Inhalers and smoking cessation

Generic facts

• People over the age of 35 lose 3 months every year they continue smoking

• Smokers over 60 develop CVD 5.5 years earlier than non-smokers

• Ex-smokers develop CVD 2 years earlier than non-smokers

• Smoking increases the risk of 12 types of cancer, CVD, diabetes, COPD and pneumonia

• Smokers over 55 have an increased risk of death from renal failure, intestinal ischaemia, hypertensive heart disease, infections, respiratory diseases, breast and prostate cancer

• Only 3-5% of people manage to quit for 6-12 months without drugs or support

How does the NHS stop smoking service work?

• Intensive support through group therapy or 1-1

• Specialist smoking cessation advisers, trained nurses and pharmacists

• Nicotine replacement therapy, varenicline, bupropion, e-cigs

 

When does medication get started for people who want to quit?

• NRT starts on quit date

• Varenicline started 1-2 weeks before quit date and then titrated up

• Bupropion is started a week before quitting

• There is no tablet formulations because nicotine has a heavy first pass metabolism which reduces bioavailability

Varenicline and bupropion should not be used in pregnancy, intermittent oral NRT (gum/lozenges) can be used as the exposure is the lowest

What are the different types of forms of treatment?

• Transdermal patches: 16 hour and 24 hour options, can be used in combo with NRT to cover cravings

• Lozenges

• Inhalators

• Nasal sprays

• Sublingual tablets

• Chewing gum

What is smoking pack years?

• Unit used to measure the amount of tobacco someone has smoked

• Number of packs in a day x number of years smoked

• More than 15 pack years is clinically significant

What is a spacer?

Empty plastic tubes

• Inhaler is at one end and medicine is breathes through the other end into mouth

• Volumatic

• AeroChamber

• Able Spacer

• Space Chamber Plus

• A2A spacer

• EasyChamber

How do spacers help with inhaled drug administration?

Easier coordination - removes need for timing of pressing down inhaler and breathing

• Benefiical for children and elderly

Better drug delivery - holds medication in chamber allowing patients to inhaler slower and deeper

• More medicine reaches lungs and not stuck in back of mouth/throat

• Less side effects (steroid inhalers)

What are the 2 methods of using a spacer?

Hold/single breath technique

Tidal/multiple breathing technique

• Prescribed for younger children as it is easier to teach

Outline the method for the single breath spacer

1. First hold your inhaler upright and take the cap off.

2. Check there's nothing in mouthpiece.

3. Shake it well

4. If your spacer has a valve, make sure the valve is facing upwards

5. Put your inhaler into the hole at the back of the spacer.

6. If your spacer has a cap, take it off.

7. Breathe out gently and slowly

8. Make a tight seal.

9. Press the canister on the inhaler once and breathe in slowly

10. Take the mouthpiece of the spacer out of your mouth and hold breath for up to 10 seconds

11. Breathe out gently away from the spacer.

12. If been prescribed a second puff, with the spacer away from your mouth, wait 30 seconds to a minute and shake the inhaler again.

13. Then repeat (7 to 11).

14. When done, take the inhaler out of the spacer and replace the caps on both the inhaler and the spacer.

Outline the method for the multiple breathing spacer

1. If your spacer has a valve, make sure the valve is facing upwards

2. Put your inhaler into the hole at the back of the spacer.

3. If the mouthpiece of your spacer has a cap, take it off. Shake inhaler

4. Make a tight seal on spacer mouthpiece

5. Press the canister on the inhaler once to release the medicine and breathe in and out slowly and steadily through your mouth into the spacer five times

6. Remove the inhaler and spacer from your mouth.

7. If prescribed a second puff, keep the spacer away from your mouth, wait a minute and shake the inhaler again.

8. Then repeat steps (4 to 6).

9. When done, take the inhaler out of the spacer and replace the caps on both the inhaler and the spacer.

A whistling sound is heard if you’re breathing in too fast while using a small volume spacer. Clicking sound should be heard as valve opens and closes

What are some tips for parents with babies using a spacer and face mask?

• Sit them on your lap facing you so you can keep eye contact and tilt them back slightly.

• Cuddle your baby on your knee or cradle them in your arms. Gently tuck their arms out of the way if they try to knock the mask away.

• Be positive and smile

• Get baby used to how it feels.

• Reassure by pretending to take the medicine or giving it to their toy.

• Distract baby with music or a video

How are spacers cleaned and how often should they be replaced?

• Replace every year

• Clean it with warm water and a detergent (washing up liquid)

• Don’t scrub the inside of the spacer, as this can affect the way it works

• Let spacer air dry as this helps to reduce static

• When completely dry put your spacer back together

What is a nebuliser?

Device that turns a liquid into a fine mist when inhaled

• Plastic container

• Air compressor

• Air tubing

• Face mask/mouth piece

When is a nebuliser used?

