July 14, 2016 Volume 21 Issue 14 Correct use of inhalers: Help patients breathe easier Asthma and chronic obstructive pulmonary disease (COPD) are life-long, U-500 syringe approved by FDA. Last potentially life-threatening diseases that represent the leading chronic res - week, the US Food and Drug Administration piratory diseases in the world. 1 Inhalation of medications is an effective (FDA) approved a dedicated syringe man - method for rapidly delivering short- or long-acting bronchodilators and ufactured by BD for the administration of corticosteroids to prevent, control, and treat respiratory symptoms that ac - regular insulin (concentrated) U-500 ( HU- company these diseases. Inhalation of medications may also reduce the MULIN R U-500) provided in vials. The risk of adverse drug effects because the medications can often be provided in lower volume of the new U-500 syringe is 0.5 mL doses than an oral form of the drug. Types of inhalers Rescue inhalers that deliver short-acting bronchodilators to relieve sudden respiratory symptoms, and maintenance inhalers that deliver long-acting bronchodilators and corti - costeroids to prevent and control respiratory symptoms, are the cornerstone of managing asthma and COPD. For a list of common rescue and maintenance inhalers used in the Figure 1. New U-500 insulin syringe from BD. Availability will be later this year. US, visit: www.ismp.org/sc?id=1764 . Inhalation devices that deliver these medications are available in four basic types: (Figure 1). The scale measures from 25 units to 250 units in 5 unit increments. The Pressurized metered-dose inhalers (MDIs) , which have been around for decades, syringe has a 31 gauge needle that is 6 mm typically consist of a small canister of medication fitted into a plastic body with a in length. The syringes will be available mouthpiece. Each dose is delivered by pressing the canister into the plastic body while later this year. inhaling through the mouthpiece. Use of a spacer that connects to the MDI makes it easier to inhale the dose, which is first released into the spacer and then inhaled slowly. Once available, this means that U-100 sy - ringes or tuberculin syringes should no Dry-powder, breath-activated inhalers are preloaded with the medication(s) inside longer be used when U-500 insulin is ad - the device. Prior to use, a single dose of the medication is loaded into the mouthpiece, ministered in hospitals or by patients at often by turning or twisting the inhaler body until a “click” signals the dose is ready to be home. In the past, product labeling included inhaled. Patients simply take a deep breath while their lips are sealed around the inhaler, a conversion table to facilitate use of a U- and a single dose is delivered (breath-activated). 100 syringe (every unit on the U-100 scale was equivalent to 5 units of U-500 insulin). Dry-powder, capsule inhalers utilize capsules as the dose-holding system, which are But this often led to confusion and medication inserted into the device by the manufacturer or by the patient prior to use, and punctured errors when patients reported doses in by the device before each dose is inhaled directly from the inhaler. terms of U-100 syringe units (e.g., 40 units when in reality they were taking 200 units). Soft mist inhalers are a propellant-free liquid inhaler that provides a slow-moving, soft With tuberculin syringes, conversion to mL aerosol cloud of medicine to help patients inhale the medication, even if they can’t take dosing was necessary, which also led to a very deep breath. dosing errors. FDA has said that since con - versions are no longer needed with this Errors with inhalers new U-500 insulin syringe, the Humu LIN R The correct use of an inhaler depends on its type; thus, each manufacturer provides U-500 insulin vial’s package insert will be detailed instructions for use, some with a Medication Guide for consumers and/or a updated to remove the dose conversion in - short online video to help visualize the technique. Unfortunately, up to 94% of patients formation for U-100 and tuberculin syringes. with asthma and COPD use their inhalers incorrectly. 2-4 Problems are not limited to one Humu LIN Regular U-500 is also available type of device, 3 nor are they limited to patients—even healthcare professionals have in a prefilled pen which measures the made errors. 2 Misuse leads to reduced efficacy and poor outcomes. For example, in a concentrated insulin in 5 unit increments. continued on page 2 —Inhalers > continued on page 2— SAFETY briefs > July 14, 2016 Volume 21 Issue 14 Page 2 > Inhalers—continued from page 1 cont’d from page 1 study published in 2015, Bonds et al. found that only 7% of patients who used MDIs Unless the U-500 pen is prescribed, U-500 demonstrated proper technique; 93% made at least one mistake, and of those, 63% syringes should be co-prescribed with U- missed 3 or more steps in the 11-step process. 