The two chronic respiratory diseases that you’ll almost definitely encounter in your practice is Asthma and Chronic Obstructive Pulmonary Disease (COPD). It’s estimated that over 3.8 million Canadians are living with Asthma and 2.0 million Canadians are living with COPD.
Challenges with breathing can lead to a significant reduction in physical function, exercise ability and conditioning. This leads to downstream effects of increased comorbidities. For example, if someone becomes sedentary because they have difficulty breathing, that will increase their risk of cardiovascular comorbidities and can have effects on their mental health. This will lead to a decrease in quality of life.
Lack of proper control of these respiratory diseases can also lead to an increase in hospitalizations leading to an increased economic burden on the health care system, lost productivity for the patient, and in many cases, mortality. Therefore, ensuring that both asthma treatment and COPD treatment are optimized for patients is essential. Optimizing therapy for these individuals goes beyond ensuring proper pharmacological therapy but also ensuring lifestyle measures such as smoking cessation are incorporated along with proper administration and compliance to their inhalers.
The role of nurses in respiratory care is incredibly important. While doctors may take the lead in the diagnosis of respiratory illness and respiratory technologists may lead management plans, nurses have an extremely important role in the actual administration of the medication and have excellent opportunities for patient education.
These conditions are unique as the mainstay of treatment are inhalers and most medications are not administered orally or through injection.
When managing respiratory diseases with inhalers, proper drug deposition into the lungs is essential for both copd treatment or asthma treatment. Success can only be achieved with a good inhaler technique. In addition, proper use of these medications from day one will influence the patient’s perception of the risks versus benefits as well as the effectiveness.
By ensuring that a patient is receiving the full benefit of their inhalers, it will also prevent an unnecessary step up of medications and reduces the burden of the illness and the likelihood of hospitalization.
How a medication is administered directly influences treatment success, especially in an acute situation where a patient is experiencing an exacerbation or a complication due to their poorly controlled respiratory disease.
For example, as their disease progresses, it’s very common that patients will be admitted for acute exacerbations of COPD. In COPD, an acute exacerbation can progress to pneumonia and in older patients with multiple comorbidities, this can very quickly lead to death. Regaining control of their disease is done through use of oral corticosteroids to bring down inflammation but also through around the clock use of their inhalers which will typically be administered by nurses. Good technique is essential here!
Moreover, a strong understanding of the different inhalers and how to use them will allow for better opportunities for patient education. This will influence their treatment success when a patient is managing the disease on their own!
COPD and Asthma are different diseases and have different management strategies. This article will introduce the basics of the management strategies and provide guidance on how to use common inhalers that will be encountered during practice, along with the differences between asthma vs. COPD.
Long acting beta agonist (LABA) in combination with inhaled corticosteroid (ICS):
Short acting bronchodilator in combination with ICS for immediate symptoms:
Short acting beta agonist (SABA) monotherapy:
Please note, guidelines changed in 2019. Previously recommended SABA monotherapy as reliever therapy for all ages. Practice has yet to catch up to recommendations for use of combination products as relievers and SABA monotherapy is still frequently seen.
The type of inhaled corticosteroids will be chosen depending on patient age and severity of asthma. *Also known as “controllers.”
Due to the heterogeneous nature of asthma, LABAs, oral therapies or biologics may be used to achieve control.
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Long-Acting Muscarinic Antagonist (LAMA)
Long Acting Beta Agonist (LABA)
ICS are only used in select patient populations in COPD.
Oral therapies and pulmonary rehabilitation will be considered if there’s frequent exacerbations.
Treatment failure is prominent in these respiratory diseases. This is measured through frequency of exacerbations and hospitalizations. Control of the respiratory diseases in an outpatient setting can usually be gauged by how often they need to use their reliever inhaler.
Before stepping up therapy, it is more important to assess their inhaler technique and adherence to controller/maintenance therapy because often that's the cause of poor control.
In an outpatient setting, nurses are often going into patient’s homes and witnessing administration of medications, especially in older adults. This is an ideal time to assess their inhaler technique and monitor adherence.
In an acute care setting where nurses are administering the medication, it is easier to monitor adherence however proper inhaler technique may still be a challenge as it is difficult to remember the proper way due to the sheer number of different devices. Another important thing to remember, is if a patient sees a nurse administer an inhaler a certain way, they will leave with the understanding that this is the correct way to use the inhaler.
