By Kaye Prather
Whether you’re a respiratory therapist working in acute care, home health, outpatient pulmonary function, pulmonary rehab, research or sleep studies our patients ask us about their medications. Respiratory medications seem to be the most confusing and often missed in their daily routines. We don’t like to use the word compliant anymore, but where there is confusion and a lack of understanding our patients tend not to use their inhaled medications. The better educated our patients, the better the outcomes for our patients.
You start with listening. Make some small talk. Ask your patient what they know and understand about their health at this point. By doing this, you get an idea of what they know from their perspective, telling you three things:
1. What they know, so don’t waste your or their time by telling them what they already know.
2. You’ll get a good idea what they don’t know or understand.
3. You will pick up on whether they have a clinical understanding of their condition or not.
During the few minutes spent in pleasant conversation, you also assessed their breathing (work of breathing, anxiety levels), what they already know and understand and how much clinical knowledge they have.
Medications are an area of constant struggle. The challenge with respiratory medications is technique and understanding which one does what.
Technique: There are MDIs and DPIs with all their variants. I have found describing the primary differences helps. MDIs deliver a liquid under pressure, and a DPI is a powder with no pressure. Knowing this helps with understanding the type and force of the inhalation. When the patient understands how it works, more often then not it becomes commonsensible. Explain that if they breathe in quickly with force most of the medicine will end up stuck to the back of their throat, which will eventually end up in their stomach. The MDI already has force built in, so a long, strong, deep inhalation is not needed to draw the medication into the airways. The DPI not having any force of its own requires a strong, long, deep inhalation to pull the medication out of the device and into the airways. I know these seem the same, it is the small details that make the difference. Your patient can perform the shake, breathe out all the way part of the technique, but it is the inhalation that trips them up. Even though nebulizers take 10 to 15 minutes for each med (unless you have a turbo model) still get the best outcomes, regardless of technique. Breathing normally with an occasional breath hold is comfortable and easy to remember. Sometimes we have to remind our patients that breathing faster and deeper will not cause the nebulizer to work faster.
The next challenge is helping our patients understand how and why their medications work and addressing how the order in which they take aerosol medications can improve outcomes as well. This is why it is important they understand their medications. It seems new medications are coming out on a daily basis. They all advertise that they open the airways. That is true. However, this is confusing for the patient, since there is a difference between keeping airways open and opening an airway. This is why most of our patients confuse their steroid, anticholinergic, long-acting bronchodilator, combos and bronchodilator meds. Many of your patients will reach for the steroid or anticholinergic with or without the LABA long-acting bronchodilator before their albuterol when they become short of breath. The television ads tell them these medications open their airways. They see more TV ads than you or their physician.
I will start with bronchodilators: we all know about “ALBETTEROL”, but they do not. They do not know the airway is smooth muscle and albuterol relaxes that muscle faster than any of their other medications. That’s when they feel their chest getting tight, finding it difficult to get air in, starting to have that dry, bothersome cough among many symptoms. Albuterol will relieve the symptoms by relaxing the airway.
There are two critical things they also need to know:
1. Their airway can only relax so much. So if they overuse albuterol, it stops working. They need to understand that after the bronchospasm the airway swells within a few hours as a reaction to the trigger and a bronchodilator cannot reduce swelling.
2. You have to be able to take a breath to use the inhaler. This may sound simplistic. However, when you wait to use the inhaler until it is an emergency then most likely you can’t breathe. I have seen, the term quick relief as a replacement for emergency regarding albuterol inhalers and I think it makes more sense. Long-acting bronchodilators, the LABA alone or in with other stuff, the LABA sits in the airway, each little particle with its own little timer waiting to tell it to relax the airway. The short of it, they sit there and in harmony keep saying relax, relax and so on keeping the airway open.
Many of our patients, when first introduced to them, think of steroids as bad and something bodybuilders use. This is the time to explain that steroids are anti-inflammatories, which reduce swelling. I find it helpful to talk about mast cell degeneration, but if you can’t make it amusing, you will lose them. Just about everyone has sprained an ankle and had it swell up. This is a relatable example. They have learned over the years, or you can tell them, that this is the body’s way of protecting itself by immobilizing the ankle. The problem in their case is that with lung disease the lungs become hypersensitive and swell too easily. This is why their steroid is referred to as a maintenance medication, to keep telling the airways to be calm and not swell up so often.
Anticholinergics and Other Medications
There are so many new meds that work to inhibit the production and reaction to the things that make it difficult to breathe. These are also maintenance medications that keep equilibrium. I call them the back door med, which comes in and covers the receptor that is hyperactive, which tells the body to be calm and not to overproduce gunk, snot, loogies, stuff like that. As well as not being so twitchy, not letting the airway tighten, cramp up and go into bronchospasm.
Every day a new medication is tweaked just enough make a small change that is helpful. When our patients come to us and ask about them, look them up to find out how they work, the delivery method, then sit down with your patient and help them to understand. Listen to their questions. You will learn what they know and how anxious they are and the language they use. Explain answers to their questions using analogies. Use something that is common and is easily relatable. You will find analogies based on your life experiences. Draw a picture, if you can’t draw, find one. Use humor, a person who laughs whether it is at you or themselves lets go of the fear for a moment, maybe longer with understanding.
Kaye Prather RRT-NPS, AE-C started her healthcare career late in life. She went back to school at age 49, graduating an accelerated program as valedictorian. During her career, she has in worked acute care, rehab, home care, pulmonary rehab and as a contract trainer.