Information is intended for healthcare professionals only.
This management algorithm was developed by WebMD Medscape UK Ltd and supported by Chiesi Ltd through the provision of a grant for its production. Chiesi Ltd had no editorial control other than to check factual accuracy. See end of algorithm for full disclaimer.
In this algorithm:
- Top tips for getting it right
- Top tips: devices
- Top tips: the right device for the right patient
- Top tips: supporting the patient
- Top tips: patients—ICE: Ideas, Concerns, and Expectations.
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Top Tips for Getting it Right
|Box 1: Environmental Position|
Top Tips: Devices
- Different devices require different techniques:
- single-dose capsule DPIs —insert the capsule into the inner chamber not into the mouthpiece chimney, and pierce capsule only once to prevent the capsule from shattering
- reservoir DPIs —prime the inhaler in the upright position, as it loads vertically
- aerosol devices (pMDIs/BAIs)—require vertical loading so keep upright when priming; most but not all need shaking
- need to coordinate activation of the device with inhalation when using pMDIs/SMIs2
- The internal resistance of DPIs may affect the patient’s ability to breathe in, and some may require a high inspiratory flow rate to deaggregate the powder and achieve the required dispersion for therapeutic effect9
- Signs that the patient may not be suitable for, or may not engage with, a DPI device include:
- discomfort when inhaling (e.g. coughing, exhausted)
- pMDIs and SMIs are aerosol-based devices and so a slow and steady inhalation is optimum to reduce oropharyngeal deposition and optimise delivery into the lungs2,3
- Many patients using a pMDI should be given a spacer to improve drug delivery and reduce oropharyngeal deposition6,8
Top Tips: the Right Device for the Right Patient
- Consider whether the patient is physically capable of carrying out each step of the inhaler technique correctly:
- do they have sufficient hand-breath coordination?
- are they able to form a good seal over the mouthpiece?
- are they able to open, manipulate, and prime the device?
- are they able to inhale at the correct speed?
- Consider the impact of cognitive impairment:
- does the patient have the ability to remember all the necessary steps, and to remember when to take their inhaler?
- Comorbidities (e.g. obesity or respiratory muscle weakness) and ageing can negatively affect inspiratory flow rate and may cause the patient to have difficulty using a particular device
- If a patient demonstrates difficulty in using a particular device or with treatment adherence, consider an alternative device that may, for example, have a reduced number of operational steps, include a dose counter, or support a formulation with a lower dosing frequency
- For a list of currently available inhaler devices and their respective drug formulations, visit www.rightbreathe.com
Top Tips: Supporting the Patient
- Ensuring that patients are comfortable with their device can improve adherence to treatment
- Support the patient in assessing whether they have received the dose, for example (if applicable):
- checking the dose counter
- listening for sound from the device dung correct inhalation
- being aware of powder/spray taste
- Check inhaler technique:
- many patients inhale too fast from pMDIs2
- many patients inhale too slowly from DPIs2
- If prescribing an inhaler as part of a treatment combination, aim to limit confusion by prescribing inhalers that use the same inhalation manoeuvre, i.e. either all DPIs (‘quick and deep’) or all pMDIs/SMIs/BAIs (‘slow and steady’).6
- Consider the use of stickers stating the inhalation manoeuvre (e.g. ‘quick and deep’ or ‘slow and steady’) that can be affixed to the patient’s inhalers, for example:
- Make sure carers (e.g. relatives, nursing home staff, or homecare team) can assist the patient to use the device if necessary
Top Tips: Patients—ICE: Ideas, Concerns, and Expectations
- The belief systems or patients’ attributions of their illness are the basis of their health-seeking behaviour
- By simplifying these beliefs into ideas, concerns, and expectations (ICE), healthcare teams will be able to understand patients’ motivations and improve their satisfaction and adherence with medical advice
- To truly understand a patient, their ideas and beliefs about their asthma or COPD need to be addressed, for example through questions/statements such as:
- ‘tell me what you think is aggravating your condition’
- ‘do you have any ideas about treatment yourself?’
- This should include any concerns the patient has, especially about the medications prescribed, such as side-effects, or whether taking medication daily makes it less effective:
- ‘is there anything in particular that you are concerned about?’
- ‘what concerns you most about what we have discussed?’
- Finally, expectations about their treatment and its effects should be discussed:
- ‘how do you think this treatment will change your symptoms?’
- ‘do you think that this plan will work for you?’
- ‘what are your goals from treatment?’10,11