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.
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:
Interval-based IMT has been shown to:
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.
- Step 1
Determine the patient’s optimal training load
Use a pressure manometer to determine the patient’s maximal inspiratory pressure. The prescribed initial training load should be 30% of the PImax. You can adjust as needed based on age and quality of airflow.
- Step 2
Teach the patient to correctly use the device
Because most training will be done in the home, it is critical that the patient understands their device and proper training technique. The first training should be supervised and respiratory rate and oxygen saturation monitored. Patients should train using a large tidal volume and should be able to take a near maximal breath with every inhalation, maintaining a slow breathing rate.
- Step 3
Establish a training schedule
Most programs consist of training three days a week for a duration of eight weeks. Each session should be 15 to 30 minutes in length. Following the initial eight-week training period, a maintenance plan can be introduced to retain progress.
- Step 4
Reasses
Following the initial training period, check in with your patient to measure the efficacy of IMT. Determine the program’s effectiveness by evaluating criteria such as dyspnea, exercise capacity, quality of life, and readmissions. If the patient should continue with training, you can increase pressure as muscle strength improves.
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.
Further reading
Reference Weiner P, Weiner M. Inspiratory muscle training may increase peak inspiratory flow in chronic obstructive pulmonary disease. Respiration. 2006;73(2):151-156.
