non: [00:00:00] You are listening to the ATS Breathe Easy podcast, brought to you by the American Thoracic Society.
Dr. Amy: Hello and welcome. You're listening to the ATS Breathe Easy podcast. With me, your host, Dr. Attaway we will be speaking about nebulizers usage and COPD. And joining me today is an expert on all things COPD and Dr. Antonio Anto. He is a professor of medicine at the University of Texas Health Science Center and Chief of the pulmonary section for the South Texas Veterans Healthcare System in San Antonio.
Anto is an active member of the gold organization and has helped develop many iterations of the gold guidelines for COPD. He also has extensive research experience and has been [00:01:00] the principal investigator of numerous large multicenter clinical trials, including the most recent enhanced trial. So thank you so much.
Welcome Dr. Anto to the podcast.
Dr. Antonio: Thank you. Thank.
Dr. Amy: Oh, great, thank you. So before we dive in since we'll be discussing nebulizers, I just wanted to go through a couple of the terms that listeners may hear about different inhaler therapies for COPD. So when we discuss inhaler therapies for COPD, there's several different types, including dry powder inhalers, which we call DPIs.
Dose inhalers, which are known as MDIs, and also there are soft mist inhalers, which are also known as Respimat devices. A nebulizer is a particular device which includes an air compressor, a cup that holds some kind of liquid medicine, and then air will pass through the machine and aerosolize medication [00:02:00] into a mist which patients can breathe in through a mouthpiece or a face mask.
So nebulizers can be used in other medical conditions, including cystic fibrosis or asthma, but today our focus will be particularly on COPD. So the goal guidelines recommend that the choice of inhaler therapy be individually tailored by, for the patient as we'll be discussing today. So, Dr. Anto, we wanted to really know when you're considering a nebulizer versus other types of inhaler devices such as M-D-I-D-P-I, or Respimat, how do you decide which is the best strategy for your COPD patients?
Dr. Antonio: Thank you. Thank you Amy. I think it's important to highlight also in the difference of liver devices that the nebulizer that we have today is not what our grandfather used to have. It is not like a big box that's noisy. That takes forever. We can now highly efficient nebulized system, but that allows the delivery of medications [00:03:00] more faster.
Way three to five minutes. And also more effective way to deliver into the lungs. So at the end of the day within the Gold Document and all the different recommendations for treatment and COPD, the interventions have to match the patient needs. And in, in chronic lung diseases, specifically in COPD, the challenge that we have is these medications have to enter inside the lungs.
So how do we deliver those? That's have to be our priority to try to identify in my patient. The powder formulation will work in my patient that the DPI or in my patient, and we have an alternative. We can give the medications nebulized. Amy, I also wanna highlight one important issue. The US is the only country that we have available, nonactive, anticholinergics, the one a day [00:04:00] medication.
We have available nonactive beta to agonist, actually two formulations for, and we have available nebulized budesonide to be used in adults. So we can reproduce in our patients the optimal therapy for the management of the condition, using a utilization as another alterna alternative for delivery medication.
So, specifically to answer your question, how to decide which is the best strategy for our patients. Patient Atory.
Also this will determine other conditions, patient concomitant medical condition. For example, a patient who has severe rheumatoid arthritis who had would be very hard to handle some of the other delivery devices. [00:05:00] So nebulized medication could be an, so this, a combination of. That will help us to determine, with the caveat that we can reproduce in any of these delivery systems, most of the therapeutic areas.
Dr. Amy: Oh, that's, so I, I deal with this a lot with my patients and I think that's really great to hear kind of how you summarize it, like so you kind of putting it together, the inspiratory flow. Coordination, comorbidities, those all kind of come into play. Are you? Um a lot of times when we, and we have patients in clinic and we're not sure if they can mount like a good inspiratory flow, we'll test for that.
Is that something you do in your clinical practice? You
Dr. Antonio: know, we, we do test in clinical practice and and there is a lot of variability in the inspiratory flow is less than 30 liters. It's less than 50 liters that the [00:06:00] patient's gonna be capable to handle it. I think we. We have also take into consideration the, the ability, you know, on the patients to handle it.
