Cleaning Inhalers: Is It Necessary? How do I Clean My Inhalers?

Cleaning Inhalers – Helps to Prevent Infection

Dear Dr. Mahler:

I recently read that I should clean my inhalers to make sure that they work correctly and to prevent infections. However, I can’t find any information that describes how to do this. I use Symbicort inhaler and Spiriva powder every day and ProAir as my rescue inhaler. What do you recommend?

Gerard from San Juan, Puerto Rico

Dear Gerard:

You ask an important question about keeping inhaler devices clean and working properly. Unfortunately, this topic – cleaning inhalers – has not received a lot of attention.

As I am sure that others with COPD have the same question or concern as you do, here is information for cleaning inhalers as well as nebulizers.

Metered-dose inhaler (abbreviated MDI)

Cleaning inhalers is important for metered-dose inhalers

Diagram of metered-dose inhaler

When you press down on the top of the chamber, the aerosol spray comes out of the metering chamber and enters the nozzle  (see above). There is concern that the spray might accumulate over time and clog the nozzle. Cleaning the actuator with running water and air drying is recommended periodically to reduce this possibility.

Dry-powder inhaler (abbreviated DPI)

Dry-powder inhalers

A clean, dry cloth should be used to wipe away any powder from the mouthpiece. This should minimize any contamination with bacterial or fungus. This should be done periodically.

Soft mist inhaler (abbreviated SMI)

Soft mist inhaler

All that is required with the soft mist inhaler is to clean the mouthpiece with a damp cloth. It is recommended that cleaning be performed periodically.

Nebulizer

The main source of nebulizer contamination is the patient. People of all ages tend to drool into the mouthpiece which explains why bacteria are frequently found in the reservoir (cup) after use.

nebulizer is one delivery system in which cleaning inhalers is important.

Hand held nebulizer

Any liquid that remains in the cup after you have finished inhaling leaves a wet environment with potential for growth of bacteria. This has led to the recommendation that the nebulizer be rinsed, washed, and air dried after each use.

Here are specific recommendations: Detach the medicine cup and mouthpiece from the tubing. Wash the medicine cup and mouthpiece with warm soapy water and rinse them with water. Place the equipment on a clean towel to fully air dry. Make sure to do this after each treatment and daily.

  • Don’t wash the tubing. If it gets wet, replace the tubing. Also, don’t put any parts of the nebulizer into a dishwasher to clean it because the heat can warp the plastic. Tubing should be changed periodically, usually every two weeks.

Here is a way to disinfect the mouthpiece and cup every other day. Mix a solution of 1 part distilled white vinegar and 3 parts warm tap water in a clean bowl. Soak the nebulizer parts (except the tubing and mask) for 60 minutes, then rinse thoroughly and air dry.

 

Nebulizer Therapy – Can It Help Me Breathe Easier?

When to Consider Nebulizer Therapy

Dear Dr. Mahler:

I have severe COPD and attend pulmonary rehab sessions at the nearby hospital.  I take Advair in the purple disk twice a day and Spiriva powder in the capsule each morning. One of the other patients at rehab told me that she uses medicines in a nebulizer machine and this helps her breathe much better than when she used different inhalers in the past. Do you think that nebulizer therapy might help me?

Tracy from Bellingham, WA

Dear Tracy,

There are four different delivery systems for inhaled medications to treat those with COPD: metered-dose inhalers (commonly called puffers); dry powder inhalers; soft mist inhalers; and nebulizers. Some examples are shown below. In general, pharmaceutical companies have mainly been developing new bronchodilator medications as dry powders.

Metered-dose Inhaler

Metered-dose Inhaler

Examples of dry-powder inhalers

Examples of dry-powder inhalers

With dry powder inhalers, you need to take a hard and fast breath in – in order to pull the powder out of the device and overcome its internal resistance. Some individuals, especially those with more advanced COPD, may not have enough strength to successfully break up the powder packet in the inhaler device and then inhale the powder particles deep into the lower parts of the lungs.

Nebulizer therapy is used frequently to deliver bronchodilator medications to those with COPD who are experiencing a flare-up (exacerbation) both in the Emergency Department and in the hospital. Many patients with COPD find that this approach works better because you just breathe in and out normally when inhaling the medications from the nebulizer, and you don’t have to have to hold your breath as you do with the other delivery systems.

