Health Professional Manual - LWWCOPDv... · Use Attachment 1 (Cue Card: ... team, their community ... • They work by opening up the airways to allow for easier breathing

Health Professional Manual

Session 4COPD Medication and

appropriate use of Inhaler Devices

➤ COPD medication➤ Inhaler devices – Metered dose inhaler (MDI) – MDI with a spacing device – Accuhaler – Handihaler – Turbohaler – Respimat Inhaler – Pulvinal – Easyhaler – Easi-breathe – Autohaler➤ Nebulisers

Adapted from the “Living Well with COPD” program (2nd edition), Montreal Chest Institute, Canada for Pulmonary Rehabilitation Programmes in Northern Ireland – 2011.

Adapted from the “Living Well with COPD” program (2nd edition), Montreal Chest Institute, Canada for Pulmonary Rehabilitation Programmes in Northern Ireland – 2011.2

COPD MEDICATION AND APPROPRIATE USEOF INHALER DEVICES

SESSION SUMMARY


Education Plan and MethodsSession Length: 30-45 minutes

• Introduction• Working Phase

1. Feedback from Learning Contract. Group Discussion 2. COPD Medication. Interactive lecturing. 2.1 Assessment of participants’ knowledge and beliefs with respect to COPD medication. Group discussion. 2.2 Presentation of the medication specific to COPD. Interactive lecturing 2.3 Medications used to treat a COPD exacerbation. Interactive lecturing 2.4 Additional medication used to manage COPD. Group discussion. 3. Inhaler devices for COPD medication. 3.1 Assessment of participants’ understanding with respect to inhaler devices. Group discussion. 3.2 Presentation of each inhaler device. Demonstration and practice. 4. Nebulisers for COPD medication. Group discussion and interactive lecturing. 5. Summary of the session and assessment of participants’ understanding and self-efficacy. Group discussion.• Closing of the sessionAppendices section: Appendix 1: Additional information: 1. Should be “Reinforcement of participants’ understanding and compliance with respect to COPD medication. 2. Reinforcement of participants’ proper use of inhalation devices.

Human Resources 1. One health professional (recommended facilitator: nurse, pharmacist or physician)

Living Well with COPD™ for Pulmonary Rehabilitation Resources 1. Information Booklet (Pages 10 to 24, and page 25 if any patients present in the session are on Oxygen) 2. Key messages: COPD Medications 3. Educational Posters: • NormalLung • COPDLung • Medications(x3posters) • Inhalerdevices(x10posters) 4. Cue cards: Action Plan, Prevent your symptoms when exercising, Inhaler technique 5. COPD Action Plan

Additional Resources 1. Board / Flipchart 2. Inhaler devices • Priortothesession,askparticipantstobringtheirowninhalerdevicesand Action Plans • Bringplacebodevicesfordemonstrationpurposes 3. Nebuliser device

Environment 1. Use a quiet and comfortable room for 10 to 15 people. Ensure proper ventilation. 2. Place the chairs in a semi-circle around the board.

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GROUP INTERVENTIONS FOR EACH PHASE OF THE SESSION


Introduction• Presentation of the Facilitator.• Outline the goals of this session.• Review the key messages from the last session and link them to this session.

Working Phase – Educational Interventions1. Feedback from learning contract

Use Attachment 1 (Cue Card: Action Plan) to support your teaching.

Evaluate how participants managed to use the strategies from their Action Plan.

Suggested script for the Facilitator:In the last session we looked at how your Action Plan plays an important part in your life, as it will help you make key decisions in treating COPD when your symptoms get worse.

Suggested questions:• DoesanyonehaveanyquestionsabouttheirActionPlan?

Provide the participants constructive feedback and reinforcement on their understanding of the directives of the Action Plan. Identify any participants having difficulty identifying their symptoms (baseline or exacerbation), understanding the Action Plan directives, getting their prescription, or any other patient that may require a one-to-one session with a member of the pulmonary rehabilitation team, their community respiratory team, practice nurse and/or doctor.

1.1 FEEDBACK FROM LEARNING CONTRACT

Present this section using Group Discussion

LifeExperiences





2. COPD Medication

Evaluate participants’ knowledge about COPD medication. Assess participants’ concerns that may affect compliance. Ask each of the participants and write the answers on the board.Suggested question:

• WhichmedicationsareusedforthetreatmentofCOPD(inhalersandpills)?

• WhichCOPDmedicationmustbeusedincaseofemergency?

• DoyouknowhowCOPDmedicationsactinsidethelungs?

• DoyoubelievethatthemedicationyoutakeforCOPDiseffective?

• DoyoubelievethatitisnecessarytotakeyourCOPDmedicationregularly?

