Comment

Asthma and COPD: inhaler and spacer rescue packs could be a game-changer

Comments are being sought on a proposal to issue an inhaler and spacer rescue pack to everyone at risk due to these conditions

Comments are sought on proposals to issue an inhaler and spacer rescue pack to everyone at risk due to asthma or chronic obstructive pulmonary disease


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For some patients, inhalers for asthma and chronic obstructive pulmonary disease (COPD) are vital to keeping well, ameliorating symptoms, reducing exacerbation and limiting morbidity and mortality. However, an article in The Lancet (Keeley and Partridge 2019) provides a reminder that in asthma and COPD, whatever the severity of the disease, exacerbations can happen without warning and with potentially fatal consequences.

Because of this, many people with these conditions are advised what to do in an emergency and what rescue medications are required. These are usually either a self-management plan or a personal action plan, and include advice on what to do and when to seek help.

Such plans are perceived to be a person-centred approach for some patients in managing their medicines, but there are many forms and definitions of these plans and they are still inadequately used despite recognition of the benefits.

Confusion in emergencies

One issue is that rescue medications are the same as those used in day-to-day management of asthma and COPD, so in an emergency no distinction may be made and people can be confused, given the plethora of devices and medications.

Salbutamol is our usual recommended rescue medication in both diseases. Some people with asthma will use a maintenance and reliever approach, increasing the dose of this one inhaler to treat exacerbations. Although it is unnecessary, they often have a salbutamol inhaler as backup.

The National Review of Asthma Deaths (British Journal of General Practice (2014) reported an over-reliance on salbutamol and underuse of inhaled corticosteroid, which is necessary to treat inflammation in asthma. In an exacerbation, this potentially puts lives at risk.

Spacer recommended

In COPD, bronchodilation is the first-line treatment for an exacerbation and there is often an over-reliance on oral corticosteroid with or without antibiotics.

During an exacerbation, inspiratory flow changes and people with asthma and COPD may be unable to generate sufficient airflow for user of a dry powder device (DPI). A pressurised metered dose inhaler (pMDI) is often prescribed alongside a spacer, as the evidence indicates that a pMDI with spacer is the most effective way of giving high dose inhaled therapies during initial self-management of an exacerbation.

People who feel anxious may not use a pMDI accurately on its own. The addition of a spacer device is recommended, always so in children.

Initial treatment

The Lancet article (Keeley and Partridge 2019) proposes a simple but potentially game-changing move to provide anyone at risk with asthma or COPD with an emergency pMDI and spacer pack for effective initial inhaled treatment of exacerbations.

The packs would consist of a spacer and MDI – salbutamol for COPD, and salbutamol and beclometasone 250 micrograms for asthma – together with instructions for their use. The packs would be sealed and kept separate from the patient’s routine treatment.

There would be instructions to contact their primary care team or phone 111 if the emergency packs needed to be used, with advice to seek a face-to-face consultation within 48 hours.

Safe and effective

The authors believe that these packs should also be available in all primary care and emergency care facilities.

This is common sense and has a minimal cost when compared with emergency visits. The proposal would make these effective interventions immediately available to all who need them, when they need them, safely and effectively.

Co-author Duncan Keeley is seeking comments on the proposal regarding the benefits of immediate access to effective therapies, which can be sent to him at duncan.keeley@nhs.net


Jane Scullion is respiratory nurse consultant at Glenfield Hospital, Leicester

 

 

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