O: Optomise Function

Question 1

Optimise Function: Where to Start

Answer 1

Assessment is the First Step. Options:

• History taking & symptom checklists
• Validated assessment tool: CAT, or mMRC Dyspnoea Scale

Question 2

Best Non-Pharmacological Strategies

Answer 2

• Acute relief: handheld fans, leaning forward
• Smoking cessation
• Formal 6-8wk pulmonary rehabilitation program
• Regular physical activity (150min/wk).

NB: regarding physical activity, instruct them to be active until they feel breathless, take a rest to recover breath, then keep going.

Question 3

Details on Pulmonary Rehabilitation

Answer 3

• Formalised program run by LFA. Education and exercise program to help patients Mx breathlessness
• Can re-refer patients for pulmonary rehab if they have since stopped being active and are declining.

NB: After completely pulmonary rehab, patients can attend weekly ‘Lung in Action’ classes at the appropriate LFA-associated community service. It counts towards one’s physical activity requirements

Question 4

Approach to Pharmacological Therapies

Answer 4

Goals (must discuss with patient)

• Improve symptoms
• Reduce risk of severe exacerbations & deterioration

Start Low, Work Up in Stepwise Approach

• 1 long-acting bronchodilator first
• ^ dose or add another agent if necessary

Question 5

Pharmacological Therapy Options

Answer 5

Short-Term Relief

• SABA (salbutamol, terbutaline)
• SAMA (ipratropium)
• Note: patients often receive Sx benefit even if no improvement in FEV1

Long-Term (if short-acting relief insufficient to control)

• LAMA (tiotropium, aclidinium)
• LABA (salmeterol, indacaterol)
• Inhaled corticosteroids (fluticasone, budesonide)

NB: Can get combinations as dual therapy if monotherapy can’t control disease. I.e., LABA and LAMA. Can sometimes get as a single inhaler

NB: ^ dose ICS is associated with risk of pneumonia. Limit triple therapy to those who are inadequately controlled by dual therapy

NB: Avoid oral corticosteroid use for any longer than 2 weeks

Question 6

When to Review Adherence and Inhaler Technique

Answer 6

• Preferably check at each visit, including inhaler technique, adherence to pharm Mx, and non-pharm strategies

Many Factors Impact Medical Adherence

• Motivation
• Understanding of inhaler technique
• Health literacy
• Cost of medicines
• Comorbidities and level of function

If concerned about adherence, consider home medicines review by a pharmacist

Question 7

When to Refer to Specialist Respiratory Services

Answer 7

There are many (here are some)

• Diagnostic uncertainty
• Rapid decline in function
• Poor control despite assumed sufficient therapy
• Assessment for at-home oxygen