Better Living with Obstructive Pulmonary Disease

Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide
Better Living with
Obstructive Pulmonary Disease
A Patient Guide
Second Edition
November 2012
Queensland Health
© The
State of Queensland (Queensland Health) and The Australian Lung Foundation 2012
a
Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide
Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide is a joint project of the
Statewide COPD Respiratory Network, Clinical Practice Improvement Centre, Queensland Health and
The Australian Lung Foundation, COPD National Program.
This work is copyright and copyright ownership is shared between the State of Queensland (Queensland Health)
and The Australian Lung Foundation 2012. It may be reproduced in whole or in part for study, education or
clinical purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced
for commercial use or sale. Reproduction for purposes other than those indicated above requires written
permission from both Queensland Health and The Australian Lung Foundation.
© The State of Queensland (Queensland Health) and The Australian Lung Foundation 2012.
For further information contact Statewide Respiratory Clinical Network, Patient Safety and Quality Improvement
Service, e-mail: PSQ@health.qld.gov.au or phone: (07) 36369505 and The Australian Lung Foundation,
e-mail: enquiries@lungfoundation.com.au or phone: 1800 654 301. For permissions beyond the scope of
this licence contact: Intellectual Property Officer, Queensland Health, email: ip_officer@health.qld.gov.au
or phone (07) 3234 1479.
To order resources or to provide feedback please email: enquiries@lungfoundation.com.au or
phone 1800 654 301.
Queensland Health Statewide Respiratory Clinical Network and The Australian Lung Foundation, COPD
National Program – Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide, 2012.
ISBN 978-0-9872272-0-1
b
Chapter 5: Your role in managing your chronic obstructive pulmonary disease
chapter
8
Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide
Using your inhalation devices
This chapter will help you to understand:
Why using inhalation devices is an important skill.
How the inhalation devices work.
How to correctly use the inhalation devices.
When the inhalation devices are empty.
How to clean and care for the inhalation devices.
Why is using inhalation devices
an important skill?
Typically you should be sitting upright or standing
while taking your inhaled medication.
Using an inhalation device is a skill. After many
years of using inhalation devices, you can develop
habits that may not allow you to make the most of
your inhaled medications. You may also have extra
medications prescribed over time that can complicate
your treatment schedule. The more device types you
are using, the greater the chance you have of using
them incorrectly. If you are using more than two
device types, talk to your doctor about reducing the
number of device types without changing the
medications you are on.
The inhalation devices covered in this
chapter include:
Having your inhalation device technique assessed
by an appropriate member of your health care or
pulmonary rehabilitation team is essential. You can
also check with your managing doctor, nurse or a
pharmacist.
To make the most of using an inhalation device, it
is important to position your body appropriately.
It is important to store your inhalation
device below 30oC and do not keep it in
the car on hot days.
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Chapter 8: Using your inhalation devices
1. Puffer (or metered dose inhaler)
2. Puffer and spacer
3. Autohaler™
4. Turbuhaler®
5. Accuhaler™
6. HandiHaler®
7. Breezhaler®
8. Nebuliser
Puffer (or metered dose inhalers)
A puffer is also known as a metered dose inhaler,
or an aerosol.
How does the puffer work?
In the puffer, the medication is stored under pressure
in the metal canister. When the puffer is fired, a fine
mist of the medication is produced that can be inhaled
into the lungs. These devices work best with spacers
or holding chambers (see the following section on
puffers and spacers).
Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide
Note: Puffers used to deliver inhaled
corticosteroids eg. QVAR®, Seretide®, Flixotide®
(see page 25) should be dry wiped weekly.
They should NOT be washed or made wet.
Puffers for short-acting reliever medication
(Atrovent®, Airomir®, Asmol®, Ventolin®) should
be washed weekly.
Remove the metal canister (do not wash the
metal canister).
Using the metered dose inhaler
Wash the plastic casing and cap with running
warm water through the top and bottom for at
least 30 seconds.
How to use the puffer
1. Remove the cap.
2. Hold the puffer upright and shake vigorously.
3. Raise your chin and look straight ahead.
Shake off excess water and allow to completely
air dry.
4. Breathe out gently and fully.
5. Place the puffer mouthpiece between your
teeth and form a seal with your lips.
6. As you slowly start to breathe in, fire the
canister by pressing firmly and continue to
breathe in deeply.
7. Remove the canister from your mouth and
hold your breath for 10 seconds, if possible.