• High doses of drugs

  • Salbutamol, ipratropium and budesonide

• Shortness of breath and patients are struggling to breather and use inhaler

• Serious respiratory conditions - patients have it at home

What are the steps to using a nebuliser?

1. Wash your hands before using your nebuliser

2. Make sure nebuliser tubing and mask/mouthpiece is fitted.

3. Fill with the amount of medicine prescribed.

4. If using a facemask, make sure there are no gaps for medicine to escape from.

5. If using a mouthpiece, make sure you seal your lips tightly around the mouthpiece.

6. Turn the machine on.

7. Sit up straight and breathe in.

8. Takes between 10 and 15 minutes.

How should nebulisers be cleaned efficiently?

1. Wash your hands.

2. Take apart the mask or mouthpiece from the tubing and medicine chamber.

3. Wash the mask or mouthpiece and medicine chamber in warm, mild soapy water, and rinse with clean water.

4. Do not wash the tubing.

5. Air-dry on a towel – don’t dry it yourself as this can create static, causing the medicine to stick to the inside of the machine.

What are the advantages and disadvantages of using nebulisers?

Easy to use High dosage delivery Effective for severe cases Passive treatment

Requires regular cleaning Limited portability Time consuming Side effects and medication waste Expensive

What drugs can be affected by stopping smoking and what actions to take?

Drug	Actions to take
Aminophylline, theophylline	Monitor plasma theophyllineconcs and adjust dose
Chlorpromazine	Look out and reduce dose for: dizziness, sedation
Clozapine	Monitor serum drug levels before stopping and a week after. Reduce dose to 75% slowly
Erlotinib	Smoker - increase daily in 50mg at 2 week intervals up to 300mg Ex - reduce to initial
Flecainide	Reduce if stop smoking
Methadone	Look out and reduce dose for - opioid toxicity
Olanzapine	Look out and reduce dose for: dizziness, sedation
Riociguat	Reduce dose if stop smoking
Warfarin	INR can increase if they stop smoking so monitor

How do e-cigs work?

• They have a battery powered heat that heats nicotine that creates an inhalable aerosol

• Emits volatile carbonyls, reactive oxygen species, furans, nickel, lead and chromium - toxic to lungs

What are the benefits to government banning vapes?

• Reduces fires, explosions, poisoning

• Decreases future smoking risk

• Reduces environmental concern

What type of inhaler is a turbohaler, what drugs are in the device and is it spacer compatible?

• Type of dry powder inhaler (DPI)

• Budesonide – a corticosteroid to reduce inflammation

• Formoterol fumarate dihydrate - a long-acting bronchodilator to relax airways

• Not spacer compatible

What are the steps to priming a turbohaler?

1. Twist off the cover and hold it up with the colour base at the bottom

2. Turn base all the way in one direction and then all the way back, hear a click

3. Repeat

What are the steps to using a turbohaler?

1. First twist off the top cover.

2. Check there's nothing inside mouthpiece.

3. Check dose counter to make sure the inhaler is not empty. When there are only 20 doses left in the inhaler, a red strip will appear in the top of the window. When it gets to the bottom of the window, this means your inhaler is empty.

4. Hold the inhaler upright.

5. Turn the coloured base to the right as far as it will go and then to the left until you hear a click.

6. Breathe out gently and slowly away from the inhaler, until your lungs feel empty and you feel ready to breathe in.

7. Hold inhaler horizontally

8. Put lips around the mouthpiece, make a tight seal, breathe in quickly and deeply until lungs feel full.

9. Take the inhaler out of your mouth and hold your breath for up to 10 seconds

10. Breathe out gently away from the inhaler

11. If you've been prescribed a second puff, repeat steps (3 to 7)

12. When done, twist the cover back on

If using an inhaler that contains steroids, rinse your mouth with water and spit it out to reduce the chance of side effects.

What are the advantages and disadvantages of using a turbohaler?

No coordination needed High lung deposition Built in counter Portable and convenient No propellant

High flow dependant Technique sensitivity Moisture sensitivity No feedback Not for lactose intolerants Expensive

What type of inhaler is a breezhaler, what drugs are in the device and is it spacer compatible?

• Type of dry powder inhaler (DPI)

• Indacaterol – LABA

• Glycopyrronium - LAMA

• Not spacer compatible

What are the steps to using a breezhaler?

1. Take the cap off. Check there's nothing inside the mouthpiece.

2. Open inhaler by pushing mouthpiece back.

3. Take a capsule from the blister pack.

4. Put the capsule inside the inhaler.

5. Close the inhaler until you hear a click.

6. Press and release the two buttons at the side of the inhaler to make a hole in the capsule.

7. Hold the inhaler horizontally

8. Breathe out gently and slowly away from the inhaler

9. Put lips around the mouthpiece for a tight seal.

10. Breathe in quickly and deeply. You should hear a vibrating noise.

11. Take the inhaler out of your mouth and hold your breath for up to 10 seconds

12. Then breathe out gently away from the inhaler.

If there’s no vibrating, capsule may be stuck. To loosen capsule:

1. Open the inhaler and loosen the capsule by gently tapping the base of the inhaler.

2. Close the mouthpiece and follow steps (8 to 12) again

3. When done, open the inhaler and check that the capsule is empty.

4. If it is, tip it out into the bin, close the inhaler and replace the cap.

If not empty, repeat the steps.

