Asthma Gadgets and Gizmos

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Asthma Gadgets and Gizmos

• Lynn Feenan RN, MSN, AE-C
• Mary Bouthiette RN, AE-C
• November 2008

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Objectives

• By the end of this presentation the participant
  will be able to
• 1. Name different methods of asthma drug
  delivery
• 2. Describe the use of the MDI, DPI, and
  nebulizer
• 3. Describe the use of the Peak Flow Meter
• 4. Discuss the use of the Asthma Action Plan

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Methods of Drug Delivery

• Intravenous
• Oral
• Leukotriene Modifiers
• Singulair and Accolate
• Oral Corticosteroids
• Palatability Counts!
• Inhaled
• Nebulizer
• Metered Dose Inhaler MDI
• Dry Powder Inhaler DPI

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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

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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)

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Nebulizer Technique

• EXTREMELY important
• Noseclips 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
• NO Blow By

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Dose inhaled (mg)
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.
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Metered Dose Inhalers (aka MDIs)

• 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)
• More care of spray spout, more priming necessary

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MDIs
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MDIs

• Several different colors, sizes, AND medications
  are available in MDIs
• 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!!!

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MDI Inhaler Technique WITHOUT spacer

• Remove the cap from the inhaler.
• Hold the inhaler with the mouthpiece at the
  bottom.
• Shake the inhaler. This mixes the medication
  properly.
• 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.
• Tilt your head back slightly and open your mouth
  wide.
• Gently breath out.
• 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.
• Hold your breath for up to ten seconds. This
  allows the medication time to deposit in the
  airways.
• Resume normal breathing.
• Repeat steps 3 - 9 when more than one puff is
  prescribed.
• Wait time between puffs varies no good data
  typically 30 -60 seconds
• RINSE MOUTH if ICS

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MDI Inhaler Technique WITH spacer

• Insert the inhaler/canister into spacer and
  shake.
• Breath out.
• Put the spacer mouthpiece into your mouth.
• Press down on the inhaler once.
• Breathe in slowly (for 3-5 seconds).
• Hold breath for 10 seconds repeat for second
  puff if needed

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Spacers and Valved Holding Chambers VHCs

• 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

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Spacers and VHCs

• 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 ICSs 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

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Spacer/VHC

• Many shapes, sizes, colors, brands, cost (15-35
  on Asthmastuff.com)
• May not be covered by insurance

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Spacer and VHC

• Prescribe more than one spacer
• School
• Daycare
• Grandmas 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

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MDIs without spacers

• Autohalers - 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)

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Dry Powder Inhalers DPIs

• 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
• 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

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DPIs

• 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

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DPIs

• Technique is everything
• Teach, demonstrate, review!!!
• Review proper cleaning as well

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DPI Use

• Read the instructions that come with your DPI.
• Remove the cap and hold the inhaler upright.
• Check that the mechanism is clean and the
  mouthpiece free of obstruction.
• Load a dose into the device as directed.
• Hold the inhaler level with the mouthpiece end
  facing down.
• 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).

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DPI USE

• Place your teeth over the mouthpiece and seal
  your lips around it. Make sure you don't block
  the inhaler with your tongue.
• Breathe in quickly and deeply (over two to three
  seconds) through your mouth to activate the flow
  of medication.
• 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.
• Rinse Mouth if ICS
• Keep DRY powder inhalers DRY
• Do not store in bathroom
• Do not exhale into them

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DPI Use

• Important to know if patient can generate enough
  negative inspiratory flow to deliver the
  medication
• In-Check Dial
• 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 MDIs, DPIs, 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.

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In-Check Dial

• http//www.alliancetechmedical.com/icdial.html

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Peak Flow Meters

• 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)

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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

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PFM

• Monitoring tool NOT diagnostic
• Typically used with children gt 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

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PFM

• Dependent on effort and technique
• Technique is everything
• Teach, demonstrate, review!!!
• Review proper cleaning as well
• NO spitting!

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How to Use a PFM

• 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).
• 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.
• 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.
• 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.)

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How to Use a PFM

• 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.

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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

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Peak Flow Meters

• Several different colors, brands, types and costs
  (12-35 online)
• High and Low Flow Devices

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PiKo1

• Can measure peak flow and FEV1
• Forced Expiratory Volume in 1 Second
• Sometimes needed in patients with severe asthma
  or patients who have rapid onset of severe asthma
• A more sensitive measurement of airway
  obstruction
• 40 online

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PFM Diary

• Document PFM readings daily
• Use an asthma diary or PFM graph

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Asthma Action Plan

• 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).

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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

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Sample of Plans
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Asthma Action Plan - Green Zone

• No signs of asthma
• No problems during sleep
• Able to do normal activities
• Peak Flow gt80 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 signs

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Early Warning Signs

• cough
• wheeze
• chest tightness
• shortness of breath
• runny or stuffy nose
• sneeze
• headache
• funny feeling in chest

• stomach ache
• poor appetite
• itchy throat or chin
• glassy eyes
• feeling tired
• coughing or waking at night

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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 lt 80 of best or predicted
• Take additional preventive medicines as prescribed

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Asthma Action Plan - Red Zone

• Late Signs - EMERGENCY!
• Peak flow lt50
• 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

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Recognizing Emergency/Late Signs

• No improvement 15 20 minutes after initial
  treatment
• Retractions - Chest and neck pulled in with
  breathing
• Stops playing and is unable to start again
• Infants unable to feed
• Trouble walking or talking
• Quick-relief medicines dont help
• Blue or gray lips or fingernails
• Get emergency help now!

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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

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Asthma Management Plan

• The Expert Panel does recommend that at least
  several key areas of quality of life be
  periodically assessed for each person with
  asthma. These include
• Any missed work or school due to asthma
• Any reduction in usual activities (either
  home/work/school or recreation/exercise)
• Any disturbances in sleep due to asthma
• Any change in caregiver activities due to a
  child's asthma (for caregivers of children with
  asthma)

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Integrate the Action Plan into Daycare School

• Comprehensive plan needs to cover the individual
  with asthma wherever they are
• Design management plans that address asthma
  control away from home and share them with
  appropriate individuals especially
  schools/daycare.
• School Nurses are your friends!!!

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Trigger Control

• Identify individual triggers
• Determine exposure to triggers
• Assess sensitivity to triggers
• Eliminate, avoid or reduce exposure to triggers.
• Document trigger control on action plan

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Revise Asthma Management Plan

• At each visit check the patients 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.

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Revise Asthma Management Plan

• During each appointment inquire if the patient
  has
• Slept undisturbed
• Participated in usual physical activities
• Required little or no quick-relief medications
• Required any urgent care
• Normal peak flow
• Met personal goals for asthma care

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Document in the Permanent Record

• Copy of Action Plan
• Assess level of severity/control, adherence,
  schedule
• Consider cultural influence, work/school schedule
• Update re-educate each visit as needed.
• Copy of Trigger Control Plan
• Assess effect of controls, new concerns/exposures
• Re-prioritize, update re-educate each visit as
  needed
• Evidence of collaboration among providers
• Discuss concerns/problems with provider as needed

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In Conclusion

• There are many asthma gadgets and gizmos to
  help us help patients control their asthma
• Use them!
• Teach about them!
• Demonstrate them!
• Review them!
• Revise them over time, as needed!