8. Breathe out gently.
9. If you need to deliver an additional dose of
your medication, repeat steps 2 to 8.
Cleaning the metered dose inhaler
10. Replace cap.
When is the puffer empty?
How to care for the puffer
A purple puffer is empty when the dose indicator on
the back reaches zero. For other puffers, it is more
difficult to know when they are empty. If the puffer
is becoming empty, the amount of and speed at
which the spray comes out is reduced, or the puffer
may feel empty when shaken.
When reassembling the puffer, ensure that
the metal canister fits securely into the
plastic casing.
Always keep the cap on the puffer when not
in use to prevent foreign objects lodging in
the mouthpiece.
If using a puffer for regular medication, you can
calculate when your puffer is likely to be empty. To
do this, work out how many puffs per day you use
and divide the number of puffs in the canister
(written on the canister box) by the number of puffs
per day you use. This will tell you how many days
you can use your puffer before it needs replacing.
Haleraid®
The Haleraid® can assist
people who have difficulties
pressing the canister.
A Haleraid® can be obtained
from independent living
centres or pharmacies, and
is available in two sizes.
How to clean the puffer
Wiping the mouthpiece with a clean cloth is often
all that is required unless the puffer becomes soiled
or blocked.
© The
Haleraid®
State of Queensland (Queensland Health) and The Australian Lung Foundation 2012
28
Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide
Puffer and spacer
Puffers (also known as a metered dose inhaler or
an aerosol) may be used with a spacer, which is
a small or large volume holding chamber.
4. Hold the puffer upright, remove the cap and
shake well.
5. Place the puffer mouthpiece into the end of the
spacer opposite to the valve.
6. Place the mouthpiece between your teeth and
close your lips around it making sure your neck
is slightly tilted back.
7. Breathe out gently and slowly.
8. Activate the puffer into the spacer once only.
9. Either:
Breathe in slowly and deeply for five seconds
through your mouth, and hold your breath
for 10 seconds, if possible.
Or
Breathe in and out through your mouth
normally for four breaths.
10. Wait 30 seconds between doses and repeat
steps 2 to 9.
Using a spacer with your puffer can increase the amount
of medication that reaches your lungs
How does the puffer and spacer work?
A spacer holds the metered dose briefly before the
spray is breathed in. Using a spacer with a puffer
allows more medication to get to where it is needed
in the breathing tubes or airways. A puffer and
spacer, when used correctly, can significantly increase
the amount of medication that reaches your lungs.
A spacer can prevent throat irritation by reducing
the amount of medication sitting in your mouth or
throat. Spacers have a one way valve that stops air
being breathed into the spacer while the spacer is
in your mouth.
If used correctly, a puffer used with a spacer is
at least as effective as a nebuliser in delivering a
similar dose of medication, that is, 4 to 10 puffs
equals one nebuliser dose.
If you change the size of the spacer you are using,
particularly for preventer or combination medications,
it is best to have the dose reviewed by your doctor.
When is the puffer empty?
To determine when the puffer is empty, refer to the
section on puffers (page 28).
How to clean your spacer
To clean the spacer:
• Once per month, dismantle the pieces of the
spacer and wash in detergent water.
1. IMPORTANT - wash the spacer before first use.
• Do not rinse as the detergent helps to reduce
the static charge in the spacer (static causes
the medication to stick to the sides of the
spacer reducing the amount of medication
delivered to the breathing tubes or airways).
2. Sit upright or stand.
• Allow to air dry thoroughly after washing.
How to use the puffer and spacer
3. Assemble the spacer and shake device to ensure
that the one way valve is not stuck.
29
Small volume spacer with puffer
Chapter 8: Using your inhalation devices
DO NOT dry with a tea towel and DO NOT wash
in dishwasher as these increase the static charge.
Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide
Autohaler™
How to clean the Autohaler™
How does the Autohaler™ work?
Medications delivered via an Autohaler™ are
Airomir® (reliever) and QVAR® (preventer).
The Autohaler™ is activated by breathing in through
the mouthpiece, which triggers the device to expel
the medication. The Autohaler™ is primed before
use by lifting the pressure lever (the grey lever),
which expels the medicine into a staging chamber.
Airomir®, delivered via Autohaler™, should
be washed weekly. After removing the canister,
and placing it aside to keep dry, wash the
mouthpiece and cap under warm running
water for 30 seconds. Allow to air dry.
QVAR® delivered via Autohaler™ should NOT
be washed. Dry wipe at least weekly; do NOT
wash the inhaler or get it wet.
