Pharmaceutical Care in Respiratory Disease

Question 1

How is pharmaceutical care defined?

Answer 1

The responsible provision of drug therapy for achieving definite outcomes that improve a patients quality of life

Question 2

What is a pharmacists role in pharmaceutical care?

Answer 2

To ensure safe, evidence-based medicines are optimally used to manage chronic and acute conditions, and promote patient self-care to achieve individual health outcomes

Question 3

What are our aims in treating patients with respiratory disease?

Answer 3

To help patients to,
Obtain the most effective therapy
Understand their disease
Use their medicines appropriately (medicines optimisation)
Experience improved QoL
We can do this by preventing disease, identifying disease and managing diagnosed conditions

Question 4

What are some of the primary prevention methods for asthma?

Answer 4

Encourage breast feeding
Allergen detection and avoidance
Smoking cessation

Question 5

What are some of the primary prevention methods for COPD?

Answer 5

Smoking cessation

Question 6

What indicators can be use to diagnose underlying asthma?

Answer 6

Frequent 'chest infections'
Persistent cough, usually at night time 
Recurrent 'wheezy' bronchitis in children
Chest tightness
SoB

Question 7

What indicators can be use to diagnose underlying COPD?

Answer 7

Current or ex-smoker
Typically older
Persistent cough
Recurrent bronchitis in winter
Breathlessness on exertion 
Wheezing 
OTC sales or prescriptions for cough medicines and antibiotics

Question 8

Newly diagnosed patients need support, what can we do to achieve this?

Answer 8

Ensure understanding of disease
Assess prescriptions (appropriate doses, interactions, sensitivities, contraindications)
Check patient has been shown how to use their inhalers/take their medicines

Question 9

Inhaler device must be…

Answer 9

Able to effectively deliver the drug to the site of action

Suitable for individual patients to be able to use

Question 10

What are some of the factors to consider when making a choice on inhalers?

Answer 10

Aerosol vs. dry powder
Breath actuated?
Manipulation (is the patient cognitively or physically able to use the product?)
Taste 
Dose counter?
Cost 
Patient preference
Patient age 
Portability 
Drug availability

Question 11

What are some of the problems that commonly occur with inhaler use?

Answer 11

Not shaking the device before use (inconsistent dosing)
Not priming the aerosol inhaler device (to check the spray is working)
Not breathing out before inhaling (breathing out reduces the amount offer in the airways and increases available space for next breath, what we want)

Question 12

With good technique, the patient will get _% lung deposition

Answer 12

20

Question 13

With bad technique, the patient will get _% lung deposition

Answer 13

5

Question 14

_% of patients have the wrong inhaler technique

Answer 14

90

Question 15

How should an MDI be taken?

Answer 15

Slow and gentle (normal breath, imagine a straight piece of road with a sharp bend at the end, any cars going too fast will crash, the product generates its own propellant)

Question 16

How should a DPI be taken?

Answer 16

Fast and forceful (need to generate enough force to break up the formulation to optimise particle size and lung deposition)

Question 17

All inhalers need a _ inhalation.

Answer 17

Deep

Question 18

Patients should always be prescribed…

Answer 18

One type of device where possible as concurrent use of multiple types of inhalers with different techniques can confuse patients
Failing that, all aerosols or all dry powders so the same inhalation technique can be used

Question 19

Why are spacers used?

Answer 19

To help patients get a better outcome from their MDI’s e.g. aerochamber, nebuhaler, volumatic

Question 20

How to spacers improve administration?

Answer 20

Avoid need for coordination with MDI
Increase lung deposition
Decrease deposition in mouth/throat

Question 21

How should spacers be cared for?

Answer 21

Wash with soap and water monthly and dry in air
Do not towel dry the spacer as this can affect its function
Should be replaced every 6-12 months

Question 22

How can nebulisers be supplied to patients?

Answer 22

Borrowed from surgery/hospital
Purchased from pharmacy
Determined by local hospital

Question 23

What advice should be given alongside nebulisers?

Answer 23

Caution with over reliance in asthma
Compatibility of different drugs being mixer in the nebuliser
Increased side effects compared with inhalers (as higher doses)
Servicing once per year

Question 24

How are oxygen cylinder supplied?

Answer 24

By commercial companies, differing for different parts of England

Question 25

How do GP surgeries/hospitals obtain oxygen cylinders for patients?

Answer 25

Use Home Oxygen Order Form (HOOF)

Question 26

What is a contraindication of oxygen therapy?

Answer 26

Smoking

Question 27

When using oxygen therapy in hospital, what else should be considered?

Answer 27

Effect on respiratory drive (hypercapnia)

Question 28

What are the general monitoring requirements for respiratory patients?

Answer 28

Changes in prescriptions Symptoms, inc. exercise limitation Inhaler technique Adherance Drug/disease interactions e.g. β-blockers, NSAID’s Adverse effects e.g. β-agonists (tremor), ICS (thrush, hoarse voice)

Question 29

What are the monitoring requirements for asthma patients?

