Patients must learn proper inhaler technique

It is important that healthcare providers -- particularly respiratory therapists, nurses, and physicians -- adequately teach respiratory patients the proper technique for using inhalers.  This is especially important now that there are so many different types of inhalers on the market.

One recent issue that came up were reports to the American Association of Poison Control Center's National Poison Data System and the FDA about patients ingesting the capsules rather than inhaling them. Poison control probably had to educate people that swallowing the capsules would not poison them, as acids in the stomach would break down the medicine before it gets to the system.  

So the safety issue here was not so much poison, as it was that these patients were not getting the benefits of the medicine.  The bottom line is that ingesting the capsules rendered them useless.

This is a quintessential example of poor inhaler training.  It's also a perfect example that shows that it should not be assumed that patients can figure out how to use inhalers on their own.

The fact of the matter is, not even the most well educated and seasoned asthmatics use their inhalers correctly.  Therefore, it should never be assumed a patient will figure it out on their own, or that even the most seasoned asthmatics are using their inhalers properly.

Most experts now recommend that all patients be educated on trained on proper inhaler use when they are given new inhalers, and then the patient should be asked to demonstrate proper use with each subsequent visit.

In February, 2008, The FDA issued a public health advisory highlighting the correct way to use Foradil. The purpose was to assure healthcare providers were aware patients were using them wrong, in order so they could make sure their patients are using them correctly.

The FDA has also been made aware that similar occurrences were reported regarding the Spiriva HandiHalter (tiotropium). That issue was also addressed.

In the past ten years there have been a ton of new inhalers enter the market.  Many times I have had to Google how to use an inhaler before teaching it to a patient.  While using most of these inhalers is generally easy, they can also be confusing and even frustrating to patients.

Bottom line: every time we as healthcare providers  -- and this included respiratory therapists, nurses, and physicians --see chronic lungers we ought to be asking them if they have inhalers, and we should be making sure they are using them correctly.

• FDA Safety Update: Asthma Medicines
• Most people don't use inhalers correctly

Most Aerosolized medicine is wasted

According to the American Association of Respiratory Care's "Guide to Aerosolized Medications," not much of the medicine inhaled by inhalers and nebulizers makes it into airways.

By device, here's how much medicine reaches the lungs?

• Metered Dose Inhalers:  9%
• Metered Dose Inhalers with spacer:  15%
• Small Volume Nebulizer:  12%
• Dry Powdered Inhaler:  13%

So that means that most of the inhaled medicine, or a whopping 85-91% depending on the device used, "is lost in the oropharynx, the device, the exhaled breath, and the environment," according to the guidelines.

When a patient is intubated the percentage of medicine getting to airways is 2.9%, according to one study. 

It appears that the best distribution into the airway is obtained by inhaler and spacer.  Of course, this would only be possible if good technique is used.  Considering studies show that up to 93% of asthmatics do not correctly use their inhalers (93% to be exact), this kind of knocks inhalers and inhalers with spacers down to a level playing ground with nebulizers.  

While some might panic at these percentages, one should not worry. Pharmaceutical companies are well aware these when the formulate their dosing criteria.  So chances are that, regardless of the route used, most patients get plenty of medicine for maximum effect. 

Plus, it must be considered that 2.5 mg of albuterol solution mixed with 3cc of normal saline contains about twice as much ventolin as in the 200 mcg of albuterol inhaled via an inhaler.  So, again, patients are getting plenty of albuterol, and probably more than enough when an SVN is used. 

So who wins the battle of inhalers vs. nebulizers?  Well, as far as distributing medicine to airways, they all work equally well.

This post was originally published on March 11, 2010.  It has been edited for accuracy by Rick Frea.  

Further reading:

• When do you end a breathing treatment?
• Aerosolized delivery in intubated, mechanically ventilated patients, Critical Care Medicine, Feb., 1985, MacIntyre, et al
• AARC: Guide to Aerosolized Medications
• Respiratory Care Principles and Practice, 2nd edition, 2012, page 316, edited by Hess, et al
• Aerosols in Critical Care, by James Fink, April, 2009, slideshow
• Most people don't correctly use their inhalers
• RT Magazine: Nebulizers VS Inhalers: And The Winner Is?

