Training Module on Asthma

For Nurses/Paramedics/Assistants
 Pointers for Discussion

• Why Asthma for Nurses?

• Knowing about Asthma
• Treatment of Asthma
– Drugs
– Devices
• Answering Common Queries
• The Need for Patient Education in Asthma
• The Role of an Asthma Nurse
 Current Status Of Asthma
• Rising trends and numbers
– 37.86 Million Asthmatics in India
– Increasing pollution, changing lifestyles leading to increasing prevalence

• Prevalent in all age groups

• Higher burden of disease
– India ranks first with1.8 L deaths a Year
– 0% patients with controlled asthma
• Normal lifestyle possible
• Use of inhaler devices requiring training
• Myths and Misconceptions

The best drugs for management of asthma are Lancet Glob Health 2018; 6: e1363–74
JAPI 2015; 63: 36-43
available at the most patient friendly prices
 Current Scenario in Asthma Practice
Physician
• Limited consultation period

• Inadequate time to teach and assess patients’ inhaler technique

Patient
• Lack of awareness about the disease

• Non-adherence or Non-compliance

• Underestimation of both the disease & the outcomes of treatment

• Incorrect use of devices

 The Misery…The Suffering
• The compromise:

Food restrictions
Missing out on sports
A constant scare of attack
Miss out on school days
Loss of workdays
Psychological
impact

Robbed of the daily joys of life

This can change…

HOW??
 You can help bring this change

You can help people to breathe better

You can instill confidence
 How can you contribute?

• Spending time with patients

• Empathy towards their suffering
• Handling FAQs of patients
• Educating patients on disease
• Training on inhaler devices
• Checking inhaler technique at each visit
Knowing about Asthma
What happens in Asthma………

Spasm & Swelling

 TRIGGERS
Trigger Factors are things that set off or start asthma
Can vary from person to person. An asthma attack can be induced
by direct irritants (allergens)

Recognition of asthma triggers and avoiding them including smoking is the

first step towards controlling asthma
What happens in Asthma………

Bronchospasm & Inflammation

Explain with the help of breathe-o tubes

If inflammation in the airways is not treated it may
lead to permanent and irreversible changes in the
structure leading to ‘Airway Remodelling’
 Diagnosing Asthma

• Medical history
• Physical examination
• Measurements of lung function
– Peak Flow Meter
– Spirometry (not always required for asthma)
• Trial use of asthma medications
 The Peak Flow Meter
like a thermometer for asthma

• Inexpensive clinic instrument

• Easy to use

• Helps in monitoring asthma

• Gives objective values

Peak flow monitoring chart
• Builds confidence in treatment

Show demo on How to use breathe-o meter

Treatment of Asthma
Drugs & Devices
 Asthma - disease
spasm and swelling

• Spasm needs a reliever Bronchodilator

• Swelling needs a controller Anti-inflammatory

 Relievers
• Acts immediately
• For quick relief of symptoms
• Not to be used regularly
• More reliever use, means
uncontrolled asthma

Common e.g. – Salbutamol / Levosalbutamol

 Relievers
 Short-acting β2-agonist
• Salbutamol
• Levosalbutamol

 Anticholinergics
• Ipratropium Bromide
• Ipratropium + Salbutamol
 Controller
 Does not act immediately
 Acts for longer duration
 Usually anti-inflammatory
(Inhaled Corticosteroids or Combinations)
 For regular use
(whether well or not well)
 Controllers
 Inhaled Corticosteroids
• Beclomethasone
• Budesonide
• Fluticasone
• Ciclesonide
 Montelukast
 Long-acting bronchodilators (LABA)
• Salmeterol
• Formoterol
 ICS + LABA combinations
• Salmeterol+fluticasone
• Formoterol+budesonide*
• Formoterol+fluticasone
• Formoterol+beclomethasone
*Formoterol+budesonide can be used as controller as well as reliever medication
 Treatment of Asthma Today…
Most Asthma Drugs are to be taken through the
Inhaled Route
 Why Inhaled Therapy?

