Getting patients on the right treatments can be life changing

Sheila, 50, lives in Stockport and works as a general practice nurse specialising in respiratory care in Manchester. Sheila has an uncle with COPD and family members with asthma, so has an awareness of how breathlessness and fatigue impact people. She shares her insights into her working day and the importance of inhaler technique and prevention.

People put up with respiratory symptoms for years before seeking care

In the late eighties, I trained as a nurse. I have been working at my current GP practice for the past ten years – because I work part-time, trying to keep on top of everything can be tricky, but it’s a rewarding job. I specialise in respiratory and it’s an area I love working in.

Sheila is a nurse specialising in respiratory care.

In parts of Manchester, we have a high population of people living with chronic lung disease, especially COPD. My patients cover a full age range, from young children with asthma to older adults with asthma and COPD.

I often find that patients whom I diagnose with COPD come to the surgery with day-to-day breathlessness, experiencing a cough in the morning and not being able to do much activity. They put up with these symptoms for years before they come into the surgery for investigation. Patients who are smokers assume because they smoke that they’ve got a smoker’s cough and that’s why they are breathless. But often, when I get them on the right treatment, they suddenly discover that they can walk the dog again.

Lots of patients have bad habits when it comes to inhaler technique

When I see a patient with asthma and their asthma has not been well controlled, I will look at their prescription and pick up on any signs of underuse of a preventer inhaler. Many patients say that they take their preventer inhaler, but their prescription tells a different story. It’s human nature, if a patient’s breathing is not too bad they might think, ‘I feel okay, so I’ll see how I go without it. And I’ve always got my blue inhaler there should I need it.’

Some people and parents of children with asthma worry about the potential side effects of preventer inhalers. I take my time to address their concerns and dispel some of the myths about treatment. I usually explain the effect of asthma in the airways using a demonstration airway model and show them how the preventer inhalers work and why they are so important for controlling symptoms.

If patients are using their reliever inhaler three times a week or more for their asthma, this can be a sign of poor control. I count how often they are requesting repeat prescriptions for their reliever inhaler and if it seems excessive, I review their treatment. Well controlled asthma only requires one or two reliever inhalers a year (of course people sometimes request more for convenience, to keep in different places, but we check regularly).

Lots of patients have bad habits with inhalers, so I always check their inhalers to see if they are blocked and ensure that they are clean. One habit I see in a lot of patients is leaving the cap off their inhaler, when it’s in their handbag or pocket. This means their inhaler has tissue or bits stuffed in the mouthpiece, which is dangerous if inhaled.

There have been times where I went to visit somebody at home who is living with COPD and they are reliant on their inhaler, but it’s attached to a dirty spacer. This is a potential risk for infection and means that they won’t get an effective dose of medication into the airways. I take the time to educate people on how to wash and care for spacers and the need to replace them yearly.

Every time I see a patient, I reinforce the message of prevention

Part of my job is to show patients the different types of inhaler and provide a clear explanation on how to use them and ask them to try them. I’ve got various placebos and an inspiratory flow monitor, which is a device used to measure a person’s ability to breathe in. This enables me to prescribe an effective inhaler for them.

I give feedback on technique and signpost people to ‘how to’ videos and leaflets, so they can go away and learn in a more relaxed setting at home – the Asthma UK and Right Breathe videos are good sources for patients looking for support on their technique. I usually explain to the patient that there are choices of inhaler and ask them what they would prefer. Then, I check their inspiratory flow to see if they have got the lung capacity to use the device. It’s no good giving a patient an inhaler and sending them away with no check or explanation. It’s important to keep that element of patient choice, while making sure that they’ll be able to use it.

Part of my role is doing a patient’s respiratory care annual review. Ideally, when they come in for a review, they’d bring their inhalers with them and you’d watch them use them. In reality, often patients don’t bring their inhalers in when they come for review even though it will ask them to do so in the appointment letter. So, I use the videos and try and assess their technique that way – we watch the videos together and I will show them the correct technique and ask them to follow the steps shown. I explain  the importance of getting the drug deep into the smaller airways and how inhalers work, and the importance of the preventer steroid versus the reliever.

I find that patients use their reliever inhaler because it makes them feel better. They think that’s the most important one. Then they ignore the preventer inhaler until they’re feeling particularly bad. There are a lot of misconceptions around inhalers.  It’s an ongoing repetitive conversation – every time you see a patient you tend to have the same conversations over and over to reinforce the message of prevention.

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The Taskforce for Lung Health is committed to improving inhaled therapy and recommends a clear pathway for accurate prescribing and adherence. The UK Inhaler Group, who work with the Taskforce for Lung Health, have helpfully put together seven steps for practitioners to follow when teaching patients correct inhaler technique. You can find these on the UK Inhaler Group website.

If you have a story to share about your experiences of using an inhaler for your lung condition, you can get in touch with us at yourstory@blf.org.uk


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11 November 2020