and forcefully for a full deep breath5. Hold breath at least 5 seconds, 10 is preferred6. Exhale normally

How to use a DPI: Diskus?1. Hold the Diskus in one hand and put thumb of other hand on thumb

grip, pushing thumb away as far as it will go until mouthpiece appears and snaps into position

2. Hold Diskus in a level, horizontal position with mouthpiece toward you and slide the lever away from you as far as it goes until it clicks

3. Exhale fully while turning head away form mouthpiece4. Close lips tightly around mouthpiece5. Breathe in steadily and deeply through the mouth, the faster the better.6. Remove Diskus form mouth7. Hold breath at least 5 seconds (10 second is preferable) 8. Exhale slowly9. Close the Diskus.10. Rinse, gargle and expectorate after use

DPI: Diskus Video• Infants• Toddlers• Young children• Older children• Teenagers

What to expect when using a Diskus? 1. A sweet taste or nothing, depending on patient.

2. The medication salmeterol will have a delayed bronchodilation.

3. There is a dose counter on the Diskus that tells the remaining number of puffs left in the device.

How to use a DPI: FlexHaler?1. Unscrew the cover and lift off2. Hold the inhaler upright and turn the colored base to the right

as far as it will go then back to the left until there is a click.3. Breathe out (with the head turned away form the mouthpiece).4. Close lips tightly around mouthpiece5. Breathe in steadily and deeply through the mouth, the faster

the better.6. Remove the TurbuHaler from mouth7. Hold breath at least 5 seconds (10 second is preferable) 8. Breath out slowly9. Rinse, gargle, and expectorate after use

DPI: TurbuHaler Video• Infants• Toddlers• Young children• Older children• Teenagers

DPI: FlexHaler Video• Infants• Toddlers• Young children• Older children• Teenagers

What to expect when using a TurbuHaler?

1. There will be no taste, but you may notice a slight sweet sensation.

2. When shaken, the dessicant (drying agent) will make a sound.

3. This everyday controller medication will not produce any identifiable change for at least a few days, if not a few weeks.

4. TurbuHaler is empty when there is a red line that appears at the bottom of the window.

How to use a DPI: TurbuTester?1. Hold the inhaler upright and turn the colored base to the right

as far as it will go then back to the left until there is a click.2. Breathe out (with the head turned away form the mouthpiece)3. Close lips tightly around mouthpiece.4. Breathe in steadily and deeply through the mouth, the faster

the better. The unit should make a horn noise during the full inhalation.

5. Remove the TurbuHaler from mouth.6. Hold breath at least 5 seconds (10 second is preferable). 7. Breath out slowly.

DPI: TurbuTester Video• Infants• Toddlers• Young children• Older children• Teenagers

How to use a DPI: TwistHaler? 1. Hold the pink base and unscrew the cover. Lift off the cap

keeping the mouthpiece facing up. This loads the dose.2. Breath out fully (with the head turned away from the

mouthpiece).3. Close lips tightly around mouthpiece.4. Breathe in steadily and deeply through the mouth, the

faster the better.5. Remove the TwistHaler from mouth.6. Hold breath at least 5 seconds (10 second is preferable). 7. Breath out slowly.8. Rinse, gargle, and expectorate after use.

DPI: TwistHaler Video

• Infants• Toddlers• Young children• Older children• Teenagers

What to expect when using a TwistHaler?

• There may be a slight sweet taste and sensation.

• This everyday controlled medication will no produce any identifiable change for at least a few days, if not a few weeks.

• After using the last remaining TwistHaler dose, the cap will screw on and not reopen

Nebulizer

• A nebulizer is used to administer the medication in the form of a mist inhaled into the lungs.

• A patient must be willing to keep in place 5-15 minute treatment.

How to use a Nebulizer?1. Measure correct amount of saline solution using a clean dropper. Put the saline

into the nebulizer cup. 2. Measure correct amount of medicine using a clean dropper and add it to

nebulizer cup containing the saline. 3. If you are using a premixed medicine, add the correct amount.4. Attach mouthpiece to T-shaped part. Fasten this unit or mask to the cup. 5. Turn on air compressor. 6. Put mouthpiece in mouth, between teeth and seal lips tightly around it.7. Take slow, deep breaths in through the mouth 8. If you are unable to take slow, deep breaths, breathe normally into mask. 9. Hold each breath for 1 to 2 seconds before breathing out or hold each breath

for 1-5 seconds every 3-5 inhalations. 10. Continue breathing this way until medicine is gone from the cup (about 5-15

minutes).

Nebulizer Video • Infants• Toddlers• Young children• Older children• Teenagers

What to expect when using a Nebulizer?

• You will see symptom improvement within 5 minutes.

• The masks should be closing fitting.

MDI Common Errors• Forgetting to shake or insufficient shaking of canister• Forgetting to prime (new or not-used-for-awhile inhaler unit)• Forgetting to clean inside plastic sleeve• Head position either too flexed or too extended (not in neutral position)• Mouth not tightly around mouthpiece (for closed-mouth technique only)• Tongue/teeth in way of mouthpiece opening• Inhaler directed upward toward palate or down toward tongue• Double actuations at one time• Poor coordination/timing with actuation/inspiration (too late or too early with actuation relative to inspiration)• Stopping inspiration (“freezing”) as aerosol strikes throat• Inspiratory flow rate too rapid; sometimes, too slow• Inhalation through nose rather than through mouth• Exhaling during actuation

Spacer Common Errors• Using an empty inhaler• Forgetting to shake or insufficient shaking of canister• Head position either too flexed or too extended• Mouth not tightly around mouthpiece• Tongue/teeth in the way of spacer mouthpiece opening• Spacer directed upward toward palate or down toward tongue• Spray all puffs at once into spacer• Waiting too long after actuation before inhalation• Start inhalation too early (before actuation)• Inspiratory flow rate too rapid; sometimes, too slow• Inhalation through nose rather than through mouth• Exhaling during actuation• Incomplete inspiration

DPI Common Errors• Head position either too flexed or too extended• Not keeping device in horizontal position when moving lever/inhaling• Not closing lips tightly around mouthpiece• Tongue/teeth in way of mouthpiece opening• Breathing into the device before inhalation• Forgetting to move lever before taking dose• Moving lever forward then back, rather than just forward• Inverting device after loading and losing dose• Thinking that inhalation should take place coordinated with moving lever forward• Inhalation through nose rather than through mouth• Inspiration effort not rapid enough• Incomplete inspiration• Ignoring counter device, and using empty inhaler as result• Opening and closing device without dosing, throwing counter off• Forgetting to close device after use

Nebulizer Common Errors• Incorrect size for child• Not fitting tightly on face/mouth/nose• Not holding nebulizer upright• Stopping too early, before dose done