Asthma inhalers: Which one's right for you?

Inhalers allow people with asthma to lead active lives without fear of an attack. Here's a
rundown of inhaler types, with tips on proper use.
By Mayo Clinic staff
Inhalers have transformed asthma treatment. They enable children and adults with asthma to deliver medicine directly
to their lungs nearly anytime and anywhere. A variety of inhalers are available to help relieve or control asthma
symptoms.

Types of inhalers
Inhalers are hand-held portable devices that deliver medication directly to the lungs. A variety of inhalers exist, but
they basically fall into two categories:

Metered dose inhalers

These inhalers use a chemical propellant to force a measured dose of medication out of the inhaler. They consist of a
pressurized canister containing medication, a mouthpiece and a metering valve that dispenses the correct dose of
medication. The medication is released either by squeezing the canister or by inhaling. You may find it easier to use a
hand-actuated inhaler with a spacer — a short tube that attaches to the inhaler. Using a hand-actuated inhaler to
release the medication into the chamber gives you time to inhale more slowly. It decreases the amount of medicine
that's deposited on the back of your throat and increases the amount that ultimately reaches your lungs.

Some metered dose inhalers have counters so that you know how many doses remain. If there is no counter, you
have to track of the number of doses you've used so that you know when the inhaler is out of medication.

The chemical propellant in metered dose inhalers has traditionally been a chlorofluorocarbon (CFC). But after an
international agreement to ban CFCs because they damage the ozone layer, other propellants such as
hydrofluoroalkane (HFA) are now used instead. The dose of medication released by an HFA inhaler may feel softer and
warmer than the dose released by a CFC inhaler. If you're used to a CFC inhaler, it may not seem like a complete dose
— even though the medication is reaching your lungs.

Dry powder inhalers

These inhalers don't use a chemical propellant to push the medication out of the inhaler. Instead, the medication is
released by breathing in more quickly than you would with a traditional metered dose inhaler.

Some people find dry powder inhalers easier to use than the conventional pressurized metered dose inhalers because
hand-lung coordination isn't required. Some models require operating a cocking device that requires dexterity.
Available types include a dry powder tube inhaler, a powder disk inhaler and a single-dose dry powder disk inhaler.
Spacers shouldn't be used with dry powder inhalers.

Comparing inhaler types

Choosing the right kind of inhaler for you depends on several factors, such as your hand-breath coordination, your
dexterity, whether you can take a deep, fast breath, and what types of medication you need. The chart below can help
you understand the pros and cons of each type. Work with your doctor to find the best inhaler for your needs.

Inhaler features

Metered dose inhaler Metered dose inhaler with a spacer Dry powder inhaler

Portable and convenient Less portable and convenient, more complex and Portable and convenient
more expensive than a metered dose inhaler
without a spacer

Doesn't require a deep, fast breath Doesn't require a deep, fast breath Requires a deep, fast breath

Accidental exhalation before activation won't Accidental exhalation before activation won't Accidental exhalation before activation will blow
disrupt medication disrupt medication away medication

Hand-actuated models without a spacer require Hand-breath coordination is not critical Hand-breath coordination is not necessary
hand-breath coordination

Can result in large amounts of medication on the Less medication settles on the back of your Can result in large amounts of medication on the
 back of your throat and tongue throat and tongue back of your throat and tongue

Minimal or no maintenance required Spacer requires periodic cleaning with soap and Minimal or no maintenance required
water

Some models require you to keep track of how Some models require you to keep track of how It is clear when the device is out of medication
many doses remain many doses remain

Requires shaking and priming Requires shaking and priming, correct use of Single-dose models require loading capsules for
spacer each use

Humidity does not affect medication Humidity does not affect medication High humidity can cause powdered medication to
clump

Medications delivered through inhalers

Inhalers are used to deliver a variety of asthma medications — some that assist with long-term control and others that
provide quick relief of symptoms. Some medications may only be available in certain inhaler types. Inhaled asthma
medications include:

 Short-acting bronchodilators. These medications, including albuterol (Proventil, Ventolin) and pirbuterol (Maxair),
provide immediate relief of asthma symptoms.

 Long-acting bronchodilators. These medications relieve asthma symptoms for longer periods of time. They include
salmeterol (Serevent) and formoterol (Foradil).

 Corticosteroids. Used long term to prevent asthma attacks, these medications include beclomethasone dipropionate
(Qvar), fluticasone (Flovent), budesonide (Pulmicort), triamcinolone acetonide (Azmacort) and flunisolide (Aerobid).

 Cromolyn or nedocromil. These nonsteroidal medications are used long term to prevent inflammation.

 Corticosteroid plus long-acting bronchodilator. This medication combines a corticosteroid and a long-acting
bronchodilator (Advair, Symbicort).

Inhalers may come with slightly different instructions. Follow those instructions carefully and ask your doctor for a
demonstration.

The importance of using inhalers properly

It's important that you use your inhaler correctly so that the medication reaches your lungs. Carefully follow the
instructions. And ask a doctor, nurse or pharmacist for a demonstration. Use the inhaler in front of this person and ask
for feedback. Then practice at home in front of a mirror.

If you're unable to use an inhaler, a nebulizer may be an option. Nebulizers are designed for those who can't use an
inhaler, such as infants, young children and those who are seriously ill. The device works by converting medication
into a mist and delivering it through a mask that you wear over your nose and mouth.

Using an inhaler is just one part of your asthma treatment plan, which may also include checking your lung function
with a peak flow meter, eliminating asthma triggers and exercising. But knowing what types of inhalers are available
and how to use them can help you better manage your asthma and get the most from your treatment.

How to Use Your Inhaler

Metered Dose Inhaler (MDI or pMDI) | Spacers |Diskus® | Turbuhaler® | Diskhaler®

How to Use a Metered-Dose Inhaler "Puffer"

A metered-dose inhaler, called an MDI for short, is a pressurized inhaler that delivers medication by using a propellant spray.
To use an MDI:

1. Shake the inhaler well before use (3 or 4 shakes)

2. Remove the cap

3. Breathe out, away from your inhaler

4. Bring the inhaler to your mouth. Place it in your mouth between your teeth and close you mouth around it.

5. Start to breathe in slowly. Press the top of you inhaler once and keep breathing in slowly until you have taken a full breath.

