What are the considerations for using Arnuity Ellipta (fluticasone furoate) in a patient with a history of lobectomy?

Arnuity Ellipta Use After Lobectomy

Arnuity Ellipta (fluticasone furoate) can be safely continued or initiated in patients with a history of lobectomy, as inhaled corticosteroids do not interfere with post-lobectomy recovery and the ELLIPTA device is particularly well-suited for patients who may have reduced respiratory capacity.

Device Suitability for Post-Lobectomy Patients

The ELLIPTA dry powder inhaler is an excellent choice for patients with reduced lung function following lobectomy because it delivers consistent doses at inspiratory flow rates as low as 30 L/min, which is achievable even by patients with significant respiratory impairment. 1

• The ELLIPTA device has moderate resistance to airflow and maintains consistent dose delivery across a range of flow rates that can be achieved by the target population (≥30 L/min) 1
• Patients demonstrate significantly fewer critical errors with ELLIPTA compared to other inhaler devices, with only 5-13% of COPD patients making critical errors after reading the patient information leaflet, compared to 44-60% with other devices 2
• The simple three-step operation (open, inhale, close) makes it ideal for patients recovering from surgery who may have pain or reduced mobility 1

Continuation of Inhaled Corticosteroids Perioperatively

Long-term respiratory medications, including inhaled corticosteroids like Arnuity Ellipta, should be continued throughout the perioperative period in patients undergoing lobectomy. 3

• The 2021 enhanced recovery guidelines for pulmonary lobectomy recommend continuing patients' long-term treatments with respiratory medications perioperatively 3
• There is no contraindication to inhaled corticosteroid use in the immediate post-lobectomy period 3

Integration with Post-Lobectomy Respiratory Care

Inhaled corticosteroid therapy should be combined with aggressive multimodal respiratory physiotherapy, which is the cornerstone of post-lobectomy recovery. 3

• Postoperative multimodal physiotherapy should combine early mobilization and walking, breathing exercises (30 deep breaths per hour while awake), and bronchial drainage and coughing techniques 3, 4, 5
• Pain management must be optimized using continuous paravertebral block or regional anesthesia techniques to enable effective respiratory exercises 5, 6
• Deep breathing exercises are more effective than incentive spirometry alone and should be prioritized 5, 6

Monitoring Considerations

Monitor for adequate pain control to ensure the patient can generate sufficient inspiratory flow to use the ELLIPTA device effectively. 6

• Severe post-operative pain may impair the ability to generate the minimum 30 L/min inspiratory flow needed for effective ELLIPTA use 1
• Optimize analgesia specifically during dynamic activities (coughing, deep breathing) using scheduled NSAIDs, acetaminophen, and regional anesthesia, reserving opioids for breakthrough pain only 6
• Teach incision splinting techniques to reduce pain during inhalation 6

Common Pitfalls to Avoid

Do not discontinue inhaled corticosteroids perioperatively without clear contraindication, as maintaining baseline respiratory medications supports optimal recovery. 3

• Do not rely on incentive spirometry alone without combining it with the ELLIPTA inhaler use, early mobilization, and respiratory exercises 5
• Do not use excessive opioids for pain control, as respiratory depression will impair both the ability to use the inhaler effectively and cough clearance 6
• Do not assume the patient knows how to use the ELLIPTA device correctly; verify proper technique, as 5-13% of patients make critical errors even with this user-friendly device 2

Device Preference and Adherence

The ELLIPTA device demonstrates superior patient preference compared to other inhalers, which may improve adherence during the challenging post-operative recovery period. 2

• More patients with COPD and asthma preferred ELLIPTA over comparator devices including DISKUS, MDI, Turbuhaler, Handihaler, and Breezhaler (all P≤0.002) 2
• Most patients (57-70%) made no errors using ELLIPTA and did not require additional instruction beyond the patient information leaflet 2
• The once-daily dosing regimen of Arnuity Ellipta is ideal for patients recovering from surgery who may struggle with complex medication regimens 7