Embed Size (px)
Citation preview
A sharp intake of breath
(But not for all of them!)
History of Respiratory medicines
• Early 1900s, anticholinergic drugs – Atropine and belladonna-containing
compounds were injected or formulated as inhaled powers or belladonna “asthma cigarettes”
• Principles and Practice of Medicine 1914 – Coffee is recommended
• In an article in the Lancet 1910 – dramatic responses to adrenaline
injection in three patients with asthma • 1947 inhalation of adrenaline
Inhalers around since ?
• Barriers to effective use
• Patients don’t like them • Patients can’t use them • Patients won’t use them • HCP’S can’t teach inhaler technique
So What?
• Higher levels of morbidity • Increased attendance at practice level
and A&E • Increased admissions • Inappropriate escalation of treatment • Increasing costs • Mortality
Inhaler technique and training in people with chronic obstructive pulmonary disease and asthma Capstick et al Expert Rev, Respir Med 2012
• Chronic obstructive pulmonary disease and asthma are both common conditions with an increasing worldwide prevalence.
• Inhaled delivery of drugs is essential for the management of chronic obstructive pulmonary disease and asthma to minimize systemic side effects vs oral or IV delivery, with currently available therapies.
• A wide variety of inhalers are available on the market, all of which have relative positive and negative aspects.
• Inhaler technique is repeatedly recognized to be poor in a significant number of patients.
• Inhaler technique training and education has been demonstrated to be successful.
• Advances in inhaler design and improvement in education may result in more efficient delivery of inhaled drugs.
Impact of repeated inhaler instruction on patients
6
Good adherence to inhalation therapy
0%
25%
50%
75%
100%
Patients with repeated instruction
Takemura et al 2011 Int J COPD
From the paper: The overall mean adherence score in COPD patients was 4.1 ± 0.7. Of the 55 respondents, 30 (55%) COPD patients were classified as having good adherence to inhalation
bring graph in line with these values unless you can show me where these values came from
Do healthcare professionals have sufficient knowledge of inhaler techniques in order to educate their patients effectively in their use?
23%
7%
70%
Incorrect technique7 steps and inspiratory flow check correctCorrect technique 7 steps
Baverstock et al Thorax 2010;65:A117
75% regularly involved in
teaching inhaler technique
*
Respiratory Inhalers – The Venn Diagram
Long-acting Muscarinic Antagonist (LAMA)
Long-acting Beta-2 agonists (LABA)
Inhaled Corticosteroids (ICS)
Spiriva (tiotropium) Elklira (aclidinium)
Seebri (glycopyrronium) Incruse (umeclidinium)
Asmabec, Clenil, Qvar (beclometasone)
Pulmicort (budesonide) Alvesco (ciclesonide) Flixotide (fluticasone)
Asmanex (mometasone)
Atimos, Oxis, Foradil (formoterol) Onbrez (indacaterol) Striverdi (olodaterol) Serevent (salmeterol)
Fostair (beclometasone/formoterol) Symbicort / DuoResp
(budesonide/formoterol) Flutiform (fluticasone*/formoterol)
Relvar (fluticasone**/vilanterol) Seretide (fluticasone*/salmeterol)
Anoro (umeclidinium/vilanterol)
Duaklir (aclidinium/formoterol)
Ultibro (glycopyrronium/indacaterol)
Spiolto (tiotropium/olodaterol)
* Fluticasone Propionate ** Fluticasone Furoate
Respiratory Inhalers – The Venn Diagram
Long-acting Muscarinic Antagonist (LAMA)
Long-acting Beta-2 agonists (LABA)
Inhaled Corticosteroids (ICS)
Not all available inhalers are shown. Not all inhalers shown are licensed for both asthma and COPD
Inhaler features to consider
Indicator that the patient has used the
correct inhaler technique4
Device dose counter2
Choice of drug1
Patient preference2
Patient has sufficient
coordination to use this inaler2
Patient can generate sufficient
inspiratory flow to use this
inhaler31.
2.
3.
4
Types of Inhaler Device?
•Think of inhalers in 2 categories: •Aerosol: Liquid medication or •Dry powder preparation
• Effectiveness of the inhaler depends on: •Patient co-ordination •Particle size •Effect of resistance of inhaler device MDI < DPI •Inspiratory Flow
So how would YOU inhale?
Quick test of how you would inhale through commonly-used devices
1. MDI 2. Dry Powder Inhaler (DPI)
Need to: 1. Simulate resistance of device 2. Measure speed of inhalation
How would you breathe in for these?
Slow and Steady
7 Steps to Success .......
1. Prepare (or load) dose 2. Prepare inhaler device 3. Breathe out (not into inhaler!) 4. Put lips around mouthpiece 5. Breathe in
– MDI: Slow and Steady – DPI: Quick and Deep
6. Remove inhaler from mouth and hold breath for up to 10 seconds
7. Repeat as directed
See product SPC for full user instructions
Don’t Forget• Priming inhalers
– First time and when they have not been used for a while for certain devices
• Content indicators • Cleaning!
- Replace reusable devices regularly, including spacers
• Placebo – single patient use only or for demonstration purposes only
The ideal inhaler?
Inhaler technique
• Check at each review • Check before increasing medication
