RESPIRATORY
> within the lungs, reducing available space for gas exchange,
and leading to under-oxygenation of red blood cells. This then causes further physiological responses as the body struggles to obtain oxygen – the main one of these being shortness of breath.
One of the main differences between asthma and COPD is that there is a greater genetic association with asthma occurring in patients, whilst in COPD, the majority of cases come about due to the patient’s smoking habits leading to the prolonged irritation of the lungs, production of various inflammatory products, and damage to lung structure.
Additionally, a number of cases can also be related to other environmental factors, such as the use of harsh chemicals in the workplace, or exposure to fine fibres or dust particles, which are inhaled over a long period of time, bringing about the same effects. The nature of this family of conditions and their pathogenesis means that the symptoms can gradually occur, allowing patients to possess the condition for a number of years before seeking help(6)
.
Much like asthma, there is no cure for COPD, and as a result, pharmacological interventions are based around alleviating symptoms, reducing respiratory inflammation, and assisting patients with the breathing. According to the BNF, symptomatic relief should be offered to patients in the form of a short-acting beta-2 agonist or a short-acting antimuscarinic bronchodilator, with these being use as required. In the case of more severe conditions (i.e. when spirometry tests such as forced expiratory volume are indicative of this) long acting versions of these drugs are recommended. Furthermore, inhaled corticosteroids can be added should the patient suffer from persistent exacerbations or breathlessness.
As always, pharmacists should familiarise themselves with these medications, and their use, in order to
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assist the patient, and also to monitor the correct nature of the treatment strategy being employed. It’s also worth noting that there is a place for oral corticosteroids in the management of COPD (and within asthma in certain situations), and pharmacists should be acutely aware of the additional counseling points for such medications (e.g. taken as single daily dose (normally), the need to taper doses if used for a long duration, provision of a steroid card, etc.).
As is always the way, there are a number of additional points of advice which you could make your patient aware of, which may help to alleviate their symptoms, and assist with control of the condition. Some useful pointers are listed in Box 1.
Box 1. Advice which may assist patients to control COPD symptoms(6)
• Use unscented cleaning products • Avoid perfume/aftershave • Avoid aerosols • Use appropriate extraction when cooking
• Avoid cigarette smoke • Cover nose and mouth when outside in cold weather
• Get an annual flu vaccination
You’ll notice that Box 1 makes reference to the avoidance of cigarette smoke – this might be difficult if your patient is a smoker, which is how most cases of COPD are brought about. Such a situation should trigger you to enquire about enrolling your patient onto a smoking cessation programme, with the multiple advantages to their health, including the vast improvement of their condition, made clear at the outset.
The problem with pneumonia… Whilst not being a condition that is regularly dealt with in the confines of the community pharmacy, it’s worthwhile having knowledge of conditions such as pneumonia, as it may be required that you speak to patients about such a condition, or that you may be involved in the aftercare of patients who are in recovery from the disease.
Pneumonia is, unsurprisingly, less common than both asthma and COPD, but it occurs more than you might think. In 2013, 200 in every 100,000 people suffered from this condition, which, whilst sounding like a lot, is significantly lower than rates throughout the rest of the UK.
Moreover, when the costs of caring for patients with pneumonia (which in almost all cases, requires hospitalisation) are factored in, as well as the death rates associated (which increase emphatically with increasing age), the severity and prevalence of this condition can be equated to these other conditions, even though the total number of people affected is lower(7)
.
Pneumonia is different to the other conditions detailed in this article, in that it is usually caused by an infection contracted by the patient. This infection then stimulates the body to activate its immune response, which leads to phenomena such as alveolar inflammation, and the production of fluid, which also pools in the lung space. These effects, unsurprisingly, affect lung function, preventing the patient from breathing correctly. In terms of causative pathogens, bacteria, viruses and fungi can all be responsible, however the main culprit is normally Strep. pneumoniae.
As a pharmacist, it’s unlikely that you’ll be directly involved in the patient’s immediate care, particularly in the community. However, it is very much worthwhile to be aware of both the signs of the condition, as well as the at-risk groups, so that this condition can be identified in presenting patients, and referral recommended if appropriate.
Symptomatically, pneumonia can present with any of the following: • Flu-like symptoms • Pyrexia • Excessive mucous clearance • Increased breathing rate • Confusion • Sharp chest pain (located at the side of the chest)
Thus, patients presenting these symptoms should be referred,
especially if they fall into categories such as: • Immunocompromised patients • Young children • The elderly • Patients with long-term heart, lung and kidney disease • Diabetics • Cancer patients
In reality however, you’ll refer on all patients who you suspect may have developed pneumonia, but you might expect to see an increased likelihood of such a condition in the patient types mentioned above.
Catching your breath The management of respiratory conditions is as complex as any other, and the role of the pharmacist is as vital as always. It’s worthwhile expanding knowledge of the conditions, their treatments, and additional applicable advice so that patients can benefit from your expertise, and so that you can play a more active role in the improvement of your patient’s quality of life. n
References (1) Northern Ireland Statistics and Research Agency. 2011 Census - Key Facts. 2012; Available at:
http://www.nisra.gov.uk/Census/key_report_201 1.pdf. Accessed 12/09, 2015. (2) Northern Ireland Statistics and Research Agency. Dea ths in No rthern Ireland 2013. 2014; Available at:
http://www.nisra.gov.uk/archive/demography/pu blications/births_deaths/deaths_2013.pdf. Accessed 12/08, 2015. (3) World Health Organisation. Asthma: Definition. 2015; Available at:
http://www.who.int/respiratory/asthma/definitio n/en/. Accessed 12/09, 2015. (4) Asthma UK. Asthma facts and FAQs. 2015; Available at:
http://www.asthma.org.uk/asthma-facts-and- statistics. Accessed 12/09, 2015. (5) Northern Ireland Chest, Heart and Stroke. Statistics about Chest, Heart and Stroke Conditions. 2015; Available at:
http://nichs.org.uk/666/statistics-about-chest- heart-and-stroke-conditions. Accessed 12/08, 2015. (6) Northern Ireland Chest, Heart and Stroke. About COPD. 2015; Available at:
http://nichs.org.uk/102/what-is-copd. Accessed 12/08, 2015. (7) British Lung Foundation. Pneumonia statistics. 2015; Available at:
http://statistics.blf.org.uk/pneumonia. Accessed 12/09, 2015.
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