Monday, October 14, 2013

"Can You Show Me How You Use Your Inhaler?"

This year a new type of delivery device for inhaled medications has become available. It is used to deliver the bronchodilators albuterol and ipratropium in combination (Combivent) and is called a “soft-mist” inhaler. With activation, a slow-moving mist of medication – somewhat like the aerosol from a nebulizer – is released for approximately 1½ seconds. A full dose of medication is contained within the mist, which is to be inhaled from the mouthpiece of the device. The soft mist inhaler joins a variety of other devices, including metered-dose inhalers, dry-powder inhalers, and hand-held nebulizers, used to deliver medications by inhalation. What strikes us as remarkable – and the subject of this blog -- is the daunting challenge faced by persons with asthma (and other lung diseases) as they try to master use of these very different inhaler devices. Some of the devices release a plume of medication traveling at high speed; others come in the form of a powder that is turned into an aerosol only by the force of a breath in. Some are best combined with a hollow chamber (“spacer”) that will hold the medicine in a confined space for a second or two prior to breathing it in; others cannot be combined with a spacer. Some medications come in more than one form – metered-dose inhaler and liquid for nebulizer; metered-dose inhaler and dry-powder inhaler – although most do not.

What we wish to share in this blog is the way that we teach inhaler use. As part of the “package insert,” each device comes with instructions that describe the steps involved in preparing and then inhaling the specific medication, and many companies provide additional printed hand-outs, often in multiple languages. In addition, video instructions are often available on-line. Nonetheless, in our opinion, there is no substitute for live demonstration in the office. It takes no more than a minute, it can be repeated as often as necessary, reading skills and internet access are not required, and there is no charge or adverse side-effect! If available, a placebo demonstration device is very useful; otherwise, role play also works well.

Here’s what we say for metered-dose inhalers: shake the medicine one or two times; with the device held upright (mouthpiece at the bottom), put the mouthpiece between lips and teeth and seal your lips around it. To release the medicine, depress and then release the canister in its plastic holder held between thumb and index finger; and then immediately take a slow, deep breath in. Slow and deep allow the medication to enter deep into the lungs (instead of impacting on the back of the throat) and to deposit onto hundreds of bronchial tubes, large and small. A slow, steady breath over 4-5 seconds should do the trick. Then hold your breath for a few seconds before exhaling, to prevent losing much of the medication in the exhaled air.

In our experience, the “slow and deep breath in and then hold your breath a bit” are the parts most often omitted. We all find ourselves too busy, in too much of a hurry, too focused on other things to concentrate on the act of properly using our inhalers. And yet it makes a difference, often a big difference. The difference between poorly-controlled asthma and well-controlled asthma can at times be a matter of properly inhaling one’s current medications, rather than escalating the dose of medicine or changing from one medicine to another.

A spacer can be used with metered-dose inhalers and helps to relieve the “stress” of getting exactly the right timing between squirting the medication from the device and immediately beginning to breathe in. By releasing the medication into the confined volume of the spacer, one can then, stepwise, breathe in only after the medication is where you want it, waiting to be pulled from the chamber into the lungs. Still, the subsequent steps are key, as before: slow and deep breath in and hold your breath for perhaps 5 seconds. Besides helping with the timing of hand-breath coordination, the spacer reduces the amount of medication that would otherwise settle on your tongue and throat. For steroid medications like flucticasone (Flovent), this means less steroid available to be swallowed and absorbed from your stomach into the rest of your body. If you are well-skilled in using your quick-relief bronchodilator inhaler such as albuterol (Proair, Proventil, or Ventolin), then you need not tack on a spacer. If you have trouble coordinating your inhaler – and, in the case of steroids, to reduce the amount of steroids settling on your mouth and throat -- the spacer is a useful addition.

No plume of medication is released from dry-powder inhalers. With the force of one’s breath in, one turns the collection of powder in the inhaler into an aerosol that can be breathed deep into the lungs. Each device is prepared for the next dose of medication in a slightly different way, but when the medication is ready to be released, the process is the same: seal your lips around the mouthpiece, take in a strong breath to pull the medication out of the device, continue a long and deep breath in to distribute the medication widely throughout the lungs, and then hold your breath for a few seconds before exhaling. Again, the long and deep and then hold your breath steps are the ones that we want to emphasize. A short, quick gasp puts medicine primarily on your uvula and windpipe without getting it far out onto the bronchial tubes where it is needed. Spacers cannot be used with dry-powder inhalers (including those that deliver steroid medication).

We recognize that many other things get in the way of our taking medications regularly for a chronic condition. An article in The New York Times recently highlighted the issue of exorbitant medication costs. And there are many other obstacles to adherence to the medical provider’s prescription: dislike of medication side-effects; concerns about long-term medication safety; fears of medication dependence or loss of potency over time; confusion when choosing among different inhalers; and forgetfulness, to name a few. It is estimated that daily use of an inhaled steroid for asthma among those prescribed a steroid inhaler for daily use is 40% or less. Still, we believe that one of the reasons for not taking your preventive inhaler and getting the most out of it should not be: “my doctor never showed how I was supposed to use it.”