Get Free Breo for one year

If you take any inhaled combination medicine -- Advair, Symbicort, Dulera, Breo, or you are supposed to take one and cannot afford it, GlaxoSmithKline (GSK) has an offer you simply cannot pass up: Free Breo for a full year.

The most common and best selling combination inhaler is Advair.  However, while asthmatics have been waiting for a generic Advair to hit the market, thus lowering the price, it does not look like this will happen in the foreseeable future. 

And even if it does happen soon, you can't beat free offer because they surely don't come around very often.  

Of course there's a reason for the offer.  GSK is hoping that after taking their medicine for a year that you will fall in love with it and stick with their product after their eventually is a generic Advair. 

Breo is the newer version of Advair.  It only needs to be taken once a day, which is nice.  It is a little stronger and a little better than Advair.  It is only approved by the FDA for COPD, but Advair is only approved for Asthma. However, they are both proven effective for both diseases, and physicians are legally allowed to prescribe them for any patients they think it will be helpful for.  

Regardless of their intentions, click on over to mybreo.com and get your free Breo today.  Or share this with your family, friends, and patients with asthma or COPD.

Pretty much, the only requirement is a prescription for Breo from a physician. 

The best way to add value to aerosol therapy

So I'm reading this article in RT Magazine called "Adding Value to Aerosol Therapy" by Mark Grzeskowiak.  The article is about adding value to aerosol therapy without cutting on quality of care.

He writes:

When a respiratory care practitioner enters a hospital room, they bring with them their experiences, assessment skills, and the necessary equipment to the bedside in order to make a patient’s breathing a little easier. But in today’s healthcare environment, there is an increasing emphasis on becoming more productive. RCPs must be able to do more in less time and with fewer resources. This scenario can sometimes leave the RCP wondering which goal is more important: providing quality care, or completing more billable procedures.

In the case of aerosol therapy, value can be added to the treatment by increasing quality while decreasing costs. However, inexpensive products do not always provide a reasonable quality of care, and it is up to respiratory care departments to resist cost-cutting strategies that look good on paper but may compromise patient care. This article will focus on strategies that can allow RCPs to provide high-quality care and still keep budget offices happy.

He offers some viable solutions:

1. Adding value with equipment:  Here he explains that by preventing half the medicine from being wasted, the patient will get more of it. This can be done by adding a reservoir to the end of the nebulizer.  Another solution is breath actuated nebulizers.  The problem with these options is that the equipment costs more, with the breath actuated costly slightly less than the reservoir nebulizer.  Personally, I think it would be too hard for some patients with true bronchospasm to initiate the breath actuated nebulizer, and I think it would be less expensive just to give another breathing treatment when it is indicated. I emphasize "when indicated" because most patients would probably not need the second treatment anyway.  
2. Adding value by subtracting:  This would involve eliminating aerosol therapy for patients where there is no perceivable benefit.  The problem is that too many doctors and nurses thing aerosol therapy is the solution for all annoying lung sounds and all causes of dyspnea.  Personally, if a hospital would incorporate a system of RT driven aerosol therapy protocols, I think this is the way to go.  I think this would save the hospital money, save the insurance companies money, save the government money.  It would  even reduce RT burnout and apathy, and stop RTs from waking up patients in the middle of the night for no good reason.  It's a win-win for everyone. 
3. Adding value through change in practice:  Give a mouthpiece instead of a mask, because studies show 50% more medicine is lost when a mask is used. Placing the aerosol close to the patient in a ventilator or BiPAP circuit. The problem:  Most of the time masks are used by patient preference, or because the patient can't hold a mouthpiece.  Personally, if the patient needs more medicine to feel better, then we might as well be giving two breathing treatments.  If we went with option #2 above, giving an extra treatment once in a while when needed would not be a burden either financially or physically.   

