Uso adecuado de dispositivos inhalatorios
16
October

By Adem Lewis / in , , , , /


Healthcare professionals who prescribe
or manage different inhalation systems ought to understand
how they work and the correct application technique. Poor inhalation technique
sends the drug to the lower airways, causing
intrapulmonary deposit levels to drop drastically. In ideal circumstances, intrapulmonary
delivery of an inhaled drug only reaches 10%
with a pressurised device and around 20% with
a dry powder device. The remainder of the administered
dose gets lost in the upper airways. for a variety of reasons: causes related to the
inhalation device itself, causes related to the patient, the
structure of the bronchial tree, the patient’s pathology,
and lastly, on account of poor technique. There are a variety of inhalation
devices available on the market. The most common can be divided
into two categories: pressurised devices and
dry powder devices. Pressurised devices include
the conventional pressurised device. This type of device sends out
particles of various sizes. It is a suspension formulation, which means it must be shaken
before it can be used. When managing this kind
of pressurised device, coordination is necessary between
squeezing the device and inhaling. Another type of pressurised device is the modulite inhaler. Although it looks quite similar to
previous devices, it is actually more modern. It contains a formulation that is in
the form of a solution, not suspension, which means that it does not
need to be shaken prior to use. It has the additional advantage of
sending out fine particles, at a slower rate, which
improves coordination, reduces oropharyngeal impact,
and increases intrapulmonary delivery. Another device is the
respimat inhaler. It is not exactly a
pressurised device, but it contains a solution that is administered through
the device in nebulisation form. This makes it easier to inhale
the drug, even with low-level flows. The downside to this device is that when it is dispensed, it
is not yet assembled. Once a patient receives
it, he or she must insert the cartridge into the
device itself before using it for the first time. Just as I am doing, the patient must
twist the base of the device closed and it’s ready for use.
The patient must be notified that when using it for the first time two or three doses must be discharged
before it can be used. Once assembled, in order to charge
the device, it must be twisted 180 degrees, like this, until you hear a click.
The patient must remove the cap and, to administer the dose,
press on the upper button. A cloud-like micronebulisation
should appear. Whenever we find coordination-related problems, we
add an inhalation chamber to the pressurised device. These problems include:
squeezing, inhaling, difficulties in the elderly, children,
and patients in a weakened state, in emergency situations, or when we observe an increase in oropharyngeal
side effects. There are a wide variety of
inhalation chambers on the market, all of different sizes, shapes, volumes, tailored
for adults or for children, with or without a mask, etc. It is our job to determine the most appropriate
inhalation mask for each patient. Dry powder devices can be
classified as: single dose and multi-dose. Single dose
devices must be loaded each time a patient needs to take a dose of the drug. The medication comes in individual
capsules that the patient must insert into the device whenever
he or she needs to take the medication. The most common varieties on the market
today are the handihaler and the breathaler. These two devices are characterised
by their interior chamber where you insert the capsule
containing the medication. Next, you close the device and press
on the tabs that will perforate the capsule in order to release the
medication when inhaling. Dose administration during inhalation
is slower with these devices than with dry powders devices, which is why we must tell the
patient to inhale deeply and to be sure to inhale twice for each
dose of the medication. Once the patient has
completed this process, he or she must empty the device, remove the capsule, and check to be sure the capsule is empty.
If not, the patient should be advised to reinsert it into the device
and repeat the process again until it is completely empty. The inner chamber in both multi-dose
devices is the same for all doses: they are easy to use and come with an
individual dose counter. Among the most common
is the turbuhaler. In order to load it, you must remove the cap
and twist clockwise twice and then counter-clockwise until you hear a click. The device is now ready for use. Another device is the accuhaler. It is also quite easy to prepare. You just have to hook your thumb in this notch and push until
you open it completely. The patient can load it
by lowering the lever, and then it’s ready to use. Another multi-dose device is the
Genuair, or the old Novolizer. It has a visual control, which allows the patient to verify that
he or she has loaded the correct dose. You remove the cap, press on the button on
the back, and release. The visual control changes from red to green.