6. Remove the inhaler from your mouth, and hold your breath for about 10 seconds, then breathe out.

If you need a second puff, wait 30 seconds, shake your inhaler again, and repeat steps 3-6. After you've used your MDI, rinse out your mouth and

record the number of doses taken.

Store all puffers at room temperature

Cleaning Your MDI

To clean your MDI, follow the instructions that came with it. In most cases, they will advise you to:

1. Remove the metal canister by pulling it out.

2. Clean the plastic parts of the device using mild soap and water. (Never wash the metal canister or put it in water.)

3. Let the plastic parts dry in the air (for example, leave them out overnight).

4. Put the MDI back together.

5. Test the MDI by releasing a puff into the air.

Important Reminders About MDIs

Always follow the instructions that come with your MDI.

As well:
 Keep your reliever MDI somewhere where you can get it quickly if you need it, but out of children's reach.

 Show your doctor, pharmacist or asthma educator how you're using your metered-dose inhaler.

 Store your MDI at room temperature. If it gets cold, warm it using only your hands.

 Never puncture or break the canister, or try to warm it using anything except your hands.

 When you begin using an MDI, write the start date on the canister.

 Check the expiry date on the MDI before you use it.

 If you're having trouble using your MDI, ask your doctor for tips or to recommend another device.

 Many doctors recommend the use of a spacer, or a holding device to be used with the MDI.

 Do not float the canister in water.

 How to Use Your Dry Powder Inhaler
Some COPD medications can be taken in the form of a dry powder using a small,
hand-held device called a dry powder inhaler (DPI). Dry powder inhalers deliver
medication to the lungs as you inhale through the device. The DPI does not contain
propellants or any other ingredients. It contains only the medication.

The Diskus (fig 1) contains 60 doses of medication. (Advair®, Flovent®, and

Serevent® are the brand names of the medication that might be prescribed for you.)
It has a dose indicator that counts down the number of doses as you use them.
Doses 5 through 0 are in red to alert you to refill your prescription. When the "0"
appears in the dose indicator, throw away the Diskus and begin a new one.

Preparing the Diskus

1. Hold the outer case in one hand. Place the thumb of your other hand in the
thumb grip. Push your thumb as far away from you as it will go. This action opens
the Diskus to expose the lever underneath and locks the mouthpiece into
position.
2. Hold the Diskus in a level position to prevent the medicine from dropping out.
Slide the lever away from you until it clicks. This action loads the dose of
medication. You will see the dose counter decrease by one.

Inhaling the medication

Once you have your DPI loaded, follow these steps to inhale the medication:

1. Turn your head away from the Diskus and breathe out as much air as you
comfortably can.
2. Place the Diskus mouthpiece in your mouth and breathe in as steadily and as
deeply as you can.
3. Remove the Diskus from your mouth and hold your breath for up to 10 seconds.
4. Close the Diskus by placing your thumb in the thumb grip and sliding the grip back
toward you, over the mouthpiece. This action resets the inhaler so it is ready to
use for the next treatment.

Caring for Your DPI

 Keep your dry powder inhaler in a dry place at room temperature.

 Never place the DPI in water.
  Never shake or breathe into the DPI.
 Never use a spacer device with the DPI.
 Unlike other inhaled medications, you might not taste, smell, or feel the dry
powder. This might be different from what you are used to. As long as you are
following the directions, you will get your full dose of medication.
 If you are using a corticosteroid medication, rinse your mouth and gargle after
using the DPI. Do not swallow the gargle solution.

The Turbuhaler® (fig 2) contains 200 doses of

medication (the brand name is Pulmicort®). There is a
small, clear window on the barrel of the Turbuhaler
that is a dose indicator. When a red mark appears at
the top of this window, 20 doses remain and you
should refill your prescription. When the red mark
reaches the bottom of the window, throw away the
Turbuhaler and begin a new one.

Preparing the Turbuhaler

When you obtain a new Turbuhaler, you must prime it

before you can use it.

1. Hold the Turbuhaler upright to ensure proper loading of the medication.

2. Twist and remove the cover.
3. Twist the brown grip on the bottom fully to the right and then back again. You will
hear a "click."
4. Repeat a second time. Your new Turbuhaler is now primed and ready to be loaded
with a dose. (Remember, you only need to prime the Turbuhaler the first time you
use a new one.)
5. To load a dose, continue to hold the Turbuhaler upright. You must hold the
Turbuhaler upright to ensure proper loading of the medication. Twist the brown
grip fully to the right and then back to the left. You will hear a click. The
Turbuhaler is now loaded with a dose.

Inhaling the medication

1. Turn your head away from the inhaler and breathe out as much air as you
comfortably can.
2. Place the device in your mouth and breathe in as quickly and as deeply as you can.
3. Hold your breath for up to 10 seconds.
4. Take the DPI away from your mouth and exhale slowly.
5. If more than one dose is prescribed, load another dose, and repeat steps 1
through 5 for each dose.
6. When your treatment is complete, replace the white cover and twist it completely
to close.

©Copyright 1995-2009 The Cleveland Clinic Foundation. All rights reserved

 How to Use Your Diskus Dry Powder Inhaler (DPI)
Some asthma medications can be taken in the form of a dry powder using a small, hand-held device called a dry
powder inhaler (DPI). Dry powder inhalers deliver medication to the lungs as you inhale through the device. The DPI
does not contain propellants or any other ingredients. It contains only the medication.

The Diskus (figure 1) contains 60 doses of medication (Advair, Flovent, or Serevent are the brand names of the
medication that may be prescribed for you). It has a dose indicator that counts down the number of doses as you use
them. Doses 5 through 0 are in red to alert you to refill your prescription. When the "0" appears in the dose indicator,
throw away the Diskus and begin a new one.

Preparing the diskus:

1. Hold the Diskus in your left hand. Place the thumb of your right hand in the
thumb grip. Push your thumb as far away from you as it will go. This action
opens the Diskus to expose the lever underneath.

2. Slide the lever away from you until it clicks. This action loads the dose of
medication. You will see the dose counter decrease by one.