• WhataretheconcernsyouhaveinregardstothemedicationsyoutakeforyourCOPD?

Use the posters “Normal Lung”, “COPD Lung” and “Medications” and Attachment 2 (Cue Card: Prevent your symptoms when exercising) to support your teaching.

Present to participants the role of each of the 3 groups of medication used in COPD treatment: Bronchodilators, Corticosteroids and Combination of long-acting bronchodilator and corticosteroid.

Suggested script for the Facilitator:

During the last education session, you recorded on your Action Plan the medications you use everyday to control your COPD symptoms. There are three main types of medications that are used everyday by patients with COPD: bronchodilators, corticosteroids, and combination bronchodilator and corticosteroids. I will talk about each of these in turn and then help you identify which of these medications you have been prescribed.

2.1 ASSESSMENT OF PARTICIPANTS’ KNOWLEDGE AND BELIEFS WITH RESPECT TO COPD MEDICATION


2.2 PRESENTATION OF THE MEDICATION SPECIFIC TO COPD TREATMENT

Present this section in an Interactive Way

LifeExperiences

LifeExperiences

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Note to the facilitator: • Remember to link this session to the participants’ action

plans by identifying the short-acting and long-acting bronchodilators that the participants have been prescribed.

Additional notes relative to anticholinergics (short- or long-acting): • Anticholinergic drugs may potentially worsen symptoms and

signs associated with narrow-angle glaucoma. Care must be taken not to allow the drug to be in contact with the eyes. This includes the following precautions: for spray inhalers (for example, MDI, Respimat), always use closed-mouth inhaling techniques and direct the inhaler away from the face when priming it; avoid touching Spiriva® capsules when discarding them, and wash hands if this occurs; make sure nebuliser mask fits properly and there are no leaks. Have at hand a list of names of common medications that contain anticholinergics.

Bronchodilators:

• Theyworkbyopeninguptheairwaystoallowforeasierbreathing.

• Theyrelievethesymptomofshortnessofbreath.

• Becausetheyworkfordifferentlengthsoftime,theyareusuallycalled“short-acting” or “long-acting” bronchodilators.

– “Short-acting” bronchodilators start to work within 5 minutes, therefore are ideal as reliever medications because they bring quick relief to shortness of breath (Attachment 2).

– “Long-acting” bronchodilators take up to 20 minutes to work but their effects last for longer, therefore they work for 12 hours or 24 hours to keep your airways open.

• Theymaybetakenineitherof2ways:

– “inhaled”, favoured since they work directly on the lungs, have fewer side effects and can be combined with other medications; or

– “oral”, less desired since there are more side effects and they are more difficult to combine with other medications.





Corticosteroids

• Corticosteroids–alsoknownasanti-inflammatories–reducecertaintypesofinflammationinyourairways.Corticosteroidscomeintwoforms

1. Inhaled

2. Oral

• Inhaledcorticosteroidsreducetheinflammationandswellinginyourairways.They are mainly helpful for COPD patients with frequent exacerbations.

• Oralcorticosteroidscanhelptotreatexacerbations(whichwewilltalkaboutshortly).

• Theydonotprovidequickreliefofsymptomsandshouldnotbeusedasrelievermedication.

• Theyarenotthetypeofsteroidthatissometimestakenillegallybyathletes.

Combination Long-acting Bronchodilator + Inhaled Corticosteroid

• Theseinhaledmedicationscombinethepropertiesofalong-actingbronchodilator(toopenupairways)andacorticosteroid(toreduceinflammationandswelling).

• ThesemedicationsarehelpfulforCOPDpatientswithfrequentexacerbations.

• Thesemedicationscanalsobehelpfulforsomepatientstofurtherrelievesymptoms.

• Theydonotprovidequickreliefofsymptomssotheyshouldnotbeusedasreliever medication.


plans by identifying the corticosteroid inhalers that the participants have been prescribed.

Additional notes relative to inhaled corticosteroids:• Remind participants to rinse their mouth with water (and

do not swallow) after inhaling any medication containing corticosteroids (alone or in combination). This is very important to avoid fungal infections in the mouth. Have at hand a list of names of common medications that contain inhaled corticosteroids

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Use the posters “Medications” to support your teaching.

Present to participants the role of oral corticosteroids and antibiotics to treat a COPD exacerbation

Suggested script for the facilitator:

During an exacerbation you may be prescribed additional medications such as oral corticosteroids and antibiotics.


plans by identifying the combination bronchodilator and corticosteroid inhalers that the participants have been prescribed.

• Informparticipantsthatiftheyfeeltheirmedicationsarenot controlling their symptoms then they should speak to a member of the pulmonary rehabilitation team, their GP or their Practice Nurse.