I think another option that's missing here is to use metered dose inhaers (MDI) instead of aerosols.  Most studies show that aerosols are equally as effective at delivering medicine to the lungs as MDIs used properly with a spacer.  So, once a patient is breathing normal, MDIs should be used.

Albuterol MDIs cost about $40 a piece, and the instruction cost is about $140, which is way less than the cost of aerosol therapy, which is estimated at between $100 and $200 each treatment.

I think you can work to try to find better ways of delivering aerosolized medication to patients, but the best method of cutting costs, if that's the goal, is simply to make sure such therapy is only given to those who would truly benefit from them, and the only way to accomplish this is with RT driven protocols.

If, on the other hand, physicians are intent on giving aerosol therapy, then RTs should be allowed, per protocol, to give MDIs to those who can generate enough flow and otherwise coordinate the therapy.

SVNs work no better than a simple MDI

One of the ongoing fallacies in the medical profession is that a small volume nebulizer (SVN) works better at delivering medicine than a metered dose inhaler (MDI). The truth is, with proper technique, they both were equally well.

Still, even thought the AARC's "A Guide to Aerosol Drug Delivery," notes that the dose of a medicine delivered with an SVN is two times greater than 2 puffs of an MDI, this doesn't matter: the end result is the same.

The guidelines note the following: "Clinically it is often thought that nebulizers may be more effective than MDIs, especially for short-acting bronchodilators in acute exacerbations of airflow obstruction. A number of studies have established that either device can be equally effective, if the lower nominal dose with an MDI is offset by increasing the number of actuations (“puffs”) to lung dose equivalence."

Thus, one test showed that 5 puffs of terbutaline had an effect on FEV1 (the best indicator on a bronchodilator's efficacy on obstructed lungs) as 2.5 mg of terbutaline given via SVN. So it's clear that an MDI is equally as effective as an SVN.

This is true "provided that the patient can use the device correctly."

Check out what your COPD, Asthma meds cost

Ever wonder what aerosolized medicine cost. The following facts were obtained from the recent AARC "Guidelines to Aerosolized Medications."

---

1. Albuterol MDI HFA:
   $30.18 (generic)
   $37.63 - $39.61 (brand name)
2. Albuterol SVN:
   $15.00 for 20 mL bottle of 0.5%; $0.38 per 0.5 mL (usual dose)
   $18.99 for 25 3-mL vials of 0.083%; $0.76/vial
3. Pirbuterol:
   $94.76 MDI (400 actuations); $0.24/puff
4. Levalbuterol MDI HFA:
   $48.99 (200 actuations); $0.24/puff
5. Levalbuterol SVN:
   $79.50 for 24 vials (0.31mg/3mL); $3.31/vial
   $70.84 for 24 vials (0.63mg/3mL); $2.95/vial
   $71.25 for 24 vials (1.25mg/3mL); $2.97/vial
6. Ipratropium MDI HFA:
   $81.75 (200 actuations); $0.41/puff
7. Ipatropium SVN:
   $77.32 for 25 vials (0.02% in 2.5mL); $3.09/vial
8. Ipratropium & albuterol CFC MDI:
   $91.99 (200 actuations); $0.46/puff
9. Ipatropium SVN:
   $123.73 for 60 3-mL vials; $2.06/vial
10. Salmeterol DPI discus:
    $111.94 for 60 doses; $1.87/dose
11. Formoterol DPI aerosolizer:
    $108.17 for 60 capsules; $1.80/capsule
12. Tiotropium DPI handhaler:
    $129.55 for 30 capsules; $4.32/capsule
13. Beclomethasone MDI HFA:
    $60.84 40 mcg/puff (100 actuations); $0.61/puff
    $73.57 80 mcg/puff (100 actuations); $0.74/puff
14. Triamcinolone MDI CFC:
    $105.99 100 mcg/puff (240 actuations); $0.44/puff
15. Flunisolide MDI CFC:
    $77.55 250 mcg/puff (100 actuations); $0.78/puff
    HFA-MDI (Available in 2007)
16. Fluticasone HFA-MDI:
    $78.24 44 mcg/puff (120 actuations); $0.65/puff
    $104.74 110 mcg/puff (120 actuations); $0.87/puff
    $170.82 220 mcg/puff (120 actuations); $1.42/puff
17. Budesonide SVN:
    $149.35 for 30 vials of 0.25 mg/2 mL; $4.98/vial
    $165.80 for 30 vials of 0.5 mg/2 mL; $5.53/vial
18. DPI (Turbuhaler):
    $152.56 (200 inhalations); $0.76/dose
19. Mometasone DPI (Twisthaler):
    $143.62 (120 doses); $1.20/dose
20. fluticasone/salmeterol DPI (Diskus):
    $146.47 for 100/50 mcg/dose (60 inhalations); $2.44/inhalation
    $166.99 for 250/50 mcg/dose (60 inhalations); $2.82/inhalation
    $229.87 for 500/50 mcg/dose (60 inhalations); $3.83/inhalation
21. Budesonide/formoterol DPI (Turbuhaler):
    (Available in 2007)
22. Cromolyn CFC-MDI:
    $107.89 (200 actuations); $0.54/puff
    $71.28 (112 actuations); $0.64/puff
23. Cromolyn SVN:
    $46.61 for 60 vials (20 mg/2mL); $0.78/vial
24. Nedocromil CFC-MDI:
    $81.43 (104 actuations); $0.78/puff
25. Acetylcysteine SVN:
    $7.99 for 10 ml vial of 10% Solution
    $14.99 for 10 ml vial of 20% Solution
    $7.99 for 10 ml vial of 20% Solution
26. Dornase alfa SVN:
    $1,589.32 for 30 2.5-mL vials; $52.98/vial
27. Tobramycin SVN:
    $3,391.92 for 56 5-mL vials; $60.57/vial

