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INHALED MEDICATIONS AND DRUGS FOR

ASTHMA AND COPD

DR. VISHNU SHARMA .M.

PROFESSOR AND HEADDEPT OF PULMONARY MEDICINE

A. J. INSTITUTE OF MEDICAL SCIENCES

MANGALORE

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WHY INHALED MEDICATION

Inhaled

Small amount of dosage used

Lesser side effects

Fast onset of action(e.g. bronchodilators)

Useful in acute symptoms

ORAL

Large dosage used

Greater side effects

Slow onset of action

Not useful in acute symptoms

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Devices

MDI

DPI

NEBULIZER

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The Best route for Asthma and COPD

Medication is the

Inhaled Route

The same holds true for

ACUTE ASTHMA ATTACK and AECOPD

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Why Nebulisation

Immediate relief is requiredwhich can be achieved only

from inhalation therapy.

Patient is critical hence unable

to co-ordinate with inhaled

devices.

Nebulisation is the best resort

to give optimal dose and

targeted drug delivery

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Nebulizer

Fill volume-2 to 4ml

Time 8-10mt

End point-Spluttering sound

O2 flow rate 6-8li/mt

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Instructions to the Patient

Sit upright

Take normal steady breaths

Breath hold if possible for 5-8 seconds

Not to talk during the nebulisation

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Mask / Mouth piece

Mask for those who cant co-operate

Mouthpiecesless chance to eye irritation

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Precautions

Aseptic precautions to prevent infection

Proper disinfection

Hand hygiene

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Respule/Respiratory solution

Respule -ready to use

Respiratory solution needs to be diluted

Respule cost is more

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RESPIRATORY SOLUTION RESPULE

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Metered dose inhaler

Quick to use

Compact

Disadvantage

Technique is difficult

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Why use a Spacer ?

Ensures correct use of an MDI by

correcting co-ordination problems.

Reduces incidence of throat infections

with inhaled steroid

As good as nebuliser for acute

exacerbations ( with MDI )

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Then do we need nebulizers ?

YES

Acute severe asthma with impendingrespiratory failure

Intensive care / Hospital / Clinic /Ambulances

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Easy to use

Compact

More oropharyngeal deposition

Dry powder inhaler

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Which inhalation Device?

Inhalers

MDI DPI Nebuliser

(acute severe

episodes only)

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When you can not use a DPI?

Patient not able to inhale-Child below 3, or Elderly

Use:

MDI + Spacer

MDI + Spacer + Baby Mask

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Disadvantages OF Inhaled medications

Needs patient co-operation

Technique should be correct

Oropharyngeal deposition

Irritation to eye with nebulization

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Inhalation Drugs in Asthma and COPDBeta 2 agonists

Anti cholinergics

Gluco-corticosteroids

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Long acting beta agonists

Salmeterol

Formoterol

Indacaterol

Arfomoterol

Bambuterol

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Formetrol

Rapid onset of action

Short duration of side effect

Response increase with dose

No cumulative side effect.

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Salmetrol

Slower onset

Long duration of side effect

No such effect

Cumulative side effect

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ADVERSE EFFECTS

Uncommon with inhalation

Tremor, dyspnoea, weakness, headache

Palpitations, tachycardia, arrhythmias

Tolerance

Hypokalemia with high doses

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PRECAUTIONS

Use with cautions in patients with diabetes,hypertension

Severe paradoxical bronchoconstr iction

Administered cautiously in cardiac patients

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DRUG INTERACTIONS

Combination of salmeterol - f luticasone &

formoterol-budesonide have synergistic

action

I ncreased risk of hypokalemia with high dose

of corticosteroid with2 agonists

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Anticholinergic drugs

Ipratropium bromide is a quaternary

ammonium derivative of atropine.

Tiotropium bromide the most recently

developed, has a longer duration of action.

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AdvantagesMinor side effects

Used in COPD

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Disadvantages

Slow onset of action

Less effective than2 agonist

No anti -inf lammatory action

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High topical low systemic activity

Suppress bronchial inflammation, increase peak

expiratory flow rate

Inhaled corticosteroids

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Modulation of cytokine and chemokine production

Inhibition of eicosanoid synthesis

Inhibition of accumulation of leucocytes in the lungs

Decreased vascular permeability

Mechanism of action

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MDIs

DPIs

Nebulization

Methods of administration

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Equivalent dosages

E i l d

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200mg beclomethasone

200mcg budesonide

80mcg cic lesom ide

100mcg f lut icasone

200mcg mometasone

Equivalent dosages

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Beclomethasone

Budesonide

Flut icasone

Ciclesonide

Mometasone

Preparations

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Hoarseness- steroid induced myopathy

Dysphonia

Oropharyngeal candidiasis

LOCAL Adverse effects

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Systemic Adverse effects Mood changes

Osteoporosis

Bruising, hyperglycemia

HPA suppression

Ad ff t

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HPA suppression- dosages above 1500mcg of

beclomethasone

Children 400mcg beclomethasone

Children with asthma even though there may be pre-

pubertal growth delay, they tend to catch up later

Thinning of skin and striae especially elderly

Adverse effects- concerns

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ICS+LABA

Potentiate each other

Equivalent to double the dosage of steroid

Interactions

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THANK YOU