here. We will introduce ourselves and then move on. So, my name is Dede Gardner. I'm the Chief Research Officer for College Genasmus Network. The only disclosure I have is that I am employed by AAN and we do receive funding from different pharma, but it's all for educational purposes. Unfortunately, Sandra's not able to be here this morning, so please don't run away, but she's under the weather. And I'm Megan Conroy. I am at Ohio State University and we really would be remiss without recognizing Sandra's contribution to this session as her brainchild and assistant. So, really appreciative of her expertise. All right. So, this morning what we plan to do is to really have you have hands-on with the devices. Each of our tables has a facilitator. Could we have the facilitators raise your hands just for a second so we know who's at the table? So, the persons raising their hand are your facilitator. They will be facilitating the discussion and helping you to pull out the devices that are in the boxes in front of you. We're going to walk through some opportunity for us to troubleshoot the inhalers and we have some video cases that we'll be showing you. And then, ideally, what we want you to do is to walk away with knowing how to choose the optimal inhaler for the right patient. We are going to have polling questions. So, if you have on your app, you may need to download the QR, take a picture of the QR code or else be able to get into the app to utilize the questions that we'll be asking because we do have a little self-assessment. So, I'll turn this over to Megan. All right. So, everybody got that QR code or up in the app? We're going to start with a little bit of a pre-test to provide you a constructive self-assessment and your knowledge on inhaler use. All right. Give it another 10 seconds for everyone to get pulled up. All right. Which of the following could be effectively used with a spacer or a valve holding chamber? Respi-Clik, Readyhaler, Ellipta, or Respi-Met? All right, so we've got a little bit of a distribution here, and the 32% has it the RESPA mat as of March of last year is approved for use with a valve holding chamber. The rest of the inhalers which we had displayed were a combination of dry powder inhalers and breath activated MDI for the ready inhaler. Which of the following inhalers should be shaken before use? The RESPA-Clik, InHub, pressurized metered dose inhaler, or the ready inhaler? All right, get your answers in. Good, 88% got this correct. The pressurized meter dose inhaler should be shaken before use to combine the propellants and the medications which are present. The Respi-Clik, the Inhub are both dry powder inhalers, and the Readyhaler is a breath-actuated MDI. When using a pressurized meter dose inhaler with a valve-holding chamber, which of the following is true, it's acceptable to actuate the dose before inhalation, a whistling noise before inhalation, during inhalation signifies proper inhalation technique, a quick deep inhalation is required for optimal lung deposition, or two puffs can be taken at once as long as the valve-holding chamber is used. For more information, visit www.FEMA.gov All right, we're just about there. Yes, the majority has it here. It is acceptable to actuate a dose when using the valve-holding chamber prior to starting inhalation, which is gonna be a difference compared to use of a pressurized meter dose inhaler without the valve-holding chamber. All right, so we're gonna start with our case videos. Our first case here is Jane. She's 56 years old. She has well-controlled asthma. According to her ACT is 22. She has moderate persistent asthma, and she's currently on a high-dose ICS pressurized meter dose inhaler. She comes to you in between your visits, and we find that her insurance formulary has changed, and she's been placed on the high-dose in-hub. During that time, we find that she's short of breath. She's having more signs and symptoms. Her ACT score does fall, and she finds herself in the urgent care, having an acute exacerbation and placed on OCS. So we want to assess her inhaler use of the in-hub because she's been used to using a PMDI, but now she's switched to something new, and so here we go. We'll show you this video. While at your tables, what we want you to do is give us a second where one of the slides is out of order, so we'll show you the video, and then we'll come back to the instructions for you, so just give me one second. So here's the video. We want you to watch the video. So we'll watch one more time what you want to do at your tables. The facilitators will be talking to you and asking you a few questions. We're trying to identify what we're seeing as incorrect. All right, so we'll have the facilitators take, we're going to take about 10 minutes. We would like to open up the boxes, pull out the inhalers that are in there, and thank you, and we want you to have some discussion time. We'll give you about 10 minutes. We'll be walking around to the different tables, and then we'll come back and assess our learning. Yeah, Maylene is the facilitator, and then Mara. Okay, yeah, Steven, and then Rick, and then Corinne. So we have a couple of minutes to do that as well. Thank you very much. Thank you. Thank you very much. Thank you very much. If you feel like you have mastered the InHub, I will challenge you to look at other devices on your table. And another resource that you can find in the Chest Events app under this session is a link to a Chest Foundation website with step-by-step