It is now ready to be inhaled. Like the Twisthaler, it is easy to prepare. You just
remove the cap and it’s ready for use. This device is loaded upon closing. Each time the patient closes the
device, he or she must check to ensure that it is fully closed,
until hearing a click. This way, it is pre-loaded for the next dose. To prepare the Nexthaler
you need only to remove the cap to the side until hearing a click. It is now ready for use. The inhalation technique is the same
for all of the devices, with only slight variations that we will later address. As a general rule of thumb, we
can summarize it in three steps: First, the patient must
be sitting or standing up or at least partially so. Next, the device must be prepared. Third, the patient must exhale deeply and forcefully and fit the device
around his or her lips and inhale deeply, holding the air in the chest, for 8 to 10 seconds. After this, we recommend slowly
releasing the air through the nose, rinsing the mouth and throat with
water to get rid of any remaining medication in this area, and storing
the device in the appropriate place. We recommend a dry place with a constant temperature. Extreme temperatures, both hot and cold, can destroy the medication
that these devices contain, and dry powder devices are particularly sensitive to moisture and humidity: the dose would solidify. If a patient needs to take more than
one dose, we recommend waiting 30 seconds between one dose and the next. As I was saying before, the technical differences in the inhalation
process lie in how the device is prepared and in the inhalation itself. As for preparing the device, we mustn’t forget that it is a pressurised device. It must be placed in an L-shape position
and squeezed two or three times before discharging the dose. A pressurised device like the modulite
would also be positioned in an “L”, although it needn’t be shaken
because it is a solution. When preparing a dry powder
device, it is important to keep it as upright as possible and to keep from shaking or turning
it upside down once it has been loaded. Additionally, you mustn’t blow through
the device because the dose would be lost. As for technical differences, when inhaling with a
pressurised device, you must breathe deeply and slowly so as to decrease oropharyngeal impact and
facilitate coordination. The patient must begin inhaling
slowly, and after two seconds, discharge the pressurised device. With a dry powder device,
inhalation must be forceful from the very start, forceful and deep, in order to discharge the dry
powder particles and ensure that a greater amount of the drug enters the lungs. Now: inhaling with a
pressurised device. First, you remove the cap. You shake the device two or three times and then exhale. The patient must fit the device around his or her lips. In
this case I will leave it out of my mouth so that you can see the difference between beginning
the inhalation process and squeezing the device. You then remove the device and hold your breath for 8 to 10 seconds,
exhaling the air through the nose. When using a dry powder
device, you must inhale more forcefully than with a
pressurised device. I will now do a demonstration.
You empty the lungs, adjust the device, and slowly let the air
out through the nose. In general, when
selecting a device, there are dry powder devices,
which are easy to use and make it possible to discharge more
of the drug into the lungs, That being said, the healthcare professional
must assess the patient’s air intake. We use a pressurised system
with a chamber or nebuliser for elderly patients, children, patients who are
weak, in emergency situations, when there is insufficient
air flow for a dry powder device. To conclude, I will review
the critical errors that would direct the drug
into the intrapulmonary area. With a pressurised device, one critical
error would be if the patient doesn’t remove the cap before taking
the medication or doesn’t shake the device when it must be
shaken before it can be used, or discharging before inhaling—
that is to say without coordinating between the device
technique and inhalation. Another critical error would be
to turn the pressurised device upside down. You must remember that the device
should be positioned in an “L”. Another major mistake with
this kind of device would be to inhale too forcefully or to fail to hold your
breath after inhaling. Squeezing the device several times
during the same inhale is yet another critical error. Critical errors with dry powder devices include
failing to load the device properly, placing it face-down after loading
it blowing through the device, not inhaling forcefully enough or failing to hold
your breath afterward. Critical errors with inhalation chambers include failing to shake the device before
inserting it or inserting
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the pressuriser
00:12:44,690 –>00:12:49,450
backwards, letting more than three seconds pass
between squeezing the pressuriser and beginning to inhale, or poor upkeep and maintenance
of the chamber, deficient hygiene, failing to replace it when
cracks are noted or after 6 or 12 months,
depending on daily use.


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