When patients are near end-of-life, they commonly experience changes in their breathing. It’s crucial to assess inhaler use & whether it improves patient comfort. Here are three things to consider before prescribing or continuing your hospice patient an inhaler.
Over time as a patient nears end-of-life, they may experience a decline in their ability to breathe normally. It’s best to assess your patient before you decide to add on an inhaler. If they cannot breathe in the medication forcefully enough, it will not be able to disperse to provide relief adequately. If there is any question regarding the patient’s ability to use an inhaler, you should switch to nebulize medication. By doing this, you will significantly improve patient comfort.
Metered-dose inhalers (MDIs) require the inhaler to be carefully coordinated with the force of breathing in (inspiration). Dry powder inhalers (DPIs) require inhalation that is deep and forceful. Assessing a patient’s peak inspiratory flow (PIF) is necessary to determine if an inhaler is beneficial. Here are some examples of inspiratory effort required for several common devices: (1) Symbicort - 30-60L/min (2) Advair, Foradill, Pulmicort & Arcapta - 60L/min. (3) Asmanex - 28L/min (4) Serevent & Spiriva - 30L/min (5) Tudorza - 35L/min.
Surprisingly, age and gender appear to be a key determinant of inspiratory flow, not the degree of expiratory airway obstruction. Advanced age, being female, and additional exacerbations can all help you determine if someone will have inadequate PIF to use an inhaler.
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REFERENCES
Elliot D, Dunne P, Guide to Aerosol Delivery Devices for Physicians, Nurses, Pharmacists, and Other Health Care Professionals. American Association for Respiratory Care 2011. Available at: https://www.aarc.org/resources/aerosol_nonrts.pdf
Laube BL, Janssens HM, Jongh FHC, Devadason SG, Dhand R, Diot P, Everard ML, Horvath I, Navalesi P, Voshaar T, Chrystyn H,
What the pulmonary specialist should know about the new inhalation therapies Eur Respir J 2011; 37: 1308–1331 DOI: 10.1183/09031936.00166410 http://erj.ersjournals.com/content/37/6/1308.full.pdf+html
Malberg LP, Rytila P, Happonen P, Haahtela T, Inspiratory Flows Through Dry Powder Inhaler in Chronic Obstructive Pulmonary Disease: Age and Gender Rather than Severity Matters. August 2010 Volume 2010:5 Pages 257 – 262 DOI: http://dx.doi.org/10.2147/COPD.S11474
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