Do You Have Poor Symptom Control of Your Asthma or COPD? Are You Using Your Inhaler Correctly?

Incorrect inhaler technique is very common in patients with asthma or chronic obstructive pulmonary disease (COPD). This leads to poor symptom control and

disease flareups and in turn affects quality of life and need for emergency hospitalisation. There is increasing evidence that correct inhaler technique increases the amount of medication reaching the lungs when a dose is inhaled.

Asthma and COPD in brief

Asthma is a reversible chronic ( long-term) inflammatory disease of the airways,

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which generally starts in children. It is characterised by the following symptoms usually in the night or early morning:

• wheezing

• coughing

• chest tightness

• breathlessness

Asthma can flareup due to exposure to certain trigger factors such as pollen, dust and smoke. The airways become narrow when exposed to these triggers and less air flows in and out of the lungs because muscles in the airways tightens, is swollen and inflamed and become blocked with mucus.

COPD on the other hand is an irreversible, progressive airways disease which gets worse over time, generally starts later in life (at least 40 years old). The main cause is cigarette smoking but you can also develop COPD if you are exposed to chemicals and pollution long term. There is no cure for COPD but treatment can help ease symptoms and lower chance of complications and improve quality of life. The common chronic obstructive airways diseases are emphysema and chronic bronchitis and symptoms vary according to the severity and progression of the disease. However it can be characterised by the following symptoms:

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• difficulty breathing

• chronic cough

• shortness of breath

• excessive mucus production therefore need to clear mucus from throat/lungs regularly

• fatigue- lack of energy

• chest tightness

• frequent colds,flu and other respiratory infections

Asthma and COPD can have overlapping symptoms, so similar medication and inhalers are used in both cases especially relievers. Incorrect inhaler technique when using inhaled corticosteroids (preventers) can cause dysphonia (hoarse voice), sore throat and oral thrush apart from poor symptom control.

Reliever Medications

Reliever medications, as the name suggests relieve asthma / COPD symptoms quickly, as little as 4 minutes but are short acting (effective for 4-6 hours). They belong to a group of medicines called short acting Beta2 agonists (SABAs) which cause the muscles in the bronchial tubes to relax and so relieves chest tightness and wheezing.

These medications are salbutamol available as Asmol inhaler(MDI ), Ventolin inhaler (MDI) and Airomir autohaler and terbutyline available as Bricanyl

turbuhaler.

Inhalers can be used with or without a spacer. A spacer is a plastic chamber which helps to deliver more medication to the lungs when used with an inhaler. All children should be encouraged to use their metered dose inhalers ( MDI) via a spacer and to use a mask especially for children under 5 years old. You should carry your reliever medication with you all the time in case of emergency.

Spacers can be used in 2 ways depending on how deeply you can breathe.For each puff, you can either:

• take one big breath by breathing in slowly, deeply and fully and holding breath for about 5-10 seconds then breathing out slowly OR

•  take 4 normal breaths if you are unable to take one big breath in.

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Spacer Care

Most spacers (depends on the brand) have to be cleaned (reduces static buildup) before use for the first time. The reason being, medication, when puffed into the spacer will stick to the inside walls of the spacer and not be inhaled which defeats the purpose of using the device. If the spacer has to be used immediately prior to cleaning, static can be reduced by putting 8-10 puffs in the spacer before first use. Spacer can be cleaned as follows:

• dismantle spacer

• rinse in warm soapy water

• do not wash out with water

• drip dry

• re-assemble and its ready for use with MDI

Spacers can also be cleaned when cloudy and should ideally be replaced 6 monthly especially if cracked or valve is no longer working properly.

Preventer Medications

Preventative medication as the name suggests when used optimally and accurately will keep symptoms of asthma and COPD at bay. They reduce inflammation by making airways less sensitive to triggers and reduce mucus production. They are longer acting so usually used once or twice daily depending on the medication. These should used daily as per dose instructions from your health professional. These preventative medications are available as a single ingredient or in various combinations and are available in the following types of devices:

• metered dose inhaler (MDI) eg. Alvesco, Atrovent, Flixotide and Fluticasone Cipla, Flutiform, Qvar, Seretide and Pavide

• dry powder inhaler (DPI) eg. Oxis, Pulmicort, Symbicort

• soft mist inhaler eg. Spiriva Respimet, Spiolto Respimet

• Accuhaler eg. Flixotide, Seretide, Serevent

• Autohaler eg. Qvar

• Rapihaler eg. Symbicort

• Duoresp Spiromex

• Ellipta eg. Anoro, Breo, Incruse and Trelegy

• Genuair eg. Bretaris, Brimica

• Breezhaler eg. Onbrez, Seebri, Ultibro

• Handihaler eg. Spiriva

The following tables show the technique used for the different types of inhalers.

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Finally, asthma and COPD are both disease of the airways. Incorrect inhaler technique is one of the reasons for symptom flareups. It is important to understand how to use MDI relievers and preventers with and without spacers. Spacers help ease of using MDIs and increase the amount of medication depositing in the lungs. MDIs should be shaken before each puff where as DPIs should not be shaken prior to use. Preventatives are available in a variety of different medications and formulations. Some devices have to be primed before use as indicated in the table above. After using inhaled corticosteroids in a single dose inhaler or in combination devices, it is important to rinse mouth and gargle thoroughly. All devices should be stored away from excessive heat and moisture. To keep disease in check, correct dose of medication and correct inhaler technique is of paramount importance.