INHALED(THERAPY(IN(ASTHMA(AND(COPD(

!

DR!JAMES!CALVERT!

RESPIRATORY!PHYSICIAN!

SW!ACADEMIC!HEALTH!SCIENCE!NETWORK!

Aims(•  Inhaler!technique!and!outcomes!

•  PaDent!percepDons!&!inhaler!technique!•  Clinician!skills!in!inhaler!tuiDon!&!use!•  Barriers!to!effecDve!inhaler!use!•  Components!of!a!successful!inhaler!educaDon!programme!

2!

•  Levels of asthma control ACT, SF-12 and Work Productivity Loss & Activity Impairment (WPLAI)

•  France, Germany, Italy, Spain, United Kingdom (n-1600 in each)

2006 2008 2010

Uncontrolled

Controlled

Pat

ient

s %

60

50

40

30

20

10

0

n=1011

n=851

n=1613

n=1290

n=1677

n=1430

Repeat(cross;sec<onal(survey(of(pa<ent(reported(asthma(control(in(Europe(in(the(past(5(

years(

European!Respiratory!Review.!2012;21(123):66Y74.!

What’s(New?(

2012;2013(

?! ? 2015………(

2014(

INHALER(TECHNIQUE(AND(OUTCOMES((

5!

•  Admission 1.47 (p=0.001)"

•  ED visit 1.62 (p=0.0006)"

•  Antibiotic 1.52 (p=0.00004)"

•  Corticosteroid 1.54 (p=0.0003)"

Relationship between risk of at least a critical error and self report of unscheduled health care resource use in last 12 months

450!paDents!in!ED!

Switch(with(no(GP(

consulta<on(

OR(for(unsuccessful(treatment(following(ICS(switch(with(no(GP(Consulta<on(1.92(

N=824(

Chrystyn!H,!Price!D.!Not!all!asthma!inhalers!are!the!same:!factors!to!consider!when!prescribing!an!inhaler.!Primary!Care!Respiratory!Journal.!2009;18(4):243Y9!

Errors(in(the(pa<ents’(use(of(DPIs(and(MDIs(

In!an!analysis!of!7412!paDents!using!tradiDonal!and!breath!actuated!MDIs!to!deliver!ICS!(UK!general!pracDce):!!BreathYactuated!MDIs!improved!outcomes!cf!usual!MDIs;!!•  PaDents!were!prescribed!25%!less!SABA!•  Used!up!to!64%!per!cent!less!oral!steroid!•  44%!less!anDbioDcs!

MDI(and(DPI(inhala<on(technique(COPD:(inhala<on(too(fast(for(pMDI(or(too(slow(for(DPI(

12!

AlYShowair!RAM,!Tarsin!WY,!Assi!KH,!Pearson!SB,!Chrystyn!H.!Can!all!paDents!with!COPD!use!the!correct!inhalaDon!flow!with!all!inhalers!and!does!training!help?!Respiratory!Medicine.!

2007;101(11):2395Y401!

13!

Choosing!inhaler!devices!for!people!with!asthma!

PATIENT(PERCEPTIONS(&(INHALER(TECHNIQUE((

14!

Pa<ent(percep<on(of(inhaler(technique(and(actual(inhaler(technique3!

15!

98%!

8%!

0%!

20%!

40%!

60%!

80%!

100%!

PaDents!believed!they!use!inhaler!correctly!

PaDents!who!actually!used!inhaler!without!error!

3.!!!!Adapted'from:!Souza!ML,!et!al.!J!Bras!Pneumol.!2009;35:824Y831.!

Number!of!paDents!in!study=60!

ThirtyYone!community!pharmacists!were!trained!to!deliver!inhaler!technique!educaDon!to!people!with!asthma!

Factors!affecDng!paDent!ability!to!use!an!inhaler!correctly!are!listed!above!

DPI(>(MDI(((Be]er(control(((Mo<vated(pa<ent(

CLINICIAN(SKILLS(IN(INHALER(TUITION(&(USE(((

18!

Do healthcare professionals have sufficient knowledge of inhaler techniques in order to educate their patients

effectively in their use?!

70%

7%

23% Incorrect technique

7 steps and inspiratory flow check correct Correct technique 7 steps

Baverstock et al Thorax 2010;65:A117

Baverstock!M,!Woodhall!N,!Maarman!V.!P94!Do!healthcare!professionals!have!sufficient!knowledge!of!inhaler!techniques!in!order!to!educate!paDents!effecDvely!in!their!use?!Thorax.!

2010;65:A118YA9!