---

Rescue bronchodilators: Here are my unfettered answers to all of your questions about them

The following are some questions real patients have asked me recently regarding rescue bronchodilators. The answers here are my humble personal and professional opinions and nothing more.

Keep in mind that your doctor might disagree with me, and that's fine. He can overrule me whenever he wants. But, the answers here are based not just on my 10 years as an RT, but over 30 years as a chronic asthmatic who's abused more than his share of inhalers and lived to tell about it.

Q) What is the recommended dose for albuterol

A) Every 4-6 hours as needed ( no surprise here.)

Q) What if I need it more often than that

A) For most patients, I'd recommend seeing your doctor if you need it more often than every 4-6 hours, because it's a sign that your asthma or COPD is getting worse and needs to be better controlled. However, it's a relatively safe medicine, and some doctors prescribe it to be used as needed for some chronic patients.

Q) What do you think of a doctor ordering Albuterol MDI every four hours?

A) Albuterol is typically a rescue medicine, and should be taken when you are short-of-breath (SOB) due to bronchospasm. It's not going to hurt if you use it more often than when you need it, but I don't see why it would be beneficial.

Q) My doctor says Albuterol will work to prevent an asthma attack, so I should use it every four hours all day. Is this true?

A) I was taught when I was kid to take my Albuterol before I took gym class, and I did. However, it never prevented me from getting SOB. It did, however, make me feel better once I was SOB. So to answer this from my own personal experience, I'd have to say no; Albuterol does not prevent asthma symptoms. However, you can try it to see if it works for you.

There are many doctors who do believe it can be used as a preventative drug. Not only that, it states this on the Albuterol package insert. However, if it is deemed necessary that preventative medicines be taken to prevent an asthma attack, there are far more effective medicines to be using, such as Vanceril, Flovent, Atrovent, Cromolyn, Advair, etc. (this will be discussed in a later post.)

Q. I've had an Albuterol inhaler for the past 3 years. Sometimes I use it more that 10 times in a day, which is more than the prescribed frequency of every 4-6 hours. Can I use Albuterol this much and feel safe?