For example, in the powder formulations, we know that is, is crucial that the patient generates a good inspiratory force in order to separate the carrier. In the most cases is lactose protein from the actual medication. So the medication will enter.
The coordination to when you guys need to take to an inspiration when you fire the device. That can be compensated somehow with a little bit with the spaces, but, but it, it's a matter to tailor, to tailor to, to the patient's condition. It's not unusual, you know. We prescribe or one medication delivery system and the patient comes back and say, [00:07:00] no, I don't like it because this and that, or, no, I don't feel the medication is working on it.
So we, we know that we have a different alternatives and it's very, very nice knowing that we can also have the nebulized system as an alternative to give these therapies to our patients.
Dr. Amy: So when you say like you were saying earlier, you can reproduce optimal therapy with nebulized medications and I guess highlighting that America is one of the few countries where you can, you have all these medications on hand.
Do you what, so while that seems. I Wonderful. I think, like you were saying it, you have to kind of tailor your therapy based on the patients. So is there some drawbacks you see to using nebulizers?
Dr. Antonio: Certainly for some people that you have to be connected to a device. There are some that are battery [00:08:00] operated and they portal portable that you can take everywhere.
The probably one of the drawbacks. It's the fact that although in the powder and in the DPI form, we have now come to the point that we had that three major classes of medication being delivered at the same time in the single inhaler. So the Lamas, lavas and ICS. We can, you have a powder and A DPI form.
With the Respimat, we have the Lava lamas combination. Unfortunately for the nebulizer, we don't have formulations that are combined for grown acting bronchodilators. The only formulations that are combined are from short acting. That is.
Like for all with the lama or the three [00:09:00] medications together in a synco vial. So that creates, that patient had to receive two or three different vials and the patient really had to keep track. What do they use on, how do they use it? Because we don't have approval to be given combined. There was a study was presented back in 2019 in chest.
That was some, some preliminary data to look at using the combination, the alone active anti, uh.
They have not been any further, um interventions or attempts to combine. So I would say the pitch fund would be patients have to keep track of three different medications, have to use three different medications, and it's okay to use sequential, but we don't know it can be [00:10:00] used together.
Dr. Amy: Okay. The things I get asked a lot by patients, like, can we mix can we mix medications?
So are you, so my understanding was there's some of them, you're, you can mix the long-acting or is that, that's not recommended. The
Dr. Antonio: only one that, that are being studied have been some preliminary studies. But that has not been approved. They don't come together. They all come separate. So that is a major pitfall that they come as a separate medications, as separate inventory, separate copayments and all that.
The patients really have to track of that because these medications work to give all together.
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So, like you were saying, you really have to, knowing that these haven't been tested together in, in great detail, really need to keep the medication separately. When they nebulize, but sequential, right? They can, they can do one after the other, after the [00:12:00] other.
Dr. Antonio: Yes, they can do a sequential one after another, another, but they cannot give it together to the patient.
The positive side also is the fact I, for example, with finishing once a day. For moderate is twice a day and budesonide. So we're talking about with the, the delivery system we have today. We talk about three to five minutes during the session. So patients not wanna sit over there for three hours, within 20 minutes.
The most half an hour. They should have all the medications. Receive all their medications.
Dr. Amy: That is a great point, I think what you were saying about the nebulizer device, because I've had patients tell me like, oh, it takes me like 10, 15 minutes for like one to nebulize one thing. And I think at that point you might need to say to your patient, like, how old is this nebulizer?
Was it like a hand me down because the technology has moved forward where nebulizing medications occurs much quicker. You [00:13:00]
Dr. Antonio: know, that is a very good advice for to tele, and I tell my patients, I always ask them, do you have a nebulizer? Nebulizer? How is it? Oh, it all, let's get a new one. Let's have a new one available in case you may use some albuterol once in a while.
Let's have a new, a new NE nebulizer. Once they utilize the new nebulizer. High flow nebulizer is highly efficient. You know, they notice it's three to five minutes. Patients say, wow, I mean, this stuff is gonna work. And gives them some eh, make, encourage them to try to use alternatives. Uh.