instructions on each inhaler device. You know, like, um... So we may not have all had the in-hub inhaler, but we do have some. So if a table doesn't have it and another table would like to use it, please go ahead and pass that on to the next, just so that maybe everyone gets an opportunity. We would like to go ahead and move on with, I would like to hear from your tables as to what did you see was a concern with the way that our patient, Jane, had completed her inhaler use. What did you see? You can have a table leader talk to us if you would like. So what did you all see that was a concern? She didn't click. Okay. Okay. Sorry. Our microphones are not all working. Nope. So what we noticed is that while she opened it lovely and she did a nice deep breath, she didn't actually actuate the device. She didn't click the thing down. Great. Great. All right. So we'll watch. We want to make sure that everyone recognizes how the in-hub should be used. All right. So as you can tell, she has held her breath afterwards, which is important to get the medication down. So we want to make sure that you recognize using the device correctly. Let me move on to the next. So I'll pass this back to Megan. Before we move to our next scenario, any questions or other thoughts or takeaways? Did everyone get hands-on with the in-hub? Apologies. Our boxes had a few mishaps. Great. All right. Different Jane. Her identical twin. Comes to you. Also with a history of moderate persistent asthma. She has been treated with ICS for motorol and a pressurized meter dose inhaler, which has been used as both maintenance and reliever therapy for her asthma. You ask her to show you how she takes her inhaler. So for this next section, we have four different possible responses from the patient. Four different responses. So what I will do is divide you guys up into groups of which video I want you to pay specific attention to for discussion. So I will have these first two tables right here on video one. Middle two tables, video two. Back two tables, video three. And two tables over here, video four. Everyone got that? One, two, three, four. I'm going to play these videos each. I want you guys to play it twice. I want you to watch how she's taking it, and I will task you with looking at what she's doing correctly, what she's doing incorrectly, and then also discuss how would you address this in the clinic. What things maybe in addition to or in place of inhaler education could you do to help improve her medication delivery? And we'll again ask for a report out at the end of the lessons that you've taken away and wonderful ideas and tactics that you all come up with at your tables. So group one. All right. Moving on. Middle tables. I ask you to pay close attention to video two. One more time. All right. Back to tables. Pay high attention on our next video, option three. One more time. And our final video, it was over here. If you do not know, there's a valve at the top of the spacer that will show you a visual directionality to her inhalation and exhalation. And one final time. All right, so at your tables, with your assigned video at minimum, talk about the correct actions, what were the incorrect actions, and how would you address this in clinic? You want to play the videos on loop if you need reference. So, do you want to just say five and a half minutes? We'll just kind of see again. Were we going to use that? Just in case. Okay. I hear somebody here had that wonderful AVI. After we tell them not to go on, they're still going on it. So, okay. Well, that's okay. Yeah. Well, in the handouts, this handout is not on there. That's the one that's missing. So, last time we actually gave them away. We made them, and then I mailed them to them. And so, I'm happy to do that again later, too. Thank you. I'll give you just a few more minutes in discussion here, and then if you can identify somebody to share out from your group some of the high points that you took away and identification of the failure points. All right. Does everyone feel like you've been able to get to a conclusion in your discussions? So we'll start with video one here, playing. And group in the front, what are your takeaways? What did you notice? The first thing that I noticed is that you don't need to go over the guidelines, right? Why not just not use this case? I think that's what we came here for. We prefer not to use those guidelines, so you don't need one. I still think they need a spacer. So that's the first one. The second one is, she stacked her puffs. You don't do two puffs at once. And then the third one is, she breathes in way too fast. So we know that these inhalers, especially the HFAs, they blow medicine out pretty quick. Granted, this one's actually fine. This one doesn't. So it's not that fast compared to the ventral inversions. They are faster. And they've been clocked at about 60 miles an hour from when I was reading American Lung Association. So I think the thing that I try to say is take your time and work through all the steps. And the key is making sure that you have the least number of steps to get the medicine in effectively so that they also can remember it. Because if they can't remember it, you're going to constantly be teaching them. Thank you. That's awesome. Good timing, actually. These are really hard devices. There's a lot of timing to be done with these. And so you're absolutely right. Here, she is actuating two puffs at once, which she should not be doing. And then she's starting to inhale after having actuated those. The speed of inhalation with a meter dose inhaler should be a slow and deep breath. So the components here that we want to make sure that you're correcting your patients on is to not do two actuations at once. If they are not using a spacer, then they need to make sure that they are starting their inhalation prior to the actuation of the dose. Other takeaways? Did y'all have a good time? We had a good amount of time. Yeah, she held her breath. Very important stuff that you don't want to miss. And how long, if you need to take a second puff on that same inhaler, how long should you wait? About a minute. 