• InformparticipantsthattheyshouldmakesurethattheirAction Plan is updated every time their medications have been changed.

Additional notes relative to inhaled corticosteroids:• Remind participants to rinse their mouth with water (and

do not swallow) after inhaling any medication containing corticosteroids (alone or in combination). This is very important to avoid fungal infections in the mouth. Have at hand a list of names of common medications that contain inhaled corticosteroids.

2.3 MEDICATIONS USED TO TREAT A COPD EXACERBATION


LifeExperiences





Oral Corticosteroids

• Oralcorticosteroidsareusuallyprescribedforshortperiods(1-2weeks).

• Theyarerarelyprescribedonapermanentbasis.

• Theycanrelievesymptomssuchasshortnessofbreath,coughandsputum.

Antibiotics

• Thesemedicationsusuallycomeastablets.Theyareusedfortreatingexacerbations caused by a chest infection such as sinusitis, infected bronchitis, pneumonia, etc.

• Theycanrelieverespiratorysymptomsrelatedtoinfectionssuchasfever,worsening of cough or sputum.

• Therearemanydifferenttypesofantibiotics,butadoctorcanrecommendwhichone is best for each patient.

• Theantibiotictreatmentmustbetakencompletely,eveniftherearesignsofimprovement.

Note to the facilitator: • Inform the participants that some medications may interact

or may not be suitable for use in every patient. They need to be aware of this and if they have any queries they should discuss this with their doctor.

Additional notes relative to side effects and/or allergies:• Some medications are associated with allergies. Advise

participants that if they experience any side-effects and/or allergies they should discuss these with their doctor as these may be associated with their medications. Inform the participants that common side effects of the medications covered in this session are summarised in their information booklets (Pages 10 to 13). Some presentations (medication and inhaler) should not be prescribed to patients with allergy to milk proteins. For example: Seretide Accuhaler®, Serevent Accuhaler®, Spiriva Handihaler®, Oxis Turbohaler®, Symbicort Turbohaler®. These presentations (medication and inhaler) contain lactose which may be contaminated with milk proteins. A milk protein allergy (or milk allergy) is not the same as lactose intolerance (or milk intolerance).

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Discuss with the participants any additional medications they have been prescribed to manage their COPD and have included on their Action Plan.Suggested question:

• HaveyouincludedanyothermedicationsonyourActionPlan?

Suggested script for the facilitator: Oxygen:

• SomepeoplewithCOPDmayneedOxygeniftheyhavebeenadmittedtohospitalwith an exacerbation. Other people may need Oxygen on a long-term basis.

2.4 ADDITIONAL MEDICATIONS USED TO MANAGE COPD

Present this section using Group Discussiony

LifeExperiences

Note to the facilitator: • Identify participants who may need additional information

on oxygen therapy, for example participants who are on long-term oxygen therapy. They may require an additional education session. This should be arranged for a later date.

• Informparticipantsthatinformationonlong-termoxygentherapy can be found in their information booklet on page 25.





3. Inhaler devices for COPD medication

Evaluate participants’ understanding about inhaler devices. Assess participants’ concerns that may affect the use of inhaler devices. Ask each of the participants and write the answers on the board.

Suggested questions:

• Whichinhalerdevicesareyouusing?Canyoupleaseshowthemtome?

• Doyoufinditdifficulttouseinhalerdevices?Whichoneandwhy?

Use placebo inhaler devices to support your teaching. If placebo inhaler devices are not available use the posters “Inhaler Devices” to support your teaching.

Present each inhaler device individually, in the following order:

1. Describe its advantages and disadvantages.

2. Demonstrate the inhalation technique and have participants practice in front of you. Correct them as needed and reinforce proper use of the technique.

3. Provide additional comments.

Suggested script for the facilitator:

So you’ve brought with you today some of the most common inhalers used with COPD medication. Let’s look at each one in turn.

3.1 ASSESSMENT OF PARTICIPANTS’ UNDERSTANDING WITH RESPECT TO INHALER DEVICES


3.2 PRESENTATION OF THE ADVANTAGES, DISADVANTAGES AND INHALATION TECHNIQUES OF EACH INHALER

Demonstration and Practice

LifeExperiences

LifeExperiences

Note to the facilitator: Only present the inhaler devices and spacers that the participants use. Start with the one that is most commonly used. If participants use any other inhalers or spacers that have not been covered by the “LWWCOPD programme” for pulmonary rehabilitation, present and discuss these also.

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METERED DOSE INHALER (MDI) OR INHALATION AEROSOL

The inhalation aerosol delivers the medication directly to your lungs. When you press on the canister, one exact dose of medication is released.

