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

Spiriva may be good option for asthma

I thought it was interesting to learn that a new study published in the New England Journal of Medicine, and reported by the AP here, showed that Spiriva worked as well as Serevent to treat hardluck asthma, and better than the technique of doubling the dose of inhaled corticosteroids.

When a patient is diagnosed with Hardluck Asthma, which means they have difficult to manage asthma despite being Gallant Asthmatics on all the best asthma medicines, the asthma guidelines recommend using a higher dose of steroids (often doubling the dose) or adding Serevent to the routine.

Usually Serevent and the inhaled corticosteroid Flutocinase are used via the Advair discuss, which offers three different doses of the steroid (100/50, 250/50, and 500/50). Most often the 250/50 dose is provided to patients, yet those who require more steroids may be prescribed the 500/50 dose.

Yet, according to AP:

Researchers found Spiriva worked better than a double steroid dose and was as effective as Serevent. When the study first began, patients on average had 77 asthma-free days a year - days in which they had no symptoms and did not have to use their rescue inhaler.

Doubling the steroid medicine gave patients an extra 19 asthma-free days; taking Spiriva gave them an additional 48 days with no symptoms, and taking Serevent gave them an extra 51 days.

Spiriva is a promising alternative asthma treatment and some doctors are already using it in people who don't respond to steroid medicine, but more study on drug safety is needed, Dr. Lewis Smith of Northwestern University wrote in an accompanying editorial.

I used to take Atropine as a kid, and later Atrovent. Yet for some reason this medicine was phased out of my asthma medicine routine. I do know some asthmatics on Spiriva, and my doctor did ask me if I wanted to try it.

I responded I didn't see a need at the present time. Yet it seems it might be justified trying Spiriva if other medicines do not control your asthma.

Atrovent Happy doc may be on to something

We have a doctor here at Shoreline who orders Atrovent on every person who is ordered up on a treatment. The idea is, if you require a treatment, you get Atrovent. In fact, if you require a continuous Albuterol, you also require continuous Atrovent.

When she's working, I stock up on Duoneb. And yes, she also gives it to kids.

When she started working here I questioned her excessive Atrovent orders, but she's the kind of doctor who knows what she wants and orders it regardless of what you think.

In fact, in RT school back in 1995, we learned that Atrovent should never be given more often than every four hours.

I've often wondered what she has read that has her so up on Atrovent. One study I found was that Atrovent can benefit asthmatics, even those having acute symptoms. But that was just one study.

Another study showed that Atrovent given in conjunction with Albuterol resulted in more patients improving in the emergency room and being discharged, compared with those just given Albuterol.

So, perhaps Dr. Atrovent knows what's she's ordering.

When I was a kid I used to take Atropine for my asthma. Back then it was common to use it for asthma. In fact, when I was first put on it by my doctor at National Jewish in Denver when I was a patient there in 1985, I was told it was a preventative medicine more so than a rescue medicine, which is basically true even as it is used today.

Then I was put on Atrovent when it came out because the side effects were less. Then I was taken off the medicine altogether because it was no longer recommended for asthma.

However, anticholinergics have long been recommended for COPD. In fact, the newest anticholinergic used is Spiriva, which has been proven (via tests) to actually improve lung function in such patients.

Yet, according to Allergy and Asthma: Practical Diagnosis and Management, "A subset of asthma patients may respond favorably to inhaled... anticholinergics such as (Atropine and now Spiriva). Although this class of medications alone is not considered sufficient as therapy in asthmatic patients, it may be a useful adjunct in some patients."

Then the author adds this, which is why I wrote this post: "There is limited experimental evidence in animal models that this class of medications may potentially limit airway remodeling, thus potentially expanding the future role of these drugs in asthma. However, at present there is not enough evidence to make such a recommendation."

Perhaps, in some asthma cases, Atrovent or Spiriva might prove beneficial. Perhaps our ER doc who is Atrovent happy is on to something. And besides, even if the Atrovent doesn't result in immediate results, there are basically no side effects so what can it hurt to try.

Random asthma questions

Every day at MyAsthmaCentral.com we get lots of asthma related questions. Below are some questions I thought my readers at the RT Cave would enjoy.

Question: can the Breathalyzer show a positive/negative due to my asthma or medications? I had one test show a positive of 0.12 and 20 minutes later show 0.00. how is that possible if the machine was calibrated correctly? HOW IS IT POSSIBLE PERIOD?

My humble answer: It's funny you ask this question, as I've heard it from other asthmatics as well. However, I have never heard any credible evidence that any asthma medicine would cause a false breathalyzer reading.

