Improving Inhaler Technique Linda Cherry Community Respiratory Practitioner

Aims: Identify the type of inhaler device prescribed Be aware of the different techniques required to use the inhaler correctly Assess your patient using their prescribed inhalers Look a the new triple therapy

When treatment is given by the inhaled route, attention to effective drug delivery and training in inhaler technique is essential. The choice of inhaler device will depend on availability, cost, the prescribing clinician, and the skills and ability of the patient. In this section be prepared to discuss issues/challenges with devices e.g. favourites, stuck in ways, assumptions, time, skill in communication, bias against/for, lack of knowledge. Discuss the importance of documenting when patients have issues with a device. Investigate with patients their beliefs, capability, dexterity, cognition, hyperinflated chest. Don’t treat a device as a medicine. Ability to make a tight seal on the mouthpiece and avoid blocking the mouthpiece with tongue. Consider patients ability to access the medication and get it into their lungs. Reference: Global initiative for chronic Obstructive Lung Disease (GOLD 2017). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated 2016. Last accessed April 2017. http://goldcopd.org/gold-reports/ 3

UK Inhaler Group Developed standards for training and assessment of inhaler technique. There are Seven basic steps to using inhaler devices. No patient should be switched to an alternative device until it has been established that they can use it effectively and they consent to the change. All healthcare professionals who work with people using inhalers should understand the fundamental difference between pressurised metered dose inhalers (pMDI) and dry powder inhalers (DPI) and their inspiratory requirements.

Assumptions! We all assume that all patients can and do use their inhalers as prescribed. The correct use of inhalers is just as important as using oral medication properly.

Baverstock et al (2010) Found that out of 150 HCP: Are Healthcare professionals the best people to check inhaler technique ? Baverstock et al (2010) Found that out of 150 HCP: Only 11 could demonstrate all the recognised steps in administration of an inhaler. 113 involved in teaching inhaler technique 72 were involved in prescribing 94 said they had received some kind of inhaler training.

Common Errors (Pts & HCP) Not breathing completely out prior to inhalation.(Pts & HCP) Lack of co ordination. (Pts & HCP) No post inhalation breath hold.(Pts & HCP) 1/3 pts with a DPI, have insufficient inspiratory effort. 25% of pts using an MDI actuate the inhaler before breathing in, often multi-dosing and failing to hold their breath. Plaza et al (2008) Janchis et al (2016).

Interestingly… Research has shown that MDI techniques tends to decline without routine review. (Basheti et al 2005. Murphy 2016) Asthma Deaths review(2014) shows a direct link between specific inhaler errors by pts and poor outcomes. A large systematic review showed a high frequency of poor and suboptimal inhaler use across all devices. In fact there has been very little improvement in inhaler technique over the last 40 years. (Janchis et al 2016).

Other concerns Inhalation of medicines can be complicated and difficult for many people, leading to sub-optimal use and effectiveness. Patient perception of device/medication. There are many different types of medicines and devices used across Asthma and COPD.

How do we check? Incheck device Flotone Whistles Use Incheck and whistles

Why is it important? Inhaled medications are central to treating Asthma and COPD. Medications are delivered directly into the airways and lungs. Higher local concentrations, lower systemic exposure and systemic side effects compared to oral and IV routes.

Effective drug deposition into the lungs, depends on: -The type of inhaler device. -The characteristics of the inhaled medicine. -The ability of the patient to use the device.

Questions to ask - review How much do you know about your respiratory diagnosis? Do you know what each of your medicines are for? Do you take your medicines as prescribed? More or Less?

Simple questions to ask: How are you getting on with your inhalers? How often and when do you take the inhalers you have? Show me how you take your inhaler. Role play

Hints and tips: Check when the pt uses their inhalers – most elderly pts take medication after breakfast, including inhalers – often after they have washed and dressed Take OD and BD inhalers on rising, may also need SABA BD dosing – 12hrs apart Encourage pts to know what is normal for them, if things change to act promptly If they are unwell, check inhaler technique and increase use of short acting bronchodilator

Spacers Do you have a spacer device? Do you know how to use it and why it was given to you? Do you use it and if not why not? Cleaning regime.

