Devices, demonstration and discussion The 3 D’s Devices, demonstration and discussion

Inhalation Medication Proven benefits Adherence and correct inhaler technique crucial Diversity in available inhaler devices -> confusion Errors in inhaler handling are common (patients AND healthcare providers) Reduced medication reaching the lungs Reduction in therapeutic benefit (disease outcomes like disease control, symptoms, quality of life, exacerbations)

Reasons why it is important to revisit inhaler technique The most expensive device is the one the patient cannot or will not use Many patients cannot use their device(s) effectively Many health care professionals cannot demonstrate them correctly Poor inhaler technique is extremely common and substantially reduces the effectiveness of inhaled therapy Cost savings cannot be made unless the patient is taking the right medicine at the right time

Mainstay of respiratory treatment

Factors influencing the choice of inhaler device GP/Nurse/Practitioner Appropriate treatment – symptomatic control & risk prevention Cost Consistency of delivery Availability of various drugs in the same device Compatibility with other devices Easy to teach technique Effectiveness of the device Patient Acceptance of the diagnosis Age Lifestyle Ease of use Inspiration flow rate Dexterity Taste Appearance of device Preferences Facilitator to present this slide as some of the factors influencing GP/nurse and patient choices when it comes to prescribing Ease of use, feeling that the drug is taken and knowing how many doses are left are some of the main points of consideration for an ideal patient inhaler device1 1. Vincken W., Dekhuijzen R., Barnes P. on behalf of the ADMIT Group, Primary Care Respiratory Journal (2010); 19(1): 10 Vincken W., et al. Prim Care Respir J 2010; 19(1): 10-20

What issues to consider? The patient Wants and needs The drug Preventer/reliever The technique Good, moderate, poor Ability Tools to help AMES/In-check

Inhaler technique Up to 90% of patients show incorrect inhaler technique in clinical studies Techniques are significantly improved by brief instruction by trained HCP However, 25% of patients have never received verbal inhaler instruction Only 11% of patients receive follow-up assessment and education

Poor inhaler technique Ask “Can you show me how you use your inhaler?” 75% of patients using an inhaler for on average 2-3 years reported they were using their inhaler correctly but on checking only 10% demonstrated correct technique Critical errors = remove cap fail to load fail to prime too fast too slow (Basheti A et al (2008)

Inhaler technique Check at each review Check before increasing medication

Do the people teaching know what they are doing? 6 different inhalers, 2 spacers 42 physicians (16 respiratory) Correct technique? 19 accuhaler 12 MDI 5 handihaler 4 turbuhaler 2 autohaler Adeni A et al AJCCM 179; 2009 Knowledge of inhaler technique amongst physicians

Results Only 24 knew when MDI was empty 14 knew when Easi-breathe was empty 12 knew when autohaler was empty 5 knew when Turbuhaler was empty Respiratory physicians scored higher than non respiratory for handi-haler only (p<0.01) In all other devices no difference in competence!

So what about other HCP’s? Incorrect inhaler technique of between 31-85% in ALL HCP’s Similar levels between Doctors, Nurses and Pharmacists! Basheti et al, 2008 Evaluation of novel educational strategy http://www.pec-journal.com/article/S0738-3991(08)00014-1/abstract

75% regularly involved in teaching inhaler technique Do healthcare professionals have sufficient knowledge of inhaler techniques in order to educate their patients effectively in their use? 75% regularly involved in teaching inhaler technique Baverstock et al Thorax 2010;65:A117

Vital variants in treatment in respiratory disease The drug The device The patient Important to get them all right!

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 www.simplestepseducation@hotmail.com 15

Pressurised MDIs High levels of prescribing – dictated by perceived costs – despite patient difficulties 51% - co-ordination of actuation with inspiration 24% - stop inhalation after actuation 12% - aerosol released into mouth whilst inhaling through the nose Reflex arrest of inspiration - cold freon effect – can further complicate the situation Ability to use pMDIs is lost with time The cochrane et al study looked at the percentage of patients not complying with individual tasks on the inhaler task list. Lack of coordination of inhaler activation and onset of inspiration ranges from 17 to 68% for the MDIs. Other tasks are not performed correctly by a significant proportion of patients, including expiration before inhaling, inhaling deeply, and holding breath at the end of the inspiration. A study by Bailey et al 32 showed that only 10% of patients did all 10 skills and 48% did eight or more skills on a checklist for MDI use correctly before a self-management education programme Broeders et al state that aerosol inhalation is considered the optimal route for administering the majority of drugs for treating obstructive airways disease. A number of MDIs and DPIs are available however inhalation is not without difficulty as it requires precise instructions on the inhalation manoeuvre. Available data indicates a frequent lack of knowledge by HCPs & patients on this manoeuvre & handling of the inhaler resulting in a reduction in therapeutic benefit Broeders et al looked at assessment of pMDI use in 1173 outpatients attending a respiratory clinic showed 51% of them had serious problems co-ordinating actuation with inspiration, 24% of these patients stopped inhaling prematurely after actuation, and in 12% the aerosol was released into the mouth while inhaling through the nose. Between 8 and 59% of pMDI users have poor or nadequate inhalation technique, the main problem being difficulty in co-ordinating pMDI actuation with inspiration. Inhaler technique in patients using the pMDI is further complicated by the exit velocity and evaporation temperature of aerosol propellants (freons). The sudden impact of cold freon onto the oropharynx can lead to a reflex arrest of inspiration (‘the cold freon effect') or continuation of inspiration through the nose instead of the mouth. This problem may be less marked with the new hydrofluoroalkane (HFA) propellant-driven pMDIs due to their slower speed of delivery Cochrane et al Chest 2000; 117: 542-50 ; Broeders et al PCRJ 2009; 18: 76 - 82