Advantages and Disadvantages

• Smallenoughtobecarriedinyourpocket.

• Youneedtobeabletocoordinateyourbreathinwiththeactivationoftheinhaler.A spacing device can help if you are having difficulty.

Steps to follow

1. Remove the cap.

2. Shake the device 3-4 times up and down (to mix the contents well).

3. Tilt your head slightly back and breathe out normally.

4. Place the mouthpiece carefully between your teeth and seal your lips around it.

5. Begin breathing in slowly through your mouth. Press down once on the canister and continue breathing in slowly (only once to release one dose of medication).

6. Continue to breathe in slowly and deeply until your lungs are full.

7. Hold your breath for 4-10 seconds, so the medication will have time to settle in your airways.

8. If another dose is required, wait one minute between puffs and repeat steps 2-7.

9. Replace the protective cap.

MDI WITH SPACER


• Aspacingdeviceimprovesthedepositionofmedicationinthelowerairways.

• Itrequireslesscoordination.

• Itreducessideeffectssuchasfungalinfectionsofthemouthandthroat.

• ThespacerdevicesarebiggerthantheMDIalone,andsomepatientswillfindthem embarrassing to use in public or cumbersome to carry.

Steps to follow

1. Remove the caps.

2. Shake the inhaler 3-4 times and connect it to the spacing device, keeping the inhaler upright.

3. Tilt your head slightly back and breathe out normally.

4. Place the spacing device mouthpiece carefully between your teeth and seal your lips around it.

5. Press canister once.

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6. Breathe in slowly and deeply through your mouth.

7. a) Single breath technique: Try to hold your breath for 4-10 seconds. Then breathe out normally.

b) Tidal volume technique: If you find it difficult to take one deep breath or to hold your breath for long, breathe slowly in and out of the spacer device, 3-4 times in a row.

8. If you need more than one dose, wait 30 seconds to 1 minute between puffs and repeat steps 2-7.

9. Replace the protective caps.

Comments

• Thereareseveralspacerdevicesavailable.ThemostcommonincludetheVolumatic and the Aerochamber.

• AsyoubreatheinandoutthroughtheVolumaticwhenusingthetidalvolumetechnique, the Volumatic will make a “clicking” sound. This indicates that you are using a good breathing pattern.

• WhenusingtheAerochamber,ifthebreathinistoofast,youwillhearamusicalsound, indicating that you should slow down your breathing, otherwise the medication will remain in the throat more than in the lungs.

• Aspacermaybeusefultodelivermedicationsduringanexacerbationwhenyouare so short of breath that you are unable to use the correct technique for your MDI.

ACCUHALER®

Accuhaler® is a breath-activated inhaler. This means that the medication is released by the effort you make when breathing in.


• Thereisadosecountersopatientscanknowexactlyhowmanydosesareleft.

• Itcontainslactose,sothesweettastewilltellyouifyouhavetakenyourdoseproperly. Although for some patients this could be a disadvantage if they do not like the taste.

• Thisinhalerdoesnotneedalotofcoordination.


Steps to follow

1. Hold the outer case in one hand and put the thumb of the other hand on the thumb grip. Push the thumb away as far as it will go until a click is heard.

2. Slide the lever away as far as it will go until a click is heard.

3. Hold the Accuhaler® away from the mouth and breathe out completely.

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4. Place the mouthpiece carefully between your teeth, seal your lips around it and breathe in quickly and deeply through the Accuhaler®. Remove the Accuhaler®, hold your breath for about 4-10 seconds, then breathe out slowly.

5. Close your Accuhaler® by sliding the thumb grip back as far as it will go until a click is heard.

6. If you need more than one dose repeat steps 1-4.

HANDIHALER®

Handihaler® is a breath-activated inhaler. This means that the medication is released by the effort you make when breathing in.


• Thisinhaleriseasytouse,nocoordinationisnecessary.

• Youonlyhavetouseitonceaday.

Steps to follow

1. Open the dust cap by pulling it upwards.

2. Open the mouthpiece.

3. Remove a Spiriva® capsule from the blister (only immediately before use) and place it in the centre chamber.

4. Close the mouthpiece firmly until you hear a click.

5. Hold the HandiHaler® with the mouthpiece upwards and press the green button completely in once, and release.

6. Hold the HandiHaler® far away from your mouth and breathe out normally.

7. Place the mouthpiece carefully between your teeth and seal your lips around it. Breathe in slowly and deeply to hear the capsule vibrate.

8. Remove the HandiHaler® while holding your breath for 4-10 seconds, then breathe out normally.

9. You can breathe in again to ensure that you have taken all the medication.

10. Open the mouthpiece again. Tip out the used capsule and dispose (avoid touching the capsule; if you do, do not touch your eyes and be sure to wash your hands properly).