30 seconds to a minute, at least. How long do patients often wait? Maybe not a minute. Right. Yeah, one of the things I always recommend, too, is a lot of our spacers come with a long Ziploc bag. If the patients will put their spacer with the MDI together, they don't have to search for it. It's there when they need to use their MDI. They pull it out. Spacer's already attached. You don't have that situation where you have one device in a drawer, and you always have to get it, and you always have to assemble it. Just keep it together in the bag. It's ready to go. Yeah, I love that. Great tip. Other takeaways, other thoughts, questions? All right, video two, group in the middle. What did you notice on this case? So two major things that we noticed over here. So first, she took a quick breath in. It should be a rather slower breath. She actually pressed the inhaler before putting the mouthpiece in. And then the third thing was that she didn't hold it in for 60 seconds or more. So she like quickly exhaled out without administering the medication. Yeah, good. So keys here that I heard you say is that here she's not emptying her lungs before and she's not holding her breath at the end. One component that is acceptable that she's doing here is that she's actuating that dose prior to starting her inhalation with that valve holding chamber, which is okay. There is a one-way valve on there. That medication will not be lost. A benefit of using the spacer is that you do not need to have that same degree of coordination of actuation of that dose and timing of inhalation, which is a very difficult thing to coordinate and is one of the many benefits to using that valve holding chamber with the use in a meter dose inhaler, having them put it together in their bag so they've always got it right there. So it simplifies the timing mechanism, but still have to empty your lungs before and hold that breath after. Other takeaways, other thoughts? Your table. We didn't really have table consensus as to whether or not she activated the puffer before breathing in. So unclear, I think it's more like a video problem that we couldn't see. Yeah, maybe some things that are hard to just find our best audio. Anybody else? So in summary here, she's not emptying her lungs and she is not taking a breath hold. Really, she should empty her lungs out, actuate the one puff, and then slowly inhale and then hold her breath for up to 10 seconds. All right. Back of the room. Video three. What were your observations? So one of the big things that we noticed here is that she's actuating it when it's upside down and since it's gravity dependent it's only getting the propellant and not the drug. This one conveys pretty well in the video, right? What what patients do you see doing this? Do you see patients doing this? Would it be anybody with arthritis? People with with pretty significant arthritis. It can be very difficult to do the mechanism of activating this or if they have weakness in their hands And so this is a kind of a common workaround that patients might get to is that it can be easier to use their thumb from below and use it, but this is a gravity dependent device and So the actuation of that dose will not occur correctly if it's not held upright And so particularly if you have patients with rheumatoid arthritis other motor issues This is going to be a difficult device for them to use and might be a consideration of why you could potentially use a different mechanism What other thoughts, observations? for our last video, this group. I just want to say thank you. I'm going to go up to the screen. So we thought that a lot of the things that she's doing is correct. She is preparing herself to take the dose by emptying out her lungs. What's different from the prior video to this one was that she's taking slow breaths instead of taking one large breath, which is what most of our adult patients take. They take deep breaths. I think she took maybe three or four breaths. And at the end of the breath, she didn't have to hold the breath, which is different from when you're taking a deep breath. You usually hold for a long period of time. So just a different way of doing the medicine inhalation with an aerogen. Yes, so this is an alternative option for breath-style technique when you're using a valve-holding chamber. This can be five tidal breaths in and out. They do not need to move their mouth from that device. That one-way valve will prevent that exhalation from dispensing that medication differently. And so this can be useful in a variety of times. I heard some discussion that we have people here that see adolescents and pediatrics as well, and it may even be useful for some other of our smaller patients. This is Dr. Adams' dog, Mikey, taking his Simbicort. Similarly, through a valve-holding chamber with a nice mask there, and you'll see him take... Look at that valve on the side. It's five