…….add a spacer? Reduce problems of co-ordinating actuation and inhalation Particle size optimised by larger particle impaction on walls of device and droplet evaporation Side effects related to oropharyngeal deposition and gut absorption reduced Optimal technique variable – e.g. multiple actuation, delay in inhalation, disuse Inspiratory flow ≤ 30 l/min needed Care/cleaning issues Does adding a spacer help? It can reduce the problems of co-ordination etc however there remains some issues which need to be addressed Broeders et al PCRJ 2009; 18: 76-82

Breath Actuated Devices Flow triggered system No difference between “good” and “bad” users Co-ordination of inspiration and puff release needed ≥ 20 - 30 l/min inspiratory flow needed to trigger drug release Fewer critical errors than pMDI According to Broeders et al there are fewer critical errors when using this system however there are still problems encountered with this delivery system. Only available for use with salbutamol in patients with COPD Broeders et al PCRJ 2009; 18: 76-82

Dry Powder Devices Multi-dose devices and single dose capsules All DPIs require the patient to prepare the dose prior to inhalation Failure to do this correctly results in no dose irrespective of inhalation technique More critical errors with single dose than multi dose devices Failure to exhale to FRC and exhaling into the device are the most common critical errors Abstract of the Azouz & Chrystyn paper explains why inhalation manoeuvres through a DPI should start with gentle expiration away from the device. Place the inhaler in the mouth ensuring there is a tight seal. This should be followed by an immediate forceful inhalation as fast as possible and continuing as long as the patient can comfortably achieve. There is a wrong assumption that inhalation flows through each DPI is the same and that low flows through some DPIs suggest that dose delivery is impaired eg. A low flow through a DPI with high resistance generates the same turbulent energy as a fast flow with low resistance. Therefore depending in the device different inhalation flows are compatible with potentially effective use, Flow measurements should be a guide to train patients to inhale faster Azouz and Chrystyn PCRJ 2011; 21: 208-13

Misconception True or false using a DPI always require a forceful inhalation  some inhalers require forceful and deep inhalation while others require slow and deep inhalation depending on the internal inhaler resistance

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 www.simplestepseducation@hotmail.com 21

How would you breathe in for these? Slow and Steady www.simplestepseducation@hotmail.com 22

How about these? Deep and fast www.simplestepseducation@hotmail.com 23

How about these? ? www.simplestepseducation@hotmail.com 24

Examples of poor technique www.simplestepseducation@hotmail.com 25

7 Steps to Success ....... Prepare inhaler device Prepare (or load) dose Stand up or sit up straight Breathe out (not into inhaler!) Put lips around mouthpiece Breathe in - MDI: Slow and Steady - DPI: Deep and fast or Deep and slow Remove inhaler from mouth and hold breath for up to 10 seconds Repeat as directed Its easy isn’t it? Murphy and Scullion 2012

Inhaler technique education Written instruction alone is not enough! Inform patients (knowledge) Practice (skills) Use uniform inhaler-specific protocols Regular monitoring of inhaler technique (using standardised checklists) and repeat instruction Provide (visual) instruction material Skilled trainers (knowledge and skills up to date!)

Take home message Adequate inhaler technique remains a real challenge Be aware of the possibility of inhaler handling mistakes (even when patients tell you they are familiar with the use of inhalers) Choose the right inhaler (involve patient preferences) Learn patients the device specific inhaler technique (using uniform protocols), inform patients, and monitor inhaler technique frequently

Take home message Proper (uniform and consistent) inhaler technique education has to be emphasised Training of health care providers highly recommended (knowledge, skills and fine- tuning of cooperation)

Take home message Proper (uniform and consistent) inhaler technique education has to be emphasised Training of health care providers highly recommended (knowledge, skills and fine- tuning of cooperation between HCPs)

Real life demonstration Inhaler technique Questions & Real life demonstration