Inhaler machine for nebulizer therapy

Hand held nebulizer

There are four major reasons why your health care provider might prescribe nebulizer therapy: you have difficulty using the other inhaler devices [because of arthritis of the hands and wrists or because of difficulty following instructions (dementia)]; you have difficulty coordinating the steps to release the medication from the device, inhaling correctly, and then holding your breath for as long as possible; you are not able to breathe easier with inhaler devices; AND you do not have adequate force when breathing in to pull the powder out of the inhaler.

I suggest that you ask your health care provider whether a trial of nebulizer medications is appropriate, especially since you don’t feel it is easier to breathe with your current inhalers. Both types of bronchodilators (beta-agonists and muscarinic antagonists) as well as an inhaled corticosteroid are available in solutions for use in a nebulizer. These three different types of medications are similar to the Advair and Spiriva dry powder inhalers that you are currently using.

Best wishes,

Donald A. Mahler, M.D.

When will Bevespi Aerosphere be Available for my COPD?

Bevespi Aerosphere – a Dual Bronchodilator

Dear Dr. Mahler:

When will bevespi aerosphere be available?
 
Kenneth from Orange, MA
 
Dear Kenneth:
Bevespi Aerosphere is an inhaler approved on April 25, 2016, by the U.S. Food and Drug Administration for use in those with COPD.
What is Bevespi Aerosphere?  It contains two different bronchodilators that act to relax muscles that wraps around breathing tubes. One medication is called glycopyrrolate – a muscarinic antagonsit – and the other medication is called formoterol – a beta agonist. The two medications are delivered using a unique co-suspension technology. It is to be used twice a day, 12 hours apart.
Bevespi contains two different bronchodilators in a single device

Bevespi is a pressurized metered-dose inhaler

AstraZeneca is the pharmaceutical company that makes Bevespi.  Current plans are that Bevespi will be available in the U.S. in early 2017.

Contact AstraZeneca

Here is information from their website. If you are in the United States and would like additional information regarding AstraZeneca products, or you are a third party with an offer of services for AstraZeneca, you can contact the AstraZeneca Information Center by phone at 1-800-236-9933 (Monday – Friday 8 a.m. – 6 p.m. ET, excluding holidays).

Why will it take that long?

For the past several years medical insurance companies decide which medications they will cover (pay for) and what medications they will not cover (pay for). These companies have contracts with health care programs like Medicare, Medicaid, Anthem Blue Cross, and many others. These contracts typically start in January and last one year.
It is common that insurance companies have new contracts for preferred bronchodilators each year. This may require those with COPD to change their medication(s) when scheduled to be refilled early in the year.  Either you agree to change or else you may have to pay full price out of pocket or have a higher co-pay.
Finally, there are two other dual bronchodilators currently available in the U.S. One is Anoro Ellipta™, a dry powder, and the other is Stiolto Respimat™, a fine mist.
 
Sincerely,
Donald A. Mahler, M.D.

New Inhaler – Bevespi – Approved for COPD

FDA approves new Dual Bronchodilator – Bevespi

On April 25, 2016, the United States Food and Drug Administration approved a new inhaler called Bevespi Aerosphere™ for long-term maintenance treatment for those with COPD.

Bevespi is a pressurized metered-dose inhaler

Bevespi is a pressurized metered-dose inhaler

 

What is Bevespi?  It contains two different bronchodilators that act to relax muscles that wraps around breathing tubes. One medication is called glycopyrrolate – a muscarinic antagonsit – and the other medication is called formoterol – a beta agonist. The two medications are delivered using a unique co-suspension technology. It is to be used twice a day, 12 hours apart.

Other Dual Bronchodilator Products Bevespi is the fourth dual bronchodilator in a single device approved in the United States.  Others dual bronchodilators in order of approval by the FDA are: Anoro Ellipta®, Stiolto Respimat®, and Utibron NeoHaler®. Studies show that using two different bronchodilators are more effective in improving how the lungs work and making it easier to breathe than one bronchodilator.

It is likely that Bevespi Aerosphere™ will be available in pharmacies later this year.