Dr Andrew Scroop

Respiratory Consultants

15th September 2018

A multitude of devices

STEPWISE PHARMACOLOGICAL

MANAGEMENT OF STABLE COPD

MILDFEV1 ≈60–80% predicted

MODERATEFEV1 ≈40–59% predicted

SEVEREFEV1 ≈<40% predicted

few symptoms

breathless on moderate exertion

recurrent chest infections

little or no effect on daily activities

increasing dyspnoea

breathless walking on level ground

increasing limitation of daily activities

cough and sputum production

exacerbations requiring oral corticosteroids and/or antibiotics

dyspnoea on minimal exertion

daily activities severely curtailed

experiencing regular sputum production

chronic cough

exacerbations of increasing frequency

and severity

CHECK DEVICE USAGE TECHNIQUE AND ADHERENCE AT EACH VISIT

REFERENCES: 1. Lung Foundation Australia. Stepwise management of stable COPD. February 2015. 2. Abramson M et al. COPD-X concise guide for primary care. Brisbane.

Lung Foundation Australia. Version 3.02, August 2015.

Short-acting reliever medication: Short-acting ß2-agonist (SABA) or short-acting muscarinic antagonist (SAMA)

LABALAMA LAMA/LABAAND/OR ORSymptom relief (some agents have been shown to also prevent exacerbations)

Exacerbation prevention When FEV1 <50%

predicted AND ≥2 exacerbations in 12 monthsLABA/ICS

Add low dose theophylline

COPD Inhalers

Adapted from: 1. Lung Foundation. COPD Medicines Chart May 2015. MDI = metered dose inhaler. The products included were those available on the PBS

as at January 2016. †Available via PBS for asthma only. ‡Not on the PBS. Please visit www.ebs.tga.gov.au for full Product Information of the products listed.

*Bretaris® Genuair® and Brimica® Genuair® are marketed in Australia by Menarini Australia Pty Ltd.

MAINTAINING FUTURE TREATMENT OPTIONS

Guide to addition of COPD maintenance treatments1

LAMA LABA LAMA/LABA LABA/ICS

LAMA ✗ ✗

LABA ✗ ✗ ✗

LAMA/LABA ✗ ✗ ✗ ✗

LABA/ICS ✗ ✗ ✗

✗ Classes of treatments that should not be used together

Adapted from Lung Foundation Australia. Stepwise management of stable COPD.1

REFERENCE: 1. Lung Foundation Australia. Stepwise management of stable COPD. February 2015.

Inhaler Types Pressurized metered dose inhaler (pMDI) – including spacer use and

breath activated

Dry powder inhaler – Preloaded or requiring capsule insertion.

“Soft Mist inhaler”

Are there differences between inhaler classes?

References: 1. Laube B et al. Eur Respir J 2011;37:1308–31. 2. Newman S. Eur Respir Rev 2005;14:96 102–108. 3. Newman

S and Busse W. Resp Med 2002; 96: 293–304. 4. Dalby R et al. Int J Pharm 2004; 283: 1–9. 5. Schurmann W et al. Treat

Respir Med 2005; 4: 53-61. 6. Kardos P et al. Eur Respir J 2005; 26 (Suppl 49): 338s (abstract 2213). 7. Hochrainer D et al. J Aerosol Med 2005; 18: 273–282. 8. Hodder R et al. Int J Chron Obstruct Pulmon Dis 2009; 4: 225–232.

pMDIs

• Active device1

• Aerosol cloud of highvelocity and short duration2

• Requires significant coordination2

Soft Mist™ Inhaler

• Active device4

• Easy to Inhale5-6

• Does not contain propellants4

• Slow-moving aerosol cloud vs pMDIs7

• Requires a slow inhalation2

• Improved coordination vs pMDIs4,7,8

DPIs

• Delivers drug in powder form2

• Breath-actuated (passive) devices2

• Delivered dose and particle size depends on inspiratory flow2,3

• Requires a forcefulinhalation2,3

• Little coordination required2

On line inhaler instructions https://lungfoundation.com.au/patient-support/copd/inhaler-technique-

fact-sheets/

https://www.nationalasthma.org.au/living-with-asthma/how-to-videos

https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd

https://www.nps.org.au/medical-info/medicine-finder

Inhaler technique Most prescriptions are without personal instruction and demonstration /

coaching

Most use device incorrectly

Duration of device use no indication of correct use

Re-educate frequently

Commonest mistakes – no or incorrect device preparation, no breath out, incorrect inhalation speed and or timing, no breath hold

pMDI Spacer

Autohaler Dry powder devices

Inspiratory Flow Assessment Accuhaler

Turbuhaler Ellipta

Genuair Spiromax

Dry powder devices - capsule Aerolizer

Handihaler Breezhaler

Respimat Device lifespan Confusing

Check expiry date

Do not forget re priming pMDIs. Never “prime” a DPI

Any air tight packaged device (including Respimat) must be discarded 6 weeks to 3 months after opening even if never used.

On line inhaler instructions https://lungfoundation.com.au/patient-support/copd/inhaler-technique-

fact-sheets/

https://www.nationalasthma.org.au/living-with-asthma/how-to-videos

https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd

https://www.nps.org.au/medical-info/medicine-finder

Dr Andrew Scroop

Respiratory Consultants