2 While most of these errors typically result 500 insulin vials for outpatients and should in diminished drug delivery rather than no delivery at all, other errors have resulted in be used in hospitals for this purpose. omitted doses, overdoses, and exacerbation of the underlying disease and respiratory symptoms. FDA and ISMP believe that patients should only use the U-500 insulin syringe with the Common errors made by patients using any inhaler include: 5,6 U-500 insulin vial, and switching between Not holding their breath long enough after inhaling a dose (hold for about 10 types of syringes should not occur. ISMP seconds or as long as comfortable) also recommends that, unless a U-500 pen Using an empty inhaler, often believing an inhaler still provides doses even after is dispensed, all U-500 doses should be the dose counter is at zero because the patient can still see or feel a “spray” prepared by pharmacy, and that U-500 vials Forgetting to exhale completely before each dose or exhaling into the inhaler and empty U-500 syringes should not be Not using maintenance inhalers when asymptomatic stored outside the pharmacy. Common errors made by patients using an MDI (with and without a spacer) include: 5,6 Crash cart drug mix-up. During a neonatal Not shaking the canister or container before each dose code, a physician asked for EPINEPHrine, Inhaling at the wrong time (not in sync with pressing the inhaler) but a nurse inadvertently prepared a Aiming the inhaler at the roof of the mouth or tongue, rather than the throat prefilled emergency syringe of infant 4.2% Inhaling an unnoticed foreign body that has entered an uncapped inhaler sodium bicarbonate injection. Three doses Damaged or sticky spacer valves that limit the delivery of the medicine of the wrong medication were given. The outcome of the neonate that coded is un - Common errors made by patients using a dry-powder, breath-activated inhaler include: 5,6 known at this time. The error was discov - Failing to load a dose before inhaling ered post-code when the empty packages Loss of some medication by holding the inhaler mouthpiece upside down during were recognized as incorrect. or after loading a dose Failure to inhale strongly enough to draw the medication out of the device Although it’s clear that the sodium bicar - bonate carton’s label must not have been Common errors made by patients using a dry-powder inhaler that requires loading and properly confirmed, part of the problem piercing of a capsule prior to each dose include: 5,6 may have been related to the way the crash Not piercing the capsule cart trays were prepared with a packing Forgetting to remove the spent capsule and not using a new capsule for each dose Failing to take a second breath (if indicated) to receive the full dose Swallowing the capsule instead of inhaling its contents Placing the capsule into the inhaler mouthpiece instead of the chamber designed to hold the capsule, which can result in swallowing or choking on the capsule during inhalation Errors with newer inhalers Figure 1. The packing slip inside the crash cart tray Over the past few years, several new devices for the administration of inhaled medications covered the EPINEPH rine carton labels, which led have been introduced. Some of the devices are used to administer newly marketed to preparation of sodium bicarbonate syringes. medications, while others contain previously available drugs in a different administration slip placed inside the tray that covered the format. They were designed to address some of the problems with older inhalers and to EPINEPHrine carton labels ( Figure 1). Also, improve the ability to use the inhalers correctly. Specifically, the newer inhalers include: the sodium bicarbonate syringe labels may A dose counter, which allows patients to see when the supply of medication is low. have been oriented upside down in com - This was previously available on some dry-powder inhalers but not on MDIs. parison to the nurse’s point of view. During A longer duration of spray at a lower speed to help patients receive the full dose a neonatal code, since doses are so small, despite problems with coordinating the spray with the breath and the depth of the more than one dose of medication might breath (e.g., Respimat soft mist inhalers). come from the same syringe, which can The inability to activate a dose when all of the medication has been used. Once the compound a selection error. The report we last dose has been taken and the inhaler is empty, the mechanism to prepare received did not specify if this was the case another dose is locked, preventing the use of an empty inhaler.