Appendix 2

Delivery system

Available products

Considerations

Metered dose inhaler (MDI)

Qvar (beclomethasone 50mcg, 100mcg); Flixotide (fluticasone 50mcg, 125mcg, 250mcg); Atrovent (ipratropium bromide 20mcg); Ventolin, Asmol, Airomir, Epaq (salbutamol 100mcg); Serevent (salmeterol 25mcg); Alvesco (ciclesonide 80mcg, 160mcg)

• MDIs should be used with a spacer device, as some people have difficulty coordinating the release of medication with inhalation.

Spacers

Aerochamber Breath-A-Tech Fisonair Nebuhaler Volumatic

• The spacer chamber acts as a reservoir for the aerosol released from an MDI. The patient can then inhale from this chamber without having to coordinate the release of the medication.
• Use of spacers with inhaled glucocorticoids reduces side effects of oral candidiasis and hoarseness, as well as optimising medication delivery.
• MDI with spacer is as effective as a nebuliser if an equivalent dose is taken; 10-15 puffs of 100mcg salbutamol MDI via a spacer is therapeutically equivalent to a 5mg salbutamol nebule.
• Spacers are cheap, portable, easily cleaned and maintained, do not require electricity and are simple and quick to use.
• A small volume spacer is preferable when the vital capacity is less than 1.5L.

Autohaler

Airomir (salbutamol 100mcg); Qvar (beclomethasone 50mcg, 100mcg)

• Breath-activated MDI containing 200 doses of medication.
• Use can improve lung deposition in patients with poor MDI inhaler technique. As the patient starts a slow, deep breath through the mouthpiece, a flap valve is triggered and the dose automatically releases.

Dry powder inhalers
(DPI)

Accuhaler

Serevent (salmeterol 50mcg); Flixotide (fluticasone 100mcg, 250mcg, 500mcg); Seretide (salmeterol 50mcg and fluticasone 100mcg, 250mcg, 500mcg)

• Breath-activated multi-dose DPI containing 60 individually sealed doses. A dose counter shows the number of doses remaining. It gives accurate and consistent drug delivery over a range of inspiratory flow rates (30-120L/minute).
• Lactose powder is combined with the active medication for patients to taste and reassure them that they have inhaled a dose.

Aerolizer

Foradile (formoterol 12mcg)

• Breath-activated single-dose powder inhaler that comes with a sheet of 60 capsules in push-out foil sheet. One capsule is loaded into the inhaler and pierced before inhaling.
• Gives consistent drug delivery over a range of inspiratory flow rates.

Turbuhaler

Bricanyl (terbutaline 500mcg); Pulmicort (budesonide 100mcg, 200mcg, 400mcg); Oxis (formoterol 6mcg, 12mcg); Symbicort (formoterol 6mcg and budesonide 200mcg, formoterol 12mcg and budesonide 400mcg)

• Breath-activated multi-dose inhaler, containing 60 (Oxis, Symbicort) or 200 (Pulmicort, Bricanyl) doses; ensures delivery without the need to coordinate inspiration with drug release.
• Dose delivery is halved if the patient cannot produce inspiratory flow above 30L/min. Very few patients with COPD cannot produce a rate of >60L/min.
• Produces very fine powder, so patients often don’t taste anything.
• Dose indicator shows when there are 20 doses remaining, and then when the inhaler is empty (it contains a drying agent that can be heard when the inhaler is shaken, which can be misinterpreted as available medication).

HandiHaler

Spiriva (tiotropium 18mcg)

• Breath-activated dry powder inhaler. A capsule containing tiotropium is dropped into the HandiHaler, and pierced by pressing a button. The patient then inhales through the mouthpiece for effective drug delivery. Studies have shown that patients with a wide range of disease severity are able to generate sufficient inspiratory airflow (as low as 20L/min) to evacuate the powder from the capsule.

Nebulisers

Most nebulisers are electric. Some ultrasonic nebulisers are battery operated. These models are not heavy duty, but are ideal for travelling. There are also 12-volt pumps that plug into a car cigarette lighter. Use of inhaled glucocorticoids requires a high-flow, heavy- duty pump.

• Glucocorticoid or ipratropium bromide aerosol should not be allowed to enter the eyes to avoid the risk of side effects such as glaucoma or urinary outlet obstruction. Patients should be advised to wipe their face dry after using the nebuliser to remove medication from the skin.
• Ipratropium can be combined with beta-agonist, but not with glucocorticoid.

The products listed are not all subsidised under the Pharmaceutical Benefits Scheme for use in COPD.