Respiratory Pharmacy

1
Respiratory Pharmacy the Ward Pharmacist
experience

• by
• Abdol Malek bin Abd Aziz, MSc

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Respiratory pharmacy

• Emphasis on pharmaceutical care of respiratory
  patients
• plus
• Other conditions that the patient is concurrently
  suffering

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Respiratory Pharmacy

• Covers
• Asthma
• COPD
• Idiopathic interstitial lung disease
• Pleural disorders
• Pneumonia
• Drug-induced pulmonary disease

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NHMS 1996 - Findings

• High percentage (62.4) not on inhalers
• Mild asthmatics 65.3
• Moderate 52.1
• Severe 23.7

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Compliance / adherence

• Generally non-compliance rate 50 (out
  patients)
• 56 in Melaka (1999)
• Leads to hospital admission
• 51.7 in Hospital Melaka
• 13.3 were asthmatics (6/45 patients)
• Non-compliance to inhaled medications 50
  (McGann Elizabeth. Am J Nursing 1999)
• Aziz AMA, Ibrahim MIM. Med J Malaysia 1999.
• Aziz AMA, Senthil N, Jenny W. J Pharm Sci.
  2003 (in press)

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Some avenues to patient care

• Patients with allergic rhinitis often experience
  symptoms of asthma (Linneburg. Allergy 2002,57)
• Allergic rhinitis preceded or developed at the
  same time as allergic asthma
• Tx of allergic rhinitis reduced asthmatic
  symptoms or reduce risk of asthma

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Inhaler technique

• good rating ranged from 5-86 using MDIs
• Technique improved after proper training
• 37.5 of pharmacy staff 45.4 (15/33)
  outpatients having good technique
• Inhaler technique survey among pharmacy staff
  and patients at the specialists clinic pharmacy,
  Hospital Melaka. Abstract of the Konferens RD
  Farmasi, Kota Bharu 2002.
• Cochrane MG, Bala MV, Downs KE et al. Inhaled
  corticosteroids for asthma therapy patient
  compliance, devices , and inhalation technique.
  Chest 2000117(2)542-550

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Lung deposition of medication

• Terbutaline
• MDI 8, DPI 22
• Effect of spacer device
• Lung deposition increase from 9 to 21
• Oropharynx deposition reduced from 81 to 17
• Borgstrom L, Derom E, Stahl E, et al. The
  inhalation device influences lung deposition and
  bronchodilating effect of terbutaline. Am J
  Respir Care Med 19961531636-1640.
• Newman SP, Millar AB, Lennard-Jones TR et al.
  improvement of pressurised aerosol deposition
  with Nebuhaler spacer device. Thorax
  198439936-941.

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Bronchial asthma

• Defn Reversible airways obstruction , airway
  inflammation, airways hyperreactivity to a
  variety of stimuli
• Incidence 3-6 in Australia, 4.2 in Malaysia ,
  2-5 in Africa
• Symptoms Wheezing, dyspnoea, chest tightness,
  cough

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Asthma in children

• Children
• Dry powder inhalers has greater systemic effects
  than MDIs
• Pharmacists recommend MDI with spacer device
  for children.
• Kereem E . Ann Allergy Asthma International
  200289.

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Pharmacists roles

• As educator and support person
• Counsel on role of each medication
• Difference between preventer reliever
• Emphasise safety of inhaled csteroids
• Discuss adverse effects ways to minimise
• Check and correct proper use of inhalers
• Encourage use of spacers and peak fl. meters

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Pharmacists roles

• Check compliance 56 noncompliance rate1
• Check usage of medications for other illnesses,
  OTC products, GPs drugs, etc
• Dispels myths about asthma and inhaler use
• Encourage asthma action plan

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Objective

• To have an influence on prescribing and related
  clinical practice

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How to start?

• Ward pharmacy
• then
• Respiratory pharmacy

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Ward pharmacy

• Back to basics
• Supplies, inventory, pricing,
• Dosage, category of drug in MOH list
• List A, std item
• Synergistic activity with in-patient
  pharmacist/satellite pharmacist

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At the ward

• Familiarise with the ward- acquaint with ward
  staff ie. sister nurses
• Ward procedures
• Own reading on common drugs used
• develop confidence

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Ward rounds

• Consultants rounds already have a high level of
  interest in optimising drug therapy
• Vigilant on ADR and side effects

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Preparation before rounds

• Very, very important
• May take an hour or more initially
• Objective
• to anticipate areas where information is likely
  to be requested
• To identify topics for discussion

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• Becoming prepared
• provides
• Confidence

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Clerking

• Same as any other pt
• Biodata, diagnosis, investigations, lab results,
  x-rays, etc,
• Document using card or form
• Monitor,
• Identify drug-related problems or issues
• Plan for solution
• - check-up
• - talk to Dr or specialist, nurse

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Things to do

• Estimate creatinine clearance ClCr if the serum
  creatinine is gt150µmol/l in adults less than 70
  yrs using Cockcroft and Gault equation
• Abnormal levels of urea or albumin may alter the
  disposition of some drugs

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Patient parameters

• Pt. with liver disease elevated liver function
  tests
• Severe cardiac failure may affect both renal and
  hepatic clearance of drugs may
  necessitate dose individualisation
• Calculate predicted blood levels if therapeutic
  monitoring of a drug is required

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Attending ward rounds

• Be PUNCTUAL
• Degree of involvement and pharmacists role
  depend on the leading physician
• Doctors may undertake management or teaching role
  or both
• They may not ask for pharmacists comments

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A successful attendance in ward rounds

• Adequate preparation
• Being tactful, yet assertive
• prioritise

• Regular attendance
• Present info on a problem concisely
• Provide adequate follow up

