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Conversations in Pulmonary, Critical Care and Sleep Medicine by the American Thoracic Society
Amy: [00:00:00] Uh, welcome everyone to another episode of ATS Breathe Easy Podcast. I'm your host, Amy Attaway. I have no financial disclosures. Joining me today is Gvenchi Isi-Buani. she's a registered respiratory therapist at NYU, Langone Health.
Gvenchi works closely with patients with asthma, um, and other chronic respiratory diseases. And we are going to be talking about the best ways to use inhalers and optimize their treatment and navigate, challenges for managing asthma. Welcome, Givenchy. We're so happy to have you here.
Givenchy: Thank you so much for having me.
Amy: our podcast is actually going to have some visual aspects. So if you would like to, um, also we'll be describing what's happening, but if you wanna kind of see the visual demonstration of the inhalers, we are also recording it, which will be shown on our YouTube channel.
So, uh, Gvenchi, I know that, you know, there's lots of different types of inhalers, and I think we, we were mentioning earlier, uh, like a s- [00:01:00] a story about how we saw an inha- well, you, you saw an inhaler not used properly at, like, a tennis, right, like a world tennis game. But that kinda prompted the idea that, like, maybe we, we need to go over this more and kind of discuss all the different, all the different types of inhalers we have.
Givenchy: So primarily I'm gonna be focusing on asthma. Um, and though there are different types of inhalers, there's really only one way to use every single type, so I'm gonna demonstrate how to use it properly, um, in the case of an emergency, but also talk about long-acting, um, inhalers and steroids are, which are more used primarily in long-term use to avoid the emergencies and for the asthma flare-ups, um, to begin with.
So, uh, hopefully after, um, going over everything, you guys have a better, um, understanding of how to use inhaler, and you won't be in a situation where you need it and you can't use it. So that's my goal.
Amy: That's, that's great. Thank you so much. And I think you have, you have, um, slides, I think. Uh,
Givenchy: So, um, I'm gonna be [00:02:00] discussing a little briefly background of what asthma is and how to use an, um, inhaler. This is something I do at bedside quite often, um, especially with pediatrics.
I, I work primarily with pediatrics, teaching the, the parents how to use inhalers for the children. So hopefully this helps. So asthma is a condition where the airway becomes inflamed and narrow. Uh, it makes it difficult to breathe, and that's what causes the wheezing that you hear, the coughing and chest tightness, um, and shortness of breath. Common triggers of asthma could be smoke, vaping, dust, pollution, um, exercise-induced asthma, which is probably what happened with the tennis match that you were describing earlier.
Air pollution and strong odors and perfumes, as well as, um, respiratory illnesses like COVID, cold, flu, um, that come around every season. So I'm gonna be discussing an inhaler. An inhaler is a device, a handheld device that allows the medication to be, um, enter your lungs directly. It helps open up your airways.
It helps reduce swelling and inflammation, [00:03:00] and if you're using the long-term acting inhalers, it helps to prevent, um, or relieve a- severe asthma symptoms The different types of inhalers. So the short-acting is what people are more familiar with, which is Albuterol, um, which is a, a, a rescue inhaler. We have long-acting bronchodilators as well, which help open up the airway for long term.
Rescue inhalers only last a couple hours, so they're really primarily supposed to be used for emergencies. You wanna use more long-acting steroids or combination inhalers to help prevent you having an emergency. Steroids help reduce an- the inflammation, um, in your airways, 'cause what happens with asthma is your airways become inflamed, which causes that tightness, whi- which causes the symptoms of the coughing and the wheezing.
So the steroids to help prevent that from happening. Combination inhalers, which a lot of asthma patients would have, like Advair and Sim- Symbicort, uses both the long-acting bronchodilators, which opens up the airways, and then the [00:04:00] steroids helps to reduce the inflammation over time, help preventing any flare-ups from happening.
So how do you use a MDI, which is a meter dose, um, inhaler? First, you shake it, um, to prime it. You wanna make sure... If you haven't used your inhaler in a long time, you shake it and then you press it, just open up to air. Any dust or residue, you don't wanna have that in your lungs, so that's what priming means.
You take a big breath out. You wanna empty your lungs as much as you can. You place it in your mouth, you press it, and you inhale very slowly, hold your breath for 10 seconds or as long as you can, then you exhale. You wanna wait about 30 to 60 seconds before you, you repeat the second dose. Oftentimes people get prescribed two puffs and just take it right away consecutively.
