Inhalers | Antibiotics | Healthy Eating | Lifestyle | Rehabilitation | Supplementary Oxygen | Surgery Options | Augmentation Therapy | Glossary | INHALERS
There is currently no cure for emphysema caused by alpha-1 anti-trypsin deficiency, though some research is being done involving Augmentation Therapy and Repar Trials.
INHALERS – The Devices
The most common type of inhaler that you will encounter is the Metered Dose Inhaler (MDI).
The MDI contains a small canister of inactive gas that propels a fixed amount of the drug for each puff. Each dose is released by pressing the top of the canister. The inhaler is quick to use, small, and convenient to carry. To be effective it needs good co-ordination to press the canister, and breathe in at the same time. The gas used in all modern MDIs is harmless and eco-friendly.
MDIs are sometimes used with a Spacer Device. The spacer is tubular clear plastic box with a connection to the MDI at one end and a valve and mouthpiece at the other. The metered dose is puffed into the spacer and the patient then breathes in from the spacer mouthpiece. A number of breaths may be taken to get the full dose into the lungs. Using a spacer means that the pressing on the MDI does not have to be finely timed to match the intake of breath.
Slightly larger than the normal MDI is the Breath-Activated MDI. This detects the intake of breath and automatically releases a measured dose of the drug. Breath-Activated MDIs are useful for patients who have difficulty in co-ordinated the acts required to use the basic model.
Dry Powder Inhalers (DPIs) do not use gas to puff out the drug, instead they rely on a strong intake of breath to pull into the longs the drug in a very fine powder form. The brand names you may come across include Turbohaler,Handihaler, Diskhaler and Accuhaler. Each type of Dry Powder Inhaler has a different method of measuring the dose. The Accuhaler comes ready with measured 60 doses; the Handihaler must be loaded with a small powder-filled capsule before each use. Even adults who have difficulty breathing in can manage to use these inhalers. Young children may not be able to cope with them.
Nebulisers are devices that take a drug as a liquid and from it create an aerosol – a vapour of microscopic droplets floating in the air. You breathe in the vapour either through a mouthpiece or by using a face mask. The normal process of breathing carries the drug into the lungs. Nebulisers come in many sizes – from large units which run on mains electricity to small battery-powered units which can fit in a pocket. In hospitals nebuliser attachments may be included in the oxygen supply line for those patients needing Oxygen Therapy.
INHALERS – The Drugs or Medications
The drug from an inhaler goes straight into the lungs. This means that only a small quantity of the drug is needed and very little of that gets into the rest of the body. Because of this side effects are rare or minor in nature.
The three main groups of inhaled drugs are Short Acting Bronchodilators (Relievers), Long Acting Bronchodilators and Steroids.
Short Acting Bronchodilators relax the tiny muscles in the airways (the bronchi) which then become wider and this usually gives quick relief. Drugs in this group include salbutamol and terbutaline. Different companies use their own brand names for these drugs, however most inhalers are either blue or grey.
Long Acting Bronchodilators work in the same way but as the name suggests the effect lasts much longer – up to twelve hours. Drugs in this group include formoterol and salmeterol. Some drugs known as anticholinergics have a relaxing effect on the smooth muscles in the lungs and this produces a long acting bronchodilatory effect (up to twentyfour hours). Drugs in this group include ipratropium and tiotropium
Steroids are inhaled to prevent the airways becoming inflamed. Even taken daily, it can take up to two weeks for an inhaled steroid to reduce inflammation of the airways and up to six weeks to have maximum effect. After this period the use of steroid inhalers may be discontinued. Inhaled steroids can cause sore throats and therefore some people use a spacer device which helps eliminate this. Inhalers tend to be coloured orange, brown or red.
There are some non-steroids which are used as preventers but they are generally less effective than steroids.
Inhaled Anticholinergics - ADAPT Response
In response to the recently published articles regarding health risks associated with inhaled anticholinergics such as Atrovent and Spiriva, ADAPT have issued the following statement which they hope will alleviate any anxiety to their patients using these medications:-
"After the recently published reviews on inhaled anticholinergics (ipratropium and Tiotropium) and risk of major adverse cardiovascular events in patients with COPD we wanted to write a response we hope will help alleviate any anxiety by our patients on these medications.
The first paper was a meta-analysis, which is a summary of several different trials. The authors concluded, after reviewing 17 trials, which included patients with moderate-severe COPD, that in the anticholinergic group 1.8% suffered cardiovascular death, heart attack or stroke compared to 1.2% in the control/placebo group and there was no increase in the number of deaths.
None of the trials which were reviewed were designed specifically to assess the cardiovascular risk of inhaled anticholinergics in patients with COPD. Also due to limited data the authors were unable to adjust the results to take into account: lung function, current smoking, high blood pressure, diabetes, high cholesterol and coronary artery disease. These are all independent significant risk factors for cardiovascular deaths.
The largest trial in this meta-analysis, which contributed 50% of the data, was the Lung Health Study. This study looked at 6,000 males between ages of 35 – 60 years of age with mild-moderate lung disease. The aim of their study was to assess whether intensive smoking intervention and inhaled bronchodilator (ipratropium) prevented or delayed the onset of COPD. Most of the cardiovascular deaths seen in this study occurred in patients who were not using their medication.
The second study looked at 32,000 COPD patients and 320,000 healthy controls. Of those who died during the 4 year observation period, 40% had their cause of death determined. They found a slight increase in risk of death in the patients who had been taking ipratropium 6 months prior to their death. Again there was no data for those currently smoking which is a cardiovascular risk factor.
Pfizer and Boerhinger Ingelheim, who are the drug companies who make these inhalers, have published a response to these recent reviews. They conducted 30 trials on their Tiotropium safety database and found that those on Tiotropium actually had a reduction in number of deaths. They had no observed increase in strokes and a possible reduction in risk of heart attack.
The UPLIFT (Understanding Potential Long-term Impacts on Function with Tiotropium) trial is a large clinical COPD study looking at 5,993 patients in 37 countries which is about to publish its results. Its aim was to look at the benefits of Tiotropium versus placebo over 4 years. There was no increased risk of death or cardiovascular death (including heart attack and stroke) observed in the Tiotropium group. If anything there was a suggestion of a reduction in deaths in the Tiotropium group. Throughout the entirety of the trial the Safety Monitoring Committee reviewed the data closely.
We would like to reiterate the benefits of taking anticholinergics (Tioptropium and atrovent) in that they help to alleviate symptoms and Tiotropium has been shown to reduce exacerbations and hospitalisation in COPD patients"
Posted Tuesday 30th Sep 2008
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