Inhaling the medication:

Once you have your DPI loaded, follow these steps to inhale the medication:

3. Turn your head away from the Diskus and breathe out as much air as you comfortably can.

4. Place the Diskus mouthpiece in your mouth and breathe in as steadily, and as deeply as you can.

5. Hold your breath for up to 10 seconds.

6. Remove the Diskus from your mouth and exhale slowly.

7. Close the Diskus by placing your thumb in the thumb grip and slide the grip back toward you, as far as it will go.
This action resets the inhaler so it is ready to use for the next treatment.

8. If more than one dose is prescribed, repeat steps 1 through 7 for each dose.

Caring for your DPI

 Keep your dry powder inhaler in a dry place at room temperature.

 Never place the DPI in water.
 Never shake or breathe into the DPI.
 Never use a spacer device with your DPI.
 Unlike other inhaled medications, you may not taste, smell, or feel the dry powder. This experience may be
different from what you are used to. As long as you are following the directions, you will get your full dose
of medication.
 If you are using a corticosteroid medication, rinse your mouth and gargle after using the DPI. Do not
swallow.

nhaler Types

There are many different inhalers used to deliver IPAs. Most people have seen someone using a "puffer" to alleviate
asthma symptoms. The technical term for such puffers is "pressurized metered dose inhaler" or "propellant metered
dose inhaler", usually abbreviated as pMDI or simply MDI. A sketch of a typical such device is shown below.
pMDIs are the most commonly used inhaler worldwide, and have been used since the mid 1950s. The aerosol is
created when a valve is opened (usually by pressing down on the propellant canister), allowing liquid propellant to
spray out of a canister (in a manner somewhat similar to everyday aerosol spray cans), involving a complex process
called cavitation. The drug is usually contained in small particles (usually a few millionths of a meter in diameter)
suspended in the liquid propellant, but in some formulations the drug is dissolved in the propellant. In either case, the
propellant evaporates rapidly as the aerosol leaves the device, resulting in small drug particles that are inhaled. Prior
to the mid 1990s, pMDIs used various chlorofluorocarbons (CFCs) as their propellant, but with the elimination of
CFCs in industry due to ozone depletion concerns, the propellants in new pMDIs typically use hydrofluoroalkanes
(HFAs), which do not result in ozone depletion.

Add-on devices (spacers, holding chambers and other modifications) are sometimes used with pMDIs (particularly in
young children) to remove the difficulty some patients have with coordinating inhalation with firing the pMDI spray.
Such add-on devices can also reduce the amount of drug depositing in the mouth and throat.

Although pMDIs are the most common type of modern day inhaler, they are not the oldest. This honour goes to
nebulizers, which have been around in one form or another for more than a century. Nebulizers produce a mist of
drug-containing water droplets for inhalation. They are usually classified into two types: electronic nebulizers and jet
nebulizers. Jet nebulizers are more common due to their lower cost, and use a source of pressurized air to blast a
stream of air through a drug-containing water reservoir, producing droplets in a complex process involving a
viscosity-induced surface instability that leads to nonlinear phenomena in which surface tension and droplet breakup
on baffles play a role. In contrast, electronic nebulizers produce droplets by mechanical vibration of a plate or mesh.
In either type of nebulizer, the drug is usually contained in solution in the water in the nebulizer and so the droplets
being produced contain drug in solution. However, for some formulations (notably Pulmicort) the drug is contained in
small particles suspended in the water, which are then contained as particles suspended inside the droplets being
produced. A schematic of a typical nebulizer is shown below.
The third major type of inhaler is the dry powder inhaler, abbreviated as DPI. In DPIs the aerosol is a powder,
contained within the device until it is inhaled. The therapeutic drug is manufactured in powder form as small powder
particles (usually a few millionths of a meter, or micrometers, in diameter). In many DPIs the drug is mixed with
much larger sugar particles (usually lactose monohydrate), that are typically 50-100 micrometers in diameter. The
much smaller drug particles attach to these excipient particles. The increased aerodynamic forces on the lactose/drug
agglomerates improve entrainment of the small drug particles upon inhalation, in addition to allowing easier filling of
small individual powder doses. Upon inhalation, the powder is broken up into its constituent particles with the aid of
turbulence and/or mechanical devices such as screens or spinning surfaces on which particle agglomerates impact,
releasing the small, individual drug powder particles into the air to be inhaled into the lung. The sugar particles are
intended to be left behind in the device and in the mouth-throat.

Although pMDIs, DPIs and nebulizers are the three major types of inhalers currently on the market today, new inhaler
designs are continually being invented and several novel designs are making their way through the regulatory
approval process, so that in the future we may see inhalers that do not readily classify into one of the three traditional
inhaler types mentioned above.

The Importance of Particle Size

When the lung is the target for the aerosol (either because the intent is to treat the lung surface or to get the drug into
the blood through the capillaries via the alveoli) the inhaled aerosol must consist of particles in a certain size range.
This is because particles larger than a certain size tend to simply land in the mouth and throat and mostly do not make
it into the lung (like a big truck travelling too fast around a corner, they have too much mass to make it around the
bends in the convoluted path through the mouth and throat). Particles somewhat smaller than a certain size tend to get
inhaled and then exhaled right back out, while very small particles usually can't be made in high enough numbers to
give high enough dosages. Thus, IPAs are usually designed to produce drug particles each having the incredibly small
mass of between approximately 1 trillionth and 100 trillionths of a gram. For particles with densities near that of
water, this corresponds to particle diameters of a few millionths of a meter (i.e. a few micrometers). For example, the
figure below shows the probability that inhaled droplets of different diameters will deposit in the mouth-throat
("extrathoracic"), tracheobronchial and alveolar regions of the lung for a particular aerosol used in treating asthma (the
curves in the figure below will be different for a different aerosol and cannot be used to evaluate other aerosols than
the one shown, particularly since the aerosol shown undergoes drug specific evaporation in the lung).

Although specific size ranges are often quoted as being ideal for IPAs (e.g. 1-5 micrometers in diameter), significant
amounts of particles outside this size range can deposit in the lung, so that these size ranges should not be viewed as
strict criteria. This is partly because the speed of the inhaled air plays a significant role in determining what size of
particles will deposit where in the respiratory tract (so that someone breathing very slowly may cause larger particles
to make it deeper in the lung than someone inhaling very rapidly). In addition, the filtering curves for particle
deposition are slowly varying functions of particle size, and do not give ideal "bandpass" filtering of particle size, as is
clearly seen in the figure above. The reader can use our Deposition Calculator to examine how different parameters
affect aerosol deposition in the respiratory tract. Finally, droplet evaporation or condensation can be different for
different aerosols and result in different deposition patterns with different aerosols.