75%!regu

larly!invo

lved!in!

teaching

!inhaler!te

chnique!

Do(the(people(teaching(know(what(they(are(doing?(

•  42!physicians!(16!respiratory)!!•  6!different!inhalers,!2!spacers!

•  Correct(technique?(•  19!accuhaler!•  12!MDI!

•  5!handihaler!•  4!turbohaler!•  2!autohaler!

Adeni!A,!McDonough!BJ,!Smyth!CM.!Knowledge!of!Inhaler!Technique!among!Hospital!Physicians.!!A104!ISSUES!IN!COPD/RESPIRATORY!FAILURE.!American!Thoracic!Society!

InternaDonal!Conference!Abstracts:!American!Thoracic!Society.!2009!!p.!A2315!

Same study...!•  Only!!24!knew!when!MDI!

was!empty!!

•  14!knew!when!!!!!!EasiYbreathe!was!!!empty!

•  !12!knew!when!autohaler!was!empty!

•  5!knew!when!Turbohaler!was!empty!!

!

•  Respiratory!physicians!scored!higher!than!non!respiratory!for!!

!!!!handihaler!only!(p<0.01)!

•  In!all!other!devices!no!difference!in!competence!

Adeni!A,!McDonough!BJ,!Smyth!CM.!Knowledge!of!Inhaler!Technique!among!Hospital!Physicians.!!A104!ISSUES!IN!COPD/RESPIRATORY!FAILURE.!American!Thoracic!Society!

InternaDonal!Conference!Abstracts:!American!Thoracic!Society.!2009!!p.!A2315!

A`er(40min(

Training(!(

BARRIERS(TO(EFFECTIVE(INHALER(USE(

23!

•  Inspiratory flow and volume"•  Co-ordination"•  Manual dexterity"•  Hand strength"•  Visual acuity"•  Less likely to retain

instructions"•  30x risk of errors vs tablets"

Elderly patients may!

Broeders!M,!Sanchis!J,!Levy!M,!Crompton!G,!Dekhuijzen!P.!The!ADMIT!seriesYYissues!in!inhalaDon!therapy.!2.!Improving!technique!and!clinical!effecDveness.!Prim!Care!Respir!J.!2009;18(2):76Y82.!

!

Error(rate(using(inhaler(by(pa<ent(age13!

25!

PaDent!age!(years)!

0%!

20%!

40%!

60%!

80%!

100%!

Error!rate!

<20! 20Y30! 30Y40! 40Y50! 50Y60! 60Y70! 70Y80! >80!

13.!!!!Wieshammer!S!&!Dreyhaupt!J.!Chest;'2007;132(4)(Suppl):479s.! UKACL2258e!!!!Date!of!PreparaDon!October!2013!

Number!of!paDents!studied=223!

Inhalers!studied:!Aerolizer,!Discus,!HandiHaler!and!Turbuhaler!

•  Compliance with therapy"–  MMSE > 24/30 – usual

therapy"

–  MMSE 20-23/30 – may manage inhaled therapy"

–  MMSE <20/30 – unable to manage"

•  Symptom recognition "•  Susceptibility to Delirium"

Dementia and inhaler use!

Allen!SC,!Jain!M,!Ragab!S,!Malik!N.!AcquisiDon!and!shortYterm!retenDon!of!inhaler!techniques!require!intact!execuDve!funcDon!in!elderly!subjects.!Age!and!ageing.!

2003;32(3):299Y302!

Think(about(the(inhaler(not(just(the(drug(

•  Most!studies!find!paDents!make!fewer!criDcal!errors!with!breathYactuated!DPIs!than!pMDIs!(eg.!49Y55%!to!76%)10!

•  BreathYacDvated!DPIs!eliminate!a!step!that!MDI!users!open!struggle!with:!the!need!to!simultaneously!press!down!on!the!canister!and!begin!a!slow,!deep!inhalaDon6!

•  Using!a!breathYacDvated!DPI!sDll!involves!a!series!of!acDons!with!potenDal!for!error!at!each!step6!and!evidence!exists!that!some!devices!are!used!with!fewer!mistakes!than!others11!

•  The!prescriber!should!ensure!that!the!selecDon!of!a!device!is!appropriate!for!individual!paDent!needs12!

27!

6.!!!!!Self!TH!et!al.!Journal!of!Family!PracDce.!2011;!60:!714Y720a ! !!12.!Newman!SP,!Eur!Respir!Rev!2005;!14:!96,!102–108! !!10. Molimard!M!et!al.!J!Aerosol!Med.!2003;!16:!249Y254 !!11. Vincken!W!et!al,!Prim!Care!Respir!J.!2010!(1):10Y20! UKACL2258e!!!!Date!of!PreparaDon!October!

