Sitting across an older man, he tells me “those inhalers don’t work for me”. He further reports “this is the fourth or fifth one they gave me and is not working” After asking him to demonstrate how he uses the inhalers, it was obvious that he did not know how to use his inhalers and what dose to use. He sounded very frustrated and tells me “I’m having a hard time breathing, can you give me something else?”
He was not my only patient in the last few weeks coming to see me for inhaler and asthma or chronic obstructive pulmonary disease (COPD) teaching. Even some of the Doctors wanted to know how to use some of the newer inhalers. We often see children for inhaler teaching, but more and more adults need educations on how to use their inhalers. Educating patients is always a challenge when it comes to inhalers because most adults have an idea how they work but children can be even more challenging. Some Doctors have taken to creative ideas to teach their pediatric patients with the use of comic books.
Asthma and COPD patients are growing in numbers, most Doctors rely on inhalers to keep their airways open and facilitate breathing. Health clinicians see many patients who have these conditions, most of whom rely on inhalers to keep their airways open and facilitate breathing. Inhalers can be expensive—costing up to $350 each—so avoiding wasting doses or incorrect use can lead to inadequate treatment for the patient. Inhalers differ in their requirements for dexterity, adequate grip strength, visual acuity, and lung capacity. Some inhalers are harder to use than others are, education becomes even more important.
There are three major types of inhalers:
Multi-dose inhalers (MDI) are small, quick to use, and less costly than alternatives. They require the patient to coordinate breath and actuation, which can be a problem for patients with low grip strength or arthritis. MDI inhalers are a poor choice for patients with low cognitive ability or difficulty actuating the mechanism.
Dry powder inhalers (DPI) differ from MDIs in that they are breath-actuated (breath-dose coordination is unnecessary) and easier to use. Patients need sufficient respiratory force to inhale the powder, and this can be a barrier for elderly COPD patients. A preparation step before inhalation may be needed; patients with low dexterity or cognitive impairment may find this difficult. Some DPIs require patients to insert a capsule before each use, and all require users to push a button or pull back on a lever to start the powder exposure process. The newest DPI, the Ellipta device, has one simple preparation step and is breath-actuated. Its air vents allow patients to inhale more slowly and with less force than other devices—advantages for patients with low lung capacity. In addition, it is prefilled and has a dose counter. Retail health care providers will need to teach patients to keep the vents clear and hold their breath for 10 seconds. This may be difficult for cognitively impaired patients.
Respimat or SoftMist inhalers are the newest technology. They create a slower-moving, longer-lasting mist, eliminating breath-actuation coordination. Although they deliver lower doses, more of each dose reaches the lungs. Setting up the inhaler for the first time requires some education, and it’s helpful if a health care provider inserts the canister the first time.
inhalers deliver a smaller effective amount of the drug directly to the site of action in the lungs, which makes them work faster and with less adverse effects (when compared with oral administration of the same medications). The National Review of Asthma Deaths (NRAD) reported that misunderstanding and misuse of inhalers was thought to have contributed to a significant number of the asthma deaths during 2012. The correct inhaler technique plays an important role in improving use of inhalers, improvement in symptoms,, quality of life and use of healthcare resources. Before prescribing a new inhaler, the patient should receive training and education in the use of the device. However, recent data suggests that only 7% of healthcare professionals could demonstrate all the correct steps for using a MDI.
TABLE: COMMON INHALERS AND WHAT TO KNOW ABOUT THEM
| DPIs | ||||||||
| Advair Diskus |
flucticasone/ salmeterol
|
Prefilled with dose counter Twice daily dosing |
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| Spiriva Handihaler |
tiotropium bromide |
Need to insert capsule before each use Once daily dosing |
||||||
| ProAir Respiclick |
albuterol |
Does not require hand-breath coordination | ||||||
| Arcapta Neohaler |
indacaterol |
Need to insert capsule before each use. Once daily dosing |
||||||
| Tudorza Pressair | aclidinium bromide | Indicated for COPD only Twice daily dosing |
||||||
| Ellipta (DPI) Inhaler | ||||||||
| Incruse Ellipta | umeclidium | Once daily dosing | ||||||
| Breo Ellipta | fluticasone furoate and vilanterol | Approved for COPD Once daily dosing |
||||||
| Anoro Ellipta | umeclidium and vilanterol | Once daily dosing | ||||||
| The Respimat inhaler | ||||||||
| Spiriva Respimat | tiotropium | One daily dosing | ||||||
| Striverdi Respimat | olodaterol | Two inhalations once daily | ||||||
| Stiolto Respimat | tiotropium | Two inhalations once daily | ||||||
| Combivent Respimat | ipratropium bromide and Albuterol SUlfate | Only product for COPD exacerbation that uses Respimat technology Once inhalation 4 times daily |
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COPD = chronic obstructive pulmonary disease; DPI = dry powder inhaler.
Inhalers are the best way to deliver medications for patients with COPD and asthma and it is very important that patients know how to use their inhalers. Patients can ask their Primary Care Doctors or Pharmacist to help them use their inhalers correctly.