Some Challenges with Inhaled Pharmaceutical Aerosols (IPAs)

Scientists and engineers must cope with several factors that make designing an IPA device quite difficult. One of the
main challenges with IPAs is producing such small particles - it is not easy to efficiently produce drug particles that
have a mass between 1 and 100 trillionths of a gram in a device that be carried around easily! Even if a process is
developed that can produce such small drug particles for one particular drug, it may work differently, or not work
well, for a different drug. Unfortunately, no general theory is available to predict the behaviour of different drugs in
different devices, so the research and development process must be revisited for each drug under consideration, a
time-consuming and labor intensive process.

Another challenge is caused by the fact that everyone inhales differently. Thus, the speed of the air that an inhaled
pharmaceutical aerosol (IPA) is exposed to is different for everyone. This presents some interesting challenges. For
example, for certain dry powder inhalers, this requires trying to design the powder so that people inhaling either
slowly or quickly both inhale similar amounts of powder from the device. Inhaled air speed can also affect where
particles deposit in the respiratory tract, as can clearly be seen by using our Deposition Calculator to examine the
effect of different flow rates on aerosol deposition in the respiratory tract.

A second complicating factor is caused by differences in the geometry of people's mouth-throat airway passages, with
some people having very sudden bends that cause many particles to deposit in the mouth-throat while others have a
relatively "smooth" mouth-throat passage with much less mouth-throat deposition. This can cause variability in the
dose reaching the lung between different patients. Recent work by us allows accurate person specific prediction of this
variability, allowing us to overcome one of the major factors responsible for intersubject variability with inhaled
pharmaceutical aerosols. A further complication is added by the differing effects of device mouthpieces on mouth-
throat geometry and their effect on the fluid mechanics in the mouth-throat (small diameter mouthpieces that have
been commonly used in the past have been shown by us to cause high mouth-throat deposition due to a high speed jet
of air impacting in the mouth). There are also differences in the lung geometry between individuals. Mouth-throat
geometry, mouthpiece diameter and lung volume effects are included in our Deposition Calculator. Finally, different
disease states can also result in differences in where IPAs deposit in the lungs of different individuals.

For drug carried by inhaled water droplets (such as are produced by nebulizers), the humidity of the air being inhaled
can cause differing amounts of droplet evaporation and also give rise to variations in where the drug deposits in the
lung. In fact, evaporation of nebulized aerosols leads to one of the most commonly made mistakes when measuring
nebulized aerosols with a measurement device called a cascade impactor. Users unfamiliar with nebulized aerosols
often mistakenly mix the nebulized aerosol with room air during sizing, or else allow the nebulized aerosol to be
warmed to room temperature inside the cascade impactor, both of which can lead to significant undersizing of the
aerosol (and incorrect assumptions regarding where in the lung the aerosol will deposit).

These are just a few of the challenges that need to be considered with IPAs. Much research goes into overcoming
these, as well other challenges not mentioned here. Indeed, the field of IPAs is relatively unexplored in comparison
with traditional engineering fields. The Aerosol Research Laboratory of Alberta is one of several laboratories that is
helping to explore this interesting and important area.

Oxeze® turbuhaler

Manufacturer: Form:
AstraZeneca breath-activated dry powder inhaler
Canada Inc.
Route:
Generic Name: oral inhalation
formoterol
fumarate

Why is it prescribed?

Oxeze® turbuhaler contains formoterol fumarate.

Formoterol is used to prevent bronchospasm associated with asthma and other pulmonary
disorders. It is indicated for people using optimal doses of an inhaled anti-inflammatory drug
but still experiencing regular or frequent breakthrough symptoms (e.g. coughing and
wheezing) which require the use of rescue bronchodilators.

Side Effects

Oxeze® turbuhaler contains formoterol fumarate.

Along with its needed effects, formoterol may cause some unwanted or undesirable effects.
Often, formoterol users who use their medication properly, never experience any unwanted
effects. The severity and duration of these effects are dependant on many factors including
duration of therapy, dose, route of administration and individual response. Common:

 headache
  tremor

 slight palpitations (awareness of heart beat)

 irritation of the mouth and throat

 dizziness

Uncommon:

 muscle cramps and pain

 feeling nervous or tired

 agitation

 difficulties in sleeping

Rare:

 allergic reaction (rash, swelling of face and throat)

 worsening of asthma symptoms

Check with your pharmacist or doctor if mild effects persist and become bothersome or if
more severe effects occur.

Precautions and Warnings for Oxeze® turbuhaler

Oxeze® turbuhaler contains formoterol fumarate

Maximum benefit cannot be achieved unless the inhalation device is used correctly. Even if
you have used this device before, you should have your technique reassessed by your
pharmacist and read the patient instructions that are provided with each inhaler.
Formoterol should be inhaled twice daily, regularly in the morning and at night. It is important
not to use formoterol more often than twice daily or to exceed the number of inhalations
prescribed by your doctor. Doing so increases the risk of potentially serious unwanted effects.
An inhalation of formoterol begins to work in 1 to 3 minutes and the effects last for up to 12
hours. Because of its long duration of action, it should never be used for
acute asthma symptoms (e.g. wheezing, coughing, shortness of breath). Use a short-
acting bronchodilator (e.g., salbutamol or terbutaline) if you experience these symptoms
between the two daily doses of formoterol.
Formoterol is not a replacement for inhaled anti-inflammatory medications (e.g.
corticosteroids). You must continue to use an inhaled anti-inflammatory at the dose that you
and your doctor have determined is best for you.
Using two or more inhaled medications can be confusing. Ensure that you know the purpose
of each inhaler and when it should be used.
Formoterol is intended for long-term treatment. It should not be started in people whose
asthma is worsening or unstable.
If your rescue medication isn't working as well as it usually does and/or you need more
frequent doses to control breakthrough symptoms, your asthma may be worsening. Your
condition should be reassessed by your doctor immediately.
Drug Interactions: Be sure to tell your doctor and pharmacist about any prescription and over-
the-counter medications you are taking in order to avoid any potential drug interactions. The
following drugs and drug classes have been known to interact with formoterol:

 short acting beta-agonists (e.g. salbutamol)

 monoamine oxidase (MAO) inhibitor antidepressants (e.g. phenelzine,

tranylcypromine)

 tricyclic antidepressants (e.g. amitriptyline)

 beta-blockers for high blood pressure (e.g. propranolol)

 certain medications for irregular heart rate (e.g. procainamide)

 certain diuretics (e.g. hydrochlorothiazide)

 prednisone

 methylxanthines (e.g. theophylline)

