Asthma Gadgets and Gizmos Lynn Feenan RN, MS, AE-C Pediatric Pulmonary Clinical Nurse Specialist Certified Asthma Educator Children’s Hospital at Dartmouth email@example.com 603-653-9884 Objectives By the end of this presentation the participant will be able to: 1. Describe rationale behind use of spacers 2. Discuss the differences in new HFA inhalers 3. Define Exhaled Nitrous Oxide 4. Discuss two strategies to get Asthma Management Plans for students Methods of Asthma Drug Delivery Intravenous Oral Leukotriene Modifiers Singulair and Accolate Oral Corticosteroids Palatability Counts! Inhaled Nebulizer Metered Dose Inhalers – “MDI” Dry Powder Inhaler – “DPI” Nebulizer A device used to change liquid medication to an aerosol particulate form. The aerosolized medication is then inhaled and deposited in the lungs. Two parts Compressor – machine that powers the delivery of compressed air Nebulizer - medication cup, mouthpiece and tubing Nebulizer Time to use About 7-12 minutes (dependent on equipment) Portability Poor - unless you have a battery operated device (costly and often not covered by insurance) Equipment Compressor Nebulizer cup and tubing Disposable brands – use up to 2 weeks PARI – use for 6 months Smaller particle size so better deposition of drug Cost ~ $100 for compressor ~$4-$20 for nebulizer cup ($35 PARI Baby with mask) Nebulizer Technique Important! Nose-clips may be needed by some Mask Used for anyone unable to hold mouthpiece firmly in mouth and breath through mouth only Most children up to age 4-5 years Disabled or elderly adults To “Blow By” or Not to “Blow By” That indeed is the ???? 1.5 Dose “inhaled” (mg) 1 0.5 0 0 1 2 Distance of mask from “face” (cm) Effect of increasing the distance between the nebulizer facemask and the face of the model on dose deposited. Everard et al. 1992. Metered Dose Inhalers (aka: “MDI’s”) The metered dose inhaler (MDI) consists of a pressurized canister of medication in a plastic case with a mouthpiece. Pressing the MDI releases a mist of medication. The canister contains medication and a propellant. Propellant Changes “CFC” to “HFA” Chlorofluorocarbon (CFC) – chemical that damages the ozone layer of the earth “Out-lawed” by Montreal Protocol (2004) after December 31, 2008 Hydrofluoroalkane (HFA) - an earth-friendly alternative Different spray force, taste and mouth-feel (warmer) More costly (~$20 more that CFC generic beta-agonist) Generics probably not available until ~ 2012 Total Cost ~ $1.2 billion per year for brand albuterol w/HFA More care of spray spout, more priming necessary MDI’s MDI’s Several different colors, sizes, AND medications are available in MDI’s Patients need to know what medication is in what inhaler Dose counters or indicators May or may not be available NO FLOATING Technique is critical MUST educate use of the MDI during the visit with demonstration and return demonstration Review technique frequently!!! MDI Inhaler Technique WITHOUT spacer 1. Remove the cap from the inhaler. 2. Hold the inhaler with the mouthpiece at the bottom. 3. Shake the inhaler. This mixes the medication properly. 4. Hold the mouthpiece 1½ - 2 inches (2 - 3 finger widths) in front of your mouth. This improves medication delivery by slowing mist delivery and only allowing small particles to be inhaled. 5. Tilt your head back slightly and open your mouth wide. 6. Gently breath out. 7. Press the inhaler and at the same time begin a slow, deep breath. Continue to breath in slowly and deeply over 3 - 5 seconds. Breathing slowly delivers the medication deeply into the airways. 8. Hold your breath for up to ten seconds. This allows the medication time to deposit in the airways. 9. Resume normal breathing. 10. Repeat steps 3 - 9 when more than one puff is prescribed. 11. Wait time between puffs varies – no good data – typically 30 -60 seconds 12. RINSE MOUTH if ICS MDI Inhaler Technique WITH spacer 1. Insert the inhaler/canister into spacer and shake. 2. Breath out. 3. Put the spacer mouthpiece into your mouth. 4. Press down on the inhaler once. 5. Breathe in slowly (for 3-5 seconds). 6. Hold breath for 10 seconds – repeat for second puff if needed Spacers and Valved Holding Chambers “VHC’s” Spacer – an open tube that is placed on the mouthpiece of an MDI to extend it away from the mouth of the patient (Example – Optihaler) Valved Holding Chamber – has one way valve that holds the dose until inhalation is initiated (Example – Aerochamber) and decreases dilution of the med by exhaled air Spacers and VHC’s Why? Helps patient coordinate the inhalation from the MDI Slows the speed of the medication to increase better deposition into the lungs Reduces deposit of ICS’s in the mouth thereby reducing side effects of thrush Must use with young children, disabled or elderly adults Huge variation in effectiveness dependent of which spacer/VHC and which MDI is used in what combination Spacer/VHC Many shapes, sizes, colors, brands, cost ($15-$35 on Asthmastuff.com) May not be covered by insurance Spacer and VHC Prescribe more than one spacer School Daycare Grandma’s house Technique is everything Teach, demonstrate, review!!! Review proper cleaning as well “Electrostaticity” – ionic charge on the inside of a plastic spacer/VHC which may change dose availability To decrease - wash with detergent or use a metal spacer MDI’s without spacers Auto halers - breath-activated inhalers that trigger the release of the mist of medication during inhalation. Can improve drug delivery in people with