Skill Building: Diaphragmatic Breathing and Inhaler Technique

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Skill Building Diaphragmatic Breathing and
Inhaler Technique

• Debora S. Chan PharmD, FASHP, CDM

Nursing in the School Diabetes and Asthma
Management 6 July 2005
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Outline

• Asthma Education
• NHLBI Guideline
• Skills
• Delivery Devices
• Nebulizer/compressor
• Dry Powder inhaler (DPI)
• Metered-dose inhaler (MDI)
• Spacers/holding chamber
• Self Monitoring
• Diaphragmatic Breathing

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NHLBI Guidelines

• Asthma Education
• Begin at diagnosis
• Multi-disciplinary approach
• Tailored approach to self-management
• Teach and Reinforce
• Basic facts
• Medications
• Skills (MDI/spacer, DPI, self monitoring)
• Environmental controls
• Written
• Asthma action plan
• Home management plan

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Delivery Devices Controller and Reliever
Medications

• Nebulizer/Compressor
• Dry Powder Inhaler (DPI)
• Metered-Dose Inhaler (MDI)
• With and without holding chamber (spacer)

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Nebulizers/Compressors

• Medication delivery
• Controller medication
• Reliever medication
• Not for O2 delivery

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DPI vs MDI

• Dry powder inhaler (DPI)
• Drug in powder form inhaled through device
• Drug delivery dependent on patients air flow
• Metered-dose inhaler (MDI)
• Drug suspended in liquid
• Drug delivered as a puff via propellant
• Chlorofluorocarbon (CFC)
• Hydrofluoroalkane (HFA)

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Dry Powder Inhalers (DPI)

• FDA phase out CFCs as propellants in MDIs
• Global effort
• 2003 deadline
• Some drugs able to be made into dry powders
• Controller medication
• Reliever medication

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Controller DPIs

• Dry Powder Inhalers
• Diskus
• Turbuhaler
• Others

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Technique Checklist Diskus

• Open mouthpiece covering
• Hold the Diskus level
• Load DPI one time
• Inhale and exhale slowly with your mouth away
  from the DPI-Do not blow or exhale into the
  inhaler-Do not shake or tip the inhaler after
  loading it
• Place mouthpiece between lips holding DPI flat
• Inhale fast and deep through your mouth (not your
  nose)
• Take DPI out of mouth and close mouth
• Hold breath for ten seconds
• Exhale slowly
• Close the Diskus

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Technique Checklist Turbuhaler

• Remove cover (Twist the cover and lift it off)
• Hold the DPI in the upright position (mouthpiece
  up) when medication is being loaded
• Load the DPI by twisting the brown grip fully to
  the right as far as it will go, Twist it back
  again fully to the left until you hear a click
• Inhale and exhale slowly with your mouth away
  from DPI-Do not blow or exhale into the
  inhaler-Do not shake the inhaler
• Place mouthpiece between lips holding DPI
  horizontally
• Inhale fast and deep
• Take DPI out of mouth and close mouth
• Hold breath for ten seconds
• Exhale slowly

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Reliever DPI

• Dry Powder Inhalers
• Maxair Autohaler

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Reliever DPI Maxair Autohaler

• Remove cap (Do not obstruct vents on bottom)
• Raise lever on top of unit to upright position
• Shake gently
• Take deep breath and exhale
• Place mouthpiece between lips
• Inhale fast and deep
• Hold breath for 10 seconds
• Close lever on top

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Metered-Dose Inhalers (MDI)

• Invented 1957 3M Company
• Pressurized
• Medication
• Surfactant
• Propellant
• CFC-free except reliever medication

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Metered-Dose Inhalers (MDI)

• HFA MDIs
• Relievers Controllers

Proventil HFA
QVAR (HFA)
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Metered-Dose Inhalers (MDI)

• FDA approved use
• Open mouth
• Closed mouth

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Spacer

• Provides contained space between MDI and mouth
• Spacer improves drug delivery into the lungs
• Less systemic effects
• FDA-approved device

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Spacer vs Holding Chamber

• Spacer Holding Chamber
• Spacer provides space only
• Holding chamber is spacer with valve

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Holding Chamber Use Video
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MDI Holding Chamber Checklist