That's not gonna help. The idea is you wanna use the first dose to open up your lungs, and then the second dose, since your lungs are now open, the second dose can actually be able to circulate properly and help keep [00:05:00] them open longer. If you're using a spacer, it's a very similar, um, way of doing it, except you're gonna attach it to the end of spacer, which I'm gonna show you guys once I, um, turn the camera back on to me You're gonna still prime it, open it up to air.
You're gonna put the mouthpiece in your mouth. You're gonna press it, but instead of just inhaling and holding your breath, you're going to inhale very slowly. You're gonna count to 10 in your head as you inhale. This allows the medication to circulate into the small airways of your lungs. Then you exhale, you wait a few seconds, and you repeat the second puff.
Amy: And so, um, Keveney, a lot of these spacers, right, they'll... If you breathe in too quickly, it will make a noise. Yeah. Right? And that's, yeah. And would you say, I, I often, I, I, I think I, I encourage my patients to use a spacer pretty much if they have, if they have an MDI, they should use with a spacer. Are there some patients where you're, where you kind of mention that, "Oh, it's okay not to use the [00:06:00] spacer"?
Um, 'cause I f- I feel like I tell everyone to use a spacer.
Givenchy: So, um, the spacer does help circulate the, um, the medication better into your lungs, and it helps you keep your technique because it will whistle. So if you're breathing it too fast, it kinda lets you know slow down and count to 10. Um, anyone can use a spacer, however, I feel like, um, once I would say past the age of 10, an MDI without the spacer would be okay because they're able to learn how to just take that slow breath in and hold it for 10 seconds, which will mimic the same type of, um, the maneuver as the spacer.
Amy: Okay.
Givenchy: A lot of times in an emergency, you may not have the whole entire thing with you, so you can use the MDI by itself. I just wouldn't recommend it for any pediatric patient under the age of 10, 'cause it's very difficult for them to, especially in a panic, to learn how to inhale slowly, wait 10 seconds, and then take another puff.
So the spacer allows them to get that whole medication properly, and it comes with a mask for the younger population that can't even, you know, create a tight seal. [00:07:00] You can hold the mask on their face, cover their nose and their mouth. That allows the medication to enter their lungs properly as well.
Amy: Yeah.
Yeah. Well, I see, I, I predominantly see adult patients, but I have to say, um, I think that it's, like, going over the technique, like we talk about, right? Like, like, you'll, um, you try to go over it at least every visit or every other visit because sometimes people forget, um, and they kinda learn how to do it a little bit differently than how we recommend.
So, um, it's nice, right, to kinda see, see them, like, make them demonstrate to you that they're doing it properly. And then, yeah, I think the spacer, that's a great point. I think, you know, if our patients are, obstructed or they're not doing well, you want them to use the spacer, right? 'Cause they're, they're able to get the more of the medication in.
Givenchy: Yes, correct.
So it's very important to know use the inhaler exactly as it's prescribed to you. Always carry your rescue inhaler with you. Um, if you have any of [00:08:00] the steroids, like Pulmicort, Symbicort, it's very important that you wash your mouth or your face if you're using a spacer and a mask because it can cause thrush or fungal infection as well.
So you wanna wash your face right after that. And then any questions, of course, ask your healthcare provider or pharmacist to check your technique as well.
Amy: And right, like a lot of rescue inhalers now you might be using, they might have an inhaled steroid in them,
Givenchy: So I do have the spacer here.
Amy: Mm-hmm.
Givenchy: This is how you would use it for adult patients primarily, right? What she was discussing earlier is that there's this flap right here. When you're inhaling, this flap will move. As you inhale and exhale, it will move. It's also supposed to help you kind of be a user-friendly way of knowing if you're breathing in properly.
If you hear like a whistle sound, you're breathing too fast, just slow down. Oftentimes you don't have to do another puff, but just slow down, inhale very slowly. It's easier to count to 10 while you're inhaling, hold your breath for a few seconds afterwards, and exhale off then before [00:09:00] you do a second puff.
If you have a child, a pediatric patient that cannot put this mouthpiece in their mouth, most of these inhalers and spacers come with a, a face mask as well for anybody that's incapable. It doesn't have to be a child. Anybody who's capable of holding the inhaler themselves and placing it in their mouth.
You can simply put the mask on Like this. Make sure that you have this part covering their nose. Create a nice tight seal. Just hold it against their face like this, mouth and nose is covered. Same thing, you press it and just let them breathe normally. If they're children or they're incapable of counting, just hold it there, hold, count to 10 in your own head.