Less Drug
Without Side effects
Straight into the
Lungs

Asthalin 4 mg Tabs 40 Puffs of Asthalin Inh

 Why Inhaled Therapy ?
Oral Inhaled
• Large dosage used • Small amount of dosage
• Greater side effects used
• Slow onset of action • Lesser side effects
• Not useful in acute • Fast onset of action
symptoms (e.g. bronchodilators)
• Useful in acute symptoms
Why does one need regular treatment with
controllers?
Normal Inflamed (untreated)

Ideal treatment Traditional treatment

Regular
Inhaled
Steroid
Partly
Treated
 Inhaled Steroid And Risk Of Death
2.5
Rate Ratio for death

2.0
from Asthma

1.5

1.0

0.5

0.0
0 1 2 3 4 5 6 7 8 9 10 11 12
No. of Canisters of Inhaled
Corticosteroids per year
N Eng J Med 2000; 343:332-6
Various Inhalation Devices for
Asthma
 Modes of inhalation
• Dry Powder Systems (Rotahaler; Revolizer; Multihaler)
• Metered Dose Inhalers with Spacers
• Breath actuated inhalers
• Nebulisers (Respules & Respirator solution)
 Dry Powder Inhalers (DPIs)
• DPIs - Deliver medication to the lungs in the form of a dry
powder.
• The drug is mixed with an inert excipient (carrier) like lactose
which helps to enhance the formulation characteristics
• DPIs are easier to use, they do not use propellants and do not
have co-ordination problems and cold freon effect associated
with the pMDIs.
 Different DPIs in the market
SINGLE DOSE MULTI DOSE

Discrete Reservoir

Revolizer Rotahaler

Multihaler Novolizer

Accuhaler Turbohaler
 The Rotahaler
• Dispenses medication in a dry powder
formulation
• Breath actuated device
• Simple to teach, easy to learn and understand
• Multiple drugs, both relievers & controllers can
be administered through the same device
• Transparency ensures complete dosing
• Easy to handle for the young, elderly and arthritic
patients
Show demo on How to use Rotahaler
 Revolizer

Pin Based DPI

Spike assembly pierces the Rotacap
Transparent Medication Chamber
enables the patient to see that the dose
has been inhaled
Easy to use, (Open, insert Rotacap, Close )
Robust
Does not require co-ordination between
inhalation and actuation
Show demo on How to use Revolizer
 The Metered Dose Inhaler
• Most widely used delivery system
• Delivers the drug in the form of an aerosol
(Propellant based)
• Device designed to release a premeasured
amount of the medication into the lungs
• Independent of the inspiratory airflow
of the patient
• Drawbacks
- Co ordination of actuation with inhalation is required
- Patient temporarily stops inhaling due to cold freon effect
- Oropharyngeal deposition due to high velocity of the spray
 Spacer

• Holds the medication for a few seconds after it has been

released from the MDI
• Overcomes coordination problems with MDI
• Increases drug deposition in the lungs
• Easy inhalation therapy for children below 3 years with a face
mask attached to the spacer
 Advantages of using pMDI+spacers

1. Makes pMDIs easier to use

2. Reduces oropharyngeal deposition
3. Improves pulmonary deposition
4. As an alternative to nebulizers in some cases
 Who should use spacers

1. Patients with co-ordination problems

2. Children and the elderly
3. Those who are prescribed high dose inhaled steroids
4. Patients with acute asthma requiring high-dose
bronchodilators, as a substitute to nebulizers
5. Those who are prescribed anti-cholinergic drugs (to avoid
the spray particles from reaching the eyes)
 Spacer + Mask

• For young children who cannot form

a good lip seal around the spacer
mouthpiece, a mask attached to the
spacer should be used
• Pre assembled Kits –
pMDI+spacer+mask (Huf Puf Kit) are
also available which makes it more
convenient to use
Show demo on How to use Hufpuf kit
 Nebulisation
• Device used for converting
a liquid drug into a fine mist
which can then be inhaled easily
• Does not require co-ordination
• Mainly used in the hospitals & clinics
• Useful in severe acute asthma
when O2 is also is requiredv
 Answering the
common Queries
 Is there a need of inhalers?

