Considerations For Inhaler Use In Hospice

As patients approach the end of life, changes in breathing are common and can impact their comfort and quality of life. While inhalers are often used to manage respiratory symptoms, their effectiveness in hospice care depends on several factors. It’s important to evaluate whether an inhaler provides meaningful relief, aligns with the patient’s goals of care, and remains practical given their ability to use it. Before prescribing or continuing an inhaler for a hospice patient, consider these key factors. 

1. Assess the Patients Inhalation Ability  

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.  

2. Proper use of the inhaler  

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.  

3. Age and gender  

Surprisingly, age and gender appear to be a key determinant of inspiratory flow, not the degree of expiratory airway obstruction. Unlike expiratory airway obstruction, which is commonly associated with lung disease, PIF is more dependent on a patient’s overall lung strength and function.  

Research suggests that older adults and female patients are more likely to have lower inspiratory flow rates, making it difficult to achieve proper medication delivery with certain inhalers, particularly dry powder inhalers (DPIs). Additionally, conditions like chronic respiratory disease, frailty, or repeated exacerbations can further reduce a patient’s ability to inhale forcefully enough.  

Cognitive and Physical Limitations 

Hospice patients often experience cognitive decline and physical limitations that can make using an inhaler difficult or ineffective. Conditions such as dementia, Parkinson’s disease, or advanced-stage illnesses may impact coordination, memory, or the ability to follow multi-step instructions which can lead to missed doses or improper medication use. 

Similarly, arthritis, muscle weakness, or limited hand mobility can make it challenging to grip, shake, or activate an inhaler properly. If a patient is unable to use their inhaler effectively, their symptoms may go unmanaged, affecting their comfort and quality of life.  

In these cases, caregivers and hospice providers should assess the patient’s ability to use an inhaler correctly and consider alternative medication options that require less coordination or physical effort. 

Alternative Medication Delivery Methods 

If an inhaler is no longer practical or effective for a hospice patient, other medication delivery methods may provide better symptom relief with less effort. Choosing the right alternative depends on factors like patient comfort and ease of administration. Hospice providers should work with their pharmacy teams to determine the best approach for each patient. 

Using an Inhaler in Hospice FAQs: 

Should hospice patients continue using inhalers? 

It depends on the patient’s ability to use the inhaler effectively and whether it provides symptom relief. If the patient struggles with proper inhaler technique or finds it difficult to inhale the medication, alternatives like nebulizers or oral medications may be more appropriate.  

Are nebulizers better than inhalers for hospice patients?  

Nebulizers can be a good alternative for patients who have trouble using inhalers, as they do not require coordinated inhalation. However, nebulizers require a power source and may take longer to administer medication. The best option depends on the patient’s comfort and hospice care goals.  

What are the signs that an inhaler is no longer effective for a hospice patient?  

If a patient continues to experience shortness of breath, wheezing, or discomfort despite using their inhaler as prescribed, it may no longer be the best option. Additionally, if they lack the coordination or strength to use the inhaler properly, switching to a different medication delivery method should be considered. 

Can caregivers help hospice patients use inhalers?  

Yes, caregivers can assist by ensuring proper inhaler technique, using spacers for metered-dose inhalers (MDIs), and monitoring the patient’s response. If the patient remains unable to use the inhaler effectively, alternative treatments should be discussed with the hospice pharmacy  

What are the best alternatives to inhalers in hospice care?  

Depending on the patient’s needs, alternatives may include:  

• Nebulizers – Convert medication into a mist for easier inhalation.  

• Oral Medications – Liquid or tablet forms of bronchodilators or steroids.  

• Transdermal Patches – Deliver medication through the skin for systemic relief.  

A hospice pharmacist can help determine the most appropriate option. 

Contact BetterRX 

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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