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Pharmacists comments

• Unlikely to be a personal insult and no offence
  should be taken
• The advice may be used on a similar pt in future
• Occasionally it may be used by the consultant
  against his junior staff communicate with the
  houseman to avoid unnecessary embarrassment
• Follow up on pts where comments have been
  accepted ie. supplies and instructions on usage

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Specialisation

• Collins English Dictionary and Thesaurus
• defines special as distinguished or set apart
  from
• Specialisation characteristics that distinguish
  a clinical pharmacist from other pharmacists
• Obtained thru further education and training

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Nursing profession development

• Shift in promotion ladder
• Dual career pathway
• management ?sister matron
• Clinical nurse ? advanced practice nurse (same
  ranking as sister/tutor)
• Similar to UK and Canada situation
• Nafsiah Shamsudin. Specialisation of the
  clinical nurse in the Malaysian setting. Sept.
  2000.

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Specialisation

• Extra qualifications preferable
• Sometimes not necessary
• MSc, MPharm
• PhD
• Experience, confidence, way of thinking,
  networking, research-oriented, etc

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Specific situations

• Asthma
• Counselling
• Pharmacoherapy issues ie. Drug of choice ß-2
  agonists (short-acting, long-acting,
  corticosteroids (inhaled , oral),
• Drug forms inhalers, oral tablets, nebs

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Other roles

• Conformance to guidelines MTS, GINA
• Research eg.
• drug use
• clinical trials on outcomes of pharmacist-treated
  pt vs non-pharmacist pts, counselled vs
  non-counselled
• Inhaler technique relate to outcomes
• Asthma clinic check peak flow, compliance to
  tx, appointments for counselling, etc

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What others have achieved

• Pediatric asthma management programme Covenant
  Health System, Texas, US
• Found many asthma pts admitted for various
  reasons ie. Lack of medication, non-compliance,
  improper inhaler technique
• Remedy face-to-face counselling. Pharmacists
  counselled pts and families
• Complete pt information leaflets given,
  videotapes
• Spent 30-60 mins per pt
• Razia M, Gordon H. Am J Health-Syst Pharm
  200259. p. 1829.

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results

• 69 pt counselled 106 vs 51 ER visits or
  admissions pre and post counselling (?52)
• Cost avoidance USD126,500/
• ? Counselling beneficial and reduces admission
  rates.

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COPD
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C.O.P.D.-X Plan

• C Confirm diagnosis, severity, complications
• O Optimise patient function (impairment,
  disability and handicap)
• P Prevent deterioration
• D Develop self-monitoring and self-management
  care plan
• X guide for managing exacerbations

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C.confirm...

• Exclude asthma, cardiac disease etc
• Assess severity
• Assess reversible components
• Identify complications and co-existing conditions
• history, examination, spirometry, xray chest, FBE

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O.optimise.

• Smoking cessation
• Optimise drugs
• safe and effective - dont over-prescribe
• Treat complications
• Optimise psychosocial issues
• Optimise nutrition (consider dietician)
• Encourage exercise (consider physio gym)
• Pulmonary rehabilitation
• Lung reduction surgery or transplantation

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P.prevent.

• Smoking cessation (help and monitor)
• AAAAA
• Occupation and other dusts
• Stop unhelpful drugs
• Prevent infections
• influenza vaccination (?Pneumococcal)
• relevant antibiotics for purulent sputum and
  fever
• Pulmonary Rehabilitation
• Transplantation

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P.prevent.

• Check for complications concurrent conditions
• osteoporosis, depression, cor pulmonale,
  OSA/hypoventilation
• Consider oxygen if hypoxaemic
• Regular review
• lung function

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D.discuss, develop.

• Educate patient and carers
• Pulmonary Rehabilitation and Patient Support
  Groups
• Assess self-management capacity
• Develop a collaborative care plan
• monitor to identify exacerbations early
• how to self-initiate treatment
• what to do in an emergency

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X Exacerbations

• Inhaled bronchodilators and systemic
  glucocortocoids are effective treatments for
  acute exacerbations (Evidence A)
• Patients with clinical signs of infection(change
  in sputum colour and/or fever, leucocytosis)
  benefit from antibiotics (Evidence A)

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Asthma Action Plan

• Designed for pts with asthma to
• recognise deterioration and
• respond appropriately
• Action Plan will prevent
• delay of initiation of preventer dose increases
• prolonged exacerbation
• adverse effects on pts life

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Peak Flow Monitoring

• Peak Expiratory Flow (PEF) the greatest flow
  velocity which can be generated during a forced
  expiration starting with fully inflated lungs
• Simple, quantitative, reproducible measure of
  airway obstruction
• Meters are cheap, lightweight and portable
• Repeated measures highly reproducible with each
  individual patient, if the same meter is used

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Peak Flow Monitoring

• Actual number not important, but the trend is
• Measures response to bronchodilator therapy
  increase by 20 post treatment (provided the
  baseline reading gt 300ml/min adults)
• Measures early deterioration before pt. feels the
  change in his disease
• diabetics monitor blood sugar, asthmatics
  measure lung function

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Pulmonary Rehabilitation Program

• Established in the Repatriation General Hospital,
  Adelaide since many yrs ago
• A structured program using weekly lectures
  spanning over 3 months
• 2 hrs session (1 hr lecture each person ) _at_1.30pm
• Coordinated by the Resp. Rehab. Clinic
• Pharmacist
• Talked about Medications and Airways Disease

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PRP team

• Respiratory physician (Chairman),
• Technical officer, Respiratory Function Unit
• Clinical Nurse Consultant, Respiratory Rehab
  Clinic
• Clinical Pharmacist
• Physiotherapist
• Rehabilitation Counsellor
• Dietician
• Occupational therapist