What asthma medicines are you taking? If what you are saying is true, it would be interesting to pin down which asthma medicine is accused of altering Breathalyzer results.

Honestly, I do not know the answer to your question, yet I remain curious

(Update 8/11/10: Check out this link)

Question: My mother (95 years old) was just diagnosed with asthma. Is this unusual?

My humble answer: Ironically, I was just reading something the other day about how more and more elderly people are being diagnosed with asthma, so I don't think it's completely unusual. When I come across this again I'll be sure to keep you in mind and send you a link.

Question: A nurse prescribed spiriva for my asthma. I thought spiriva was for COPD not asthma. Is it safe for me to use spiriva or is it the incorrect medication?

My humble answer: Spiriva is a safe medicine for both asthma and COPD patients. It is an anticholinergic medicine like Atrovent that acts as a bronchodilator, only it's taken once daily and works for up to 24 hours. There have been studies that showing Spiriva actually improved lung function and decreased exacerbation's in COPD patients. While Atrovent used to be used as a controller medicine for asthma, Anticholinergics are no longer recommended as a top line medicine for asthma as there are other bronchodilators that work better, such as Albuterol and Serevent and Formeterol.

Usually Spiriva is not the first medicine prescribed to control asthma. However, without knowing the rest of your medical history, and what other medicines you are on or have tried, it's tough for me to form an opinion on your NP (nurse practitioner) ordering Spiriva for your asthma.

As is noted in this post, finding what medicine(s) works best to control your asthma can often be a game of trial and error. Likewise, if you want to find out what your NPs plan of action is for you, ideally you should ask your NP.

Question: Which is better, singulair or pulmicort. Advair is to expensive but is a great product. Is there a generic for it?

My humble answer: At this point there is not generic for Advair. I have heard rumors that say Advair wil be available in generic form soon, but I have heard no verification of this.

Singulair and Pulmicort are two different kinds of medicines, and you can read about them in the links I provided. Which one "is better" basically depends on you and your doctor. Sometimes the best way to determine which one works best is by trial and error. Some asthmatics find Singulair alone works great to control their asthma, and some find that Pulmicort alone works fine. For some asthmatics, other meds or combination of them works best.

For a great article on which asthma medicine works best for you, click here.

Question: I have heard that there will soon be a generic version of Advair. How soon?I credit Advair with controlling my asthma enough that I seldom ever need my rescue inhaler. I am on Medicare and Advair is very expensive. Because I must take other non generic medications for other problems, I reach the "gap" of Medicare very quickly, so a generic version of Advair would be would be most helpful.

My humble Answer: I have heard similar rumors, but I have also not heard any credible evidence that the rumors are true. However, at the present time there is no Generic Advair available. As soon as one is available I'm sure we will report this news here on this site. In the meantime, there was a similar question asked here if you care to read more.

If you have a question you would like to ask you may inquire at freadom1776@yahoo.com

New drug combo may greatly benefit COPDers

I had an uncle with COPD call me about a year ago because he wanted to learn ways he could improve his lung function. Basically, I gave him three recommendations off the top of my head:

1. Stop smoking

2. Stay as active as you possibly can

3. Take all your lung medicines exactly as prescribed

4. Talk to your doctor about Spiriva.

I told him I had read about studies that proved Spiriva improved lung function in COPD patients. He heeded my advice, but he passed away before I could talk to him about how it worked for him.

A new study released this past month shows not only does Spiriva improve lung function in COPD patients, if it is used in conjunction with Symbicort. According to an article at medicalnewstoday.com, the combination of Spiriva plus budesonide/formoterol combination (the contents of Symbicort):

• Reduced the rate of severe exacerbations by 62% (p<0.001)2
• Improved clinical lung function as measured by improvement in pre and post dose FEV1 (p<0.001,>
• Improved morning symptoms and activities (p<0.05)
• Improved health-related quality of life
• Was well tolerated

Typically, according to the above article, a combination of a long acting bronchodilator and corticosteroid and Spiriva is indicated in any COPD patient with a lung function (FEV1) of less than 50%.

So this is all the more reason to keep in touch with the latest research. If your doctor is unaware of this study, perhaps you'll want to nudge him.

However, keep in mind this is just one study, although one that showed significant improvements in lung function with those taking the trio of medications compared to those who received a placebo.

While there is no cure for COPD, the goal of therapy is to make sure all COPD patients are able to remain productive members of society. Aside from avoiding cigarette smoke and staying active, new medicines can help COPD patients accomplish the goal of maintaining a quality of life.