tidal breaths. He'll take a large breath, and then he denotes that he's done. His eyebrows, I love his eyebrows, they're just awesome. And so if you have patients, particularly as you're having them show you, we heard a whistling sound up here once earlier. If you have patients that just cannot get their timing right on the spacer, the speed of inhalation of that slow and deep breath in, no matter how much they try or how many times you're reteaching them, you can come back to this option of five tidal breaths in and out, which is correct use and will deliver that medication. And I'll do this for each actuated dose. So this might be getting this from the vet or from Dr. Adams? Yeah. Yeah, yes. Well, a well taken care of dose. Yes. So looking through the steps that you will want to make sure that you have with that valve holding chamber, you need to shake that, shake that device. For how long? Least five seconds. It's longer than most do. First failure point. Remove the cap and place your meter dose inhaler into your valve holding chamber. And then don't forget the patients need to empty their lungs. Full exhalation away from the device, away from the device, particularly important in our dry powder inhalers. But away from the device is a good thing to coach them in for this in the event that they have another mechanism that they are using. Actuate just one puff and then breathe in slowly, usually over three to five seconds. Hold their breath for up to 10 seconds or as long as they comfortably can. Breathe out, wait at least 30 to 60 seconds and repeat all of these steps for their second dose. So how, did anybody have discussion at their tables regarding options other than inhaler education that you might do for any of these failure points? Are you guys seeing patients do this in your office? Seeing these similar failure points, pretty common. And I think really the value that we have, this is sort of video version of correct use. The value in asking your patients to show you how to use these inhalers is that you can really visualize from start to finish each of these steps. I'm walking around, some of the discussion was talking about just starting with actuation of the dose. Well, there's steps leading up to that. We need to make sure that they've shaken it. We need to make sure that they've emptied their lungs. And so really starting from start to finish. How often are you all able to do inhaler teaching in your clinics? Right. 110% of the time? Yeah. Every single patient, every time? Which we should strive for, right? Yeah. But I think we recognize that there are some barriers to that. And so we are hoping that you will convene at your tables right now and discuss what are the barriers, what are the things that make it harder to do this in clinic and brainstorm how can you overcome that. And then similarly, again, we want to hear your wisdom. We'll give you a little bit of a few minutes. Oh, thank you. So you will press, and then it tells you that a dose is ready. You need to press down and then let go. And then after inhalation, that will turn red, after that dose has been delivered. If you don't let go of that, then the dose will not be fully actuated. So patients may press down and then inhale, not getting any medicine. They need to press fully up and down, green, breathe in, red, counter down, done. Yes, until the dose has been removed. All right. We want to welcome everyone back. After having the opportunity to discuss some of your barriers, we would like to hear from you. So do you want to start with one of the tables? Sounds like discussion is taking place in a good place. Are you on? Yeah. Oh, there we go. All right. Can I put you guys on the spot at this table? Can you share with me what are some of the barriers and some of the solutions that you all came up with? So one of the barriers was time, with your patients, figuring out how to do that. We talked about you could actually bill for your time, because there is inhaler education available fee that you could use. Another barrier was sometimes insurance. You'll do a lot of education on a device, and then that's not the device that actually gets filled by them, was another barrier. How could you overcome that, if you have a different device that's filled after they leave your office? To have them call back, yeah, if that's not. Yeah. I have another. We have a patient portal messaging system. And so anytime that I prescribe a device that I have not taught the patient how to use in the office, I will send them the step-by-step written out instructions. Just make a dot phrase, and then you've got it for each one. And then a link to videos, high quality videos for this. I will give you options. This is not a conflict of interest of mine because it is Sandra, and she did not ask me to do this. And she's not here. She doesn't know I'm saying it. She has a nonprofit called Wipe Diseases Foundation. And similar to the high quality videos that she helped us make here in showing wrong inhaler use, she has step-by-step inhalers on YouTube. Wipe Diseases Foundation YouTube channel, W-I-P-E, and great step-by-step instructions on that. Again, that's Sandra's nonprofit foundation separately. I hold no interest or conflict in that. But send them videos, links to the videos. And there are other websites, use-inhalers.com has videos that are dubbed over in different languages. And so for patients who are not English speaking, they can have more access to that. They're a little bit lower fidelity in the videos. But