poor inhaler technique. Once triggered, drug delivery is not dependent on the strength of the inhalation (unlike breath- activated dry powder devices). Example – “Maxair” (pirbuterol) Dry Powder Inhalers “DPI’s” Asthma medication that comes in a dry powder form - inside a small capsule, disk or compartment inside the inhaler. Alternative to MDI Requires differing inspiratory flow rates Must be older than ~ 5 yrs Frequently includes dose counters/indicators No propellant BUT does contain a “carrier” – often lactose No need for spacer Typically less or no taste/feel Single and “Combo” drug delivery DPI’s Several variations of types and medications Aerolizer® - formoterol - “Foradil” Handihaler® - tiotroprium bromide - “Spiriva” Diskus® - fluticasone/salmeterol - “Advair” Rotahaler® - albuterol Turbuhaler® - budesonide - “Pulmicort” Twisthaler® - mometasone - “Asmanex” DPI’s Technique is everything Teach, demonstrate, review!!! Review proper cleaning as well DPI Use 1. Read the instructions that come with your DPI. 2. Remove the cap and hold the inhaler upright. 3. Check that the mechanism is clean and the mouthpiece free of obstruction. 4. Load a dose into the device as directed. 5. Hold the inhaler level with the mouthpiece end facing down. 6. Tilt your head back slightly, and breathe out slowly and completely without straining or breathing into your DPI (moisture from your breath can clog the inhaler valve). 7. Place your teeth over the mouthpiece and seal your lips around it. Make sure you don't block the inhaler with your tongue. 8. Breathe in quickly and deeply (over two to three seconds) through your mouth to activate the flow of medication. 9. Remove the inhaler from your mouth. Hold your breath for 10 seconds (or as long as is comfortable), and then breathe out slowly against pursed lips. This step is very important. It allows the medication to get deeply into your lungs. 9. Rinse Mouth if ICS 10. Keep DRY powder inhalers DRY 1. Do not store in bathroom 2. Do not exhale into them DPI Use Important to know if patient can generate enough negative inspiratory flow to deliver the medication In-Check Dial ® Use in MD Office “a hand held low range inspiratory flow measurement device with a dial top. The DIAL orifices have been designed to accurately simulate the resistance of popular inhaler devices such as MDI’s, DPI’s, Turbuhaler® and Diskus®, enabling clinicians to train patients to use more or less inspiratory force, to achieve their optimal flow rate with a particular device”. http://www.alliancetechmedical.com/icdial.html Peak Flow Meters (“PFM”) A peak flow meter measures the patient's maximum ability to expel air from the lungs, or peak expiratory flow rate 2007 Asthma Expert Panel Recommendations If peak flow monitoring (“PFM”) is performed a written asthma action plan should use the personal best flow as a reference value Consider long term daily PFM for: Pts with moderate or severe persistent asthma (Evidence B) Pts with a history of severe exacerbations (B) Pts with poor perceptions of obstruction or worsening asthma (D) Pts who prefer to monitor their asthma with a PF Meter (D) Further Recommendations Long term daily monitoring can be helpful to Detect early changes in disease state that require treatment Evaluate responses to changes in therapy Afford a quantitative measure of impairment PFM during exacerbations will help determine the severity of the exacerbation and can guide therapy PFM Monitoring tool – NOT diagnostic Typically used with children > 4-5 years old Either PFM or symptom monitoring may be equally effective (B) Some kind of self monitoring is crucial to management of asthma (A) WRITTEN asthma action plan should include self adjustment of medications in response to changes in PFM PFM Dependent on effort and technique Technique is everything Teach, demonstrate, review!!! Review proper cleaning as well NO spitting! No tongues! How to Use a PFM 1. Before each use, make sure the sliding marker or arrow on the Peak Flow Meter is at the bottom of the numbered scale (zero or the lowest number on the scale). 2. Stand up straight. Remove gum or any food from your mouth. Take a deep breath (as deep as you can). Put the mouthpiece of the peak flow meter into your mouth. Close your lips tightly around the mouthpiece. Be sure to keep your tongue away from the mouthpiece. In one breath blow out as hard and as quickly as possible. Blow a "fast hard blast" rather than "slowly blowing" until you have emptied out nearly all of the air from your lungs. 3. The force of the air coming out of your lungs causes the marker to move along the numbered scale. Note the number on a piece of paper. 4. Repeat the entire routine three times. (You know you have done the routine correctly when the numbers from all three tries are very close together.) 5. Record the highest of the three ratings. Do not calculate an average. This is very important. You can't breathe out too much when using your peak flow meter but you can breathe out too little. Record your highest reading. 