Inhaler Technique & PEFR Maeve Corry http://geekymedics.com/inhaler-technique-osce-guide/ GET INHALER/PEAK FLOW TO DEMO!

OSCE Overview 16 stations over 2 days 8 stations per day 3 sessions a day Each station: 1 minute briefing 7 minute station 1 min questions/summary No rest stations! Topics History taking Examinations Interpretation Communications 8 minutes? Buzzer sounds

OSCE Outline Introduction Inhaler Technique Station PEFR Station Asthma & COPD Inhaler types Explanation Demonstration Assess technique Additional devices PEFR Station Conclusion

Introduce yourself with good morning/afternoon, not hi! Introduction Introduce yourself with good morning/afternoon, not hi! Wash hands Introduce yourself Patient details (name, DOB, preferred name!) Explain procedure & confirm consent Check patients understanding of their: Condition: Asthma / COPD Inhaler type & technique PEFR technique & measurement Explain at patient’s level: use patient lingo, avoid jargon & keep it simple!

Asthma Caused by narrowing of the small air passages (breathing tubes/bronchi) in the lungs The narrowing happens because the air passages become swollen & inflamed This makes it harder for air to get through & causes wheezing, coughing & problems with breathing Asthma is a common condition caused by narrowing of the small air passages (breathing tubes/bronchi) in the lungs. The narrowing happens because the air passages become swollen and inflamed. This makes it harder for air to get through and causes wheezing, coughing and problems with breathing. About one in four children will have wheezing sometime during childhood. With the right medicine and treatment, nearly all children with asthma will be able to join in sport and lead active lives. Explain that when they have an asthma exacerbation they will find breathing more difficult, but treatment aims to prevent this and relieve symptoms

COPD Break it down for the patient: Chronic bronchitis Emphysema Chronic (long term, does not go away) Obstructive (makes it hard to expel air) Pulmonary (affects the lungs) Disease (a problem to be taken seriously) Chronic bronchitis Is caused by inflammation of your bronchi (main airways that lead from windpipe (trachea) to your lungs) This can lead to excess mucus that may block airways. Emphysema Is caused by damage to the air sacs (alveoli) at the end of the smallest tubes of the lungs (the bronchioles). These tiny air sacs are where oxygen moves from the lungs into the blood. Most likely to have COPD if you are 65+ and have smoked for a long time

Inhalers

Inhaler Explanation Explain the type of inhaler MDI – Metered Dose Inhaler DPI – Dry Powered Inhaler SMI – Soft Mist Inhaler Explain inhaler medication & that it contains a set dose SABA/LABA Steroid Mixed etc. Explain aim: “to get the medication to the lungs (target organ) to relieve symptoms and manage your condition” Explain method (using a demonstration with placebo) Commonly used inhalers: DPI – turbohaler, accuhaler, easyhaler, handihaler MDI – Evohaler, Easibreathe SMI - Respimat

Inhaler Summary 3 type: Preventer Reliever Mixed Preventer (e.g. beclomethasone inhaler)
“(Name of inhaler) is a preventer – it helps to reduce the swelling in the airways and stops them from being so sensitive. You use this to lower the risk of severe attacks. I would like you to inhale …(x puff(s))…(x time(s) a day)…everyday. It’s really important that you don’t miss doses, as regular use is key to keeping your asthma/COPD under control”  – Remind the patient to rinse mouth after use if the inhaler contains a steroid due to risk of oral candidiasis.   Reliever (e.g salbutamol inhaler)
“(Name of inhaler) is a reliever. This is useful to help relieve immediate wheezing/asthma attacks. It works by relaxing the airways so that you can breathe more easily. You shouldn’t need this more than 3 times a week if your asthma is well controlled. Ask your GP for a review if you are using this more frequently. I would like you to inhale (x puff(s)) when you feel short of breath.” If prescribing SMART (Symbicort Maintenance and Reliever Therapy) regime
“Symbicort is used as both a preventer and a reliever. You need to use this regularly …(x puff(s))…twice a day to prevent symptoms and …(x puff(s))…each time you have an attack.” – Remind the patient to rinse mouth after use due to risk of oral candidiasis. 

Demonstration Demonstrate on yourself first – with a different placebo inhaler Check expiration date Shake (MDI) / insert capsule (Handihaler) Remove cap, check mouth piece is clean Stand or sit upright Position inhaler – upright, index finger on top, thumb on bottom Breathe out completely Tightly seal lips around mouth piece Press canister down + breathe in slow & deep Hold breath for 10secs Breathe out slowly Repeat as directed Replace cap 8. Load the dose – press button to puncture capsule if handihaler/press lever once if accuhaler/twist bottom if turbohaler 8. Breathe in: Dry powder inhalers (DPI) need to be breathed in quick and deep Metered dose inhalers (MDI) need to be breathed in slow and deep Soft mist inhalers (SMI) need to be breathed in slow and deep 9. Aim for back of throat, not tongue

Assess Patient’s Technique & Advise Ask patient to demonstrate the technique whilst you observe Feedback & fine tuning First point out positives Constructive criticism Patient advice: Seek emergency help if symptoms are severe and not relieved by inhaler. Seek GP if experiencing side effects or using inhaler more than 3 times per week. “You are doing … very well, but doing … may help your inhaler(s) work more effectively for you.” “You are doing … very well, but doing … may help your inhaler(s) work more effectively for you.”

