A Guide to Asthma Medications and Delivery Devices

Transcription

1 A Guide to Asthma Medications and Delivery Devices February 20, 2009 This program was made possible through an unrestricted grant from: Monaghan Medical Corporation, Lupin Pharmaceuticals Inc., and Forest Laboratories Inc. American Association for Respiratory Care 9425 N. MacArthur Blvd., Suite 100 Irving, Texas Phone: (972) Fax: (972)

2 3 Asthma Medications Because each student s asthma symptoms and triggers are different, the medications required to manage asthma will vary. The student s health care provider will develop a medication treatment plan based upon the student s age, frequency of asthma episodes, results of peak flow monitoring, and the severity of the asthma episodes. In general, there are three categories of asthma medications: Quick-relief medications (short-acting bronchodilators) Long-term-control medications (inhaled corticosteroids and long-acting bronchodilators) Nonsteroid anti-asthma agents (leukotriene modifiers, mast cell stabilizers, anti-ige agents) Quick-Relief Medications These medications are medically known as short-acting bronchodilators since they can stop the symptoms of an asthma episode and provide quick relief in minutes. These medications are taken as needed to provide relief when a student begins to experience asthma symptoms, such as coughing, wheezing, chest tightness or shortness of breath. They are also beneficial when taken prior to exposure to a student s known asthma trigger or following a drop in peak flow meter readings. Most quick-relief medications last between four to six hours and are considered short-acting bronchodilators. The most commonly prescribed short-acting medication for asthma is albuterol. Most students with asthma will be prescribed an albuterol metered dose inhaler (MDI) or an albuterol nebulizer solution. Student access to prescribed quick-relief medications varies by school policy and state law. Students must be familiar with how to access their quick- relief bronchodilator throughout the school day as well as during special school activities such as field trips. The following is a partial list of short-acting bronchodilators: Generic Name Trade Name Albuterol ProAir HFA, Proventil HFA, Ventolin HFA, Accuneb inhalation solution Pirbuterol MaxAir Autohaler Levalbuterol Xopenex HFA, Xopenex inhalation solution During asthma episodes when the short-acting bronchodilator doesn t provide relief, the student s health care provider may prescribe additional medications to reduce or eliminate the symptoms. These medications may include oral corti-

3 4 costeroids such as prednisone, methylprednisolone, or prednisolone or alternative bronchodilators such as ipratropium. Long-Term Control Medications For students with persistent asthma, daily medications are required to control chronic symptoms and help prevent asthma episodes. Inhaled corticosteroids with either a long-acting bronchodilator or a leukotriene modifier may be prescribed. The student s health care provider will determine which medications will be required based upon the student s age and severity of symptoms. Inhaled Corticosteriods Inhaled corticosteroids are prescribed to reduce the inflammation in the airways. This helps to make the airways less sensitive to triggers and helps prevent acute asthma episodes. Depending upon the student s age, the inhaled steroids may be in a dry-powder inhaler, a metered-dose inhaler, or an inhalation solution for use in a nebulizer. The following is a partial list of inhaled corticosteroids: Generic Name Trade Name Beclomethasone QVAR HFA Fluticasone Flovent HFA, Flovent Diskus Budesonide Pulmicort Respules, Pulmicort Flexhaler Mometasone Asmanex Twisthaler Ciclesonide Alvesco HFA Triamcinolone Azmacort Flunisolide Aerobid, Aerospan HFA Note: Following administration of an inhaled steroid, the student should be instructed to rinse and spit : rinse the mouth with water and spit it out without swallowing. Long-Acting Bronchodilators Long-acting bronchodilators can help prevent symptoms and keep the airways open for 12 hours. They are used in the management of moderate to severe asthma and to prevent nighttime symptoms. Long-acting bronchodilators are prescribed in conjunction with inhaled corticosteroids. Depending upon the age of the student, the student s health care provider may prescribe a combination medication that contains a long-acting bronchodilator and inhaled corticosteroid in a single unit.