Below is a review on how to use common inhaler devices:
A pressurized inhaler that delivers a stream of aerosolized medication via propellent.
This is a type of inhaler that all individuals with COPD or Asthma will likely become familiar with. Ventolin (salbutamol) is a MDI and various ICS such as Flovent (fluticasone), QVAR (beclomethasone) and Alvesco (ciclesonide) come in this form.
Here is how to administer it:
Other information to keep in mind:
A dry powdered inhaler is an inhaler that delivers a dose through deep inhalation (breath activated).
Here is how to administer a few different dry powdered inhaler devices:
This is another type of inhaler that you will see very frequently as Symbicort (budesonide/formoterol) comes in this form. Other medications in this form include Oxeze Turbohaler (formoterol), Pulmicort (budesonide) and Bricanyl Turbohaler (terbutaline).
Examples include Incruse Ellipta (umeclidinium), Trelegy (fluticasone furoate/ vilanterol/ umeclidinium) and Breo Ellipta (vilanterol/fluticasone).
Examples include Flovent (fluticasone), Ventolin (salbutamol) and Serevent (salmeterol)
Other information to keep in mind:
This device punctures a capsule and the medication powder is inhaled.
This is a type of inhaler frequently seen in COPD. Spiriva (tiotropium) is a VERY common medication used to manage COPD and is available in this device.
Here is how to administer it:
Other information to keep in mind:
For more information:
Check out these two resources for more information on inhaler technique and inhaler devices:
As nurses, you are on the floor not only directly interacting with patients but also with their medications. For administration of as needed (PRN) medications, in an inpatient setting, a nurse’s assessment of appropriateness of therapy is needed prior to administration of these medications.
This is an excellent time to monitor how frequently they are using their reliever and referring them to the proper health care professional to optimize their medication if they do not have good control of their disease. Using a rescue inhaler more than twice a week is cause for a concern.
Additionally, if you notice that an inhaler choice does not seem right for a patient’s condition (i.e. Symbicort as an initial therapy in COPD), it’s useful to flag this the respiratory technologist or pharmacist. Also keep in mind that a lot of patients have been living with these comorbidities for a very long time. As recommendations change, some patients may stay on inhalers that are not actually the best medication choice for them. It never hurts to have extra eyes identifying these issues.
It can’t be stressed enough how big of a role inhaler technique has in patient outcomes. Remember the differences between COPD vs. Asthma.
Ensuring a good understanding of the various inhaler types will allow for proper deposition of medications when administering medications. As nurses often administer inhalers, a strong understanding is essential.
In a variety of different settings, nurses are perfectly poised to provide education to patients. In addition to showing patients how to administer medication, regularly reviewing, and reinforcing proper inhaler technique is key.
As patient’s disease progresses (i.e. COPD becomes severe) or comorbidities change (i.e. recently diagnosed with Parkinson’s), their inhaler device may no longer be appropriate. When a disease becomes long standing, these other factors are often forgotten, which is why the nurses’ role in ongoing monitoring and education remains very important.
Asthma and COPD are respiratory diseases that are prominent in Canada. Medications are available to manage and prevent progression of the diseases, but proper inhaler technique is necessary in order to ensure delivery of medication to the lungs.
As nurses, in an inpatient setting, you are the primary health care professional that administer the inhaled therapies. Building a strong foundational understanding of these different devices will allow for proper administration of medications to patients.
In an outpatient setting, nurses have a strong role in reviewing and reinforcing inhaler technique as well as ensuring inhaler choices remain appropriate.
In addition to administering therapies, having an understanding of the different medications and management strategies will allow nurses to identify red flags such as overuse of their relievers or inappropriate inhaler choice. These insights are incredibly valuable when optimizing therapy.
Azra Chatur, BScPharm
Azra is a pharmacy graduate from the University of Alberta. All aspects of pharmacy and healthcare interest her but the majority of her experience has been focussed on long term care, geriatrics and community pharmacy. Writing is her passion and she is excited to be able to share her pharmaceutical knowledge with nurses! If you have questions don’t hesitate to connect with her on Linkedin.