Use is not recommended in the following situations:

 allergy to formoterol

 allergy to milk, lactose

 cardiac arrhythmia (irregular heartbeat), especially increased heart rate arrhythmias

Caution is recommended in the following situations:

 diabetes

 heart disease

 high blood pressure

Use in pregnancy: Consult your doctor or pharmacist if you suspect you are pregnant or if you
plan to become pregnant.
Use while breastfeeding: Consult your doctor or pharmacist before using formoterol while
breastfeeding.
Use in children: Use of formoterol has not been adequately evaluated in children less than 6
years old.
Patient Information

Before using Oxeze® for the first time, be sure you understand how to use the turbuhaler: (dry
powder inhaler). Your doctor or pharmacist will demonstrate the proper method of loading
and inhaling Oxeze® but you should also read and keep the package insert which comes with
each inhaler. To ensure that you are getting maximum benefit from Oxeze® ask your
pharmacist to assess your inhalation technique.
Do not shake Oxeze® before use.
When the inhaler is loaded, your dose will be lost if the inhaler is accidentally dropped,
shaken, or if you breathe into the inhaler. If this happens, reload the inhaler before using.
Oxeze® turbuhaler does not contain an aerosol propellant. You draw the powder into your
lungs with your breath. Therefore, it is important to inhale sharply and deeply through the
mouthpiece when using the inhaler. Since only a very small amount of powder is inhaled with
each dose, you may not taste or feel anything when you use the inhaler. As long as you are
using the inhaler correctly, you will be receiving the prescribed amount of Oxeze®.
Oxeze® should not be used more often than twice a day. If your forget a dose, take it as soon
as possible. But, if it is almost time for your next dose, do not take the missed one, just resume
your regular schedule. Doubling up on your regular dosage could increase the chance of
serious unwanted effects.
Each turbuhaler contains 60 doses. When a red mark appears in the little window under the
mouthpiece there are approximately 20 doses remaining. You should refill your prescription at
this time.
When the red mark reaches the bottom of the window, all the doses of Oxeze® have been
used. The drying agent in the inhaler will still make a rattling sound if the inhaler is shaken.
This does not indicate that there is active ingredient remaining in the inhaler.
Oxeze® turbuhaler will not operate properly if it is exposed to moisture. Never use water or
other fluids to clean the inhaler. Always replace the cap on the inhaler after using. Store at
room temperature (15 to 30 degrees Centigrade) in a dry place.
Clean the turbuhaler once weekly using a clean, dry cloth.

Directions for Use

The usual maintenance dose of asthma in adults is 6 to 12 mcg twice daily, at 12 hour
intervals. In adults, the maximum recommended daily dose is 48 mcg. The usual maintenance
dose of asthma in children between the ages of 6 to 16 years is 6 to 12 mcg twice daily, at 12
hour intervals. In children, the maximum recommended daily dose is 24 mcg.

Lung Diseases Treated with this Drug

 asthma

 bronchospasm associated with COPD

  chronic bronchitis (COPD)

 COPD

 emphysema (COPD)

SPACER DEVICES FOR ASTHMA INHALERS

A spacer is a large chamber which is fitted to an inhaler. An asthma spacer is a device used by an asthmatic to
increase the effectiveness of an asthma inhaler.

Spacers are specially designed plastic or metal tubes that fit an inhaler on one end, while the patient breathes
normally on the other end. Some spacers utilize a collapsing bag design to provide visual feedback that successful
inspiration is taking place.

In order to properly use an inhaler without a spacer, one has to co-ordinate a certain number of actions in a set order
(pressing down on the inhaler, breathing in deeply as soon as the medication is released, holding your breath,
exhaling), and not all patients are able to master this sequence. Use of a spacer avoids such timing issues. Spacers
slow down the speed of the aerosol coming from the inhaler, meaning that less of the asthma drug impacts on the
back of the mouth and more gets into the lungs. Because of this, less medication is needed for an effective dose, and
there are fewer side effects from corticosteroid residue in the mouth.

Valves on the spacers cause the patient to breathe the contents of the spacer, but exhalation goes out into the air.
The problem of co-ordinating an inspiration with the press of an inhaler is avoided, making use easier for children
under 5 and the elderly. It also makes asthma medication easier to deliver during an attack.

Polystyrene cups or large plastic bottles can be used as spacers for children in an emergency.

Instructions for using each of these inhaled medicine devices:

 Metered-dose Inhaler (also called a "puffer" or MDI)

 Spacing chamber (also called spacer or holding chamber)

 Turbuhaler®

 Diskus®

 Diskhaler®

 Rotahaler®

 Nebuliser

 Peak flow meter

Metered-dose inhaler (also called a "puffer" or MDI)

Metered dose inhalers deliver a precise dose of medication to your airways. To get the
proper dose, it's important you use the device correctly. It's best to use the metered
dose with a spacing chamber – the spacing chamber allows more medicine to get to
the lungs.

How to use a metered dose inhaler – if you don't have a spacing chamber

1. remove the cap from the mouthpiece and shake the inhaler
2. breathe out to the end of a normal breath
3. position the mouthpiece end of the inhaler about 2-3 finger widths from your
mouth
4. open your mouth widely & tilt your head back slightly, or close your lips
around the mouthpiece
5. start to breathe in slowly, then push down once on the container – this will
spray medication into your mouth
6. continue breathing in slowly until your lungs are full
7. once you have breathed in fully, hold your breath for 10 seconds or as long as you can
8. breathe out normally
9. if you need a second puff, wait one minute and repeat these steps
 10. rinse you mouth out & gargle with water after you use your inhaler, to prevent a local yeast infection (thrush) in your mouth,
and hoarseness in your throat.