4 5 The following is a partial list of long-acting bronchodilators and combined inhaled corticosteroids and long-acting bronchodilators: Generic Name Trade Name Salmeterol Serevent Diskus Formoterol Foradil Aerolizer Combined Corticosteroid and Long-Acting Bronchodilator: Fluticasone and Salmeterol Advair HFA, Advair Diskus Budesonide and Formoterol Symbicort Note: Following administration of an inhaled steroid, the student should be instructed to rinse and spit : rinse the mouth with water and spit it out without swallowing. Nonsteroidal Anti-Asthma Agents All of the drugs in this category work by either blocking the production or release of harmful chemicals following exposure to allergic triggers. The potent chemicals, such as histamine and leukotrienes can cause airway inflammation and asthma symptoms. The student s health care provider will determine whether any of the medications in this category are indicated based upon the student s age, current medication plan, and severity of symptoms. Several medications in this category may be prescribed to prevent asthma symptoms triggered by exercise. The following is a partial list of nonsteroidal anti-asthma agents: Category Generic Name Trade Name Leukotriene Modifier Montelukast Singulair Leukotriene Modifier Zafirlukast Accolate Mast Cell Stabilizer Cromolyn sodium Intal Anti-IgE Omalizumab Xolair Change in Propellants Effective in 2009, albuterol metered-dose inhalers (MDIs) using chlorofluorocarbons (CFCs) as a propellant have been discontinued in the United States because of their negative effects on the ozone layer. They have been replaced by albuterol MDIs that use hydrofluoroalkane (HFA) as the propellant, a safe and effective chemical that does not harm the environment. The medication delivered from the HFA inhaler remains the same. MDIs containing CFC propellant may continue to be used until empty or until the expiration date has been reached. The prescription will be refilled with an albuterol MDI containing HFA. These units will be marked with HFA following the medication s trade name on the MDI canister and the medication packaging. The student s health care provider or pharmacist can answer questions about

5 6 the new device, including how and when to prime the MDI, proper breathing instructions, and how to clean and store the MDI. Similarities Between HFA and CFC MDIs The medicine in the inhaler is the same. The shape of the device is similar. The size of the device is similar. Both devices are convenient to use. Differences in the New HFA MDIs The mist from the HFA MDI is less forceful and warmer. There may be a slightly different smell and taste with HFA MDIs. The care and cleaning of an HFA MDI is different. HFA MDIs should not get wet. The device is now ozone-friendly to the environment. Patient Assistance Programs (PAP) There are many groups, organizations, and companies that may be able to help individuals who lack prescription coverage to get free prescription medications. In fact, there are more than 475 public and private patient assistance programs, including more than 180 programs available from pharmaceutical companies. The eligibility criteria and application process varies among the organizations and companies. Many of the programs require that the applicant be a U.S. citizen or legal resident, have a household income below 200% of the Federal Poverty Level, and have no prescription coverage. There are numerous websites and online assistance programs dedicated to helping qualifying individuals receive medication at reduced rates. Many of the websites offer coupons and discount programs. If you have questions about the reliability of a particular service, check with the student s health care provider or pharmacist. Here are two examples of programs that may be able to offer prescription assistance to qualifying individuals: Free Medicine Program ( Partnership for Prescription Assistance (

