Pharmaceutical Care in Respiratory Disease Flashcards
How is pharmaceutical care defined?
The responsible provision of drug therapy for achieving definite outcomes that improve a patients quality of life
What is a pharmacists role in pharmaceutical care?
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
What are our aims in treating patients with respiratory disease?
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
What are some of the primary prevention methods for asthma?
Encourage breast feeding
Allergen detection and avoidance
Smoking cessation
What are some of the primary prevention methods for COPD?
Smoking cessation
What indicators can be use to diagnose underlying asthma?
Frequent 'chest infections' Persistent cough, usually at night time Recurrent 'wheezy' bronchitis in children Chest tightness SoB
What indicators can be use to diagnose underlying COPD?
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
Newly diagnosed patients need support, what can we do to achieve this?
Ensure understanding of disease
Assess prescriptions (appropriate doses, interactions, sensitivities, contraindications)
Check patient has been shown how to use their inhalers/take their medicines
Inhaler device must be…
Able to effectively deliver the drug to the site of action
Suitable for individual patients to be able to use
What are some of the factors to consider when making a choice on inhalers?
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
What are some of the problems that commonly occur with inhaler use?
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)
With good technique, the patient will get _% lung deposition
20
With bad technique, the patient will get _% lung deposition
5
_% of patients have the wrong inhaler technique
90
How should an MDI be taken?
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)
How should a DPI be taken?
Fast and forceful (need to generate enough force to break up the formulation to optimise particle size and lung deposition)
All inhalers need a _ inhalation.
Deep
Patients should always be prescribed…
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
Why are spacers used?
To help patients get a better outcome from their MDI’s e.g. aerochamber, nebuhaler, volumatic
How to spacers improve administration?
Avoid need for coordination with MDI
Increase lung deposition
Decrease deposition in mouth/throat
How should spacers be cared for?
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
How can nebulisers be supplied to patients?
Borrowed from surgery/hospital
Purchased from pharmacy
Determined by local hospital
What advice should be given alongside nebulisers?
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
How are oxygen cylinder supplied?
By commercial companies, differing for different parts of England
How do GP surgeries/hospitals obtain oxygen cylinders for patients?
Use Home Oxygen Order Form (HOOF)
What is a contraindication of oxygen therapy?
Smoking
When using oxygen therapy in hospital, what else should be considered?
Effect on respiratory drive (hypercapnia)
What are the general monitoring requirements for respiratory patients?
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)
What are the monitoring requirements for asthma patients?
PEF Self-management/action plan Use of bronchodilators (gives an indication of how well controlled a patients asthma is) Annual flu vaccine Weight loss
What are the monitoring requirements for COPD patients?
Sputum production Annual flu vaccine Annual pneumococcal vaccine Worsening symptoms Osteoporosis
What are the monitoring requirements for respiratory patients in hospital?
Blood gases Theophylline levels U&E's (e.g. K+) HR/RR O2 saturation Temperature C&S
What are some of the reasons treatment failure may occur?
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
What are some of the counselling points in asthma?
Smoking
Allergens
Avoid β-blockers and NSAID’s
PEF and diary
What are some of the counselling points in COPD?
Smoking Nutrition (importance of BMI, skeletal muscle wastage) Avoid β-blockers, NSAID’s and sedatives
What are some of the medicine specific counselling points for β-agonists?
Time to affect
ADR’s - tremor
What are some of the medicine specific counselling points for SABA’s?
‘Reliever’
Used PRN or regularly
Usually blue
What are some of the medicine specific counselling points for LABA’s?
‘Controller’
Regular use
Usually green
What are some of the medicine specific counselling points for ICS?
'Preventers' For inflammation Use regularly, even if well Rinse mouth after use ADR's Usually brown or orange (lots of colours available)
What are some of the medicine specific counselling points for oral steroids?
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)
What are some of the medicine specific counselling points for theophylline?
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
What are some of the medicine specific counselling points for antibiotics?
Used in COPD mainly
Complete course
Take regularly
Drink plenty of fluids
What are some of the medicine specific counselling points for LTRA’s?
Take regularly
Thirst and bedwetting if child
What is an ‘asthma action plan (AAP)’?
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.
In which patients is it critical that they have an AAP?
Patients with moderate to severe disease i.e. BTS step 3 or above and/or previous admission
What is the use of PEF in asthma management?
Allows patient and HCP to monitor asthma control by keeping a PEF diary (available on FP10)
PEF measurements are…
Effort and technique dependent (should use the best of 3 attempts)
Dependent on sex, age and height
What is the aim for PEF measurements in asthma patients?
> 70% or 0.7 of predicted normal or best
When is a PEF considered ‘normal’?
> 80% of predicted normal or best
When does a PEF value indicate acute severe asthma?
<50%
AAP’s are linked to…
Improved health outcomes and reduced hospital admissions
What is the AAA test?
Avoid Asthma Attack test
Asks a series of questions to detect worsening asthma control i.e. night time waking, symptoms, reliever use
What does a self-care strategy in a COPD patient look like?
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.
When monitoring a patent against their action plan, which factors can we use to determine if they are achieving their treatment aims?
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)