11. Close the mouthpiece and dust cap for storage.

Comments

• Thecapsulesaresensitivetolightandhumidity,thereforeonlyopenthealuminium cover immediately before use, and be careful in order to not to expose more than one capsule each time.



14Adapted from the “Living Well with COPD” program (2nd edition), Montreal Chest Institute, Canada

for Pulmonary Rehabilitation Programmes in Northern Ireland – 2011.

TURBOHALER®

Turbohaler® is a breath-activated inhaler. This means that the medication is released by the effort you make when breathing.


• Thisinhalerdoesnotneedalotofcoordination.

• TheTurbuhaler®isactivatedbybreathinginasdeepandashardasyoucanthroughyourmouth.Aminimuminspiratoryflowrateisneededinorderforthemedication to be delivered effectively into the lungs.

• Thepatientmaybeunabletofeel,smellortastethemedicationwhenbreathingit in.


• TheTurbohaler®mustbeprotectedagainsthumidity,sincethepowderwithinthe container could clump.

Steps to follow

1. Unscrew plastic cover.

2. Hold the Turbohaler® upright.

3. To load the inhaler with a dose turn the grip as far as it will go in one direction and then turn it back again as far as it will go in the opposite direction. You will hear a ‘click’ some time during this procedure.

4. Hold the Turbohaler® far away from your mouth and breathe out normally.

5. Place the mouthpiece carefully between your teeth and seal your lips around it. Breathe in deeply and forcefully through your mouth.

6. Remove the Turbohaler® from your mouth and hold your breath for 4-10 seconds.

7. If another dose is required, repeat steps 2-6.

8. Put the protective cap back on.

Comments

• Thedevicehasadosecounterthatcanbeseenthroughasmallwindowbelowthe mouthpiece indicating the amount of doses remaining. When the red mark appears, the device is almost empty.

• DonotshaketheTurbohaler®(itisnotnecessaryandthiswillwastethedoseifcharged).

• Therattlethatcanbeheardwhenthedeviceisshakenisnotthemedication,buta desiccant (agent to absorb the humidity that could damage the Turbohaler®) and it is not an indication of the amount of medication still available inside the device.

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RESPIMAT®


• TheSpirivaRespimat®contains60doses.Whenthepointerenterstheredarea there are enough doses for approximately 7 days. You should order a new prescription from your GP.

• Oncethedoseindicatorhasreachedtheendoftheredscale,therearenodosesleft and the Spiriva Respimat® locks. It can no longer be used.

Steps to follow

1. Hold the Spiriva Respimat® upright with the cap closed. Turn the clear base until it clicks. Open the plastic cap.

2. Breathe out slowly and holding the Spiriva Respimat® level, place the mouthpiece carefully between your teeth. Seal your lips around the mouthpiece without covering the air vents.

3. While taking in a slow, deep breath, press the dose release button and continue to breathe in slowly.

4. Remove the Spiriva Respimat® from your mouth and hold your breath for about 10 seconds.

5. Replace the plastic cap.

Comments

• BeforeusingtheSpirivaRespimat®forthefirsttimeitneedstobeprepared.Please refer to the manufacturer’s instructions for guidance on preparing the Spiriva Respimat® for use or ask a member of the pulmonary rehabilitation team for guidance.

• Donottaketheinhalerapart,orremovethetransparentbase,oncethecartridge has been inserted.

• IfyourSpirivaRespimat®hasnotbeenusedformorethan7daysreleaseonepuff towards the ground.





PULVINAL®


• Easytouse,nocoordinationisnecessary.

• IfyoutasteaslightlysweetpowderinyourmouthafterbreathinginthroughthePulvinal® you have received the dose

Steps to follow

1. Unscrew the protective cap.

2. Hold the Pulvinal® upright and tap it gently against a hard surface, to level the powder in the container.

3. Hold the Pulvinal® upright. Press the button on the mouthpiece with one hand and rotate the inhaler body anti-clockwise with the other hand until it clicks. You should see a red mark through the hole in the mouthpiece. This is the loading position.

4. Keep holding the Pulvinal® upright. Rotate the inhaler body clockwise until it clicks again and a green mark shows through the hole in the mouthpiece. This is the dose-delivery position.

5. Breathe out deeply. Do not breathe out through the Pulvinal®.

6. Place the mouthpiece carefully between your teeth and seal your lips around it, while holding the Pulvinal® upright. Breathe in through your mouth as quickly and as deeply as possible.