Dr. Amy: Oh, that's, that's a great point. And I think encourages adherence, which is one of the things we're worried about when we're ever trying to prescribe a medication.
Dr. Antonio: Yeah, so adherence is, you know, is huge and it's a big challenge on underutilized medication. I'm a hundred percent convinced that my COPD [00:14:00] patients adherence is not a challenge for them.
The fact that they will choose not to take the medication because I don't feel like getting, because they understand that taking do medication, they wanna feel better. The challenges adherence from the patients sometimes can be medication decision cost. You know, the copayment changes. I always ask my patients, are you able to take your medications?
And they say, no, the copayment increased, or whatever. I always tell 'em, tell me. I will, I will go shopping. I will find you samples, I will find your ways we'll look into in your plan to see what is the medication to be on the lowest payment because. The, the adherence at the end of the day is because the difficulty acquisition of the medication but the patient understand that they have to take the medication and they have experienced the the [00:15:00] much better feeling much better using these medications.
Dr. Amy: Mm-hmm. Yeah. No, I, I agree. I, I think a lot of patients are. It's, it's just such a struggle after they see us. So I think one of, one of, we have a, in, in our clinic we have a pharmacist who actually kind of follows up with them and there's just a lot of the times things kind of get lost in translation and just with, with insurance and all the the push things may not be covered.
So things get switched. Maybe we don't hear about it. Yeah, that's a common issue. Unfortunately,
Dr. Antonio: I try to shortcut that, that circuit. So I tell my nurse, my medication needs this classroom, me, that this is a C of medication he or she needs. Let's look at the insurance and I will co sign, I will sign an order of medication that I know is part of the, the low tier, his insurance, I.
Once the patient goes to the [00:16:00] pharmacy, they found this huge copayment. They won't take the medication, they will get upset. Everybody's gonna get upset. So at the end, the patient is not gonna get benefits. So I, I always encourage my providers, they try to shortcut that system. They try to identify, let's take another treatment to identify what is the medication that his or her insurance will have, the lower copia, and that's the one we should prescribe.
Very often nebulized medications will fall into this Medicare Part B and, and in Medicare patients this will have, you know, the, the lowest copayments. So that will also have, even using the nebulized alternative for financial reasons, you know, in some patients could be very advantageous.
Dr. Amy: Yeah. Yeah, I would, that's a good point about how usually the nebula, so almost always the nebulizer device can be covered by Medicare as part B, as long as you kind of document [00:17:00] appropriately that it's clinically needed and everything like that.
And then medication is, it's a, it's a little less clear if it's covered, but but usually you have a good chance, right?
Dr. Antonio: Yeah. Most of the time you get a coverage for that.
Yeah.
Dr. Antonio: Nebulizers, I haven't had any problem getting the patient nebulizers almost even private insurance all cover those nebulizers.
That that is something very standard
Dr. Amy: is. So when you, we, we talked earlier about comorbidities in COPD, you had mentioned like rheumatoid arthritis or those kind of patients, you may. Worry that they can't tolerate other inhaler therapies. Is that something you've noticed for like COPD patients with like muscle weakness, muscle wasting,
Dr. Antonio: you know, coordination?
Yeah. I, I have, I have prescribed a nonactive anticholinergic for last 25 years and.[00:18:00]
Saw a blister or put out a capsule for a blister. One day a patient came and said, Hey, have you ever tried to put a blister out here? Say no. Okay. Please try to pull it. And it says there, if you put more than one, you have to discard. I mean, it was very hard to put. And I put three. So I mess it up two days of his treatment.
So those little things, you know, that really we have to take into consideration that, you know, in your fine tooth and your fine motor coordination, you have bar rheumatoid arthritis, you know, you cannot use those devices. And we have to remember that our COPD patient know most of them only have COPD.
Their s very likely have significant cardiovascular disease. They are taking 6, 8, 9 medications. So how do we facilitate our interventions, our [00:19:00] treatments, that will be the benefit for the patient. So at the end, sometimes I don't think myself, you know, I, I go over the medication list is, is endless. You know, go on there and say.
