Syed (Inhaler counselling)

Question 1

Asthma

Answer 1

One of the major non-communicable diseases.
Chronic disease of the air passages of the lungs which inflames and narrows them.
It is a common disease among children.
The strongest risk factors for developing asthma are inhaled substances and particles that may provoke allergic reactions or irritate the airways.
Medication can control symptoms (not cure).
Inhalation therapy is mainstay of treatment. The advantages of this method of drug delivery are that it uses low doses of drugs and reduces incidence of systemic side effects.
Appropriate management of asthma can enable people to enjoy a good quality of life.
Avoiding asthma triggers can also reduce the severity of asthma.

Question 2

Asthma pathophysiology

Answer 2

Can be divided into 2 based on the presence or absence of eosinophils in the airways. They might be described as
- Extrinsic (allergic) asthma: where the allergen is thought to be the cause, this is much more common in children especially with a history of atopy. (IgE mediated response)
- Intrinsic (non-allergic) asthma: develops later in life and can be triggered by factors like viral infection

Question 3

Asthma summary

Answer 3

Chronic inflammatory airway disorder
- Airway obstruction
- Airway hyper-responsiveness

Common symptoms
- Wheeze
- Breathlessness
- Tight chest
- Cough- usually at night

Attacks can occur
- Suddenly
- Over a period of days

Unknown cause
- Genetics?
- Hygiene practices?

Question 4

Methods of dispersing drug into an aerosol

Answer 4

Aerosol inhalation
Dry powder inhalation
Via a nebuliser

(Inhaled dose- quick action, low dose, safe and more effective
Oral dose- long action, less safe and less effective)

Question 5

Why do patients have problems with inhalers?

Answer 5

Patients vary
- Pulmonary function (reversible and irreversible diseases)
- Ability to learn to be taught the correct technique
- Physical size of the lungs child vs adult)
- Effort varies from dose to dose

Devices vary
- Mechanical action- passive vs active
- Internal resistance to airflow
- Formulation of drug (particle size)

Question 6

Methods of dispersing drugs for inhalation

Answer 6

As an aerosol- as colloidal suspension of particles enclosed under pressure and released as a fine spray by means of a propellant gas.

As a dry powder- do not contain propellant or any other ingredients, just the drug.

Via a nebuliser- a machine changes medication from liquid into a mist for easy inhalation into the lungs.

Question 7

Steps to using an inhaler

Answer 7

Remove mouthpiece
Shake (most inhalers)
Breath out as gently as far as comfortable
Make a tight seal with your lips (not teeth) around the mouthpiece
Breathe in
Remove mouthpiece from mouth and hold breath for up to 10 seconds (or as long as is comfortable)
Breathe out slowly

Question 8

MDI (metered-dose inhaler)

Answer 8

Aerosol is made by the device.
Inhaler technique is important- need to inhale slowly.
Classic blue inhaler.
Low dose is inhaled.
Doesn’t go through first pass metabolism.
Prime inhaler- especially first use.
Can use a spacer.

Question 9

Advantages and disadvantages of MDIs

Answer 9

Advantages
- Compact, portable and rug is sealed in a canister to prevent tampering
- Multiple doses available and relatively inexpensive

Disadvantages
- Required hand to mouth coordination and education- need good technique
- High levels or oropharyngeal deposition

Question 10

For inhalers where the aerosol is made for you…

Answer 10

Always breathe in slowly
Examples
- pMDI
- Breath activated MDI/Easibreathe
- Tiotropium Soft Mist (COPD)

Question 11

DPI (dry powder inhaler)

Answer 11

Aerosol is made by the patient
Need to inhale forcefully/sharply
Powder formulation
More side effects
Some inhalers you have to load the capsule, some re-load automatically

Question 12

Advantages and disadvantages of DPIs

Answer 12

Advantages
- Breath actuation removed the need for coordination

Disadvantages
- Humidity can cause degradation of drug
- Needs minimum inspiration flow to achieve drug dispersion
- Patients may be intolerant to additives e.g. lactose intolerance

Question 13

For inhalers where the patient makes the aerosol

Answer 13

Alway breathe in forcefully
Examples
- Accuhaler
- Tiotropium Handihaler
- Turbohaler

Question 14

SMI (soft mist inhaler)

Answer 14

For patients that find MDIs and DPIs hard to use
Turns liquid into fine mist

Question 15

Lung deposition

Answer 15

Lung deposition from pMDIs and DPIs is influenced by inspiratory flow.

Question 16

Spacer devices

Answer 16

Spacer is longer for adults and shorter for children.
Can have a mask on to cover mouth and nose.
Issues- not breathing in quickly enough, not breathing in deeply enough, not holding breath for long enough.
Spacer devices
1- Capture aerosol avoiding coordination problems
2- Reduces particles deposited in oropharynx

Question 17

Nebulisers

Answer 17

A machine which changes medication from liquid into a mist for easy inhalation into the lungs.
Not portable- hospital or GP setting

Question 18

Advantages and disadvantages of nebulisers

Answer 18

Advantages
- Large dose of drug can be delivered with relaxed tidal breathing
- Suitable for the young, elderly and acutely unwell patients

Disadvantages
- They can be very bulky and cumbersome as well as expensive to buy outright
- Usually need a power source (or charging) and require maintenance
- Drug can be wasted in the nebuliser reservoir

Question 19

Why is it important for patients to have follow up assessments about their inhalers?

Answer 19

Inhaler technique has been found to deteriorate over time so instruction needs to be repeated at regular intervals.
Only an estimated 11% of patients receive follow-up assessment and eduction on their inhaler technique.
Therefore, provision of resources and sign posting to both pharmacists and respiratory specialists is essential.