6 7 Using an MDI A metered dose inhaler (MDI) consists of a pressurized canister of medicine inserted into a plastic actuator. MDIs deliver medication that is inhaled directly into the lungs. Some MDIs are designed to be inserted directly into the mouth. Others require an open mouth technique with the MDI held 1-2 inches away. For others, a valved holding chamber (VHC) or spacer might be recommended. Depending on the age of the patient and the prescribed medication, the student s health care provider will determine which of the three techniques shown below for the student to use and will instruct the student on proper breathing technique for the prescribed medication. Open Mouth Technique Closed Mouth Technique MDI with a VHC (use this method with CFC inhaler only) Before using an MDI, remove the cap and check that there are no foreign objects inside the mouthpiece. Most MDIs require shaking. Check whether the student s prescribed MDI must be shaken and follow the manufacturer s instructions. Each new MDI must be primed before using. Release the specified number of test sprays into the air away from the face. If the MDI has been idle and not used for awhile, additional priming may be required. Follow the manufacturer s instructions regarding when and how to re-prime the MDI for use. Following a puff from the MDI, the student should be instructed to hold the breath for 10 seconds to allow the medication to reach deep into the lungs. If more than one puff is prescribed, the student should wait seconds between doses. Valved holding chambers (VHC) are often prescribed to help increase the amount of medication delivered to the lungs. They may be used to administer medications from MDIs to young children or to those who may have difficulty using the MDI. VHCs may be prescribed to reduce the incidence of possible local effects in the mouth from inhaled corticosteroids. In addition, the student is instructed to rinse the mouth or brush the teeth after receiving an inhaled corticosteroid. For more information on VHCs, refer to page 9.

7 8 Students should use only their own medications and devices prescribed by their health care providers. Determining How Much Medicine Is in the MDI Canister The number of doses contained in an MDI will vary depending upon the medication. The medication packaging and insert will identify the number of actuations (puffs) in the canister. Some of the new MDIs have built-in dose counters and indicate the number of remaining doses. If the student s prescribed MDI does not have a dose counter, record the number of doses in a full canister and subtract the number of puffs used. Be sure to subtract the number of test primes. Never float an MDI in water to determine the contents.

8 9 Using the Valved Holding Chamber (VHC) Remove the cap from the MDI and check for foreign objects. After shaking the MDI (if required), insert the mouthpiece of the MDI into the open end of the holding chamber. Exhale gently and place the mouthpiece of the holding chamber in the mouth. (If using a mask, fit the mask over the student s nose and mouth.) Push down on the MDI canister to release the medication. Inhale slowly and deeply. Hold the breath and count to 10 before exhaling. If more than one puff of a quick relief medicine is prescribed, wait 60 seconds between actuations. If using an inhaled steroid, be sure to rinse mouth or brush teeth after each use. VHC should be cleaned regularly following the manufacturer s cleaning instructions. If powder is visible around the MDI mouthpiece, remove the MDI from the VHC. Remove the metal canister from the actuator and set it aside. Rinse only the mouthpiece and cap in warm water. Air dry. Reassemble by inserting the medication canister into the actuator and replacing the cap on the mouthpiece.

9 10 Why Use a Valved Holding Chamber (VHC) with a pmdi? 1. Why Use a Valved Holding Chamber (VHC)? a. Only one in five people use their pmdi properly 1 b. Valved holding chambers play a significant role in ensuring the effective delivery of fine particles to the lung by helping overcome the challenges of PMDI technique c. The National Heart Lung and Blood Institute (NHLBI) 2007 recommends a VHC for anyone with asthma 2 i. who cannot effectively use pmdi alone ii. who is prescribed an inhaled corticosteroid d. Global Initiative for Asthma (GINA) 2006 recommends that children younger than 4 years of age use a VHC with a face mask and children 4 to 6 years of age use a VHC and a mouthpiece 3 2. Most Common Mistakes with a pmdi a. Poor coordination of actuation and inhalation of pmdi b. Breathing too quickly, too shallow, or through the nose during inhalation c. Incomplete inhalation and/or not holding their breath after inhalation d. Not understanding the VHC product instruction 3. Particle Deposition Size Distribution a. A typical pmdi delivers a single dose at over 60 miles/hour b. Without a VHC, 60-80% of the released dose is deposited in the upper airway c. VHCs minimize oropharayngeal (mouth & throat) deposits by reducing the speed of pmdi and removing larger non-respirable particles in the pmdi Larger particles are impacted on the interior surfaces of the VHC Fine particles are typically < 5 μm diameter these are typically inhaled and reach the lower respiratory tract efficiently, where the drug receptors are located using a VHC 1. P. Barnes, J.C. Virchow, J. Sanchis, T. Welte and S. Pedersen. Asthma Management: Important Issues. European Respiratory Review, Volume 14, Number 97: Guidelines for the Diagnosis and Management of Asthma, US Department of Health and Human Services. National Institute of Health, National Heart, Lung and Blood Institute. NIH publication number , October Global Initiative for Asthma. Pocket Guide for Asthma Management and Prevention in Children. A Pocket Guide for Physicians and Nurses. Medical Communication Resources, Inc

