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Inhaler Therapy

Rafael J. Fernandez III, Patrick Barney

Inhaler therapy

  • Current inhaler device delivery options

    • MDI – typical handheld inhaler

      • Pro is same dose of medicine each time you use them – if used correctly.

      • Con is that it requires coordination. Patient must be able to time 3-5s slow inhalation and 5-10s breath hold w/ release of medicine, can be helped w/ spacer.

    • SMI – “soft mist inhaler,” handheld. Creates cloud of medicine that is inhaled without propellant.

      • Pros are more medicine gets into lungs than w/ MDI so lower dose can be used, does not require coordination.
    • DPI - handheld inhaler, delivers medicine whenever patient breathes in through the device, requiring less coordination.

      • Pro is lack of need to coordinate breath; Con is inconsistent dose delivery.
  • Nebulizers

    • Bronchodilators -Short-acting beta agonist (SABA): beta-2 agonism of bronchial smooth muscle for bronchodilation; also decreases mast cell mediator release). Ex: albuterol, levalbuterol
      • Long-acting begat agonist (LABA): same as SABA but have lipophilic side changes that allow longer binding and slow onset of action. Ex: formoterol, salmeterol, olodaterol
  • Corticosteroids (budesonide, fluticasone, mometasone): suppress airway inflammation

  • Anticholinergics

    • COPD and asthma exacerbation: bronchodilation and secretion inhibition in acute setting
    • Ipratropium (Atrivent) intermittent nebulizer or Ipratropium-ambuterol (Duo-Neb) intermittent or continuous nebulizer; long acting Yupelri (revefenacin)
  • Hypertonic saline, NS, 3% and 7%: Can be used to thin secretions and produce deep cough in pts who need to expectorate as part of treatment. For CF, chronic tracheostomy, NM weakness. No evidence for benefit in COPD

  • Enzymatic Agents (Dornase alpha/Pulmozyme/DNAse): enzyme that breaks down polymerized DNA in high concentrations in CF airways; indicated specifically for CF pts

  • Disulfide disruptors

    • Sever disulfide bonds of glycoproteins in mucus, lowering its viscosity and making it more amenable to suction, expectoration
    • N-acetylcysteine (Mucomyst) - nebulized form available in “adult burn inhalation injury protocol” when search “mucomyst”
  • Prostacyclin (e.g. epoprostenol): Prostaglandin analog used for pulmonary hypertension. Requires Pulmonary approval. Largely used for rescue with refractory hypoxia in ARDS


  • May be indicated in pts with CF, non-CF bronchiectasis, VAP as salvage therapy

  • Tobramycin: only nebulized antibiotic available at VUMC

  • Pentamidine: nebulized antibiotic for PJP prophylaxis, given once/month

VUMC Inpt Options

  • SABA : Albuterol (Proventil/Ventolin/Proair) - MDI, neb, continuous aerosol available

  • SABA/SAMA: Ipratropium-albuterol (Duo-Neb) - neb and continuous neb available

  • LABA – only available in combination w/ ICS. LABA/ICS: vilanterol-fluticasone (Breo Ellipta), salmeterol-fluticasone (Advair Diskus/HFA)

  • LAMA: Tiotropium (Spiriva Respimat)

  • ICS: Budesonide inhaler (Pulmicort) or neb, fluticasone furoate (Arnuity Ellipta)

  • Triple therapies (Trelegy/Breztri) are NOT available inpt. Combine ICS/LABA with LAMA as replacement.