How to use a metered dose inhaler with a spacing chamber

How to clean your metered dose inhaler

To keep the inhaler clean, keep the cap on the mouthpiece. Once a week,remove the medication canister from the plastic casing and
wash the plastic casing in warm, soapy water. Rinse it in clear water. When the casing is dry, replace the medication canister in the
casing and place the cap on the mouthpiece. Make sure the hole is clear. Check the expiry date.

How to keep track of how much is left in your metered dose inhaler
People have a hard time figuring out how much medicine is left in their inhaler. Inhalers have two ingredients in them- your medicine,
which helps you breathe, and a propellant, which is there to push the medicine out, but which is not medicine itself. If you have some
fluid left in your inhaler, you just can't tell what in it- it could be medicine and propellant, or it could just be propellant. If it's just
propellant, and you take it, you won't get any benefit, and it could actually make your breathing worse.

Sometimes people try to shake the inhaler, float it in water, or taste it to see how much is left. None of these methods work. The only
way to tell how many doses are left in the inhaler is to keep track of the doses you've taken by writing them down. You can tape
a piece of masking tape to the outside of the inhaler, and mark a line every time you take a dose. Or you can keep a notebook and pen
in a bag with your inhaler, and record each dose in the notebook.

Metered-Dose Inhaler Used with a Valved Holding Chamber

A metered-dose inhaler (MDI) is a pressurized canister
of medicine that releases a medicated mist. The valved
holding chamber is a spacer device that can be used
with a metered-dose inhaler. The valved holding
chamber helps you inhale more medicine into your
lungs.

To attach the MDI to the valved

holding chamber:
1. Remove the caps from the valved holding chamber
and metered-dose inhaler.
2. Shake the metered-dose inhaler vigorously.
3. Insert the mouthpiece of the inhaler into the
rubber-sealed end of the valved holding chamber.

To use the MDI with the valved

holding chamber:
1. Breathe all the air out of your lungs. Then put the
valved holding chamber into your mouth between
your teeth. Make a tight seal around the
mouthpiece with your lips.
2. Press the MDI down once to release a spray of
medicine. The medicine will be trapped in the
chamber.
3. Breathe in slowly and deeply.
4. Hold your breath for 10 seconds. (This gives the
medicine time to reach the airways.)
5. Take the valved holding chamber out of your mouth.
 Breathe out slowly.
6. Take a few normal breaths and then repeat steps 1
through 5 for another inhalation (puff) if required.
Take the number of puffs prescribed by your health
care provider.

Cleaning the MDI and valved holding chamber

Wash the chamber and the plastic case for the
metered-dose inhaler once a week with soapy
tap water. Rinse and dry them thoroughly.

With time, the flap valve may harden and start

to curl, making the chamber inefficient. You
will then need to get a new valved holding
chamber.

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Spacing chamber (also called a spacer or holding chamber)

Spacing chambers are devices with one-way valves that hold the
medication for a few seconds after it has been released from the puffer.
Different companies make different models of spacing chambers- they
all work in about the same way.

Ask your pharmacist or yourlocal Lung Associationabout where to buy a

spacing chamber.

How to use a spacing chamber without a mask

1. Remove the cap of the spacing chamber

2. Remove the cap of the inhaler and shake it up and down
3. Insert the inhaler in the inhaler adaptor (hole) at the back of the spacing chamber
4. Blow all your breath out until your lungs are empty
5. seal your lips around the spacing chamber mouthpiece
6. Press the down once on the inhaler's container – this will spray medication into the chamber
7. Breathe in slowly and deeply until you can't take in any more breath. If your inhaler makes a whistling sound, that means you
're breathing too quickly- slow down
8. Once you have breathed in fully, hold your breath for 10 seconds or as long as you can
9. Take the spacing chamber mouthpiece out of your mouth, and breathe out normally
10. If you need a second puff, wait one minute and repeat these steps
11. Rinse you mouth out and gargle with water after you use your inhaler, to prevent a local yeast infection (thrush) in your
mouth, and hoarseness in your throat.

How to use a spacing chamber with a mask

Doctors recommend spacing chambers with masks for certain people, including children.

 Remove the cap and shake the inhaler to mix the contents.

 Place the inhaler mouthpiece in the inhaler adapter of the Aero Chamber®.

 Place the mask over your mouth and nose, making sure it is well sealed.

 Press the canister down to spray one puff of medication into the AeroChamber®.

 Breathe in and out through your mouth 3-4 times.

 If more than one puff is prescribed, repeat the procedure (do not spray more than one puff at a time into the
AeroChamber®).

How to clean your spacing chamber

Store the spacing chamber with its cap on. To wash your spacing chamber, follow the manufacturer's instructions. In general, you 'll be
advised to wash the chamber at least once a week with warm water, and let it air dry. The chamber should be completely dry before you
use it.

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Diskus® (dry powder inhaler)
A Diskus® consists of a plastic device containing powdered medication. A Diskus® is breath activated. This means when you inhale,
the Diskus® automatically releases the medication. When inhaled correctly, the medication has a better chance to reach the small
airways. This increases the medication's effectiveness.

How to use the Diskus®

1. Take the Diskus® out of the foil wrapper. Once the foil wrapper is opened the Diskus® must be used within two months.
2. Hold the Diskus® level with one hand.
3. Place the thumb of the other hand on the thumbgrip.
4. Push your thumb away from you until the Diskus® clicks. This will open the Diskus® so you can see the mouthpiece.
5. Hold the Diskus® level and slide the lever away from you until the Diskus® clicks. This will load the medication. Keep the
Diskus® level so you don't loose the medication. Hold the Diskus® level and away from your mouth and gently breathe out.
Never exhale into to Diskus®.
6. Seal your lips around the mouthpiece.
7. Inhale rapidly and deeply. Continue to take a full, deep breath.
8. Hold your breath for up to ten seconds. This allows the medication time to deposit in the airways.
9. Resume normal breathing.
10. Close the Diskus® by placing your thumb on the thumpgrip. Pull your thumb toward you until the discus clicks. The
mouthpiece will be hidden and the lever will be reset.
11. If the medicine you are taking contains a corticosteroid, rinse your mouth out & gargle with water after you use it, to prevent a
local yeast infection (thrush) in your mouth, and hoarseness in your throat.