7. Hold your breath for 10 seconds.

8. Remove the Pulvinal® from your mouth.



Comments

• Aredringwillappearatthebottomofthecontainerwhentheinhalerneedstobe replaced. If you continue to use your inhaler after the red ring appears you may not get the correct dose that has been prescribed for you.

• Mustbekeptinadryplaceatroomtemperature.

• Donotremovetheprotectivecapuntilthemomentofuse.

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EASYHALER®



Steps to follow

1. Remove the dustcap.

2. Shake the Easyhaler® 3 to 5 times, then hold it upright.

3. Release the dose by pressing the device between thumb and forefinger – just once, until you hear a click.

4. To inhale your drug dose, first breathe out normally. Then place the mouthpiece carefully between your teeth and seal your lips around it. Take a strong, deep breath. Hold your breath for 5 to 10 seconds.

5. If you need more than one dose repeat steps 2-4.

6. Replace the dustcap after use.

Comments

• Theinhalerhasadosecounterthatshowsthenumberofremainingdoses.Thecounter turns after every 5 doses. When the counter turns red there are 20 doses left. Now’s the time to get your prescription renewed.

• ItisrecommendedthatyoukeepyourEasyhaler®initsprotectivecover.

• IfyourEasyhaler®getsdampyouwillneedtoreplaceitwithanewone.

• IfyouthinkthatyouclickedtheEasyhaler®morethanonce,removethedosefrom the mouthpiece by tapping it against the palm of your hand or, for example, a table and start again.

EASI-BREATHE®

Easi-breathe® is a breath-operated inhaler. This means it only releases a dose when you breathe in.



Steps to follow

1. Shake the Easi-breathe® vigorously.

2. Hold the Easi-breathe® upright and open it by folding down the cap which fits over the mouthpiece.

3. Breathe out normally as far as you comfortably can.





4. Place the mouthpiece carefully between your teeth and seal your lips around it.

5. Hold the Easi-breathe® upright and make sure that your hand is not blocking the airholes.

6. Breathe in slowly and deeply through the mouthpiece. Don’t stop breathing when the inhaler puffs the dose into your mouth. Carry on until you have taken a deep breath.

7. Take the Easi-breathe® out of your mouth and hold your breath for 10 seconds or for as long as you comfortably can. Then breathe out slowly.

8. After you have used your inhaler, hold it upright and close the cap immediately.

9. If you need to take more than one puff wait about one minute and repeat steps 1-8.

Comments

• Testspraytheinhalerbyfiringtwoshotsintotheairbeforeyouuseitforthefirst time or if you have not used it for five days or more. To test spray your inhaler, unscrew the top of it so you can see the metal can inside. Open the cap, shake the inhaler and spray the aerosol by pressing the can with your finger or thumb. Close the cap and put the top back on.

• Itisimportantwhenusingthismedicinetoholdtheinhaleruprightasitwillnotwork if it is not held in this position.

AUTOHALER®

Autohaler® is a breath-activated inhaler, which means that the medication is released when you breathe in.


• Doesnotrequireco-ordination.

• WhenyoubreatheinthroughtheAutohaler®youwillhearaclickandfeelmistwhen your breath activates the medication.

Steps to follow

1. Remove the cap from the Autohaler®.

2. Shake the Autohaler®.

3. Hold the Autohaler® upright.

4. Push the lever up so that it stays up.

5. Keep holding the Autohaler® upright, making sure that your hand is not blocking the air vent at the bottom.

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6. Breathe out as far as you comfortably can and immediately place the mouthpiece carefully between your teeth and seal your lips around it.

7. Breathe in slowly and deeply through the mouthpiece. Do not stop breathing in when you hear the click and feel the mist in your mouth. It is important that you keep breathing in after the puff is released.

8. Hold your breath for 10 seconds and then breathe out slowly.

9. Return the lever to the down position while keeping the Autohaler® upright.



Comments

• ThemedicinewillonlybereleasedfromtheAutohaler®ifyoupushtheleverupfirst. This gets the dose ready so that it will be released when you breathe in through the inhaler.

Note to the facilitator: • Emphasise to participants the importance of taking their

prescribed medication regularly. Correct inhalation technique is vital to prevent and control symptoms (shortness of breath, wheezing, etc).

• Emphasisetoparticipantstheimportanceofregularlycleaning and maintaining their inhalers and spacers. Refer them to the manufacturers instructions included with each device and also to their information booklet (Pages 14 to 23).





4. Nebulisers for COPD medication

Evaluate participants’ understanding about nebulisers.


• Doesanyoneuseanebuliser?

• Whatisanebuliser?Whydoyouuseit?

Use a nebuliser device to support your teaching.

