Inhaled medications such as Advair and Incruse Ellipta are often prescribed to control symptoms in advanced COPD patients. These inhalers contain Long-Acting Beta-2 Agonist (LABA), Long-Acting Muscarinic Antagonist (LAMA), Steroid, and/or combination of the three. The long-acting inhaler can be administered daily or BID and may decrease the need for rescue inhaler.

However, long active inhalers require precise technique that can be challenging to most patients, especially elderly and end-of-life patients.

Correct inhaler administration requires the patient to take a slow, deep breath (4-6 seconds) while actuating the inhaler, followed by a 5-10 second breath hold prior to a slow exhale once the medication is inhaled. Many patients are receiving minimal effectiveness due to three main errors: upper airway disposition, actuation-inhalation coordination, and insufficient breath-hold.

Upper airway disposition:

Some patients do not inhale long enough after actuation of the device. As a result, much of the medication is deposited in the back of the throat or on the tongue, which often results in ulcerations and/or change in voice quality

Actuation-inhalation coordination — 

The other major cause of inefficient delivery of inhaled medications is lack of coordination between actuation and inhalation. The patient must be able to actuate the inhaler during a deep inhalation. If actuation occurs prior to or following an inhalation, it is unlikely that the patient will receive adequate medication.

Insufficient breath-hold — 

5-10 second breath hold is required for correct administration. By exhaling prior to this time, much of the medication is exhaled.

A cost-effective and simplistic alternative is Short-Acting Beta-2 Agonist (SABA) and/or Short-Acting Muscarinic Antagonist (SAMA) nebulized with additional oral steroids if needed. This option can be very effective if administered on a routine scheduled basis. Also, nebulized medications are simple to administer and do not require the coordination techniques required in inhaler administration.

Example: 
Trelegy Ellipta (LAMA, LABA, and corticosteroid): Daily Alternative

Albuterol/Ipratropium (SABA/SAMA): QID

Prednisone: daily

References

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease: 2021 Report.

Hess, D. and Dhand, R. (2020). The use of inhaler devices in adults.

Sanchis, J., Gich, I., Pedersen, S. (2016). Aerosol Drug Management Improvement Team (ADMIT).

Systemic Review of Errors in Inhaler Use: Has patient technique improved over time? Chest 150:394.

Mindi Henry MSN, APRN-CNP, ACHPN -
Director of Clinical Services PDC Rx