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Chapter 145: Pulmonary Pharmacotherapy

Karen J. Tietze; Scott Manaker

Content Updates - December 2018

New Combination Agents, Biologics, and Anti-Immunoglobulin E Biologics

Introduction

A wide spectrum of therapeutic agents is currently employed in the treatment of respiratory disorders, including obstructive lung diseases. This chapter reviews the rationale for, and clinical use of, these agents in current clinical practice.

Drug Delivery

Inhaled drug administration is preferred for many medical conditions. Advantages of inhaled drug administration include rapid onset of action and the ability to deliver small drug doses directly to the lungs, minimizing systemic drug exposure. Compressed air nebulizers have been in use for more than 150 years; the first metered-dose inhaler (MDI) became available in the 1950s, followed by the first dry powder inhaler (DPI) in the 1960s.1 Many new and innovative devices have been marketed as the result of the phase-out of chlorofluorocarbon-containing MDIs.2

Device selection depends on drug–device availability, patient characteristics (e.g., age, cognitive function, manual dexterity), and patient preference (Tables 145-1 and 145-2).3,4 MDIs and nebulizers share universal designs; other drug delivery devices are unique, individually patented devices.

Table 145-1Inhaled Drug–Device Availability
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Table 145-1 Inhaled Drug–Device Availability
Drug Class pMDI BAC MDI DPI SMI Nebulizer
SABA X Xa X
SAMA X X
SABA + SAMA Xb X X
LABA X X
LAMA X
ICS X X X
ICS + LABA X X
MCS X

pMDI, metered-dose inhaler; DPI, dry powder inhaler; SMI, soft-mist inhaler; BAC MDI, breath-actuated metered-dose inhaler; SABA, short-acting β-agonist; SAMA, short-acting muscarinic antagonist; LABA, long-acting β-agonist; LAMA, long-acting muscarinic antagonist; ICS, inhaled corticosteroid; MCS, mast cell stabilizer.

aDecember 31, 2013 was the last date for sale for Maxair (pirbuterol) Autohaler, the only marketed chlorofluorocarbon-containing breath-actuated metered-dose inhaler.

bDecember 31, 2013 was the last date for sale for Combivent (albuterol plus ipratropium bromide), the only marketed chlorofluorocarbon-containing combination SABA + SAMA metered-dose inhaler.

Table 145-2Age–Device Guidelines
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Table 145-2 Age–Device Guidelines
Device Age
pMDI ≥5 y
<5 y, use with spacer or VHC and face mask
DPI
Spacer or VHC		 ≥4 y
≥4 y
<4 y, use VHC and face mask
Nebulizer Infants: SVN with face mask or hood
≤3 y: SVN with face mask
≥3 y: SVN with mouthpiece
≥5 y: breath-actuated nebulizer
All ages unable to use pMDI with VHC and face mask

pMDI, metered-dose inhaler; DPI, dry powder inhaler; VHC, valved holding chamber; SVN, small volume nebulizer.

Source: Data from National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Report No. 07–4051. Bethesda, MD. National Heart, Lung, and Blood Institute (US); 2007. www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf.

MDIs are small portable ...

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