How to tell when the Diskus® is empty

 The Diskus® has a dose indicator on the top of the device. Numbers on the dose indicator shows how many doses are
left in the diskus®.
 When there are five doses left in the Diskus® the numbers on the dose indicator will turn red. This means the Diskus®
is almost empty.
 When the red number is at 0 the Diskus® is empty. Start using a new Diskus®.

How to care for your Diskus®:

Keep the Diskus® closed when not in use. Keep the diskus® dry. The Diskus® does not need to be cleaned routinely. If the mouthpiece
is dirty, wipe it with a cloth.

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Turbuhaler® (dry powder inhaler)

A Turbuhaler® is a plastic device containing dry powdered medication. A Turbuhaler®
is breath activated. This means when you inhale, the Turbuhaler® automatically
releases the medication. When inhaled correctly, the medication has a better chance to
reach the small airways. This increases the medication's effectiveness.

How to use a Turbuhaler®

1. Unscrew the cover and remove it

2. Holding the device upright, turn the coloured wheel one way and back the other way, until it clicks - it is now loaded
3. Breathe out
4. Place the mouthpiece between your lips and tilt your head back slightly
o Breathe in deeply and forcefully
o Hold your breath for 10 seconds or as long as you can
o Remove the Turbuhaler from your mouth, and breathe out
o If a second dose is prescribed, repeat the steps
o If your Turbuhaler;reg; contains a corticosteroid medicine, rinse you mouth out and gargle with water after
you use it, to prevent a local yeast infection (thrush) in your mouth, and hoarseness in your throat.

How to tell when the Turbuhaler® is empty

The Turbuhaler® is empty and should be thrown out when the zero is in the centre of the dose-counting window.

How to clean your Turbuhaler®

Clean mouthpiece two or three times a week. Using a dry cloth, wipe away any particles which have collected on the mouthpiece. Never
wash the mouthpiece. When a red mark and the number zero appears in the centre of the little window, the Turbuhaler® is empty.

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Diskhaler® (dry powder inhaler)
Diskhaler® is a device you load with a small plastic disk. The disks contain several small pouches (blisters), each
holding one dose of medication. Each time you need a dose, the Diskhaler® punctures (bursts) a pouch of the
medication on the disk, so you can inhale it.

How to use a Diskhaler®

1. Remove the cover and check that the Diskhaler and mouthpiece are clean.
2. If a new medication disk is needed, pull the corners of the white cartridge out as far as it will go, then press the ridges on the
sides inwards to remove the cartridge.
3. Place the new medication disk on the white rotating wheel, numbers facing up. Slide the cartridge all the way back in.
4. Pull the cartridge all the way out, then push it all the way in until you can see the highest number on the medication disk in
the indicator window.
5. With the cartridge fully inserted, and the device kept flat, raise the lid as far as it goes, to pierce both sides of the medication
blister.
6. Move the Diskhaler® away from your mouth and blow out all of your breath.
7. Place the mouthpiece between your teeth and lips, making sure you do not cover the air holes on the mouthpiece. Inhale as
quickly and deeply as you can.
8. Take the Diskhaler® away from your mouth and holding your breath for about 10 seconds.
9. Breathe out slowly.
10. If you need another dose, pull the cartridge out all the way and then push it back in all the way. This will move the next blister
into place. Repeat steps 5 through 9.
11. After you have finished using the Diskhaler®, put the cap back on.
12. If your Diskhaler® contains a corticosteroid medicine, rinse you mouth out & gargle with water after you use it, to prevent a
local yeast infection (thrush) in your mouth, and hoarseness in your throat.

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Rotahaler® (dry powder inhaler)

A Rotahaler® is a dry powdered inhaler that's breath-activated. The device releases medicine from Rotacaps®.

How to use your Rotahaler®

1. To load the Rotahaler®, hold it by the mouthpiece and twist the barrel in one direction until it stops turning.
2. Holding the Rotahaler® vertically, press the clear end of the Rotacap? into the capsule insert hole (the top of the Rotahaler®
should be level with the top of the hole).
3. Holding the Rotahaler® vertically, with the white dot up, twist the barrel in the opposite direction until it stops - the Rotahaler®
is now loaded.
4. Breathe out.
5. Place the mouthpiece in your teeth and close your lips around it.
6. Tilt your head back slightly.
7. Breathe in deeply and forcefully through your mouth.
8. Hold your breath and remove the Rotahaler®: from your mouth.
9. Hold your breath for 10 seconds or as long as you can.
10. Breathe out slowly.
11. To ensure you have inhaled the full dose, replace the Rotahaler? in your mouth and repeat the above steps.
12. Discard the empty Rotacap® shell.
13. Sometimes 2 or 3 forceful inhalations are needed to make sure you have inhaled the full dose.
14. If a second Rotacap® is prescribed, repeat the procedure.
15. If your Diskhaler® contains a corticosteroid medicine, rinse you mouth out & gargle with water after you use it, to prevent a
local yeast infection (thrush) in your mouth, and hoarseness in your throat.

How to clean your Rotahaler®

About once a week, wash each of the two halves of the Rotahaler® in warm water, making sure that the empty rotocap shells have
been removed first. Dry rotahaler® thoroughly before reassembling.

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Peak flow meter

Peak flow meters measure how fast people can blow air out of their
lungs. Peak flow meters work like this: you blow into the meter, and it
gives you a reading (a ?score?). This reading shows how well your
lungs are working.

Doctors often ask people with chronic lung disease to take peak flow
readings every day, and by recording their readings. Sometimes people use an asthma diary card to record their readings. Taking your
peak flow regularly can help you recognize changes in your airflow, and can help you catch exacerbations before they get out of control.

You can buy a peak flow meter at your drugstore; they cost between $20.00 - $70.00.
A peak flow meter measures the rate of airflow, or how fast air is able to pass through the airways. The narrower your airways, the
slower the rate will be. Peak flow monitoring is one useful tool to measure airway obstruction (blockage).

How to use a peak flow meter

1. Move indicator to the base (to zero)

2. Stand or sit up tall
3. Take a deep breath
4. Put mouthpiece in your mouth
5. Blow as hard and quickly as possible into the mouthpeice
6. Make a mental note of your reading (your ?score?)
7. Repeat 2 more times
8. Record the highest of your three readings

Ask you doctor, certified asthma educator, or pharmacist to show you how to use your peak flow meter. Ask them how to understand
what your peak flow readings mean. Find out how you should change your treatment and medication depending on what the peak flow
meter readings are.