IMPROVING INHALER TECHNIQUES Respiratory Team Scarborough Hospital “Assessing inhaler technique should happen at the first prescription and then be reassessed regularly throughout primary, community and secondary care services “ NICE COPD Quality Statement “An assessment of inhaler technique to ensure effectiveness should be routinely undertaken and formally documented at annual review” National Review of Asthma Deaths (May 2014) 7 Steps Metered Dose Inhalers Metered Dose Inhaler with Spacer Dry Powder Inhalers 1 Remove mouthpiece cover 2 Prepare: Shake the inhaler 3 Breathe out as far as possible 4 Place inhaler in mouth and close lips around it 5 As you breathe in press canister and continue breathing in slow and steady 6 Remove inhaler from mouth and hold breath for up to 10 seconds 7. Wait a few seconds before repeating dose if necessary. Replace mouthpiece cover. 1. Remove cap 2 Prepare: shake inhaler and insert into spacer through hole at the end 3. Breathe out gently as far as is comfortable 4. Place spacer mouthpiece in mouth and close lips around it 5. Press canister down and breathe normally for 5 breaths in and out 6. Remove spacer from mouth 7. Wait a few seconds and repeat if necessary Replace mouthpiece cover. 1. Prepare the inhaler device (remove cap) 2. Prepare or load the dose 3. Breathe out fully and gently, but not into the inhaler 4. Place inhaler mouthpiece in mouth and seal lips around mouthpiece 5. Breathe in quick and deep 6. Remove inhaler from mouth and hold breath for up to 10 seconds 7. Wait a few seconds and repeat if necessary. Replace cap Acknowledgement: Anna Murphy, Senior Pharmacist, Leicester Owner: K Braviner and L Francis , Respiratory Unit Scarborough v1 May 2017 29

New kids on the block. Triple combination. Trimbow. Beclomethasone (ICS) formoterol(LABA) glycopyrronium. (LAMA). Maintence and treatment of moderate to severe COPD. Gold category D MDI + Aero chamber. Twice daily. Price £44.50.

Flutocasone(ICS) / Umeclodinium (LAMA) / vilanterol(LABA) Trelegy Ellipta. Flutocasone(ICS) / Umeclodinium (LAMA) / vilanterol(LABA) Maintence and treatment of moderate to severe COPD. Gold category D. Once daily. £44.50

Benefits of Triple Therapy The step up treatment for patients with symptoms & history of frequent exacerbations and who are already on a LAMA / LABA combination. Group D on gold guidelines (2017) May improve lung function and patient reported outcomes. May benefit those with a higher peripheral blood eosinophil count or ACOS (Malerba,M 2017) May improve adherence and reduce inhaler device errors.

Cons of Triple Therapy A study found that 1/3rd patients with no diagnosis of Asthma, low risk of exacerbations, and in Gold’s category A B C went onto a triple therapy quicker. A RCT did not demonstrate any benefit of adding ICS to LABA plus LAMA on exacerbations. Malerba,M et al (2017), A study by Rossi (2014) found those with a low risk of exacerbation gained no benefit from adding in an ICS. Gold (2018)concluded that more evidence is needed to draw conclusions on the benefits of triple therapy LABA/LAMA/ICS compared to LABA/LAMA.

Resources: www.rightbreathe.com Inhaler prescribing information, including licensing and inhaler technique videos BLF : disease specific information, self-management plans, patient support. Asthma UK : asthma self-management plans, patient support. BTS/SIGN, GOLD (2017), NICE (2012) guidelines Malerba,M et al (2017), Single-inhaler triple therapy utilizing the once-daily combination of fluticasone furoate, umeclidinium and vilanterol in the management of COPD: the current evidence base and future prospects. Ther Adv Respir Dis. 2018, Vol. 12: 1–12 Rossi,A. et al (2014) Withdrawal of inhaled corticosteroids can be safe in COPD patients at low risk of exacerbation: a real-life study on the appropriateness of treatment in moderate COPD patients (OPTIMO). Respir Res. 2014; 15(1): 77.