What can I do from the pulmonary point of view to facilitate that, that the patient don't have to worry, worry the list as possible. Even a lot of refills, you usually get three months. I get always refills. I keep an eye on those one and then try to get delivery resistance and wait to deliver to be very, very handy, very friendly to use our patients.
Dr. Amy: Mm-hmm. Yeah, I think so. One of the unique things about COPD and, and other, um. Other lung diseases is that you use inhalers, right? That's one of most other medications you can take a pill and, and, and derive the benefit from there. But yeah, I think that's what makes things more, more important for us to address in the clinic with our patients is, is how they're actually using their inhaler, which is [00:20:00] rec and, and that's also something we also need to follow up.
With our patients, right? Like once we've taught them we need to follow up in clinic, just double check that they're using things properly over time, right?
Dr. Antonio: Yeah. For, for example, in the delivery systems one delivery system, patient had to breathe very fast to get the medication. But in the.
Insurance change and give a delivery system. Like for example, the soft miss, if they breathe fast, they won't get the medication right. So that's what I think is very important. Every time we see the patients try to ask them what, how does medication look like? How do they use it during a study publish from a clinic in Germany when the patient check in?
There is a, a small screen, a computer screen, and ask how do your, the, the medication looks like. So they press a picture and they give them [00:21:00] 90 seconds. This medication, you're supposed to do this, this, this, and this. That by itself significant increase compliance of the medication use. So they are, these are very low cost intervention that can have a huge impact on the patients.
Dr. Amy: Yeah, that's, that's true. I mean, you know, we, it's, it's, it's great if you have time to go through it with the patient, but there's also videos, right? Like there's videos on YouTube. You can, you can show your patient maybe while they're waiting to, you know, right. So there's a, I think a lot of ways we can tailor our, our practice to really help emphasize the teaching as, as often as we can.
Dr. Antonio: That's correct.
Dr. Amy: Well, where, and, and I just, just to get kind of think about the future, where, where do you kind of see nebulizers going into the future? What are your, what are things that you're really excited about in nebulizer medications?
Dr. Antonio: So, I think it's exciting to know that nebulizer is an alternative for our [00:22:00] patients.
We have the new phosphodiesterase inhibitor, the phospho DS three and four inhibitor that was delivered by nebulizer and the ACHILL standard of the oral phosphodiesterase four was side effects. All type of side effects from gastrointestinal to weight loss to psychiatry issues, and all that can be overcome using the nebulization.
So I think the nebulize provides to our patients an alternatives of of care that we can achieve maximum efficacy with the minimum side effects. I seeing nebulized, as you said before on cf antibiotics has been used nebulized for a while. We have a medication available nebulized Amikacin for the treatment of patients with a Mac and a typical MAC bacteria.
So we, I think we are discovering [00:23:00] more and more. That the utilization for respiratory conditions is a good alternative that allows with the position and all this is because these new de systems are highly eff, efficacious, and very efficient.
Dr. Amy: That's great. That's a great point about the devices and how they've really moved.
The technology has really improved with them, so I think that's something always to think about in our patients who may be using an older device or have a hand-me-down or something like that. So well, thank you. Thank Dm, for your lending your expertise to the podcast for the expertise in all things COPD.
But thank you for focusing on nebulizers today and really helping us clarify how to integrate these into our clinical practice.
Dr. Antonio: So, Amy, I think it's important to highlight that COPD is a treatable disease. There is a lot that we can [00:24:00] give to our patients. We have terrific medications that we have developed the last 20, 25 years.
The advantage is we know the efficacy, we know the safety. We have identified the appropriate doses to deliver system. So we have all these choices to our patients. And utilization is part of those choices to give optimal therapy for have our patient control, our patients control the condition.
Dr. Amy: Yes, absolutely.
I, I think it's such an exciting time for COPD and I think that we have so many new tools in our toolbox to help our patients and just really make them feel better and, and help them move forward with their their disease.
non: Thank you for joining us today. To learn more, visit our website@thoracic.org. Find more ats Breathe Easy Podcasts on transistor YouTube at. Apple Podcasts and Spotify. [00:25:00] Don't forget to like, comment, and subscribe, so you never miss a show.