Answer 29

``` PEF Self-management/action plan Use of bronchodilators (gives an indication of how well controlled a patients asthma is) Annual flu vaccine Weight loss ```

Question 30

What are the monitoring requirements for COPD patients?

Answer 30

``` Sputum production Annual flu vaccine Annual pneumococcal vaccine Worsening symptoms Osteoporosis ```

Question 31

What are the monitoring requirements for respiratory patients in hospital?

Answer 31

``` Blood gases Theophylline levels U&E's (e.g. K+) HR/RR O2 saturation Temperature C&S ```

Question 32

What are some of the reasons treatment failure may occur?

Answer 32

Failure to take medicines as prescribed Failure to use devices correctly Failure to use peak flow meter regularly No action plan Drug causes, ADR's Worsening of underlying disease or acute exacerbation Depression (common in chronic diseases) leading to non-adherance

Question 33

What are some of the counselling points in asthma?

Answer 33

Smoking Allergens Avoid β-blockers and NSAID’s PEF and diary

Question 34

What are some of the counselling points in COPD?

Answer 34

``` Smoking Nutrition (importance of BMI, skeletal muscle wastage) Avoid β-blockers, NSAID’s and sedatives ```

Question 35

What are some of the medicine specific counselling points for β-agonists?

Answer 35

Time to affect | ADR's - tremor

Question 36

What are some of the medicine specific counselling points for SABA's?

Answer 36

'Reliever' Used PRN or regularly Usually blue

Question 37

What are some of the medicine specific counselling points for LABA's?

Answer 37

'Controller' Regular use Usually green

Question 38

What are some of the medicine specific counselling points for ICS?

Answer 38

``` 'Preventers' For inflammation Use regularly, even if well Rinse mouth after use ADR's Usually brown or orange (lots of colours available) ```

Question 39

What are some of the medicine specific counselling points for oral steroids?

Answer 39

Usually short course (5 days in asthma and 7 days in COPD) Steroid card if maintenance Rx Continue with inhaled steroids Take all tablets in the morning with or after food ADR's - increased appetite, acne Long term ADR's - osteoporosis (consider prophylaxis)

Question 40

What are some of the medicine specific counselling points for theophylline?

Answer 40

Same brand (narrow therapeutic window) Take regularly but don't increase if breathing worsens Avoid OTC preparations including theophylline ADR's - headache, irritability and nausea (signs that a patient is toxic with theophylline, need to go to A&E) Interactions - smoke, antibiotics

Question 41

What are some of the medicine specific counselling points for antibiotics?

Answer 41

Used in COPD mainly Complete course Take regularly Drink plenty of fluids

Question 42

What are some of the medicine specific counselling points for LTRA's?

Answer 42

Take regularly | Thirst and bedwetting if child

Question 43

What is an 'asthma action plan (AAP)'?

Answer 43

Written and personalised to each individual patient Includes, Inhaler/PEF training Knowledge of drug types Supports self care Helps patient recognise worsening asthma and action points e.g. when to, increase dose of inhaled steroids, start oral steroid, seek medical attention etc.

Question 44

In which patients is it critical that they have an AAP?

Answer 44

Patients with moderate to severe disease i.e. BTS step 3 or above and/or previous admission

Question 45

What is the use of PEF in asthma management?

Answer 45

Allows patient and HCP to monitor asthma control by keeping a PEF diary (available on FP10)

Question 46

PEF measurements are...

Answer 46

Effort and technique dependent (should use the best of 3 attempts) Dependent on sex, age and height

Question 47

What is the aim for PEF measurements in asthma patients?

Answer 47

>70% or 0.7 of predicted normal or best

Question 48

When is a PEF considered 'normal'?

Answer 48

>80% of predicted normal or best

Question 49

When does a PEF value indicate acute severe asthma?

Answer 49

<50%

Question 50

AAP's are linked to...

Answer 50

Improved health outcomes and reduced hospital admissions

Question 51

What is the AAA test?

Answer 51

Avoid Asthma Attack test | Asks a series of questions to detect worsening asthma control i.e. night time waking, symptoms, reliever use

Question 52

What does a self-care strategy in a COPD patient look like?

Answer 52

Start oral steroids if worsening dyspnoea Antibiotics if purulent sputum Increasing bronchodilators if breathless Oxygen care Nebuliser care Pulmonary rehabilitation Review sedative medications and those that reduce respiratory drive i.e. opiates, benzos, tricyclics etc.

Question 53

When monitoring a patent against their action plan, which factors can we use to determine if they are achieving their treatment aims?

Answer 53

PEF for asthma (>70% normal or best) and FEV1% for COPD (declining or stable?) β-agonist use in asthma Symptoms ADR's Holistic (depression, effect on daily life) Smoking Inhaler technique (review as often as possible) Review pharmacological treatments in asthma 3 monthly (with a view to step down where possible) Review pharmacological treatments in COPD at least annually MUR/NMS in asthma and Asthma Control Test (ACT)