Let them breathe normal breaths in and out. If they're breathing really fast, just prompt the person to slow down, breathe nice and easy, normal. Allow the medication to circulate. The spacer's gonna make sure that they get the entire dose. Take it off, let them exhale before you do the second dose. Same thing, hold it, press it.
You see the mist go in. Let the patient breathe in and out [00:10:00] normally. Wait about 10 seconds, take it off, and that's how you administer two doses to somebody that cannot do it on their own.
Amy: Yeah, I think that's a great point, right? Like, so, um, sometimes I see patients, I think you described, well, they're do- like two puffs at once.
Yeah. Right? You don't want that. You wanna do one puff, take, breathe it, take a breath, hold it for 10 seconds or as long as you can, then you do your second puff, right? Yeah.
Givenchy: And a lot of times patients won't have the spacer, so you might be more familiar with how it looks like this. It's the same way.
Always prime it before. Press it. You wanna always prime any MDI before you use it because it does collect a lot of dust and debris, and you don't wanna inhale that into your lungs, especially if you haven't used it in a long time. You place it in your mouth, take a breath in. Slow, hold it, count to 10 or as long as you can.
You're actually gonna physically feel the medication kinda circulating in your lungs. Take a deep breath out. Before, like she said, administer the second dose. Same thing, press, inhale. [00:11:00] Hold for 10 seconds, then take a deep breath out.
Amy: And are you, um ... Do you talk about the ... We, we kinda talked about MDIs.
Do you do any of the, like, DPIs, the dry powder inhalers, with your, with your, uh- Nope ... patient?
Givenchy: Okay. Primarily no, yeah. Okay. Not, not primarily, no. Okay. Um, but it's, it's a similar way of taking it except sometimes you do have residue in your mouth, so you do wanna rinse your mouth afterwards with those.
Amy: And have you no- So I know we went through some of the triggers, uh, for asthma, which, you know, it's a summer month right now, and we just had all that wildfire smoke. Did you kinda see that in real time? Uh, uh, 'cause I definitely saw, like, my patients struggling with the air quality.
Givenchy: Yeah. Yeah. I, I did.
Even I was struggling. And, you know, even somebody who doesn't have respiratory, um, illnesses who struggle with the air quality. I did see ... Right now I'm working, um, in the pulmonary function, um, lab. So I w- work a lot with, like, the lung transplant patients primarily. So, [00:12:00] um, yeah, I did see a lot of the patients coming in, um, requiring more oxygen than usual.
They're saying they're using their MDIs more, and I advise them to stay indoors and wear a mask if they have to go outside. Mm. When the air quality is just really bad, especially if you have severe respiratory issues, I wouldn't advise you to go outside. Um, if you do, wear a mask.
Amy: And it, it should be an N95, right?
Yeah, for sure. For the, the small particles, yeah. so going back to inhalers, so y- I know you work with pa- uh, patients all the time. What do you think are, like, the common mistakes that you see? like, what are, what are some ... And how do you troubleshoot that?
Givenchy: Um, the common mistake I see is the two puffs at the same time.
Amy: Okay.
Givenchy: Um, a lot of times when it's prescribed, uh, it just says two puffs on the actual box. Yeah. It doesn't explain how to use it. So, uh, you know, it's a com- it, it's, it's common that you would think I just take two puffs in, one, two, and I should be fine. You're not getting any of the medication with that, so that's the common troubleshoot that I do.
I just tell the parents ... Well, I work primarily with children, [00:13:00] so, uh, most of my education is with the parents of the children. Um, but I tell the patients, um, to do one, prime it, take, take a deep breath in, hold it for 10 seconds. I know you're panicking, just calm down. Let the medication do its job. Trust in it.
Exhale, take another breath in. You're gonna feel better immediately, especially with the short-acting medications. Same thing with the long-acting medications. I tell them the same thing. Always take a deep breath in and hold it, 'cause you wanna allow ... These are inhalers, right? These, this is a mist form. Even if it's a dry powder, it's still supposed to circulate in s- into your lungs.
You wanna give it time to actually reach the smaller airways of your lungs. That's the whole point of waiting 10 seconds, so. Mm-hmm. That's one of the primarily, um, mistakes I see. I also see with the combination or the steroids, people aren't wiping their mouth, or they're not wiping their face 'cause they just, they're not aware of that.