10 11 Key Characteristics of a Well-Designed Valved Holding Chamber (VHC) Core Value Enhances Effectiveness VHC Characteristics 1. Responsive inhalation and exhalation valves 2. Ability to ensure a good facemask seal to face 3. Constructed from shatter-resistant materials and designed to prevent dislodgement of small components when subjected to mechanical shock 4. Use of transparent materials 5. Designs that are specific for infant, child, or adult use 6. Facemask with minimal dead volume and comfortable fit with the minimum of applied force to achieve a seal to the face 7. Exhalation valve in facemask that offers low resistance to exhaled flow Cap Design Strong tether to VHC Whistle To indicate improper inhalation To train patients in proper technique Inspiratory/Expiratory Valve Safe and secure (not removable) Low resistance silicone valve Exhaustion away from the face Chamber Clear body chamber Clear instructions on the barrel pmdi Receptacle Universal accepts all approved pmdis

11 12 Dry-Powder Inhalers (DPI) A dry-powder inhaler (DPI) delivers a small dose of medication from the device as the user takes in a deep breath. Unlike MDIs, there is no propellant used to deliver the medication. Once the dose is loaded, the device must be held level until the dose is inhaled. It is important to avoid exhaling into the unit. A deep, rapid breath is required to remove the medication from the DPI. Because the dose is so small, DPI users might not feel, taste, or smell the powdered medication. Some DPIs require the user to load a powdered medication into a capsule each time. Other DPIs are pre-filled with multiple doses and contain a counter that displays the number of doses remaining in the unit. The following are examples of several of the DPIs currently available: Diskus Aerolizer Flexhaler

12 13 Using a Diskus The student should: 1. Hold the Diskus in a flat level position in one hand. 2. Place the thumb of the other hand in the thumb grip. 3. Open the Diskus by pushing the thumb grip around until it clicks and the mouthpiece appears. 4. Slide the lever until it clicks. 5. Breathe out away from the Diskus. 6. Place the lips around the mouthpiece until a good seal is formed. 7. Breathe in quickly and deeply through the mouth. 8. Remove the Diskus from the mouth and hold the breath for approximately 10 seconds 9. Breathe out slowly away from the Diskus. 10. Slide the thumb grip and click the Diskus shut. 11. Store in a dry location away from heat and sunlight. To clean the Diskus : Wipe the mouthpiece with a clean, dry tissue or cloth. Note: Remember to rinse the mouth after using an Advair Diskus or Flovent Diskus.

13 14 Using an Aerolizer The student should: 1. Lift off the blue cap. 2. Hold the blue base with one hand and grasp the white mouthpiece with the other. Twist in the direction of the arrow. 3. Remove a medication capsule from the blister pack and place in the slot inside the white base. 4. Twist the mouthpiece back into place. 5. Hold the Aerolizer upright and firmly squeeze the two blue buttons on the side once to pierce the capsule. 6. Breathe out away from the mouthpiece. 7. Tilt head back slightly, hold the Aerolizer level, and seal lips around the mouthpiece. 8. Inhale deeply and rapidly. (The capsule will rattle in the chamber.) 9. Remove the mouthpiece and hold the breath for 10 seconds. 10. Breathe out slowly. 11. Open the chamber to see whether any powder remains in the capsule. (If powder is visible, twist the mouthpiece back into place and repeat steps 6-10.) 12. Remove and discard the empty capsule. 13. Replace the blue cap. Cleaning the Aerolizer Wipe mouthpiece with a clean, dry tissue or cloth. Store the Aerolizer in a dry place away from heat.

