Asthma Gadgets and Gizmos (PowerPoint)

							Asthma Gadgets and
     Gizmos
        Lynn Feenan RN, MS, AE-C
Pediatric Pulmonary Clinical Nurse Specialist
         Certified Asthma Educator
     Children’s Hospital at Dartmouth
         lynn.feenan@hitchcock.org
                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!