How to use the Autohaler™
Turbuhaler®
1. Unclip the mouthpiece cover from the back
and shake (Below A).
How does the Turbuhaler® work?
2. Hold the Autohaler™ upright and click the grey
lever upwards so that it stays up (Below B).
3. Breathe out gently.
4. Place the Autohaler™ between your lips to form a
seal (do not block the air vents with your hands).
5. Tilt head back and breathe in with a slow,
deep steady breath – don’t stop when you
hear the click.
6. Hold breath for 10 seconds, if possible.
7. Breathe out gently.
8. Push the grey lever down.
A Turbuhaler® is a device that is activated by breathing
in. When you load the Turbuhaler®, a precise dose
of powdered medication is measured and deposited
into a reservoir by gravity. Therefore, it is important
that you hold the Turbuhaler® upright when you
load it.
When the Turbuhaler® is placed in your mouth and
you breathe in, air is drawn through vents on the
side of the Turbuhaler®. This causes the air in the
Turbuhaler® to become turbulent. This turbulence
breaks up the powdered medication into very fine
particles. As you breathe in, these very fine particles
are able to go further down the breathing tubes
or airways.
9. Wait 30 to 60 seconds between doses.
Fine particles
of powdered
medication that
can be breathed in
10. If another dose is required repeat steps 2 to 8.
11. Replace mouthpiece cap.
A
Mouthpiece
B
Indicator window
Air vents
A. Remove the cap and hold the Autohaler™ upright.
B. Push the lever up until it clicks and stays up.
When is the Autohaler™ empty?
The Autohaler™ is empty when you do not hear
any medication being delivered. To test if the
Autohaler™ is empty, lift the lever, slide the lever
on the bottom of the Autohaler™ across; if the
Autohaler™ does not fire, it is empty.
© The
Turning grip
The Turbuhaler®
State of Queensland (Queensland Health) and The Australian Lung Foundation 2012
30
Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide
How to prime a new Turbuhaler®
Before you start to use a new Turbuhaler® you
need to “prime” it.
1. Remove the cap.
2. Hold the device upright and twist the base left
and right as far as it will go. You will hear a ‘click’.
3. Repeat step 2 one more time.
On other Turbuhalers®, a red line will appear at
the top of the indicator window on the side of the
device, which indicates that 20 doses are left (this
is a good time to organise a new device). When
the red line appears at the bottom of the window,
the Turbuhaler® is empty.
How to clean the Turbuhaler®
Wipe the inhaler with a clean, dry tissue after use.
®
The Turbuhaler is now primed. To use the
Turbuhaler®, follow the instructions below.
Do not wash any part of the Turbuhaler® or
get it wet.
How to use the Turbuhaler®
How to care for the Turbuhaler®
1. Remove the cap.
2. Hold the device upright and twist the base left
and right as far as it will go. You will hear a ‘click’.
3. Breathe out gently away from the Turbuhaler®.
4. Place the mouthpiece between your lips and form
a seal (do not put your lips over the air vents on
the side of the Turbulaher®).
5. Hold the coloured part of the Turbulaher®
(to make sure the air vents are not covered).
6. Breathe in forcefully and deeply through
your mouth.
7. Remove the Turbuhaler® from your mouth
and hold your breath for up to 10 seconds,
if possible, before breathing out.
Do not breathe into the device as the medication
is a dry powder.
Do not expose to water (keep the cap on tightly
to prevent moisture entering the device).
The powder you hear when you shake the
device is NOT medication, it is a drying agent.
The medication is inhaled directly into the lungs;
therefore, you may not feel or taste anything.
Accuhaler™
How does the Accuhaler™ work?
The Accuhaler™ is a breath activated device that
contains a hidden foil strip that has 60 regularly
spaced doses of medication.
8. If another dose is required, repeat steps 2 to 7.
9. Replace the cap.
20 doses
left
Indicator
window
Empty
Accuhaler™
How to use the Accuhaler™
1. Check the window that indicates the number
of doses left.
Determining when the Turbuhaler® is empty
When is the Turbuhaler® empty?
The Symbicort® Turbuhaler® (red base) has a counter
that counts down to zero (in twenties). When the
counter is at ‘0’, the device is empty.
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Chapter 8: Using your inhalation devices
2. To open, hold the base of the Accuhaler™
horizontally in one hand; place the thumb
of the other hand in the thumb grip and push
the thumb grip around as far as possible.
3. With the Accuhaler™ held horizontal, push the
lever around until it clicks. The number indicator
reduces by one.
Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide
4. Breathe out gently away from the Accuhaler™.
HandiHaler®
5. Put the mouthpiece between your teeth and
lips to form a seal.
How does the HandiHaler® work?
6. Breathe in steadily and deeply through your mouth.
7. Hold your breath for about 10 seconds, if possible.
8. Remove the Accuhaler™ from your mouth.
9. Breathe out away from the Accuhaler™.
10. If another dose is required, repeat steps 3 to 9.
11. To close the Accuhaler™, put your thumb in
the thumb grip and slide it until the cover
clicks in place.
The HandiHaler® is activated by breathing in
through the mouthpiece. When loaded, a capsule
(containing the medication) inside the HandiHaler®
is pierced, allowing the medication to be inhaled.
How to use the HandiHaler®
1. Have the HandiHaler® and capsules ready for use.
2. Open the dust cap by pressing the green
piercing button.
Dust cover
Mouthpiece
The Accuhaler™ is empty when the dose counter
indicates zero.
Centre
chamber
Green
piercing
button
When is the Accuhaler™ empty?
The Accuhaler™ is empty when the dose counter
on the top indicates zero. The last five doses will
appear in red.
How to clean the Accuhaler™
Wipe the inhaler with a clean, dry tissue
after use.
Do not wash any part of the Accuhaler™
or get it wet.
Base
3. Open the mouthpiece by pulling upwards.
4. Peel the foil back carefully to expose only
one capsule.
5. Remove the capsule from the foil and drop
the capsule into the centre chamber.
6. Firmly close the mouthpiece, leaving the
dust cap open.
How to care for the Accuhaler™
Keep your Accuhaler™ dry.
Keep your Accuhaler™ closed at all times.
Mouthpiece
Green
piercing
button
Air intake
valve
7. Press the green button once to pierce the
capsule, and then release the green button.
8. Breathe out gently away from the HandiHaler®.
9. Put the mouthpiece between your lips to form
a seal, making sure not to block airway vents
with your fingers.
10. Breathe in slowly and deeply (enough to hear or
feel the capsule vibrate) and fully through your
mouth, keeping your head in an upright position.
© The
State of Queensland (Queensland Health) and The Australian Lung Foundation 2012
32
Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide
Breezhaler®
How does the Breezhaler® work?
The Breezhaler® is activated by breathing in through
the mouthpiece. When loaded, a capsule (containing
the medication) that has been pierced inside the
Breezhaler® allows the medication to be inhaled.
How to use the Breezhaler®
1. Have the Breezhaler® and capsule ready for use.
11. Hold your breath for about 10 seconds,
if possible.
2. Pull off the cover/cap.
12. Remove the HandiHaler® from your mouth.
3. Open the inhaler by holding the base firmly and
tilt the mouthpiece.
13. Breathe out away from the HandiHaler®.
14. Repeat steps 8 to 11 to completely empty the
capsule. Do not pierce capsule a second time.
4. Remove one capsule from blister pack with dry
hands (always keep capsules in blister pack
until use), and insert into base of the inhaler.
When is the HandiHaler® empty?
When you have run out of capsules, you will have
no more medication. The HandiHaler® should be
replaced yearly.
How to clean the HandiHaler®
Once a month, you should:
• Open the dust cap.
• Open the mouthpiece.
• Open the bottom part by pressing
the green lever in and up.
5. Close the inhaler fully. You should hear a ‘click’
as it closes fully.
6. Hold the inhaler upright. There are two blue
buttons at the base of the inhaler. Press both
of these buttons fully, one time. You should hear
a “click” as the capsule is being pierced. Then
release the buttons. DO NOT PRESS THE
PIERCING BUTTONS MORE THAN ONCE.
• Rinse under warm water to remove
dry powder.
• Shake out excess water.
• Leave to air dry for 24 hours with the
HandiHaler® open.
Dry the outside with a clean cloth, if needed.
®
• Remember that as the HandiHaler takes 24
hours to dry, you should wash it immediately
after a dose to ensure that it is completely dry
before the next dose.
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Chapter 8: Using your inhalation devices
7. Breathe out gently away from the device.
8. Place the mouthpiece in your mouth and form a
seal with your lips around the mouthpiece. Hold
the inhaler with the buttons to the left and right
(not up and down).
9. Breathe in rapidly and steadily, as deeply as
you can.