14 15 Using the Autohaler The student should: 1. Release two test sprays according to manufacturer s directions if the MDI is new or hasn t been used for 48 hours. 2. Remove the mouthpiece cover. 3. Hold the Autohaler in an upright position without blocking the vents at the base. 4. Lift the gray lever up at the top and shake the device gently. 5. Breathe out normally. 6. Seal the lips around the mouthpiece. 7. Breathe in through the mouth deeply. A click can be heard as the Autohaler releases a dose of medication. 8. Remove the Autohaler from the mouth and hold the breath for 10 seconds. 9. Return the gray lever to its original position and replace the mouthpiece cover. Cleaning the Autohaler Wipe mouthpiece with a clean, dry tissue or cloth.

15 16 Using a Flexhaler The student should: 1. Twist and remove the cover. 2. Hold the Flexhaler upright (mouthpiece pointed up). 3. Twist the brown grip to the right as far as it will go then twist it fully back in the opposite direction. A click will be heard during the twisting motion. 4. Breathe out away from the Flexhaler. 5. Seal the lips around the mouthpiece and breathe in forcefully and deeply. 6. Remove the Flexhaler from the mouth and hold the breath for approximately 10 seconds. 7. Breathe out away from the Flexhaler. 8. Repeat steps 2-7 if more than one dose is prescribed. 9. Replace the cover. Cleaning the Flexhaler Wipe mouthpiece with a clean, dry tissue or cloth. Store in a dry place away from heat.

16 17 Using a Compressor-Driven Nebulizer Nebulizers are commonly used to deliver medications to infants and small children as well as individuals who may be unable to effectively use an MDI or DPI during acute asthma symptoms. Nebulizers change asthma medications from a liquid to an aerosol mist that can easily be inhaled into the lungs. The following supplies are required: Portable air compressor Nebulizer medication cup Medications Mouthpiece or mask Nebulizer tubing Instructions for Using the Nebulizer: 1. Place the air compressor on a sturdy surface. 2. Connect the air compressor to the appropriate power source (3-prong electrical outlet or battery source). 3. Wash hands with soap and water and thoroughly dry them. 4. Insert the prescribed medication dose into the nebulizer medication cup. 5. Connect the nebulizer cup, the top of the nebulizer, and the mouthpiece or mask. 6. Connect the tubing to the air compressor and to the nebulizer. 7. Turn the air compressor on. A light mist should be visible. 8. Sit upright and place the mouthpiece between the teeth or place the mask over the nose and mouth and adjust the head strap for a comfortable fit. 9. Take slow, deep breaths. Try to hold the breaths for 2-3 seconds before exhaling. This helps the medication settle out in the airways. 10. Continue the treatment until the nebulizer makes sputtering noises. The treatment will take approximately 10 minutes. A small amount of medication will stick to the sides of the nebulizer cup and may be gently shaken to loosen the droplets.

17 11. When the treatment is complete, turn the air compressor off. Disconnect the tubing from the nebulizer and store with the compressor. Clean the rest of the nebulizer unit as directed. 12. If dizziness or jitteriness occurs during a treatment, stop and rest for 5 minutes. Resume the treatment and breathe slowly. If dizziness or jitteriness continues to be a problem, inform the student s health care provider. Cleaning and Disinfecting Nebulizers Nebulizers, mouthpieces, and masks should be cleaned and disinfected according to the manufacturer s directions. Use the recommended solutions to clean the nebulizer components. The nebulizer tubing does not require rinsing or disinfection. Replace the nebulizer as recommended by the manufacturer. Keep the compressor clean and dry. Call your medical equipment provider to report any problems. Do not attempt to repair it yourself. Replace the equipment as recommended by the manufacturer.