Ventolin metered dose inhalers (AU) Our Safety & Quality Committee has been alerted to changes to the design of metered dose inhalers (MDIs/‘puffers’) for salbutamol (Ventolin) in Australia. Specifically, the inhalers have been modified to enhance community safety with the addition of a counter showing the number of remaining doses. In some situations, MDIs are used for urgent patient treatment for bronchospasm by administering salbutamol from inhalers down endotracheal tubes. This may be facilitated by using a specific circuit adapter or syringe, noting that this may be considered off-label usage However these practices require removing the inner canister from the inhaler. With the new design, the nozzle of the canister has been modified by welding the dose counter onto the canister. This precludes using the inhalers in the ways done previously. Importantly, these new dose counting inhalers have already been widely distributed throughout hospitals and have similar packaging to the older preparations. This new MDI will be rolled out as the universal device – i.e. inhalers without dose counters will no longer be available following the transition to inhalers with dose counters. Recommended actions Ensure that any residual stock of the older MDIs are reserved for crisis management supplies. Anaesthesia departments should check what type of inhalers are currently held in anaesthesia trays. Until further evidence is available, and in urgent situations, one option for intubated patients may be to administer doses from the MDI directly in the endotracheal tube from the intact MDI. Other options for management include (see references below) nebulized salbutamol intravenous salbutamol boluses +/_ infusion Adrenaline boluses +/- infusion The New South Wales Clinical Excellence Commission has advised that adaptors are available that are compatible with the new presentation of salbutamol MDIs. Product details are available here. ANZCA advises clinicians to avoid approaches that could cause harm to themselves or others. ANZCA will update fellows as more information becomes available. References Australian and New Zealand Anaesthetic Allergy Group (ANZAAG), Perioperative Anaphylaxis Management Guidelines: Adult Refractory Management Card and Paediatric Refractory Management Card. Garvey LH, Dewachter P, Hepner DL, Mertes PM, Voltolini S, Clarke R, et al. Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations. Br J Anaesth. 2019 Jul;123(1):e50-e64.