6. Measure your peak flow rate close to the same time each day. You and your doctor can determine the best times. One suggestion is to measure your peak flow rate daily between when you wake up and before you use any asthma medicines You may want to measure your peak flow rate before or after using your medicine. Some people measure peak flow both before and after taking medication. Try to do it the same way each time. 7. Keep a chart of your peak flow rates. Discuss the readings with your doctor. PFM Personal Best Best and CONSISTENT measure during a healthy two week period Daily monitoring in the AM before medications Personal bests change with growth – recalculate periodically “Zoning” Personal Best Numbers 80-100% - Green Zone – Doing well 50-80% -Yellow Zone – Having trouble Less than 50% - Red Zone – Call Doctor Peak Flow Meters Several different colors, brands, types and costs ($12-$35 online) High and Low Flow Devices PFM Diary Document PFM readings daily Use an asthma diary or PFM graph FeNO Analyzer = “NIOX” Nitric oxide (“NO”) – smooth muscle relaxant found in the expired breath of humans and animals Fraction of Exhaled (“Fe”) NO Can be measured easily through one single exhalation FeNO is elevated in asthma patients FeNO level correlates significantly with the degree of bronchial hyper-responsiveness, bronchial reversibility and atopy FeNO levels correlate with airway inflammation Elevated FeNO has high specificity and sensitivity for diagnosing asthma Elevated FeNO can be diagnostic for asthma FeNO > 35 ppb in steroid naïve patient with respiratory symptoms = asthma Adult Values 25-50 = Gray Zone > 50 = + asthma Pedi Values 10-25 = Gray Zone > 25 = + asthma Elevated in both allergic and non allergic patients Higher in allergic patients Normal FeNO levels do not preclude an asthma diagnosis Can be normal in mild non-atopic patients Can be normal in patients whose asthma is in good control Level of FeNO does not differentiate between grades of severity of asthma OR correlate with FEV1 Useful in predicting asthma relapse, maintaining asthma control, monitoring adherence and assessing loss of asthma control “Steroid-ometer” Asthma Action Plan aka “AAP” 2007 Asthma Expert Panel Recommendations “Provide to all patients who have asthma, a written asthma action plan that includes instructions for Daily management Recognizing and handling worsening asthma, including adjustment of dose of medications “Particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma” (B). Asthma Action Plans Must include Daily Management What medicine to take daily, including the specific names of the medications What actions to take to control environmental factors that worsen the patients asthma How to recognize and handle worsening asthma What signs, symptoms, and PEF measurements (if doing PFM) indicate worsening asthma What medications to take in response to these signs What symptoms and PEF measurements indicate the need for urgent medical attention Emergency telephone numbers for the MD, ED, and person or service to transport rapidly for medical care Sample of Plans Asthma Action Plan - Green Zone No signs of asthma No problems during sleep Able to do normal activities Peak Flow >80% of Best or Predicted Everyday controller medicines as needed if persistent asthma based on history and NHLBI/NAEPP guidelines Pre-treat exercise if needed Watch for early warning signs Early Warning Signs cough stomach ache wheeze poor appetite chest tightness itchy throat or chin shortness of breath glassy eyes runny or stuffy nose feeling tired sneeze coughing or waking at headache night funny feeling in chest Asthma Action Plan - Yellow Zone Symptoms are present Cough, wheeze, chest tightness Increased need for inhaled quick-relief medications Usual activities somewhat limited Awakening at night due to asthma symptoms Peak flow 50 to < 80% of best or predicted ─ Take additional preventive medicines as prescribed Asthma Action Plan - Red Zone Late Signs - EMERGENCY! Peak flow <50% Very short of breath Usual activities are severely limited Asthma medications have not reduced symptoms Call doctor or nurse Call emergency number if needed — Take additional preventive medicines as prescribed Recognizing Emergency/Late Warning Signs No improvement 15 – 20 minutes after initial treatment Retractions - Chest and neck pulled in with breathing “Quiet” chest Stops playing and is unable to start again Infants unable to feed Trouble walking or talking Quick-relief medicines don’t help Blue or gray lips or fingernails Get emergency help now! Asthma Management Plans Discuss and regularly review decision-making criteria with an individual with asthma and his or her family based on the asthma management plan. This should include: Proper use of quick-relief medications Proper use of long-term controller medications When to seek care The importance of, and how to implement early intervention to prevent the progression of an acute episode Revise Asthma Management Plan At each visit check the patient’s compliance with, and concerns about, the management plan, including: – Use of medicines – Skill in using the inhaler, spacer, peak flow meter, or other devices – Avoidance of triggers Once control is established, regular follow-up visits (at 1- to 6-month intervals as appropriate) are essential to review together whether the management plan is meeting expected goals. But how do I GET an AAP from the Doctor? ? Require it for an asthma medication to be used in school Have one ready to fax to the MD if needed Talk to a NURSE directly in the office to ask for an AAP Other suggestions? In Conclusion……… There are many asthma “gadgets and gizmos” to help us help patients control their asthma Use them! Teach about them! Demonstrate and get demos back! Review them over and over! Revise them over time, as needed! Document their use in an Asthma Management Plan!
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