Inhalers in Asthma and COPD

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. 

Asthma vs. COPD

What is Asthma? 

• A long-term disease characterized by inflammation and narrowing of airways
• Cardinal symptoms are cough, shortness of breath, chest tightness and wheezing
• Poor control can result in irreversible narrowing of airways and an increased risk of flare-ups
• Diagnosed with spirometry, often in childhood

Risk Factors:

• Genetics
• Smoking
• Obesity
• Prone to allergic reactions

Management:

1. Non pharmacologic management to manage inflammation and prevent exacerbations

• Identify triggers and avoiding triggers.
  
  
• Treat risk factors where applicable (i.e. smoking cessation or obesity).

2. Rescue inhalers for immediate relief of chest tightness

Long acting beta agonist (LABA) in combination with inhaled corticosteroid (ICS):

• Symbicort (budesonide/formoterol) is preferred. 
• As of 2019, guidelines recommend this option as first line.

Short acting bronchodilator in combination with ICS for immediate symptoms:

• If Symbicort cannot be used, then this is the next best option.

Short acting beta agonist (SABA) monotherapy:

• Ventolin (salbutamol)
• Recommended in children, only.

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. 

3. Inhaled corticosteroids to manage the underlying inflammatory component of asthma

• Beclomethasone
• Budesonide
• Ciclesonide
• Fluticasone
• Mometasone

The type of inhaled corticosteroids will be chosen depending on patient age and severity of asthma. *Also known as “controllers.”

4. Step up or step-down therapy based on patient symptoms. 

Due to the heterogeneous nature of asthma, LABAs, oral therapies or biologics may be used to achieve control. 

What is COPD?

• A systemic disease characterized by progressive and only partially reversible airway limitation.
• Cardinal symptoms are shortness of breath, cough, and sputum production.
• Frequent exacerbations, hospitalizations, and further reductions in air flow mark increase disease severity.
• Diagnosed with spirometry, often in adults over the age of 55.

Risk factors:

• Cigarette smoking (80-90% of cases are attributed to smoking)
• Occupational exposure to dust
• A genetic deficiency in alpha-1-antitrypsin, a marker that protects the lung from damage

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Management:

1. Non pharmacologic management to prevent progression of disease and to promote self management

• Smoking cessation
• Encourage physical activity
• Annual influenza vaccine and pneumococcal vaccine

2. Short acting bronchodilator for immediate symptoms management: 

• Ventolin (salbutamol)
• Bricanyl Turbuhaler (terbutaline)

3. Long acting bronchodilators for optimal bronchodilation and reduction of symptoms. 

Examples: 

Long-Acting Muscarinic Antagonist (LAMA) 

• Spiriva DPI and Respimat (tiotropium)
• Seebri Breezhaler DPI (glycopyrronium)
• Incruse Ellipta DPI (umeclidinium)

Long Acting Beta Agonist (LABA)

• Serverent Diskhaler and Diskus (salmeterol)
• Oxeze Turbuhaler (formoterol)
• Onbrez Breezhaler DPI (indacaterol)

Combination LABA/LAMA

• Ultibro Breezhaler (DPI) (glycopyrronium/​indacaterol)
• Inspiolto Respimat (tiotropium/ olodaterol)
• Anoro Ellipta DPI (umeclidinium/​vilanterol) 

Combination LABA/LAMA/ICS

• Trelegy (fluticasone furoate/ vilanterol/ umeclidinium) 

ICS are only used in select patient populations in COPD.

4. Step up or step-down therapy based on patient symptoms

Oral therapies and pulmonary rehabilitation will be considered if there’s frequent exacerbations.

Vital differences in the algorithms of Asthma treatment and COPD treatment

1. Inhaled corticosteroids with or without LABAs are the mainstay of therapy for control in Asthma.
   
   
2. LAMAs and/or LABAs are the mainstay of therapy for control in COPD. 
   
   
3. In Asthma, you will not ever see LABA monotherapy, but you will see that in COPD.

Inhaler Technique

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:

Metered dose inhaler (MDI):

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: 

1. Shake the inhaler a few times before use. Remove cap.
2. Have the patient breathe out fully.
3. Place the inhaler between the lips of the patient, have them seal with mouth around it. It should be placed between the teeth but should be over the tongue.
4. As the patient slowly inhales, press the canister of the inhaler to release the dose.
5. Remove puffer from their mouth. Instruct patient to hold their breath as long as they can (around 10 seconds) before exhaling. 
   