• You should hear a whirring noise, which is
the capsule spinning in the chamber. If you
don’t hear the noise, the capsule may be
Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide
stuck in the cavity. If this occurs, open the
inhaler and carefully loosen the capsule by
tapping the base of the device. Do not press
the piercing buttons to loosen the capsule.
10. Continue to hold your breath as long as is
comfortable up to 10 seconds. Then breathe out.
11. Most people are able to empty the capsule with
1 or 2 inhalations. You can check this by
opening the inhaler to see if any powder is left
in the capsule. Repeat steps 7 to 10 if needed.
12. Remove capsule and discard, close the inhaler
and replace the cap.
You may experience a sweet taste as the medication
goes into your lungs.
Nebuliser Machine
Some people occasionally cough soon after inhaling
the medicine. If you do, don’t worry, as long as the
capsule is empty you will have received the full dose.
How to use the nebuliser
Do not store capsules in the Breezhaler®.
1. Assemble clean dry equipment (face mask
or mouthpiece, nebuliser bowl, tubing and
nebuliser pump).
2. Place pump on a firm flat surface.
How to clean the Breezhaler®
Clean your inhaler once a week.
3. Ensure the two halves of the nebuliser bowl
are connected.
Wipe the mouthpiece inside and outside
to remove any powder with a clean,
dry, lint-free cloth.
4. Fill the nebuliser bowl with the required amount
of medication.
Do not wash your inhaler with water.
Keep it dry.
5. Connect the tubing and the mouthpiece or face
mask to the nebuliser bowl.
Do not take the inhaler apart.
6. Put the facemask on or the mouthpiece in your
mouth, and turn the machine on.
Nebuliser
How does the nebuliser work?
Medications delivered by inhalers are an effective,
easy and convenient way to deliver the correct
amount of medication into your breathing tubes or
airways. Most people with COPD can effectively
use their inhalers to manage their conditions.
This is preferred as inhalers are more practical,
convenient and are less likely to cause infection.
However, if you cannot use your inhalers correctly
a nebuliser might be prescribed.
In a nebuliser, pressurised air is pumped through
liquid to form a fine mist that is inhaled through
a face mask or mouthpiece. The pump is usually
driven by electricity; some pumps may be driven
by a battery or 12 volt car batteries.
A mouthpiece stops the medication going into the eyes
and on the skin which sometimes causes irritations.
© The
7. Sit upright and breathe normally until the nebuliser
starts to splutter and the amount of vapour
coming out is minimal (usually 10 minutes).
8. Switch the machine off when finished.
How to clean the nebuliser
After each use, rinse the nebuliser bowl and
the facemask or mouthpiece.
Ensure that the nebuliser parts are completely
dry before storage (liquid left in the bottom of
the nebuliser bowl is an ideal site for germs
to grow).
Do not wash the tubing. You may remove the
mask and bowl from the tubing and turn the
nebuliser on to blow air through the tubing.
This can reduce any condensation in the tubing.
Replace the tubing if it is discoloured or there
is any sign of mould.
State of Queensland (Queensland Health) and The Australian Lung Foundation 2012
34
Better Living with Chronic Obstructive Pulmonary Disease A Patient Guide
Each week, soak the nebuliser bowl and the
mouthpiece or facemask in half vinegar and
half water, rinse and allow to air dry.
the bowl called a baffle (sometimes the baffle
is missing, and if so, the bowl will need to
be returned).
Replace your nebuliser tubing, bowl and face
mask or mouthpiece every three months.
The filter on the nebuliser pump may need to
be replaced occasionally. See the manufacturer’s
manual for how often the pump may need
replacing.
Correct cleaning of your nebuliser will reduce
the risk of chest infections.
How to care for the nebuliser
Inspect the nebuliser bowl and tubing for cracks,
and if cracks are found, replace.
Nebuliser bowls have a limited life span. Check
the manufacturer’s manual for the expected life
span of your nebuliser bowl.
If you have acquired a nebuliser bowl through
a hospital, it will only last one to three months
and should be replaced (check manufacturer’s
recommendations).
If you have a new nebuliser bowl and it is not
working, check for an extra piece of plastic in
35
Chapter 8: Using your inhalation devices
Have the nebuliser pump checked annually for
correct airflow and pressure by the company
that sold you the nebuliser or by your local
pharmacy.
If nebulising Atrovent® or Pulmicort®, the use
of a mouthpiece is preferable. If you do not
use a mouthpiece, the use of eye protection
is advisable.
Ensure you rinse your mouth and face afterwards.
Nebuliser bowls have a limited life span.
Check manufacturer’s manual for expected
life span.