A. I'm treading on thin water here, but I will say yes. I find from my own personal experience as a former Albuterol abuser, and professional experience giving treatments, that Albuterol is a very safe medicine. The most common side effect is that it might make you jittery, which you probably already know if you've done it before. If you were going to have a negative reaction to the medicine, like an increase in heart rate, it would have happened already.

However, if you have other medical issues besides just COPD or Asthma, then I'd be really cautious of using too much Ventolin. I'd recommend consulting your doctor if you need to do this. Personally, though, I still think Albuterol is safe and effective in most situations where real bronchospasm is the issue.

Q. But my doctor has me on all the right preventative medicines and I'm still finding myself going through an inhaler a week. Will this have long term implicaitons on my life span?

A. I asked my doctor that exact question when I was a kid, and he told me using my inhaler was better than suffering and chancing an anoxic episode. If you absolutely have no choice than to use your inhaler more than every 4-6 hours, make sure your doctor knows about this. Chances are, he will still renew your prescription because he doesn't want you to suffer. However, he may also continue to try to adjust your other medicines to make your life easier. Sometimes, however, as in some cases of COPD or end stage COPD, this is not possible.

Let me answer this question this way. I went through an inhaler a week from the time I was 13 or 14 until about a year ago when I started taking Advair. That was 25 years. I'm getting along just fine now. Will my Albuterol abuse cut some years off the end of my life? Well, nobody really knows. Albuterol has only been around since 1987. Personally, I doubt it will.

Q. My doctor prescribed Atrovent as my rescue inhaler, what do you think of that? Should I be worried if I use it more than four times a day, because I do?

A. Atrovent is not a rescue inhaler. Atrovent takes about 20-30 minutes to work, while Albuterol, idealy, should work almost instantaneously for bronchospasm. Then again, if Atrovent works for you, then that's great. If it isn't, then I'd talk to your doctor about getting an Albuterol inhaler.

Q. Am I safe using Atrovent more often than every four hours, because I do?

A. I don't see what it would hurt. When I was in school ten years ago we were taught never to use Atrovent more often than Q4. However, some new research shows that addtitional Atrovent during an exacerbation does benefit patients. If Atrovent is working for you as a rescue drug, all the power to you. However, if you continue to be short-of-breath, you should talk to your doctor about getting an Albuterol inhaler or (ideally) adjusting your preventative medications.

Q. Can I use my Combivent more than every 4 hours?

A. Again, I don't think it would hurt you, but it's not necessary. Technically speaking, the Atrovent in this medicine shouldn't need to be taken more than every four hours. If you need to use Combivent more than every four hours, then you should talk to your doctor and get an Albuterol inhaler. You can then use your Combivent four times a day, and Albuterol in between if you get short-of-breath. (and still I'd only recommend this only if other preventative medicines weren't working.)

Q. Do you think Xoponex is better than Albuterol?

A. No. I have never noticed a difference. Original studies claimed that Xoponex was stronger than Albuterol, but I've never noticed that to be true in my real life experiences with the two drugs. Not only that, I don't think the claim that Xoponex has fewer side effects than Albuterol is true either. Recent studies have confirmed this.

However, if you have experienced cardiac side effects, or excess jitteriness or nervousness, then you might be a candidate for a trial of Xoponex, if you want to flip the bill: Xoponex costs 5-10 times more than Albuterol.

Q. What if I go through an inhaler a week?

A. Every patient is different. Do you have end stage COPD? If so, you have to do what you need to do. Do you have asthma? Then perhaps you could trial Advair. Advair worked like a miracle drug for me. I went from one inhaler a week and 600mg of theophylin twice a day down to two 300mg pills a week and 4 puffs of Albuterol a day after being on Advair 9 months.

You and your doctor have to find what works best for you. If there is no other alternative, then an inhaler a week might be the best solution.

I meet albuterol abusers at work all the time, and the majority of them are end-stage COPD patients. However, on occasion, I have met a fellow asthmatic who abuses too. Most of them think they are the only one. And, most of them think they are doing this furtively without their doctor's knowing.

Many times I walk into a patients room to give a breathing treatment and find that MDI hidden under the pillow, a sign of a true rescue inhaler abuser.