6. If another puff is needed, wait 30-60 seconds before the next puff. 

Other information to keep in mind:

• Most MDIs do not have a dose counter. Paying attention to when the device started to be used and how often the device is used is important. 
• Rinsing the mouth after use of an MDI, especially when using an ICS is recommended! 
• Generally, MDI’s require priming (a few sprays) into the air before use, when first used and if not used for a few days.
• For more effective use and to minimize risk of side effects, a spacer is recommended to be used with MDIs.

Dried Powder Inhalers (DPI):

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:

1. Turbuhaler®:

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).

• Twist cover and remove it
• Turn the colored wheel one way and then the other way. The dose is loaded once you hear a click.
• Have the patient breathe out normally.
• Place the mouthpiece between the lips of the patient and have them tilt their head back slightly.
• Direct the patient to take a deep and forceful inhalation.
• Instruct the patient to hold their breath for as long as they can (at least 10 seconds). 
• Remove the device from their mouth and advise them to breathe out.

2. Ellipta®:

Examples include Incruse Ellipta (umeclidinium), Trelegy (fluticasone furoate/ vilanterol/ umeclidinium) and Breo Ellipta (vilanterol/fluticasone). 

• For the first use, the inhaler will have to be removed from the tin packaging. There is a short 6-week expiry date after it’s been opened.
• Slide the cover down, uncover the mouthpiece. When you hear a click a dose is loaded.
• Follow steps 3-7 as above with the Turbohaler.

3. Diskus®:

Examples include Flovent (fluticasone), Ventolin (salbutamol) and Serevent (salmeterol)

• Remove the inhaler from packaging. Please look at the packaging for expiry date details as each medication device has a specific expiry date once opened.
• To open the device hold the device in the palm of one hand. Place the thumb of your other hand onto the thumb grip and push the thumb grip away from you until you hear a click. This opens to device and will expose the mouthpiece 
• To load the device, slide the lever away from you until you hear a click! 
• Follow steps 3-7 as above with the Turbohaler.

Other information to keep in mind:

• Typically, these inhalers have a dose counter. 
• No need to shake these inhalers!
• Rinsing mouth after use will minimize risk of side effects especially if there is an ICS component. 
• The different inhalers in DPI format may require different methods to open and load the device but actual administration and the breath required are the same for all DPI devices. 
• These inhalers require a deep, sharp and forceful breath. Therefore, they may not be appropriate in young children or in individuals with severe COPD as they may not be able to produce a breath that will fully expel a dose. 
• A lot of DPIs contain lactose! Very important to be mindful of allergies.

HandHaler®:

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:

1. Remove capsule from blister package of medication.
2. Open the dust cap and the mouthpiece. Place the capsule into the centre chamber.
3. Once placed, close the mouthpiece until you hear a click.
4. Press the green button on the side of the device. This will poke a hole into the capsule and release the medication.
5. Follow steps 3-7 as above with the dried powder inhalers however while a deep breath is needed, the same force is not needed for this device. 

Other information to keep in mind:

• Often, there is confusion and capsules are taken orally. This is always good to assess for and monitor.
• If the Handihaler is vibrating, this means it is being used correctly.   
• This is not the best format for patients that may be cognitively impaired or may lack hand/dexterity strength.
  
  

For more information:

Check out these two resources for more information on inhaler technique and inhaler devices:

1. Asthma Canada
2. National Lung Association

The Essential Role of Nurses in Management of COPD and Asthma

Identification and Management of COPD treatment & Asthma treatment:

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.

Proper Administration:

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. 

Patient Education:

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. 

Conclusion

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.

Resources:

Factual information in this post is supported by Asthma Canada, The Lung Association, Public Health Agency of Canada and Compendium of Therapeutic Choices.

Author Bio  

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.