giving them multiple different learning techniques that if they're getting something filled between visits, that they can then learn how to use that new device. The Wipe, W-I-P, like Wipe a Table Foundation, she has a YouTube channel, Wipe Diseases. Any other barriers? Concerns? I like the idea of billing. That is, if your state allows for that, that's always important if you can get that in. What other barriers? One concern of mine is it's troubling for those that are non-funded patients. We can teach them all day long how to use the device and the importance of the medication, but a lot of times pharmacy labels the medication for in-hospital use. It's got to be relabeled so the patient can take it home. A lot of times staff gets in a hurry and the patient's dismissed, the patient's non-funded, and now they don't have access to the medication. We should work better with the labeling of medication to facilitate the dismissal of the patient from the beginning of the instruction and administration of the medication in-house so they can just take it home and we eliminate that extra step that sometimes becomes a great issue for staff and nurses and the medication is left behind and we have to dispose of it. And that's also, what a shame. Thank you so much. Costs on these inhalers can be a difficult thing to overcome. And then hospital formularies, to your point, I often see patients who have been to the hospital discharged on the formulary inhalers we have in patients that are not their insurance formulary. So attention to those things. And we can talk a little bit more at the end about sort of strategies to overcome cost barriers. What other barriers to inhaler teaching and solutions? »» We had talked about it's often times hard to do this without an actual demo device or without something, especially if, say, someone's very hard of hearing or visually impaired and they're already having a hard time putting it all together. So if you don't have a demo device it's almost impossible. »» The demo devices are helpful. How many of you have them all in your clinic though? So that was not very many. I would submit that there is value in air guitaring it, in pretending. This is, my hand can be a RespiClick, a meter dose inhaler, an ellipta. And doing those motions, if they don't bring it in or if you don't have those, don't have those demonstrators, a lot of failure points may be they're not exhaling before. They're not shaking their device. So though you may not have as high of fidelity in teaching without that demonstrator, you can still assess so many of the steps surrounding that dose actuation and provide correction when necessary. »» All right. So the air guitar I think is important. We know that we've been using that for many, many years. But if you are able to get your hands on a demonstration device, that would be huge. I can put a plug in, and again, not a conflict of interest, but if you need demos, please reach out to me. I have quite a few. And happy to share or send them to you for just the cost of shipping. Regular assess, it's always important for us to assess our patients at all aspects from the beginning to the end to make sure that the patient does show you specifically how they are using the device. If it's not you and it's another staff member, then making sure that they're informed. And then also, you know, finishing those steps and making sure that you're the one that's identifying those failure points. Because again, we need to be able to remedy those so that the patient is getting the medication. I was listening to one of the attendees a minute ago talk about the cap not coming off of an MDI and the patient wondering why they weren't getting the meds. So it's very important. And then you all need to be familiar with the devices that you're prescribing. Some of us get comfortable with prescribing what we know. And that's fine based on what the formularies are for your patients. And then learn the resources. And Megan has shared with you about Wipe Diseases, which is a video YouTube that is extremely helpful for practitioners but also for patients. We also have a plug that this is the latest and greatest of all posters that CHEST and our organization have come together. And this is the first time people are seeing it. So just know that it is updated if you're needing that for your office. And then Sandra and the group has made this other handout for help. Just again, not so much step-by-step, but more of the key messaging on what not to forget when you're talking to your patient about the steps. And then always assess the technique, even if no device is available. Air guitar is better than nothing. And we'll direct you all that also in the session for this session in the app, the CHEST Events app. If you scroll down below the item description, we have a link to a website of patient handouts created by the CHEST Foundation that has step-by-step instructions on every single inhaler device. So we direct you to that link in the app on this session. You can download them. You can use them in your patient instructions and use them for your own education. We'll ask you all, as we're wrapping up today, if you can put those inhaler devices in your table back into that plastic box there. And that will help us clean up for the next session. Thank you so much for your participation.

inhaler devices

video cases

optimal inhaler

polling questions

groups

common errors

additional instructions

barriers to inhaler teaching

regularly assessing patients