Pharmacy In Focus Issue 117

RESPIRATORY

Table 4: NICE Guidance 2010 COPD severity and staging Stage

Stage 1 Stage 2 Stage 3 Stage 4

Severity mild

moderate Severe

very Severe

50% – 79% 30% - 49% < 30%+

* Symptoms should be present to diagnose patients with mild severity + FEV1 < 50% with respiratory failure

they are treated empirically first, then the tests are done 9

.

mANAgEmENt coPd, asthma and pneumonia are all managed according to guidelines. the NIcE guidelines can be used to provide appropriate treatment; however, there are other guidelines that can be used also. for the treatment of coPd, guidelines published by the global Initiative for chronic obstructive lung disease (gold) could be followed and for the treatment of pneumonia guidelines from the British thoracic Society (BtS) could be used. treatment for coPd and asthma should be done on an individual basis and should aim to reduce the patient's symptoms and reduce the patient's risk.

Pharmacotherapy a patient would receive includes: inhaled bronchodilators and corticosteroids, oxygen therapy, immunisation and medication used to relieve other symptoms. Selection of inhaled bronchodilators, corticosteroids, or even the combination of them used to treat a patient would be selected based on the severity of the coPd or asthma symptoms. other medicines would include: theophylline, phosphodiesterase inhibitors, and mucolytics (eg, four-week trial of carbocisteine), diuretics (patient with peripheral oedema) and promethazine or dihydrocodeine (both used to treat the sensation of breathlessness) for patients with coPd. Patients may receive a course of oral antibiotics or oral corticosteroids as rescue medication if they are having frequent exacerbations. Non-pharmacological therapy would include: smoking cessation, pulmonary rehabilitation

Table 5: CURB-65 Scoring 9 C

confusion

U Urea < 7mmol/l R B

65 Age≥ 65 year Respiratory Rate≥ 30/min

Blood Pressure (Systolic < 90 or diastolic≤60 mmhg

and surgical intervention. Surgical intervention would be lung volume reduction and lung transplant, which would have its own set of guidelines.

When recommending treatment for cAP, a patient is first given a cURB- 65 score and empirical treatment will be given based on the score. the patient scores one point for every feature that is present. If a patient has a score that is less than one, they can be treated at home; however, if the patient has a score greater than one,

FEV1predicted percentage (%) ≥ 80% *

counselling a patient with coPd or in a respiratory mUR. • does the patient know the difference between their inhalers – are they aware which inhaler is used as a reliever and which is used as a preventer? • checking and teaching good inhaler techniques - now that there has been an increase in the number of different inhaler devices, pharmacists should make sure that they know how to use each one. Also check to see if there are any dexterity or co-ordination issues with using the inhaler • does the patient get confused with the number of inhalers they are using – if the patient is on a number of inhalers and confused how to take each one, perhaps a suggestion could be made to the doctor or nurse about prescribing a combination inhaler. • compliance and frequency – is the patient using their reliever frequently?

“AS thE INcIdENcE of dEAth ANd dISABIlItY cAUSEd BY RESPIRAtoRY

dISEASES INcREASES, PEoPlE ShoUld BE mAdE AWARE of thE RISK

fActoRS ANd hoW thEY cAN BE REdUcEd AS mANY RESPIRAtoRY coNdItIoNS ARE PREvENtABlE”

or any other unstable comorbid illness, they would need to be treated in hospital 9

.

Smoking cessation is the most important intervention that can be made, as it helps with reducing the risk of asthma exacerbations and the severity of coPd. most people find this difficult, especially people with coPd as the majority of them have been smoking for years. It is important to let these patients know that, although quitting is the end- game, even a reduction in the amount of tobacco smoked can help to slow down the progression of coPd 10

multidisciplinary program that incorporates: physical training, education of condition, nutritional counselling and breathing exercises which help with gas management. Practical respiratory consultation points Below are some key points that should be mentioned when

. Pulmonary rehabilitation is a

Are they using their preventer or steroid inhaler everyday? • do they know how to check if the inhaler is almost empty? • Ask if the patient is experiencing any side effects • Smoking status of the patient – advice can be offered in the pharmacy or they can be signposted to local pharmacy that offers the smoking cessation service. • Signs of an exacerbation and frequency of exacerbations – does the patient know the signs of an exacerbation? do they know how to use their rescue medication? Are they having exacerbations frequently? • have they received the flu vaccine?

coNclUSIoN As the incidence of death and disability caused by respiratory diseases increases, people should be made aware of the risk factors and how they can be reduced as many respiratory conditions are

preventable. Smoking cessation is the most important intervention that can be made as it helps to reduce the severity and the exacerbations of the disease. Pharmacists should continue to give advice to patients about managing their long-term respiratory condition and encourage them get the best out of their medications.

REfERENcES 1. lung health in Europe: facts and figures [Internet]. European lung foundation. 2013 [cited 15 december 2016]. Available from: http://www.europeanlung.org/assets/files/publi cations/lung_health_in_europe_facts_and_figu res_web.pdf 2. Society B. Burden of lung disease | British thoracic Society | Better lung health for all [Internet]. Brit-thoracic.org.uk. 2006 [cited 15 december 2016]. Available from: https://www.brit-thoracic.org.uk/working-in- respiratory/burden-of-lung-disease/ 3. Who | chronic obstructive pulmonary disease (coPd) [Internet]. Who.int. 2016 [cited 14 december 2016]. Available from: http://www.who.int/respiratory/copd/en/ 4. chronic obstructive Pulmonary disease [Internet]. NIcE clinical Knowledge Summaries. 2015 [cited 15 december 2016]. Available from: https://cks.nice.org.uk/chronic- obstructive-pulmonary-disease 5. British thoracic Society, 2012. coPd care Bundles Project, london 6. global Strategy for diagnosis, management, and Prevention of coPd - 2016 - global Initiative for chronic obstructive lung disease - gold [Internet]. global Initiative for chronic obstructive lung disease - gold. 2016 [cited 14 december 2016]. Available from: http://goldcopd.org/global-strategy-diagnosis- management-prevention-copd-2016/ 7. Asthma [Internet]. NIcE clinical Knowledge Summaries. 2013 [cited 15 december 2016]. Available from: https://cks.nice.org.uk/asthma 8. Yawn B. differential Assessment and management of Asthma vs chronic obstructive Pulmonary disease [Internet]. Pubmed central (Pmc). 2009 [cited 15 december 2016]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/Pm c2654706/ 9. A quick Reference guide for the management of community Acquired Pneumonia in Adults [Internet]. Brit- thoracic.org.uk. 2009 [cited 15 december 2016]. Available from: https://www.brit- thoracic.org.uk/document-library/clinical-infor mation/pneumonia/adult-pneumonia/a-quick- reference-guide-bts-guidelines-for-the-manage ment-of-community-acquired-pneumonia-in- adults/ 10. how smoking cessation affects the progression of coPd - Stop-tobacco.ch - help and advice on quitting smoking [Internet]. Stop-tobacco.ch. [cited 15 december 2016]. Available from: http://www.stop- tobacco.ch/en/how-smoking-cessation-affects- the-progression-of-copd

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