Eyes Ear

Lungs

Skin Eczema Nasal Congestion

 Will I be addicted to Inhaler?

Tea or Coffee

Affects the Brain

Smoking Alcohol

Acts in the Lungs

 Are you addicted to your toothpaste,
then why inhalers?

• Toothpastes, perfumes, soaps, have more chemicals

and more unknown chemicals in them
• Emphasize that necessity is not addiction
How long should I take regular Therapy?
What happens if I suddenly
stop the Controller Therapy?
 Regular therapy even when I am Ok ?
Normal Inflamed (untreated)

Regular
Occasional
Controller
Controller

Regular controller therapy helps control the chronic

inflammation in asthma and prevents attacks
 Are Inhaled Steroids safe?
YES
• Safe for long-term use
• Long term studies in children prove
no growth retardation in children
• Produced in our body
(glucocorticosteroids – not anabolic steroids)
How Long should they be taken?
These are controller medicines which help to reduce the
inflammation and reduce future asthma attacks. Hence have to
be taken long term. If asthma is controlled the dose of the
steroids may be stepped down.
 What are the signs suggesting that
asthma is getting worse?
• Frequent cough & breathlessness
• Waking in night
• Breathlessness on walking
• Reliever medicines required more frequently
 Managing acute asthma

• An episode of progressive increase in shortness of breath, cough, wheezing,

or chest tightness, or some combination of these symptoms

• Mild Acute Asthma

Managed at Home with MDI + Spacer

• Mild/Moderate & Severe Acute Asthma

Managed in Emergency Departments
with MDI + Spacer/ Nebulisation/
Intravenous injections

• Moderate & Severe/Life Threatening Asthma

Managed in ICU set up
 Some more realities about Asthma
• Asthma is not an infectious disease
• Today control in Asthma is as good as Cure
• All asthmatic children do not outgrow their asthma
• No specific diet restrictions except identified ones triggering
an attack
• Asthmatics of today can lead a completely active normal life
The Need for Patient Education in
Asthma
The Need for Patient Education in Asthma

Asthma treatment is incomplete without patient education

• Removes fears and concerns
• Removes misconceptions
• Instills confidence in therapy
• Ensures compliance
 Why patients don’t take
medicines regularly?
• Patients are not aware about the
chronic inflammation & the need of regular therapy
• Patients are not aware about the consequences of not taking
long term therapy
• Fear about Addiction to therapy and side effects

Role of Nurses in improving adherence

• Reinforce importance of adherence
• Check for adherence at every clinic visit
• Check dose counter
• Address issues related to non adherence
 Success of asthma therapy
=
Treatment + Good Communication
 What to tell patients?

• Provide information on Disease, Devices & importance of

taking long term therapy
• Improve patient attitudes and behaviour towards disease &
expectation from therapy
• Explain the rationale of mode of therapy
• Ensure good communication and partnership
The Role of An Asthma Nurse
 Role of Asthma Nurses

• Concept of airway inflammation/narrowing

• Diagnosis and Home Monitoring with PFM
• How to recognize worsening asthma
• Concept of Controllers and Relievers
• Rationale and correct use of Inhalers
 Role of Asthma Nurses

• Counselling on lifestyle modification

• Family education, myths and misconceptions
• What patients can achieve from regular therapy
• Compliance and Follow-ups
 What should you keep in
your ward?
• Placebo dry powder inhaler
• Placebo dry powder capsules
• Placebo MDI
• Hufpuf kit/Spacer/Baby Mask
• Respules
• Nebuliser (for emergencies only)
• Height measure
• Peak flow meter (Breathe-o meter)
• Patient education material
 Patient Education material

Patient education on Patient education on

asthma pediatric asthma

Device usage tear offs Diet & Exercise tear offs