Respiratory Care 2. Clinical Skills School of Medicine 2015/16

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1 Respiratory Care 2 Clinical Skills School of Medicine 2015/16

2 Learning Objectives Identify the different types of inhalers and demonstrate the correct inhaler techniques for the different inhalers. Demonstrate how to use a nebulizer. Identify reasons for and demonstrate how to correctly obtain a peak flow reading. Demonstrate how to correctly put on Respiratory Mask.

3 Inhalers Poor inhaler technique is a very common problem among patients. Poor inhaler technique contributes to asthma control. Choice of inhaler could be based partially on patient preference and ability to use. Review the patients technique. (Haughey et al, 2008)

4 Types of Inhalers Preventers steroid inhaler, brown, orange, wine. Long acting slow release beta 2 agonist, green Relievers fast acting beta 2 agonist, blue Combined long and steroid inhalers.

5 Types of Devices Pressurized Metered Dose Inhaler (MDI) Convenient Cheapest option Portable Difficult to use due to need for correct coordination of actuation and inhalation.

6 Types of Devices Spacers Easier to use than a MDI. Can be combined with an MDI. Many have one way valve which produces better clinical effective. As effective as a nebulizer during acute attacks of bronchoconstriction. Bulky and difficult to carry around.

7 How to use a Metered Dose Inhaler 1. Breathe out gently. Remove the cap and shake the inhaler. 2. Put the mouthpiece in the mouth and at the start of inspiration, which should be slow and deep, press the canister down and continue to inhale deeply. 3. Hold the breath for 10 seconds, or as long as possible. 4. Wait about 30 seconds before taking another inhalation.

8 How to use a Spacer Device e.g. Volumatic 1. Remove cap, shake inhaler and insert into the device. 2. Place the mouthpiece in the mouth. 3. Press the canister once to release a dose and take a deep, slow breath in. 4. Hold the breath for about 10secs, then breath out through the mouthpiece. 5. Breathe in again but do not press the canister. 6. Remove from mouth and wait 30secs before taking a second dose.

9 How to use the Easi-Breathe 1. Shake the inhaler and open cap.. 2. Breathe out gently. Keep inhaler upright, put mouthpiece in the mouth and breathe in steadily through the mouthpiece. DON t stop breathing when the inhaler puffs and continue to take a really deep breath. 3. Hold breath for 10 secs. 4. After use hold inhaler upright and close the cap. 5. For a second dose wait 30 secs and repeat the steps above.

10 Types of Devices Dry Powder Inhalers (DPI) E.g dischaler, turbohaler. Single dose inhaler. Can be difficult to use due to need for correct coordination of actuation and inhalation. Between 4% and 95% of patients, depending on inhaler type do not use their dry powder inhalers correctly (Lavorini et al, 2008).

11 How to use the Accuhaler 1. Pushing the thumbgrip away until a click is heard. 2. Hold Accuhaler with mouthpiece towards you, slide lever away until it clicks. Breathe out gently away from device, put mouthpiece in mouth and suck in steadily and deeply. 3. Hold the breath for about 10 seconds. 4. To close, slide thumbgrip towards you as far as it will go until it clicks.

12 How to use the Turbohaler 1. Unscrew and lift off white cover. Hold Turbohaler upright and twist the grip forwards and backwards as far as it will go. You should hear a click. 2. Breathe out gently, put the mouthpiece between the lips and breathe in deeply. Even when a full dose is taken there may be no taste. 3. Remove the Turbohaler from the mouth and hold breath for about 10 seconds. Replace the white cover.

13 Types of Devices Nebulizers Simple to use - little coordination is needed by patient. Preferred in acute severe asthma useful that 02 can be administered through the nebulizer at the same time as β2- agonist. Expensive, bulky, time consuming and inconvenient. (Pederson, 1996)

14 How to use a nebulizer 1. Fill the medication cup with the medication(s) and connect tubing. 2. Holding the medication cup upright, insert the mouthpiece or put the mask up to the face. 3. Turn the machine on. 4. If possible, breathe deeply and slowly through your mouth until finished. 5. Equipment should be stored in a plastic bag or container in between use.

15 Mask versus Mouthpiece British Thoracic Society recommend the mask due to less side effects such as medication going into eyes. Mask requires little patient involvement

16 Peak Flow PEFR: Peak Expiratory Flow Rate Measured using a peak expiratory flow meter. Lung function measurements assess airflow limitation and help diagnose and monitor the course of asthma. Such objective measurements are important because patients and physicians often do not recognise asthma symptoms or their severity.

17 Peak Flow Daily PEF monitoring for 2 to 3 weeks is useful, when it is available, for establishing a diagnosis and treatment. Accurate and frequent peak flow measures helps to assess pt progress and response to medications. Long-term PEF monitoring is useful, along with review of symptoms, for evaluating a patients response to therapy. PEF monitoring can also help detect early signs of worsening before symptoms occur. (GINA, 2000)

18 How to use the Peak Flow Meter 1. Stand up if possible. 2. Check cursor is on zero. 3. Take a deep breath in and place peak flow meter in the mouth horizontally and close lips. 4. Blow suddenly and hard. 5. Note the number indicated by the cursor. 6. Return cursor to zero and repeat twice to obtain three readings. 7. Record the best of the three readings

19 The Facts Ireland 7000 cases of TB in Ireland in 1950 s 2003 data. 407 cases in Ireland Highest rates in 65years 74% Irish born Outcome 264 completed treatment, 32 died (6 due to the TB).

20 What is TB? Disease caused by Mycobacterium tuberculosis, africanum bovis Usually effects lungs but can effect glands, bones, brain, kidney, spine Notifiable disease Infectious (open/smear positive/active) Non-infectious (closed/smear negative) Latent TB (dormant)

21 How is it spread? Infectious only when smear positive or open TB. Spread by droplet infection. Coughing, sneezing, spitting. Close and prolonged contact is needed. Symptomatic within weeks or months. Most positive case stop being infectious after 2 weeks of treatment.

22 Infection Control Suspected or definite diagnosis of open pulmonary TB negative pressure room. Respiratory mask and standard precautions.

23 Respiratory Mask 1. Respiratory mask 0.3 micron efficacy meets CDC guidelines for exposure to TB. 2. Masks worn by staff free of facial hair. Seal checking of masks at each application. 3. Importance of removing mask not touching outside and handling by the straps and bringing down the face not over the top of head. 4. Discard not to be reused. 5. Wash hands.

24 References GINA (2000) Asthma management and prevention. Asthma Guidelines for the Republic of Ireland. Irish medical Journal. (Supp) July-Aug. Report on the Epidemiology of Tuberculosis in Ireland Health protection Surveillance centre. February. Haughey. J et al (2008) Achieving asthma control in practice:understanding the reasons for poor control. Respiratory Medicine 102, Lavorini, F. et al (2008) Effect of incorrect use of dry powder inhalers on management ot patients with asthma and COPD. Respiratory Medicine. 102, Pederson, S. (1996) Inhalers and nebulizers: which to choose and why. Respiratory Medicine 90,

25 With thanks to Bettina Korn (Respiratory Nurse Specialist) and Dr Finbar O Connell (Consultant Respiratory Physician) for their assistance.

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