Suggested script for the Facilitator:• Anebuliserisusedbypatientswhohavedifficultyusinganinhalerand/orspacer.Most

people with COPD do not need a nebuliser.• Thenebuliserchamberholdstheliquidmedication.Thecompressoristhemachinethat

provides the pressure to produce fine droplets from the liquid medication. The fine droplets are breathed in through a mouthpiece or mask.

• Itcanbeusefulwhenyouaretakinghighdosesofmedication.Itisusedinhospitals,especially in Accident and Emergency.

• Nebuliserscanbeusedwithanymedicationthatisavailableinliquidform.Youshouldonly use a nebuliser if your doctor has advised you to.

4.1 ASSESSMENT OF PARTICIPANTS’ UNDERSTANDING WITH RESPECT TO NEBULISERS


4.2 PRESENTATION OF THE USE OF NEBULISERS FOR COPD MEDICATION


LifeExperiences

LifeExperiences

Note to the facilitator: Emphasise to participants the importance of regularly cleaning and maintaining their nebulisers. Ask them to get a member of the community respiratory team to help them practice how to set up and use their nebuliser. Also refer them to the manufacturer’s instructions.

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5. Summary of the session and assessment of participants’ understanding and self-efficacy

Evaluate participants’ understanding and self-efficacy to comply with COPD medication by taking it as prescribed on a regular basis and using the proper technique. Use this opportunity to summarise the key messages from the session. Use Attachment 3 (Key messages: COPD Medications) to support your teaching.


• HowconfidentareyouthatyouknowwhyyouuseyourCOPDmedication?

• HowconfidentareyouthatyouknowhowtouseyourCOPDmedication?

• Howconfidentareyouthatyoucanuseyourmedicationsasprescribed,withoutforgettingdoses?

Suggested script for the Facilitator:• Takeyourmedicationsregularlyandasprescribedinordertomanageandcontrolyour

symptoms.• Usingyourinhalerswiththepropertechniqueisveryimportanttogetthemaximum

benefit. Ask a member of the pulmonary rehabilitation team, your GP or your Practice Nurse to review your technique on a regular basis.

• Ifyoufeelyourmedicationsarenotcontrollingyoursymptoms,speaktoamemberofthe pulmonary rehabilitation team, your GP or your Practice Nurse.

• MakesurethatyourActionPlanisupdatedeverytimeyourmedicationshavebeenchanged.

5.1 SUMMARY OF THE SESSION AND ASSESSMENT OF PARTICIPANTS’ UNDERSTANDING AND SELF-EFFICACY


LifeExperiences

Note to the facilitator: • Remind participants to ask their GP and/or Practice Nurse

to review their inhaler techniques at each follow-up visit.• Informparticipantsthatthekeymessagesfromthis

session are summarised on their key messages sheet (attachment 3) and the inhaler techniques are summarised in their information booklets (Pages 14 to 23).


ATTACHMENTS





If participants feel confident complying with their COPD medication by taking it as prescribed, on a regular basis and using the proper technique, ask them to continue applying the strategies suggested in this session.

If some participants do not feel confident, ask them to speak to a member of the pulmonary rehabilitation team on an individual basis to investigate the reasons and reinforce the compliance with medication and the proper use of inhalation techniques.

Closing the session

• Answerthequestionsoftheparticipants.

• Learning contract: Encourage the participants to ask their doctor and/or practice nurse, at each visit, to check their inhaler technique and also how they set up and use their nebuliser (Attachment 4: Cue card: Inhaler technique).

• Evaluatethesatisfactionoftheparticipantswithregardstothepresent session.

CONTRACT

23


ATTACHMENTS


Action Plan

www.livingwellwithcopd.com

Would you like to discuss your Action Plan today?

Ask a member of the pulmonary rehabilitation team.

Attachment 1:


ATTACHMENTS



ATTACHMENTS



If you become wheezy or very short of breath when doing your exercises, remember to take your

short-acting bronchodilator (reliever) before the class.

Prevent your symptoms when exercising

Attachment 2:

25


ATTACHMENTS



Attachment 3:

COPD Medications


• Takeyourmedicationsregularlyandasprescribedinordertomanageandcontrolyoursymptoms.

• Usingyourinhalerswiththepropertechniqueisveryimportanttogetthemaximumbenefit.Askamemberofthepulmonaryrehabilitationteam,yourGPoryourPracticeNursetoreviewyourtechniqueonaregularbasis.

• Ifyoufeelyourmedicationsarenotcontrollingyoursymptoms,speaktoamemberofthepulmonaryrehabilitationteam,yourGPoryourPracticeNurse.

• MakesurethatyourActionPlanisupdatedeverytimeyourmedicationshavebeenchanged.

