1. Inhaler Technique & PEFR
Maeve Corry
GET INHALER/PEAK FLOW TO DEMO!

2. 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

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

4. 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!

5. 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

6. 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

7. Inhalers

8. 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

9. 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. 

10. 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

11. 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.”

12. 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.

13. 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

14. 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

15. Peak Expiratory Flow Rate
(PEFR)

16. 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

17. 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: 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

18. 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!

19. 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

20. Any Questions?

21. 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

23. Helpful Resources
Geeky Medics
OSCE Skills
OSCE Stop
Unofficial Guide to Passing OSCEs
Just remember… practice, practice, practice!