What are the advantages and disadvantages of using a breezhaler?

Low resistance and ease of use Breath activated Gives feedback Low error rate Once a day dose

Capsule handling Multi steps Coughing risk User swallows’ capsule Sensitive to humidity

What type of inhaler is a pMDI inhaler, what drugs are in the device and is it spacer compatible?

• Pressurised metered dose inhaler – Asthma and COPD

• Albuterol, beclomethasone, formoterol, fluticasone and glycopyrronium

• Yes it is spacer compatible

When and how is a pMDI inhaler tested?

Test inhaler if it’s the first use or it has been 5 days

• Take cap off and shake the inhaler well, pointing the mouthpiece away from you.

• Press the canister to release a puff into the air. Test sprays you need to do will depend on instructions.

• Check dose counter is not empty

What are the steps to using a pMDI inhaler?

1. Hold inhaler upright and take cap off.

2. Check there’s nothing in the mouthpiece.

3. Shake the inhaler well

4. Breathe out gently and slowly away from the inhaler

5. Make a tight seal around mouthpiece

6. Start to breathe in slowly and steadily, at the same time, press the canister on the inhaler once.

7. Continue to breathe in slowly until lungs feel full.

8. Take inhaler out of your mouth and hold your breath for up to ten seconds

9. Breathe out gently through your mouth away from your inhaler.

10. If you have been prescribed a second puff wait 30 seconds to a minute and shake the inhaler again, then repeat steps (4 to 9).

11. When done replace the cap on inhaler.

What are the advantages and disadvantages of using a pMDI inhaler?

Portable Consistent dosing Versatility Rapid use for emergencies Cost effective

Coordination necessary Med can get stuck in throat High carbon footprint due to propellant Dose tracking issues Slow and steady technique

What type of inhaler is a easi-breathe inhaler, what drugs are in the device and is it spacer compatible?

• Breath-actuated inhaler (BAI)

  • Acts as a bronchodilator to open airways

• Salbutamol sulphate

• Not compatible with a spacer

How is an easi-breathe inhaler tested?

Test by spraying 2 puffs in the air

1. Unscrew top of your inhaler so you can see the metal canister inside.

2. Fold down the cap and shake inhaler

3. Pointing the mouthpiece away from you, spray the aerosol into the air

4. Spray a second puff, then put the top back on and close the cap.

What are the steps to using a easi-breathe inhaler?

1. Hold the inhaler up and shake inhaler

2. Then open the cap.

3. Check there's nothing in mouthpiece

4. Make sure you're not covering the air holes at the top.

5. Breathe out gently and slowly away from the inhaler.

6. Make a tight seal.

7. Breathe in slowly and steadily. Continue to breathe in when you feel the inhaler puff in your mouth until you have taken a full deep breath in.

8. Take inhaler out of your mouth and hold your breath for up to 10 seconds

9. Breathe out gently away from inhaler.

10. If prescribed a second puff, close the cap. Wait one minute and shake the inhaler again. Then repeat steps (5 to 10).

11. When you've finished, close the cap.

What are the advantages and disadvantages of using a easi-breathe inhaler?

Easy to use Improved drug delivery Preferred Hygienic Environmentally friendly Effective relief

Less portable Needs good inspiratory flow Side effects if overused Proper maintenance No integrated dose counter

What type of inhaler is a ellipta inhaler, what drugs are in the device and is it spacer compatible?

• Dry powder inhaler (DPI) - up to 60 doses

• Fluticasone furoate, umeclidinium and vilanterol

• Not spacer compatible

What are the steps to using a ellipta inhaler?

1. Check dose counter to make sure the inhaler is not empty.

2. Slide the cover open with your thumb until it clicks.

3. Check there's nothing in mouthpiece.

4. Hold the inhaler horizontally

5. Breathe out gently and slowly

6. Make a tight seal, making sure you do not cover the vent.

7. Breathe in quickly and deeply

8. Take inhaler out of your mouth and hold your breath for up to 10 seconds

9. Breathe out gently through your mouth

10. When you've finished, close the cover.

What are the advantages and disadvantages of using a easi-breathe inhaler?

Easy to use Once a day dosing Consistent dose delivery Clear dose counter Portable Low maintenance

Not for emergency use Common side effects Risk of thrush Needs deep inhalation Users with COPD have a risk of pneumonia Not for people with milk allergies Strict timing