Key Messages

26


ATTACHMENTS


Attachment 4:


Would you like your inhaler technique checked today?

Ask a member of the pulmonary rehabilitation team.

Inhaler technique

27


APPENDICES SECTION



Appendix 1:

1. Reinforcement of understanding and compliance to medication

Evaluate and reinforce participants’ understanding and compliance with respect to COPD medication. Invite patients to ask questions. Have each patient respond at least one of the questions. Write the answers on the board.

Suggested questions to foster discussion:

• Whatistheuseofabronchodilator?

• Whatistheuseofananti-inflammatory?

• Whichmedicationshouldyouuseincaseofemergency?

• AntibioticsandPrednisonearehelpfultotreat…?

• WhyisitimportanttotakeyourCOPDmedicationregularlyandasprescribed?

• Whatcouldhelpyoutotakeyourmedicationregularly?

1.1 REINFORCEMENT OF PARTICIPANTS’ UNDERSTANDING AND COMPLIANCE WITH RESPECT TO COPD MEDICATION


LifeExperiences


APPENDICES SECTION


NOTES



2. Reinforcement of participants’ proper use of inhalation devices

Evaluate participants’ understanding with respect to inhalation devices. Reinforce the importance of taking medication as prescribed and using the proper technique. Invite patients to ask questions. Write the answers on the board.


• Whatarethebenefitsofusingyourinhalationdevicescorrectly?

• Whataretheadvantagesofusingaspacingdevicewithyourinhalationaerosol?

• Whatcanyoudotouseproperlyyourinhalationdevices?

Explain to participants the importance to verify the techniques for the use of the various inhalation devices at each follow-up visit to their clinic or home visit. Support your explanation on scientific data

Suggested script for facilitator:

• Studieshavedemonstratedthatmorethan75%ofthepatientshavedifficultiesusing metered-dose inhalers. 1,2

• 38%ofthepatientsdonotkeepanadequatetechniqueovertime.3,4

Remember the importance of taking regularly the prescribed medication. A proper use of the different devices is vital to prevent and control the symptoms (shortness of breath, wheezing, etc.).

2.2 REINFORCEMENT OF PARTICIPANTS’ PROPER USE OF INHALATION DEVICES.


LifeExperiences

1Goodman DE, Isreal E, Rosenberg M, et al. The influence of age, diagnosis and gender on proper use of metered-dose inhalers. Am J Respir Crit Care Med 1994;150:1256-61.2Van Beerendonk I, Mesters I, Mudde AN, Tan TD. Assessment of the inhalation technique in outpatients with asthma or COPD using a metered-dose inhaler or dry powder device. J Asthma 1998;35:273-9.3De Blaquiere P, Christensen DB, Carter WB, Martin TR. Use and misuse of metered-dose inhalers by patients with chronic lung disease. Am Rev Respir Dis 1989;140:910-6.4Cromptom GK. The adult patient’s difficulties with inhalers. Lung 1990; Suppl 168:658-62.

Remind participants to ask their resource person to review their inhalation techniques at each follow-up visit.

29


NOTES



ACKNOWLEDGEMENTSLiving Well with COPD was developed in coordination with

health professional educators on COPD and patients with COPD.Adaptation from the “Living Well with COPD” program (2nd edition),

Montreal Chest Institute, Canada for Pulmonary Rehabilitation Programmes in Northern Ireland – December 2011

Participating Institutions

University of Ulster, Northern Ireland

Belfast Health and Social Care Trust, Northern IrelandMontreal Chest Institute, McGill University Health Center, Canada

Belfast Health andSocial Care Trust

Public HealthAgency


Authors:

Northern Ireland: B.O’Neill,PhD,BSc,MCSP•D.Cosgrove,PhD,BSc,MCSP•

J.MacMahon,FRCP•J.M.Bradley,PhD,BSc,MCSP

Canada: M.Lebel,RN,BSc•M.Sedeno,BEng,MM•D.Nault,RN,MSc•

J. Bourbeau, MD, MSc, FRCPCThe Living Well with COPD programme for pulmonary rehabilitation has been endorsed by:

The Association of Chartered Physiotherapists in Respiratory Care

The Northern Ireland Regional Respiratory Forum

Original Authors (Montréal, Québec, Canada, 2006)D.Nault,RN,MSc•M.Sedeno,BEng,MM•D.Paul-Émile,RRT•M.Paquette,RRT•

J. Bourbeau, MD, MSc, FRCPC

Participating InstitutionMontreal Chest Institute, McGill University Health Center, Canada

Documents

Health Professional Manual - LWWCOPDv... · Use Attachment 1 (Cue Card: ... team, their community ... • They work by opening up the airways to allow for easier breathing