Use the same peak flow meter consistently; peak flow meters might take different readings, and using more than one device can
confuse the results.

How to clean your peak flow meter

Dirt trapped in your peak flow meter can make the readings inaccurate- that's why it's important clean it regularly. Follow the
manufactuer's instructions to clean your peak flow meter. In general, you should wash your peak flow meter in warm soapy water. Rinse
it gently in clear water, then let it air dry. If you have a virus (cold, flu, etc), wash your peak flow meter after every use. Make sure your
peak flow meter is completely dry before using it.

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Nebuliser
Nebulisers are medical devices that deliver medicine as a vapour for people to inhale.

How to use a nebuliser

1. Find a location where you can sit comfortably for 10-15 minutes. Plug in the compressor.
2. It is very important to get specific written instructions if you are mixing your own nebulized treatments. Mix the medication as
directed, or empty the prepared unit dose vials (UDVs) into the nebulizer. Do not mix different types of medications without
permission from your doctor or pharmacist.
3. Assemble the mask or mouthpiece and connect the tubing from this to the port on the compressor.
4. Sit in an upright position, making sure you are comfortable. Put the mask over your nose and mouth (make sure it fits
properly so the mist doesn't flow up into your eyes); OR, if you are using a mouthpiece, put it into your mouth.
5. Turn on the compressor.
6. Take slow, deep breaths. If possible, hold your breath for 10 seconds before slowly exhaling.
7. Continue until the medication chamber is empty.

How to clean your nebuliser and equipment

Wash the mask with hot, soapy water. Rinse well and allow to air dry before re-use.

This information is not intended to replace the medical advice of your doctor or health care provider. Please
consult your health care provider for advice about a specific medical condition.

© Copyright 1995-2005 The Cleveland Clinic Foundation. All rights reserved

Drug delivery devices: Dry powder inhalers

This small device is similar to a metered dose inhaler (MDI), but the drug is in powder form. The patient exhales out a
full breath, places the lips around the mouthpiece, then quickly breathes in the powder. Note that the technique is
different than for MDIs -- dry powder inhalers do not require the timing and coordination that are necessary with
MDIs. There are other important differences, so make sure that you always know the proper technique for the method
you are using.

Dry powder inhalers are becoming more common, in part because they do not use the "CFC" propellant that used to
be in all MDIs. (CFCs damage the ozone and will be phased out of MDIs in the next few years.) Dry powder inhalers
are as effective as MDIs -- in fact, some may prove to be slightly more effective.

Naturally, there are several disadvantages. If the patient exhales directly toward the device, the powder can be blown
out. Also, much of the powder ends up in the mouth, which can cause unwanted side effects -- this is similar to what
happens when a patient puts an MDI directly into their mouth. As with MDIs, it is recommended that you wash your
mouth after administering the drug.
Figure 1. Cross-section of Easyhaler® - a new generation, multidose dry powder inhaler.
Figure 1. Easyhaler® multidose dry powder inhaler.
MDI Technology for Inhalation and Nasal/Buccal Drug Delivery

Metered Dose Inhalers (MDIs), first introduced in the 1950s as a novel therapy for treating respiratory diseases like asthma and chronic
obstructive pulmonary disorder (COPD), are important medicines.

Asthma often occurs in the form of life threatening, acute attacks which need immediate treatment. Therefore, patients always have to
carry with them the necessary active substance in the small pocket-sized dispensers, the metered dose inhalers. The dispenser contains
a mixture consisting of the propellant and the pharmaceutical active substance dissolved or suspended in the liquefied propellant and
sometimes with further excipients such as cosolvents and /or surfactants added in very small amounts. When the patient actuates the
MDI, the propellant immediately evaporates at ambient conditions and produces a fine spray, the aerosol.

The incidence of asthma in developed countries is around 5 to 8% of the population and increasing at an average rate of around 5% per
year. Asthma and COPD are particulary prevalent amongst children, as the incidence in this group now approaches 15% in Western
Europe.
Worldwide, at least 300 million people suffer from asthma, and a comparable number from COPD. A minimum of 50 to 60 million
patients therefore rely on metered dose inhalers. There is international consensus that the primary treatment of these diseases should
be via inhalation – with the MDI remaining the dominant inhaled delivery system in most countries and for all categories of drugs.

Major advantages of MDIs over oral therapy and stationary nebulisers are the ease of use, its reliability, its self-contained power source,
the low costs per unit, and most important, the high patient compliance, including use by young children.

Fig. 10: Metered Dose Inhaler (MDI)

The MDI is a pocket-sized, hand-held, pressurised multiple-dose inhalation delivery system. It delivers small, precisely measured
therapeutic doses, greatly minimising the risk of adverse side effects. Unlike most nebulisers, it is portable and convenient to use.

The function of an MDI is the consistent delivery of the same amount of medication in the form of an aerosol. This allows deposition in
the passageways of the lungs.[36]

MDIs are used for the inhalation of all commonly prescribed respiratory medication and account for 70% of all inhalation therapy in the
world’s fifteen largest patient populations.[36]

A broad range of medications worldwide has been developed for the treatment of asthma, chronic obstructive pulmonary disorder
(COPD) and respiratory infection.

Already available as HFA-MDI medications are e.g. disodium cromoglycate, nedocromil, reproterol, isoproterol in combination with
atropinmethylbromide and dexamethasone, procaterol, salmeterol, salbutamol, beclomethasone, fenoterol, ipratopium bromide,
fluticasone, and combinations thereof.[35]

HFA MDIs are more efficient than CFC MDIs because virtually every aspect of MDIs has improved in recent years.

Moreover, MDIs are capable of systemic delivery, including proteins and peptides, and are also developed for nasal and buccal drug
delivery.

Diseases currently targeted for pulmonary or buccal drug delivery include, among others, diabetes, Alzheimer’s, influenza, multiple
sclerosis, pain disease, cystic fibrosis and osteoporosis.
Fig. 11: HFA 227 propelled MDI Product “Stomerin” launched by Fujisawa in September 2001 in Japan

Fig. 12: Development of world asthma market

List of applications

Air Conditioning and Refrigeration

Refrigerants (Solkane)

Pharmaceuticals

Propellant for pharmaceutical aerosols