COPD insider

Medications are advancing—are your patients strong enough to use them?

How inspiratory muscle training can remove barriers to success

 

 

Don’t let your patients’ weakened respiratory muscles inhibit medication adherence. Discover how respiratory muscle training along with correct use of a medication delivery system can improve medication adherence and reduce readmissions. 

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Consider this patient

Name: Michael

Age: 72 years old

Condition: Stage 3 COPD

Prescription: DPI LABA + LAMA combination

Despite a medical treatment plan, Michael routinely readmits with severe exacerbations

At first glance, it may appear that Michael is not adherent with his prescribed treatment plan. If he were taking his medication correctly, he would not be readmitting so frequently. He claims that he uses his inhaler daily, as prescribed, but continues to experience severe dyspnea.

 

A closer look would reveal that Michael had both knees replaced, making whole-body exercise nearly impossible. This lack of exercise has compromised his skeletal muscles and has led to further respiratory muscle wasting and deconditioning. Additionally, lung hyperinflation and hypoxemia has compromised his respiratory muscle strength. Due to respiratory muscle weakening, he no longer has the breath strength to effectively take his inhaled medication. His suboptimal peak inspiratory flow inhibits sufficient drug delivery. This results in costly readmissions for Michael’s care network and reduced quality of life for him.

 

Adequate peak inspiratory flow is required for patients to successfully inhale powder from a dry-powder inhaler (DPI) into the lungs. Some patients with severe COPD cannot achieve adequate inspiratory force to break up drug particles sufficiently enough to reach the lower respiratory tract to have clinical benefit. 

With guidelines come limitations

According to GOLD Guidelines, patients with stage 3 and 4 COPD should be treated with a long-acting bronchodilator and a long-acting muscarinic. However, many of these drugs are only available through a dry powder inhaler.

 

For patients like Michael, this means that even when a physician prescribes medications in line with the GOLD guidelines, they may not be able to comply with the medication delivery system due to breathing limitations.

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So, how can you ensure patients are getting the medication they need?

Break through with respiratory muscle training

 

Systemic inflammation from COPD can extend to the skeletal muscles and respiratory muscles, causing them to become weak.  

 

Respiratory muscle training (RMT) is a technique that works to improve respiratory muscle function through breathing exercises. By increasing the strength and endurance of the respiratory muscles, some patients experience improved respiration.

 

One type of RMT is inspiratory muscle training (IMT). This type of pulmonary rehab is designed to strengthen the respiratory muscles through breathing exercises that focus on inspiratory capacity.  

There are three main types of IMT:

1

Voluntary normocapnic hypernea

 

Patients maintain high target levels of ventilation up to 30 minutes. Use of this technique is reserved for in-clinic due to use of complex equipment and the difficulty in accurately determining training load.  

2

Resistive loading

 

Patients breathe through a device with variable sized apertures that provide resistance to respiratory muscles. The drawback of this type of device is that patients can lower their training load through the device by changing their breathing pattern. 

1

Pressure threshold loading

 

Patients produce a negative pressure sufficient to overcome the load of the device and thereby initiate inspiration. The inspiratory pressures are independent of flow rate. Thus, changes in breathing rate that alter the inspiratory flow do not alter the inspiratory load. Therefore, threshold loading devices are the most popular type of device used in the clinic as well as in the home.

Interval-based IMT has been shown to:

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Increase maximum inspiratory pressure (PImax)

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Increase inspiratory muscle endurance and strength

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Reduce dyspnea and fatigue

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Improve functional exercise capacity measured via the six-minute walk test

 

Peak inspiratory flow (PIF), which is partially dependent on the strength inspiratory muscles, may improve with increased inspiratory muscle strength, which may also improve drug delivery. 

Who can benefit from IMT?

 

Routine exercise is usually standard in a COPD treatment plan. For your patients who are unable to withstand regular exercise, consider adding IMT to their treatment plan to maintain respiratory strength and adequate device usage.  

 

Four steps to implementing IMT

 

Once appropriate patients have been identified, careful implementation is critical to success. Here are the four key steps you can take to ensure your patients are set up for success as they begin an IMT program.

 

Help your patients breathe easier

 

As more pharmacologic therapies for COPD emerge, it’s more critical than ever to make sure patients are matched with the right one. This goes beyond the drug itself to the medication delivery system.  

 

Don’t let respiratory muscle weakness inhibit adequate drug delivery, leaving your patients to suffer the consequences. By starting the right patients on an IMT program, you can improve their quality of life while ensuring they are getting the most from their prescribed therapies.  

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Reference

Weiner P, Weiner M. Inspiratory muscle training may increase peak inspiratory flow in chronic obstructive pulmonary disease. Respiration. 2006;73(2):151-156.