Additional Inhalation Devices for Kids Types: AeroChamber spacer: smaller volume Volumatic spacer: larger volume Benefits: Improves deliverance to lungs Aids technique Reduce S/E’s Easy to use Inexpensive Portable Easy to maintain Touch up on steroid side effects! Spacers are used to improve drug deposition to the lungs in patients who cannot master their aerosol inhaler technique. They are useful in reducing side effects of high dose inhaled corticosteroids by reducing the amount of drug deposited in the mouth. 1. Prepare inhaler (shake aerosol inhaler) 2. Attach inhaler mouthpiece to the spacer device
3. Breathe out gently as far as is comfortable 4. Seal lips around the spacer mouthpiece
5. Release 1 dose into the spacer device 6. Breathe in and out through the spacer mouthpiece several times
7. Administer second dose if needed and finish   The spacer device should be washed with detergent (washing up liquid is fine) once a month and left to air-dry. It should never be wiped dry as this can cause static within the device and drug particles will stick to sides of the spacer as a result. Spacers should be replaced at least once a year.

Inhaler Technique with Spacer Assemble spacer Check expiry date Shake inhaler and remove cap Attach inhaler mouthpiece to the spacer Breathe out gently Seal lips around the spacer mouthpiece Press to release 1 dose into spacer Breathe in and out normally, through the spacer mouthpiece approximately 5 times Repeat if required after 30 seconds

Spacer Hygiene & Information Do not allow anyone else to use your spacer Clean once a week Take spacer apart Wash in warm water & a some mild soap Do not rise and drip dry overnight Re-assemble Replace every 6-12 months Do not wipe the with towel/ kitchen paper but allow it to air dry

Peak Expiratory Flow Rate (PEFR)

About PEF/Peak Flow PEFR measures the maximum speed of expiration, which shows how controlled the patient’s condition is Used to help diagnosis & management PEFR is a crude measurement (not as accurate as spirometry!) Compare to normal range (depends on gender, age & height) on chart  A peak flow diary is often recommended to monitor scores & check disease progression http://www.peakflow.com/top_nav/normal_values/PEFNorms.html

It measures the ‘puff’, so they don’t need to expire fully! Peak Flow Technique Connect a fresh cardboard mouthpiece Set the meter dial to zero Stand or sit upright Hold the meter horizontally, don’t touch the dial Take a deep breath to full capacity Seal lips tightly around mouthpiece Blow out as hard & fast as you can! Repeat two more times (1 min rest between each) Observe & record the HIGHEST reading (range: 60-800 litres/min) Thank patient & dispose of mouth piece It measures the ‘puff’, so they don’t need to expire fully! Demo on a new card board mouth piece It measures the ‘puff’ – so they don’t need to expire fully! Encourage the patient to really go for it Correct patients mistakes ASK: Any concerns or queries? To complete: Thank patient Bin cardboard mouth piece Say you would document the findings in the notes – highest reading, not the average

Just ask if you have any questions! Practice Time Please get into pairs Person 1 explain inhaler technique to person 2 Person 2 explain PEFR to person Just ask if you have any questions!

Conclusion Summarise station/findings to patient Provide leaflet (if available) ASK: Any questions/concerns? ADVISE: the patient to get touch should they have any questions/concerns Thank patient Wash hands

Any Questions?

Some advice Don’t panic! Be confident, it’s a performance Tips: Don’t introduce yourself with “Hi!”, don’t over expose the patient, don’t examine from the left hand side, check stethoscope setting, state the obvious! Refer to S4S slides, OSCE books etc. and make check list to ensure you on the right track! Practice often with friends, it’s the key to success Practice on patients on the ward for real clinical signs (especially heart murmurs and breath sounds!) Sleep well, eat well, rest, exercise & take care of yourself during the lead up to OSCEs

Helpful Resources Geeky Medics http://geekymedics.com/inhaler-technique-osce-guide/ OSCE Skills http://www.osceskills.com/e-learning/subjects/explaining-the-peak-expiratory-flow-rate-technique/ OSCE Stop http://www.oscestop.com/Inhaler%20techniques.pdf Unofficial Guide to Passing OSCEs Just remember… practice, practice, practice!