1. Inhalers The Perfect technique Vicky Walker Clinical Lead for Respiratory Services Sarah Wilson Respiratory Nurse Specialist

2. Which inhaler is right for your patient?

3. Contents n Quiz - test your current knowledge n Information on devices n Practical demonstrations of common inhalers, through DVD and audience participation (thats you!) n case studies n Our role - how we can help? n What to do next……………….

4. Aims of the teaching n Update and increase knowledge on different devices n Test baseline knowledge ( to improve at the end of the session!) n To become more familiar with delivery devices n Increase skills in assessment of technique n How to trouble shoot

5. Quiz time

6. Metered dose inhalers (MDI) n Cheap, Quick & convenient to use n Poor inhaler technique is common n When used correctly only 10%-20% of the drug reaches the lungs n may continue to deliver propellant after active drug gone if not shaken correctly n important to wait 30-60 secs between doses due to 2nd actuation being of poorer quality

7. Breathe actuated inhalers n Spring mechanism is triggered by inspiratory flow rate of 22-36 l/m n drug delivery less dependent on technique n When cap is removed the inhaler is primed and ready to fire n Ref: AJ Corlett 1996 Caring for Older People: Aids to compliance with medication BMJ 1996;313:926-929 12 October

8. Spacer devices n Removes the need for co-ordination of breathing and actuation n Pharyngeal deposition is greatly reduced n smaller particles penetrate further into lungs depositing a greater proportion of drug n Available with mask n Electrostatic charge reduces delivery

9. Dry Powder inhalers (DPI) n Inspiratory airflow releases the fine powder - therefore no co-ordination needed n dose counters helps patients to know when empty (between 60-200 doses) n DPI can make some patients cough n Inspiratory flow rate needed may be a problem with some devices

10. Dry Powder inhalers (DPI) continued n More expensive than MDIs n DPIs such as turbohalers have no taste, hence there could be uncertainty it has been taken by the patient n Turbohalers delivers 20%-30% of drug n Diskhaler delivers 11%-15% of drug n Ref:Optimizing deposition of aerosolizesd drug in the lung

11. Important points n Patient needs to be in a good upright position to use inhaler n Important to check inhaler technique regularly n Bad habits form quickly n If a patient is requiring repeat prescriptions – alarm bells should be ringing

12. DVD & Inhaler demonstration

13. Case Study 1 n 73 year old lady with severe COPD n referred for Pulmonary Rehabilitation n probable low inspiratory breath n using Turbohalers but struggling n Tested with Turbotrainer whistle n Switched to MDI and Volumatic spacer n beautiful technique with tidal breathing

14. Case Study 2 88 year old with moderate COPD Using MDI & aerochamber Struggling to fire inhaler consistently Tried on turbohaler trainer whistle Successful with whistle Switched to turbohaler Reviewed by CSW 1 month later managing well, with good benefit

15. Case Study 3 n Bingo dobber V turbohaler

16. The Good, The Bad and The Ugly

17. The Bad n Allergy to the cat n Down the nose n Christmas present n Current prescription n Blowing n Upside down n Huff and puff n If at first……..

18. n Mrs Smith has moderate COPD the GP asks for your advice on combination therapy. n Which device would you recommend?

19. Trick question ?

20. How we can help patients? Home visits Perform spirometry in patients home Advice on smoking cessation Inhaler technique check Telehealth in the patients home Early discharge scheme from LTHT Refer to our Pulmonary Rehabilitation programme Patients can self refer to the Respiratory Team Home exercise programme for patients What to do when ill A name for your chest problem Refer to the respiratory team if commenced on oxygen Do they need a portable/ambulatory cylinder Telephone support and advice

22. What to do next? n If you are still struggling with a tricky or complex patient then please refer on to your local Respiratory Team n contact details n East Wedge 2953499 n South Wedge 2954641 n West Wedge 3059293 (west, north west & north east)

23. Which inhaler is right for your patient? The one they can use.