Managing asthma & Inhaler devices for respiratory disease

Managing asthma

Unfortunately …asthma is a major cause of chronic morbidity and mortality throughout the world ( estimated 300million ) and there is evidence that its prevalence has increased considerably over the past 20 years, especially in children. Fortunately …asthma can be effectively treated and most patients can achieve good control of their disease. Global Initiative for Asthma (2012)

When asthma is under control patients can;  Avoid troublesome symptoms night & day.  Use little or no reliever medication.  Have productive, physically active lives.  Have (near) normal lung function.  Avoid serious attacks. Global Initiative for Asthma (2012)

Four components of asthma care; Global Initiative for Asthma (2012) 1. Develop patient/doctor partnerships 2. Identify and reduce exposure to risk factors 3. Assess, treat and monitor symptoms 4. Manage asthma exacerbations

1. Develop patient/doctor partnerships;  Effective management requires partnership between the person with asthma and the health care team.  Education should be an integral part of all interactions between patient & HCP.  Together prepare a written, personal asthma action plan.

With your help, the help of others on the health care tem, patients can learn to;  Avoid risk factors  Take medication correctly  Understand the difference between ‘controller’ & ‘reliever’ medication.  Monitor their status using symptoms and, if relevant PEFR.  Recognise signs that asthma is worsening and take action.  Seek medical advice as appropriate.

2. Identify and reduce exposure to risk factors;  Many patients react to multiple risk factors that are ubiquitous to the environment, avoiding these can be impossible, therefore medication to maintain control have an important role.  Physical activity is common cause of asthma symptoms but patients should not avoid exercise.  Moderate/severe asthma should receive flu vaccination every year

Avoidance of common allergens/pollutants  Tobacco smoke  Drugs, food & additives  Occupational sensitizers  House dust mite  Animal fur  Outdoor pollen & mold  Indoor mold

3. Assess, treat and monitor symptoms a. Assessing asthma control b. Treating to achieve control c. Monitoring to maintain control

a. Assessing asthma control  Current treatment regime  Adherence to current regime  Level of asthma control  Daytime symptoms  Limitation of activity  Nocturnal symptoms/waking  Need for reliever/rescue inhaler  Lung function – rapid decline  Risk of exacerbation  instability

b. Treating to achieve control - prescribing devices  Inhaled medications are preferred because they deliver drugs directly to the airways, this results in potent therapeutic effects with fewer systemic side effects.  Only prescribe inhalers after patient has received training in the use of the device and have demonstrated satisfactory technique.  The choice of device may be determined by the choice of drug. (GINA 2012)

b. Treating to achieve control - prescribing devices  Patients should have an assessment of their ability to use an inhaler device by a competent health care professional.  Reassess inhaler technique as part of structured clinical review.  Exacerbations of mild/moderate asthma should be treated by pMDI + spacer with dose titrated according to clinical response. (BTS/SIGN Quick Reference Guide 2011)

b. Treating to achieve control  Use a step-wise approach.  At each step, reliever medication should be provided for quick relief, as needed.  If asthma is not controlled on current treatment regime then treatment should be stepped up until control is achieved.  Patients who do not reach acceptable level of control at step 4 should be referred to an asthma specialist (unless already known to specialist as difficult to treat)

c. Monitoring to maintain control (GINA 2012)  Ongoing monitoring is essential to maintain control & establish the lowest step & dose to minimize cost & maximize safety.  Review;  1-3 months after initial diagnosis  3 monthly  2-4 weeks after exacerbation  Monitoring is necessary after control is achieved as asthma is variable  Treated has to be adjusted periodically in response to exacerbation

4. Managing exacerbations  Exacerbation = episodes of increase in SOB; cough; wheeze or chest tightness, or combination of these symptoms  Do not underestimate the severity of an exacerbation – severe asthma can be life threatening.  Patients should be taught to recognise the symptoms of an acute exacerbation and when to seek immediate medical attention. Can be part of a written management plan.

4. Managing exacerbations  Mild exacerbation may be treated at home, if the patient is prepared.  Community  increased rapid acting B2-agonist  oral glucocorticosteroids – prednisolone  Oxygen  Monitor response to treatment  Follow up  Severity of Asthma Exacerbation – GINA 2012 p.22  Special Consideration in Managing Asthma – GINA 2012 p.23

 Pregnancy  Obesity  Rhinitis, sinusitis & nasal polyps  Occupational asthma  Gastroesophageal reflux  Aspirin & asthma  anaphylaxis Special considerations in managing asthma

Inhaler medication  RELIEVERS Short acting bronchodilators  PREVENTERS Corticosteroids  CONTROLLERS Long acting bronchodilators  COMBINATION

Inhaler technique

What is an aerosol? An aerosol is a microscopic substance of fine solid particles or liquid droplets dispersed in air or another gas

Therefore;  all inhaler devices generate an aerosol  Some are PASSIVE the device creates the aerosol  Some are ACTIVE the person has to create the aerosol

Sort the devices into passive and active devices

Where does the medication need to go?

What are the barriers to good deposition?

Aerosol Deposition at varying Particle Size 0 Micron size Deposition Optimal tracheobronchial deposition Optimal alveolar deposition Particles exhaled if <0.5 micron

Deposition in the lungs – consider what is happening to the aerosol Particles of drug are moving, when something that possesses weight is travelling at speed it has momentum, (mass x velocity = momentum) an energy that travels in a straight line

Mechanical activation  Passive  MDI – the device creates the aerosol  GENTLE inspiration  Active  DPI – person dependent – relies on personal effort, the energy of inspiration  FORCEFUL inspiration

 Inhaled medications is a waste of money if not used properly  Poor technique is a barrier to good control  Check at each visit  Don’t rely on patient’s knowledge – ask them to demonstrate  Use aids such as the in-check dial, AIMS