Um, that can cause skin breakdown and fungal infections. So I always tell parents or anybody, just take a little bit of wipe if you're outside, wipe your face, wipe your tongue off, rinse your mouth with water, you know, [00:14:00] just to kinda keep that residue from sitting there causing more problems th- down the line.
Amy: Mm-hmm. Yeah, I think that's ... I mean, that's one of the most unique things about asthma and COPD, is that you're delivering the medication directly to the lungs, right? Most of the time when you take a medication, it's a pill, right, so you don't have to worry about all these things. Um, but, we see it o- over and over again that technique can make such a huge difference and really make a difference in patients' symptoms too.
Um, do you think that, um ... Are there any other recommendations kind of that you give to, um, like you notice with children and, and their parents, um, when using their inhalers? Do you kinda go through, like, their, their schedule or, or try to ... Any other thoughts?
Givenchy: Um, one of the things I've noticed now is, like, more with exercise-induced asthma with the, the, the population.
A lot of kids will say, like, "I feel okay," but then after soccer or basketball, "I feel like I can't breathe." Um, so one of the things that we do say is, like, take the two puffs before you engage in the [00:15:00] activities. Um, it helps open up your lung, and that can kinda help prevent, um, you having that asthma attack.
But also ideally just keeping to your regimen and taking your long-acting, your combinations, and your daily, um, inhalers, that can help avoid you even getting to that point. But if you're still taking it and you still find yourself in that situation, it's okay to kinda take those two puffs before you engage in any, um, strenuous activities, especially if you have exercise-induced asthma.
So that's one of the things that I've been kind of going over with some of the parents recently.
Amy: Mm-hmm.
Givenchy: A lot more recently now in the summer 'cause they're all, like, you know, playing-
Amy: Yes ... all the sports and stuff like that so. Yeah. I think also, right, I, I, I recommend that to my patients who kind of know that their, um, cold air.
Mm-hmm. Like dry, cold air is, like, a big trigger, and they're about to go outside. Um, sometimes I'll advise them to if they kn- if they kinda know it's gonna, they're gonna struggle to, to pre-treat. Um, or even, right, like you put the scarf around your ... I was always taught you tell them put the scarf around your mouth, like, try to, try to avoid that direct cold [00:16:00] blast.
that's wonderful. So I think kind of some, some takeaways from this is that, um, we should, we should be going over this at pre- like every visit or every other visit with our patients because I probably you see, you know, that tech- you work kind of directly with patients, you see that technique is, is an ongoing issue, right?
It's always a work in progress. Um, and then to think, especially in these, this hot weather, the wildfire smoke, um, to protect yourself from these triggers, um, we may, you know, might have to use an N95 if the air quality's really poor. And then that's a great, I think, great tip for exercise-induced asthma too, to just talk to your patients about pre-treating.
Any, any other thoughts? Any-
Givenchy: Um, with the air quality too, one thing I've heard that a lot of patients use the air purifier in their room.
Amy: Oh, yeah.
Givenchy: A lot of patients started getting air purifiers, and they said that they realized that they have less triggers. Um, the, it collects the dust, it keeps the air clean.
So that's something that if you feel like you're at home and you're still having all these problems, it could be [00:17:00] your carpet. You know, it could be the dust in the air. It could be anything in your area. So a, a simple air purifier can also help manage the symptoms as well. It's very important to know what your triggers are, um, and not only to avoid it, but how to manage them.
'Cause sometimes you can't avoid the triggers in the air, right? Triggers outside- Mm-hmm ... environmental triggers. So just learning how to manage and work around them is very important. At the end of the day, you have to make sure that you don't put... You, you're not in a situation where you can't breathe, you know?
You know what I mean? Yeah. That you don't want to get to a situation where you re- require a rescue inhaler. Mm-hmm. Um, most of my education is to prevent that from happening. I don't want you to be in a situation where you need to use that. You shouldn't be using that often. Mm-hmm. Um, so yeah.
Amy: Yeah, if you're using it often, you should talk with your doctor.
You might need to- Yeah ... uptitrate your therapy. Yeah, yeah. That's great. Well, um, thank you so much. We really appreciated this. And, um, I think especially for our pediatric patients, um, you know, we always need to be thinking about this, but even our adults. So thank you so much for that demonstration. And, uh, for people who are kind of [00:18:00] listening to the podcast, uh, keep in mind there was a demonstration that you can watch, uh, a visual demonstration on our, uh, YouTube channel.
So thank you again. You're welcome. Thank you. Yeah.