• Properly assemble puffer-spacer
• Shake well before each puff
• Inhale and exhale slowly
• Place spacer mouthpiece between lips holding
  puffer upright
• Press puffer down one time
• Inhale slowly (no whistle sound) Parents should
  watch to make sure they see valve on chamber open
  when child inhales
• Take spacer out of mouth and close mouth
• Hold breath for ten seconds (or as long as
  possible)
• Exhale slowly
• Wait one minute between puffs

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Holding Chamber with Mask Use Video
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MDI Holding Chamber with Mask Checklist

• Properly assemble puffer-spacer and mask
• Shake well before each puff
• Place mask on face making a good seal with puffer
  upright
• Inhale and exhale (slowly if possible)
• Press puffer down one time
• Inhale and exhale into spacer 6 times while
  keeping mask on face with a good seal Parents
  should watch to make sure they see valve on
  chamber open when child inhales
• Remove mask from face
• Wait one minute between puffs

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EZ Spacer Use Video
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Skills MDI EZ Spacer Checklist

• Shake canister well before each puff
• Properly assemble canister-spacer
• Inhale and exhale slowly (if possible)
• Place spacer mouthpiece between lips
• Press canister down one time
• Inhale slowly
• Take spacer out of mouth and close mouth
• Hold breath for ten seconds (if unable to hold
  for 10 seconds, exhale and inhale into spacer up
  to 3 times)
• Exhale slowly
• Wait one minute between puffs

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Skills Administration of Medications

• MUST watch patients technique
• Common MDI/S errors
• Forget to shake canister
• Blow into spacer rather than inhale through
  spacer
• Dont hold breath after inhaling or not hold
  breath long enough
• Inhale too fast
• Dont open valve when inhaling
• Confuse inhalation with exhalation valve on mask
• Use EZ spacer upside down

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Tricks of the Trade

• MDI/holding chamber
• Nose breathing instead of inhaling dose or while
  holding breath
• MDI/holding chamber with mask for small children
• Hold on lap with legs between yours and childs
  arm behind your back
• Move hand from MDI area toward mask once puffed
• Make sure enough air movement to open valve

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Skills Self Monitoring

• Early recognition
• Early treatment
• Less medication needed
• Feel better faster

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NHLBI Management of Exacerbations

• Albuterol first
• Assess child sxs
• 2 puffs wait 5 minutes and reassess
• Give 2 more puffs if child has sxs
• Stop if albuterol working
• Up to 6-8 puffs in 15-20 minutes

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Medication Reliever

• Albuterol
• Intermittent and persistent asthma severity
• Works fast to relieve bronchoconstriction or
  tightness
• May initially worsen cough
• Should last 3-4 hours
• prn or as needed medications
• Albuterol Asthma Attack

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Albuterol MDI Medication Refills

About ½ empty
Full
Almost full
Empty
Less than 1/3 full
Cain WT, Oppenheimer JJ. Ann Allergy Asthma
Immunol. 2001 Nov87(5)417-9
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Skills Self Monitoring

• Difficulty breathing
• Chest tightness
• Cough interfering with activity or sleep
• Inability to speak in sentences
• Wheezing
• Itchy, watery, glassy eyes
• Sore, scratchy, itchy throat
• Stroking of neck
• Fever
• Congestion
• Sneezing
• Runny nose

• Headache
• Dark circles under eyes
• Change in face color
• Change in appetite
• Change in activity level
• Retractions
• suprasternal
• supraclavicular
• intercostal
• substernal
• subcostal
• Grunting
• Flaring

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Skills Self MonitoringDiaphragmatic Breathing

• Stress and anxiety
• Turn a mild attack into a more serious attack
• Breathing retraining
• Accessory muscle use
• Meant only to be used in emergencies
• Inefficient and fatigue quickly

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Skills Self MonitoringDiaphragmatic Breathing

• Belly breathing
• Teaches breathing control using the diaphragm
• Pursed-lip breathing
• Helps to improve oxygenation and aids removal of
  CO2

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Diaphragmatic Breathing Technique

• Sit up straight in a chair or lie down on the bed
  or floor with knees bent
• Place hands lightly on stomach
• Breathe in slowly through your nose
• As you take air in feel, your stomach expand
• Keep your chest still
• Blow the air slowly out of your mouth through
  pursed lips
• Feel your stomach get smaller
• Do not breathe fast
• Take more time to breathe out then to breathe in
• Repeat ten times or until you feel that you are
  breathing better

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Questions?