RESPIRATORY
A Breath of FRESH AIR?
Of all the disease types dealt with by pharmacists, be they in the community or otherwise, respiratory conditions are some of the most common. As we know, the conditions grouped under this umbrella heading can vary in both severity, and impact on patient’s quality of life.
D
ue to the high numbers of patients suffering from these conditions, it’s critical that
pharmacists are confident with the basics of such conditions, and use this information to build up an even greater knowledge base, resulting in more educated and successful patient care.
Struggling to breathe Chances are if you’re a pharmacist working in N. Ireland, you’ve dealt with a patient with some sort of chronic breathing difficulty. In fact, if you’re reading this in the dispensary right now, you probably dealt with more than one respiratory patient before your morning tea break. This is indicative of the size of the problem of these conditions in Northern Ireland, and is backed up from various sources of data. According to the last census, 8.72% of the N. Irish population reported having a long-term condition that resulted in them having regular shortness of breath or difficulty breathing(1)
. The seriousness of these
conditions is compounded with more data from the N.I. Statistics and Research Agency, with latest data reporting that over 2000 people died from these conditions in 2013, accounting for 14% of all deaths in the province that year(2)
.
These are obviously not numbers to be balked at, and when other factors such as the need for hospitalisations in exacerbated cases, and the cost of treatment associated with such conditions are considered, it’s clear that respiratory conditions and their management will benefit from greater input from pharmacy, particularly due to the improvements that we can offer in terms of patient compliance, for example. If you think about all the other advice that pharmacists can offer, both in the community, and more recently, within the G.P. surgery, regarding individual treatments and additional lifestyle factors which may assist with improvement of such
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conditions, it’s obvious that we can act as a highly trained resource that will bring about better patient care, and also vital cost reductions for the health service.
This article aims to recap some points about some of the more common conditions that you’ll regularly deal with during your practice. You might already know a lot of the information already, but it may also expose a few areas which you might want to learn more about, providing you with opportunities for your professional development, and improvement of your patient care.
A is for Asthma When most pharmacists think of respiratory conditions, asthma is one of the first conditions that comes to mind. According to the WHO, asthma can be defined as “a condition which is due to the inflammation of the air passages in the lungs, and which affects the sensitivity of the nerve endings in the airways so that they become easily irritated”(3)
. This
sensitivity and swelling then lead to the occlusion of the main airways, hindering air flow into and out of the lungs, leading to the characteristic “attack” style appearance of the condition. These attacks lead to breathlessness and wheezing, and can occur with alarming regularity if a patient is severely affected. Asthma can affect patients of all ages, but the first signs of asthma often appear in childhood.
Again, asthma is a major player in N. Ireland when it comes to chronic conditions – at last estimate, 182,000 people in the Province were receiving treatment for asthma (that’s 1 in 10). A further breakdown of this indicates that over 30,000 of these patients are children, and nearly 150,000 of them are adults, making it the most common long term condition in younger patients. If we spread the net out a bit wider to the whole of the
UK, we have one of the highest rates in Europe. Moreover, 3 people a day in the UK die from this condition, further reinforcing it’s potential as a lethal condition, which needs to be treated as such(4)
.
The diagnosis of asthma is particularly difficult, and this is especially true within the community pharmacy setting. As already alluded to, wheeze, and shortness of breath are two diagnostic factors, but in addition, chest tightness and a persistent cough are also indicative. As such, pharmacists should pay particular care and attention to patients who present with a tenacious dry cough, particularly if this is in children, or if the cough appears to get worse at night. It should also be remembered that all coughs should be referred on for more investigation should they persist for three weeks or more to rule out sinister pathologies. During your questioning, it might also be worth asking the patient about a family history of atopy, and about their medication history – if the patient takes a beta-blocker or NSAID, and this worsens the condition, then asthma should be suspected.
As with many of these conditions, treatment of asthma is far from straightforward, and consists of a stepped approach. Progress to the next step of treatment occurs when the previous step has failed to bring about control of the condition. Failure of treatment can be defined in a number of different ways, namely when a reliever inhaler is needed more than twice a week, if night time symptoms worsen at least once a week, or if there has been an exacerbation over the course of the last two years.
In terms of the treatments and drugs used, the BNF provides handy guidelines based on the recommendations of the British Thoracic Society, which are laid out in
an easy to use format. Pharmacists are strongly encouraged to be aware of these guidelines, and make reference to them when counseling patients or fielding enquiries – the guidelines are useful to identify when a patient may need to move to the next step of treatment, but are also very valuable at identifying when a patient is perhaps receiving medication that they shouldn’t be, triggering you to make a recommendation to patient and prescriber alike, that medications could be withdrawn without having an effect on the patient’s asthma control. Pharmacists should also make sure that they’re confident when it comes to the details about the drugs which are recommended at each step of treatment – your counselling about these medications, and importantly, how they are used correctly, are critical in ensuring that your patient can get their asthma under control!
It’s a fair COPD Chronic obstructive pulmonary disease (COPD) is another condition that is far from uncommon in N. Ireland. Latest figures suggest that 2% of the population (over 36,000) suffer from the condition. In 2014, 6% of deaths were directly related to it as well, meaning that 846 lives were taken by this disease alone(5)
.
So, what is COPD anyway? Well, the term is a catch-all term used to describe a number of long term conditions, all of which bring about restrictions in breathing. Of the conditions covered by COPD, bronchitis and emphysema are the most commonly occurring. To break this down further, bronchitis can be described as the swelling of the bronchi over time, which leads to the over production of mucous, which then needs to be expelled via the cough reflex. Emphysema is entirely different to this, and is a progressive disease, bringing about destruction of alveolar architecture. This breakdown leads to a reduction of surface areas >
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