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Family Health Magazine - PHARMACY CARE

Inhaled Asthma Medications
How to use them

If you are like most people with asthma, you use some form of medication that is breathed into the lungs. Asthma medications are best inhaled. Breathing them in allows for fewer side effects and increases the effect compared to oral medications.

Asthma medications can be divided into two categories. Some control (prevent) asthma, while others relieve it. Both are available as inhalation devices.

Controllers are long-term control medications that are taken daily. They prevent symptoms and help manage asthma. These inhalers must be used every day, even if you feel well. If you are feeling well, your medication is working to keep inflammation or swelling down. These medications take about two to three days to start working. You should notice a dramatic improvement after two weeks of use. If you stop using it, inflammation and asthma symptoms can return.

Relievers are taken only when needed. Most are short-acting bronchodilators. They give quick relief when an asthma attack occurs. Relievers relax tight muscles around the airways, temporarily making it easier to breathe. They do not reduce inflammation. Do you use your reliever more than three times a week? This suggests your asthma is poorly controlled and should be reassessed. Asthma should not interfere with your quality of life.

New inhalers combine a controller and a long-acting reliever all in one device. This may be more convenient if you are currently using more than one inhaler. Considering discussing this option with your doctor.

The three most popular types of devices used are the MDI (metered dose inhaler), the Turbuhaler®, and the Diskus®. The last two devices are breath-activated. Every device has advantages and disadvantages, and contains different medications. Work with your doctor to choose the one best suited to you.

The metered dose inhaler (MDI)

The MDI has two parts. A canister holds the medication, while the ‘boot’ houses the canister. The drug is combined with a propellant that forces medication particles out of the canister. This device is the most difficult to use. Proper timing and co-ordination is needed to get the medication into the lungs rather than in the mouth or back of the throat. Only about nine per cent of people using an MDI do so properly. However, using a spacer can correct issues with effective use.

Follow these steps to use your MDI and spacer correctly.

• Remove the cap. Make sure the mouthpiece is clear of debris. (To keep the mouthpiece clear, cap it closed after use. Do not throw the cap out!)
• Stand or sit completely upright. Lying down or hunching over will limit the amount of air and medication entering your lungs.
  Shake the MDI about 10 times. This allows an even dose of medication to be delivered each time.
• Insert the MDI into the spacer device.
• Exhale away from the device. Place the spacer mouthpiece between your teeth and close your lips to ensure there is a tight seal. Make sure the inhaler is straight up.
• Press down on the MDI once. Adults are advised to take one full breath in via the spacer device. Children and adults having problems breathing in should take six small breaths in and out, using the spacer device to get the full dose.
• Hold your breath for about 10 seconds. This gives the medication time to settle in your lungs, rather than being exhaled out.
• Remove the spacer from your mouth.

If you need a second dose, wait 30 seconds and follow the steps once again. Never press the canister twice during one procedure, as the second puff will be mostly propellant and very little medication. You will go through your puffer faster this way without using all of the medication in it.

MDI with a spacer/air chamber (AeroChamber™ or OptiChamber™)

These chambers are designed to be used with an MDI. They coordinate the two actions of pressing the canister and breathing in. They are very easy to use. MDIs should always be used with a spacer to reduce side effects and allow the maximum amount of medication to reach the lungs. They are also suggested for those having an asthma attack, who have trouble coordinating the dose, or have arthritis. Spacers are available with a mouthpiece or mask that goes over the mouth and nose. Children can switch from a masked spacer to a mouthpiece spacer at the age of four to five years.

The chamber allows you to comfortably inhale the dose after it has been loaded into the chamber. It may take two to three breaths to clear the chamber of a single dose. Infants and young children need five to six breaths. If you hear a whistle while using the chamber, your breathing is too fast. Slow your breathing until the whistle stops.

Using a chamber with your device increases the amount of medication being delivered into your lungs. It also reduces the amount being wasted in your mouth and at the back of the throat. Even if your technique is perfect without a chamber, you still get more medication in the airways when using one.

Using an MDI plus a chamber is generally considered more efficient and effective than using a nebulizing device.

Breath-activated devices (Turbuhaler® and Diskus®)

Breath-activated means that rather than having a propellant push medication out of a device, you inhale to draw or suck the medication in. The device is much easier to use than an MDI, as you do not have to co-ordinate pressing and inhaling. It may also be better for anyone bothered by propellants, or who gets a lot of medication deposited in the mouth. Since medication is delivered in powder form, these are also called dry powder inhalers.

Using these devices is very easy. Most children over age five can use dry powder. The steps are similar for both devices, though they look completely different.

1. Turbuhaler®: remove the cap.
   Diskus®: slide back the cover. Load a single dose into the device. Do not shake.
2. Turbuhaler®: Turn the grip as far as it will go counter-clockwise. Do not force. Then, turn it clockwise (the opposite direction) as far as it will go. You will hear and feel a click. The Turbuhaler® is ready to use.
   Diskus®: Slide the lever away from you with your thumb until you hear a click. The Diskus® is ready to use.
3. Stand or sit completely upright and tilt your head up slightly.
4. Exhale away from the device.
5. Hold the device level.
6. Place the mouthpiece between your teeth and close your lips. Breathe in quickly and deeply through your mouth.
7. Remove the inhaler from your mouth and hold your breath for 10 seconds.

If a second dose is required, repeat steps two to six. These medications are sensitive to moisture, so remember to cover the mouthpiece when done. You can wipe lipstick or debris off the cover with a soft cloth, but do not wet or submerge the device to clean it.

When using a dry powder inhaler, you are inhaling very tiny amounts of dry powder. Unlike the MDI, you often do not taste or feel the dose. Rest assured that you do get a full dose of medication.

With the Turbuhaler®, a rattling sound may be heard in the bottom of the device. This is not medication, but rather a desiccant that removes moisture. When the medication is running low, people often mistake the rattle for medication left in the device. An indicator window lets you check the amount that remains. The Diskus® counts down the exact number of doses you have left. Be sure to get your prescription refilled before you are out completely.

With proper teaching, anyone can use all of the inhalation devices correctly. It is important to reassess the way you use your inhaler device from time to time. If you are not sure that you are using your device correctly, ask your pharmacist for instructions and a demonstration.

Many pharmacies have demos of the various devices. Watch them to decide which device will work best for you. With your doctor and your pharmacist, you can determine the device that best fits your needs. It is nice to know you have options.

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