You are a medical student rotating through a general practice placement. Jessica Wales, a 23-year-old patient, attended the practice as part of her asthma follow up. Your consultant GP has tasked you with re-educating the patient on adequate inhaler technique. You are NOT required to take a full history.

Perform and teach the patient adequate inhaler technique.
At 8 minutes, the examiner will ask further questions.

2 Minutes Reading Time

10 Minutes Station Time

Total 12 Minutes

EXAMINER INSTRUCTIONS

Timing Instructions: At 8 minutes, stop the candidate and ask the following questions:

Question 1: What can aid in the diagnosis of asthma?

Answer 1:

Clinical assessment
Fractional Exhaled Nitric Oxide (FeNO) Testing
Spirometry
Bronchodilator Reversibility
Variable Peak Expiratory Flow readings (PEFR)
Direct Bronchial Challenge test with Histamine or Methacholine

Question 2: What are the two types of inhalers most likely to be started after an initial asthma diagnosis?

Answer 2:

Short-Acting Beta Agonist (SABA) inhaler - 'blue' reliever therapy
Inhaled Corticosteroid (ICS) inhaler - 'brown' preventer therapy

Question 3: How is the severity of an asthma exacerbation graded based on peak expiratory flow readings?

Answer 3:

Moderate (PEFR 50% - 75% best or predicted)
Severe (PEFR 33% - 50% best or predicted)
Life-threatening (PEFR < 33% best or predicted)

PATIENT INSTRUCTIONS

Patient details:
Name: Jessica Wales
Age: 23 Years Old
Date of Birth: 9 February 2001
Location: General Practice
Occupation: University student
“I have been feeling quite out of breath lately, it feels like my blue and brown asthma inhalers are becoming ineffective as well.”
Ideas: “I was looking through the internet and I think my asthma is getting worse because of my inhaler technique.”
Concerns: “I’m just worried I would end up in hospital from a bad asthma attack.”
Expectations: “Could we go through the inhaler techniques again please? I just want to make sure I’m using them the correct way!”
- First diagnosed with asthma 5 years ago
- Occasionally gets asthmatic attacks, around once every few weeks
- Symptoms include breathlessness and wheezing. Sometimes gets a dry cough too.
- Never presented to the hospital for an asthma exacerbation
- Otherwise usually fit and well.
Regular medications:
- Blue asthma inhalers - uses them every time she gets an asthma attack
- Brown asthma inhalers - uses them once a day on most days (sometimes forgets to use them)
Drug allergies:
Allergic to penicillin - gets a rash with penicillin

MARK SCHEME

Introduction

Introduces self with full name and role

Washes hand

Identifies patient with at least 2 identifiers

Explains purpose of consultation and gains consent

Position patient so that they are sitting comfortably

Ideas, Concerns & Expectations

Explore ideas, concerns, and expectations

General Review

Review the patient's asthma symptoms

Review the frequency and number of asthma exacerbations requiring salbutamol inhaler

Review concordance of use of their preventer steroid inhaler

Check patient's understanding of inhalers, techniques and compliance

Explain the types of inhalers, their purpose and when to use them ℹ

Explain that inhalers contain a set dose of medications - the aim of using the inhaler is to get these medications directly into the lungs. The medications are released by pressing the canister or by twisting/clicking the device, depending on the type of inhaler. Make sure to check the patient's understanding by asking them to repeat the key points back to you.

Inhaler Technique Explanation

Check the dose counter and expiry date of the inhaler

Hold the inhaler upright

Remove the cap from the inhaler and inspect the mouthpiece ℹ

Inspection is vital to make sure there is nothing obstructing the inhaler mouthpiece as this may reduce the amount of medications that gets inhaled into the lungs.

Shake the inhaler before using

Sit or stand straight with a slightly upward tilt to the chin ℹ

This position opens up the airway, helping the medication reach the lungs.

Breathe out gently and slowly away from the inhaler until your lungs feel empty

Put your lips around the mouthpiece of the inhaler to create a tight seal

Start to breathe in slowly and steadily while pressing the canister of the inhaler once ℹ

Aim for the medications to hit the back of the throat whilst breathing in. Continue to breathe in until lungs feel full.

Remove the inhaler from your mouth and seal your lips

Hold breath for 10 seconds or for as long as the patient is comfortably able to ℹ

This step is vital to help the medications settle in the lungs before being expelled again during exhalation.

Breathe out gently away from the inhaler

Replace the cap once finished with using the inhaler. Otherwise repeat the steps above if a second dose is required. ℹ

If a second dose is required, wait 30 seconds to a minute before repeating the steps above. This will give time for the first dose of medications to settle and work.

If the inhaler used was a preventer steroid inhaler, rinse mouth with water after each use ℹ

Steroid inhalers predisposes patients to oral candidiasis. Rinsing their mouth with water after each use will minimise the risk of the fungal infection.

Demonstrate the techniques yourself in front of the patient ℹ

Through demonstration, patients tend to absorb and remember the steps and techniques better. This also gives an opportunity for the patient to clarify and questions or confusion.

Ask the patient to use their own inhaler or a placebo inhaler to demonstrate back what you have demonstrated ℹ

This provides an opportunity to correct any incorrect techniques and clarify any misunderstanding from earlier explanation and demonstration.

Provide feedback based on what you observed to allow patient to refine their inhaler technique. If required, ask the patient to repeat the steps until their inhaler technique is correct.

Endpieces

Safety net the patient on obtaining emergency help if symptoms are severe and not relieved by inhaler ℹ

Advice that if the patient has an asthma attack that does not respond to their reliever inhaler after 4 puffs (with 30 seconds between each puff), they should call 999 for urgent medical assessment

Suggests seeking GP or specialist help if suffering with side effects or using reliever inhaler more than three times per week ℹ

Go through the side effects of inhalers with the patient. These may include tremors, headaches, muscle cramps or palpitations with a salbutamol inhaler or sore throat, difficult or painful speech with a steroid inhaler.

Check if the patient has any further questions

Provide an information leaflet

Arrange a follow up

Thank the patient

Questions

Identifies at least 3 diagnostic aids of asthma

Identifies the correct types of inhalers

Identifies the correct grades of severity of asthma exacerbation based on peak expiratory flow readings

Patient Scores

Rate how well the candidate has performed from a patient’s perspective out of 5 points.

Enter Your Score Here: /43

SCORE GUIDE

High Pass: > 35

Pass: > 26

Borderline Pass: 22 – 26

Fail: < 22

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