Inhaler Check Service Training Update – Group Work Tutor Notes
Scenario 1:
You invite a patient for a respiratory medicines use review (MUR). Information
from the PMR:
 Male
 Aged 62,
 Salbutamol pMDI 200mcg 1-2 puffs PRN,
 Flixotide 250mcg accuhaler 2 puffs BD,
 Spiriva 18mcg capsules for inhalation 1 OD,
 Felodipine 5mg OD,
 Simvastatin 40mg ON,
 Co-codamol 30/500mg 1-2 qds,
 Amoxicillin 500mg TDS for 7 days
 Prednisolone 30mg for 7 days.
Patient is also a current smoker.
1. What do you think is the patient’s likely respiratory diagnosis?
A. Asthma
B. COPD
Patients age, smoking history, Rx for LAMA (Spiriva), suggest COPD.
Short courses of antibiotics and oral corticosteroids suggest history of
chest infections.
NB: absence of a LABA with the ICS could suggest asthma however
the LAMA and mucolytic are not appropriate for asthma.
2. From the patients medication history what action would you take during
the MUR consultation:
A. Check inhaler technique, enquire about medicine use and symptom
control and discuss smoking cessation.
B. Check inhaler technique, enquire about medicine use and symptom
control and discuss smoking cessation. Contact GP regarding
fluticasone use without a long-acting beta agonist (LABA).
C. Check inhaler technique, check inspiration rate using in-check
device, enquire about medicine use and symptom control, advise
on purpose and use of medication, how to identify signs of an
exacerbation, nutrition and smoking cessation.
D. Check inhaler technique, check inspiration rate using in-check
device, check for physical disability, enquire about medicine use
and symptom control, advise on purpose and use of medication,
how to identify signs of an exacerbation, vaccinations, nutrition and
smoking cessation.
E. Check inhaler technique, enquire about medicine use and symptom
control and discuss smoking cessation. Review PMR history for
frequency of oral corticosteroid use.
1. Check inhaler technique and inspiration rate using InCheck device – 3
different inhaler devices prescribed. When used alone a standard pMDI
is rarely appropriate for older people as many have poor inhaler tech.
Addition of a large volume spacer improves both acquisition and
retention of drug and allows carers to assist people with cognitive or
physical impairment. Some frail people cannot consistently achieve the
minimum inspiratory flow rate for use of DPIs or breath actuated MDIs.
2. Co-codamol may be prescribed for OA – check for any physical
disability affecting the hands.
3. An ICS should NOT be prescribed alone in COPD – pt should be
referred to GP for a combination inhaler containing both ICS plus
LABA. Although a clinical issue and technically out of the scope of an
MUR however this does need bringing to the prescribers attention.
4. Explain that the purpose of most treatments for chronic obstructive
pulmonary disease (COPD) is to control symptoms or to reduce the
rate of exacerbations, but that only smoking cessation has been shown
to slow the decline in lung function.
5. Stress the importance of correct use of maintenance medication.
6. Smoking cessation advice
7. Importance of vaccinations
8. Advice on nutrition – COPD patients with low BMI associated with
worse outcomes.
9. Check PMR for frequent courses of oral corticosterioids – osteoporosis
prophylaxis may be required. Again a clinical issue.
10.How to identify signs of an exacerbation:
An exacerbation of COPD causes an acute deterioration of respiratory
symptoms, particularly increased breathlessness and cough, and
increased sputum volume and/or purulence. Exacerbations of COPD
can be associated with the following symptoms:
• Increased dyspnoea.
• Increased cough; increased sputum purulence and increased sputum
volume.
• Upper airway symptoms (eg, colds and sore throats).
• Increased wheeze and chest tightness.
• Malaise.
• Reduced exercise tolerance.
• Fluid retention.
• Increased fatigue.
• Marked respiratory distress with dyspnoea and tachypnoea, acute
confusion, increased cyanosis, peripheral oedema.
Respiratory failure - may develop and may require non-invasive
ventilation (NIV)
Scenario 2:
Your pharmacy technician informs you that a patient is eligible for the new
medicine service (NMS) for newly prescribed inhalers.
Rx:
Salbutamol Easibreathe 200mcg 2 puffs BD
Clenil modulate 100mcg pMDI 2 puffs BD
Aerochamber device standard
Patient is female, aged 26 and says her partner uses inhalers so she has an
idea how to use them.
1. Which of the following best reflects what you would cover in the initial
NMS consultation:
A. You hand her the prescription and say you will give her a ring in a
week to see how she is getting on.
B. You hand her the prescription and ask her if you can arrange an
appointment for her to come back in a week to see how she is
getting on with the new medicines and check her inhaler technique.
C. You explain that she has been prescribed two different inhalers and
you need to show her how to use them. During the consultation you
explain what the medicines are for, dosage regimens, possible side
effects, counsel patient on inhaler technique and use the In-check
device to demonstrate optimal inspiratory flow. Demonstrate use of
spacer. Advise on minimising side effects, cleaning devices and
check smoking status.
D. You explain that she has been prescribed two different inhalers and
you need to show her how to use them. During the consultation you
explain what the medicines are for, dosage regimens, possible side
effects, counsel patient on inhaler technique and demonstrate use
of spacer. Advise on minimising side effects, cleaning devices and
check smoking status.
E. You explain that she has been prescribed two different inhalers and
you need to show her how to use them. During the consultation you
find out what the patient knows already about her diagnosis,
prescribed medicines and inhaler devices and tailor your advice
accordingly ensuring the patient knows; what the medicines are for,
dosage regimens, possible side effects, optimal inhaler technique
and optimal inspiratory flow. Advise on minimising side effects,
cleaning devices and check smoking status.
 Patient centred consultation – find out what they know already and
what they would like to get out of the consultation.
 Explain what the new medicines are for; salbutamol = ‘reliever’, Clenil =
‘preventer’
 Dosage regimens
 Possible side effects
 How to use the Easibreathe inhaler; explain it is ‘breath actuated’,
remove mouth piece, shale inhaler, hold upright & do NOT cover air
holes, breathe in steadily, don’t stop breathing when the inhaler ‘clicks’
continue to breathe in slowly and deeply until lungs are full then hold
breath for a count of 10. Wait several seconds before taking second
dose. Replace mouthpiece cover.
 Demonstrate use of Clenil pMDI with aerochamber. If inhaling too
quickly device will make a noise.
 Use InCheck dial device to demonstrate optimum inspiratory flow.
 Importance of rinsing mouth and spitting out after using clenil to
minimise oral and systemic side effects.
 Wash inhalers and spacers regularly – air dry.
 Lifestyle advice
During the consultation the patient is unable to achieve the optimal inspiratory
flow rate (IR) for these devices consistently breathing in too quickly.
2. With rationale explain which of the following may be appropriate
alternatives?
A. Salbutamol pMDI inspiratory flow too quick + flixotide accuhaler
B. Seretide accuhaler patient has been newly diagnosed with asthma patient needs a short acting beta 2 agonist – salmeterol is long
acting – addition of a LABA is step 3 of treatment ladder
C. Salbutamol nebs + ipratropium nebs – ipratropium SAMA not
appropriate for asthma
D. Salbutamol accuhaler + flixotide accuhaler – best choice both DPIs
with a wider range of IR
E. Ventmax MR tabs – possible option but may have systemic effects
e.g. tachycardia