2013!

COMPONENTS(OF(A(SUCCESSFUL(INHALER(EDUCATION(PROGRAMME((

28!

Inhaler(features(to(consider(

29!

14.!!!Dolovich!MB,!Chest.!2005!;127(1):335Y71 ! ! !!17.!!!Lavorini!!F!et!al,!Respiratory!Medicine!2008!102,!593–604!!15.!!!Heslop!K!et!al.!PCRSYUK!Tailoring!Inhaler!Choice!Opinion!Sheet!Devices.!!No!49.!2012!16.!!!Malmberg!LP!et!al,!InternaDonal!Journal!of!COPD!2010:5!257–262!

Choice!of!drug14!

PaDent!preference15!

PaDent!has!sufficient!

coordinaDon!to!use!this!inhaler15!

PaDent!can!generate!sufficient!inspiratory!flow!to!use!this!inhaler16!

A!feedback!mechanism!indicaDng!that!the!drug!has!

been!delivered!to!the!lungs17!

Device!dose!counter15!

UKACL2258e!!!!Date!of!PreparaDon!October!2013!

Inhaler(technique(–(the(basics(

•  Forgerng!to!exhale!before!inhaling!is!a!common,!and!significant,!mistake!regardless!of!the!type!of!device6!

•  It!is!paramount!to!stress!the!need!to!exhale!gently!for!a!few!seconds!before!inhaling:!

–  slowly!and!deeply!for!paDents!using!an!meteredYdose!inhalers!(MDIs)7!

–  quickly!and!deeply!with!most!dry!powder!inhalers!(DPIs)7!

•  However,!please!ensure!you!check!the!precise!technique!for!each!individual!inhaler!device8!

!

30!6.  Self!TH!et!al.!Journal!of!Family!PracDce.!2011;!60:!714Y720a!2011 !!!!!!!!!!!!!!!!!!!!!!!!!8.!!!!Levy!M!&!Pearce!L.!PCRSYUK!Inhaler!Devices!Opinion!Sheet!Devices.!No!20.!2011!7.  SimpleStepsEducaDon!Inhaler!Technique!.!2013!(Available!at!www.simplestepseducaDon.co.uk)!! UKACL2258e!!!!Date!of!PreparaDon!October!

2013!

Impact(of(repeated(inhaler(instruc<on(on(pa<ent(adherence5!

31!UKACL2258e!!!!Date!of!PreparaDon!October!2013!

5.!!!!Adapted'from:!Takemura!M,!et!al.!InternaDonal!Journal!of!COPD!2011;!6!97–104(!

73%!

42%!

Number!of!paDents!in!study=77!

32!

24%(

79%(•  Training(<me:(6(minutes(

•  ACQ(improved(by(28%(at(1(month(

•  ACQ(showed(greatest(improvement(in(those(with(best(inhaler(technique(

!

How(Should(We(Teach(Inhaler(Technique?(

Verbal( Augmented(Verbal(

Augmented(Verbal(+(Physical(

33!

BasheD!IA,!Reddel!HK,!Armour!CL,!BosnicYAnDcevich!SZ.!Counseling!About!Turbuhaler!Technique:!Needs!Assessment!and!EffecDve!Strategies!for!Community!Pharmacists.!Respiratory!

Care.!2005;50(5):617Y23!

6!month!protocolYbased!intervenDon!addressing:!•  Asthma!control!•  Inhaler!technique!•  MedicaDon!adherence!

How(would(you(breathe(in(for(these?(

35!

How(about(these?(

36!

Take(home(messages(

37!

When!selecDng!a!device!consider!the!ability!of!the!paDent!to!correctly!handle!the!selected!device11!

PaDent!device!preference!is!important15!

Train!and!check!inhaler!technique,15!review!at!subsequent!visits17!

Health!professionals!must!keep!abreast!of!new!devices!and!master!the!techniques!themselves18!

11.!!!Vincken!W!et!al,!Prim!Care!Respir!J.!2010!(1):10Y20 ! !18.!!!Beaucage!S!&!Nesbit!S,!Ontario:!BC!Decker!Inc..!2002!p83Y107.!!!15.!!!Heslop!K!et!al.!PCRSYUK!Tailoring!Inhaler!Choice!Opinion!Sheet!Devices.!2012!17.!!!Lavorini!!F!et!al,!Respiratory!Medicine!2008!102,!593–604! UKACL2258e!!!!Date!of!PreparaDon!October!

2013!